a field guide to good decisions

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Readers are invited to contact Greg S. Loeben in writing atMidwestern University, Glendale Campus, Bioethics Program,19555 N. 59th Ave., Glendale, AZ 85308 ([email protected]) regarding books they would like to see reviewed or booksthey are interested in reviewing.

A Field Guide to Good Decisions: Values in

Action, by Mark D. Bennett and Joan McIverGibson. New York: Praeger, 2006. 216 pp. $39.95.

Decisions are something we all face.Decisions change our lives. As par-ents, as community members, as pro-fessionals, we find ourselves daily incomplex situations that require gooddecisionmaking. Most decisions im-pact not only the decision maker, butalso a network of others whose lives

they affect. For healthcare providersand clinical bioethicists, decisions lieat the heart of daily practice and areparticularly challenging as they touchthe lives of individuals who are oftenvulnerable and in need of guidanceand clarity.

Decisions are often difficult becausethey come with a price tag. They in-volve complex choices that cannot

make everyone happy and rarely allowus to honor everything we value. Fre-quently, we find that the struggle be-tween right and right is even morepainful than the struggle between rightand wrong, as it forces us to leavesome important values behind or evenviolate others. In the healthcare arena,where the stakes are typically high, asin cases involving life and death or

future quality of life, such difficultchoices can be especially thorny.A guide to good decisions that fo-

cuses on the values underlying theprocess of decisionmaking therefore hasthe potential to be an invaluable re-

source for healthcare professionals. AField Guide to Good Decisions: Values in

Action meets these expectations andgoes beyond, offering readers a clearand structured process that they canemploy not only as professionals, butalso in other aspects of their lives.Reading it as a bioethicist, I hoped for

some guidance in approaching clinicalconsultations and ethics committeesdiscussions. I found myself engagedon every level and applying the pro-cess recommended in the book to re-evaluate the important decisions Irecently made in my professional aswell as my personal life. I believe Iwill not approach another future deci-sion without considering at least some,

if not all, of the steps that are so clearlysuggested in this valuable volume.Written by a philosopherbioethicist

and a lawyermediator, this book is theoutcome of over 20 years of the au-thors practical experiences, workingwith people who face tough decisions:watching their decision-making pro-cesses, helping them find ways to speakand listen to deeply held and often con-

flicting values, and working with themto create and communicate good deci-sions. This book takes the reader step

by step through a simple, yet challeng-ing process, clarifying the values thatunderlie decisionmaking, providing

Cambridge Quarterly of Healthcare Ethics (2006), 16, 114117. Printed in the USA.Copyright 2006 Cambridge University Press 0963-1801/06 $16.00114


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guidance and tips that finally lead to acoherent and effective decision. This pro-cess can be applied around patients

beds as well as family kitchen tables or

corporate boardrooms.This is indeed a practical guide for

decision makers who must tackle com-peting values and interests. However,it does not lack conceptual depth or phil-osophical insight. Clearly written, wellstructured, and easily accessible, thisguide is also a captivating read. Packedwith stories taken from the authors ex-periences with families, business lead-

ers, professionals, and neighborhoodand community associations, it reads attimes like a collection of narratives thatengages the reader on an everyday level,encouraging her to apply the processto her own experiences.

As the authors point out, whereas whatwe decide reveals what really mattersto us, how we decide plays an essentialrole in whether or not our decisions will

succeed or fail. What, then, makes agood successful decision? Such a deci-sion does not require that everyone behappy with the result, but it does re-quire considering those who will haveto implement it. A good decision, ac-cording to the authors, must be whole,coherent, and transparent. It is wholewhen the process of decisionmaking in-volves serious reflection on values and

on what really matters to all stakehold-ers. It is coherent when the reasons forit actually align with the decision itself,when beliefs and actions integrate. It istransparent when it is communicatedto others openly and honestly, directlyand candidly telling them why it wasmade and how it will impact them, evenwhen the choices are tough and somemay feel hurt. Such a decision builds

integrity, accountability, and trust. Thebook prescribes a process that ensuresall these elements are in place.

Although many books deal withpractical ethics on a philosophical, ab-stract level, very few cross over into

the domain of action and offer practi-cal assistance. This book bravely fillsthis gap by telling readers how towalk their talk and by dealing with

the behavioral aspects of decisionmak-ing. It focuses on transferable skillsand shows how value talk can beproductive and effective. Each chapterfeatures a what you can do section,and the appendix contains exercisesand worksheets that have been devel-oped, refined, and used by the au-thors over the years.

