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Ethics in Dentistry: Part III – Ethical Decision-making

Course Number: 546

Ethical Decision-making Models

Ethical decision-making models provide a suggested mechanism for critical thinking and planning for the resolution of ethical dilemmas. An ethical decision-making model is a tool that can be used by health care providers to help develop the ability to think through an ethical dilemma and arrive at an ethical decision. A number of models are presented in the ethics literature, most of which are similar in design and content. The goal of each model is to provide a framework for making the best decision in a particular situation with which the health care provider is confronted. Most of these models use principle-based reasoning, an approach primarily derived from the work of philosophers Beauchamp and Childress.7 These models consider ethical principles, obligations and values. They advocate the use of resources such as published evidence, clinical data and consulting colleagues in dentistry. Some of these models incorporate four, five or seven steps for resolving dilemmas but all support careful reasoning through the structure of a decision model whether in solo private practice, large clinical settings, or dentally-related advocacy organizations.

The model suggested in this module is a simple six-step approach derived from the decision-making literature as interpreted by Atchison and Beemsterboer and used since the early 1990s with dental and dental hygiene students in a combined ethics course. It is a reasoned approach based on theory and principle.8

Diagram emphasizing use of past info and experiences on current and future decision making.

Figure 1.

The process of decision-making is dynamic, evolving as additional information comes to light. Dentists and dental hygienists are confronted with myriad questions to consider, requiring them to factor in the code of ethics and their own values and beliefs before arriving at a decision. The evaluation process involved in an ethical dilemma is not unlike that which occurs when the practitioner is faced with a clinical or scientific problem. Careful attention to and systematic analysis of the evidence, facts, and details will help the health care professional reach an appropriate decision. Applying the decision-making model gives a tool to use throughout professional life.

Six-Step Decision-making Model

  1. Identify the Ethical Dilemma or Problem. Step 1 is the most critical step in the process as awareness of an issue must occur to move through the steps. Many situations are simply never perceived to be ethical problems or dilemmas. Once the problem has been recognized, the decision maker must clearly and succinctly state the ethical question, considering all pertinent aspects of the problem. If the ethical question does not place principles in conflict, it is a simple matter of right and wrong and no process of ethical decision-making is required. Proceeding to step 2 is not necessary if a clear determination of right or wrong has been made.

  2. Collect Information. The decision maker must gather information to make an informed decision. This may be factual information about the situation as it developed, and it may come from more than one source. Information such as the medical and/or dental history, diagnosis or prognosis may come into play here. Are the treatment expectations attainable?  Is the patient competent or is there a surrogate involved? The values of the parties, including those of the health care provider, are needed.

  3. State the Options. After gathering all the necessary information, one may proceed to the third step, which involves brainstorming to identify as many alternatives or options as possible. Often the best decision is not the first one that comes to mind. Also, a tendency exists to think that a question has only one answer. This step forces us to stop and view the situation from all angles to identify what other people might see as alternative answers to the problem. An enlightened and open mind is required to recognize often more than one answer to a problem exists.

  4. Apply the Ethical Principles to the Options. Focus on the ethical principles (autonomy, beneficence, nonmaleficence, justice, veracity) and ethical values and concepts (paternalism, confidentiality, and informed consent). In general, one or more of these will be involved in any ethical decision. State how each alternative will affect the ethical principle or rule by developing a list of pros and cons. In the pro column, show alternatives that protect or hold inviolate each principle or value. In the con column, state how an alternative could violate the principle or value. Do this for each option. This process will enable you to see which ethical principles are in conflict in this situation. Refer to the appropriate code of ethics for guidance. Often discussing the issue with a trusted colleague can help one gain a better-rounded appraisal of the situation and subsequent solutions.

  5. Make the Decision. When each alternative has been clearly outlined in terms of pros and cons, a reasonable framework is apparent for making a decision. Each option must then be considered in turn, with attention to how many pros and cons would attend each decision. The seriousness of the cons must then be weighed by the clinician, remembering that, as a professional, he or she is obliged to put the patient’s interests first. Simply by examining the options in a careful way, the best solution to an ethical dilemma frequently becomes obvious. Before implementing the decision, the practitioner should replay each principle against the decision to see if the decision holds up to this evaluation.

  6. Implement the Decision. The final step involves acting on the decision that has been made. The decision process will have been futile if no action is taken. This is where moral courage may be required. Many appropriate decisions are never implemented because this step is omitted. Remember that no action represents tacit approval of a situation.

Other Ethical Decision-making Models

A frequently used ethical decision-making model in medicine is called the Jonsen or Four Box Model. This model was developed by Drs. Albert Jonsen, Mark Siegler and William Winslade and is particularly helpful when dealing with complex medical cases. The authors describe this framework as an ethics workup similar to the history and physical when first assessing a patient. This approach organizes and displays the relevant data and questions in a four domain arrangement. The 4 boxes, quadrants or paradigms are: medical indications, patient preferences, quality of life, and contextual features.

Medical Indications – Autonomy, Beneficence

Consider the medical condition, diagnosis, prognosis, interventions.
Patient Preferences – Autonomy

Does the patient have capacity? What are the patients’ wishes?
Quality of Life – Autonomy, Nonmaleficence, Veracity

Consider the patient’s quality of life from his/her view.
Contextual Features – Justice

What are the social, cultural, legal, economic and institutional circumstances?

Assessing the importance of facts, opinions, and circumstances in light of complex ethical issues is a challenging and perplexing task. This is what an ethical decision-making model framework can provide the clinician – an approach to problem solving.