Summary of Methodology

In Clinical Ethics, three clinical ethicists (a philosopher - Jonsen, a physician - Siegler, and a lawyer - Winslade) developed a method 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 use when learning how to "workup" a patient's primary complaints. While this method has deep philosophical roots, clinicians who use this method like the way it parallels the way they they think through tough medical cases.

We will introduce this method briefly here, offer the decision-making 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 Albert Jonsen, Mark Siegler, & William Winslade's Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. Seventh Edition. McGraw Hill, 2010. (see the Introduction from the 4th edition of the book)

Jonsen, Siegler and Winslade have identified four "topics" that are 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 diagnosis, prognosis, and treatment options, and include an assessment of goals of care
Patient Preferences - The patient’s preferences and values are central in determining the best and most respectful course of treatment.
Quality of Life - The objective of all clinical encounters is to improve, or at least address, quality of life for the patient, as experienced by the patient.
Contextual Features - All clinical encounters occur in a wider social context beyond physician and patient, to include family, the law, culture, hospital policy, insurance companies and other financial issues, 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 (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, 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 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, but will be influenced by how similar cases have been handled, debated, and adjudicated.

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 is often the next step.