International Association for Hospice & Palliative Care
Promoting Hospice & Palliative Care Worldwide
SYSTEMATIZATION OF THE ETHICAL ANALYSIS OF CLINICAL CASES
Health care professionals frequently confront ethical dilemmas in the care of terminally ill patients. Some of them do not feel confident in dealing with these ethical dilemmas, especially if they did not get a formal ethical education during their training. They often distrust their skills for a systematic analysis of the conflicts in values that can arise in actual clinical decisions.
Appropriate knowledge of the basic ethical principles helps to analyze major dilemmas in the delivery of care to the terminally ill, such as issues related to communication, withholding or withdrawing treatments, hydration, nutrition or sedation, etc. In addition to their use in general discussions of specific issues, ethical analysis can be useful in reaching decisions in individual cases.
Bernard Lo ope rationally defined an ethical problem in clinical settings as a difficulty in the decision-making process with regard to an individual case, for the resolution of which one needs to refer to ethical principles that specify what should be done, in contradistinction to what can be (technically) done (Cf. Arch Intern Med 1981; 141: 1063 -1064).
In spite of some limitations of this definition, it has the merit of pointing out the fact that a clinician is confronted with an ethical problem when the question rises whether he should do something that could be actually done from a merely technical point of view. Another contribution of the definition is the reference to the key that would help in solving the dilemma: the referral to ethical principles or values. Nevertheless, precisely this point raises further questions to health care professionals, such as: Which are these ethical principles? How many are they? Are there ethical principles that might be accepted by people from different places, cultures or religious backgrounds? Is a rational analysis of ethical problems possible at all? Does this domain not rather belong to the realm of subjectivity?
In the context of these short lines, it is not possible to give a proper answer to the complex questions related to the objective or subjective character of ethics. Hence, without neglecting the importance of undertaking such an effort, I shall rather propose here a systematization of the ethical analysis of clinical cases that has proven to be helpful according to my experience with ethics consultations in the teaching hospital of the Pontifical Catholic University (Cf. Taboada, P: Ética Clínica: Principios básicos y modelo de análisis. Boletín Escuela de Medicina. 1998; 27, 1: 7 – 13).
Although I suggest to proceed in six different steps (Table 1), it might be good to state from the outset that I do not mean that these steps need to be applied in a rigid manner. They shall rather help as a reminder of the different types of information that should be always collected and revised when solving an ethical problem.
An ethical dilemma commonly rises when some values or principles seem to confront – or do actually confront - with each other, and one does not know for sure which one should have the priority. Hence, one has to make an effort to clearly identify the conflicting values: e.g., respect for life, non-maleficence, beneficence, confidentiality, respect for the patient’s autonomy, etc.
In my future monthly contributions to this newsletter I shall exemplify the practical application of the proposed tool to the analysis of some ethical dilemmas that are frequent in the care of terminally ill patients.
Table 1: Systematization of the ethical analysis of clinical cases
· Define the specific ethical dilemma/s
· Refer to the ethical principles involved
· Collect and analyze the ‘ethically relevant’ clinical information
· Review alternative courses of action
· Formulate an ethical solution
· Consider the best way of implementing the solution
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