Ethical Decision Making Models and Their Application

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Ethical decision-making is a basic interpersonal capacity, which every doctor must possess in his or her career. This article shows that having thorough knowledge of the concepts of deontology, utilityism, existentialism, virtue and ethics of treatment helps to select the right cause of behavior when nurses are faced with moral dilemmas. Such practitioners are often inspired to step beyond their assigned roles to provide their patients with the best care facilities, support their colleagues and represent their society's best interest. In other words, the ethics rules direct carers on how they always act and what they can do. Deontology and Utilitarianism have been found to be crucial in dealing with the various complex issues characterizing the nursing careers such as respecting the patients’ autonomy including in cases where they make poor choices that may expose them to greater harm.  

Consequentialism Debate: Comparing and Contrasting Deontology and Utilitarianism

Deontology ethics emphasizes that individuals should not judge choices by their effects but through their conformity to social norms or predetermined rules and regulations. According to Mitchell (2015), deontologists require individuals’ actions to adhere to particular codes of conduct no matter the outcome. That is, if a particular activity is not in line with the norms, then it would be wrong for a person to engage in it simply because of its positive impacts. A good example is a case where a patient refuses to give consent for surgery. Although the patient is likely to lose his/her life without undergoing the procedure, the nurse must respect the client’s decision.   From a deontologist’s perspective, persuading the patient to give the consent is unethical even if the treatment is crucial in delivering quality care.

On the other hand, utilitarianism promotes actions that create the highest value to the largest population of stakeholders. Philosophers refer to it as a consequentialist approach since it requires a decision maker to attach more value to the outcome of the chosen course of action.    As Mandal, Ponnambath, & Parija (2016) points, utilitarianism theorists believe that people should morally assess their actions and intentions based on their repercussions.  They should then turn down options that cater their own interests or those of the minority in favor of alternatives which maximize all parties’ needs.

As such, the action itself determines whether an individual is right or wrong among deontologists while the outcome dictates the morality of the intervention in utilitarianism. This means that a supervisor or a manager at a medical institution who is a staunch believer in the latter may reward a nurse that convinces a patient to give consent. In contrast, a manager relying solely on the deontological principle would take a disciplinary action against such a caregiver.

However, both the approaches are geared towards enhancing the concerned parties’ welfare. Applying the principles means that some stakeholders bear most of the burden created by the reached decision. In deontology, the harm may affect the minority or all stakeholders. The action may be acceptable to the decision maker but may lead to undesirable outcomes to his/her society. Similarly, the dire consequences often accrue to a few parties whenever utilitarianism approach is applied.  According to Mandal et al. (2016), the concept is divided into act and rule utilitarianism. Act component focuses on individual cases.  The parties involved weigh the benefits of particular actions against their adverse effects and then select options which create the most value to the highest number of people.

Balancing the benefits and the harm does not necessarily require an individual to examine experience or evidence.  Rule utilitarianism is based on carefully selected moral codes that often maximize the stakeholders’ well-being. Masters (2017) also found that nurse-patient relationships are mostly deontological in nature. This is because medical teaching, evidence-based practices, and policies have stressed the critical norms required to maintain professional and healthy interactions with the patients.  Breaching the rules relating to patients' autonomy and beneficence often amount to negligence. For example, the nursing code of ethics stresses on the need to obey the clients’ rights. Therefore, as much as the overlap in the principles may create confusion among nurses, the authorities have established policies to minimize such challenges.

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Bentham and Mill’ Versions of Utilitarianism

Although both Jeremy Bentham and Stuart Mill are classical utilitarians, their theories differ significantly in various aspects. Bentham’s model revolves around pleasure and pain (Eggleston & Miller, 2014). All rational people desire to maximize pleasure and avoid situations that cause pain. They seek actions associated with happiness and disapprove matters denying them opportunities to achieve joy.  He is accredited with developing hedonistic utilitarianism. According to hedonic calculus, although pleasure and pain are measurable it is impossible to distinguish them quantitatively.  This means that what is pleasurable for an individual can be a source of pain to another person. At the same time, an individual's happiness does not matter more than others.

However, Bentham’s assumptions contradict with Mill’s views on pleasure. As opposed to Bentham, Mill believes that happiness is a better standard for measuring utility than pleasure (Mitchell, 2015).  This is because pleasure only leads to gratification while happiness creates satisfaction. In addition, while happiness results from other activities, pleasure is a final product of such actions. For example, a stressed nurse may gain pleasure from alcohol but lack happiness at the work place.  According to Mill, Bentham’s theory does not account for the impacts of an individual’s behaviors on others. He asserts that the good outcomes of an action should offset the displeasure caused to the other stakeholders (Eggleston & Miller, 2014). Therefore, Mill’s modified the theory that an action is ethical if it generates maximum pleasures for the highest number of stakeholders both qualitatively and quantitatively.  

