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Markkula Center for Applied Ethics

Ethical Case-Reasoning in Behavioral Health

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In summary, the framework asks moral reasoners to distill background facts and identify all relevant stakeholders before articulating options for ethical action. Then, it encourages them to ask: 

• Which option will produce the most good and do the least harm? (The utilitarian approach) 
• Which option best respects the rights of all who have a stake? (The rights approach) 
• Which option treats people equally or proportionally? (The justice approach) 
• Which option best serves the community as a whole? (The common good approach) 
• Which option leads me to act as the sort of person I want to be? (The virtue approach) 

Mindfully proceeding through these questions can greatly assist moral reasoners facing a difficult case. In some cases, the results of that process may converge clearly on one best option. 

Sometimes, however, such questioning reveals answers in conflict. For example, what if the option that one thinks will do the most good violates a patient’s rights? 

Distinctive tensions within mental and behavioral health complicate things further. For example, respecting patient’s autonomous wishes is generally one way of respecting patient rights. But what if a substance abuse patient in relapse, or a patient with a mental health disorder in an acute episode, voices wishes different from he or she have when more stable? Respecting which wishes best honors patient rights? 

In cases of conflicting moral claims, what is needed is a systematic way of thinking through ethical dilemmas. A robust process should encourage re-evaluation of options (could there be any new creative options that reduce tension between moral goals?), and enable negotiation of trade-offs. 

Two senses of “dilemma” 

It is important to distinguish between two senses of the term “ethical dilemma.” In common parlance, the term is used to describe situations in which the moral actor feels tension between two or more moral principles or values that one normally wishes to uphold. In other words, the term is used as a shorthand label for situations experienced as “hard cases.” 

However, in the philosophical sense, “dilemma” has a narrower definition. Philosophically, a true, or strict, dilemma is a situation in which the conflict between ethical values is so extreme that there is no course of action available except those which violate one ethical ideal for the sake of the other. 

True, strict dilemmas are a smaller subset of cases that may feel like dilemmas in the broader sense of common parlance. 

Avoiding strict dilemmas when possible 

Of course, health professionals and others should try as much as possible to avoid strict dilemmas, by discerning ways of acting that either lessen the tension between competing values, or balance competing values. Indeed, it can be a serious ethical error to wrongly interpret a challenging situation as a strict dilemma--thereby justifying the violation of a commonly-held ethical value---when in fact there were other courses of action that could reduce or balance the tension between ideals without violating one for the sake of another. 

Negotiating unavoidable strict dilemmas 

How should one proceed when convinced through the framework-process that a situation indeed poses a strict dilemma? 
Tom Beauchamp and James Childress suggest the following tests for potential choices about which ethical value to violate for the sake of the other:3 

• “Better reasons can be offered to act on the overriding norm than on the infringed norm” (for example if intrinsic rights are at stake in one but not the other); 
• “The moral objective justifying the infringement must have a realistic chance of suçcess;” 
• “The infringement selected must be the least possible infringement;” 
• “The agent must act impartially in regard to affected parties” (un-influenced by morally irrelevant information about any party). 
• “The agent must seek to minimize the negative effects of the infringement;” 

According to Beauchamp and Childress, violating norms even when necessary in a strict dilemma results in ethically “stained hands.” Even when ethically unavoidable, the violation will not only hurt one party’s interest or undermine one moral value. It will also hurt the moral actor’s character, by eroding the cultivated habituation of honoring the infringed value. 

That is why it is so important to: 

• try to avoid strict dilemmas; 
• when faced with one, try as much as possible to mitigate the negative effects caused by the infringement of one ethical ideal, both in the short and long run. 

3 Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 5th ed. Oxford University Press, 2001; pp. 19-21 

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