Decision-making capacity (DMC) plays an important role in clinical practice—determining, on the basis of a patient’s decisional abilities, whether they are entitled to make their own medical decisions or whether a surrogate must be secured to participate in decisions on their behalf. As a result, it’s critical that we get things right—that our conceptual framework be well-suited to the task of helping practitioners systematically sort through the relevant ethical considerations in a way that reliably and transparently delivers correct (...) verdicts about who should and should not have the authority to make their own medical decisions. Unfortunately, however, the standard approach to DMC does not get things right. It is of virtually no help in identifying and clarifying the relevant ethical considerations. And, embedded in the prevailing anti-paternalist paradigm, DMC assessments obfuscate and distort the underlying ethical justification for granting or withholding decisional authority. Here, we describe the core commitments of the standard approach to DMC and then highlight three problems with it. We then argue that these problems are significant enough that they call for more than merely tinkering and fine tuning—variations of the standard approach cannot adequately address them. Instead, we should ditch DMC. (shrink)

Ethical decision-making descriptive theoretical models often conflict with each other and typically lack comprehensiveness. To address this deficiency, a revised EDM model is proposed that consolidates and attempts to bridge together the varying and sometimes directly conflicting propositions and perspectives that have been advanced. To do so, the paper is organized as follows. First, a review of the various theoretical models of EDM is provided. These models can generally be divided into rationalist-based ; and non-rationalist-based. Second, the proposed (...) model, called ‘Integrated Ethical Decision Making,’ is introduced in order to fill the gaps and bridge the current divide in EDM theory. The individual and situational factors as well as the process of the proposed model are then described. Third, the academic and managerial implications of the proposed model are discussed. Finally, the limitations of the proposed model are presented. (shrink)

Decision-making Capacity matters to whether a patient’s decision should determine her treatment. But why it matters in this way isn’t clear. The standard story is that dmc matters because autonomy matters. And this is thought to justify dmc as a gatekeeper for autonomy – whereby autonomy concerns arise if but only if a patient has dmc. But appeals to autonomy invoke two distinct concerns: concern for authenticity – concern that a choice is consistent with an individual’s commitments; (...) and concern for sovereignty – concern that an individual exercises control over that which is hers to control. Here, I argue, neither concern can alone explain why dmc matters. Instead, dmc matters because it indicates a harmony between the two concerns – the demands of each concern are more likely to agree if a patient has dmc. This vindicates the standard story, but also makes clear that dmc is an inappropriate gatekeeper for autonomy. (shrink)

Unrepresented patients are some of the most vulnerable patients encountered in the healthcare system today. One of the challenges associated with healthcare for unrepresented patients is the lack of a standardized legal approach to decision making for this highly vulnerable population. Current statutory approaches vary widely without best practices or consensus guidelines. In 2016, Colorado passed a medical proxy law that established a process for the appointment of an independent physician to serve as a temporary proxy decision (...) maker for an unrepresented patient. Although this approach helps to identify a decision maker when no proxy is available, the appropriate standards for decision making remain uncertain. A peer-to-peer session at the Clinical Ethics Unconference in 2022 approached this conundrum with a focus on the best interests standard and the appropriate use of patients’ context in decision making. (shrink)

This paper examines a decision making under uncertainty criterion first introduced by Starr, which differs from the classical criteria. The rationale and properties of this criterion, called the Domain criterion, are discussed and compared with the traditional approaches of Wald, Hurwicz, Savage and Laplace. The computational complexity and usefulness of the criterion are discussed, as well as the underlying decision philosophy.

A discussion of ethical decision-making literature is overdue. In this article, we summarize the current literature of ethical decision-making models used in mental health professions. Of 1,520 articles published between 2001 and 2020 that met initial search criteria, 38 articles were included. We report on the status of empirical evidence for the use of these models along with comparisons, limitations, and considerations. Ethical decision-making models were synthesized into eight core procedural components and presented based (...) on the composition of steps present in each model. This taxonomy provides practitioners, trainers, students, and supervisors relevant information regarding ethical decision-making models. (shrink)

Recently, bioethicists and the UNCRPD have advocated for supported medical decision-making on behalf of patients with intellectual disabilities. But what does supported decision-making really entail? One compelling framework is Anita Silvers and Leslie Francis’ mental prosthesis account, which envisions supported decision-making as a process in which trustees act as mere appendages for the patient’s will; the trustee provides the cognitive tools the patient requires to realize her conception of her own good. We argue that (...) supported decision-making would be better understood as a collaborative process, giving patients with intellectual disabilities the opportunity to make decisions in a respectful relationship with trusted others. We offer an alternative account of supported decision-making where the primary constraint is to protect the patient from domination by the trustee. This is advantageous in its preservation of the prospects for genuine collaboration, for the mental prosthesis approach ultimately reinforces a problematic ideal of isolated patient self-determination. (shrink)

