Ethics

Question 1

Goal of clinical ethics (applied medical ethics)

Answer 1

1. Help individuals apply moral theory and reasoning to specific clinical cases and scenarios
2. Inform the larger field of bioethics by providing information on evolving standards of clinical practice

Question 2

Clinical ethics methodology

Answer 2

1. Identify the ethical dilemma
2. Gather pertinent information
3. Analyse the information in the context of the dilemma
4. Prioritize recommendations and articulate supporting argumentation

Question 3

Clinical ethics methodology: Step 1: Identify the ethical dilemma

Answer 3

• Typically involves a scenario with more than one legitimate and ethically valid choice (not black and white)
• Often involves competing goods (choosing best of several good options) or competing harms (avoid least of several harmful options)

1. Identify principle of bioethics involved (Autonomy, non-maleficence, beneficence, justice)
2. Ask relevant questions:
   - Implications of either option
   - Social/cultural factors
   - Ethical dimensions of working within a team (or alone)
   - Moral and professional obligations of the healthcare team
   - Ethical principles guiding the intervention (or lack thereof?)

Question 4

Fundamental principles of bioethics

Answer 4

1. Autonomy
   - Patient has capacity to act intentionally, free of controlling or undue influence upon decision making
2. Non-maleficence
   - Avoid inflicting additional or unnecessary harm, especially when not justified by proportionate gain in benefits for the patient
   - Harm can be either by commission or omission
3. Beneficence
   - Duty to act for the benefit of the patient, and to prevent and remove harm from the patient
4. Justice
   - Equality and fairness
   - Involves questions of distribution, resource allocation, opportunity, etc.

Question 5

Fundamental principles of bioethics: Autonomy

Answer 5

Autonomy

- Patient has capacity to act intentionally, free of controlling or undue influence upon decision making

Question 6

Fundamental principles of bioethics: Non-maleficence

Answer 6

Non-maleficence

• Avoid inflicting additional or unnecessary harm, especially when not justified by proportionate gain in benefits for the patient
• Harm can be either by commission or omission

Question 7

Fundamental principles of bioethics: Beneficence

Answer 7

Beneficence

- Duty to act for the benefit of the patient, and to prevent and remove harm from the patient

Question 8

Fundamental principles of bioethics: Justice

Answer 8

Justice

• Equality and fairness
• Involves questions of distribution, resource allocation, opportunity, etc.

Question 9

Clinical ethics methodology: Step 2: Gather all of the pertinent information

Answer 9

1. Attempt to gather all relevant information
2. Ensure that the information is:
   - Comprehensive
   - Morally relevant
   - Appreciate what information might be absent and its impact
   - Organised in a succinct/useful way
3. Integrate data according to a ‘schema’
   - Clinical data (diagnosis, prognosis with/without intervention, nature of disease)
   - Social data (Laws, codes of ethics, policies, regulations)
   - Personal data (Preferences of patient, surrogate, and caregivers
4. Specific questions relevant to palliative medicine:
   - What do we understand as ‘palliative’ and ‘dying’, and is prognosis imminent or more protracted?
   - Is the patient able to be meaningfully involved in decision making, and is there anything that can enhance their ability to be involved?
   - Which interventions will modify the prognosis and how? Prolong life, improve QOL, or both? What about shorten lifespan? Reduce QOL? Probability of success?
   - Clearly delineate the personal preferences of all involved, including patient/family/nurses/other clinicians/admin, etc. to ensure the picture is clear

Question 10

Clinical Ethics Methodology: Step 3: Analyse the information in the context of the dilemma

Answer 10

1. Generate all realistic options
2. For each option, access the underlying principles of bioethics (autonomy/beneficence/non-maleficence/justice) and consequences that support it
3. Compare and contrast the burdens and benefits of each option
4. Judge which option brings the best consensus outcome

Question 11

What is Casuistry

Answer 11

Casuistry

• Integration of principles and consequences
• Often involves the ‘middle road’ rather than simply looking at only two dichotomous choices

Question 12

Clinical Ethics Methodology: Step 4: Prioritize recommendations and articulate supporting argumentation

Answer 12

• After coming up with all options in Step 3, rank order the options (preferred option, other acceptable options, unaccetable options)
• Once an ethical recommendation is decided upon, substantiate the recommendation with supporting moral arguments
  1. What (state position)
  2. Why (reasoned argumentation invoking the balancing of competing values, principles, and consequences)
  3. How (who, where, when)
  4. Qualifiers (unique aspects of each particular case which limit ability to generalise)