Ethic And Legal 850 words Article for nurses Eun-Jun Park Kyungwon University, Korea Abstract The study revie

Ethic And Legal 850words Article

An integrated ethical
decision-making model
for nurses

Eun-Jun Park
Kyungwon University, Korea

Abstract
The study reviewed 20 currently-available structured ethical decision-making models and developed an
integrated model consisting of six steps with useful questions and tools that help better performance
each step: (1) the identification of an ethical problem; (2) the collection of additional information to
identify the problem and develop solutions; (3) the development of alternatives for analysis and com-
parison; (4) the selection of the best alternatives and justification; (5) the development of diverse, prac-
tical ways to implement ethical decisions and actions; and (6) the evaluation of effects and development
of strategies to prevent a similar occurrence. From a pilot-test of the model, nursing students reported
positive experiences, including being satisfied with having access to a comprehensive review process of
the ethical aspects of decision making and becoming more confident in their decisions. There is a need
for the model to be further tested and refined in both the educational and practical environments.

Keywords
decision making, ethics, ethical issues, nursing ethics, problem solving

Introduction

Patients’ safety and well-being are dependent, to a large extent, on professionals’ ethical decisions.
1

Regardless of his or her excellence in clinical knowledge and skills, a healthcare professional who has low

or non-existent ethical standards should be considered unfit to practice. For responsible healthcare, profes-

sionals have to be competent in ethical decision making.
2

An ethical problem is ‘as [an ethical] matter or

issue that is difficult to deal with, solve, or overcome and which stands in need of a solution’ (p.94).
3

Ethical

problems in a clinical setting are those we rarely confront in our daily lives, and ethical norms learned from

our parents or schools are not sufficient to resolve clinical ethical issues. There are concerns about profes-

sionals’ ethical competency. Health professionals often adopt an inconsistent decision-making process or

reach inconsistent ethical conclusions in attempts to resolve identical ethical problems.
1,4,5

Moreover, they

tend to come to decisions of an ethical nature before reviewing all possible alternatives or going through a

systematic and comprehensive decision process.
2

It is challenging for clinicians to make ethical decisions.

Health professionals attempt to achieve the best possible and morally-justifiable resolution while prior-

itizing a patient’s interest.
6

Accordingly, the quality of ethical decision making should be evaluated in terms

not only of its conclusion but also the process of decision making. For example, whether all individuals

Corresponding author: Eun-Jun Park, Department of Nursing, Kyungwon University, San65, Bokjeong-Dong, Sujeong-Gu,

Seongnam-Si, Gyeonggi-Do, 461-701, Korea

Email: eunjunp@gmail.com

Nursing Ethics
19(1) 139–159

ª The Author(s) 2012
Reprints and permission:

sagepub.co.uk/journalsPermissions.nav
10.1177/0969733011413491

nej.sagepub.com

139

affected by the decision have an opportunity to share their informed decisions or preferences.
7

An explicit

and systematic method for ethical decision making is highly likely to improve the quality of such deci-

sions for several reasons.
2,8-11

First, ‘a model functions as an intellectual device that simplifies and clari-

fies the sources of moral perplexity and enables one to arrive at a self-directed choice’ (p.1701).
2

Second, it eliminates a possibility of deviated assessment of an ethical problem, for example, not con-

sidering all relevant parties and their diverse preferences,
12

or reaching conclusions based on his/her

intuition rather than on intellectual rigor.
13,14

Third, ‘communication and documentation of an explana-

tion for a course of action’
8

and collaboration among stakeholders become easier throughout an ethical

decision-making process when a systematic decision-making model is shared.
7

A systematic decision-

making model helps identify where a gap in understanding an issue or a difference in value systems (dis-

agreements) exist among stakeholders (interdisciplinary team) through transparent communication.
1,15,16

Finally, the use of a systematic model of ethical decision making will allow for the accumulation of

information concerning ethical decisions, thus revealing norms.
7

Although nurses make ethical decisions

every day, we know little about how similar are our ethical decisions to those of other nurses. If we

collect information on our ethical decisions, codes of ethics can be developed being based on our nor-

mative ethics,
7

which can be more acceptable and evidence based.

