Moral
Reasoning
and
Decision
Making
Moral Reasoning and Decision
Making
 The aim in this session is to develop an
understanding of how ethical decisions are made in
practice, rather than in terms of abstract ethical
theories.
 At the end of this session, you should understand
how theory and practice are connected, how
empirical ethics is used and gain an understanding of
ethical decision making models.
Introduction
 What are we to make of the numerous ethical
theories that have developed over the last two or
three millennia?
 When we say that someone is thinking ethically or
resolving an ethical problem using reasoning, should
this involve appeals to the theories of moral
philosophers?
RIGHTS
COMMUNITARIAN
ETHICS
UTILITARIANISM
NARRATIVES
DEONTOLOGY
PRIMA FACIE
ETHICS
NATURAL LAW
VIRTUE ETHICS
4 PRINCIPLES OF
BIOMEDICAL ETHICS CASUISTRY
Other Approaches
 A number of different ways of considering how to
make ethical decisions in practice have been
suggested:
 Consider individual’s intuitions and ‘considered
judgements’ in relation to existing theory,
 Use empirical methods to reflect upon how
individuals actually act,
 Offer pragmatic and practical models of ethical
decision making.
Linking Theory and Practice
 It has been increasingly argued that traditional,
normative ethical theories fail to be of relevance in
actual situations.
 Hegel’s famous criticism of Kant’s deontological
approach as ‘empty formalism’ may reflect a difficulty
in applying/conforming to some theories.
 Society has also become increasingly secular and has
largely rejected a monistic or religious approach to
ethical justification.
 Post-modernism rejects the Enlightenment’s rational
aims in the light of linguistic and social uncertainty.
Up and Down
 The traditional way of thinking about ethical
theory was deductively – ‘top down’ - proceeding
from accepted general ethical concepts and
applying them to particular situations. E.g.
Kant’s Categorical Imperative
Specific formulation ‘treat others as ends in themselves’
Applied to volunteers in drug trial
Leads to decision never to exploit them
Up and Down
 Increasingly, however, inductive or ‘bottom up’
approaches have been championed. These appeal to
our considered judgements and also settled cases and
from which generalisations can be made and applied
to other situations. (e.g. Casuistry)
 But perhaps the most generally accepted form of
decision making used is a coherentist one – where one
belief can only be justified in relation to another.
Rawls’ reflective equilibrium is often used and he
describes a process where our considered judgements
are tested with reference to more generalised
theories that explain these intuitions.
Linking theory and practice
 Coherentist approaches appeal because they do not
require either a search for definitive, paradigm cases
on which to decide in an analogous situation or rely
upon an abstracted, formal (and perhaps difficult,
uncompromising) general ethical theory.
Reflect on considered
judgements (intuitions)
Consider how these
relate to generalised
theories
Are these judgements and
theories/rules consistent
NO
Revise theory
or intuitions
YES
Apply to ethical situation and make decision
Criticisms
 One initial problem with coherentist approaches is
that the process of formulating general rules or
theories that accommodate intuitions could have
justified Nazism, for example.
 Inductivists would also argue that intuitions lack
ethical credibility.
 Perhaps try to combine the two by arguing that one
should balance intuitions with existing ethical
theories but how can one weigh-up such concerns?
Linking theory and practice
 So far, an approach to understanding practical
decision making has been offered that is still
grounded in philosophy, albeit one that is sensitive
to an individual’s ‘gut feelings’ and intuitions.
 Obvious points to remember are that ethical
reasoning should be free from contradictions and
follow logical conclusions (e.g. syllogisms):
The taking of any life is ethically wrong.
Abortion involves the taking of a life.
Therefore, abortion is ethically wrong.
Exercise 1
 How would you deal with the following situation and
what are your intuitions about the situation:
“Mrs. Singh calls at your pharmacy to ask if you could check her son’s
computer record and tell her what her son received last month from a locum
doctor. The medicine is working but her GP has no record. Her son is not
with her today as her has missed two day’s of the effective treatment.”
 Now thinking about ethical theories, consider how
utilitarianism, a rights-based approach, Kant’s
Categorical Imperative and the ‘4 principles’ might
be used.
 Are your views consistent with theory?
Cognitive Moral Development
 As psychology developed as a discipline, connections
were made between cognitive processes and moral
reasoning. Developing Piaget’s work with
infant development, Lawrence Kohlberg
developed a theory of CMD that has
become extremely influential.
