A case-based approach to ethical decision-making
Adapted from AR Jonsen, M Siegler, W Winslade, Clinical Ethics, 7th edition. McGraw-Hill, 2010.
The Principles of Beneficence and Nonmaleficence
- What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
- What are the goals of treatment?
- In what circumstances are medical treatments not indicated?
- What are the probabilities of success of various treatment options?
- In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
The Principle of Respect for Autonomy
- Has the patient been informed of benefits and risks, understood this information, and given consent?
- Is the patient mentally capable and legally competent, and is there evidence of incapacity?
- If mentally capable, what preferences about treatment is the patient stating?
- If incapacitated, has the patient expressed prior preferences?
- Who is the appropriate surrogate to make decisions for the incapacitated patient?
- Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of beneficence and Nonmaleficence and Respect for Autonomy
- What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
- On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
- Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
- What ethical issues arise concerning improving or enhancing a patient’s quality of life?
- Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
- What are plans and rationale to forgo life-sustaining treatment?
- What is the legal and ethical status of suicide?
The Principles of Justice and Fairness
- Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
- Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
- What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
- Are there financial factors that create conflicts of interest in clinical decisions?
- Are there problems of allocation of scarce health resources that might affect clinical decisions?
- Are there religious issues that might affect clinical decisions?
- What are the legal issues that might affect clinical decisions?
- Are there considerations of clinical research and education that might affect clinical decisions?
- Are there issues of public health and safety that affect clinical decisions?
- Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?