Structured models for ethical decision making have been introduced by different authors. To name a

few, Johnstone’s moral decision-making model
3

includes stages to assess the situation, to identify moral

problem(s), to set moral goals and plan moral action, to implement moral plans of action, and to evaluate

moral outcomes. According to Davis, Fowler, and Aroskar,
17

if a conflict of moral duties or values

exists, we need to go through the following stages: 1) review of the overall situation to identify what

is going on; 2) identification of the significant facts about the patient; 3) identification of the parties

or stakeholders involved in the situation or affected by the decision(s) that is made; 4) identification

of morally relevant legal data; 5) identification of specific conflicts of ethical principles or values; 6)

identification of possible choices, their intent, and probable consequences for the welfare of the patient(s)

as the primary concern; 7) identification of practical constraints and facilitators; 8) make recommenda-

tions for action; 9) take action if you are the decision maker and implementor of the decision(s) made;

and 10) review and evaluate the situation after action is taken. In addition, Thompson et al.’s
11

DECIDE

model suggests to: 1) Define problems – what is an ethical issue?; 2) Ethical review – what principles

are relevant to case?; 3) Consider options; 4) Investigate – ethical outcomes, costs and benefits; 5)

Decide on action; and 6) Evaluate results. However, it is hard to say what are their strengths or weak-

nesses and which one is more greatly-accepted by clinicians. Therefore, the current study critically

reviewed structured ethical decision-making models found via a systematic search of literature and sug-

gested an integrated and comprehensive ethical decision-making model by synthesizing strengths of the

different ethical decision-making models and by pilot-testing it. The suggested ethical decision-making

model is meant to be prescriptive so that nurses may directly apply it in practice.

Methods

Peer-reviewed journal articles were searched using Medline and CINAHL databases. The following

keywords and the subject headings were entered into the PubMed and CINHAL interface on 30 June

2010: (ethical OR moral) AND ((decision AND making) OR (decision AND model)). Four hundred

and twenty-six articles from Medline and 202 additional articles from CINAHL were retrieved. Their

titles and abstracts were reviewed for potential relevance, and then the selected 78 articles were

reviewed for their full-text. Studies were selected if (1) their authors originally developed an original

ethical decision-making process or model, (2) the ethical decision-making process or model clearly

presented steps for decision, and (3) they were written in English. Studies were excluded mostly

140 Nursing Ethics 19(1)

140

because (1) the authors introduced or applied an ethical decision-making process or model developed

by other people, (2) they described only a theoretical background of ethical decision making without a

decision-making process, or (3) their ethical decision-making process or model were developed for

non-healthcare practitioners or for non-clinical settings, such as business, information technology,

education, or research. A report of an ethical decision-making process for family physicians of

Canada
18

was included after reviewing references of the selected articles. Twenty structured ethical

decision-making processes were reviewed systematically.

An integrated ethical decision-making model was developed and modified through a pilot test of its

usability. In two nursing ethics courses, 67 second-year baccalaureate nursing students were asked to

solve four cases of clinical ethical problems through a group discussion involving three or four people

and to submit a report of their decisions. This was a regular classroom activity of a nursing ethics course

taught by the author. To test the developed model, 22 student groups discussed an initial two cases

before learning the model, and, after a brief orientation, a further two cases applying the model. After

the discussion class, the students were invited to participate in this study as a group by submitting their

reflective essay of how the use of the structured model influenced their decision-making process or out-

comes. Twenty student groups voluntarily participated without revealing their names, and thus individual

participants were not identifiable so as to protect the students. Accordingly, whether or not they parti-

cipated in this study, their grades or student-teacher relationships were unaffected.

