Ethical Decision Making Model for Marriage and Family Therapy Exercise “


Ethical decision making can be difficult because some things have very specific laws and criteria to follow and other decisions are guided by grey area. For this assignment, you will select an ethical decision-making model from the list of models provided below and critically evaluate the model in relation to its process for ethical decision making. After providing a critical evaluation of the selected model, develop a checklist or decision algorithm from the model that you can use to guide your ethical decision making during supervision and clinical practice. Then discuss, how you as a supervisor will help your trainees and associates maintain their awareness, learn to find, understand, and utilize law and ethics in their own clinical practice. 


Evaluate the ethical model you are using to develop your ethical decision making algorithm/decision tree or checklist.  Use the following questions to guide your evaluation. 

  • What are the stated or implied process of the model that guide the decision making process?
  • What questions does the model create for the decision maker?

What should or does the decision maker do with the answers to these questions?

  • Develop your ethical decision making algorithm/decision tree or checklist  (page 2 of your document)
  • Evaluate your algorithm or checklist’s potential effectiveness by applying it to 1 or more of the scenarios listed below (Developed by AAMFT) and using the following questions to guide your responses (page 3 of your document).
  • What ethical issues should be considered?
  • How would you apply your decision making model to this issue?
  • What are several actions that could be taken based on your model to address the situation. Scenario #3
    A 35-year-old single male sought treatment to deal with sexual concerns, primarily his lifelong history of fantasies of sexually abusing children. His past behaviors included going to parks, watching children, and fantasizing various sexual acts with them. During the course of therapy, he talked about his obsessive thoughts of acting out these fantasies with his 9-year-old godson, whom he would soon be taking with him, alone, on a European trip. The therapist attempted to get the client to realize the danger he was placing his godson in and the risk to himself if he committed a sexual offense, and tried to persuade him to change the travel plans, but he refused.Scenario #4
    You are supervising an intern who is working toward licensure. She has been discussing a case with you about a man who seems to have a volatile temper and she has reported that she has felt intimidated by him. One evening, you receive a phone call from your supervisee, who is in tears and reports that she was just physically accosted by the client.

