Chapter 25 Ethical reasoning
Ethics has been defined as a systematic study of and reflection on morality. Systematic, because it is a discipline that uses special methods and approaches to examine moral situations, and a process of reflection because it consciously calls into question assumptions about existing components of our moralities, including our reasoning, that fall into the category of habits, customs or traditions (Purtilo 2005, p. 15). Ethics in professional practice has elements that go beyond just the reasoning and decision-making process and these are well summed up in a four component ‘scaffold’: moral sensitivity (the perception and recognition of ethical issues); moral judgement (making decisions about right and wrong); moral motivation (prioritizing ethical values in relation to other values); and moral courage (the taking of moral actions even in adversity) (Swisher 2005, p. 230). In this chapter we focus on the moral judgement component while recognizing that the ethical reasoning process cannot be separated from these other dimensions.
The component of ethical reasoning or making moral judgements can also be divided into four parts. They comprise first, a knowledge of ethical theory; second, a knowledge of the perspectives and values of those involved in the scenario; third, a knowledge of self as health practitioner; and fourth, an ability to understand and articulate these different types of knowledge and associated values in the reasoning process.
In this chapter we present two research-derived perspectives from physiotherapy on ethical reasoning which we contend have relevance for debates on the practice of ethics within health professions other than physiotherapy. The first perspective (Delany 2005) is from a philosophical and normative ethical position, and proposes a re-consideration of the theory/ies underlying principles. Normative ethics expressed in the form of biomedical ethical principles continues to be the dominant form of bioethics and is characterized by a deductive logic or reasoning process (Fox 1994, Swisher 2002). The second perspective (Edwards et al 2005), is from a social science and descriptive ethical position, and describes the inductive reasoning processes of understanding patient/carer narratives as a counterpoint (but not as a substitute) for more traditional deductive processes of principles-oriented ethical reasoning. The ethical reasoning framework we propose seeks to recover, on the one hand, the rich ethical content underlying ‘principles’ within the principlist approach, and, on the other, the ethical values found in a richer understanding of patient perspective(s) in clinical practice (Edwards et al 2005). The two approaches together offer complementary sets of insights important for the development of skills in ethical reasoning, including accounting for moral judgements (Swisher 2005, Zussman 2000). We structure this chapter by first establishing links between the processes and underlying assumptions of clinical reasoning and the components and process of ethical reasoning. We contend that recognizing similarities between clinical and ethical reasoning processes enhances a deeper understanding, provides a more rigorous framework and facilitates an integrated implementation of ethical knowledge in everyday practice. We then examine two of the key components of ethical reasoning and their relationship in depth: the understanding and application of ethical theory/knowledge and the understanding and application of knowledge of context, patient values and experience.
There has been a long expressed need for a better understanding of the relationship between ethical reasoning and clinical reasoning (Clawson 1994, Swisher 2002). One reason for this is so that clinicians can integrate and align their ethical reasoning with both a familiar and a rigorous method of clinical reasoning and problem solving in clinical practice. Another reason lies in the importance of understanding the assumptions or rationale underlying all types of decision making in clinical practice. Traditional understandings of clinical reasoning have emphasized the deductive process (commonly termed diagnostic and procedural reasoning) and described it as largely cognitive, occurring ‘inside the head’ of the health practitioner or clinician, generating and testing hypotheses in a unilateral manner. This understanding has now broadened and clinical reasoning is widely accepted as a collaborative and interactive process where two sets of understanding (the patient’s and the practitioner’s) are brought into a sense of coherence in the decision-making process in clinical practice. This inductive process of understanding particular patient beliefs and their interpretation of illness or disability experience in the clinical reasoning process has, therefore, assumed a more explicit and valued role in clinical reasoning.
There is a parallel situation in bioethics (Edwards et al 2005). The dominant form of bioethics, termed the principlist approach (Fox 1994, Swisher 2002), is a deductive approach which relies upon a theoretical framework of accepted biomedical ethical principles (Beauchamp & Childress 2001) to guide the development of ethical codes and ethical decision making. Codes of ethics in the caring professions in Australia (such as nursing, pharmacy, occupational therapy, physiotherapy, social work and medicine) are based on variations of the principlist approach (Hugman 2005). Although there continues to be a high degree of consensus regarding these principles as a foundation for ethics in the health professions (Hugman 2005), bioethics has shifted since the mid-1990s, in a similar way to contemporary understandings of clinical reasoning, towards hearing and interpreting a much richer and contextual variety of moral voices and approaches (Charlesworth 2005).