Findings

Reviews of ethical decision-making or problem-solving models

Twenty different ethical decision-making models were classified into two groups and ordered by their

publication year: ‘Nine ethical decision-making processes’ (Table 1) and ‘Eleven ethical problem-

solving processes’ (Table 2). An ethical problem-solving process includes an ethical decision-

making process, which refers mainly to a cognitive process, but goes further by adding implementing

the decision and evaluating its results. However, the authors of the reviewed articles did not clearly

distinguish this difference, and interchangeably used the two terms: ‘ethical problem solving’ and

‘ethical decision making’. Only two studies
1,18

out of the 11 (Table 2) explicitly acknowledged the

difference by mentioning it in their article titles. These two terms were differentiated in this study,

as necessary; otherwise the term ‘ethical decision making’ is used to refer to both, and they are ana-

lyzed and discussed together. The reviewed 20 studies were published from 1976 to 2010: one in the

1970s, seven in the 1980s, four in the 1990s, and eight in the 2000s. They show that interest in ethical

decision-making process has been ongoing and that new models are being constantly developed even

today. A chronological pattern of change was not found in ethical decision-making or problem-

solving models. Among the reviewed 20 models, seven were developed for RNs or nurse practi-

tioners, five for health professionals in general, four for physicians, two for psychologists, one for

social workers, and one for a neonatal intensive care unit.

Theoretical backgrounds and contextual factors. Most authors suggested ethical pluralism applying diverse
ethical theories and perspectives in decision making as one ethical theory or perspective was unlikely

to be a panacea for every ethical problem. Ethical pluralism seems to be natural in modern societies that

are experiencing an increasing diversity of values.
3

By adopting various theoretical alternatives, nurses

are more likely to have a comprehensive moral vision.
16

Deontology (principle-based approach) and

consequentialist theory (teleology, ends-based approach) were predominantly adopted by the authors

of the models, whereas some models were based on a single ethical theory: consequentialism.
7,15,19

Park 141

141

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o
r

p
re

fe
re

n
ce

o
f
th

e
d
e
ci

si
o
n

m
ak

e
r,

co
n
te

x
t

o
f
th

e
e
n
vi

ro
n
m

e
n
t,

in
d
iv

id
u
al

d
e
ci

–
si

o
n

m
ak

in
g

st
yl

e
s

P
h
ys

ic
ia

n
s

E
th

ic
al

p
lu

ra
lis

m
in

cl
u
d
in

g
co

n
se

–
q
u
e
n
ti
al

is
m

&
d
e
o
n
to

lo
gy

N
e
o
n
at

al
in

te
n
si

ve
ca

re
u
n
it

C
o
lla

b
o
ra

ti
ve

d
e
ci

si
o
n

(C
o
n
se

q
u
e
n
ti
al

is
m

ap
p
ro

ac
h
)

In
d
iv

id
u
al

va
lu

e
sy

st
e
m

&
th

e
co

re
va

lu
e
s

o
f
th

e
u
n
it

7
st

ag
e
s

7
st

ag
e
s

6
st

ag
e
s

7
st

ag
e
s

1
.
S
ta

te
th

e
p
ro

b
le

m
p
la

in
ly

(c
o
n
ti
n
u
ed

)

143

T
a
b

le
1

(c
o

n
ti

n
u

e
d

)

