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Moral Reasoning and Decision Making

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Page 1: Moral Reasoning and          Decision               Making

MoralMoralReasoningReasoning andand Decision Decision

MakingMaking

Page 2: Moral Reasoning and          Decision               Making

Moral Reasoning and Moral Reasoning and Decision MakingDecision Making

The aim in this session is to develop an The aim in this session is to develop an understanding of how ethical decisions are understanding of how ethical decisions are made in practice, rather than in terms of made in practice, rather than in terms of abstract ethical theories.abstract ethical theories.

At the end of this session, you should At the end of this session, you should understand how theory and practice are understand how theory and practice are connected, how empirical ethics is used and connected, how empirical ethics is used and gain an understanding of ethical decision gain an understanding of ethical decision making models.making models.

Page 3: Moral Reasoning and          Decision               Making

IntroductionIntroduction

What are we to make of the numerous ethical What are we to make of the numerous ethical theories that have developed over the last two theories that have developed over the last two or three millennia?or three millennia?

When we say that someone is thinking ethically When we say that someone is thinking ethically or resolving an ethical problem using or resolving an ethical problem using reasoning, should this involve appeals to the reasoning, should this involve appeals to the theories of moral philosophers?theories of moral philosophers?

Page 4: Moral Reasoning and          Decision               Making

UTILITARIANISM

COMMUNITARIANETHICS

VIRTUE ETHICS

DEONTOLOGY

CASUISTRY

NATURAL LAW

4 PRINCIPLES OFBIOMEDICAL ETHICS

NARRATIVES

RIGHTS

PRIMA FACIEETHICS

Page 5: Moral Reasoning and          Decision               Making

Other ApproachesOther Approaches

A number of different ways of considering how A number of different ways of considering how to make ethical decisions in practice have been to make ethical decisions in practice have been suggested:suggested:

Consider individual’s intuitions and ‘considered Consider individual’s intuitions and ‘considered judgements’ in relation to existing theory,judgements’ in relation to existing theory,

Use empirical methods to reflect upon how Use empirical methods to reflect upon how individuals actually act,individuals actually act,

Offer pragmatic and practical models of ethical Offer pragmatic and practical models of ethical decision making.decision making.

Page 6: Moral Reasoning and          Decision               Making

Linking Theory and Linking Theory and PracticePractice

It has been increasingly argued that traditional, It has been increasingly argued that traditional, normative ethical theories fail to be of relevance normative ethical theories fail to be of relevance in actual situations. in actual situations.

Hegel’s famous criticism of Kant’s deontological Hegel’s famous criticism of Kant’s deontological approach as ‘empty formalism’ may reflect a approach as ‘empty formalism’ may reflect a difficulty in applying/conforming to some theories. difficulty in applying/conforming to some theories.

Society has also become increasingly secular and Society has also become increasingly secular and has largely rejected a monistic or religious has largely rejected a monistic or religious approach to ethical justification.approach to ethical justification.

Post-modernism rejects the Enlightenment’s Post-modernism rejects the Enlightenment’s rational aims in the light of linguistic and social rational aims in the light of linguistic and social uncertainty.uncertainty.

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Up and DownUp and Down

The traditional way of thinking about ethical The traditional way of thinking about ethical theory was theory was deductivelydeductively – ‘top down’ - – ‘top down’ - proceeding from accepted general ethical proceeding from accepted general ethical concepts and applying them to particular concepts and applying them to particular situations. E.g.situations. E.g.

