Clinical Analysis Using the 4 Boxes

Question 1

ethical issues

Answer 1

• informed consent
• truth telling
• confidentiality
• patient rights
• pain relief
• end-of-life care

Question 2

Four general topics to organize and analyze clinical ethical cases

Answer 2

1. Medical Indications
2. Patient Preferences
3. Quality of Life
4. Contextual Features (the social, economic, legal, and administrative context).

Question 3

the case of dax cowart

Answer 3

• Severely burned in 1973, at 25
• After stabilization, subjected to extensive, painful treatment, despite his protests and demands that he be allowed to die
• Eventually discharged blind, badly scarred, and dependent on others to provide care and ADL

Question 4

medical indications

Answer 4

(Principles of Beneficence and Nonmaleficence)

1. What is the medical problem? Is it acute? Chronic? Critical? Reversible? Emergent? Terminal?
2. What are the goals of treatment?
3. When would medical treatments not be indicated?
4. Probability of success of different treatment options?
5. How can this patient benefited from medical care?
6. How can harm be avoided?

Question 5

patient preferences

Answer 5

(Principle of Respect for Autonomy)

1. Has the patient been informed of benefits and risks, understood this information, and given consent?
2. Is the patient mentally capable and legally competent, and is there evidence of incapacity?
3. If mentally capable, what preferences about treatment is the patient stating?
4. If incapacitated, has the patient expressed prior preferences?
5. Who is the appropriate surrogate to make decisions for the incapacitated patient?
6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Question 6

Quality of Live

Answer 6

(Principles of Beneficence, Nonmaleficence, and Respect for Autonomy)

1. Prospects for a return to normal life?
2. How do we the judge patient’s quality of life?
3. Biases regarding the patient’s quality of life?
4. Ethical issues regarding the patient’s quality of life?
5. Questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
6. Plans and rationale to forgo life-sustaining treatment?
7. Local legal and ethical status of suicide?

Question 7

contextual features

Answer 7

(Principles of Justice and Fairness)

1. Professional, interprofessional, or business interests conflicts of interest?
2. Other parties, i.e. family members, with an interest in clinical decisions?
3. Limits on patient confidentiality by the legitimate interests of third parties?
4. Financial factors that cause conflicts of interest?
5. Problems with allocation of health resources?
6. Religious issues?
7. Legal issues?
8. Current clinical research and education issues?
9. Public health and safety issues?
10. Conflicts of interest within the organizations (e.g. hospitals)?