 Based upon the experimental methods of
psychology, Kohlberg’s theory was empirically based
but also contained normative aspects.
Cognitive Moral Development
 Basing his theory on a longitudinal study of
adolescent American boys, Kohlberg argued that
individuals develop moral reasoning ability in a
number of discrete stages.
 The theory was significant because it claimed that
moral development occurs in much the same way as
other psychological attributes like language, social
skills, abstract reasoning and cognitive processes.
 Individuals develop only a stage at a time and the
theory applies to everyone.
Exercise 2
 Consider the famous Heinz dilemma used in CMD:
“A woman was near death from a special kind of cancer. There was
one drug that the doctors thought might save her. It was a form of
radium that a druggist in the same town had recently discovered.
The drug was expensive to make, but the druggist was charging ten
times what the drug cost him to produce. He paid $200 for the
radium and charged $2,000 for a small dose of the drug. The sick
woman's husband, Heinz, went to everyone he knew to borrow the
money, but he could only get together about $1,000 which is half of
what it cost. He told the druggist that his wife was dying and asked
him to sell it cheaper or let him pay later. But the druggist said: "No,
I discovered the drug and I'm going to make money from it." So
Heinz got desperate and broke into the man's store to steal the drug
for his wife.”
(Kohlberg, 1963, p. 19)
 Should Heinz break into the laboratory to steal the
drug for his wife? Why or why not? Explain
 Stage one (obedience): Heinz should not steal the medicine,
because he will consequently be put in prison.
 Stage two (self-interest): Heinz should steal the medicine,
because he will be much happier if he saves his wife, even if
he will have to serve a prison sentence.
 Stage three (conformity): Heinz should steal the medicine,
because his wife expects it.
 Stage four (law-and-order): Heinz should not steal the
medicine, because the law prohibits stealing.
 Stage five (human rights): Heinz should steal the medicine,
because everyone has a right to live, regardless of the law. Or:
Heinz should not steal the medicine, because the scientist has
a right to fair compensation.
 Stage six (universal human ethics): Heinz should steal the
medicine, because saving a human life is a more fundamental
value than the property rights of another person. Or: Heinz
should not steal the medicine, because that violates the
golden rule of honesty and respect.
Cognitive Moral Development
Level 1
Stage 1 reasoning related to external
punishment
Pre-conventional
Stage 2 egoistic self-interest
Level 2
Stage 3 reasoning that considers ones
immediate peers
Conventional
Stage 4 broader social implications and
laws
Level 3
Stage 5 principled reasoning that
recognises the social contract
Post-conventional Stage 6 universal ethical principles of
Justice
Relevance of CMD
 In short, its popularity! Especially in its latter
development as a psychometric questionnaire test,
CMD has been viewed as an ‘easy’ tool that
operationalizes ethics and appears to have validity
and reliability. Frequently used in health care.
 CMD offers insights into how individuals actually
make ethical decisions and could be used to identify
more basic forms of reasoning.
 However, despite empirical origins, it is inherently
normative and assumes that higher reasoning is
JUSTICE based. The choice of boys in original study
and justice dilemmas may be contributory.
Criticisms
 Despite its empirical origins, Kohlberg’s CMD is
inherently normative and assumes that higher
reasoning is JUSTICE based.
 However, Gilligan has famously argued that Kohlberg’s
male sample and selection of scenarios were
inherently biased towards justice-based reasoning.
Using a sample of women, initially, Gilligan proposed a
possible alternative ethic of care.
 In later forms, a psychometric‘defining issues test’
was developed (Rest) that pre-coded responses and
produced statistical scores. Can you score ethics?
Ethical Decision Making Models
 These are not the same as those in the psychological or
statistical fields, which are grounded in issues such as
probability, decision trees and outcome values.
 Ethical decision making models are usually derived from
two distinct concerns:
 A research interest in explaining and also predicting
how individuals make ethical decisions in practice.
 A practical and pragmatic desire to offer help and
assistance to individuals in making ethical decisions.
Ethical Decision Making Models
Are they useful?
Ethical Decision Making Models
Are they useful?
Ethical Decision Making Models
 Should we be suspicious of attempts to reduce complex
human activities and any attendant reasoning and
decision making into convenient models?
 It may be argued that some models are underpinned by
empirical study and although this applies to models that
attempt to predict or explain ethical behaviour,
Kohlberg’s normativity might make us suspicious!
