Assignment #4

IMPORTANT NOTE: Thispaper must be submitted by Saturday in the last week of class no laterthan 11:59pm EST and if late will not be accepted. In addition to thewritten instructions, there are 2 VIDEOS that explain this assignment.See above links for videos.

The final project for this course is an analysis of the legal and orethical issues involved in the below health care scenario. See questionsto be answered at end of this factual scenario below. I have alsoprovided, after the formatting requirements for the paper, two articlesthat will aid you in your analyzing the scenario and writing your paper.

The two articles to base the analysis of your paper are entitled:

Clinical Ethics Issues and Discussion and

A Framework for Thinking Ethically

This is the final paper for the class and must be double spaced andbe approximately 4-5 pages in 12 point New Times Roman font. Include acover page [not counted as a page] which should have student name andtitle of your paper. See more formatting requirements later in thesepaper instructions.

NOTE: For this paper it is unnecessary to do any research beyond thetwo articles I furnished with this assignment. Both are after thespecific paper requirements. You may use all the articles in the classalso. To do internet research would only be wasting your valuable time.

Case Scenario

A 72 year old woman was admitted to the Neurological Intensive CareUnit following a cerebral hemorrhage which left her with severe braindamage and ventilator dependent. One year before this event, the patientand her husband had drawn up "living wills" with an attorney. She wasdiagnosed by her treating physician as being in a permanent unconsciouscondition. The patient's living will specified that the patient did notwant ventilator support or other artificial life support in the event ofa permanent unconscious condition or terminal condition.

The patient's husband is her legal next of kin and the person withsurrogate decision-making authority. When the living will was discussedwith him, he insisted that the patient had not intended for the documentto be used in a situation like the present one. Further discussion withhim revealed that he understood that the patient would not be able torecover any meaningful brain function but he argued that the living willdid not apply because her condition was not imminently terminal. Hefurther indicated that he did not consider his wife to be in a permanentunconscious condition. The immediate family members (the couple’sadult children) disagreed with their father’s refusal to withdraw lifesupport.

The treatment team allowed a week to pass to allow the husband moretime to be supported in his grief and to appreciate the gravity of hiswife’s situation. Nevertheless, at the end of this time, the husbandwas unwilling to authorize withdrawal of life support measuresconsistent with the patient's wishes as expressed in her living will.End of scenario.

You paper should have 3 major sections. Each is numbered 1, 2 and 3. Questions to be discussed based on the facts above. Youmust weave into your discussion the relevant facts from above scenarioto support your discussion in discussion areas 2 and 3 below. And fordiscussion area 3 you must weave into your discussion the ethicsphilosophy you pick for each issue from the article A Framework forThinking Ethically. A penalty will be deducted if you fail to use appropriate headings in your paper.

1. Three Legal/Ethical Issues. Just list the three most important legal/ethics issues in this scenario that you will discuss. They must be three separate, different and distinct issues. Pay particular attention to the article I furnished with this assignment. No explanation needed, just state them 1, 2, 3.

2. Discussion of Three Legal/Ethical Issues. Discussthe three most important ethical/legal issues you listed above. Must usethe relevant facts in the scenario to support your discussion of thelegal/ethical issues.

Must use headings below. Headings will be:

Legal/Ethical Issue 1 [state the issue] then discussion

Legal/Ethical Issue 2 [state the issue] then discussion

Legal/Ethical Issue 3 [state the issue] then discussion

For each legal/ethical issue above discuss

a. Why each is a legal /ethical issue?

b. Discuss each issue in the context of the scenario facts and

c. Define the concepts you use

3. How I would Handle Each Issue. First, in thissection and for each issue, as a health care provider, how would youhandle each of the three issues discussed above and why? Must use therelevant facts in the scenario to support your positions. Secondly foreach issue, using the article in these requirements, entitled "AFramework of Thinking Ethically" fully discuss the specific ethicsphilosophy that would epitomize your handling of each issue. Fullydefine the specific ethics philosophy used and weave the ethicsphilosophy into your discussion. See article below entitled A Frameworkfor Thinking Ethically.