This article argues that supported decision making is ideal for people with dynamic cognitive and functional impairments that place them at the margins of autonomy. First, we argue that guardianship and similar surrogate decision-making frameworks may be inappropriate for people with dynamic impairments. Second, we provide a conceptual foundation for supported decision making for individuals with dynamic impairments, which integrates the social model of disability with relational accounts of autonomy. Third, we propose a three-step (...) model that specifies the necessary conditions of supported decision making: identifying domains for support; identifying kinds of supports; and reaching a mutually acceptable and formal agreement. Finally, we identify a series of challenges for supported decision making, provide preliminary responses, and highlight avenues for future bioethics research. (shrink)

In patient-centred care, shared decision-making is advocated as the preferred form of medical decision-making. Shared decision-making is supported with reference to patient autonomy without abandoning the patient or giving up the possibility of influencing how the patient is benefited. It is, however, not transparent how shared decision-making is related to autonomy and, in effect, what support autonomy can give shared decision-making. In the article, different forms of shared decision-making (...) are analysed in relation to five different aspects of autonomy: (1) self-realisation; (2) preference satisfaction; (3) self-direction; (4) binary autonomy of the person; (5) gradual autonomy of the person. It is argued that both individually and jointly these aspects will support the models called shared rational deliberative patient choice and joint decision as the preferred versions from an autonomy perspective. Acknowledging that both of these models may fail, the professionally driven best interest compromise model is held out as a satisfactory second-best choice. (shrink)

The integration of artificial intelligence technologies is transforming healthcare and nursing education, offering significant benefits for patient care and professional development. However, as their use grows, it is crucial to address the ethical implications to ensure that fundamental principles like justice and integrity are maintained in both clinical and educational settings. The aim of this integrative review is to explore the ethical challenges, risks, and future perspectives of integrating artificial intelligence into nursing education. It examines how these tools influence ethical (...) decision-making processes, identifies critical barriers, and proposes strategies for ethical implementation. Following an integrative review methodology, 184 articles were identified, with 124 remaining after duplicate removal. Fifteen peer-reviewed studies analyzed. The methodological quality of the included studies was assessed using appropriate Joanna Briggs Institute Critical Appraisal Checklists based on study design. Searches were conducted in the PubMed, Cochrane Library, MEDLINE (Ovid), Scopus, Web of Science, CINAHL, and ScienceDirect databases from 2014 to September 2024. Data was analysed using constant comparative analysis. The review is registered in the PROSPERO database (CRD42024609440). Guided by Rest’s Four-Component Model of Moral Behavior, the synthesis was organized under four components. Moral Sensitivity included themes such as ethical and psychosocial effects, data privacy, equity in access, and cultural sensitivity. Moral Judgment covered ethical reasoning skills, AI accuracy, bias, and academic integrity. Moral Motivation addressed over-reliance on AI and the need for ethical frameworks. Moral Character highlighted educator roles and research priorities for ethical AI use. Artificial intelligence offers transformative opportunities for nursing education, but also presents significant ethical challenges. To ensure its responsible integration, nursing curricula must adopt clear ethical frameworks, equip educators with the skills to guide students and address disparities in access. (shrink)

In this chapter, it is argued that some animal shelters fulfill the conditions that make triage protocols necessary, namely, the operation with limited financial budgets, space, medical resources, and staff. It is suggested that requirements presented for triage in humans can be fruitfully applied to the context of animal shelters. The focus lies on the criteria of maximizing benefit, justice, medical criteria, life-span considerations, fair decision-making, patient will, re-evaluation of triage decisions and changes in the therapeutic goal, and (...) burden of triage and staff support. The establishment of triage protocols for shelters will make the decision-making process less arbitrary, fairer, and more transparent. Furthermore, it is argued that, in situations where disagreement persist among shelter staff, an external Ethics Board could be called in to help analyze and potentially resolve some of the remaining ethical issues. (shrink)

Moral pragmatism has been largely ignored in Business Ethics, despite its natural attraction and the fact that it is prominent in philosophy and socio-economic theories. The main premise of the book is that the complexity of today's business world does not permit a grand ethical theory, notwithstanding the different attempts made by scientists. Moral pragmatism is the 'go-to' approach where the ethical decision-making of managers varies dependent on different circumstances but it always integrates moral considerations. Ethical decision- (...) class='Hi'>making is no longer based simply on known rules, but entails the constant dynamic interaction of circumstances, the development of new rules, managers' past experiences, their knowledge concerning ethics, and skills of moral reasoning. This book interweaves the postmodern approach to management studies and, based on its innovative research, reintroduces moral pragmatism in Business Ethics. The combination of decision-making theories, philosophy and postmodernism paves the way for future novel research in Business Ethics, making it an excellent resource for researchers, academics, and advanced students in the field of Business Ethics. Practitioners, on the other hand, will benefit by improving their skills in ethical decision-making and leadership. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, (...) different versions of SDM are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

