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- Summary of Methodology
- Paradigm (4 boxes)
- Sample Case Analysis
- Introduction to Clinical Ethics, 4th edition
Sumary of Methodology
In 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.
- Medical Indications - all clinical encounters include a review of diagnosis and treatment options
- Patient Preferences - all clinical encounters occur because a patient presents before the physician with a compliant. The patient's values are integral to the encounter.
- Quality of Life - the objective of all clinical encounters is to improve, or at least address, quality of life for the patient
- Contextual Features - all clinical encounters occur in a wider context beyond physician and patient, to include family, the law, hospital policy, insurance companies, and so forth.
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.
- What is at issue?
- Where is the conflict?
- What is this a case of? Does it sound like other cases you may have encountered? (e.g., Is it a case of "refusal of potentially life-sustaining treatment by a competent patient"?)
- What do we know about other cases like this one? Is there clear precedent? If so, we call this a paradigm case. A paradigm case is one in which the facts of the case are very clear cut and there has been much professional and/or public agreement about the resolution of the case.
- How is the present case similar to the paradigm case? How is it different? Is it similar (or different) in ethically significant ways?
- The resolution in any particular case will depend on the facts of that case.
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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