an interactive model of clinical-ethical decision making

AN INTEGRATIVE MODEL OF

CLINICAL-ETHICAL DECISION MAKING

RIVKA GRUNDSTEIN-AMADO

Department of Psychiatry, Baycrest Centre for Geriatric Care, 3560 Bathurst Street, North York, Ontario M6A 2E1, Canada

ABSTRACT. The purpose of this paper is to propose a model of clinical-ethical decision making which will assist the health care professional to arrive at an ethically defensible judgment. The model highlights the integration between ethics and decision making, whereby ethics as a systematic analytic tool bring to bear the positive aspects of the decision making process. The model is composed of three major elements. The ethical component, the decision making component and the contextual component. The latter incorporates the relational aspects between the provider and the patient and the organizational structure. The model suggests that in order to arrive at an ethically, justifiable sound decision one make reference to those three elements.

Key words: decision making process, ethical clinical decision making models, medical ethics, moral thought process, organizational structure, professional-patient relationship, value theory

1. INTRODUCTION

The study of ethical decision making in a health-care system is undertaken to

enable health professionals to increase their awareness of ethical issues involved

in their practice and to guide them in arriving at sound, justifiable decisions. The

basic assumption of this paper is that ethical decisions will be better made if

they are not habitual or hasty ones but rather are based on a systematic analysis

or method.

There are several benefits of approaching clinical-ethical decisions through a

systematic sequential method. A model enables the individual decision makers

to ascribe ethical validity to their statements. A statement that is subjected to a

rigorous analytic thought process can be a better guide to action than one based

on intuition or blind adherence to pre-existing rules. Through a model of this

kind the individuals can clarify the nature of the ethical problem, search for

other sources of information, and enhance justification of the chosen course o f

action. Furthermore, the model can prompt the individual decision makers to

enlarge their conceptual space beyond their past experience and, consequently, develop a meaningful understanding of new concepts o f which they may not

Theoretical Medicine 12: 157-170, 1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

15 8 RIVKA GRUNDSTEIN-AMADO

have been aware.

Several strategies for making ethical decisions are reported in the literature [1-4]. All of these serve to expand the health care providers' thinking about moral issues and each emphasizes different aspects of ethical decision making. However, they fail to recognize two essential features that are imperative for the attainment of a desirable moral end. First, the organizational component as a necessary frame of reference needs to be considered while making a clinical ethical decision. Second, ethics and decision making are integrated into a synergistic complementary process. Furthermore, these existing models for making ethical clinical decisions have not been empirically tested.

The purpose of this paper is foremost to propose a model of clinical-ethical decision making that will assist the health care professionals (HCPs) to arrive at a sound, defensible judgment. The paper will then review four existing models in the literature and will demonstrate their major characteristics and their deficiencies in the light of the proposed model. It should be noted that in contrast to previous-practice models, this model has been tested in two hospital settings with eighteen HCPs (i.e., nine nurses and nine doctors) [5]. This provides some evidence as to the viability of the model and its practical use in dealing with clinical-ethical problems in a concrete case situation.

The model I am about to propose involves two underlying assumptions: first,

decision making is a process of choice leading to action, and both are influenced by context and content. The context includes the HCPs' relationship with the patient, organizational constraints, and possibilities for the decision makers' personal fufillment. The content refers to the specific details of a particular case. Second, action is an expression of the decision makers' personal, cultural, and religious values, mad of their ideological position, which is justified through a

process of appealing to ethical principles and theories. This justification process provides the decision makers with the means for advocating their decisions and ascribing ethical validity to their choices.

The model is composed of three major elements: the ethical component, the decision theory component, and the contextual component that comprises the relational aspects between the provider and the patient and the organizational structure. The model suggests that in order to arrive at an ethically justifiable, sound decision reference can be made to these three elements or frames of content.

2. THE ETHICAL FRAMEWORK

The ethical framework of the health care professional is determined by the individual moral reasoning structure. Ethical reasoning is hierarchical and

CLINICAL-ETHICAL DECISION MAKING 159

deductive, and begins with a particular value judgment, one that is rooted in the various ethical principles that are grounded in ethical theory [6]. It is important to note that it is my intention to introduce merely the basic concept of a moral reasoning structure and not to discuss in details the existing sophisticated

literature around ethical principles and theories. The moral reasoning structure starts with the identification and elicitation of

the individual value system. Values can be perceived as an internal code or standard arising from human needs. Kluckhohn [7] maintains that value implies a persistent internalized code or standard of action. Moral reasoning, then, involves an internal mechanism that enables individuals to distinguish between right and wrong, good and bad.