The rapidly increasing role of automation throughout the economy, culture and our personal lives has generated a large literature on the risks of algorithmic decision-making, particularly in high-stakes legal settings. Algorithmic tools are charged with bias, shrouded in secrecy, and frequently difficult to interpret. However, these criticisms have tended to focus on particular implementations, specific predictive techniques, and the idiosyncrasies of the American legal-regulatory regime. They do not address the more fundamental unease about the prospect that we might (...) one day replace judges with algorithms, no matter how fair, transparent, and intelligible they become. The aim of this paper is to propose an account of the source of that unease, and to evaluate its plausibility. I trace foundational unease with algorithmic decision-making in the law to the powerful intuition that there is a basic moral and legal difference between showing that something is true of many people just like you and showing that it is true of you. Human judgment attends to the exception; automation insists on blindly applying the rule. I show how this intuitive thought is connected to both epistemological arguments about the value of statistical evidence, as well as to court-centered conceptions of the rule of law. Unease with algorithmic decision-making in the law thus draws on an intuitive principle that underpins a disparate range of views in legal philosophy. This suggests the principle is deeply ingrained. Nonetheless, I argue that the powerful intuition is not as decisive as it may seem, and indeed runs into significant epistemological and normative challenges. At an epistemological level, I show how concerns about statistical evidence's ability to track the truth can be resolved by adopting a probabilistic, rather than modal, conception of truth-tracking. At a normative level, commitment to highly individualized decision-making co-exists with equally ingrained and competing principles, such as consistent application of law. This suggests that the “rule of law” may not identify a discrete set of institutional arrangements, as proponents of a court-centric conception would have it, but rather a more loosely defined set of values that could potentially be operationalized in multiple ways, including through some level of algorithmic adjudication. Although the prospect of replacing judges with algorithms is indeed unsettling, it does not necessarily entail unreasonable verdicts or an attack on the rule of law. (shrink)

There is wide consensus among bioethicists about the importance of autonomy when determining whether or not a patient has the right to refuse life-saving treatment (LST). In this context, autonomy has typically been understood in terms of the patient’s ability to make an informed decision. According to the traditional view, decision-making capacity (DMC) is seen as both necessary and sufficient for the right to refuse LST. Recently, this view has been challenged by those who think that considerations (...) of authenticity and putative counterexamples should lead us to revise the traditional account. In this paper, we respond to these revisionist arguments, and we defend the traditional view according to which we have autonomy-based reasons to respect a patient’s decision to refuse LST if and only if she has DMC. (shrink)

In recent years, increasing attention has been given to virtue ethics in business. Aristotle's thought is often seen as the basis of the virtue ethics tradition. For Aristotle, the idea of phronësis, or 'practical wisdom', lies at the foundation of ethics. Confucian ethics has notable similarities to Aristotelian virtue ethics, and may embody some similar ideas of practical wisdom. This article considers how ideas of moral judgment in these traditions are consistent with modern ideas about intuition in management decision (...) making. A hypothetical case is considered where the complexity of ethical decision making in a group context illustrates the importance of intuitive, phronësis-like judgment. It is then noted that both Aristotelian and Confucian virtue ethics include suggestions about support for moral decision making that are also consistent with modern theory. (shrink)

Approximately one in 10 children in foster care are medically complex and require intensive medical supervision, frequent hospitalization, and difficult medical decision making. Some of these children are in foster care because their parents cannot care for their medical needs; other parents are responsible for their child’s medical needs due to abuse or neglect. In either case, there can be uncertainty about the role that a child’s biological parents should play in making serious medical decisions. Here we (...) highlight some of the ethical challenges inherent in making these decisions for children in foster care, as seen through the lenses of a child welfare provider, an inpatient care physician, and a primary care pediatrician. (shrink)