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Six-step framework for ethical
decision making
Journal of Health Services Research &
2014, Vol 19(1) 62–64
! The Author(s) 2013
Reprints and permissions:
DOI: 10.1177/1355819613511599
Gavin Enck
The expectation, from the ethos of medicine and society, is that a practitioner should make the correct ethical decision
in the clinical setting. Yet there is little help for them as to a process for making ethical decisions. A structured six-step
framework may assist. It is not an algorithm to arrive at a determinate answer in all situations and ethical issues but
instead offers a process that indicates the most relevant information and biomedical considerations a practitioner needs
to be aware of and helps to make ethics issues more manageable. The issues practitioners face are complex and resistant
to reduction; it is hubris to pretend otherwise. Yet, the difficulty of these issues warrants practitioners relying on a
framework to guide them in the process of making ethical decisions.
decision aids, decision quality, patient-centered care, Patient-Reported Outcome Measure (PROM)
The expectation, from the ethos of medicine and
society, is that a health care practitioner should make
correct ethical decisions. As a practitioner, imagine
encountering the following scenarios:
Case 1: A 43-year-old man with gastric cancer and
metastatic liver disease is in your medical centre.
He has an advanced directive and his sister is his medical power of attorney, but his mother comes to the
medical centre asking about his condition. She is unaware of her son’s condition and while she is high functioning, she has dementia and short-term memory
Case 2: The parents of a 12-year-old girl with a terminal
glioblastoma multiforme request that you do not tell
the patient that she is terminal and being transferred to
hospice care. However, the patient currently has cognitive capacity and keeps asking you and other sta?
about her condition and plans of care.
Case 3: The spouse of a terminally ill woman is a
former law enforcement o?cer. He is attentive and
loving, but you notice that tucked in the small of his
back is a concealed weapon. This medical centre, like
most medical centres, has strict prohibitions against
carrying even permitted weapons in the facility.
These types of scenarios are a regular occurrence. While
there is much literature that provides broad, biomedical
ethical approaches towards resolving an issue or an ethical justi?cation for a resolution, there are few resources
available o?ering a framework which walks a practitioner through the practical process of addressing an
ethics issue. In my experience, it is not that practitioners
are unable to make an appropriate decision. Rather, it
is that they are often overwhelmed by the process – the
information, ethical considerations and potential
courses of action – when attempting to address an
ethics issue. However, many experienced practitioners
and clinical ethicists are not overwhelmed when handling ethics issues because they follow a step-by-step procedure that makes addressing these issues manageable.
Such a step-by-step procedure is nothing new: it relies on
the literature of biomedical ethical accounts for
approaching such issues, decision making and their
own experiences. So, what is the practical information,
considerations and options that are available to practitioners when making a clinical ethics decision?
Clinical Ethics Fellow, The University of Texas MD Anderson Cancer
Center, Texas, USA
Corresponding author:
Gavin Enck, The University of Texas MD Anderson Cancer Center, 1400
Pressler, Houston, TX 77030-3722, USA.
Before o?ering a six-step framework, it needs to be
clearly stipulated that my goal is not to imply that it is a
broad biomedical ethical account of how practitioners
should approach ethical issues. Instead, the framework
is merely an amalgamation of the best parts of these
approaches codi?ed into a practical procedure to guide
practitioners. In addition, it is not an algorithm which
always arrives at a determinate answer. In the clinical
setting, ethics issues are complex and resistant to simple
reductions. There is often a range of appropriate solutions rather than a single one, so any algorithm which
posits the ability to provide a determinate answer, for
all situations and cases, is not feasible.
integrity and conscientiousness – stipulate that practitioners have a ?duciary responsibility to patients. More
importantly, these biomedical ethical principles and
ideals underwrite the relevant ethical considerations in
an assessment of an ethical issue. Relying on a slightly
modi?ed version of Jonsen, Siegler and Winslade’s
terms, these ethical considerations are medical indications, patient’s preferences, interests and values, quality
of life and contextual aspects of the situation.5 These
ethical considerations are used in the assessment of an
ethical issue which is a situation in which con?ict occurs
between patients, lay carers, practitioners or the health
care institution involving values, preferences or professional responsibilities.4,5,8
Concepts of biomedical ethics
In moral philosophy, the study of normative ethics
often takes the central questions to be, but not limited
to, ‘how ought a person act’ or ‘what sort of person am
I to be?’1,2 These questions, in turn, are often speci?ed
further in regards to intricate and sophisticated theories
of right action, with a focus on ‘what properties make
an action right’ or ‘what are the limitations on these
actions?’ The focus is on elucidating a justi?cation (or
exposing the lack of) on the theoretical grounds from
which moral agents act. Yet, moral philosophy does
not (nor should it be required to) provide a method
for making an ethical decision.
At least one reason that moral philosophy need not
o?er a method of ethical decision making is because, in
everyday life, people’s common understanding of
ethics – of what are right, permissible or wrong actions –
manages quite well. For the most part, the majority of
people do not wantonly murder, rape and steal. Yet, in
some situations, people’s preferences, interests and