In Mill's view, Bentham ignored the important roles played by the qualitative aspects in measuring an action’s outcome. Fortner, & Fackler, (2017) give an example of a case where a woman is gang-raped. From Bentham’s perspective, the abuse is acceptable because it causes pleasure to the majority. On the other hand, Mill’s version reveals that the displeasure caused to the victim is of a higher magnitude such that it overrules the happiness achieved by the gang.  He further created a system that separates high and low levels of pleasure. For example, achieving intellectual desires leads to greater happiness than obtaining the pleasure of the body.  Satisfaction among human beings is more important than among animals.

Utilitarianism’s Political and Ethical Implications

Utilitarianism has far reaching effects on virtually all disciplines. The concept has been instrumental in the growth of the world’s politics, law, and economics. Ethical implications include creating societal systems that foster virtues such as equality, justice, law and order and fairness (Mitchell, 2015). The moral principles are applied concurrently in establishing comprehensive political infrastructures for maximizing the wellbeing of all citizens.  Utilitarian promotes punishments as a means of ensuring that people act justly towards each other.  Societies implement laws to protect individuals from undermining other members’ rights. According to Utilitarianism, individuals who do not adhere to the societal norms as well the laid rules are liable to punishment. It prohibits any behavior, action or policy infringing on the members’ rights.

Governments relying on the utilitarianism principles value democracy.  Their policies not only protect the society from the selfish leaders but also provide opportunities for creating sustainable welfare activities to the highest number of members. As such, utilitarianism provides tools for assessing the soundness of policies. For examples, it guides the policymakers and governments to initiate public health projects that yield maximum benefits to the medical practitioners, their clients and the general public (Fortner, & Fackler, 2017).     

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Virtue and Care Ethics as Alternatives to the Deontological and Utilitarian Principles

Aspects of virtue and care ethics can serve as alternatives to deontology and utilitarianism. Virtue ethics stress on moral character as opposed to the other models that are based on rules and consequences of actions. The principles are different sides of the same coin. According to Grace (2017), there is no universal way for making moral choices. All the existing models have elements dedicated to fostering happiness among the majority without necessarily infringing on the rights of the minority. Like the other concepts, traits contributing to happiness and stakeholders’ well being are the foundations of virtue ethics.

Virtuous individuals do not need laws to act morally. They always just, prudent, selfless, and impartial hence are trusted to implement the best problem-solving approaches while faced with any type of dilemma. In fact, every rational being would prefer virtue ethics over the other models if there were practical means of inculcating the virtues on all the members of the society. However, empirical evidence reveals that the ambiguity characterizing the definition and assessment of virtuous person present significant challenges in implementing the model in many institutions especially those with multicultural stakeholders (Mitchell 2015; Fortner, & Fackler, 2017; Grace, 2017). The scholars concur that the definition of virtues is relative to the cultures of the decision makers. This is because being virtuous is a human quality that most people acquire from their environments. Family backgrounds, friends, and attitudes towards social norms are all critical in not only gaining the traits but also incorporating them into daily practices.          

Nurses, as well as other medical practitioners, can rely on any of the models to find ethical solutions to the dilemmas they face in their line of duties. For example, applying the principles while formulating strategies for providing high-class quality care services to all clients of a hospital most frequented by patients from economically challenged families, may lead to different operational policies. However, all the decisions would provide the facility with means for maximizing the stakeholders’ well-being. Utilitarianism would result in operational activities such as subsidizing the treatment prices in order to increase the affordability or deliver the services to the highest number of patients (Mandal et al., 2015).  

Deontology approach would focus the hospital’s management attention to the consequences of each alternative (Mitchell, 2015). That is, lowering prices would be the best decision only if it does not compromise the quality of the health care services. Similarly, virtue ethics will support all the measures promoting the positive consequences such as fairness, equity, charity and discourage vices such as profit maximization at the expense of the vulnerable patient. In such a case, virtue ethics would be a perfect alternative for utilitarianism and deontology.     

Care ethics theorists have also demonstrated that the circumstances surrounding the decision makers often require them to overrule the generally accepted the code of conduct such as justice and selflessness. The approach is more relevant to in medicine than other disciplines as it comprehensively provides guidelines for managing the relationship between the caregiver and his/her client. Otte, Jung, Elger, & Bally (2017) explain that the caregiver should not just fulfill their patients’ desires but rather assesses their needs and implement measures that result in the best values or well-being. Carol Gilligan, the founder of care ethics model, argues that individuals should choose compassion over justice-based choices.

Another scholar, Nel Noddings, further emphasized that people have various degrees of dependence (Mitchell, 2015). Therefore, offering caring services to meet each individual’s unique needs and at the right time is a foundation of humanity.  That is, it is important to evaluate the contextual facts about situations so as to make the right choice that promotes the affected parties’ particular interests. The assertion contradicts with deontological and utilitarianism that view individuals as having independent interest.

Care ethics presents the best alternative theory in cases involving terminal illnesses. For example, it will best apply where an elderly cancer patient has less than half a year left to live. Her health has been deteriorating thereby exposing her to extreme pain. The patient is contemplating physician-assisted suicide while a few members of her extended family comprising of daughters, sons and several grand children are against the idea. The patient hails from a country where physician-assisted suicide is lawful. Care ethics require the physicians to show compassion to the patient by helping her to overcome the unbearable pain. Providing her with access to medication for terminating her life would be the best way to achieving such a goal (Otte et al., 2017).