The number of admissions to hospitals of patients without a proxy decision maker is rising. Very often these patients need fairly immediate medical intervention for which informed consent—or informed refusal—is required. Many have recommended that there be a process in place to make these decisions, and that it include a variety of perspectives. People are particularly wary of relying solely on medical staff to make these decisions. The University Hospitals Case Medical Center recruits community members from its Ethics Committee (...) to serve on a subcommittee, the Patients Without Proxies (PWP) Committee, which works with medical staff during the decision-making process for these patients. Generally, the community members go to the bedside to observe patients. This article looks at how those unused to observing hospitalized patients who are sick and/or dying are affected, comparing them to mock jurors in a research study who are exposed to graphic photographs related to a fabricated crime scene. Judgments made by the mock jurors are affected by viewing such images. The personal experience of witnessing unfamiliar and shocking scenes affects their subsequent judgments. While it may be difficult to tease out whether observing patients causes PWP members to be benefited or harmed, they are affected by what they see. If a variety of perspectives is desirable to reduce possible bias or error, this article argues that at least one community member should refrain from seeing the patient in order to add a different and valuable voice to the decision-making process. Members of the subcommittee base their judgments on the various kinds of information available. Sometimes the things they see, hear, or feel may affect them particularly deeply, and affect their judgments as well. In this article I explore the idea that something like this may be happening in a particular kind of clinical ethics case consultation. (shrink)

Decision-making assisted by algorithms developed by machine learning is increasingly determining our lives. Unfortunately, full opacity about the process is the norm. Would transparency contribute to restoring accountability for such systems as is often maintained? Several objections to full transparency are examined: the loss of privacy when datasets become public, the perverse effects of disclosure of the very algorithms themselves (“gaming the system” in particular), the potential loss of companies’ competitive edge, and the limited gains in answerability to (...) be expected since sophisticated algorithms usually are inherently opaque. It is concluded that, at least presently, full transparency for oversight bodies alone is the only feasible option; extending it to the public at large is normally not advisable. Moreover, it is argued that algorithmic decisions preferably should become more understandable; to that effect, the models of machine learning to be employed should either be interpreted ex post or be interpretable by design ex ante. (shrink)

In recent years there has been an explosion of interest in Artificial Intelligence (AI) both in health care and academic philosophy. This has been due mainly to the rise of effective machine learning and deep learning algorithms, together with increases in data collection and processing power, which have made rapid progress in many areas. However, use of this technology has brought with it philosophical issues and practical problems, in particular, epistemic and ethical. In this paper the authors, with backgrounds in (...) philosophy, maternity care practice and clinical research, draw upon and extend a recent framework for shared decision-making (SDM) that identified a duty of care to the client's knowledge as a necessary condition for SDM. This duty entails the responsibility to acknowledge and overcome epistemic defeaters. This framework is applied to the use of AI in maternity care, in particular, the use of machine learning and deep learning technology to attempt to enhance electronic fetal monitoring (EFM). In doing so, various sub-kinds of epistemic defeater, namely, transparent, opaque, underdetermined, and inherited defeaters are taxonomized and discussed. The authors argue that, although effective current or future AI-enhanced EFM may impose an epistemic obligation on the part of clinicians to rely on such systems' predictions or diagnoses as input to SDM, such obligations may be overridden by inherited defeaters, caused by a form of algorithmic bias. The existence of inherited defeaters implies that the duty of care to the client's knowledge extends to any situation in which a clinician (or anyone else) is involved in producing training data for a system that will be used in SDM. Any future AI must be capable of assessing women individually, taking into account a wide range of factors including women's preferences, to provide a holistic range of evidence for clinical decision-making. (shrink)

In recent years, some have argued that supported decision-making can be ethically superior to surrogate decision-making with respect to decisions involving adults with cognitive and intellectual impairments or disabilities. In this paper, we argue that supported decision-making could also be ethically superior to surrogate decision-making in the context of clinical research that involves greater than minimal net risks. In current practice, adults who lack decisional capacity are often excluded from research that involves (...) greater than minimal net risks (call this the minimal risk requirement). While this approach is intended to protect them, it can be ethically problematic, in part because excluding adults who cannot consent blocks scientifically valuable research that needs to enroll them and undermines the generalizability of the research that excludes them. With this concern in mind, we argue that supported decision-making can provide an ethical means to enroll adults who cannot independently consent in greater than minimal net risk research. Supported decision-making thus offers a valuable modification to the surrogate enrollment requirement, and provides good reason to reject the minimal risk requirement as well. (shrink)