Must use headings below. Headings will be:

Handling of Legal/Ethical Issue #1 (followed by the discussion)

Handling of Legal/Ethical Issue #2 (followed by the discussion)

Handling of Legal/Ethical Issue #3 (followed by the discussion)

[A penalty will be deducted if you fail to use appropriate headings in your paper. ]

This is an independent paper and you are on the honor system not todiscuss or consult with any students or other individuals about thispaper. You may use the information we have discussed in the class, thearticles in the class, and the two articles I have furnished below. Justso you know, all you need to read to analyze the questions for yourpaper are the two articles I have furnished with this assignment andinformation in the class.

All you need to read to analyze the questions for this paper are the two articles below entitled:

Clinical Ethics Issues and Discussion & A Framework for Thinking Ethically

The paper must be:

• Late submission – No late assignment 4 papers will beaccepted. Paper is due Saturday in the last week of class no later than11:59pm EST..

Paper must be in narrative format not outline or bullets.

• Double spaced and be 4-5 pages in 12 point New Times Roman font. [Nodeduction if paper exceeds a page or so. Thus 3 and half page paperwill be penalized.]
• Must cite to source of all your facts in the text of your paper in APA format.
• You can cite directly to the original source. Here are the links tothe sources where the University received copyright permissions for thematerials:
• Clinical Ethics and Law:http://depts.washington.edu/bioethx/topics/law.html
• A Framework for Ethical Decision Making:https://www.scu.edu/ethics/ethics-resources/ethical-decision-making/a-framework-for-ethical-decision-making/

• Include a cover page [not counted as a page] which should havestudent name and title of your paper [Provide a short name for the legalresponsibility the specific health care organization has for one typeof patient right in a specific setting ]
• A the end of the paper a list of references [not counted as a page]
• Be prepared using word-processing software and saved with a .doc, .docx, or .rtf extension. No pdf.
• Be uploaded to your Assignments Folder by 11:59 p.m. EST on the due date.
• The paper is to be posted in Assignment #4 drop box.

Grading rubric for assignment is with assignment in Assignments area of class.

Background articles to support the issues you will discuss in the paper.

Article One of Two

Clinical Ethics Issues and Discussion Article

Relationships: I. clinical ethics, law & risk management

1. Definitions and sources of authority

In the course of practicing medicine, a range of issues may arisethat lead to consultation with a medical ethicist, a lawyer, and/or arisk manager. The following discussion will outline key distinctionsbetween these roles.

• Clinical ethics may be defined as: a discipline ormethodology for considering the ethical implications of medicaltechnologies, policies, and treatments, with special attention todetermining what ought to be done (or not done) in the delivery ofhealth care.
• Law may be defined as: established and enforceable socialrules for conduct or non-conduct; a violation of a legal standard maycreate criminal or civil liability.
• Risk Management may be defined as: a method of reducing risk of liability through institutional policies/practices.

Many health care facilities have in-house or on-call trainedethicists to assist health care practitioners, caregivers and patientswith difficult issues arising in medical care, and some facilities haveformally constituted institutional ethics committees. In the hospitalsetting, this ethics consultation or review process dates back to atleast 1992 with the formulation of accreditation requirements thatmandated that hospitals establish a “mechanism” to consider clinicalethics issues.

Ethics has been described as beginning where the law ends. The moralconscience is a precursor to the development of legal rules for socialorder. Ethics and law thus share the goal of creating and maintainingsocial good and have a symbiotic relationship as expressed in thisquote:

[C]onscience is the guardian in the individual of the rules which the community has evolved for its own preservation. William Somerset Maugham

The role of lawyers and risk managers are closely linked in manyhealth care facilities. Indeed, in some hospitals, the administratorwith the title of Risk Manager is an attorney with a clinicalbackground. There are, however, important distinctions between law andrisk management. Risk management is guided by legal parameters but has abroader institution-specific mission to reduce liability risks. It isnot uncommon for a hospital policy to go beyond the minimum requirementsset by a legal standard. When legal and risk management issues arise inthe delivery of health care, ethics issues may also exist. Similarly,an issue originally identified as falling within the clinical ethicsdomain may also raise legal and risk management concerns.

To better understand the significant overlap among these disciplinesin the health care setting, consider the sources of authority andexpression for each.