Kant’s Categorical ImperativeKant’s Categorical Imperative

Specific formulation ‘treat others as ends in themselves’Specific formulation ‘treat others as ends in themselves’

Applied to volunteers in drug trialApplied to volunteers in drug trial

Leads to decision never to exploit themLeads to decision never to exploit them

Page 8: Moral Reasoning and          Decision               Making

Up and DownUp and Down

Increasingly, however, Increasingly, however, inductiveinductive or ‘bottom up’ or ‘bottom up’ approaches have been championed. These appeal approaches have been championed. These appeal to our considered judgements and also settled to our considered judgements and also settled cases and from which generalisations can be made cases and from which generalisations can be made and applied to other situations. (e.g. Casuistry)and applied to other situations. (e.g. Casuistry)

But perhaps the most generally accepted form of But perhaps the most generally accepted form of decision making used is a decision making used is a coherentistcoherentist one – where one – where one belief can only be justified in relation to one belief can only be justified in relation to another. another. Rawls’ reflective equilibriumRawls’ reflective equilibrium is often used is often used and he describes a process where our considered and he describes a process where our considered judgements are tested with reference to more judgements are tested with reference to more generalised theories that explain these intuitions. generalised theories that explain these intuitions.

Page 9: Moral Reasoning and          Decision               Making

Linking theory and Linking theory and practicepractice

Coherentist approaches appeal because they Coherentist approaches appeal because they do not require either a search for definitive, do not require either a search for definitive, paradigm cases on which to decide in an paradigm cases on which to decide in an analogous situation or rely upon an abstracted, analogous situation or rely upon an abstracted, formal (and perhaps difficult, uncompromising) formal (and perhaps difficult, uncompromising) general ethical theory.general ethical theory.

Reflect on considered judgements (intuitions)

Consider how these relate to generalised

theories

Are these judgements and theories/rules consistent

Apply to ethical situation and make decision

Revise theory or intuitions

YES

NO

Page 10: Moral Reasoning and          Decision               Making

CriticismsCriticisms

One initial problem with coherentist approaches One initial problem with coherentist approaches is that the process of formulating general rules is that the process of formulating general rules or theories that accommodate intuitions could or theories that accommodate intuitions could have justified Nazism, for example.have justified Nazism, for example.

Inductivists would also argue that intuitions lack Inductivists would also argue that intuitions lack ethical credibility.ethical credibility.

Perhaps try to combine the two by arguing that Perhaps try to combine the two by arguing that one should balance intuitions with existing one should balance intuitions with existing ethical theories but how can one weigh-up such ethical theories but how can one weigh-up such concerns? concerns?

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Linking theory and Linking theory and practicepractice

So far, an approach to understanding practical So far, an approach to understanding practical decision making has been offered that is still decision making has been offered that is still grounded in philosophy, albeit one that is sensitive grounded in philosophy, albeit one that is sensitive to an individual’s ‘gut feelings’ and intuitions.to an individual’s ‘gut feelings’ and intuitions.

Obvious points to remember are that ethical Obvious points to remember are that ethical reasoning should be free from contradictions and reasoning should be free from contradictions and follow logical conclusions (e.g. syllogisms):follow logical conclusions (e.g. syllogisms):

The taking of any life is ethically wrong.The taking of any life is ethically wrong.

Abortion involves the taking of a life.Abortion involves the taking of a life.

Therefore, abortion is ethically wrong.Therefore, abortion is ethically wrong.

Page 12: Moral Reasoning and          Decision               Making

Exercise 1Exercise 1

How would you deal with the following situation How would you deal with the following situation and what are your intuitions about the situation:and what are your intuitions about the situation:““Mrs. Singh calls at your pharmacy to ask if you could check her son’s Mrs. Singh calls at your pharmacy to ask if you could check her son’s computer record and tell her what her son received last month from a computer record and tell her what her son received last month from a locum doctor. The medicine is working but her GP has no record. Her son locum doctor. The medicine is working but her GP has no record. Her son is not with her today as her has missed two day’s of the effective is not with her today as her has missed two day’s of the effective treatment.”treatment.”

Now thinking about ethical theories, consider how Now thinking about ethical theories, consider how utilitarianism, a rights-based approach, Kant’s utilitarianism, a rights-based approach, Kant’s Categorical Imperative and the ‘4 principles’ might Categorical Imperative and the ‘4 principles’ might be used.be used.

Are your views consistent with theory?Are your views consistent with theory?

