solving

An Analysis and Justification Method for Ethics

"Men decide many more problems by hate, love, lust, rage,
sorrow, joy, hope, fear, illusion, or some similar emotion,
than by reason or authority, or any legal standards, or legal precedents, or law."
– Cicero

"In a republican nation,
whose citizens are to be led by reason and persuasion and not by force,
the art of reasoning becomes of the first importance."
- Thomas Jefferson

On matters of right and wrong, good and evil, justice and injustice, people are often quick to pick a side. Should the government provide welfare to the poor? Is abortion evil? Is capital punishment justified? On these and many more topics we're fast and sure with our opinions, having lived with and defended them for a long while. There are, however, other ethical issues which force us into a more reflective mode. For example, consider the following:

Case study: the Unstable Mom

" Following an auto accident Ms. A and her four children are admitted to a small rural hospital. Three of the children are doing well, but the fourth, a young girl, was dead on arrival. Ms. A suffers from broken ribs and internal bleeding; she is fully conscious, and deeply distraught over her children. She repeatedly asks how they are doing.”

“Ms. A’s physician, Dr. B, assures her that her children are fine, and writes an order in the chart specifying that Ms. A is not to be told of the child’s death until morning, at which time her condition will have stabilized and her husband will have arrived to support her. Ms. A’s nurse, Ms. C, understands the physician’s concerns but worries that patients have a right to the truth and, in any case, thinks it would be horrible to have to look her patient in the eye and repeat a lie of such magnitude. After the physician has gone, Ms. A asks, “Tell me the truth, are my children all ok, and why can’t I see them?” Ms. C wonders whether she shouldn’t tell this mother what she so clearly wants to know.” [i]

In this case, it is not obvious on first glance whether the doctor or nurse did the right things: telling the truth might very well have caused the mother's death, since she was in an unstable condition; but it is hard to accept a lie of "such magnitude." This is a standard example of a moral dilemma, in that whatever the doctor or nurse does, she seems likely to violate an important moral obligation: the obligation not to cause significant harm, or the obligation to tell the truth to patients under one's care. This is not to say there is no way to avoid the dilemma, or to resolve it satisfactorily, only that there is an apparent conflict of obligations that demands some reflective thinking. The point of this essay is to introduce a method that will provide a fairly systematic way of approaching dilemmas such as the one above. But before going into the method, we need to say a bit about why it is important to have one.

Why Not Just Rely on Gut Instinct?

Obviously, if you find yourself uncertain about what is the right thing to do, a method would be welcome. But what about the cases of welfare, abortion, or capital punishment mentioned above where you are likely to already have a strong feeling about what should be done? Is that enough, or might a more systematic method still prove to be useful?

The aim of a method of analysis and justification is to go beyond gut instincts about moral questions, by giving and weighing reasons for one's views. This process is useful in at least three different ways:

1. Gut instincts won't convince anyone else of your view.

If you have a view about what is right or wrong, saying to someone that it is your deeply felt intuition is not going to be very helpful, informative, or persuasive. But an analysis that identifies the reasons behind your view, and perhaps shows why the reasons on the other side are weaker, would have a chance of convincing an open-minded person that your view is the better one. At the very least, the two of you can begin to understand exactly where you disagree, e.g. whether one of you is weighing the probabilities of a risk to be higher, or holds some value to be more important than others. While there is hardly a guarantee that the method described below will enable you to convince others of all your moral views, the method at least holds more promise than merely relying on one's initial instincts about the matter.

2. Case analysis helps one to understand the real basis of one's own views, rather than leaving them a complete mystery.

If all you have are instincts and intuitions about what is morally right, then you have no idea what grounds your moral views. Since morality is an extremely important part of one's life, governing how one treats one's fellow human beings, and how one expects others to treat oneself, it would be a shame to be so completely in the dark about one's own views of the matter. This is not to say there is no place in ethical analysis where one has to rely on one's intuitions about what is right and wrong, only that such a place is often far from the starting point that gut instincts provide. Discovering that path of reasons for one's views can be an enlightening process.

3. Gut instincts can be mistaken.

For instance, your gut instincts might be based on prejudices and biases learned from parents and teachers who have mislead you. The sons of slave owners tended to "instinctively" feel slavery was perfectly OK, and the daughter of Nazis was convinced it was terribly wrong to help Jews avoid the gas chambers. But these instincts, most of us feel, were mistaken, and the kind of careful thought involved in case analysis can give us a way of avoiding such mistakes.