 The prescriptive models often claim modesty in not
attaching any specific ethical theory to their stages.
Ethical Decision Making Models
Model
Stages in each model
Weinstein
(1996)
Wingfield
(1997)
Veatch,
Haddad
(1999)
Gather facts:
law, codes,
professional
knowledge
Consider why
situation is
ethical problem:
Consider who
is involved and
their values
Generate
options
Make decision
a) Distinguish
facts from
evaluative
statements
Define who
should act and
when
b) Distinguish
moral and
non-moral
evaluations
List possible
options
c) Determine
who should
decide
Parker
Adapted from
Pellegrino
method. See
Ethox website
What are
relevant facts
Rest (1986) *
Jones (1991)*
Schneider and
Snell (2000)
Identify ethical
problem
What are my
Core beliefs
Apply ethical
reasoning
How have I
Acted in past
Establish
Moral Intent
What are
Reasoned
opinions of
others
Act Ethically
BMA (2004)
Recognise
ethical situation
Break down
dilemma into
parts
Seek
information
from patient
and others
Jonsen,
Seigler and
Winslade
(1992)
Holm (1997)*
Establish
medical facts
Identify
patient’s
preferences
Consider
quality of life
What personal
experience tells
us
Ethical
perception
Ethical
Reasoning
Identify
morally
significant
parts of options
What is
Experience of
others in
similar
situations
Identify
relevant legal
& professional
guidance
Think about
religious, legal
and cultural
factors
Ethical
decision
Consider the
range of
ethical
theories.
What does
law say
What
other rules
might
apply?
Identify
pros and
cons of
moral
arguments
If no solution
found, apply
critical
ethical
analysis
Justify
decisions
with
sound
arguments
Consideration
of practical
possibilities
Final
Decision
Choose option
based on
consistency,
concepts and
logic
Find best
counterargument.
If you can rebut
it, decide.
Implementation
(* denotes explanatory models, all other practical/prescriptive)
Ethical Decision Making Models
 Despite the plethora of prescriptive and empirical
models that exist in relation to ethics problem
solving, there appear to be several common features
and also some ‘front runners’:
 For example, the model by Rest and Jones has been
cited in many research papers and has been applied
to business ethics and also healthcare (Holm).
However, it remains an empirical rather than
prescriptive model and provides insights into what
individuals are understood to do in practice.
Ethical Decision Making Models
 The Rest/Jones model contains 4 stages:
 Identify ethical problem. An obvious point but
concept of ethical attention or perception is often
over-looked in literature.
 Apply ethical reasoning. Rest (and Jones but not
Holm) used CMD but other theories possible.
 Establish moral intent (not egoistic self-interest).
 Engage in ethical action (again obvious?) Related
to moral motivation.
 Influential but remains an explanatory model.
Ethical Decision Making Models
 The prescriptive models often have similarities. In
part, this is because they appear to have been
influenced by proceeding models (Parker/Pellegrino,
Wingfield/Weinstein).
 There are several common features that may help
guide the ethically conflicted:
 Identify the problem and gather all the facts
 Consider how law, rules, past experience and
advice of others might be of use.
 Use some form of ethical reasoning
 Justify decision and act.
Exercise 3
“Sally calls into a pharmacy late on a Saturday afternoon and
asks if she could be supplied with emergency hormonal
contraception. The pharmacist, David, believes that EHC is a
form of abortion and will not supply it or even recommend
where else to obtain it. David does not want to offend Sally
and simply says he doesn’t have any. Sally appears to be upset and asks where else she can obtain EHC.”
 Use one of the models described or a combination of
them to consider whether David’s actions were
ethically justified and what could be done in this
situation.
Summary
 This session has attempted to identify three
approaches to how ethical decisions are made in
practice and have considered:
 Coherentist approaches that try to balance existing ethical
theory with one’s intuitions.
 CMD that uses empirical data to suggest that individuals
progress through different stages but that justice is the most
ethical form of reasoning.
 Various models that try to either offer assistance or
explanations as to how decisions could be made in practice.
Summary
 Many of the criticisms identified in this session
appear to be internecine. Realists clash with
idealists, foundationalists with coherentists,
psychologists with philosophers with social scientists.
 What of the poor pharmacist?
 Perhaps simply gaining a basic understanding of the
diversity of ethical decision-making, recognising the
role of intuitions,having an awareness of existing
theory and applying simple rules of consistency and
logic could be a helpful start.