Ethical norms may be derived from:

• Law
• Institutional policies/practices
• Policies of professional organizations
• Professional standards of care, fiduciary obligations

Note: If a health care facility is also a religious facility, it mayadhere to religious tenets. In general, however, clinical ethics ispredominantly a secular professional analytic approach to clinicalissues and choices.

Law may be derived from:

• Federal and state constitutions (fundamental laws of a nation orstate establishing the role of government in relation to the governed)
• Federal and state statutes (laws written or enacted by electedofficials in legislative bodies, and in some states, such as Washingtonand California, laws created by a majority of voters through aninitiative process)
• Federal and state regulations (written by government agencies aspermitted by statutory delegation, having the force and effect of lawconsistent with the enabling legislation)
• Federal and state case law (written published opinions of appellate-level courts regarding decisions in individual lawsuits)
• City or town ordinances, when relevant

Risk Management may be derived from law,professional standards and individual institution’s mission and publicrelations strategies and is expressed through institutional policies andpractices.

1. Conceptual Models

Another way to consider the relationship among the three disciplines is through conceptual models:

1. Linear
2. Distinctions
3. Interconnectedness
4. Orientation to law for non-lawyers
5. Potential legal actions against health care providers

There are two primary types of potential civil actions against healthcare providers for injuries resulting from health care: (1) lack of informed consent, and (2) violation of the standard of care. Medical treatment and malpractice laws are specific to each state.

1. Informed Consent. Before a health care provider delivers care,ethical and legal standards require that the patient provide informedconsent. If the patient cannot provide informed consent, then, for mosttreatments, a legally authorized surrogate decision-maker may do so. Inan emergency situation when the patient is not legally competent togive informed consent and no surrogate decision-maker is readilyavailable, the law implies consent on behalf of the patient, assumingthat the patient would consent to treatment if he or she were capable ofdoing so.

Information that must be conveyed to and consented to by the patientincludes: the treatment’s nature and character and anticipated results,alternative treatments (including non-treatment), and the potentialrisks and benefits of treatment and alternatives. The information mustbe presented in a form that the patient can comprehend (i.e., in alanguage and at a level which the patient can understand) and that theconsent must be voluntary given. An injured patient may bring aninformed consent action against a provider who fails to obtain thepatient’s informed consent in accordance with state law.

From a clinical ethics perspective, informed consent is a communication process, and should not simply be treated as a required form forthe patient’s signature. Similarly, the legal concept of informedconsent refers to a state of mind, i.e., understanding the informationprovided to make an informed choice. Health care facilities andproviders use consent forms to document the communication process. From aprovider’s perspective, a signed consent form can be valuable evidencethe communication occurred and legal protection in defending against apatient’s claim of a lack of informed consent. Initiatives at thefederal level (i.e., the Affordable Care Act) and state level (e.g.,Revised Code of Washington § 7.70.060) reflect approaches that supportshared decision-making and the use of patient decision aids in order toensure the provision of complete information for medicaldecision-making.

1. Failure to follow standard of care. A patient who is injured duringmedical treatment may also be able to bring a successful claim against ahealth care provider if the patient can prove that the injury resultedfrom the provider’s failure to follow the accepted standard of care. Theduty of care generally requires that the provider use reasonablyexpected knowledge and judgment in the treatment of the patient, andtypically would also require the adept use of the facilities at hand andoptions for treatment. The standard of care emerges from a variety ofsources, including professional publications, interactions ofprofessional leaders, presentations and exchanges at professionalmeetings, and among networks of colleagues. Experts are hired by thelitigating parties to assist the court in determining the applicablestandard of care.

Many states measure the provider’s actions against a nationalstandard of care (rather than a local one) but with accommodation forpractice limitations, such as the reasonable availability of medicalfacilities, services, equipment and the like. States may also applydifferent standards to specialists and to general practitioners. As anexample of a statutory description of the standard of care, WashingtonState currently specifies that a health care provider must “exercisethat degree of care, skill, and learning expected of a reasonablyprudent health care provider at that time in the profession or class towhich he belongs, in the State of Washington, acting in the same orsimilar circumstances.”