Another source of mistakes is in simply failing to see the other side of an issue, or perhaps in failing to see the strength of the reasons on that side. In this case, one is not blinded by prejudice, just by ignorance, self-interest, or one's own strong feelings about the matter. But the method of case analysis forces one to consider the reasons on both sides of an issue. If one then finds it impossible to show that the reasons against one's initial view are weak, that suggests the view might not be as secure as one thought, and reassessment is in order. Going through case analysis does not guarantee avoiding mistakes -- no method can guarantee that everyone thinks clearly and insightfully -- but it does provide a framework that helps one to minimize them.

A Four-Step Procedure for Moral Reasoning

As in any case where judgment is involved, there is no substitute for experience and practice in developing good moral reasoning skills: seeing many cases, making tough moral decisions, observing and living with the results. A course in ethics will provide many cases on which to practice. You may well find that on your first glance at each issue, you have a “gut instinct”, an intuitive sense of what should or should not be done. But on reflection, after speaking with others or reading some of the commentaries, it will usually become clear that the intuition needs some support: there are moral arguments, and moral principles on the other side.

The procedure for moral reasoning described below involves four simple steps to take when faced with an ethical issue.[ii] The first three steps are ‘neutral’ ones, involving a careful analysis of the issue with which all parties should agree; only the last step involves taking a stand on the moral issue, and that step requires explaining and justifying (to oneself or others) why one set of reasons outweighs those on the other side. Going through the procedure does not guarantee avoiding mistakes or coming up with the right view -- no procedure can guarantee that everyone thinks clearly and insightfully, and there may be more than one reasonable stand on a moral question. But the recommended procedure does provide a framework that helps one to minimize mistakes, and to better understand the deeper issues involved. The procedure is thus a way to expand your moral imagination, bringing you to take into account more of the moral factors involved in an issue, making your judgments more subtle, complex, and well-grounded.

Step 1: Creative Problem Solving (CPS)

The ideal way of handling a tough ethical dilemma is to come up with a creative plan of action that avoids the whole problem, a plan that cannot be reasonably objected to on moral grounds. This resolves the moral dilemma in the most satisfying manner, by avoiding it – thus not having to choose between the ethically troubling alternatives. In health care contexts, this is often where ethical reflection begins and, with a little good fortune, ends, in a creative strategy which all parties recognize to be ethically untroubling. For instance, if an expensive, medically recommended procedure is not covered by a patient’s insurance, and the patient cannot afford to pay for it, there is an apparent dilemma: forego the procedure, at risk to the patient’s health, or provide it anyway, billing the patient while knowing payment will never be forthcoming. A creative solution would avoid moral controversy, which would mean finding a way to satisfy beneficence – providing good health care to the patient – while not incurring costs that have to be absorbed by others (which might violate fairness, rights, or utility). Perhaps there is another medical procedure, covered by the patient’s insurance, which is a reasonable alternative to the one that is not covered? Or perhaps further negotiations with the insurance agency can convince it to extend the coverage in this instance? If either strategy worked, ethical controversy would be avoided; the problem would be solved.

This stage of moral reasoning is perhaps the most important one for the everyday practice of health care. People in the health care professions are very talented at it, and take it to be a major part of their jobs. Psychology and counseling are quite often at the center stage in such creative problem solving, since ethical dilemmas are often raised by conflicts amongst patients, family, and medical staff, and those conflicts can often be resolved by good dialog, further information, and various other practical strategies (e.g. participation in a support group, viewing of informational videos, etc.) When conflicts between the parties can be resolved, the dilemma goes away as everyone agrees on the proper course of care. But this is not always the case: sometimes health care professionals cannot find successful creative solutions, and must face the hard choice between morally troubling options.