Page 13: Moral Reasoning and          Decision               Making

Cognitive Moral Cognitive Moral DevelopmentDevelopment

As psychology developed as a discipline, As psychology developed as a discipline, connections were made between cognitive connections were made between cognitive processes and moral reasoning. Developing processes and moral reasoning. Developing Piaget’s work with infant Piaget’s work with infant development, Lawrence Kohlberg development, Lawrence Kohlberg developed a theory of CMD that has developed a theory of CMD that has become extremely influential. become extremely influential.

Based upon the experimental methods of Based upon the experimental methods of psychology, Kohlberg’s theory was psychology, Kohlberg’s theory was empirically based but also contained normative empirically based but also contained normative aspects.aspects.

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Cognitive Moral Cognitive Moral DevelopmentDevelopment

Basing his theory on a longitudinal study of Basing his theory on a longitudinal study of adolescent American boys, Kohlberg argued adolescent American boys, Kohlberg argued that individuals develop moral reasoning ability that individuals develop moral reasoning ability in a number of discrete stages. in a number of discrete stages.

The theory was significant because it claimed The theory was significant because it claimed that moral development occurs in much the that moral development occurs in much the same way as other psychological attributes like same way as other psychological attributes like language, social skills, abstract reasoning and language, social skills, abstract reasoning and cognitive processes.cognitive processes.

Individuals develop only a stage at a time and Individuals develop only a stage at a time and the theory applies to everyone.the theory applies to everyone.

Page 15: Moral Reasoning and          Decision               Making

Exercise 2Exercise 2 Consider the famous Heinz dilemma used in CMD:Consider the famous Heinz dilemma used in CMD:

““A woman was near death from a special kind of cancer. There was A woman was near death from a special kind of cancer. There was one drug that the doctors thought might save her. It was a form of one drug that the doctors thought might save her. It was a form of radium that a druggist in the same town had recently discovered. The radium that a druggist in the same town had recently discovered. The drug was expensive to make, but the druggist was charging ten times drug was expensive to make, but the druggist was charging ten times what the drug cost him to produce. He paid $200 for the radium and what the drug cost him to produce. He paid $200 for the radium and charged $2,000 for a small dose of the drug. The sick woman's charged $2,000 for a small dose of the drug. The sick woman's husband, Heinz, went to everyone he knew to borrow the money, but husband, Heinz, went to everyone he knew to borrow the money, but he could only get together about $1,000 which is half of what it cost. he could only get together about $1,000 which is half of what it cost. He told the druggist that his wife was dying and asked him to sell it He told the druggist that his wife was dying and asked him to sell it cheaper or let him pay later. But the druggist said: "cheaper or let him pay later. But the druggist said: "No, I discovered No, I discovered the drug and I'm going to make money from it."the drug and I'm going to make money from it." So Heinz got So Heinz got desperate and broke into the man's store to steal the drug for his desperate and broke into the man's store to steal the drug for his wife.”wife.” (Kohlberg, 1963, p. 19) (Kohlberg, 1963, p. 19)

Should Heinz break into the laboratory to steal the Should Heinz break into the laboratory to steal the drug for his wife? Why or why not? Explaindrug for his wife? Why or why not? Explain

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Stage oneStage one ( (obedienceobedience):): Heinz should not steal the medicine, because he Heinz should not steal the medicine, because he will consequently be put in prison. will consequently be put in prison.

Stage twoStage two ( (self-interestself-interest):): Heinz should steal the medicine, because he Heinz should steal the medicine, because he will be much happier if he saves his wife, even if he will have to serve a will be much happier if he saves his wife, even if he will have to serve a prison sentence. prison sentence.

Stage threeStage three ( (conformityconformity):): Heinz should steal the medicine, because his Heinz should steal the medicine, because his wife expects it. wife expects it.

Stage fourStage four ( (law-and-orderlaw-and-order):): Heinz should not steal the medicine, Heinz should not steal the medicine, because the law prohibits stealing. because the law prohibits stealing.

