Complexity of ethical decision making in psychiatry

Psychiatric residents and psychiatrists have little difficulty in making judgments about a clinical course of action to take with patients. However, making ethical clinical decisions is more challenging, because psychiatric residents are usually provided little formal training in ethics. Further, many ethical dilemmas are complex, requiring knowledge of the psychiatric profession's ethics code, moral principles, law, and practice standards and of how they should be weighed in the decision-making process. The purpose of this article is to demonstrate this complexity in regard to the identification of potential ethical dilemmas, understanding the issues that these dilemmas raise, and formulating potential solutions to them. Two common but important areas of treatment in which ethical dilemmas arise (informed consent and competence of care) are used as examples for our presentation. The article demonstrates that to successfully engage in ethical analysis in psychiatry is impossible without substantial formal training in the process.     

The importance of meta-ethics in engineering education

Our shared moral framework is negotiated as part of the social contract. Some elements of that framework are established (tell the truth under oath), but other elements lack an overlapping consensus (just when can an individual lie to protect his or her privacy?). The tidy bits of our accepted moral framework have been codified, becoming the subject of legal rather than ethical consideration. Those elements remaining in the realm of ethics seem fragmented and inconsistent.Yet, our engineering students will need to navigate the broken ground of this complex moral landscape. A minimalist approach would leave our students with formulated dogma—principles of right and wrong such as the National Society for Professional Engineers (NSPE) Code of Ethics for Engineers—but without any insight into the genesis of these principles. A slightly deeper, micro-ethics approach would teach our students to solve ethical problems by applying heuristics—giving our students a rational process to manipulate ethical dilemmas using the same principles simply referenced a priori by dogma. A macro-ethics approach—helping students to inductively construct a posteriori principles from case studies—goes beyond the simple statement or manipulation of principles, but falls short of linking personal moral principles to the larger, social context. Ultimately, it is this social context that requires both the application of ethical principles, and the negotiation of moral values—from an understanding of meta-ethics.The approaches to engineering ethics instruction (dogma, heuristics, case studies, and meta-ethics) can be associated with stages of moral development. If we leave our students with only a dogmatic reaction to ethical dilemmas, they will be dependent on the ethical decisions of others (a denial of their fundamental potential for moral autonomy). Heuristics offers a tool to deal independently with moral questions, but a tool that too frequently reduces to casuistry when rigidly applied to “simplified” dilemmas. Case studies, while providing a context for engineering ethics, can encourage the premature analysis of specific moral conduct rather than the development of broad moral principles—stifling our students’ facility with meta-ethics. Clearly, if a moral sense is developmental, ethics instruction should lead our students from lower to higher stages of moral development.     

Moral judgement in adolescents: Age differences in applying and justifying three principles of harm

This study investigated the application and justification of three principles of harm in a cross-sectional sample of adolescents in order to test recent theories concerning the source of intuitive moral judgements. Participants were 46 early (M _age = 14.8 years) and 40 late adolescents (M _age = 17.8 years). Participants rated the permissibility of various ethical dilemmas, and provided justifications for their judgements. Results indicated participants aligned their judgements with the three principles of harm, but had difficulty explaining their reasoning. Furthermore, although age groups were consistent in the application of the principles of harm, age differences emerged in their justifications. These differences were partly explained by differences in language ability. Additionally, participants who used emotional language in their justifications demonstrated a characteristically deontological pattern of moral judgement on certain dilemmas. We conclude adolescents in this age range apply the principles of harm but that the ability to explain their judgements is still developing.     

Compassion, Ethics, and Neuroscience: Neuroethics Through Buddhist Eyes

As scientists advance knowledge of the brain and develop technologies to measure, evaluate, and manipulate brain function, numerous questions arise for religious adherents. If neuroscientists can conclusively establish that there is a functional network between neural impulses and an individual??s capacity for moral evaluation of situations, this will naturally lead to questions about the relationship between such a network and constructions of moral value and ethical human behavior. For example, if cognitive neuroscience can show that there is a neurophysiological basis for the moral appraisal of situations, it may be argued that the world??s religions, which have traditionally been the keepers and purveyors of ethical values, are rendered either spurious or irrelevant. The questions point up broader dilemmas in the interface between science and religion, and raise concerns about the ethics of neurological research and experimentation. Since human beings will still arbitrate what is ??moral?? or ??ethical,?? how can religious perspectives enrich the dialogue on neuroethical issues and how can neuroscience enrich dialogue on religion? Buddhist views on the nature of consciousness and methods of practice, especially meditation practice, may contribute to discussions on neuroscience and theories about the interrelationship between consciousness and ethical awareness by exploring the role that karma, intentionality, and compassion play in Buddhist understandings of the interrelationship between consciousness and ethics.     