In contrast, a deontologist will support the decision because it conforms to the principles of his/her professions while a utilitarian care giver would grant the patient such a wish because the outcome is desirable to the majority.  Therefore, care ethics will offer the best approach since it allows the physician to act both impartially and in the patient's best interest. On the other hand, relying on deontology or utilitarianism means that the care givers would deny such a vulnerable patient her wish not because they care about her suffering; but due to the fact that the action adheres to predetermined rules or minimize the pain for the majority (Otte et al., 2017). That is, the team may disrespect the patient’s autonomy that gives the competent people the right to make decisions regarding the quality of life they want to enjoy in the face of terminal illnesses. Instead, they would please the family members as their patient suffers extreme pain only to lose her life after a couple of weeks.  

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Existential Ethics and the Significance of Free Will in Decision Making

Existentialism examines the essence of humans’ existence and their interactions with the universe. According to the theory, every person first comes into existence through birth then he/she spends her entire lifetime discovering new aspect and meaning of life. Its underlying concept includes free will, freedom, ambiguity, and desire (Mitchell, 2015).  Existentialists believe that although people should act on their free will, personal responsibility is a critical component of life. Soren Kierkegaard argues that life comprises series of choices. Every course of action pursued either adds meaning to life or challenge the previous beliefs an individual holds (Mitchell, 2015).

However, the unexpected encounter does not necessarily mean that one should pass the responsibility of discovering their purpose in life to the society or religion. Instead, it should motivate him/her to live authentically and pursue more satisfying life goals. Nurses can put such an idea into practice by engaging in activities that would add value to their career as well as personal lives. Enrolling for further studies, social interactions, joining online nursing associations and volunteering to communal projects are some of the ways for exercising the free will while acquiring professional skills at the same time.

Kierkegaard and other existentialists advise their followers to be cautious in handling influence from mass cultures and media (Mitchell, 2015). News, behaviors, and lifestyles depicted in these mass cultures disrupt authentic thoughts. Moreover, passivity hinders critical and creative thinking since individuals adopt opinions depicted in the influential television programs and social media. In Jean-Paul Sartre's, a leading existentialist philosopher, view every person should make decisions as if they are alone on the earth (Udo, 2014). The scholar further asserts that a person’s experience depends on the destiny he/she forges.

However, this is not always the case as life itself is characterized by multiple ambiguous encounters. During childhood, people do not have any responsibility and adopts the ready-made values. Ambiguity sets in as individuals reach maturity and begin to pursue their own goals. They experience existential anxiety occurs as people encounter various challenges (Mitchell, 2015). Some maintain childhood ways while others are manipulated by the parents and friends to engage in desires that hinder them from accomplishing personal ambitious. Sarte compared such barriers to bad faith as they impose irrational behaviors thereby hindering freedom and capabilities to explore the real meaning of life (Udo, 2014).

Other obstacles such as illnesses, accidents and natural calamities challenge people existence. The victims experience anxiety and distress that if not successfully overcame may undermine peoples’ life purpose. Nurses play a crucial role in helping their patients to access professional counseling. The care givers provide existential well-being by restoring their patients’ ability to enjoy their freedom. Nurses collaborate with the psychiatrists in assisting the clients to interpret their conditions (Udo, 2014).

In conclusion, deontology, utilitarianism, existentialism, virtue and care ethics are crucial in gaining profound insights on various moral dilemmas nurses face in their careers. The similarities and differences provide the professionals with multiple alternatives for making moral choices and delivering the best values to all their stakeholders. Utilitarianism and deontology create cultures for maximizing all the society members’ welfare.  In contrast, virtue, care ethics and existentialism guide the caregivers on their pursuit of knowledge, acquisition of interpersonal attributes and problem-solving skills.  

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Eggleston, B., & Miller, D. E. (2014). The Cambridge companion to utilitarianism. Cambridge: Cambridge University Press.

Fortner, R. S., & Fackler, P. M. (2017). World media ethics: cases and commentary. Boston: John Wiley & Sons.

Grace, P. J. (2017). Nursing ethics and professional responsibility in advanced practice. Burlington: Jones & Bartlett Learning.

Mandal, J., Ponnambath, D. K., & Parija, S. C. (2016). Utilitarian and deontological ethics in medicine. Tropical parasitology, 6(1), 5 - 7.

Masters, K. (2017). Role development in professional nursing practice. Burlington: Jones & Bartlett.

Mitchell, H. (2015). Roots of wisdom: A tapestry of philosophical traditions. Cengage Learning.

Otte, I. C., Jung, C., Elger, B., & Bally, K. (2017). " We need to talk!" Barriers to GPs' communication about the option of physician-assisted suicide and their ethical implications: results from a qualitative study. Medicine, health care, and philosophy, 20(2), 249-256.

Udo, C. (2014). The concept and relevance of existential issues in nursing. European Journal of Oncology Nursing, 18(4), 347-354.

Urban, P. (2014). Toward an expansion of an enactive ethics with the help of care ethics. Frontiers in psychology, 5, 1354.

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