Step 2: Listing Pros and Cons

Faced with the hard choice, one must explore the moral reasons for and against each of the morally troubling choices, the moral “pros and cons”. To keep track of the various ethical considerations, one can construct a simple list of the main options, and the reasons for or against each option. As mechanical as such a procedure seems, keeping track of all of the important moral arguments can make a tremendous difference in the quality of moral reasoning. In a group setting, it ensures all participants have their reasons written down and addressed, and in personal decision-making it provides a map of the relevant moral reasons for further analysis. In addition, this is the point where the CARVE principles are especially useful. After going through the moral reasons you take to be obvious, go through each CARVE principle and see what it would lead you to consider important about the case. This often brings out moral factors you miss at first glance, given your own initial bias about the case, or your specific moral perspective. Even if a consideration seems trivial, if a CARVE principle would point to the reason perhaps it deserves further thought. The resulting list of moral reasons can take the following form (with the CARVE principles included in parentheses to identify the general values behind each reason):

OPTIONS

PROS

CONS

1^st Option

1. Reason for 1^st Option

(CARVE Principle)

3. Reason against 1^st Option

(CARVE Principle)

2^nd Option

2. Reason for 2^nd Option

(CARVE Principle)

4. Reason against 2^nd Option

(CARVE Principle)

The goal at this stage is to provide a map of the moral reasons for further reflection, a map that will be neutral in an important sense, viz. that people who disagree about which option is best could still accept the map as identifying the main moral considerations important to the case. Usually it is best not to list trivial reasons, since that can clutter up the chart, and to keep the options to two or three. Note that not every pro/con box needs to be filled: as long as there is a reason or argument listed on each diagonal (in a two-option chart), each option has something in the chart that is in its favor. Also, be prepared for cases where a reason could fit either as a pro for one option or a con against an alternative. For instance, one might argue for providing surgery for the reason that it could save the patient’s life (a pro), or against foregoing surgery because the patient could die (a con). Rather than double-entering this basic idea, it is best to list the reason one place or the other but not both.

Step 3: Analysis

The next step is the most challenging and difficult one, where the strengths of the various reasons in the pro/con list are evaluated. The key here is to be thorough, seriously considering whether each reason is a strong one, taken independently or in comparison to other reasons on the pro/con list. One way to do this is to keep in mind the question:

What assumptions are necessary to consider the reason extremely important?

Some assumptions will be factual, in the sense of not directly involving moral values. These may not be known or provable, but they are still assumptions about the facts, i.e. about the likelihood of an outcome, the long-term consequences of a decision, or the true motivations or intentions of the parties. But some assumptions will instead be about the deeper values and moral principles at stake, and their relative importance. For instance, if one is considering a complicated rehabilitative surgery to give a disabled patient full use of his arms, one might be making factual assumptions about the degree of risk or the likelihood of success, or one might be making a value assumption about whether it is worth risking a patient’s life to improve its quality in this way. Thus, a reason should be considered a strong one only if it is quite likely to protect or promote an important value. These two judgments, of likelihood and importance, rest on assumptions that need to be examined.

This is especially apparent when people from different religious or cultural backgrounds are involved in a case or its analysis, since such differences often go along with radically different assumptions. For instance, some people from religious traditions assume that spiritual strategies of healing have a very good chance of success. So when physicians admit that an illness is not easily treated with a proven cure, some religious people forego the recommended but uncertain medical strategies, in favor of their spiritual approach. Note that this choice is based on a factual assumption of the religious persons that spiritual strategies have good prospects for curing. The assumption is not ‘factual’ in the sense of ‘provable’, but it is factual in the sense that it has to do with the factual outcomes involved, not with the weighting of values. Alternatively, a religious person might place more value on reverence for life itself, apart from the quality of the life. This could lead to avoiding surgical risks, on the basis of a different value assumption than the one made by a person who counts life not to be worth living, once its quality drops sufficiently.

Notice that this analysis step is still ‘neutral’, in the sense that people who disagree about which option is best can agree on the analysis. At this stage one is only further exploring the reasons, considering what might lead a person to take a reason to be especially strong (or weak), and raising questions about the factual and value assumptions thus unearthed. This means that even before making up one’s mind about a case, or taking a position in a discussion, the proposed method requires one to imaginatively put oneself in the shoes of those who weigh the reasons in different ways. Nevertheless, this can bring to light the more vulnerable or unsupported assumptions, thus leading into the next step of taking a position and defending it. For instance, if an assumption that is crucial to considering a reason a strong one is factual, one can ask if there is any good evidence for it, or if would one be making a mere guess. If one would be guessing, is it reasonable to base a morally significant decision on such a guess? Alternatively, if an assumption is evaluative or moral in nature, one can ask if there are any good moral reasons for that assumption: why should we interpret rights or autonomy in the requisite way, and what moral assumptions are built into that way of interpreting the value? This process helps one to see which are the more and less reasonable weightings of the reasons, since some of the assumptions are likely to look more plausible than others.

