|ETHICS IN MEDICINE University of Washington School of Medicine
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Sumary of MethodologyIn a collaborative effort, 3 clinical ethicists (a philosopher - Jonsen, a physician - Siegler, and a lawyer - Winslade) have developed a method with which to work through difficult cases. The process can be thought of as the "ethics workup," similar to the "History and Physical" skills that all medical students come to use when learning how to "workup" a patient's primary complaints. While this method has deep philosophical roots, what clinicians who use this method like about it is the ease with which it fits into how they normally think about tough medical cases.
We will introduce this method briefly here, offer the decisionmaking tool (the "4 boxes"), and then discuss a sample case to illustrate the method. For a more in depth discussion of this method and for extensive examples of case analysis, students should refer to Jonsen, Siegler, Winslade's Clinical Ethics (see the Introduction to Clinical Ethics from the 4th edition volume of the book).
Jonsen, Siegler and Winslade have identified four "topics" that are basic and intrinsic to every clinical encounter. Focusing our discussion around these four topics gives us a way to organize the facts of the particular case at hand.
These four topics are present in every case. In the interest of consistency, the order of the review of topics remains the same (again, much like the review of systems in a complete H&P), yet no topic bears more weight than the others. Each will be evaluated from the perspective of the facts of the case at hand.
Once the details of a case have been outlined according to the four topics (using the 4 boxes), there are a series of questions that the clinician should ask.
After analyzing a difficult case in this way, clinicians are usually able to think clearly about what is at issue and to identify the best course of action available to them. If a best course of action remains elusive, a formal ethics consultation can be helpful.
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