D
e
W

o
lf

B
o
se

k
(1

9
9
5
)1

5
M

at
ti
so

n
(2

0
0
0
)1

3
K

al
d
jia

n
e
t

al
.
(2

0
0
5
)9

B
au

m
an

n
-H

o
lz

le
e
t

al
.
(2

0
0
5
)1

4

1
.
Id

e
n
ti
fy

d
e
si

re
d

o
u
tc

o
m

e
s

2
.
A

ss
ig

n
u
ti
lit

ie
s

1
.
B
ac

k
gr

o
u
n
d

in
fo

rm
at

io
n

/c
as

e
d
e
ta

ils
2
.
S
e
p
ar

at
in

g
p
ra

ct
ic

e
co

n
si

d
e
ra

ti
o
n
s

an
d

e
th

ic
al

co
m

p
o
u
n
d
s

2
.
G

at
h
e
r

an
d

o
rg

an
iz

e
d
at

a:
m

e
d
ic

al
fa

ct
s,

m
e
d
ic

al
go

al
s,

p
at

ie
n
t’
s

go
al

s
an

d
p
re

fe
re

n
ce

s,
co

n
te

x
t

1
.
D

e
sc

ri
p
ti
o
n

o
f
th

e
ch

ild
’s

m
e
d
ic

al
in

fo
rm

at
io

n
,
ca

re
an

d
so

ci
al

si
tu

at
io

n
2
.
D

if
fe

re
n
t

as
p
e
ct

s
o
f
e
va

lu
at

io
n

th
e

in
fa

n
t’
s

ch
an

ce
s

o
f
su

rv
iv

al
th

e
in

fa
n
t’
s

ch
an

ce
s

o
f
d
yi

n
g

if
m

e
ch

an
ic

al
ve

n
ti
la

ti
o
n

an
d

o
th

e
r

cr
it
ic

al
as

si
st

an
ce

ar
e

co
n
ti
n
u
e
d
/w

it
h
d
ra

w
n

th
e

in
fa

n
t’
s

ac
tu

al
su

ff
e
ri

n
g

th
e

in
fa

n
t’
s

p
o
ss

ib
ili

ty
to

liv
e

in
d
e
p
e
n
d
e
n
tl
y

in
th

e
fu

tu
re

w
it
h
o
u
t

d
e
ve

lo
p
in

g
se

ve
re

h
an

d
ic

ap
s

3
.
Id

e
n
ti
fy

in
g

va
lu

e
te

n
si

o
n
s

4
.I

d
e
n
ti
fy

in
g

p
ri

n
ci

p
le

s
in

th
e

co
d
e

o
f
e
th

ic
s

w
h
ic

h
b
e
ar

o
n

th
e

ca
se

3
.
A

sk
:
Is

th
e

p
ro

b
le

m
e
th

ic
al

?
4
.
A

sk
:
Is

m
o
re

in
fo

rm
at

io
n

o
r

d
ia

lo
gu

e
n
e
e
d
e
d
?

3
.
Id

e
n
ti
fy

p
o
ss

ib
le

ac
ti
o
n
s

4
.
A

ss
ig

n
p
ro

b
ab

ili
ti
e
s

5
.
C

al
cu

la
te

e
x
p
e
ct

e
d

va
lu

e
s

5
.
Id

e
n
ti
fy

p
o
ss

ib
le

co
u
rs

e
s

o
f

ac
ti
o
n

(b
e
n
e
fi
t/

co
st

,
p
ro

je
ct

e
d

o
u
tc

o
m

e
s)