Tragic Dilemmas and the Priority of the Moral

My purpose in this paper is to argue that we are not vulnerableto inescapable wrongdoing occasioned by tragic dilemmas. I directmy argument to those who are most inclined to accept tragicdilemmas: those of broadly Nietzschean inclination who reject``modern moral philosophy' in favor of the ethical ideas of theclassical Greeks. Two important features of their project are todeny the usefulness of the ``moral/nonmoral distinction,' and todeny that what are usually classified as moral reasons always oreven characteristically ``trump' nonmoral reasons in anadmirable agent's deliberations.I show critics of modern moral philosophy such as BernardWilliams that their acceptance of tragic dilemmas underminestheir project of denying the moral/nonmoral distinction and thepriority of moral reasons. The possibility of tragic dilemmasrequires an account of practical deliberation in which moralreasons appear as already in-force obligations, with blame andguilt ready to be invoked, while nonmoral reasons appear as merereasons. This makes moral reasons importantly different fromnonmoral reasons in how they achieve their deliberative weight,and also makes them characteristically weightier. Thus,accommodating tragic dilemmas reinforces the moral/nonmoraldistinction and the priority of moral reasons, the very thingsthese critics want to deny. By accepting the possibility oftragic dilemmas, these critics are undermining their own project.The standard normative theories are dead set against tragicdilemmas, and the critics of modern moral philosophy shouldreject tragic dilemmas for the good of their project. Thus we allshould reject tragic dilemmas.     

The Definition of Moral Dilemmas: A Logical Problem

This paper concerns one of the undecided disputes of modern moral philosophy: the possibility of moral dilemmas. Whereas proponents of the possibility of moral dilemmas often appeal to moral experience, many opponents refer to ethical theory and deontic logic. My aim in this paper is to clarify some of the tension between moral experience and ethical theory with respect to moral dilemmas. In Part One I try to show that a number of logical arguments against the possibility of moral dilemmas, though apparently very different, turn out to be basically the same, as they are all based on the following concept of ought: if A ought to be done, doing B is impermissible and doing A itself is permissible. In Part Two I present an overview of several definitions of moral dilemmas that have been given by proponents of moral dilemmas: definitions that define moral dilemmas in terms of oughts and definitions that define them in terms of reasons. I conclude that, while reason is to weak, ought is too strong a concept to define moral dilemmas with. In this way, the arguments from Part One create a logical problem for proponents of the possibility of moral dilemmas to define moral dilemmas.     

The context as a moral rule in medical ethics

A purely deductive medical ethics cannot properly account for the varieties of circumstances which arise in medical practice. By contrast, a purely inductive medical ethics lacks sufficient guidance from ethical principles. In resolving ethical dilemmas in medicine, most often an appeal is made to middle-level axioms and methodological rules to mediate between theory and practice. I argue that this appeal must be augmented by considerations of context, such considerations, in effect, constituting a moral rule based on the social structure of medical practice. A contextual grid is proposed which assists the process of weighing values in resolving cases.     

Ethical Dilemmas in the Use of Information Technology: An Aristotelian Perspective

As computer-based information systems start to have a great impact on people, organizations, and society as a whole, there is much debate about information technology in relation to social control and privacy, security and reliability, and ethics and professional responsibilities. However, more often than not, these debates reveal some fundamental disagreements, sometimes about first principles. In this article the authors suggest that a fruitful and interesting way to conceptualize some of these moral and ethical issues associated with the use of information technology is to apply the principles of Aristotle's ethics to this topic. They argue that framing the moral and ethical choices associated with information technology in Aristotelian terms draws attention to the fact that there are fundamental dilemmas to be addressed. These dilemmas are discussed in relation to the four areas suggested by Dejoie, Fowler, and Paradice (1991): (a) privacy, (b) information accuracy, (c) access to information, and (d) intellectual property rights. The dilemmas associated with all four areas are illustrated with references to recent legal developments in Australia and New Zealand.     

Competing Conceptions of Justice: Faculty Moral Reasoning About Affirmative Action

College faculty (N = 115) were recruited to investigate the influence of moral reasoning on hiring decisions about affirmative action dilemmas. Participants completed the Defining Issues Test (DIT), a standard test of moral reasoning, a measure that presented two hypothetical moral dilemmas about affirmative action that manipulated candidates' race and moral issues, and a scale evaluating the use of external norms versus self-chosen principles. Results indicated that moral issue but not race of a minority candidate affected hiring decisions. Faculty used greater percentages of principled reasoning when solving the more salient affirmative action dilemmas than when solving the hypothetical dilemmas of the DIT. Higher scores on the DIT were related to the use of principles rather than norms when making hiring decisions. Findings suggest that faculty decisions about hiring a hypothetical affirmative action candidate are more influenced by moral reasoning level and competing conceptions of justice than racial bias or ambivalence.     

