What is ethical decision-making?

As a health and social care professional, you may have already faced many ethical dilemmas and challenging decisions in the current COVID-19 pandemic.

Ethical decision-making is the process by which you aim to make your decisions based on ethical values.

On this page, we aim to acknowledge existing knowledge, and provide additional information and key considerations for ethical decision-making, to help support Macmillan professionals and the wider cancer workforce during this time.

In the following video, Richard, a Macmillan health professional, talks about the extra challenges pertaining to ethical decision-making, that have arisen due to the COVID-19 pandemic.

Ethical Decision Making on Vimeo.

What is an ethical dilemma?

An ethical dilemma may be present when there are two opposing ethical principles or values clashing. In some cases, this can be quite obvious. But sometimes you may feel something is not quite right intuitively, or you may be uncomfortable about the situation, problem, circumstances, or the possible options of actions that could be taken.

What can an ethical decision-making approach offer?

As a result of the pandemic, healthcare professionals have experienced more ethical dilemmas and have had to make complex and challenging decisions.

An ethical decision-making approach can:

  • clarify thinking about the issue/dilemma
  • assist in the analysis of the issues involved, the dissection of the presenting problems and clearer identification of the dilemma
  • provide an individual or organisation with a rational way in which to defend a particular course of action (Fry and Johnstone, 2008). 

What are the key messages for ethical decision-making?

  • Challenging and complex decisions should be based on the best available evidence and information.
  • Personal choices, preferences and best interests should be respected.
  • Sensitive open communication, transparency and inclusion should be core elements in all decisions, if possible.
  • When engaged in ethical analysis we have a duty to consider motives for the actions taken, consequences of the outcomes and the benefits/harm ratio.
  • Ethical theory, principles and values do not solve ethical dilemmas on their own but can provide a framework for structure, clarity, and justifying decisions.
  • Important to take responsibility for ethical knowledge and skills to support ethical decision-making.
  • Be accountable in providing committed action in the delivery of effective ethical decision-making.
  • Recognise the importance of self-care and seek appropriate support, if necessary.

An ethical action depends on:

  • The ability of people to recognise that a moral issue exists in a given situation.
  • Knowing how to take appropriate action if and when required.
  • Personal commitment to achieve moral outcomes (Fry and Johnstone, 2008).

Responding appropriately and effectively to moral issues requires:

  • Moral sensitivity: recognising when values/options are being compromised.
  • Moral reasoning: applying principles and values to direct and justify decisions.
  • Moral Character: A sense of doing good, having good character; being fair, trustworthy, achieving best outcomes for all/individuals. (Morton et al, 2007).

What are the Four Principles of Biomedical Ethics?

There are many different models for ethical decision-making and you may well have engaged with some of these. Or you may have a particular preference or a decision-making model from a professional body or organisation that you use regularly.

The following Four Principles of Biomedical Ethics, first introduced by Beauchamp and Childress as a framework of four broad moral principles, have been widely adopted and applied within health care to guide ethical decision making (Beauchamp and Childress, 2019a).

These principles are often in tension with one another but good ethical analysis requires that each principle should be considered in deliberations and reflections on what to do in a given situation or circumstance (Beauchamp and Childress, 2019b).

The tensions that arise, particularly in the context of a pandemic, are often the result of trying to uphold respect for individuals, their choices, preferences and rights and at the same time, trying to uphold the rights, equitable care and services for the wider population; all deemed worthy of respect as moral equals.

In trying to balance these tensions Health Care professionals may suffer distress when circumstances collide with personal moral or ethical codes, which can increase the risk of moral injury (Greenberg and Tracey, 2020).

Greenberg and Tracey (2020) acknowledge that many people with moral injury develop mental illness and that organisations and leaders should ensure that structured peer support is available.

A brief description of the four principles:

  • Autonomy: Autonomy requires that an individual has the capacity to understand information, benefits and risks of any health care interventions. The individual’s capacity to be autonomous will impact on their ability to engage fully in this process and provide informed consent. Legislation for incapacity provides safeguards and processes in such events.
  • Beneficence: This considers the balancing of benefits of any treatment against the risks. This principle may clash with autonomy when an individual makes a decision that health care professionals do not think will benefit that individual i.e. it is not in their best interests.
  • Non-maleficence: This principle is to avoid the causation of harm if possible, or if that is not possible, to minimise the level of harm in favour of the benefits that may be gained, i.e. the harm should not be disproportionate to the benefits to be gained. 
  • Justice: During a pandemic the distribution of resources is complex because it requires the balance of individual rights to best treatment and care against a wider societal perspective, resulting in prioritisation of need and available resources i.e. societal focus rather than an individual focus. Tensions arise further around what is deemed fair and equitable.

National ethics advice and guidance

Within the devolved UK nations, there are national documents for ethical advice and guidance for use during a pandemic and particularly in response to the COVID-19 pandemic

Ethical practice for Health Care services across the UK have been developed and adapted from the committee on ethical aspects of the Flu Pandemic (Cabinet Office, DHSC. (2017) Flu Pandemic. Guidance. Ethical Framework) of which the following fundamental principles, were provided to guide practice:

  • People should be treated with equal concern and respect.
  • Everyone matters.
  • Everyone matters equally - this does not mean everyone is treated the same.
  • The interest of each person, are the concern of us all, and of society.
  • The harm that might be suffered by every person matters and so minimising the harm that a pandemic might cause is a central concern.

These principles underpin the work of the UK Moral and Ethics Advisory Group.

Core values within the devolved nations guidance also stem from the values identified from the UK MEAG. Key values from the original document above have been incorporated in the devolved nations' Ethical Guidance Advice and Support Frameworks (see below). Within the frameworks, there is a clear recommendation for good decision-making to be open, transparent, and inclusive.

Identified (shared) values

Respect

Informed, personal choices, best interests

Fairness

Equality, equal choices

Minimise harm

Physical, psychological, social, economical

Working together

Share information, be helpful to all

Flexibility

Changing circumstances, adaptability

Reciprocity

Mutual exchange


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