In addition, looking at the assumptions behind the evaluation of reasons helps identify what really lies at the core of disagreements about which option is best. In this context a useful question is:

What difference in basic assumptions can explain why reasonable people might disagree about the strength of a reason?

Once again, sometimes the differing assumptions will be about the factual elements of a case -- what is the likelihood of a certain outcome, how a patient will accommodate to a certain outcome – and sometimes the assumptions will be about the values at stake. But it is important to figure out what is the real source of a difference in perspective about the case.

People in health care contexts often focus their discussions and arguments on the strictly factual aspects of bioethics dilemmas: on what the chances are for recovery, on the likely outcome for various parties, on the relevant psychological and legal factors, or on the long-term consequences of a given decision. These are matters about which health care professionals can offer their expert judgments, and such matters are reasonably comfortable to discuss. But restricting the conversation to factual matters risks ignoring the underlying value issues at stake, and it is at least equally important to consider those issues. Indeed, there is sometimes little or no good evidence for some of the factual predictions on which people base their arguments, raising the question of whether their positions are really based on something else, specifically on value assessments that are less comfortable to defend. For instance, one might argue for the rehabilitative surgery mentioned above on the grounds that it safe and quite likely to succeed, when the real reason is that one doesn’t much value a life of disability. So it is important in this analysis step to question any factual assumptions for which there is no real evidence, in case a deeper value commitment is really at work, and then to consider whether that value commitment can be adequately supported.

Step 4: Justification

At this point one has identified the relevant moral reasons, the moral principles on which they depend, and the factual and value assumptions being made by those who take one or another reason to be especially significant. This means one should have a good understanding of the ethical issue, why people might disagree about it, and usually a sense of which option has stronger moral support, in light of the reasons, principles, and assumptions one has determined to be most important or plausible. The next step is to work through a systematic justification of the morally preferable option, explaining why the reasons for that option are more convincing than the reasons on the other side. This can be done in different spirits -- simply to test one’s initial view, or as a final defense of one’s position. It can also be done in different contexts -- as a presentation at a meeting, in conversation with friends, as a series of notes on paper for oneself, or in a formal essay for sharing with others. In any of these cases, the most important thing to remember is to cover all the reasons someone could consider significant, i.e. all the reasons listed in the pro/con chart. An outline of this process can aid in constructing presentations or written work:

I. Introduction: Briefly introduce the moral issue, and indicate the option your analysis has shown to be morally preferable.

II. Support: Write a paragraph detailing what your analysis has shown about each reason that supports the morally preferable option. In each paragraph, introduce and explain the reason, identifying why it is strong or important (if it is), and discussing and defending any factual or value assumptions behind that judgment. The reasons that “support” an option include the pros for the option, but they also include the cons against the alternative options, since those provide indirect support (by working against the alternatives).

III. Defense: Write a paragraph detailing what your analysis has shown about each reason that goes against the morally preferable option. In each paragraph, introduce and explain the reason, identifying why it is weak or unimportant, and discussing and defending any factual or value assumptions behind that judgment. The reasons that “go against” an option include the cons directly against it, as well as the pros that attempt to support the alternative options.

IV. Summary: Summarize the reasoning. Review the most important reason favoring the better option, and remind the reader why the main reason against that option is not as significant.

This format ensures every reason from the pro/con list is carefully presented and evaluated. All too often presentations and written justifications simply put forward the supporting side, including the reasons against alternative views, without explaining why the reasons on the other side, against one’s position, are not being weighed as heavily. That can lead to parties speaking past one another, or to a kind of tunnel vision when working through moral dilemmas on one’s own. A way to avoid this is always to keep in mind a reasonable critic, one who disagrees with your position but is willing to hear your reasons and be convinced if the reasons are good ones. What could sway such a person to weigh the reasons as you would? Here the key is to further defend the factual and value assumptions behind your weighing of reasons. What is your evidence for the factual assumption about which someone might initially disagree? What kinds of moral argument can support a value assumption about the importance of one moral principle, as compared to the other principles at issue in the case? Why might someone disagree, and what mistake or misunderstanding lies behind that disagreement?