III. Common clinical ethics issues: medical decision-making and provider-patient communication

There are a number of common ethical issues that also implicate legaland risk management issues. Briefly discussed below are common issuesthat concern medical decision-making and provider-patient communication.

If a patient is capable of providing informed consent, then thepatient’s choices about treatment, including non-treatment, should befollowed. This is an established and enforceable legal standard and alsoconsistent with the ethical principle of respecting the autonomy of thepatient. The next two sections (Surrogate decision-making; Advancedirectives) discuss how this principle is respected from a legalperspective if a patient lacks capacity, temporarily or permanently, tomake medical decisions. The third section briefly introduces the issueof provider-patient communication, and highlights a contemporary dilemmaraised in decisions regarding the disclosure of medical error topatients.

1. Surrogate decision-making

The determination as to whether a patient has the capacity toprovide informed consent is generally a professional judgment made anddocumented by the treating health care provider. The provider can make adetermination of temporary or permanent incapacity, and thatdetermination should be linked to a specific decision. The legal term competency (or incompetency) may be used to describe a judicial determination of decision-making capacity. The designation of a specific surrogate decision-maker may either be authorized by court order or is specified in state statutes.

If a court has determined that a patient is incompetent, a healthcare provider must obtain informed consent from the court-appointeddecision-maker. For example, where a guardian has been appointed by thecourt in a guardianship action, a health care provider would seek theinformed consent of the guardian, provided that the relevant court ordercovers personal or health care decision-making.

If, however, a physician determines that a patient lacks the capacityto provide informed consent, for example, due to dementia or lack ofconsciousness, or because the patient is a minor and the minor islegally proscribed from consenting, then a legally authorized surrogatedecision-maker may be able to provide consent on the patient’s behalf.Most states have specific laws that delineate, in order of priority,who can be a legally authorized surrogate decision-maker for anotherperson. While these laws may vary, they generally assume that legalrelatives are the most appropriate surrogate decision-makers. If,however, a patient has previously, while capable of consenting, selecteda person to act as her decision-maker and executed a legal documentknown as a durable power of attorney for health care or health care proxy, then that designated individual should provide informed consent.

In Washington State, a statute specifies the order of priority ofauthorized decision-makers as follows: guardian, holder of durable powerof attorney; spouse or state registered partner; adult children;parents; and adult brothers and sisters. If the patient is a minor,other consent provisions may apply, such as: court authorization for aperson with whom the child is in out-of-home placement; the person(s)that the child’s parent(s) have given a signed authorization to provideconsent; or, a competent adult who represents that s/he is a relativeresponsible for the child’s care and signs a sworn declaration statingso. Health care providers are required to make reasonable efforts tolocate a person in the highest possible category to provide informedconsent. If there are two or more persons in the same category, e.g.,adult children, then the medical treatment decision must be unanimousamong those persons. A surrogate decision-maker is required to make thechoice she believes the patient would have wanted, which may not be thechoice the decision-maker would have chosen for herself in the samecircumstance. This decision-making standard is known as substituted judgment. Ifthe surrogate is unable to ascertain what the patient would havewanted, then the surrogate may consent to medical treatment ornon-treatment based on what is in the patient's best interest.

Laws on surrogate decision-making are slowly catching up with socialchanges. Non-married couples (whether heterosexual or same sex) have nottraditionally been recognized in state law as legally authorizedsurrogate decision-makers. This lack of recognition has left providersin a difficult legal position, encouraging them to defer to thedecision-making of a distant relative over a spouse-equivalent unlessthe relative concurs. Washington law, for example, now recognizesspouses and domestic partners registered with the state as having thesame priority status.