Background: Independent decision-making is one of the basic rights of patients. However, in clinical practice, most older cancer patients’ treatment decisions are made by family members. Objective: This study attempted to analyze the treatment decision-making process and formation mechanism for older cancer patients within the special cultural context of Chinese medical practice. Method: A qualitative study was conducted. With the sample saturation principle, data collected by in-depth interviews with 17 family members and 12 patients were subjected (...) to thematic analysis. Ethical considerations: The study was approved by the ethics committees of Sun Yat-sen University. All participants provided verbal informed consent after being told their rights of confidentiality, anonymity, and voluntary participation. They had the right to refuse to answer questions and could withdraw at any time. Results: Three themes emerged: (1) complex process; (2) transformation of family decision-making power; and (3) individual compromise. Family members inevitably had different opinions during the long process of treatment decision-making for older cancer patients. The direction of this process could be regarded as an extension of the family power relationship. The patient usually compromised the decision to survive, which was made by family members. Conclusion: This study describes the treatment decision-making process of older cancer patients in the context of Chinese culture. The reasons underlying this process are related to the views on life and death and family values. An individual is a part of the family, which is often seen as the minimal interpersonal unit in Chinese society. It is significant that while emphasizing patient autonomy in the decision-making process, health professionals should also pay attention to the important roles of culture and family. (shrink)

Patients can be harmed by a religiously motivated surrogate decision maker whose decisions are contrary to the standard of care; therefore, surrogate decision making should be held to a high standard. Stewart Eskew and Christopher Meyers proposed a two-part rule for deciding which religiously based decisions to honor: (1) a secular reason condition and (2) a rationality condition. The second condition is based on a coherence theory of rationality, which they claim is accessible, generous, and culturally sensitive. (...) In this article, I will propose strengthening the rationality condition by grounding it in a theory of intellectual virtue, which is both rigorous and culturally sensitive. (shrink)

BackgroundCommentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units (ICUs). Our aim was twofold: (1) to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and (2) determine the association between the ethical climate, moral distress, and intention to leave.MethodsWe performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 (...) nurses and physicians in a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire (EDMCQ) and the Measure of Moral Distress for Healthcare Professionals (MMD-HP) tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.ResultsNurses perceived the ethical climate for decision-making as less favorable than physicians (p < 0.05). They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units (3.54 ± 0.66 vs. 3.43 ± 0.81 vs. 3.30 ± 0.69; respectively; both p ≤ 0.05) and also demonstrated lower moral distress scores (both p < 0.05) and lower “intention to leave” scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated (r = −0.58, p < 0.001); moral distress and "intention to leave" was positively correlated (r = 0.52, p < 0.001); and ethical climate and “intention to leave” were negatively correlated (r = −0.50, p < 0.001).ConclusionsSignificant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care. (shrink)

The authors review the empirical literature in order to assess which variables are postulated as influencing ethical beliefs and decision making. The variables are divided into those unique to the individual decision maker and those considered situational in nature. Variables related to an individual decision maker examined in this review are nationality, religion, sex, age, education, employment, and personality. Situation specific variables examined in this review are referent groups, rewards and sanctions, codes of conduct, type of (...) ethical conflict, organization effects, industry, and business competitiveness. The review identifies the variables that have been empirically tested in an effort to uncover what is known and what we need to know about the variables that are hypothesized as determinants of ethical decision behavior. (shrink)

Our research’s aim is to assess the effect of cultural factors on business ethical decision-making process in a Western cultural context and in a non-Western cultural context. Specifically, this study investigates ethical perceptions, religiosity, personal moral philosophies, corporate ethical values, gender, and ethical intentions of U.S. and Moroccan business managers. The findings demonstrate that significant differences do exist between the two countries in idealism and relativism. Moroccan managers tend to be more idealistic than the U.S. managers. There is (...) a strong positive relationship between religiosity and idealism. There were mixed findings in examining the correlates of religiosity and various components of ethical intentions. Moroccan managers were more homogenous in their corporate ethical values than were the U.S. managers. The results demonstrate that (in general) idealism is a good predictor of ethical intentions and behaviors. Additionally, managers from the two countries differed in the degree of relationship between perceptions and intentions in three of the four scenarios. This study’s results confirm other research findings that, in general, female business managers have higher ethical sensitivity in terms of their ethical judgment than their male counterparts. Managerial implications are also discussed. (shrink)

Algorithm Decision Making (ADM) systems designed to augment or automate human decision-making have the potential to produce better decisions while also freeing up human time and attention for other pursuits. For this potential to be realised, however, algorithmic decisions must be sufficiently aligned with human goals and interests. We take a Principal-Agent (P-A) approach to the questions of ADM alignment and trust. In a broad sense, ADM is beneficial if and only if human principals can trust (...) algorithmic agents to act faithfully on their behalf. This mirrors the challenge of facilitating P-A relationships among humans, but the peculiar nature of human-machine interaction also raises unique issues. The problem of asymmetric information is omnipresent but takes a different form in the context of ADM. Although the decision-making machinery of an algorithmic agent can in principle be laid bare for all to see, the sheer complexity of ADM systems based on deep learning models prevents straightforward monitoring. We draw on literature from economics and political science to argue that the problem of trust in ADM systems should be addressed at the level of institutions. Although the dyadic relationship between human principals and algorithmic agents is our ultimate concern, cooperation at this level must rest against an institutional environment which allows humans to effectively evaluate and choose among algorithmic alternatives. (shrink)

BackgroundDeciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.MethodsWe conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.ResultsThe main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that (...) justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.ConclusionsParticipants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/ku Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018. (shrink)

Across two studies the hypotheses were tested that stressful situations affect both leadership ethical acting and leaders' recognition of ethical dilemmas. In the studies, decision makers recruited from 3 sites of a Swedish multinational civil engineering company provided personal data on stressful situations, made ethical decisions, and answered to stress-outcome questions. Stressful situations were observed to have a greater impact on ethical acting than on the recognition of ethical dilemmas. This was particularly true for situations involving punishment and lack (...) of rewards. The results are important for the Corporate Social Responsibility (CSR) of an organization, especially with regard to the analysis of the Stressors influencing managerial work and its implications for ethical behavior. (shrink)

The article describes a framework that identifies event, organizational, and individual factors that threaten ethical decision making in organizations facing discrete crises or in an ongoing crisis environment. Nine propositions are stated that predict threats to ethical decision making during crisis. A comparison between predictions from our model and from Jones's (1991) model is made. Suggestions for research to test and refine the framework are proposed.

This paper reports on a study of ethical decision-making in a fair trade company. This can be seen to be a crucial arena for investigation since fair trade firms not only have a specific ethical mission in terms of helping growers out of poverty, but they tend to be perceived as (and are often marketed on the basis of) having an "ethical" image. Eschewing a straightforward test of extant ethical decision models, we adopt Thompson''s proposal for a (...) more contextualist understanding rooted in ethnographic data. Our findings suggest that the fair trade mission of the firm is experienced as an over-riding ethical claim, which is often invoked to justify potentially ethically questionable decisions. Moreover, decision precedents emerge which can mean that the decision process is bypassed or hurried through. Finally we provide evidence that the significance of these precedents, and indeed, even moral intensity itself, could be actively shaped and constructed by organization members to support different, even shifting, conceptions of what is a morally acceptable decision for a fair trade company to make. (shrink)

This paper discusses the philosophical argument and the application of the Triple Font Theory for moral evaluation of human acts and attempts to integrate the conceptual components of major moral theories into a systematic internally consistent decision-making model that is theoretically driven. The paper incorporates concepts such as formal and material cooperation and the Principle of Double Effect into the theoretical framework. It also advances the thesis that virtue theory ought to be included in any adequate justification of (...) morality and the need to integrate or coordinate notions of virtue into various act-oriented or principles-based ethics. The TFT offers a comprehensive and practical approach to ethical decision-making and is a useful alternative embedded in traditional wisdom. This paper provides a more general framework of the TFT than traditionally presented. Practical judgment is shown to play a constitute role in providing a guide for right action and is the “glue” that integrates the various components of the TFT. (shrink)

In this article we report findings from a qualitative study that explored how doctors and nurses in nursing homes describe professional collaboration around dying patients. The study also examined the consequences this can have for the life-prolonging treatment of patients and the care of them and their relatives. Nine doctors and 10 nurses from 10 Norwegian nursing homes were interviewed about their experience of decision-making processes on life-prolonging treatment and care. The findings reveal that the frameworks for the (...) professional collaboration and organization of physicians and nurses prevent patient treatment and care complying with ethical considerations and the law. These conditions have a challenging impact on the care of dying patients and their relatives. (shrink)

The stakes associated with an algorithmic decision are often said to play a role in determining whether the decision engenders a right to an explanation. More specifically, “high stakes” decisions are often said to engender such a right to explanation whereas “low stakes” or “non-high” stakes decisions do not. While the overall gist of these ideas is clear enough, the details are lacking. In this paper, we aim to provide these details through a detailed investigation of what we (...) will call the “Simple Stakes Thesis”. The Simple Stakes Thesis, as it will turn out, is too simple. For even if the stakes associated with a specific one-off decision are low—and hence does not engender a right to an explanation—such decisions may nevertheless form part of a high stakes pattern or aggregate of decisions. In such cases, we argue, even a low stakes decision may engender a right to explanation. Not only does this show that the right to explanation is more demanding than so far recognized. It also shows that the stakes thesis is significantly harder to apply in practice. (shrink)