A value is a conception, explicit or implicit, distinctive of an individual or characteristic of a group, of the desirable which influences the selection from available modes, means, and ends of action ([7], p. 395).

Accordingly, values contain both an affective and a cognitive dimension. Kluckhohn incorporates reason and feeling into the value notion. The combina- tion of "conception" with "desirable" generates a complementary basis of reason

and feeling. Similarly, Callahan maintains that "emotions and thinking are complementary, synergistic, parallel processes constantly blending and interact-

ing as a person functions" ([8], p. 10), and consequently the person selects one course of action over the other. Kluckhohn and Strodtbeck also support this

view and they claim that values merge affect and concept. Values contain cognitive, affectional and directional aspects and they serve as criteria for

judgment, preference and choice, and thus constitute grounds for decision making ([9], p. 5).

Another view of values perceives them as a system, an organized set of

preferential standards that are used in the making of selections of objects and actions. Values provide direction in resolving conflicts, in invoking social

sanctions, and in coping with needs or claims for social and psychological defenses of choices made or proposed ([10], p. 20). Similarly, Beck claims that

values are ordered within a system that provides the frame for their interactive ongoing relationship [ 11 ].

Additionally, values can be seen as an expression of human needs, and as such they create a specific mode of conduct or end-state of existence ([10], p. 5).

Beck also maintains that values are grounded in basic human needs. A fairly common set of universal values thus exists, since individuals have similar needs

[11]. Those values common to a large group of people can be established as rules and norms. For example, the value of 'respect for others' and 'self respect', identified by Beck as among the basic human values, are established as ethical rules in the Western societies. The other basic human values that Beck identifies include survival, happiness, companionship, friendship, helping others (to an

160 RIVKA GRUNDSTEIN-AMADO

extent), participating in a community, knowledge, freedom, and a sense of meaning in life [11]. Beck claims that the concept of 'universal values' provides

a common basis for value inquiry. Basic human values are interconnected and also form part of a larger value system that includes moral values, social and political values, intermediate-range values, and specific values. According to Beck, values are not absolute, but rather are interconnected within a system; every value is both a means and an end [12].

To sum up, values may be seen to exist in an ordered system. They are interconnected, they are changeable, and they carry a sense of fluidity. They serve as an internal mechanism that filters conflicting stimuli. They are linked to needs and thereby help the individual to formulate a standard of what is acceptable and appropriate action and to determine finally the ultimate course of action.

Value theory, as a foundation of basic human values, generates three main ethical principles: the principle of beneficence, the principle of autonomy, and the principle of justice.

The principle of beneficence refers to an obligation to secure the well-being of individuals [13]. Physicians need to exercise their own discretion in order to safeguard the patients' needs. Generally speaking, beneficence requires the balancing of benefits and harms [6].

The principle of autonomy requires that one recognize both the patients' right to have a major say in decisions affecting them and the physician's obligation to respect and enhance that right. An autonomous person is an individual who is capable of making a deliberate choice, of refusing or accepting any medical intervention. This principle promotes individuals' involvement in decisions affecting their well-being, and involves their fundamental human values. The principle of autonomy encompasses two elements: respect for wishes and respect for rights. Being responsive to the patients' wishes is not identical to acknowledging the patients' rights.

The principle of justice has been given many interpretations in the literature. Basically, it refers to the fundamental equality of human beings: every individual deserves equal respect and equal consideration [14]. John Rawls' central conception of justice expresses itself in terms of fairness and economic distribution. Justice requires a fair distribution of burdens and benefits. This can be achieved through communal efforts to promote the good of all society's members [15]. Justice might be seen as most closely linked to harmony and balance. It demands a global perspective on the concerns of a large number of people and seeks an overall harmony among these concerns.

All of these ethical principles can be implemented by combining two major ethical theories concerned with the determination of fight and wrong actions: the telological and the deontological. The former holds that the worth of an action is


determined by its consequences. In contrast, the latter approach considers the nature of the act itself and the relevant principles and duties.