values do con?ict, and deciding the most appropriate
action is often di?cult. In part, the di?culty is that
rational and reasonable people do often disagree in
profound ways on what are the right, permissible or
wrong actions in certain situations (e.g. killing one
person to save ?ve). This does not mean, as a cynic
would hold, that there is no such thing as morality
but that the world in which we live in is complicated.
As Aristotle remarks about the complexity of ethics,
‘Our discussion will be adequate if it has as much clearness as the subject matter admits of’.3
While the complexity of ethics for those working in
health care is great, a distinct advantage is that biomedical ethical concepts clearly stipulate the obligations,
responsibilities and conduct of practitioners. It is reasonable to think that their conduct is governed by certain
principles, rules and ideals.4–7 The bioethical principles
of bene?cence, non-male?cence and respect for patient
autonomy and justice – as well as the ideals of human
excellence or virtues of compassion, trustworthiness,
The six steps of the framework
The relevant ethical considerations can be allocated
within a six-step framework that facilitates the
making of an ethics decision by outlining, in a clear
and structured manner, the practical information, considerations and options.4,5,8–11 This will allow practitioners to work through an ethics problem in a
manner that is more manageable, limits the scope of
the ethics issues and (hopefully) prevents them from
being overwhelmed in the process. This six-step process
is as follows:
Obtain as much information as possible about the
patient’s medical and social history: diagnosis, prognosis, goals of care, treatment plan and the primary
and/or consulting services involved.
Assess whether this is an ethics issue or if it is a legal,
institutional or social issue better addressed by other
services or departments.
Does the practitioner and other members of the team
know and understand all the necessary and relevant
medical information?
Does the patient and/or their family know and
understand all the necessary and relevant medical
Are there other options readily available, e.g. switching services, departments or transferring the patient?
Is a trial period possible?
Is it an ethical issue or dilemma?
Frame as an ethical question.
Assess the considerations of medical indications,
patient’s preferences, interests, values and their quality of life.
Make a recommendation all parties can understand.
Journal of Health Services Research & Policy 19(1)
Document the recommendation in the patient’s
Follow up.
Feedback: ask for comments, suggestions and
thoughts about the ethical issue or dilemma, recommendation or decision-making process.
issues. It does not always provide a determinate
answer but it is at least one way they can avoid being
overwhelmed when encountering an ethics issues.
Although ethical issues in clinical settings are complex
and resistant to reduction, it does not follow that we
cannot strive to provide practitioners with a framework
for guidance.
How the framework can help
I thank Christina Guajardo and Brittany Campbell for editorial advice and Jessica A Moore for academic advice.
Using this six-step framework, let us return to the three
scenarios presented earlier. It o?ers a structured process that assists a practitioner:
Case 1: At the clari?cation step, a practitioner could ask
the patient whom in his family he has told about his
condition. By asking the patient, it is possible to discover
a reason, preference or indication of a personal value
that could be useful for determining disclosing this
information. Moreover, if he says he does not want
you to tell his mother – and since she is not his medical
power of attorney, surrogate decision maker, or caregiver and thus does not have an ethical right to that
information – the practitioner clearly does not have an
obligation to disclose the son’s condition to his mother.
Case 2: At the clari?cation step, the ethical problem is
categorized as an ethical dilemma and then framed as a
question: ‘Given the parents’ preferences and the
patient’s age and prognosis, is it ethically justi?able to
not inform the patient that her condition is terminal?’
One relevant ethical consideration for answering this
question is to consider the patient’s preferences, interests
and values. While the patient is only 12 years old, her
preferences, interests and values do matter. Consider
that even if her parents were to consent to a particular
treatment, a practitioner would want to obtain assent
for the treatment from the patient.12–14 Therefore, in
this scenario, a practitioner needs to assess the bene?ts,
harms, risks and burdens of the parents’ preferences for
not telling the patient against the obligation to respect
and inform the patient of this information.
Case 3: The ?rst step, identi?cation, is the important
step here. While this patient’s spouse is attentive and
loving, the possession of a concealed weapon is an institutional safety issue rather than an ethical issue. Yet, a
practitioner should take steps to address the concealed
weapon, such as notifying security personnel to inform
the patient of the institution’s rules rather than trying
to address this issue on their own.
This six-step framework is but one structured method
for practitioners to rely on when encountering ethics
This work was supported by the Section of Integrated Ethics
in cancer care at the University of Texas MD Anderson
Cancer Center.
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Oxford: Oxford University, 2006.
2. Schneed JB. The misfortunes of virtue. In: Virtue ethics.
Oxford: Oxford University Press, 1997, pp.178–200.
3. Aristotle. The complete works of Aristotle: The revised
Oxford translation, Barnes B (ed). Princeton: Princeton
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ethics, 6th ed. Oxford: Oxford University Press, 2009.
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7th ed. New York, NY: McGraw-Hill Medical, 2010.
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2, 2013).
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