Decision Making Competence (DMC) reflects individual differences in rational responding across several classic behavioral decision-making tasks. Although it has been associated with real-world risk behavior, less is known about the degree to which DMC contributes to specific components of risk attitudes. Utilizing a psychological risk-return framework, we examined the associations between risk attitudes and DMC. Italian community residents (n = 804) completed an online DMC measure, using a subset of the original Adult-DMC battery (A-DMC; Bruine de (...) Bruin, Parker, & Fischhoff, 2007). Participants also completed a self-reported risk attitude measure for three components of risk attitudes (risk-taking, risk perceptions, and expected benefits) across six risk domains. Overall, greater performance on the DMC component scales were inversely, albeit modestly, associated with risk-taking tendencies. Structural equation modeling results revealed that DMC was associated with lower perceived expected benefits for all domains. In contrast, its association with perceived risks was more domain-specific. These analyses also revealed stronger indirect effects for the DMC  expected benefits  risk-taking than the DMC  perceived risk  risk-taking path, especially for risk behaviors that may be considered more antisocial in nature. These results suggest that DMC performance differentially impacts specific components of risk attitudes, and may be more strongly related to the evaluation of expected value of the given behavior. (shrink)

Decision-making capacity is a vital concept in law, ethics, and clinical practice. Two legal cases where capacity literally had life and death significance are NHS Trust v Ms T [2004] and Kings College Hospital v C [2015]. These cases share another feature: unusual beliefs. This essay will critically assess the concept of capacity, particularly in relation to the unusual beliefs in these cases. Firstly, the interface between capacity and unusual beliefs will be examined. This will show that the (...) “using and weighing of information” is the pivotal element in assessment. Next, this essay will explore the relationship between capacity assessment and a decision’s “rationality.” Then, in light of these findings, the essay will appraise the judgments in NHS v T and Kings v C, and consider these judgments’ implications. More broadly, this essay asks: Does capacity assessment examine only the decision-making process, or is it also influenced by a decision’s rationality? If influenced by rationality, capacity assessment has the potential to become “a search and disable policy aimed at those who are differently orientated in the human life-world”. In contentious cases like these, this potential deserves attention. (shrink)

Decision making is a key activity, perhaps the most important activity, in the practice of healthcare. Although physicians acquire a great deal of knowledge and specialised skills during their training and through their practice, it is in the exercise of clinical judgement and its application to individual patients that the outstanding physician is distinguished. This has become even more relevant as patients become increasingly welcomed as partners in a shared decision making process. This book translates the (...) research and theory from the science of decision making into clinically useful tools and principles that can be applied by clinicians in the field. It considers issues of patient goals, uncertainty, judgement, choice, development of new information, and family and social concerns in healthcare. It helps to demystify decision theory by emphasizing concepts and clinical cases over mathematics and computation. (shrink)

Decisions are made under uncertainty when there are distinct outcomes of a given action, and one is uncertain to which the act will lead. Decisions are made under indeterminacy when there are distinct outcomes of a given action, and it is indeterminate to which the act will lead. This paper develops a theory of (synchronic and diachronic) decision-making under indeterminacy that portrays the rational response to such situations as inconstant. Rational agents have to capriciously and randomly choose how (...) to resolve the indeterminacy relevant to a given choice-situation, but such capricious choices once made constrain how they will choose in the future. The account is illustrated by the case of self-interested action in situations where it is indeterminate whether you yourself will survive to benefit or suffer the consequences. The conclusion emphasizes some distinctive anti-hedging predictions of the account. (shrink)

Federal disability anti-discrimination laws expect clinical trials to render study processes and sites accessible to potential participants, including through the provision of reasonable accommodations. Nonetheless, people with disabilities, and particularly people with mental illness, are often excluded from clinical trials. Supported decision-making, a strategy that allows people to select trusted others to help them understand and communicate decisions, is an important accommodation to further inclusion. However, because mental illness can be dynamic and vary widely in nature (e.g., diagnosis, (...) symptom severity, functional impairment) and duration (e.g., short-term, intermittent, progressive, permanent), supported decision-making is neither a one-size-fits-all strategy nor one that can serve as a reasonable accommodation in every situation. While prior work on supported decision-making has focused predominantly on adults with intellectual and developmental disabilities or dementias, people with mental illness may also benefit from supported decision-making, although the variability in decision-making capacity in mental illness presents nuanced challenges. Here, we explore supported decision-making in the case of people with intermittent or episodic mental illness that may impact decision-making capacity to varying degrees at different times. (shrink)