3. THE DECISION THEORY COMPONENT

The second component of the model is the procedural schema which lists eight steps that need to be taken in making an ethical decision. The eight categories imply that ethical decision making is a process consisting of progressive dynamic functions, leading the individual decision maker to reach a desirable choice. The eight categories are as follows:

A. Problem perception. (i) Identification of the ethical problem. (ii) Identification of the medical problem.

B. Information processing. (i) Gathering medical-technical information. (ii) Seeking other sources of information.

C. Identification of the patient preferences. D. Identification of the ethical issues. E. Listing the alternatives. F. Listing the consequences. G. The choice. H. Justification.

The four main steps of the procedural schema are based on classical decision making theory which has focused chiefly upon rational, logical decisions that are made through the definition of the issue, through analysis of the existing

situation, through identification of all possible alternatives and consequences, and through subsequent evaluation of all of these [16]. The distinction between the ethical component and the medical component can help professionals to understand the very nature of the ethical problem. Such distinction enables individuals decision makers to be aware of other aspects of the problem. This is supported by Elstein's claim that in the course of making clinical decisions professionals may omit certain aspects of the problem. This may lead to different representations of the problem resulting in a different decision outcome [17].

Simon in his book Administrative Behavior [16] focusses on the process of choosing from among alternatives. This process leads to a selection of a particular course of action. Simon asserts that decisions contain factual and ethical content. The factual is a descriptive mode of actions and can be proven to be true or false. The ethical has an imperative qualitative dimension, which


means that in the final analysis the option that is the most preferable or desirable is chosen over another. The final course of action results from the calculation and delineation of alternatives and ultimately the selection of one option to the exclusion of the others. The individual decision makers are bounded by their rationality and cannot anticipate all of the consequences of their actions. The

limitations of knowledge, personal experience, habits, cognitive ability, and the value-religious system of the decision maker become obstacles in reaching a rational decision [16]. Increasing the knowledge that influences the generation

of alternatives and consequences might overcome, to a certain degree, the limitations that bound the rational process.

March and Simon, suggest a different approach to decision making by proposing a strategy of 'satisfying': "Most human decision making, whether individual or organizational, is concerned with the discovery and selection of satisfactory alternatives" ([18], p. 140). As well, they make a distinction between the optimal and the satisfactory. In the optimal situation the decision maker is assumed to have all the alternatives against which to apply the criteria,

whereas in a satisfactory situation the decision maker applies the criteria to a

few satisfactory alternatives considered good enough to meet the desirable

objective [19]. Similarly, Wilson and Alexis claim that the individual decision maker starts

with ideal goals that coincide with his or her 'aspiration level'. The aspiration

level can be seen in terms of the general motives, needs, and values the decision

maker possesses. Then, the decision maker engages in a search activity that involves delineating a limited number of alternatives and consequences and

thereafter searching for a satisfactory solution among these limited alternatives [20]. Consequently, the decision maker's level of aspiration is instrumental in

determining whether a satisfying alternative exists among those already available.

Hodgkinson develops further the role of values, motives and aspirations in the

process of decision making. Values are defined as "concepts of the desirable with motivating force" ([21], p. 120). He emphasizes the value notion by claiming that: "the intrusion of values into the decision making process is not merely inevitable, it is the very substance of the decision" ([21], p. 55). Moreover, he continues to assert that "the presence of an internal value component ... in the decision making process assures the process of a philosophical status" ([21], p. 64). Value knowledge is an integral part of professional competence. Additionally, he, like Simon, contends that decisions are not made

in isolation or in a vacuum. Decisions are made within a context; they are constrained by environmental influences.


4. THE CONTEXTUAL COMPONENT

The third component of the model comprises the contextual element that affects the ethical decision making process, that is, the decision maker's relationship with the client (i.e. the patient) and the organizational structure (i.e. the health care system). Both contexts impose various constraints on the individual decision maker and eventually influence the final course of action.

4.1. The Relational Context

The encounter between patient and HCPs may be characterized as the focus of the entire health-care enterprise. The relationship between HCPs and patients is the place where the interest of the patient is created with reference to the totality of medical discourse [22]. HCPs and the patients share the burden of ethical clinical decisions. Together they are involved in constant interaction in which they transform their experiences in order to achieve the best decisions.