3
.
D

e
ve

lo
p
in

g
at

le
as

t
th

re
e

d
if
fe

re
n
t

sc
e
n
ar

io
s

4
.
D

e
ci

si
o
n

(c
o
n
se

n
su

s)
5
.
P
la

n
n
in

g
th

e
d
is

cu
ss

io
n

w
it
h

th
e

p
ar

e
n
ts

6
.
D

is
cu

ss
io

n
w

it
h

th
e

p
ar

e
n
ts

6
.
Id

e
n
ti
fy

th
e

b
e
st

ac
ti
o
n

6
.
A

ss
e
ss

in
g

w
h
ic

h
p
ri

o
ri

ty
/o

b
lig

a-
ti
o
n

to
m

e
e
t

fo
re

m
o
st

an
d

ju
s-

ti
fy

in
g

th
e

ch
o
ic

e
o
f
ac

ti
o
n

7
.
R

e
so

lu
ti
o
n

5
.
D

e
te

rm
in

e
th

e
b
e
st

co
u
rs

e
o
f

ac
ti
o
n

an
d

su
p
p
o
rt

it
w

it
h

re
fe

re
n
ce

to
o
n
e

fo
r

m
o
re

so
u
rc

e
s

o
f
e
th

ic
al

va
lu

e
:
e
th

ic
al

p
ri

n
ci

p
le

s,
ri

gh
ts

,
co

n
se

–
q
u
e
n
ce

s,
co

m
p
ar

ab
le

ca
se

s,
p
ro

fe
ss

io
n
al

gu
id

e
lin

e
s,

co
n
sc

ie
n
ti
o
u
s

p
ra

ct
ic

e
7
.
E
va

lu
at

e
th

e
ac

ti
o
n

ch
o
ic

e
(j
u
st

if
ic

at
io

n
)

6
.
C

o
n
fi
rm

th
e

ad
e
q
u
ac

y
o
f
th

e
co

n
cl

u
si

o
n

7
.
E
va

lu
at

io
n

o
f
th

e
d
e
ci

si
o
n

m
ak

in
g

p
ro

ce
ss

144

T
a
b

le
2
.
E
le

ve
n

st
u
d
ie

s
o
f
e
th

ic
al

p
ro

b
le

m
so

lv
in

g
p
ro

ce
ss

e
s

M
u
rp

h
y

an
d

M
u
rp

h
y

(1
9
7
6
)1

9
A

ro
sk

ar
(1

9
8
6
)2

5
T

ym
ch

u
k

(1
9
8
6
)7

C
as

se
lls

an
d

R
e
d
m

an
(1

9
8
9
)2

6

C
lin

ic
ia

n
s

in
ge

n
e
ra

l
(T

h
e

U
n
iv

e
rs

it
y

o
f

C
o
lo

ra
d
o

M
e
d
ic

al
C

e
n
te

r)
C

o
n
se

q
u
e
n
ti
al

is
m

R
N

s
C

o
n
se

q
u
e
n
ti
al

is
m

&
d
e
o
n
to

lo
gy

P
sy

ch
o
lo

gi
st

s
C

o
n
se

q
u
e
n
ti
al

is
m

R
N

s
&

n
u
rs

in
g

st
u
d
e
n
ts

C
o
d
e

o
f
e
th

ic
s,

e
th

ic
al

p
ri

n
ci

p
le

s

9
st

ag
e
s

7
st

ag
e
s

7
st

ag
e
s

1
1

st
ag

e
s

1
.
Id

e
n
ti
fy

th
e

h
e
al

th
p
ro

b
le

m
.

2
.
Id

e
n
ti
fy

th
e

e
th

ic
al

p
ro

b
le

m
.

1
.
D

is
ti
n
gu

is
h
in

g
a

p
re

d
o
m

in
an

tl
y

e
th

ic
al

si
tu

at
io

n
fr

o
m

o
n
e
,
fo

r
e
x
am

p
le

,
th

at
is

p
ri

m
ar

ily
a

co
m

m
u
n
ic

at
io

n
is

su
e

1
.
Id

e
n
ti
fy

th
e

m
o
ra

l
as

p
e
ct

s
o
f
n
u
rs

in
g

ca
re

3
.
S
ta

te
w

h
o
’s

in
vo

lv
e
d

in
m

ak
in

g
th

e
d
e
ci

si
o
n

4
.I

d
e
n
ti
fy

yo
u
r

ro
le

(q
u
it
e

p
o
ss

ib
ly

,y
o
u
r

ro
le

m
ay

n
o
t
re

q
u
ir

e
a

d
e
ci

si
o
n

at
al

l.)