A sample case

To see how this four step procedure can be used, consider once again the case of the unstable Mom (from above). Ms. C, a nurse, wonders whether she should do as the physician asked, and lie to a mother, Ms. A, about the death of her daughter in a car crash. It is not obvious at first glance what would be the right thing to do: if Ms. C tells the truth it might cause Ms. A’s condition to worsen, perhaps causing her death; but faced with a direct question the only other option seems to be to tell a lie, one of great magnitude. Telling the truth is responsive to Ms. A’s rights and autonomy, but it threatens to violate non-maleficence, arguably the most important principle governing the care of patients. So this is a genuine moral dilemma, one worth wrestling with.

Step 1: Creative Problem Solving

A natural thought is for Ms. C to try to avoid the dilemma by not directly lying, yet also not telling the mother directly that her child has died. There are various techniques the nurse might use, including simply trying to redirect Ms. A’s concern by saying “we need to worry about you right now.” Alternatively, Ms. C could pretend ignorance of the children’s condition, which would involve a lie, but arguably a less troublesome one than saying that all the children are fine. But notice that these techniques could actually cause Ms. A to become more irritated and anxious about not receiving the answers she is seeking, which may still risk causing her condition to worsen. So the strategies might be worth trying, but if they do lead to psychological frustration and physiological decline, the nurse would be faced still with the question of whether to ease the anxiety by telling the lie.

Another creative strategy would be to find other family or close friends to support the mother before telling her the truth. One could even make sure the husband is on the phone, having been informed of the situation – and perhaps he could help answer whether the mother would be able to handle the news, with his knowledge of how she deals with emotional difficulties. But notice that these sorts of strategies still involve acting against the physician’s orders, a moral concern involving virtue and rights, so they do not completely avoid the dilemma. As a result, such strategies would be best considered part of the option of telling the truth – one could assume, in later reasoning, that such efforts would be made (though not that they would be successful, i.e. that the family or friends or husband would be available and capable of mitigating the stress).

Another possibility would be to medicate Ms. A so that she is unable to ask or worry about her children. Of course, this is very unlikely to be a reasonable option, given Ms. A’s condition, but it may be that induced sleep would be medically advantageous, in which case it is a solution that would avoid the dilemma.

Step 2: Listing the Pros and Cons

Let us suppose these creative strategies all fail, or face serious moral objections, so the nurse faces just two options: telling the mother about the death of her daughter, or lying and saying her daughter is still alive. Of course, there are lots of different ways of telling the truth -- bluntly and insensitively, or with care and compassion. And there are different ways of lying -- saying her daughter is perfectly OK, saying you are unsure how she is doing, or saying she is in surgery. But for simplicity, we can speak of two options, telling the truth and lying, keeping in mind that there are various ways of exercising each of the options.

The question then is which of the two options is the better one, and to answer it we need to list the pros and cons, putting down the obvious ones first. In favor of telling the truth is that the mother has a right to know about the condition of her own child, which involves the CARVE principle of rights. But in favor of lying to her, despite her apparent right to know, is the consideration that the physician has instructed the nurse to do so, and ordinarily nurses should follow physician’s orders. This involves the CARVE principle of virtue, since it is appealing to a general trait of character that nurses should have – a tendency to respect and follow the instructions of the physicians in charge of their patient’s care. Against that idea is of course the thought that lying is wrong, a violation of the autonomy and rights of patients; but against telling the truth is the thought that doing so could seriously harm the mother, given her vulnerable medical condition. This leaves us with the following chart of basic moral pros and cons, with the related CARVE principles in parentheses:

OPTIONS	PROS	CONS
Tell the truth	1. Ms. A has a right to know about her child (Rights)	3. It could cause her condition to worsen (Nonmaleficence)
Lie	2. Dr. B has instructed Ms. C not to tell Ms. A about the daughter’s death (Virtue)	4. Lying is wrong (Autonomy, Rights)

To be systematic, let us go on to consider each of the CARVE principles in more detail, to see if we have missed anything. Nonmaleficence is represented by reason #3, the concern not to harm the mother with the news. Beneficence might lead one to try to comfort Ms. A with the lie, but that concern, while morally relevant in most contexts, is trivial in this one, and so it need not be included. Utility requires looking to all those persons affected by one’s choices, and that means considering others besides the mother, something not yet incorporated in the pro/con list. Who else might be affected? The other children, of course, if the mother is harmed by hearing the news. There is also a larger concern about the effects of lying on the reputation of health care professionals. If the lie is told, the mother may come to distrust and resent those who lied to her, and that sentiment is one she may share with others. This could harm the reputation of the profession – however important and well-intentioned the lie may have been – leading to future patients not trusting medical professionals, which could mean withholding information or even refraining from seeking medical assistance (at least until it is urgent, and perhaps too late). These are significant concerns overlooked in the first list, and worth adding as a separate reason against lying (see below).

