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3 simple ways to upgrade your ethical decision-making skills

In my experience, registered dietitians are ethical, conscientious, and patient-centered health care professionals. However, as is true of all skills – the skills required to effectively negotiate ethical problems can be sharpened and honed to enhance effectiveness and minimize work-related stress.
For me, dedicating time to enhancing my ethical problem-solving skills has led to me feeling more confident as I approach ethical decision-making in my practice. As a result, I am less likely to carry around residual stress in the days and weeks following a particularly difficult decision or case.
The importance of honing these skills first became clear to me as a student in a graduate level Philosophy of Nursing course, taken as part of my doctoral program in the Faculty of Nursing at the University of Alberta. The required readings, assignments, and class discussions shed new light on the vast expanse of knowledge relevant to decision-making in the health care setting.

Following completion of this course, my colleagues and I adapted my final paper for publication in the Journal of Nutrition Education and Behavior. The paper, “Strengthening Moral Reasoning Through Dedicated Ethics Training in Dietetic Preparatory Programs,” was published in the March-April 2015 issue of the journal.1
One of the theories I became familiar with while drafting and revising the paper was Kohlberg and Hersh’s Stages of Moral Development.2 Moral development is upgraded through advancement of moral reasoning skills. Moral reasoning is defined as the mental processes of identifying ethical actions as right or wrong before settling on a course of action. Kohlberg and Hersh outline six hierarchical stages of moral development, ranging from “Obedience” to “Social Cooperation.”3 Those who’ve reached higher levels of moral development are more capable of understanding complex ethical arguments and can more successfully resolve ethical conflicts.4 
Canadian-trained dietitians complete their internships with knowledge of professional ethics and, through their practical experiences, are required to demonstrate competence in professional practice (inclusive of ethics). Every provincial dietetic regulatory body has a Code of Ethics that all members must abide by.
Typically, ethics, as a topic in preparatory coursework, is incorporated within mandatory professional practice courses. Although the content, duration, and format of these courses vary across Canadian universities, all accredited dietetic preparatory programs have met agreed upon standards for ethical education.
Empiric research is limited, but indicates that health care professionals, including dietitians, top-out at a “Conventional” (stage 3 or 4) level of moral development. “Post-Conventional” (stage 5 or 6) is the highest level of moral development, as per Kohlberg and Hersh. Research indicates that moral development occurs when individuals participate in intensive ethics education5,6 that is mandatory and discussion-driven.7,8  

There are many ways that those of us who have already completed our dietetic education can aim to enhance our moral reasoning and ethical decision-making skills. I have drawn from the paper I published to outline three ways of doing so:

1. Enrol in a health care ethics or philosophy course.

The rise of the massive open online course (MOOC) has made university level courses easily accessible to anyone with a computer. Search for a course in ethics or philosophy that sounds interesting to you and give it a try. Of possible interest is a free Justice course offered online by Harvard University.

2. Read, read, read! 

Expose yourself to books or articles that force you to see things from another point of view (or many points of view at the same time).9 Jodi Picoult, author of many novels including My Sisters Keeper and Handle with Care, is an example of an author who explicitly explores health care ethics through narrative fiction. A recent novel by Canadian novelist Miriam Toews, All My Puny Sorrows, gives a human (fictional) face to the debate surrounding mental health and assisted suicide.
Margaret Atwood, Lisa Genova, Rohinton Mistry, and Anne-Marie MacDonald consistently author novels that force me to see through the eyes of characters with points-of-view distinct from my own. In non-fiction, Elizabeth Abbott introduced me to the murky history of sugar production in her book Sugar and Jon Ronson, author of So You’ve Been Publicly Shamed, deftly and humorously shared the stories of individuals whose lives have been profoundly changed as a result of internet shaming.
By immersing myself in the works of these authors (and others), I have been forced to face gaps in my own understanding and to reflexively examine my knee-jerk emotional responses to others’ stories. As a result, I am steadily evolving to be more empathetic and less judgmental.

