The PVs and Ethical Decision-Making

April 12, 2022 by Beth Sitzler

By Kimberly Peer, EdD, ATC, FNATA, Gretchen Schlabach, PhD, ATC, Marisa Colston, PhD, ATC, Carrie Baker, PhD, ATC, and Midge Peterson, MS, LAT, ATC, NATA Professional Responsibility in Athletic Training Workgroup


Given professional values (PVs) are moral in nature, not only do they guide our professional behaviors, but also our ethical decisions.

Moral reasoning is a complex process requiring reflection on several elements of consideration. James Rest, a cognitive-developmental researcher, provides us with a backward design model used widely in ethical decision-making. This means that we look to act with moral intent as the ultimate outcome yet progress through the former steps in order to do so. It is not enough to just identify the issue and apply judgement – we must be motivated and committed to take action.

Rest’s original model (1986) and the Rest and Narvaez collaborative model (1994) identified four processes that determine moral behavior by health professionals. These processes offer guidelines that allow for the application of a range of decision-making principles and theories that can assist in resolving ethical conflicts. Rest’s models provide a strong foundation for moving toward ethical practice in athletic training as we integrate the shared PVs (CIRCA) into this important step.

Ethical actions are not an outcome of a single decision-making process, but rather a combination of cognitive structures and psychological processes. Rest’s four-step model provides the foundation for moral reasoning and includes the following steps: 1) identification of the ethical dilemma (ethical sensitivity); 2) application of moral judgment; 3) engagement of moral motivation; and 4) acting with moral intent.

Ethical sensitivity is the ability to see things from the perspective of others rather than focusing on one's own views. Ethical sensitivity involves an awareness of one’s own personal values. Furthermore, it also requires us to be mindful other others’ values, whether you are interacting with a patient, colleague, administrator, etc. As such, you can appreciate multiple points of view and show sensitivity to the feelings and reactions of others.

As athletic trainers, we engage the values of care and compassion and respect, for example, when we recognize that there are multiple options for the plan of care, rather than advocating for only their own perception of the best plan. Although the other shared PVs can also be applied here, this example focuses on just a few. As NATA’s shared PVs are engaged in the moral sensitivity component of this model, athletic trainers can be confident that they are meeting the social contract as a health care provider.

Rest’s second component is moral judgment. Moral judgment requires knowledge of discipline specific information, standards of practice, shared PVs, ethical principles and theory to identify the guidelines that support a decision. Being able to understand and integrate formal and informal guidelines for professional practice will promote sound moral judgement in the consideration of justifiable outcomes.

Athletic trainers are bound by a compliance orientation, laws, ethical codes, state regulation and practice guidelines to reason about choices to resolve dilemmas, a time-intensive, methodical form of ethical reasoning. In contrast, the values orientation, such as NATA’s shared PVs, is intuitive and easy to recall. As such, shared PVs are very effective in initiating ethical action in emerging situations. When considering the ideal solution after consideration of multiple options, athletic trainers may infuse the shared PVs of competence as they decide on the ultimate path of care with their patient that complies with the standards set forth for the profession.

Rest's model continues to unfold as the third component, moral motivation, comes into play. Moral motivation is the difference between knowing the right thing to do and making it a priority. Generally speaking, moral motivation addresses competing choices and discerns which one is best aligns with the shared PVs of the profession. In your role as an athletic trainer, personal values should not take precedence over NATA’s shared PVs and self-interest should not be the deciding factor motivating the decision. Athletic trainers can’t be motivated by the outcome of a game at the risk of the safety of the injured player. Athletic trainers can’t be motivated by the ensuring a balanced budget at the expense of reducing health care services where they are most needed. Both of these examples reflect a breach of NATA’s shared PVs of integrity and respect.

Rest’s last component, moral action, is anchored in choice and character. This step requires the athletic trainer to take action and display courage in their actions. This is often a difficult step. Athletic trainers are faced with many challenges that are influenced by situational factors that distract from moral action. Being able to choose without outside influences is reflective of morally courageous behavior.

Rushworth Kidder, an ethics guru who founded the Institute on Global Ethics, identified an ethical decision-making model that guides professionals in difficult situations. Kidder’s work has withstood the test of time and is a valuable tool for facilitating ethical decision making. Kidder’s model integrates aspects of the Rest Model and anchors in the concepts of right versus right decisions. He revealed four paradigms (truth/loyalty; individual/community; short term/long term; justice/mercy) to help professionals through their decision-making processes. He further develops an ethical decision-making model involving: Identifying relevant facts including detail and context; recognizing and identifying relevant moral issues; determining the moral agents; investigating the moral trilemma; testing for right versus wrong issues; testing for right versus right issues using paradigms; applying resolution principles and justifying the decision. These steps are intended to guide you along your path toward consideration of NATA’s shared PVs in action through outcomes that reflect the behaviors set forth for the profession. By doing so, athletic training’s responsibility to support the social contract will be met and athletic trainers across settings can confidently make difficult decisions in a consistent fashion.

Think of an ethical dilemma you’ve faced. Did you see the four steps evolve as you moved through the issue? Did you use any of Kidder’s paradigms to resolve and focus on the most relevant issues? Did you consider right-wrong and right-right issues?