Parental decision-making and minor children. A parent maynot be permitted in certain situations to consent to non-treatment ofhis or her minor child, particularly where the decision wouldsignificantly impact and perhaps result in death if the minor child didnot receive treatment. Examples include parents who refuse medicaltreatment on behalf of their minor children because of the parents’social or religious views, such as Jehovah’s Witnesses and ChristianScientists. The decision-making standard that generally applies tominor patients in such cases is known as the best interest standard.The substituted judgment standard may not apply because the minorpatient never had decision-making capacity and therefore substitutedjudgment based on the minor’s informed choices is not able to bedetermined. It is important to note that minors may have greaterauthority to direct their own care depending on their age, maturity,nature of medical treatment or non-treatment, and may have authority toconsent to specific types of treatment. For example, in WashingtonState, a minor may provide his or her own informed consent for treatmentof mental health conditions, sexually transmitted diseases, and birthcontrol, among others. Depending on the specific facts, a health careprovider working with the provider’s institutional representatives couldpotentially legally provide treatment of a minor under implied consentfor emergency with documentation of that determination, assumetemporary protective custody of the child under child neglect laws, orif the situation is non-urgent, the provider could seek a court order toauthorize treatment.

1. Advance directives

The term advance directive refers to several different typesof legal documents that may be used by a patient while competent torecord future wishes in the event the patient lacks decision-makingcapacity. The choice and meaning of specific advance directiveterminology is dependent on state law. Generally, a living will expressesa person’s desires concerning medical treatment in the event ofincapacity due to terminal illness or permanent unconsciousness. A durable power of attorney for health care or health care proxy appoints a legal decision- maker for health care decisions in the event of incapacity. An advance health care directive or health care directive maycombine the functions of a living will and durable power of attorneyfor health care into one document in one state, but may be equivalent toa living will in another state. The Physician Orders for Life Sustaining Treatment (POLST) form isa document that is signed by a physician and patient which summarizesthe patient’s wishes concerning medical treatment at the end of life,such as resuscitation, antibiotics, other medical interventions andartificial feeding, and translates them into medical orders that followpatients regardless of care setting. It is especially helpful ineffectuating a patient’s wishes outside the hospital setting, forexample, in a nursing care facility or emergency medical responsecontext. This relatively new approach is available in about a dozenstates, although the programs may operate under different names: POST(Physician Orders for Scope of Treatment), MOST (Medical Orders forScope of Treatment), MOLST (Medical Orders for Life-SustainingTreatment), and COLST (Clinician Orders for Life-Sustaining Treatment).The simple one page treatment orders follow patients regardless of caresetting. Thus it differs from an advance directive because it iswritten up by the clinician in consultation with the patient and is aportable, actionable medical order. The POLST form is intended tocomplement other forms of advance directives. For example, WashingtonState recognizes the following types of advance directives: the healthcare directive (living will), the durable power of attorney for healthcare, and the POLST form. Washington also recognizes another legaldocument known as a mental health advance directive, which canbe prepared by individuals with mental illness who fluctuate betweencapacity and incapacity for use during times when they areincapacitated.

State laws may also differ on the conditions that can be covered byan individual in an advance directive, the procedural requirements toensure that the document is effective (such as the number of requiredwitnesses) and the conditions under which it can be implemented (such asinvalidity during pregnancy).

Advance directives can be very helpful in choosing appropriatetreatment based upon the patient’s expressed wishes. There aresituations, however, in which the advance directive’s veracity isquestioned or in which a legally authorized surrogate believes theadvance directive does not apply to the particular care decision atissue. Such conflicts implicate clinical ethics, law and riskmanagement.

1. Provider-patient communications: disclosing medical error

Honest communication to patients by health care providers is anethical imperative. Excellent communication eliminates or reduces thelikelihood of misunderstandings and conflict in the health care setting,and also may affect the likelihood that a patient will sue.

One of the more contentious issues that has arisen in the context ofcommunication is whether providers should disclose medical errors topatients, and if so, how and when to do so. Disclosure of medical errorcreates a potential conflict among clinical ethics, law and riskmanagement. Despite a professional ethical commitment to honestcommunication, providers cite a fear of litigation as a reason fornon-disclosure. Specifically, the fear is that those statements willstimulate malpractice lawsuits or otherwise be used in support of aclaim against the provider. An increase in malpractice claims couldthen negatively affect the provider’s claims history and malpracticeinsurance coverage.

There is some evidence in closed systems (one institution, one statewith one malpractice insurer) that an apology coupled with disclosureand prompt payment may decrease either the likelihood or amount of legalclaim. In addition, a number of state legislatures have recently actedto protect provider apologies, or provider apologies coupled withdisclosures, from being used by a patient as evidence of a provider’sliability in any ensuing malpractice litigation. It is currently tooearly to know whether these legal protections will have any impact onthe size or frequency of medical malpractice claims. For this reason andothers, it is advisable to involve risk management and legal counsel indecision-making regarding error disclosure.