The importance of understanding ethical theory and ethical approaches and the different perspectives they offer for ethical decision making has been previously recognized in established models of ethical reasoning (Kerridge et al 2005, Purtilo 2005, Sim 2004, Swisher 2005). However, in the ethical reasoning literature, the way in which the different perspectives and ethical approaches might be incorporated into an ethical reasoning process has received less attention. For example, some authors have discussed making ethical decisions by following a particular step-by-step process in one or other direction (Sim 2004, Swisher 2005). A four-tiered process describes how therapists can defend or reason through an ethical decision in practice. Starting from the bottom tier, the practitioner’s ability to trace the steps from a case-based decision through to ethical theory provides an ‘objectivity’ or rationale to ethical decision making (Sim 2004, p. 230). These steps begin with a specific contextually based ethical decision which can be defended by reference to different ascending, as it were, tiers of knowledge; professional rules or codes of practice, then ethical principles, and finally ethical theory/philosophy. This four-tiered model is portrayed by Sim (2004) as a bottom up, inductive process. Other authors have found that therapists make decisions from the top down. For example, in a study of how physiotherapists implemented the ethical obligation to obtain patients’ informed consent to treatment, Delany (2006) found that therapists’ reasoning processes moved from an interpretation of an ethical principle downwards to a particular clinical scenario. Specifically, their implementation of the ethical obligation to obtain their patients’ informed consent to treatment was derived or deduced from their interpretation and analysis of their obligation to provide an overall benefit for the patient (the principle of beneficence). In an earlier study, Barnitt & Partridge (1997) also found that physiotherapists used a top down, deductive process (described as a diagnostic or procedural reasoning approach) when reasoning through ethical problems. This compared with a narrative (inductive) approach used by occupational therapists.
A key difference which has developed between the clinical reasoning literature and the ethical reasoning literature is the identification of underlying epistemological bases. Epistemology refers to the study of knowledge and how knowledge is constructed. In contemporary models of clinical reasoning (Edwards et al 2004, Jensen et al 1999, Mattingly 1994) epistemological bases underlying particular reasoning processes have been identified and the relevance of understanding these differences is made explicit. Existing models of ethical reasoning recognize reasoning approaches but do not explicitly require an epistemological basis for therapists’ adoption of a particular approach. Moreover, they tend to leave the choice of an ethical approach in the process of ethical decision making as an ontological enterprise rather than an epistemological one. By this we mean that the choice and direction of application of which ethical approach to use as a primary tool to both gather and analyse data concerning the ethical problem is left, even implicitly, to the practitioner’s views concerning the nature of truth or reality. That is, the models have not focused on practitioners providing an epistemological rationale of different bases of knowledge and values. For example, it has been implied that practitioners may see themselves as being intrinsically more orientated towards a benefit- or outcome-driven (utilitarianism) approach as opposed to a duty-driven (deontological) approach (e.g. Sim 2004). And yet, the manner in which practitioners’ views of professional and practice realities (including ethics) are formed is a complex process and one that draws from many realms of knowledge. It may be learned socially, within practice communities, or personally derived from an individual ontological perspective (Abrandt Dalhgren et al 2004, Barnitt & Partridge 1997, Benner et al 1996, Edwards 2001). In addition, in many clinical situations there is scope for more than one ethical interpretation. Our contention is that in the same way that practitioners are required to account for clinical decisions on an epistemological basis, they should also be aware of and able to defend or account for the underlying epistemological framework informing (in both directions) their ethical reasoning process and decisions. To this end, and in agreement with Swisher (2005), we emphasize the importance of practitioners having a critical awareness of both inductive (bottom up) and deductive (top down) processes of clinical and ethical reasoning. We also advocate that practitioners have a thorough understanding of both the top end (ethical principles and their theoretical bases) and the bottom end (patient values and clinical contexts) in order to justify and recognize how the two ends might contribute and interact when they make ethical judgements.
To understand the nature and scope of knowledge which might influence ethical reasoning processes, and to appreciate the rationale for the place of both deductive and inductive reasoning, we suggest the inclusion of an epistemological approach in addition to an ontological understanding. In this book there is a recurrent theme concerning ‘how we know what we know’ for decision making in clinical practice. There is now consensus that this occurs, at least in part, through an appreciation of several different types of knowledge which, in turn, are constructed based on different assumptions of reality (see Chapter 45). We propose that in ethical reasoning (as for clinical reasoning) practitioners should have the capacity to engage in applied epistemology by understanding how the various types of knowledge (and values) in a situation which involves ethical issues are constructed.
The rationale for an applied epistemology has to do with the basis on which health practitioners make decisions in practice, and this is not always explicitly understood by the practitioners themselves. For example, practitioners may conduct the important processes of data gathering and analysis in practice from a particular paradigm of practice (as observed by Barnitt & Partridge (1997) in relation to ethical problem solving by physiotherapists and occupational therapists), without being aware of the implications of how a paradigm shapes the resultant decision-making processes. One of the mandates of clinical reasoning is that practitioners understand the assumptions upon which they gather data and then make decisions from their chosen analysis of the data in clinical practice. Few clinical educators would accept the notion of clinical decision making on the basis of personal inclination rather than through critical reflection of assumptions underlying the reasoning process which is in use. For example, it would be hard to defend the choice of a narrative form of reasoning in order to determine the possible structures at fault in an impingement of the shoulder. Alternatively, choosing a hypothetico-deductive (biomedical) reasoning approach to understand the cultural influences on decisions made by patients regarding their health would be of limited value.
Deductive and inductive processes of reasoning, just as deductive and inductive forms of research, have quite different underlying assumptions regarding the nature of truth, reality and knowledge (Edwards 2001). Both contribute quite different forms of valuable knowledge in the clinical reasoning process, and this is equally true in ethical reasoning (Edwards et al 2005). The relationship of deductive and inductive forms of ethical reasoning can be described as the crossing and re-crossing of a bridge by the practitioner (Hudson Jones 1997). In the next two sections we discuss the two sides of the bridge (or two ends of the reasoning spectrum) in greater depth. We demonstrate how an awareness of the ethical theories underlying principles on one side, and ethical value found within patient perspectives on the other, can enhance and enrich the reasoning process.