02-24-03
Is It Possible To Be Ethical?
John F. Morris
Summary
In the wake of recent corporate scandals, the topic of ethics is gaining new attention. But is it possible to act ethically while meeting the needs and expectations of everyone involved in a dilemma? The model presented here provides a step-by-step process for ethical decision making that aims at consensus among all those involved in an ethical dilemma.
One of the common complaints about ethics is that most ethical dilemmas seem too complicated to be solved. Although it is true that ethical dilemmas can often become quite complex, especially in today's technological, global community, resolving ethical dilemmas need not be viewed as an impossible task. To claim at the outset that ethics simply cannot be accommodated is to set one's self up for failure. Even the most difficult of ethical dilemmas can be sorted through and resolved with enough time, patience, and careful reflection.
This article offers a model for ethical decision making that strives to help its users reach consensus. Although many in the public forum are fond of the claim that we can all just "agree to disagree," such an approach simply cannot work when one has entered into a therapeutic relationship, thereby making a professional promise to assist someone in the pursuit of health and optimal occupational performance. Therapy is a collaborative effort, and consensus is an implicit part of collaboration.
Striving for Consensus
To clarify the need for consensus in the therapeutic relationship, we must understand what it means. Let me begin with what consensus is not. Consensus is not 100%, total agreement. Anyone could rightly question whether, in a pluralistic society, total agreement can ever be achieved. Further, consensus cannot be completely equated with compromise. Most will recognize that compromise involves giving up something you believe in or hold as a value. However, one of the foundational points of ethics is that each person must maintain personal integrity, meaning that to remain ethical there are some things that each of us should not be asked to give up. Each of us must guard the sanctity of our own conscience. Ethics never obligates one to sacrifice her or his own integrity.
What, then, does consensus entail? I would suggest that authentic consensus is achieved when all parties involved in a debate, dispute, or dilemma can accept and live with the decision being offered. By the phrase live with I mean that the decision under consideration does not violate one's integrity and conscience. Such a decision may not be one's top choice—to that degree, there is some give and take in arriving at consensus. But all involved must be able to accept the decision and follow through with the recommended course of action. Given this, the task of reaching a consensus must involve dialogue with all those involved.
Dialogue, of course, takes time, and so this phase is often where problems arise. Many are under the impression that ethical decisions must be made quickly and on the spur-of-the-moment. This attitude may partly reflect the influence of capitalism on contemporary American society. The business community tells us we need to be ready to respond to the global market at any time, that opportunities only come along once and can be lost in a minute, and that in the world of business the slow always lose. And so, we live in a world of overnight shipping, 24-hour stores, e-commerce, and fast food. Naturally, many assume that ethical decision making must follow the same model—be quick and responsive to the marketplace of dilemmas.
But is this presumption true? No. We all remember the story of the tortoise and the hare. Speed has its uses, but it can also breed recklessness. Remember such marketing fiascoes as New Coke and Pepsi Clear? In a hospital emergency room, decisions often need to be made quickly (although rarely as fast as the popular television drama portrays them). But for most of health care and therapy, there is indeed time to carefully study and reflect before making a decision—if one but takes the time, or requests it of others. Indeed, it is even better from a business standpoint to take some time before acting instead of spending twice as much time after the fact trying to clean up whatever mess has been made. And some decisions can never really be "cleaned up."
And so, the first step in sound ethical decision making is to take the time to reflect on one's actions from the perspective of ethics. I often hear from people who have found themselves seemingly trapped in very complex ethical dilemmas when they never even realized that what they had been doing had ethical implications—it was just business, just billing, just legal, just personal, etc., etc., etc. Furthermore, the truly complicated ethical dilemmas that we so often hear about on newsmagazine shows rarely arise from a single action—more often, they are the result of a series of smaller, but still unethical, actions. Carefully reflecting on one's day-to-day actions can go a long way toward avoiding these larger dilemmas.
A Model for Ethical Decision Making
Even the most careful people can find themselves facing an ethical dilemma—either one of their own doing or one into which they have been dragged. So, how can one resolve a complex ethical dilemma? With so many different theories of ethics to choose from, how can one really figure out the best way to act? Is ethics just a crapshoot—roll the dice and take your chances? Again, my response to this is, no! What is needed is a way to sort through the complexity of a moral dilemma. To this end, I offer the following model for ethical decision making.