Using an Ecological Ethics Framework to Make Decisions about the Relocation of Wildlife

Relocation is an increasingly prominent conservation tool for a variety of wildlife, but the technique also is controversial, even among conservation practitioners. An organized framework for addressing the moral dilemmas often accompanying conservation actions such as relocation has been lacking. Ecological ethics may provide such a framework and appears to be an important step forward in aiding ecological researchers and biodiversity managers to make difficult moral choices. A specific application of this framework can make the reasoning process more transparent and give more emphasis to the strong sentiments about non-human organisms held by many potential users. Providing an example of the application of the framework may also increase the appeal of the reasoning process to ecological researchers and biodiversity managers. Relocation as a conservation action can be accompanied by a variety of moral dilemmas that reflect the interconnection of values, ethical positions, and conservation decisions. A model that is designed to address moral dilemmas arising from relocation of humans provides/demonstrates/illustrates a possible way to apply the ecological ethics framework and to involve practicing conservationists in the overall decision-making process.     

Dimensions of Moral Intensity and Ethical Decision Making: An Empirical Study

Moral intensity is a construct that relates to issues in terms of their perceived moral significance. Individuals' perceptions of moral intensity should impact their recognition of issues as posing moral dilemmas and should also affect ethical judgments and behavioral intentions regarding issues. This study examined the relationship between 4 dimensions of moral intensity and the ethical decision-making process. Two work-related actions were presented to respondents, who then completed measures of the 4 dimensions of moral intensity, whether the actions posed an ethical issue, ethical judgments regarding the actions, and the likelihood that they would engage in the actions. Results indicate that moral intensity dimensions were associated with individuals' ethical decisions. Social consensus and seriousness of consequences were particularly important influences on the ethical decision-making process.     

The Moral Dilemmas Debate, Deontic Logic, and the Impotence of Argument

In this paper I argue for modesty concerning what theoretical reason can accomplish in the moral dilemmas debate. Specifically, I contend that philosophers' conclusions for or against moral dilemmas are driven less by rational argument and more by how the moral world intuitively appears to them.I support this thesis by first considering an argument against moral dilemmas, the argument from deontic logic, and showing that its persuasive force depends on one's having already accepted its conclusion. I then make a different, and general, case that any argument in the moral dilemmas debate concerning the defeasibility of conflicting obligations can be marginalized by making not-unreasonable adjustments in the conditions for wrongdoing.These two strands of argument are related by the notion of inescapable wrongdoing. It is our standing intuitions about inescapable wrongdoing which make the relevant deontic logical principles plausible or implausible to us. And whether wrongdoing can be inescapable is central to deciding what the conditions for wrongdoing are. My conclusion is that the arguments in the moral dilemmas debate merely implement whatever standing intuition we have concerning inescapable wrongdoing, and that apart from any such intuition the arguments are unpersuasive.     

Problems in Integrating Traditional Group Therapies with New Group Forms

The authors describe a range of critical issues that are common within homogeneously composed groups for patients suffering from Acquired Immunodeficiency Syndrome (AIDS) and AIDS Related Complex (ARC). They examine the need for these patients to understand their physical symptomatology, to reconsider life's priorities, and to confront their ethical and moral dilemmas. The authors also highlight special affects, unique group atmosphere and process, and the nature of the group contract that is essential for these patients.     

Professional Ambivalence: Accounts of Ethical Practice in Childhood Genetic Testing

Childhood genetic testing raises complex ethical and moral dilemmas for both families and professionals. In the family sphere, the role of communication is a key aspect in the transmission of ‘genetic responsibility’ between adults and children. In the professional sphere, genetic responsibility is an interactional accomplishment emerging from the sometimes competing views over what constitutes the ‘best interests’ of the child in relation to parental preferences on the one hand, and professional judgements on the other. In the present paper we extend our previous research into parental accounts of childhood genetic testing and explore the ethical accounts of professionals in research interviews. Interviews (n = 20) were conducted with professional practitioners involved in the genetic diagnosis and management of children and their families. We first identify four inter-related themes—juxtaposition of parental rights vis-à-vis child’s autonomy, elicitation of the child’s autonomy, avoidance of parental responsibility and recognition of professional uncertainty. Then, using Rhetorical Discourse Analysis, we examine the range of discourse devices through which ethical accounts are situationally illustrated: contrast, reported speech, constructed dialogue, character and event work. An overarching device in these ethical accounts is the use of extreme case scenarios, which reconstruct dilemmas as justifications of professional conduct. While acknowledging ambivalence, our analysis suggests that professional judgement is not a simple matter of implementing ethical principles but rather of managing the practical conditions and consequences of interactions with parents and children. We conclude that more attention is needed to understand the way professional practitioners formulate judgements about ethical practice.     