The literature has developed various models of HCP-patient relationships, and each incorporates some important ethical elements. The basic issue that underlies the relationship is the relative knowledge and power of the involved parties. There are different approaches with regard to how the HCPs interpret

their relationship with the patient. One mode of interpretation is the paternalistic mode. Conceptually, paternalism refers to the idea of limiting the individual autonomy by others, for the promotion and protection of individual well-being

and avoidance of harm. It contains two features: one is beneficence, that which benefits the other person, and the other is the refusal in some circumstances to accept that person's choices and actions ([23], p. 12). If this is the prevailing pattern the HCPs instruct the patient to follow or submit to a course of treatment and the patient co-operates to the extent that he/she obeys. The HCPs provide health care to the best of their ability and consistent with what they believe will be in the patient's best interest. The paternalistic model assigns moral authority and discretion to the HCPs because good health is assumed to be a shared value, and because the HCPs' competence places them in a position in which they are obliged to help the patient recover and get better [24].

The second mode is one of participatory, shared decision making. This model stresses the notion that the HCPs and the patient are partners in the pursuit of the shared value and goal of health. It emphasizes the mutual contribution of both parties. The HCPs help the patients to help themselves, while the patients use expert help to realize their (and the HCPs') ends [24]. In this mode the HCPs do not describe a priori what is best for the patient. The search is mutual. This becomes the essence of the relationship.

The third mode is that of advocacy. This model grants the patients a


decisional authority. The health team provides information, advice and guidance to the patient, and consequently enables the patient to make an ethical decision in a constructive manner. The patient's needs, wishes, preferences and ideals are the major criterion in making the final choice. The HCPs follow the patient's interests and genuinely probe the cues the patient presents about the nature of the problem. In cases when the patient indicates that he/she cannot follow the HCPs' line of reasoning, they will try another approach [25]. It should be noted that, the participatory and the advocacy modes incorporate certain hermeneutical aspects, such as those which propose a dialectical relationship between the explanatory powers of science and the need for these explanations to be modified by and understood through the patients' own terms and context [26].

4.2. The Organizational Context

The ethical decision making process occurs in a general context as well, that is, in the health care system. The HCPs interact with the organization, which is

generally bureaucratic and hierarchical and imposes a considerable restriction on the individual decisional autonomy. The external structure includes the division of work, standards, procedures and policy guidelines, the line of authority, and

the communication system [27].

The most fundamental given through which the organization set limits on the decisional context of the individual decision makers is in the division of work.

The individuals' thought processes are limited and directed and their scope

becomes narrow and restricted. Thus, the creative endeavor involved in the exercise of personal moral judgment becomes hampered, as does the individuals' ability to move towards a more inclusive perspective with regards to a particular ethical problem.

Standards, procedures or policy guidelines limit the individuals' action by imposing restrictions to which the individual must adhere. Policy guidelines and

rules become the guiding criteria for making ethical decisions. The line of command or structure of authority is another important strategy by

means of which the organization is able to continue functioning. Decision

making power is delegated through an hierarchical ladder. This imperative tool affects and controls the ethical practice of health professionals.

The last factor affecting the ethical decision making process is the way in which information is communicated. The more information there is, and the

better the system of communication itself, the easier it will be to clarify problems, solutions, and consequences.

All the above-mentioned organizational constraints can to an extent, serve as an impediment to the decision making process in particular, and to organiza-

tional effectiveness in general. However, these constraints may also create


change and fluidity within the organization and might serve as an external device for shaping the world as one might wish it to be shaped [28],

Within the health-care system, there are several modes of care delivery: individual care, community care and institutional care. The hospital itself is an institutional setting with a highly stratified occupational structure containing two main hierarchies of authority: the administrative and the clinical. There is also a

third locus of authority: the board of directors whose legal responsibility applies to the hospital as a whole [29].

The administration is accountable to the board of directors, and neither directly determines the HCPs' practice. At the same time, the HCPs are bound

by their dependence on the hospital and by its budgetary and organizational restrictions. For example, the nurses are bound by their employer (i.e. the hospital administration), by the doctors who order the treatment, and by the patients who require care.