Article Two of Two

A Framework for Thinking Ethically Article

This document is designed as an introduction to thinking ethically.We all have an image of our better selves-of how we are when we actethically or are "at our best." We probably also have an image of whatan ethical community, an ethical business, an ethical government, or anethical society should be. Ethics really has to do with all theselevels-acting ethically as individuals, creating ethical organizationsand governments, and making our society as a whole ethical in the way ittreats everyone.

What is Ethics?

Simply stated, ethics refers to standards of behavior that tell ushow human beings ought to act in the many situations in which they findthemselves-as friends, parents, children, citizens, businesspeople,teachers, professionals, and so on.

It is helpful to identify what ethics is NOT:

• • Ethics is not the same as feelings. Feelings provide importantinformation for our ethical choices. Some people have highly developedhabits that make them feel bad when they do something wrong, but manypeople feel good even though they are doing something wrong. And oftenour feelings will tell us it is uncomfortable to do the right thing ifit is hard.
• • Ethics is not religion. Many people are not religious, but ethicsapplies to everyone. Most religions do advocate high ethical standardsbut sometimes do not address all the types of problems we face.
• • Ethics is not following the law. A good system of law doesincorporate many ethical standards, but law can deviate from what isethical. Law can become ethically corrupt, as some totalitarian regimeshave made it. Law can be a function of power alone and designed to servethe interests of narrow groups. Law may have a difficult time designingor enforcing standards in some important areas, and may be slow toaddress new problems.
• • Ethics is not following culturally accepted norms. Some culturesare quite ethical, but others become corrupt -or blind to certainethical concerns (as the United States was to slavery before the CivilWar). "When in Rome, do as the Romans do" is not a satisfactory ethicalstandard.
• • Ethics is not science. Social and natural science can provideimportant data to help us make better ethical choices. But science alonedoes not tell us what we ought to do. Science may provide anexplanation for what humans are like. But ethics provides reasons forhow humans ought to act. And just because something is scientifically ortechnologically possible, it may not be ethical to do it.

Why Identifying Ethical Standards is Hard

There are two fundamental problems in identifying the ethical standards we are to follow:
1. On what do we base our ethical standards?
2. How do those standards get applied to specific situations we face?

If our ethics are not based on feelings, religion, law, acceptedsocial practice, or science, what are they based on? Many philosophersand ethicists have helped us answer this critical question. They havesuggested at least five different sources of ethical standards we shoulduse.

Five Sources of Ethical Standards

The Utilitarian Approach
Some ethicists emphasizethat the ethical action is the one that provides the most good or doesthe least harm, or, to put it another way, produces the greatest balanceof good over harm. The ethical corporate action, then, is the one thatproduces the greatest good and does the least harm for all who areaffected-customers, employees, shareholders, the community, and theenvironment. Ethical warfare balances the good achieved in endingterrorism with the harm done to all parties through death, injuries, anddestruction. The utilitarian approach deals with consequences; it triesboth to increase the good done and to reduce the harm done.

The Rights Approach
Other philosophers andethicists suggest that the ethical action is the one that best protectsand respects the moral rights of those affected. This approach startsfrom the belief that humans have a dignity based on their human natureper se or on their ability to choose freely what they do with theirlives. On the basis of such dignity, they have a right to be treated asends and not merely as means to other ends. The list of moral rights-including the rights to make one's own choices about what kind of lifeto lead, to be told the truth, not to be injured, to a degree ofprivacy, and so on-is widely debated; some now argue that non-humanshave rights, too. Also, it is often said that rights imply duties-inparticular, the duty to respect others' rights.

The Fairness or Justice Approach
Aristotle andother Greek philosophers have contributed the idea that all equalsshould be treated equally. Today we use this idea to say that ethicalactions treat all human beings equally-or if unequally, then fairlybased on some standard that is defensible. We pay people more based ontheir harder work or the greater amount that they contribute to anorganization, and say that is fair. But there is a debate over CEOsalaries that are hundreds of times larger than the pay of others; manyask whether the huge disparity is based on a defensible standard orwhether it is the result of an imbalance of power and hence is unfair.