Recovered Memories of Abuse Among Therapy Patients: A National Survey

This research explored the ethical decision-making process of civilians in response to real-world military dilemmas. Results revealed the complexity of these dilemmas, with about equal proportions of civilians choosing each of two response options. The moral intensity dimension of social consensus significantly predicted moral judgment in both dilemmas, whereas that of magnitude of consequences did so in only one dilemma, partially supporting our hypothesis. Both dimensions were significant predictors of moral intent in both dilemmas as was moral judgment, also supporting our hypotheses. We conclude with suggestions for future research questions in this compelling area.     

Everyday dilemmas: New directions on the judgment and resolution of benevolence–integrity dilemmas

Many everyday dilemmas reflect a conflict between two moral motivations: the desire to adhere to universal principles (integrity) and the desire to improve the welfare of specific individuals in need (benevolence). In this article, we bridge research on moral judgment and trust to introduce a framework that establishes three central distinctions between benevolence and integrity: (1) the degree to which they rely on impartiality, (2) the degree to which they are tied to emotion versus reason, and (3) the degree to which they can be evaluated in isolation. We use this framework to explain existing findings and generate novel predictions about the resolution and judgment of benevolence–integrity dilemmas. Though ethical dilemmas have long been a focus of moral psychology research, recent research has relied on dramatic dilemmas that involve conflicts of utilitarianism and deontology and has failed to represent the ordinary, yet psychologically taxing dilemmas that we frequently face in everyday life. The present article fills this gap, thereby deepening our understanding of moral judgment and decision making and providing practical insights on how decision makers resolve moral conflict.     

Ethical principles of the American Psychological Association: an argument for philosophical and practical ranking

Unlike the American Psychological Association (APA), the Canadian Psychological Association has adopted a code of ethics in which principles are organized in order of importance. The validity of this hierarchical organization has received some empirical and theoretical support. We conducted a theoretical analysis that revealed conceptual justification for a ranking of the 6 principles in the APA code. Such a ranking could assist psychologists in making more informed and consistent moral choices when confronted with ethical dilemmas that involve conflicts among principles.     

The Uses and Abuses of Moral Theory in Bioethics

Moral theory is an important guide to bioethical decision-making, but it can confuse and mislead those who offer ethical advice to clinicians and researchers, delaying decisions that must be made in a timely fashion. In this paper I examine the ways moral theory can lead bioethicists astray. Absent a sensitivity to the empirical realities of ethical problems, moral theory 1) contributes to the disappearance of the persons caught in an ethical quandary, 2) focuses on the puzzle-solving rather than examining the conditions that generate moral problems, and 3) universalizes ethical dilemmas, overlooking local processes for resolving moral questions. Taken together, empirically informed moral theory and theoretically informed empirical research can help bioethicists transcend the is/ought problem in ethical work.     

The influence of decision time on sensitivity for consequences,moral norms,and preferences for inaction: Time,moral judgments,and the CNI model

It is often discussed that moral judgments are either consistent with the principle of utilitarianism or with the principle of deontology. Utilitarianism is a moral principle stating that the right act is the one that produces the best overall outcome. Deontology represents an ethical position indicating that the morality of an action depends on the intrinsic nature of the action regardless of the consequences. Criticism on the structure of moral dilemmas includes the problem that these dilemmas confound norms and consequences. Recently, a multinomial model (the CNI model) was developed to disentangle and measure sensitivity to consequences (C), sensitivity to moral norms (N), and general preference for inaction versus action (I), respectively. In Experiment 1, we examined the influence of time pressure on moral judgments using the CNI model. We found that time pressure influenced moral dilemma judgments by decreasing participants' sensitivity for consequences. There were no significant effects of time pressure on participants' sensitivity to norms and general preference for inaction. Furthermore, in Experiment 2, we examined the link of reaction times to moral judgments more closely by fitting a hierarchical Bayesian version of the CNI model. Longer reaction times lead to an increase in parameter N, and there was no influence of reaction times on parameter C or I.     

The Impact of Constructive Controversy on Moral Development

We examined the effects of a constructive controversy compared with individualistic learning on 3^rd, 4^th, and 5^th‐grade students' (N = 56) moral development, ethical skills, academic achievement, and attitudes toward social interdependence. The results indicated that participating in constructive controversy (compared with individualistic learning) resulted in greater moral development (i.e., moral reasoning, moral motivation, moral character), greater ethical skills (i.e., perspective taking, perception of self as a moral person, rule orientation), higher academic achievement, and more positive attitudes toward competition. These results extend constructive controversy theory, as well as Piagetian and social interdependent theories. They also provide guidance as to how discussions of moral dilemmas and conflicts among students should be structured and conducted.