Background: Decision making is a highly complex task when providing care for seriously ill children. Physicians, parents, and children face many challenges when identifying and selecting from available treatment options. Methods: This qualitative interview study explored decision-making processes for children with cancer at different stages in their treatment in Switzerland and Romania. Results: Thematic analysis of interviews conducted with parents and oncologists identified decision making as a heterogeneous process in both countries. Various decisions were (...) made based on availability and reasonableness of care options. In most cases, at the time of diagnosis, parents were confronted with a “choiceless choice”—that is, there was only one viable option (a standard protocol), and physicians took the lead in making decisions significant for health outcomes. Parents' and sometimes children's role increased during treatment when they had to make decisions regarding research participation and aggressive therapy or palliative care. Framing these results within the previously described Decisional Priority in Pediatric Oncology Model (DPM) highlights family's more prominent position when making elective decisions regarding quality-of-life or medical procedures, which had little effect on health outcomes. The interdependency between oncologists, parents, and children is always present. Communication, sharing of information, and engaging in discussions about preferences, values, and ultimately care goals should be decision making's foundation. Conclusions: Patient participation in these processes was reported as sometimes limited, but parents and oncologists should continue to probe patients' abilities and desire to be involved in decision making. Future research should expand the DPM and explore how decisional priority and authority can be shared by oncologists with parents and even patients. (shrink)

Background Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or (...) stranger) perspective. -/- Methods A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design. -/- Results Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences. -/- Conclusions These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker’s true self. (shrink)

By the late 1990s, several converging trends in economics, psychology, and neuroscience had set the stage for the birth of a new scientific field known as “neuroeconomics”. Without the availability of an extensive variety of experimental designs for dealing with individual and social decision-making provided by experimental economics and psychology, many neuroeconomics studies could not have been developed. At the same time, without the significant progress made in neuroscience for grasping and understanding brain functioning, neuroeconomics would have never (...) seen the light of day. The paper is an overview of the main significant advances in the knowledge of brain functioning by neuroscience that have contributed to the emergence of neuroeconomics and its rise over the past two decades. These advances are grouped over three non-independent topics referred to as the “emo-rational” brain, “social” brain, and “computational” brain. For each topic, it emphasizes findings considered as critical to the birth and development of neuroeconomics while highlighting some of prominent questions about which knowledge should be improved by future research. In parallel, it shows that the boundaries between neuroeconomics and several recent sub-fields of cognitive neuroscience, such as affective, social, and more generally, decision neuroscience, are rather porous. (shrink)

In their thoughtful and rigorous article, Peterson and colleagues extend an account of supported decision-making that was originally developed for people with static cognitive impairments, t...

This study uses judgment and decision-making (JDM) perspective with the help of framing and schema literature from cognitive psychology to evaluate how managers behave when problems with unethical overtones are presented to them in a managerial frame rather than an ethical frame. In the proposed managerial model, moral judgment of the situation is one of the inputs to managerial judgment, among several other inputs regarding costs and benefits of various alternatives. Managerial judgment results in managerial intent leading to (...) managerial action. The model and the effects of taking an ethics course on ethical and managerial judgment and managerial intent were then indirectly tested in this study, wherein subjects judged the ethical wrongness, managerial badness, and the managerial intent regarding decisions made in a case. Forty-nine MBA students analyzed a case involving budget-based bonuses and production, in which the ethical issue evolved over three stages. It appears from the Path-analysis results that managerial judgment mediated between moral judgment and the judgment of managerial intent as suggested by the proposed model, and that taking an ethics course directly affected managerial judgment but did not affect the moral judgment. Additionally, in the first stage of decision-making (early stage of a developing “ethical slippery slope”), moral judgment did not significantly influence managerial judgment. However, students with ethics course still were more inclined to judge the decision as managerially bad as compared to others, indicating that they were more aware or sensitive to the moral issues involved. (shrink)

The present article explores the integration of the Konstanz Method of Dilemma Discussion (KMDD®) in doctoral education, particularly within Applied Ethics programs. The primary objective of this study was to examine how KMDD® contributes to the development of moral competence and consequently, ethical decision-making skills in doctoral students, preparing them to navigate complex ethical challenges in both academic and professional contexts. The methodology involved incorporating KMDD® into doctoral seminars, where students engaged in structured discussions on semi-real moral dilemmas. (...) Over the course of the program, students’ ability to reflect critically on ethical issues, engage in moral reasoning, and collaborate on problem-solving was assessed using both quantitative and qualitative measures. A validated moral competence test, alongside qualitative evaluations, was used to measure the study’s results. The results revealed a significant 23% improvement in the students’ average C-scores, indicating a notable enhancement in their ethical reasoning abilities. Additionally, students exhibited increased confidence in addressing moral dilemmas and ethical issues, leading to more stimulating and productive discussions. This improvement was further evident in stronger argumentation and a deeper understanding of ethical complexities. Furthermore, fostering moral competence resulted in an enhanced ability to apply ethical theories to real-world professional contexts. The findings underscore the effectiveness of KMDD® in fostering moral competence and enhancing ethical decision-making skills among doctoral students, suggesting its potential for broader application in doctoral education and across diverse academic programs and scientific disciplines. (shrink)