The various models for ethical decision making typically have five to fourteen ordered steps that begin with fully comprehending the ethical dilemma and conclude with the evaluation of the implemented decision. Perhaps the easiest model to use at the bedside remains the MORAL model. Many nurses prefer this model, as the letters of the acronym remind nurses of the subsequent steps of the model, and thus the model can easily be used in all patient care settings.
The model includes the following steps:
M Massage the dilemma. Identify and define issues in the dilemma. Consider the opinions of the major players—patients, family members, nurses, physicians, clergy, and other interdisciplinary health care members—as well as their value systems.
O Outline the options. Examine all options fully, including the less realistic and conflicting ones. Make two lists, identifying the pros and cons of all the options identified. This stage is designed to fully comprehend the options and alternatives available, not to make a final decision. This is also one of the most time-consuming steps of the process and a stage that can be revisited as new information becomes available.
R Resolve the dilemma. Review the issues and options, applying basic ethical principles to each option. Decide the best option based on the views of all those concerned in the dilemma.
A Act by applying the chosen option. This step is usually the most difficult because it requires actual implementation, whereas the previous steps allow for only dialogue and discussion.
L Look back and evaluate the entire process, including the implementation. No process is complete without a thorough evaluation. Ensure that all those involved are able to follow through on the final option. If not, a second decision may be required and the process must start again at the initial step.
Example of the Moral Model (do not use for this paper, this is only an example)
Using the MORAL Model
Jody Smith, a retired nurse with three adult children and numerous adult grandchildren, lives alone in a small rural area. Her income is limited. Two months ago, she fell and broke her left with hip. After surgery for an artificial hip replacement, she was transferred to a rehabilitation center, where she had a left-sided cerebrovascular accident (CVA). She was then readmitted to the acute care facility, where she has received aggressive therapy for the CVA.
Completely paralyzed on her left side, Mrs. Smith has decided that she no longer desires aggressive therapy and frequently asks the staff why she cannot die in peace. “The rehabilitation is so painful and I’ll never walk again. What’s the use?”
Both the doctors and her family are much more optimistic. The orthopedic surgeon is convinced that she will walk again, and the neurologist believes that she will make a full recovery and be able to return home and care for herself. Both doctors have excluded Mrs. Smith from their conversations, assuring her children that she will be “as good as new” and ignoring her requests to discontinue anticoagulant and rehabilitative therapy.
While not in a life-threatening condition, Mrs. Smith refuses to cooperate with the physical and occupational therapists and to take her medications. She also refuses to perform simple tasks, relying on staff to meet her activities of daily living.
Using the MORAL model, how would you begin to resolve this dilemma?