As for the principle of respect for autonomy, its protection of self-determination mitigates against lying, as reflected already in the chart. Autonomy might also tell against reason #3, on the grounds that the nurse’s autonomy means she should make her own moral decision. That is worth noting, but it is something that can be considered later in analysis and justification, rather than listing in the chart, since it concerns an evaluation of the strength of a reason rather than a new reason altogether. Rights are represented – the right to know the truth about your children, and the right not to be lied to. Virtue appears, as the idea that a good nurse should follow a physician’s orders. But notice that virtue can cut the other way: it is not obvious that the virtue of obedience should override virtues of honesty and integrity in the nursing profession. So it would be worth inserting this idea into the chart, especially since Ms. C’s own concern, as reflected in the case description, seems to have to do with the matter of her own personal integrity in participating in the lie (see below). Finally, equality (and the related concept of fairness) do not seem directly relevant, unless one speaks of the unfairness of lying to the mother, something better captured by the idea of her rights. The revised pro/con list then reads:

OPTIONS

PROS

CONS

Tell the truth

1. Ms. A has a right to know about her child (Rights)

3. It could cause her condition to worsen (Nonmaleficence)

Lie

2. Dr. B has instructed Ms. C not to tell Ms. A about the daughter’s death (Virtue)

4. Lying is wrong (Autonomy, Rights)

5. May contribute to loss of trust in the medical profession (Utility)

6. Violates the nurse’s honesty and integrity (Virtue)

Step 3: Analysis

All the reasons listed in the chart are morally relevant, and have some moral force. What assumptions must be made to consider any one reason substantially stronger than another?

The most obvious place to start is with assumptions about how likely the truth is to cause the mother serious harm. One might assume that there is a significant risk, on the grounds that this must be why the doctor wanted to wait until the morning, or based on general knowledge of the effects of emotional stress on the physiology of those under critical care. But is this sufficient evidence? Alternatively, one could argue that it is just as likely the doctor simply wanted to wait so the husband could deal with the mother and her emotional reaction, rather than having to deal with it himself.

If we are forced to admit uncertainty about the likelihood of harm, it raises the question of what the ‘default’ position should be when one is uncertain about causing harm. One might assume that even a slight chance of causing death is a powerful, overwhelming moral consideration, based on the idea that the most significant moral principle for health care is to avoid harm. Note that this would be an assumption about values, not an assumption about the facts; people who agree about the chance of causing death could disagree about its moral importance. For why think non-maleficence should override prohibitions on lying, or considerations of rights and autonomy? In recent years more emphasis has been put on respecting the rights and autonomy of patients, even when doing so means that patients may be harmed by hearing bad news, or be allowed to make poor choices. Why not extend this argument to cases where risk of death is involved? Here it might be useful to consider what led to the increased importance of autonomy and rights in health care, and whether the reasons extend to the current kind of case.

Alternatively, one might assume patient’s rights and autonomy are so important that they can only be overridden if there is clear and convincing evidence of its necessity to avoid serious harm. What could justify putting the burden of proof on the side of the paternalist here? Is this based on a suspicion of the motives of physicians, or on a prioritization of principles of autonomy and rights? If the former, what is the evidence; if the latter, what considerations (or examples) might be used to show that the patient’s welfare should not be the sole or main focus of health care ethics? One way to think about this is to notice that there is a chance the mother will die even if lied to, and then she would die under the false belief that her daughter was fine. Is that a terrible thing, suggesting that there is something important about knowing (and telling) the truth regardless of the consequences? Or is it a mercy that the mother did not have to spend her last hours agonizing over the loss of her child, and perhaps her own responsibility for the death?