This model has developed through a collaborative effort with other professionals, and I have presented it in ethics courses and workshops. I do not offer it as the only way to solve ethical dilemmas, but merely as one possible guide for sorting through the complexity of some of the challenges we find ourselves facing from day to day. As such, this model is a response to the claim that ethics is often too complex to really address. Using a model can help one break the dilemma into manageable pieces, thereby reducing the complexity of the situation. It is also worth noting that using a model for thinking through a problem will not necessarily make ethics "simple." Indeed, most often the difficult part of ethics is following through upon the decision one has reached—knowing what is right and doing what is right are two different things. And so, the goal of this model is to present an orderly way of approaching an ethical dilemma so that one can have a firmer foundation from which to make an ethical decision as well as increased confidence in following through with that action.
Am I Facing an Ethical Dilemma?
The process of ethical decision making begins, quite naturally, with the realization that one may be facing an ethical dilemma. I start the model with this question, however, because at times what may appear to be an ethical problem may actually be more of a legal matter, a personnel issue, or some other kind of dilemma (although at times laws and policies are broken and concurrently ethical principles are violated). So the first question is, does the situation involve a violation of the AOTA Occupational Therapy Code of Ethics (2000)?1 Does the problem impinge upon your personal integrity and conscience? If so, then you may be facing an ethical dilemma, and you should begin to clarify the situation.
What Are the Relevant Facts, Values, and Beliefs?
As you begin to examine the situation causing the dilemma, you should carefully examine all the pertinent facts—which also means sorting through those factors that are irrelevant. In many cases ethical problems arise, in part, because one or both parties do not know all the facts. In such cases getting the facts straight at the outset may lead to a quick resolution.
It is also important to try to identify the values at stake in the dilemma—both your own and those of everyone else directly involved. Values are those things we hold dear, and when values clash, ethical dilemmas arise. A misunderstanding, or outright ignoring, of others' values will only worsen the situation, putting resolution and consensus further out of reach.
Finally, what are the beliefs guiding everyone involved? Beliefs and values are both subjective, and so they will vary from person to person. But recognizing different beliefs can lead to understanding—even when disagreement over the beliefs remains.
Being clear about the facts, values, and beliefs involved in an ethical dilemma will help pave the way for dialogue among all those involved.
Who Are the Key People Involved?
Next, identify the people involved in the dilemma. It can also be helpful to prioritize each person's role. For example, in all dilemmas surrounding the therapeutic relationship, the client being served should always remain at the forefront of the dialogue.
As part of identifying the key people involved, it is also helpful to consider what might be called the "ripple effect" in ethics—those people not directly involved at that precise moment, but who nonetheless will be affected (e.g., future clients, other students or faculty, other members of a clinic or hospital, other professionals, the school district, etc.).
Be thorough, so as not to leave anyone out of consideration. True dialogue cannot take place if everyone does not have a seat at the table.
State the Dilemma Clearly
As you begin to sort through the details of the situation under consideration, you must be able to bring the problem into focus. A helpful format for structuring the dilemma is to form a question identifying the possible ethical conclusions: "Is it (or
was it)
permissible,
impermissible, or
obligatory to _______________?"
2 Stating the dilemma in this manner leaves the issue under consideration open ended and allows for honest dialogue and debate. Being able to state the dilemma also provides direction for the dialogue. If you are in a situation that involves multiple problems, it is best to focus on the most pressing issue in need of resolution first. The other problems can be addressed at a later time. However, care should be taken not to lump too many problems together, because doing so just adds to the confusion of sorting through complex problems. It is better to sort through each problem on its own so as not to miss anything important. This kind of careful reflection can also help avoid future problems of a similar nature.
Analyze
What Are the Possible Courses of Action?
After it is clear that you are indeed facing an ethical dilemma, and you have identified the key factors and people involved with the problem, you can begin to search for a resolution. The first step in moving toward a consensus is to identify possible courses of action. For example, in every situation, you could always just do nothing. Even if you were in a situation in which you absolutely knew you were going to do something, it is helpful to recognize that doing nothing is always an option.
Laying out the possible actions facilitates being thorough in your reflections, and considering all the possibilities can help keep you from missing something important. People having serious dilemmas often point out that they did not realize all of their options before ending up in their present situation. We hear people say, "What was I thinking?" But the problem may have been that they were not thinking—at least not thoroughly enough to avoid trouble. Taking time for reflection will add to the dialogue involved with resolving the situation at hand.
What Conflicts Could Arise From Each Action?
After the possible courses of action are identified, they must be analyzed. The task here is to consider the impact of each action as reasonably as possible. It is also important to consider the possible course of action from the vantage point of each of the key people involved with the dilemma. Granted, we cannot always predict how people will react, but the point here is not to play fortune teller; rather, the idea is to consider the consequences of your actions—both for yourself and for everyone else involved.