Practically, the organization limits nurses' power to fulfill their values and ideals; this accordingly influences their capacity to act as moral agents. The

physicians are evidently in a different position having greater autonomy, but

they are prone to fail in their moral practice due to external pressures coming

from the consumer movement, malpractice suits, and formal institutional rules

which limit their scope of action. To sum up, ethical decision making can be perceived as a single comprehen-

sive process encompassing two Oisciplines, ethics and decision making theory. These two disciplines are integrated and unified as part of a complementary

process in which ethics are used as a systematic tool brings to bear and em- phasize the positive aspects of the decision making process. The integrated structure which results is affected by vankms relational modes of interaction. The HCPs have the obligation to safeguard the panem's moral rights and to

provide appropriate care, and the patient needs in turn, to accept, negotiate or refuse the proposed treatment. This dynamic process is an integral part of a

larger entity - the organization itself, which affects HCPs' practice by imposing the various, diverse forces that regulate or limit action.

5. REVIEW OF EXISTING MODELS OF CLINICAL ETHICAL DECISION MAKING

A review of four existing models in the literature outlines their strengths and

weaknesses with respect to the three frames of content mentioned above (i.e., the ethical component, the decision theory component, the contextual com-

ponent). The first model to be reviewed is a 'clinical model for decision making'

developed by Martin [1]. It proposes a reflective analytical method as the


appropriate means of making ethical decisions in a given medical situation. Martin's model consists of four basic dimensions. First, the purpose of ethical analysis is to provide the means by which the decision makers' ideals can be fulfilled in action. Second, the optimal decision is one which is appropriate for both the patient and the physician. Decision making is an interactive process between the health professional and the patient. The patient brings his own values, such as personal ideology and interests, and also factual elements, such as symptoms, signs, history, etc, which are significant for the decision making process. The professionals bring their rational ability, special technical-scientific skills and a certain value structure, which enable them to interact with the data provided and select the responsible and appropriate course of action.

The third aspect of the model is the reflective mode. By this process the decision makers determine whether their intentions are being realized or their decisions need to be reconsidered. This process is based once again on the assumption that decisions should be responsive to both context and moral ideals.

The fourth aspect of the model is the one in which ethicists help in providing a more accurate understanding of the issues and possibilities for decisions and action. They help to clarify what the physicians' value system is like and provide a means of systematically assessing its adequacy for fulfilling their moral ideal. Consequently physicians and ethicists can jointly accomplish their

common goal, namely the well-being of the patient. Martin's model strengthens the reflective-cognitive element in the decision

making process. He places emphasis on the application of epistemological skills in order to contribute meaning and significance to the clinical data and also on the importance of understanding one's own values in order to reach a responsible and appropriate decision in a given situation. However, the weakness of the model is that it neither incorporates any specific step-wise procedure for making the actual decision nor suggests at which stage of the decision making process the ethicist should perform his role. Additionally, the model ignores the integrative element between ethics and decision making.

The second model to be examined is Siegler's model [2], that offers a systematic approach to clinical-ethical decisions. It involves four categories into which most considerations in a clinical case can be placed. These categories are: the medical indication in the case, such as diagnosis, prognosis, risks and benefits of various treatments; the patient's preferences; quality of life considerations; and external factors, such as the wishes and needs of the patient's family, the costs of medical care, the allocation of medical resources, the research and teaching needs of medicine and the safety and well-being of society. The last two considerations will be invoked in a clinical situation when the patient is incompetent to make an informed decision or when the medical indications are limited (e.g. untreatable illnesses). However, while this decision making


approach emphasizes the technical component in the decision and the preferences of the patient, it disregards the need for a comprehensive ethical analysis of a particular bioethical problem. Additionally, no structure is offered to suggest how to reach a sound decision. No regards has been given to the organizational component as part of the external factors that might influence the decision making process. This approach embodies the view that ethical decisions are to be made solely by physicians and patients, without their sharing the decision with other professionals. Furthermore, no suggestion has been offered to resolve a potential conflict that may arise between the different categories. For example, the preferences of the patient might conflict with external considerations such as the high costs of a specific medical treatment.