Stage fiveStage five ( (human rightshuman rights):): Heinz should steal the medicine, because Heinz should steal the medicine, because everyone has a right to live, regardless of the law. Or: Heinz should not everyone has a right to live, regardless of the law. Or: Heinz should not steal the medicine, because the scientist has a right to fair steal the medicine, because the scientist has a right to fair compensation. compensation.

Stage sixStage six ( (universal human ethicsuniversal human ethics):): Heinz should steal the medicine, Heinz should steal the medicine, because saving a human life is a more fundamental value than the because saving a human life is a more fundamental value than the property rights of another person. Or: Heinz should not steal the property rights of another person. Or: Heinz should not steal the medicine, because that violates the golden rule of honesty and respect. medicine, because that violates the golden rule of honesty and respect.

Page 17: Moral Reasoning and          Decision               Making

Cognitive Moral Cognitive Moral DevelopmentDevelopment

Level 1Level 1 Stage Stage 11

reasoning related to reasoning related to external punishmentexternal punishment

Pre-Pre-conventionalconventional

Stage Stage 22

egoistic self-interestegoistic self-interest

Level 2Level 2 Stage Stage 33

reasoning that considers reasoning that considers ones immediate peersones immediate peers

ConventionalConventional Stage Stage 44

broader social implications broader social implications and lawsand laws

Level 3Level 3 Stage Stage 55

principled reasoning that principled reasoning that recognises the social recognises the social contractcontract

Post-Post-conventionalconventional

Stage Stage 66

universal ethical principles universal ethical principles of Justiceof Justice

Page 18: Moral Reasoning and          Decision               Making

Relevance of CMDRelevance of CMD In short, its popularity! Especially in its latter In short, its popularity! Especially in its latter

development as a psychometric questionnaire test, development as a psychometric questionnaire test, CMD has been viewed as an ‘easy’ tool that CMD has been viewed as an ‘easy’ tool that operationalizes ethics and appears to have validity operationalizes ethics and appears to have validity and reliability. Frequently used in health care.and reliability. Frequently used in health care.

CMD offers insights into how individuals actually CMD offers insights into how individuals actually make ethical decisions and could be used to make ethical decisions and could be used to identify more basic forms of reasoning.identify more basic forms of reasoning.

However, despite empirical origins, it is inherently However, despite empirical origins, it is inherently normative and assumes that higher reasoning is normative and assumes that higher reasoning is JUSTICE JUSTICE based. The choice of boys in original study based. The choice of boys in original study and justice dilemmas may be contributory.and justice dilemmas may be contributory.

Page 19: Moral Reasoning and          Decision               Making

CriticismsCriticisms

Despite its empirical origins, Kohlberg’s CMD is Despite its empirical origins, Kohlberg’s CMD is inherently normative and assumes that higher inherently normative and assumes that higher reasoning is reasoning is JUSTICE JUSTICE based. based.

However, Gilligan has famously argued that However, Gilligan has famously argued that Kohlberg’s male sample and selection of scenarios Kohlberg’s male sample and selection of scenarios were inherently biased towards justice-based were inherently biased towards justice-based reasoning. Using a sample of women, initially, reasoning. Using a sample of women, initially, Gilligan proposed a possible alternative ethic of care. Gilligan proposed a possible alternative ethic of care.

In later forms, a psychometric‘defining issues test’ In later forms, a psychometric‘defining issues test’ was developed (Rest) that pre-coded responses and was developed (Rest) that pre-coded responses and produced statistical scores. Can you score ethics?produced statistical scores. Can you score ethics?

Page 20: Moral Reasoning and          Decision               Making

Ethical Decision Making Ethical Decision Making ModelsModels

These are These are notnot the same as those in the psychological or the same as those in the psychological or statistical fields, which are grounded in issues such as statistical fields, which are grounded in issues such as probability, decision trees and outcome values.probability, decision trees and outcome values.