Through the process of identifying the conflicts involved with certain actions, you will begin to see why certain actions are not viable—either because they are impractical or because there is something preventing them from occurring, or even because they can now be seen as unethical. With such an analysis you will be able to explain and, if necessary, defend your actions.
The ultimate goal of this analysis, then, is to identify a single course of action, or a connected series of actions, that will resolve the dilemma. It is this proposed course of action that will then be evaluated for its adherence to ethical standards.
Evaluate
The final part of the ethical decision-making process evaluates the proposed course of action. For this part of the process I am going to work backwards, so to speak, beginning with an examination of one's self-interests, to a consideration of one's social roles, then finally to a consideration of the Code and general ethical principles. This part of the model reflects the model proffered by Gregory Beabout and Daryl Wennemann in Applied Professional Ethics,2 which builds on Developmental Psychologist Lawrence Kohlberg's ideas about moral development but also considers a critique of Kohlberg's work that incorporates notions of Carol Gilligan's "ethics of caring." The reason for this approach is that we must be careful not to justify our decisions through a simple process of rationalization. Beginning with the Code and principles may give the appearance of not being fair in our deliberations, and not recognizing that at times we have a personal interest in a decision or in fulfilling a social role that is pressuring us to act. To avoid any such problems, it helps to begin with self-interest and build toward general ethical principles. That way, it will be clearer that your principles are supporting the decision at the highest levels of moral reasoning, as opposed to your own interests.
4. Self-Interests (Level I)
The simple fact is that each of us has personal interests at stake in the actions we perform. This alone is not necessarily a problem. We all want to give and receive good things—while at the same time we want to avoid having bad things happen to us. When a therapist creates a technically sound intervention that is also successful, it is quite natural to feel good about this accomplishment. Most people who enter the profession of occupational therapy do so because they want to help people. The problem arises when a person focuses only on his or her own interests, especially to the detriment and neglect of others. For example, spending $200 on a weekend golfing trip is not in itself unethical. But it would be if a parent did so at the expense of necessary food and clothing for his or her children. The first case is clearly an example of self-interest; the second evolves into selfishness. Therefore, it is important to recognize one's personal interests in a situation so as to recognize which interests are appropriate and which are not.
Some people believe that we should all act at the level of self-interest. This ethical theory is known as egoism and has been defended by people such as Ayn Rand. The idea behind the theory is to maximize one's personal happiness. But the problem is that our interests always conflict. I might want to speed to get home faster—but I don't want to get a ticket. If I am an egoist, and I decide to be safe and not speed, then when I get home without I ticket I think, "I could have sped and been home 20 minutes ago—there weren't any cops out tonight!" But if I speed and get a ticket, then I chastise myself, saying, "I knew this would happen—I should have been more careful!" In short, every action that holds some promise of benefit also brings with it some risk or hardship. The dieter wants to eat the doughnut, but not gain weight. The two interests are incompatible. And so, when one begins to thoroughly reflect on all the options that go into making a decision, it becomes clear that acting solely out of personal interest will not bring satisfactory results. Nor will this approach help us attain a consensus; rather, it only divides us.
Identify your interests, admit that they are there, then move on to a higher level of moral reasoning.
3. Social Roles (Level II)
After you move past the narrow focus of self-interest, you begin to realize that you belong to various communities. These communities are broad and include family, work, religious group, political affiliation, and friends. You will also begin to realize that the members of these groups have certain expectations of each other. These expectations establish our social roles. With our social roles come obligations. At this level, then, one moves out of the purely individualistic thinking of self-interest and begins to recognize that other people also matter. Regarding the needs and interests of others moves us to consider how our actions affect others in the groups to which we belong so as to further the interests and needs of the group over our own. It is helpful to identify your social roles in a dilemma and to clarify the expectations that may be influencing your thinking.
Clearly, social roles provide a better and more satisfactory perspective for ethics than pure self-interest. Yet, this level does have its limitations because our social roles often conflict. A promotion at work that requires travel may bring added income for your family, helping to fulfill the social role of provider. But the travel required will also reduce time spent with the family, which detracts from the social roles of spouse and parent. Because each of us has so many different social roles, trying to use these roles as a basis for making a decision is often difficult—clear solutions can be hard to find.
A second problem with this level is that it is not all-inclusive. Whereas our social roles call us to consider the other members of our groups, they do not necessarily move us toward the needs and interests of those who fall outside our social groups. If I am a Democrat, do I have to care about a Republican? If I am Baptist, should I care about the Jews? Is my only priority to care for my family, or do I have any obligations toward people in other countries? At this level there is nothing that pushes us to look past our own social groups to a more global perspective.
