Cognitive Moral Development and Decision-making

Cognitive Moral Development and Decision-making
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The “partner” of law is ethics. Ethical judgment forms the basis around which we take critical actions that determine our success as a practitioner and as a manager. One component of ethics is cognitive moral development. Cognitive moral development (CMD) describes the mechanisms persons use to arrive at a particular decision or behavior. CMD is said to progress through several stages, beginning in one nearly infant-like stage in that the person makes judgments based solely on their most primal needs without regard to anyone else or in respect to any repercussions. This proceeds to next stages that involve doing exactly what is told of you regardless of the greater good, then upward from there to decisions that help form relationships, and then to a broad consideration of total societal welfare to the extent possible when making a decision.

Lee et al examined CMD; more specifically, they used it as a framework to evaluate moral disengagement among pharmacists, specifically in treating patients with lifestyle diseases.1 They codified moral disengagement into 8 components: moral justification (eg, certain patients won’t benefit from counseling, anyway); displacement of responsibility (eg, I'm not obligated to provide counseling when corporate management demands higher prescription volumes); diffusion of responsibility (eg, I only play a small part in patient nonadherence); attribution of blame (eg, some patients deserve their fate); dehumanization (eg, nonadherent patients are mentally weak); euphamastic labeling (eg, smokers can be labeled as light smokers); advantageous comparison (eg, other patients need more attention than these patients); and disregard or distortion of consequences (eg, this disease actually isn’t as bad as people assume). The authors point out what might seem obvious to readers in that this compromises quality of care, but they provide additional nuance into how this type of thinking if too common could impinge upon the profession’s community sanction (professional autonomy) and result in increased government interference; that even just a minority of pharmacists behaving this way could jeopardize the likelihood that the profession will ever be recognized as health educators and be reimbursed for the provision of services. Often times in the long run, the morally disengaged pharmacist can actually end up with poorer quality of work life and burnout more quickly than a pharmacist who is actively engaged and gets charged from doing things the right way fueled by morally advanced decision-making.

Contrary to popular belief, ethics, ethical decision-making, and cognitive moral development are not innate; rather, they are learned behaviors. Growing as a pharmacist and reputed practitioner requires the acquisition of such skills and avoidance the kinds of disengaged thinking and acquiescence to stigmas mentioned above. Pharmacy managers can encourage and support their staff to seek development in these areas as well as a provide a climate and culture conducive to this kind of mindset to permeate the organization.

Additional information about Ethical Decision Making can be found in Pharmacy Management: Essentials for All Practice Settings, 5e. If you or your institution subscribes to AccessPharmacy, use or create your MyAccess Profile to sign-in to Pharmacy Management: Essentials for All Practice Settings, 5e. If your institution does not provide access, ask your medical librarian about subscribing.

1Lee C, Segal R, Kimberlin CR. Reliability and validity for the measurement of moral disengagement in pharmacists. Res Social Adm Pharm. 2010;14:297-312. 

Authored by:

Shane P. Desselle, RPh, PhD, FAPhA, Professor of Social/Behavioral Pharmacy at Touro University California

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