Ethical decision making models are usually derived from Ethical decision making models are usually derived from two distinct concerns:two distinct concerns: A research interest in explaining and also predicting A research interest in explaining and also predicting

how individuals make ethical decisions in practice.how individuals make ethical decisions in practice. A practical and pragmatic desire to offer help and A practical and pragmatic desire to offer help and

assistance to individuals in making ethical decisions.assistance to individuals in making ethical decisions.

Page 21: Moral Reasoning and          Decision               Making

Ethical Decision Making Ethical Decision Making ModelsModels

Are they useful?Are they useful?

Page 22: Moral Reasoning and          Decision               Making

Ethical Decision Making Ethical Decision Making ModelsModelsAre they useful?Are they useful?

Page 23: Moral Reasoning and          Decision               Making

Ethical Decision Making Ethical Decision Making ModelsModels

Should we be suspicious of attempts to reduce complex Should we be suspicious of attempts to reduce complex human activities and any attendant reasoning and human activities and any attendant reasoning and decision making into convenient models?decision making into convenient models?

It may be argued that some models are underpinned by It may be argued that some models are underpinned by empirical study and although this applies to models that empirical study and although this applies to models that attempt to predict or explain ethical behaviour, attempt to predict or explain ethical behaviour, Kohlberg’s normativity might make us suspicious!Kohlberg’s normativity might make us suspicious!

The prescriptive models often claim modesty in not The prescriptive models often claim modesty in not attaching any specific ethical theory to their stages. attaching any specific ethical theory to their stages.

Page 24: Moral Reasoning and          Decision               Making

Weinstein (1996) Wingfield (1997)

Gather facts: law, codes, professional knowledge

Consider who is involved and their values

Generate options

Make decision

Veatch, Haddad (1999)

Consider why situation is ethical problem:

a) Distinguish facts from evaluative statements

b) Distinguish moral and non-moral evaluations

c) Determine who should decide

Consider the range of ethical theories.

What other rules might apply?

Parker Adapted from Pellegrino method. See Ethox website

What are relevant facts

Define who should act and when

List possible options

Identify morally significant parts of options

What does law say

Identify pros and cons of moral arguments

Choose option based on consistency, concepts and logic

Find best counterargument. If you can rebut it, decide.

Rest (1986) * Jones (1991)*

Identify ethical problem

Apply ethical reasoning

Establish Moral Intent

Act Ethically

Schneider and Snell (2000)

What are my Core beliefs

How have I Acted in past

What are Reasoned opinions of others

What is Experience of others in similar situations

BMA (2004) Recognise ethical situation

Break down dilemma into parts

Seek information from patient and others

Identify relevant legal & professional guidance

If no solution found, apply critical ethical analysis

Justify decisions with sound arguments

Jonsen, Seigler and Winslade (1992)

Establish medical facts

Identify patient’s preferences

Consider quality of life

Think about religious, legal and cultural factors

Holm (1997)* What personal experience tells us

Ethical perception

Ethical Reasoning

Ethical decision

Consideration of practical possibilities

Final Decision

Implementation

(* denotes explanatory models, all other practical/prescriptive)

Ethical Decision Making Ethical Decision Making ModelsModels

Model Stages in each model

Page 25: Moral Reasoning and          Decision               Making

Despite the plethora of prescriptive and empirical Despite the plethora of prescriptive and empirical models that exist in relation to ethics problem models that exist in relation to ethics problem solving, there appear to be several common solving, there appear to be several common features and also some ‘front runners’:features and also some ‘front runners’:

For example, the model by For example, the model by RestRest and and JonesJones has has been cited in many research papers and has been been cited in many research papers and has been applied to business ethics and also healthcare applied to business ethics and also healthcare ((HolmHolm). However, it remains an empirical rather ). However, it remains an empirical rather than prescriptive model and provides insights into than prescriptive model and provides insights into what individuals are what individuals are understoodunderstood to do in practice. to do in practice.