In the end, we can see that each of us has multiple social roles, and those roles tend to cause tension in our lives. Resolving these conflicts requires a higher level of moral reasoning, one that can help us prioritize our roles and bring them into harmony. This higher perspective can also draw us to a more inclusive view of humanity that challenges us to recognize the needs and rights of all.
2. Code of Ethics (Level II)
The highest level of moral reasoning is the level of universal moral principles, such as those embodied in the AOTA
Occupational Therapy Code of Ethics. These are principles that apply to all occupational therapy personnel, regardless of race, gender, and creed. The spirit of the
Code is not limited only to members of AOTA, but extends an obligation of respect and care toward all.
As you continue to reflect on the proposed course of action, having identified personal interests and social roles, evaluating the action using the Code will bring you toward resolution. Does the Code explicitly require that the action under consideration be performed? Does the Code explicitly forbid the proposed course of action? If the Code is not explicit, what is the spirit of the Code regarding the situation? Use the Code and its principles to support your decision or to show why the decision is unethical and should not be carried out. In doing so, you will recognize how personal interests and social roles are brought into harmony through the higher, unifying perspective of the Occupational Therapy Code of Ethics.
1. Ethical Principles (Level III)
You can often further support a good decision with more general, ethical norms, such as justice, beneficence, autonomy, and so forth, which form the philosophical basis for the
Occupational Therapy Code of Ethics. Appealing to general ethical principles is especially helpful when dealing with people who are not members of the profession and who have no specific obligations toward the
Code. By pointing out the general societal norms that further support the decision at hand, you can show that action was not based solely on the role of occupational therapy (which would be Level II thinking), but rather is truly based on ethical principles. Additionally, an appeal to general ethical principles helps foster dialogue and will help further the spirit of the AOTA
Occupational Therapy Code of Ethics in the public forum.
Proceed: Yes or No
In the end, the final question to ask is: "Does your proposed course of action lead to consensus?" If yes, then proceed, knowing that the decision can be supported and defended. If no, then return to the analysis portion of the model and review your evaluations. Perhaps there were more options that you did not consider, or another course of action could be proposed for evaluation.
Conclusion
We should not be alarmed when we find that we have no consensus and that we must continue our ethical deliberations and dialogue. The process of ethical decision making can indeed be involved, especially as a situation becomes more serious. I offer the model work sheet here (see Figure 1 under Related Content in right column.) because in difficult cases it can help to sit down and organize our thoughts on paper. The work sheet can even prove useful in a group setting to foster dialogue and to help reach consensus.
If time does not allow for further consideration, then you must do the best you can and be open to reflection and critique in the future. Remember, becoming a virtuous person takes time and experience. It is a life-long endeavor. That does not mean we can be cavalier with our decisions now and straighten up later. But it does mean that we most likely will not get everything right the first time around. Through our life experiences we all grow and develop. The same is true of our ethics. The decisions we make affect our future selves. Good decisions pave the way for more good decisions, and bad decisions must be dealt with if we are to improve ourselves and our world.
References
1. American Occupational Therapy Association. (2000). Occupational Therapy Code of Ethics (2000). American Journal of Occupational Therapy, 54, 614–616.
2. Beabout, G. R., & Wennemann, D. J. (1994). Applied professional ethics. New York: University Press of America.
Acknowledgments
Many thanks go to Robin Bowen, EdD, OTR, FAOTA, and Shelly Chabon, PhD, CCC-SLP. Drs. Bowen and Chabon are members of Rockhurst University and have collaborated with me on the development of this model of ethical decision making. Both have also presented this model with me at professional conferences. I especially thank them for their gracious permission to publish this model for use by members of AOTA.
John F. Morris, PhD, is the public member of AOTA's Commission on Standards and Ethics.
For More Information
Core Values and Attitudes of Occupational Therapy Practice
By the American Occupational Therapy Association. American Journal of Occupational Therapy, 47, 1085–1086.
Reference Guide to the Occupational Therapy Code of Ethics (Rev.)
Edited by J. Scott, 2003. Bethesda, MD: American Occupational Therapy Association. ($20 for members, $25 for nonmembers. To order, call 877-404-AOTA or go to www.aota.org. Order #1139B-MI)
AOTA's Ethics Office is available to help you sort through your ethical dilemmas. Contact the Ethics Office at ethics@aota.org or 301-652-6611, ext. 2903.
