Ethical Principles and Decision-Making Process PDF

Ethical principles and Decision-Making Process Dr F. K. Mburu Community and Preventive Dentistry School of Dentistry  Scope of the Presentation Highlight of principlism. Highlight of theories of ethics. Rights and duties Decision-...

Ethical principles and Decision-Making Process Dr F. K. Mburu Community and Preventive Dentistry School of Dentistry  Scope of the Presentation Highlight of principlism. Highlight of theories of ethics. Rights and duties Decision-making process.  Principlism Bioethicists Beauchamp and Childress coined principlism. This is a 4 principle approach for analyzing ethical situations in healthcare. The 4 principles are: Respect for autonomy (right for self determination) Non-maleficence (avoid causing harm) Beneficence (promote overall benefit) Justice (for one or more individuals)  Autonomy Protect patients’ freedom of thought, intention and action in matters of their health. Ensure patients understand diagnosis, treatment options, prognosis, success, risks, side effects, costs, etc. Respect and promote patients’ autonomy, and warn patients about to take harmful decision. Execute autonomy through informed consent, confidentiality, protection of privacy, and veracity. Though autonomy is an overriding principle, it is not absolute.  Non-Maleficence Primum non nocere: Latin for “First and foremost, do no harm.’’ Therapy should not harm the patient or others in the society. Justify double effect therapy. Violation of non-maleficence principle may attract litigation.  Beneficence Act in the best interest of patient and overall good. Develop and maintain knowledge and skills through continuous learning. Consider and do the best within the specific circumstances of the patient. However, guard against paternalistic tendencies.  Justice Fair distribution of scarce resources. Prudent adjudication of competing needs. Coupling of rights and obligations. May conflict with legislation.  Theories of Ethics Consequentialism Deontology/Kantianism Virtues/Character Ethics Liberal Individualism Communitarianism Ethics of Care Casuistry Narrative Ethics  Consequentialism Consequentialist theory states that the morally correct action is that that results in the best overall outcome irrespective of the means used. Inherent rightness or wrongness of an action is not considered. Utilitarianism is the most influential consequentialist theory. Principle of utility provides that morally correct action is that which promotes the greatest happiness for the greatest number. Benefit is considered within the context of healthcare. Considers the consequence for present and future generation. Considers both the consequences of action and inaction. Considers unhappiness caused to calculate net happiness. Weakness: Difficult to predict future consequences accurately.  Deontology/Kantianism Deon=Greek for duty/obligation. Focusses on duties/rules rather than consequences. Some actions are inherently wrong irrespective of consequences. Kantianism consider duties to arise from rational human beings. Kant’s categorical imperative requires application of moral duties universally: treat others the way would like to be treated. Action may ignore consequences or emotions and needs of a person. Emphasizes on action but silent on inaction. Hence provides moral space to act: do not lie; but could be moral to withhold truth. Weakness: no list of duties; does not suggest what to be done if two duties collide; less stringent than consequentialism that constantly assesses the consequences of an action.  Virtue/Character Ethics Introduced by Aristotle. According to virtue theory, actions by a virtuous person lead to human flourishing. To be virtuous, incorporate virtues in decision-making: Aristotle. In doctor-patient relationship, main virtues include: honesty, compassion, benevolence, discernment, integrity and justice. Strength and weakness of virtue theory is that the choice of virtues to apply in a situation is subjective. Virtuous doctor should consider facts, his emotions, patient’s emotion to decide on the virtues to use to reach a moral decision.  Liberal Individualism This is a rights-based theory including positive and negative rights. Rights are coupled with responsibility such as compliance. Water fluoridation may be viewed as an intervention devoid of individuals autonomous choice, and hence not supported by this theory. Rights may be limited by distributive justice e.g. the individual right may end where public peril begins.  Communitarianism Communitarianism is a community based theory polarised with liberal individualism. Needs of the community are ranked above those of an individual. Rather than which rights have been infringed, the theory considers to what extent community best interests, values and relationships have been impacted.  Ethics of Care Focuses on details of people involved and their relationships. Is sceptical of abstract application of principles. It overlaps with virtue ethics, communitarianism and narrative ethics. The question to be asked is: What would a caring person do if confronted by the problem? Virtues a caring person would consider are: attentiveness, responsibilities, competence, responsiveness, etc.  Casuistry Process of answering practical questions via interpretation of rules, or cases that illustrate such rules. Method of applying theories that is more practical and easier to use in clinical practice. Choice is made depending on decision made earlier on similar cases. A reflection of common law. The weakness is that junior doctors do not have adequate experience to use this principle.  Narrative ethics It involves taking account of those involved. Has 2 essential elements: Use of cases as stories for their content. Analysis of stories for analytical and reflective learning. Has more substantial role than other theories in education of health professionals and solving medical dilemmas. Every individual’s role in the story is examined and analysed. Each character is listened to determine beliefs and wishes. But patient’s voice should be listened first-patient’s history. Coupled with other principles as it does not offer clear guidance on ethical dilemma.  Rights and Duties There are different rights e.g. political, religious and personal—right to bodily integrity and to life. Rights are also attached to groups in society. There are moral rights and legal rights. Negative right: non-interference: not to be assaulted. Positive right: Impose duty of support or assistance. Only the person with the right can demand the duty be performed or can waive the right. Few rights are absolute: right to life? Except in special circumstances. Some rights may be in conflict: right to life and to defense.  Ethical Decision-Making Decision-making ranges from simple to complex. Simple may just entail following golden rules. Complex may require weighing principles and utilizing theories. Decision-making involves judging and choosing. Emotional state, incompetence, impairment, etc. affect dentist’s decisioning-making capacity.  Decision-Making Steps Step 1: Problem: Identify the ethical problem: dilemma, weak morality or moral uncertainty. Step 2: Facts: Establish relevant information including dental, medical, legal, ethical, socio-political, patient’s preferences, dentist’s value system. Step 3: Analyse: Considering facts gathered, weigh and rank values and ethical principles. Step 4: Solutions: Formulate solutions, make recommendations, justify them with sound argument. Step 5: Implementation: Implement the solutions. Step 6: Evaluation: Reflect on the outcome of the decision-making process.  Summary There are four main ethical principles that must be considered in making ethical decisions. Sometimes complex situations demand utilization of theories to make ethical decisions. Decision-making involves judgement and choice. Decision-making is a process involving several steps. Once solutions have been found they should be implemented and evaluated.  Further Reading Dental Ethics Manual 1. https://www.fdiworlddental.org/sites/default/files/2020-11/1- fdi_dental_ethics_manual_1st_edition_2007.pdf Dental Ethics Manual 2. https://www.fdiworlddental.org/sites/default/files/2020-11/fdi- dental_ethics_manual_2.pdf Hippocrates Oath. http://www.crossculturalthinkers.com/preview/1/Hippocrates%E2%80%99_Oath.pdf Ethics Handbook for Dentists. https://www.dentalethics.org/wp- content/uploads/Ethics_Handbook_for_Dentists_2016.pdf Thank You