2
.
G

at
h
e
ri

n
g

an
ad

e
q
u
at

e
in

fo
rm

at
io

n
b
as

e
3
.
Id

e
n
ti
fy

in
g

th
e

va
lu

e
co

n
fl
ic

ts

1
.
D

e
te

rm
in

at
io

n
o
f
w

h
o

sh
o
u
ld

p
ar

ti
ci

p
at

e
in

th
e

d
e
ci

si
o
n

2
.
G

at
h
e
r

re
le

va
n
t

fa
ct

s
re

la
te

d
to

a
m

o
ra

l
is

su
e

3
.
C

la
ri

fy
an

d
ap

p
ly

p
e
rs

o
n
al

va
lu

e
s

4
.
U

n
d
e
rs

ta
n
d

e
th

ic
al

th
e
o
ri

e
s

an
d

p
ri

n
ci

p
le

s
5
.
U

ti
liz

e
co

m
p
e
te

n
t

in
te

rd
is

ci
p
lin

ar
y

re
so

u
rc

e
s

5
.
C

o
n
si

d
e
r

as
m

an
y

p
o
ss

ib
le

al
te

rn
at

iv
e

d
e
ci

si
o
n
s

as
yo

u
ca

n
6
.
C

o
n
si

d
e
r

th
e

lo
n
ga

n
d

sh
o
rt

-r
an

ge
co

n
se

q
u
e
n
ce

s
o
f
e
ac

h
al

te
rn

at
iv

e
d
e
ci

si
o
n

4
.
S
e
e
in

g
w

h
at

h
e
lp

m
ay

b
e

ga
in

e
d

b
y

lo
o
k
in

g
at

th
e

al
te

rn
at

iv
e
s

fr
o
m

th
e

p
e
rs

p
e
ct

iv
e

o
f
e
th

ic
al

th
e
o
ri

e
s

an
d

co
n
ce

p
ts

2
.
D

e
te

rm
in

at
io

n
o
f
av

ai
la

b
le

al
te

rn
at

iv
e
s

3
.
D

e
te

rm
in

at
io

n
o
f
w

h
o

sh
o
u
ld

d
e
ci

d
e

w
h
ic

h
al

te
rn

at
iv

e
to

im
p
le

m
e
n
t

6
.
P
ro

p
o
se

al
te

rn
at

iv
e

ac
ti
o
n
s

7
.
A

p
p
ly

n
u
rs

in
g

co
d
e
(s

)
o
f
e
th

ic
s

to
h
e
lp

gu
id

e
ac

ti
o
n
s

7
.
R

e
ac

h
yo

u
r

d
e
ci

si
o
n

8
.C

o
n
si

d
e
r

h
o
w

th
is

d
e
ci

si
o
n

fi
ts

in
w

it
h

yo
u
r

ge
n
e
ra

l
p
h
ilo

so
p
h
y

o
f
p
at

ie
n
t

ca
re

5
.
M

ak
in

g
a

d
e
ci

si
o
n

4
.
D

e
te

rm
in

at
io

n
o
f
w

h
ic

h
al

te
rn

at
iv

e
to

im
p
le

m
e
n
t

5
.
R

e
vi

e
w

p
ro

ce
d
u
re

s

8
.
C

h
o
o
se

an
d

ac
t

o
n

a
re

so
lu

ti
ve

ac
ti
o
n

6
.
T

ak
in

g
ac

ti
o
n

6
.
Im

p
le

m
e
n
ta

ti
o
n

9
.
P
ar

ti
ci

p
at

e
ac

ti
ve

ly
in

re
so

lv
in

g
th

e
is

su
e

1
0
.
A

p
p
ly

st
at

e
/f
e
d
e
ra

l
la

w
s

go
ve

rn
in

g
n
u
rs

in
g

p
ra

ct
ic

e
9
.
F
o
llo

w
th

e
si

tu
at

io
n

u
n
ti
l
yo

u
ca

n