3. Start an ethics club.

Do you participate in a journal club? Consider making every fourth journal club meeting an ethics club meeting. Or, start an ethics club that meets once a month! Begin each meeting with a story of an ethical dilemma. The problem needn’t be related to nutrition.
There are several rich sources of dilemmas:
  • The media/news cycle
  • Your colleagues’ past experiences
  • A story from a book, movie or podcast (e.g. NPR’s Radiolab)
  • The Defining Issues Test (DIT), which is used to measure moral development. Stories from the DIT are available online here.
Importantly, research indicates that superior moral reasoning impacts positively on clinical performance.10,11Thus, dedicating time and energy to working on your moral development is likely to result in positive benefits in your work-life.
I noticed a distinct difference in my own work-life when I returned to clinical practice after several years of full-time academics. Ultimately, I consider this time a period of moral development. It helped me to become a more patient person. I was no longer as quick to attribute ambivalence or indecision on the part of patients or their families to stubbornness, ignorance, or spite.
Instead, I was better able to put myself in their position and “think my way” to a place where their indecision or ambivalence appeared to be a rational response to their circumstances. As a result, I found that my ability to maintain positive therapeutic relationships with patients and their families was enhanced. I was better able to meet them where they were and to provide tailored rationale for evidence-based treatment options that better addressed their questions and concerns.
I have not (and don’t expect to) reached a point of maximum moral development. I expect to be perpetually upgrading my ethical decision-making skills for the remainder of my professional life through continuing education, diverse reading habits, and purposeful, deep discussion of ethical issues with colleagues and friends.

Editor’s noteWhile working with Sarah on this blog post, she introduced me to a quote I really like by Ralph Waldo Emerson: “Nothing is at last sacred but the integrity of your own mind.” 
Dietitians deal with very difficult ethical issues, such as end-of-life feeding, that benefit from advanced moral reasoning skills. Dietitians are equipped with these skills, but using Sarah's tips could be a great way to practice and hone them. 
Have you taken a course in this area that you would recommend? Please share thoughts, comments, and questions below.

  1. Hewko SJ, Cooper SL, Cummings GG. Strengthening moral reasoning through dedicated ethics training in dietetic preparatory programs. Journal of Nutrition Education and Behavior. Mar-Apr 2015;47(2):156-161.
  2. Kohlberg L, Hersh R. Moral development: A review of the theory. Theory Into Practice. 1977;16(2):53-59.
  3. Swisher LL. Moral reasoning among physical therapists: Results of the defining issues test. Physiotherapy Research International. 2010;15:69-79.
  4. Kohlberg L. The implications of moral stages for adult education. Religious Education. 1977;72(2):183-201.
  5. Geddes EL, Salvatori P, Eva KW. Does moral judgement improve in occupational therapy and physiotherapy students over the course of their pre-licensure training? Learning in Health and Social Care. 2008;8(2):92-102.
  6. Dieruf K. Ethical decision-making by students in physical and occupational therapy. Journal of Allied Health. Spring 2004;33(1):24-30.
  7. Rest J, Narvaez D, Thoma SJ, Bebeau MJ. DIT2: Devising and testing a revised instrument of moral judgment. Journal of Educational Psychology. Dec 1999;91(4):644-659.
  8. Self DJ, Olivarez M, Baldwin DCJ. The amount of small-group case-study discussion needed to improve moral reasoning skills of medical students. Academic Medicine. 1998;73(5):521-523.
  9. Jarvis C. Fiction, empathy and lifelong learning. International Journal of Lifelong Education. 2012;31(6):743-758.
  10. Sisola S. Moral reasoning as a predictor of clinical practice: The development of physical therapy students across the professional curriculum. Journal of Physical Therapy Education. 2000;14(3):312-335.
  11. Krichbaum K, Rowan M, Duckett L, Ryden MB, Savik K. The Clinical Evaluation Tool: A measure of the quality of clinical performance of baccalaureate nursing students. Journal of Nursing Education. 1994;33(9):395-404.
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