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 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 organisations.
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 The model has been diagrammed as a circle to emphasize the use of past information 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
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 organises 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 Patient’s 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.