se

e
th

e
ac

tu
al

re
su

lt
s

o
fy

o
u
r

d
e
ci

si
o
n
,a

n
d

u
se

th
is

in
fo

rm
at

io
n

to
h
e
lp

m
ak

in
g

fu
tu

re
d
e
ci

si
o
n
s

7
.
R

e
vi

e
w

in
g

th
e

p
ro

ce
ss

to
le

ar
n

w
h
at

n
e
e
d
s

to
b
e

ch
an

ge
d

in
d
e
al

in
g

w
it
h

fu
tu

re
e
th

ic
al

si
tu

at
io

n
s

in
p
at

ie
n
t
ca

re

7
.
E
va

lu
at

io
n

1
1
.
E
va

lu
at

e
th

e
re

so
lu

ti
ve

ac
ti
o
n

ta
k
e
n

(c
o
n
ti
n
u
ed

)

145

T
a
b

le
2

(c
o

n
ti

n
u

e
d

)

D
e
W

o
lf

(1
9
8
9
)3

0
T

h
o
m

p
so

n
an

d
T

h
o
m

p
so

n
(1

9
9
0
)1

2
H

ad
jis

ta
vr

o
p
o
u
lo

s
an

d
M

al
lo

y
(2

0
0
0
)2

2

R
N

s
A

n
te

ce
d
e
n
t

fa
ct

o
rs

:
p
ro

x
im

it
y

in
ti
m

e
,

an
e
m

o
ti
o
n
al

in
vo

lv
e
m

e
n
t,

a
fa

ct
u
al

d
e
fi
ci

t,
p
e
rs

o
n
al

in
vo

lv
e
m

e
n
t,

co
n
fu

–
si

o
n

o
f
va

lu
e
s

S
u
p
p
o
rt

in
g/

n
e
ga

ti
n
g

fa
ct

o
rs

to
su

p
p
o
rt

a
p
re

fe
rr

e
d

o
p
ti
o
n

in
st

ag
e

3
:
as

su
m

p
–

ti
o
n
s,

co
n
se

q
u
e
n
ce

s,
le

ga
l
fa

ct
o
rs

,
e
m

o
ti
o
n
s,

p
ro

x
im

it
y

in
d
is

ta
n
ce

an
d

ti
m

e
,
p
re

vi
o
u
s

e
x
p
e
ri

e
n
ce

s,
va

lu
e
s,

fa
ct

s,
an

d
ro

le
re

sp
o
n
si

b
ili

ti
e
s

M
ay

b
e

cl
in

ic
ia

n
s

in
ge

n
e
ra

l
(n

o
t

m
e
n
ti
o
n
e
d
)

U
ti
lit

ar
ia

n
is

m
,
d
e
o
n
to

lo
gy

C
o
n
te

n
ts

an
d

d
e
ta

ils
ar

e
p
ro

vi
d
e
d

in
e
ac

h
st

ag
e

P
sy

ch
o
lo

gi
st

s
T

e
le

o
lo

gy
,
d
e
o
n
to

lo
gy

,
e
x
is

te
n
ti
al

is
m

,
sy

n
th

e
si

s
o
f
d
if
fe

re
n
t

e
th

ic
al

th
e
o
ri

e
s

In
d
iv

id
u
al

in
fl
u
e
n
ce

s:
le

ve
l
o
f
co

gn
it
iv

e
m

o
ra

l
d
e
ve

lo
p
m

e
n
t,

e
th

ic
al

o
ri

e
n
ta

–
ti
o
n
,
d
e
m

o
gr

ap
h
ic

p
ro

fi
le

Is
su

e
sp

e
ci

fi
c

in
fl
u
e
n
ce

s
(m

o
ra

l
in

te
n
–

si
ty

):
te

m
p
o
ra

l
im

m
e
d
ia

cy
,
m

ag
n
it
u
d
e

o
f
co

n
se

q
u
e
n
ce

,
p
ro

x
im

it
y,

co
n
ce

n
–

tr
at

io
n

o
f
e
ff