The third model to be reviewed is that developed by Candee and Puka [3]. The model outlines two classical orientations in moral philosophy - teleology and deontology - which might be used to resolve a bioethical problem. Both approaches strive to be systematic and internally consistent, but they approach the ethical problem from different perspectives. The steps that Candee and Puka

suggest for the moral reasoning process are as follows. The teleological

approach, gathers general information; lists relevant alternatives; predicts the consequences of each alternative; determines probability of each outcome occurring; assigns value to each outcome; and determines utilities. The deon-

tological approach, gathers general information; lists relevant alternatives; lists relevant rights-claims, duties and principles; establishes the validity of rights- claims; and determines priorities between the listed rights, duties and principles, and balance claims.

Both teleology and deontology suggest a way in which the individual decision makers may systematically reflect in the course of making ethical decisions. The decision making process thus became organized into an ordered series of steps whose function is to offer assistance in arriving at a decision. In contrast to the previous models, Candee and Puka offer a way of reaching a decision through

the systematic application of a valid ethical approach. This kind of model

increases the possibility that decision makers could tailor their own values to the best interests of the client.

The weaknesses of this model manifests itself in several areas. It doesn't show how to choose between telological and deontological approaches [30]; it

suggests a quantitative approach for reaching an optimal course of action, whereas some elements in the decision making process are not amenable to quantification and are inaccessible to the decision maker due to time and cost constraints [19]; no account is given of how a clear definition of the ethical problem could be achieved, nor is there any consideration of the ethical issues

involved in each particular case; and, it does not recognize the influence of

external factors such as organizational constraints, that might affect the process


of reaching a sound ethical decision. The fourth model has been developed by Pellegrino [4]. This model com-

prises two analytical structures: one substantive and one procedural. The

substantive structure consists of four conceptual dimensions that formulate the moral choices of the decision makers. The procedural structure comprises five steps that enable the individual decision maker to arrive at a final course of action [4]. The four substantive issues in Pellegrino's model are: understanding the philosophy of the physician-patient relationship; understanding the theory of ethics, the various moral theories, and the principles that are common to clinical ethical decisions; understanding the interpretation the physicians place on this theoretical ground; and, identifying and recognizing the ultimate moral sources of the health-care provider and the patient.

The procedural schema in the model involves a set of steps to be used in making the decision itself. The five steps are as follows: establish the technical facts of the specific problem; determine what is in the patient's best interests; define the ethical issues and principles involved in the specific problem; state ones decision in clear and concrete terms; and, justify the decision.

The major strength of this model lies in the fact that Pellegrino offers in his

procedural schema, a clear distinction between the medical facts and the ethical elements in the decision making process, a distinction which can help prac-

titioners deal with the complexity of the process of medical ethical decision making. Additionally, he recognizes the importance of combining the concep-

tual elements and the technical aspects of the decision making process in order to reach the best course of action in a particular case.

However, this model, too, has its weaknesses. To begin with, it makes

reference only to physicians. Other health care professionals are not taken into

consideration. In the substantive part, the organizational context is not taken into consideration. An action is the determination of both specific content and general context. There is no reference to collaborative decision making between HCPs and others who will be affected by the future course of action, such as the family and society.

The deficiencies in the procedural part reside in two areas: the integrative point between ethics and decision making is missing; and there is no indication of a method for the formulation of the ethical problem and the determination of a definite set of relevant alternatives. In the classical rational decision making

process, this element is essential to making a desirable choice [16]. The procedural schema might differ depending on whether the decision makers choose to follow the teleological approach or the deontological approach. For

example, after listing the alternative courses of action, according to the teleological approach the decision makers should anticipate the consequences of each alternative; but if decision makers choose to follow the deontological approach,


they would list only the feasible rights, duties, rules and principles independent of their consequences.

6. CONCLUSION

In conclusion, my aim in this paper is to propose a new comprehensive model that will address deficiencies in some of the previous practice-models proposed for ethical-clinical decision making. The proposed model highlights the

inclusion of the organizational component as a necessary frame of reference for making ethical decisions. The model suggests that in order to make a sound responsible ethical decision one must make reference to ethics, decision making and contextual elements. In addition, the model can be conceptualized as an integrated structure composed of two major elements: ethics and decision making. This integration can be seen as a complementary process whereby ethics as a systematic tool provides the individuals decision makers with the critical-reflective skills and the justification of the ultimate choice that are lacking in the general decision making process. Ethics enhances the exploration

of new insights into problems and strengthens the search for new knowledge, goals and alternative options. The search activity (i.e., the information process-

ing) is analogous to the whole notion of 'ethics', as a progressive attempt to broaden one's horizons, to discover and explore hidden dimensions of the stated problem. The employment of an integrative model can lead to clear thinking and

increased confidence in the justification of decisions. More importantly, the model can serve as a vehicle that enables the individual to move from an

understanding of the self to an understanding of others.

