One mechanism to promote ethical practice is by incorporating a standard approach to difficult business and/or clinical discussions at the Board or within the hospital. Where difficult management or clinical issues are being discussed and debated, the following framework may be utilized to provide assistance in the analysis of the problem and subsequent decision making:

1) Problem

What precisely, is the problem that requires solution?
Who is responsible for taking the action required to implement the solution?

Objectives at this stage:

  • Clarify the question
  • Narrow question down to manageable proportions

2) Issues

What are the ethical issues at play in this problem?
What hospital/professional policies or goals are relevant to the problem?

Objectives at this stage:

  • Formulate ethical context

3) Stakeholders

Who are the relevant stakeholder groups?
What are their interests?
Are there conflicting interests between stakeholder groups
Stakeholders would include, but need not be limited to: patients/clients, future patients/clients, service providers, community groups, taxpayers etc.

Objectives at this stage:

  • Identify stakeholders
  • Assess need for stakeholder consultation
  • Identify conflicts 

Sometimes ethical conflicts are conflicts between the legitimate interests of different groups. At this stage we need to identify those interests and assess their legitimacy.
We are accountable to our stakeholders.

4) Options and Assessments

What are the possible courses of action?
How do they rank?

Objectives at this stage:

  • Identify alternatives
  • Evaluate
  • Form judgement
  • Make decision


However, it is always possible that some pressing moral value will outweigh normal considerations. These values could arise from a number of possible sources, for instance a previous commitment that creates an unavoidable ongoing obligation, or compassion for an especially troubling set of cases.

Does the best option (when identified through this process) clash excessively with other ethical values?
These values would include, but need not be limited to: autonomy, justice (fairness), caring (compassion), privacy,
Why is this value (or these values) most important, in this case?

5) Decision

State the favoured outcome from stage 4 above.
Explain reasons for preferring chosen outcome over the alternatives.

Objectives at this stage:

  • Clearly identify decision
  • Clearly articulate reasons for choice


As a stand-alone piece, stage 5 represents your public accountability for your decision. Would you be comfortable publicly stating and explaining your decision? (It cannot be expected that everyone’s demands are satisfied, but there should be a sense that an impartial and fair observer would accept the decision and the reasons upon which it was made.)

6) Implementation

Identify the steps required to put the choice into action.
Identify evaluation mechanism for follow up, if required.

Identify educational, information strategies as required.

Objectives at this stage:


  • Turn decision into action
  • Provide evaluation mechanism
  • Inform and educate