Similar analysis can be provided for the other reasons in the chart. What assumptions are involved in thinking a nurse should follow a physician’s orders (reason # 2), even when those conflict with the nurse’s own moral judgment? Is that based on an assumption about the best role for nurses in overall practice, as in worries about nurses regularly second-guessing physicians in ways that could cause harm? What is the evidence for that? If one assumes nurses should follow their own moral compass, valuing integrity and professional autonomy over obedience to physicians, what justifies that assumption? Again, is it based on assumptions about what would work better for the health care profession, for example that nurses are needed in certain cases to protect patients against mistaken or unethical conduct by physicians? What justifies that assumption? Or perhaps there are value assumptions at the root of this question of virtue: perhaps anyone, in any job, should always consider his or her own moral compass, at least when asked by superiors to do things which would be a serious violation of his or her moral conscience. Perhaps that is a view based simply on the dignity of human beings, their ultimate autonomy to live by their own values?

Another reason worth examining is #4, that lying is wrong. Some people assume all lies are serious moral violations, while others take beneficent and ‘white’ lies to be morally legitimate.[iii] What is behind these differing assumptions? In the case at hand, all would agree the lie is one of great magnitude or import, so it isn’t a trivial or ‘white’ lie, but arguably it is a beneficent lie – designed to save a life. What assumption must be made to think this beneficence sufficient to justify the lie? Is the assumption that the reason lying is wrong is that it typically is harmful to persons to lie? Is that the essence of the wrongness of lying? Or is lying an interference with rights not so easily overridden by considerations of utility? What assumption must one make to think lying is wrong independent of such utility considerations? If no one is harmed by a lie – indeed, if people are helped -- what is left to make the lie wrong?

Step 4: Justification

At this point, having worked through the analysis, one should be better prepared to determine which option is morally preferable. There may be room for reasonable people to disagree about the current case, but let us consider the position that the nurse should lie to the mother, waiting until the morning and the arrival of her husband to tell her of her loss. A justification, fitting the recommended format, could be offered as follows:

I. Introduction:

Faced with Ms. A’s continual request for information about her children, Ms. C should follow the physician’s orders and lie, seeking to calm the mother and help her make it through the night, when she will be in a more stable and safer condition to receive the news about her loss.

II. Support:

The most significant reason for this course of action is the need to protect Ms. A from harm (reason #3). Telling Ms. A of the death of her child could cause her condition to worsen, and increase the risk that she will die. These are reasonably likely consequences, given that she is likely to feel substantial grief and anguish about her involvement, and those emotions are well known to cause physiological stresses that threaten those under critical care. The likelihood is further supported by the physician’s order, written in the chart, which indicates the seriousness of the threat in the eyes of the physician. It is not for a nurse to second-guess such a medical judgment. Moreover, it is extremely important that a nurse not cause such harms, or take substantial risk of doing so. That is the primary ethical command in health care, since its purpose is defined by the goal of tending to the well-being of patients.

Another reason for telling this difficult lie is that the nurse is on orders from the doctor to do so (reason #2). This is not a trivial reason, since physicians are in a clear line of command over nurses. It is an important virtue of nurses that they respect and obey the directives of physicians, since that is their nursing role and generally reflects the differences in levels of education, training, and expertise. Nevertheless, it must be admitted that there is also an important role for nursing autonomy, even on medical questions about which the nurse is especially experienced, and certainly on ethical questions, since a physician’s medical training is no guarantee of superior ethical instincts. In addition, respect for moral integrity requires that nurses be considered free to consult their own moral conscience. So if a nurse believes following a physician’s orders would involve a serious violation of ethics, it should be open to the nurse to not do so. As a result, this reason is not a strong one in this case – the nurse has serious reservations, and the existence of a physician’s orders does not alone settle what to do.

[Notice: each supporting reason listed in the chart above has been considered, although the author says one of the reasons is not a very important one. The goal is to represent one's own genuine views, not to simply use any reason that one can.)