REFERENCES

1. Martin A. A clinical model for decision making. J Med Ethics 1978;4:200-6. 2. Siegler M. Decision making strategy for clinical-ethical problems in medicine. Arch

Intern Med 1982;142:2178-9. 3. Candee D, Puka B. An analytic approach to resolving problems in medical ethics. J

Med Ethics I983;9/10:61-9. 4. Pellegrino ED. The anatomy of clinical ethical judgments in perinatology and

neonatology: a substantive and procedural framework. Semin Perinatot 1987; 11:202-9.

5. Grundstein-Amado R. Ethical Decision Making Processes in the Health Care System. [Dissertation]. Toronto: University of Toronto, 1990.

6. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 3rd ed. New York: Oxford University Press, 1989.

7. Kluckhohn C. Values and value-orientations in the theory of action: an exploration in definition and classification. In: Parson T, Shils EA, eds. Toward A General


Theory of Action. Cambridge, MA: Harvard University Press, 1951:388-433. 8. Callahan S. The role of emotions in ethical decision making. Hastings Cent Rep

1988;18:9-14. 9. Kluckhohn FR, Strodtbeck FL. Variations in Value Orientations. Evanston: Row,

Peterson and Company, 1961. 10. Rokeach M. The Nature of Human Values. New York: The Free Press, 1973. 11. Beck C. Educational Philosophy and Theory: An Introduction. Boston: Little

Brown and Company, 1974. 12. Beck C. The Nature of Values and Implications for Value Education, 1984

(unpublished manuscript). 13. Levine RJ. Ethics and Regulation of Clinical Research. Baltimore: Urban &

Schwarzenberg, 1986. 14. Jameton A. Nursing Practice: The Ethical Issues. New Jersey: Prentice-Hall, Inc,

1984. 15. Rawls J. A Theory of Justice. Cambridge MA: Harvard University Press, 1971. 16. Simon HA. The Administrative Behavior. New York: Free Press, 1957. 17. Elstein AS. Cognitive processes in clinical inference and decision making. In: Turk

DC, Salovey P, eds. Reasoning, Inference, and Judgment in Clinical Psychology. New York: The Free Press, 1988:17-50.

18. March J, Simon H. Organizations. New York: John Wiley, Inc, 1958. 19. Harrison F. The Managerial Decision Making Process. Boston: Houghton Mifflin

Company, 1987. 20. Wilson C, Alexis M. Basic framework for decisions. Journal of the Academy of

Management 1962;5:20-5. 21. Hodgkinson C. Towards A Philosophy of Administration. Oxford: Basil Blackwell,

1978. 22. Broekman JM. The philosophical basis of medicine as a philosophical question.

Theor Med 1987;8:135-45. 23. Childress JF. Who Should Decide? Paternalism in Health Care. New York: Oxford

University Press, 1982. 24. Childress JF, Siegler M. Metaphors and models of doctor-patient relationships: their

implications for autonomy. Theor Med 1984;5:17-30. 25. Hoffmaster B, Weston W. The patient in the family and the family in the patient.

Theor Med 1987;8:321-32. 26. Lock JD. Some aspects of medical hermeneutics: the role of dialectic and narrative.

Theor M ed 1990; 11:41-9. 27. Mouzelis NP. Organisation and Bureaucracy. London: Routledge & Kegan Paul,

1985. 28. Perrow C. Complex Organizations. A Critical Essay. New York: Newbery Award

Records, Inc, 1986. 29. Eakin J. Hospital power structure and the democratization of hospital administration

in Quebec. Soc Sci Med 1984; 18:221-8. 30. Fletcher C. Commentary. J Med Ethics 1983;9:69-70.

an interactive model of clinical-ethical decision making

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