At the heart of this field guide lies a

five-step process that smoothes the roadto a good decision. These steps re-quire you to clarify, comprehend, com-mit, choose, and communicate. Thechapters in the first part of the bookare organized around these catchyterms. The first step is to clarify per-spectives by understanding the ele-ments that shape or frame them, suchas our roles (the hats we wear), our

life experiences, and our training. Beingaware of how our perspectives areshaped is the first step in appreciatingwhat we bring to the table and main-taining focus as we begin to considera sometimes overwhelming amount ofrelevant information.

The second step is to comprehendwhat matters by better understandingthe full range of values at work. This

can be achieved by acknowledging thecontext of the specific decision at hand(its place, time, the unique histories ofits stakeholders), naming the relevantvalues and deepening the conversa-tion by peeling the onion, or expos-ing the personal beliefs and intereststhat values are shorthand for. To fullycomprehend what matters, we mustelicit from others what matters to them

and make sure we understand eachother by avoiding jargon, abstractterms, and unchecked assumptions.

The third step is to determine whatmatters most and to commit to it. Aftergathering and understanding the multi-

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plicity of relevant values, we must testour allegiance to them and determinewhich ones carry enough weight toorient our decision. This is the most

challenging step on the road to a gooddecision because here some values must

be left behind and the prices emerge.As the decisionmaking clock ticks, itis important to pause and consciouslycommit to a few guiding values. Atthis point, the authors offer manypractical strategies for managing theprocess, whether one is making thedecision alone or as a part of a large

organization.One may wonder whether this pro-

cess is grounded in moral relativismand whether the book is based on theassumption that any set of values canunderlie a good decision, as long asone commits to it after reflection. Thisis not the message of this book. Theauthors encouragement to expand ourperspectives, challenge our assump-

tions and reassess our values does notlead to moral relativism. Rather, it is

based on the compelling idea that tak-ing a stand against what is wrong is

just the beginning of the decisionmak-ing process. We are confronted withthe more difficult moral challenge whenwe embark on the journey of consid-ering the complexity of legitimate, com-peting goods and their price tags. This

book is grounded in the belief thatwhen moving toward the good, wefind ourselves on a more productiveterrain of moral discourse than whenwe are focused on tackling wrongdoing.

The fourth step is choosing to actbased on our top values. The authorsdescribe this step as coming to a cross-road: The stage of reviewing and an-alyzing is behind us, and action lies

ahead. We are now expected to walkour talk. At this point, it is importantto acknowledge the often regrettableor painful consequences of our deci-sion, along with the expected benefits.Those who will not benefit from the

decision are likely to point to its weak-nesses. Anticipating the downside istherefore crucial for an effective deci-sion that actually works and engages

everyone.The fifth and last step is to commu-

nicate the decision transparently tothose who have a stake in it, thus

becoming accountable and responsi-ble for it. Those who deserve to knowshould receive a direct and honestaccount of the decisionmaking pro-cess and its product. We live in aclimate where secrets flourish, argue

the authors. From national security tofamily harmony, we find many ex-cuses for not being truthful or account-able for our actions. Although oftendifficult, communicating decisionstransparently is therefore also an im-portant means of building characterand integrity.

The second part of the book focuseson obstacles along the road to a good

decision, such as mental and emo-tional detours and the need to bridgecultural divides or navigate in organi-zations. I found the discussion on cul-ture of particular interest, because theauthors adopt an unusually broad andsensitive definition that allows themto embrace the various challengesraised by cultural differences. Theychallenge the common approach that

limits culture to ethnicity or heritage,acknowledging that cultural identityis also formed by families, profes-sions, faith communities, work envi-ronments and political affiliations.They also challenge the notion of ra-tioning culture, which assigns onecultural identity to each person. Eachone of us, they emphasize, wears manycultural hats and is a unique multicul-

tural phenomenon. Unraveling our owncultural complexity is thus essential tothe process of reaching a good deci-sion. Here again, the book does notfail to offer insightful guidance. Con-sidering the truly diverse nature of

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North American society, the culturalrichness of each individual, and themany ways in which cultural differ-ences can generate conflict, this guid-

ance is of particular importance.Overall, both as a practical guide and

as a theoretically challenging work, this

book provides helpful guidance andconceptual clarity that make it a usefultool and an invaluable resource to any-one confronting difficult decisions.

Vardit Ravitsky

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a field guide to good decisions

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