Ethical Decision Making Ethical Decision Making ModelsModels

Page 26: Moral Reasoning and          Decision               Making

The Rest/Jones model contains 4 stages:The Rest/Jones model contains 4 stages: IdentifyIdentify ethical problem. An obvious point but ethical problem. An obvious point but

concept of ethical attention or perception is concept of ethical attention or perception is often over-looked in literature.often over-looked in literature.

Apply ethical Apply ethical reasoningreasoning. Rest (and Jones but not . Rest (and Jones but not Holm) used CMD but other theories possible.Holm) used CMD but other theories possible.

Establish moral Establish moral intentintent (not egoistic self- (not egoistic self-interest).interest).

Engage in ethical Engage in ethical actionaction (again obvious?) (again obvious?) Related to moral motivation.Related to moral motivation.

Influential but remains an explanatory model.Influential but remains an explanatory model.

Ethical Decision Making Ethical Decision Making ModelsModels

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The prescriptive models often have similarities. The prescriptive models often have similarities. In part, this is because they appear to have been In part, this is because they appear to have been influenced by proceeding models influenced by proceeding models (Parker/Pellegrino, Wingfield/Weinstein). (Parker/Pellegrino, Wingfield/Weinstein).

There are several common features that may There are several common features that may help guide the ethically conflicted:help guide the ethically conflicted: Identify the problem and gather all the factsIdentify the problem and gather all the facts Consider how law, rules, past experience and Consider how law, rules, past experience and

advice of others might be of use.advice of others might be of use. Use some form of ethical reasoningUse some form of ethical reasoning Justify decision and act.Justify decision and act.

Ethical Decision Making Ethical Decision Making ModelsModels

Page 28: Moral Reasoning and          Decision               Making

Exercise 3Exercise 3

““Sally calls into a pharmacy late on a Saturday afternoon Sally calls into a pharmacy late on a Saturday afternoon and asks if she could be supplied with emergency and asks if she could be supplied with emergency hormonal contraception. The pharmacist, David, believes hormonal contraception. The pharmacist, David, believes that EHC is a form of abortion and will not supply it or that EHC is a form of abortion and will not supply it or even recommend where else to obtain it. David does not even recommend where else to obtain it. David does not want to offend Sally and simply says he doesn’t have any. want to offend Sally and simply says he doesn’t have any. Sally appears to be up-set and asks where else she can Sally appears to be up-set and asks where else she can obtain EHC.”obtain EHC.”

Use one of the models described or a Use one of the models described or a combination of them to consider whether combination of them to consider whether David’s actions were ethically justified and what David’s actions were ethically justified and what could be done in this situation.could be done in this situation.

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SummarySummary

This session has attempted to identify three This session has attempted to identify three approaches to how ethical decisions are made approaches to how ethical decisions are made in practice and have considered:in practice and have considered:

Coherentist approaches that try to balance existing Coherentist approaches that try to balance existing ethical theory with one’s intuitions.ethical theory with one’s intuitions.

CMD that uses empirical data to suggest that individuals CMD that uses empirical data to suggest that individuals progress through different stages but that justice is the progress through different stages but that justice is the most ethical form of reasoning.most ethical form of reasoning.

Various models that try to either offer assistance or Various models that try to either offer assistance or explanations as to how decisions could be made in explanations as to how decisions could be made in practice.practice.

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SummarySummary

Many of the criticisms identified in this session Many of the criticisms identified in this session appear to be internecine. Realists clash with appear to be internecine. Realists clash with idealists, foundationalists with coherentists, idealists, foundationalists with coherentists, psychologists with philosophers with social psychologists with philosophers with social scientists.scientists.

What of the poor pharmacist?What of the poor pharmacist? Perhaps simply gaining a basic understanding of Perhaps simply gaining a basic understanding of

the diversity of ethical decision-making, the diversity of ethical decision-making, recognising the role of intuitions,having an recognising the role of intuitions,having an awareness of existing theory and applying simple awareness of existing theory and applying simple rules of consistency and logic could be a helpful rules of consistency and logic could be a helpful start.start.


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