III. Defense:

A significant reason against lying is the simple idea that lying is wrong, a violation of patients’ rights and their autonomy (reason #4). For this reason to prevail, in the face of the risk to Ms. A’s life, we would need to assume that considerations of rights and autonomy are of equal or greater import than ones of welfare in health care contexts. But what could justify such an assumption? The central mission of medicine is by any lights to serve patient well-being, and any rights or other moral rules are themselves best understood in the service of that mission. It is true that in recent years medical paternalism and its prioritization of patient welfare over autonomy has become less accepted, cut back by various rules and laws about informed consent and the rights of patients. But the history of these changes shows that the new rules and laws were developed precisely because they were seen as necessary to protect patients. Thus informed consent rules have their birth in the discovery of the abuse of patients in medical research (most importantly in the case of the Tuskegee Syphilis Study). And many of the other rules are due to the decline of the family doctor and the rise of bureaucratic, specialized medicine, where the familiarity and trust crucial to a paternalist model are far more rare. So while there are some good utility reasons for taking rights and autonomy seriously, they do not extend to situations where a person’s unwanted and preventable death might be the result. In such a context, one should always look to the ultimate mission of medicine and err on the side of life.

Another argument against lying is that the mother has a right to know information about her own daughter (reason #1). This is true, but there is the question of timing. The mother has the right to know at some point, but not necessarily right away, in a situation where knowing could endanger her health (or that of others). The right to know is like the right to free speech: it generally holds, but not when someone wants to yell "fire" in a crowded theatre. Telling the mother the truth immediately would be like yelling "fire”, possibly leading to serious harm or death, and so we need not do so.”

“There are also concerns about whether lying in this case, or in cases like this one, could lead to a decrease in trust and respect for the medical profession (reason #5). Again, this is an important consideration, but not a crucial one. The mother will learn the truth in the morning, and it can be explained that the delay was to protect her own life given her unstable condition. Some mothers would focus on the loss of their child, and forget, forgive, or even be grateful for the beneficent lie. Others may be indignant and severely upset, but it is doubtful that would last very long. The chance that Ms. A will reject the paternalist justification, leading to a long-term distrust of the medical profession that leads to her not seeking necessary care, is fairly small, and worth risking in face of the alternative of definitely risking her health and survival this very night.”

“Finally, the point can be raised that for the nurse to tell a lie goes against the virtues of honesty and integrity, virtues which we would want nurses to cultivate (reason #6). Here the key is to recognize that those virtues, like all virtues, need to be evaluated in context. Honesty is important, as a basic disposition to tell the truth, but there are exceptions where telling the truth can be a vice. That is obvious when it comes to truths which are confidential or inappropriate, but it also means that there are some cases where lying is consistent with virtue, as in the trivial cases of white lies to put people at ease in social situations (“fine, how are you?”). As for integrity, if the nurse thinks through the arguments put forward here, she would recognize the moral legitimacy of the lie, and thus it would not violate her integrity to do so. So the virtues of honesty and integrity are insufficient to undermine the beneficent lie in this case, as important as they are in other contexts.

IV. Summary:

As difficult as it may be for Ms. C, she should tell Ms. A that her children are doing well, to help increase Ms. C’s chances of getting through the night. The sole reason is to avoid worsening Ms. A’s condition with the terrible news of her child’s death. Though telling the lie flies in the face of many ordinary moral norms, it is justified by the motive behind it – protecting the well-being of the patient – and the primacy of that motive in the mission of health care.

Quick recap: here are the four basic steps of the recommended procedure for ethical reasoning:

1.      CPS: Creative Problem Solving
2.      CHART: Charting the Pros and Cons
3.      DIAGNOSIS: A Diagnosis of Why People Might Disagree (facts/values)
4.      JUSTIFICATION: A Justification of Your Position

Steps 1-3 can be done briefly, in outline form (partial sentences). Only Step 4, Justification, requires a full essay. The essay in Step 4 should follow the following outline:

4. JUSTIFICATION

|I.      Introduction: Briefly introduce the moral issue, and indicate the option your analysis has shown to be morally preferable.

II. Support: Write a paragraph detailing what your analysis has shown about each reason that supports the morally preferable option. In each paragraph, introduce and explain the reason, identifying why it is strong or important (if it is), and discussing and defending any factual or value assumptions behind that judgment. The reasons that “support” an option include the pros for the option, but they also include the cons against the alternative options, since those provide indirect support (by working against the alternatives).

III. Defense: Write a paragraph detailing what your analysis has shown about each reason that goes against the morally preferable option. In each paragraph, introduce and explain the reason, identifying why it is weak or unimportant, and discussing and defending any factual or value assumptions behind that judgment. The reasons that “go against” an option include the cons directly against it, as well as the pros that attempt to support the alternative options.

IV. Summary: Summarize the reasoning. Review the most important reason favoring the better option, and remind the reader why the main reason against that option is not as significant.

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