The Common Good Approach
The Greek philosophershave also contributed the notion that life in community is a good initself and our actions should contribute to that life. This approachsuggests that the interlocking relationships of society are the basis ofethical reasoning and that respect and compassion for allothers-especially the vulnerable-are requirements of such reasoning.This approach also calls attention to the common conditions that areimportant to the welfare of everyone. This may be a system of laws,effective police and fire departments, health care, a public educationalsystem, or even public recreational areas.

The Virtue Approach
A very ancient approach toethics is that ethical actions ought to be consistent with certain idealvirtues that provide for the full development of our humanity. Thesevirtues are dispositions and habits that enable us to act according tothe highest potential of our character and on behalf of values liketruth and beauty. Honesty, courage, compassion, generosity, tolerance,love, fidelity, integrity, fairness, self-control, and prudence are allexamples of virtues. Virtue ethics asks of any action, "What kind ofperson will I become if I do this?" or "Is this action consistent withmy acting at my best?"

Putting the Approaches Together

Each of the approaches helps us determine what standards of behaviorcan be considered ethical. There are still problems to be solved,however.

The first problem is that we may not agree on the content of some ofthese specific approaches. We may not all agree to the same set of humanand civil rights.

We may not agree on what constitutes the common good. We may not even agree on what is a good and what is a harm.

The second problem is that the different approaches may not allanswer the question "What is ethical?" in the same way. Nonetheless,each approach gives us important information with which to determinewhat is ethical in a particular circumstance. And much more often thannot, the different approaches do lead to similar answers.

Making Decisions

Making good ethical decisions requires a trained sensitivity toethical issues and a practiced method for exploring the ethical aspectsof a decision and weighing the considerations that should impact ourchoice of a course of action. Having a method for ethical decisionmaking is absolutely essential. When practiced regularly, the methodbecomes so familiar that we work through it automatically withoutconsulting the specific steps.

The more novel and difficult the ethical choice we face, the more weneed to rely on discussion and dialogue with others about the dilemma.Only by careful exploration of the problem, aided by the insights anddifferent perspectives of others, can we make good ethical choices insuch situations.

We have found the following framework for ethical decision making auseful method for exploring ethical dilemmas and identifying ethicalcourses of action.

A Framework for Ethical Decision Making

Recognize an Ethical Issue

1. Could this decision or situation be damaging to someone or to somegroup? Does this decision involve a choice between a good and badalternative, or perhaps between two "goods" or between two "bads"?
2. Is this issue about more than what is legal or what is most efficient? If so, how?

Get the Facts

1. What are the relevant facts of the case? What facts are not known?Can I learn more about the situation? Do I know enough to make adecision?
2. What individuals and groups have an important stake in the outcome? Are some concerns more important? Why?
3. What are the options for acting? Have all the relevant persons and groups been consulted? Have I identified creative options?

Evaluate Alternative Actions

1. Evaluate the options by asking the following questions:

• Which option will produce the most good and do the least harm? (The Utilitarian Approach)
• Which option best respects the rights of all who have a stake? (The Rights Approach)
• Which option treats people equally or proportionately? (The Justice Approach)
• Which option best serves the community
  as a whole, not just some members?
  (The Common Good Approach)
• Which option leads me to act as the sort of person I want to be? (The Virtue Approach)

Make a Decision and Test It

1. Considering all these approaches, which option best addresses the situation?
2. If I told someone I respect-or told a television audience-which option I have chosen, what would they say?

Act and Reflect on the Outcome

1. How can my decision be implemented with the greatest care and attention to the concerns of all stakeholders?
2. How did my decision turn out and what have I learned from this specific situation?

This framework for thinking ethically is the product of dialogueand debate at the Markkula Center for Applied Ethics at Santa ClaraUniversity. Primary contributors include Manuel Velasquez, DennisMoberg, Michael J. Meyer, Thomas Shanks, Margaret R. McLean, DavidDeCosse, Claire André, and Kirk O. Hanson. It was last revised in May2009. End of article.