The subtitle of our book states that clinical ethics is a “practical” approach. This implies that the approach must go beyond simply identifying the problem by collecting and sorting the facts of the case. As “practical,” the approach must guide practice, that is, it must lead from identification of the ethical problem to decisions about how to manage the problem. It must show the clinician how to manage those obstacles to decision making that the ethical problem had posed. Clinical ethics is seldom a matter of deciding between what is right versus what is wrong; rather it involves finding the better, more right, and more reasonable solutions among several options. Our approach seeks to guide the clinician and others involved in the case toward such resolutions.
Good ethical deliberation must go beyond gathering of information about the case. It must sort that information into the relevant and irrelevant, the important and unimportant. The boxes help to do this sorting. The boxes, however, must be fitted into a form of moral reasoning that can produce some closure to the deliberation. That closure is a resolution, a judgment that one course of action among the range of options is most probably the right one. We admit, before going on, that there are moral problems that do not seem to allow resolution (these are often called “dilemmas”). We do not believe that every moral problem, even the most complicated, is a dilemma. We propose a method of “weighing” the information sorted into the boxes so that a resolution can be reached and formed into a recommendation which a clinician or an ethicist might offer to a patient or to a colleague who is perplexed by the moral problem at hand.
The term “weighing” appears frequently in writings about ethics. We are asked to weigh norms and principles against each other in order to discern their superiority or ability to “trump” in an argument. The most celebrated moral theory of recent years, Theory of Justice by John Rawls, elaborates “reflective equilibrium,” which implies a balancing. The major textbook of bioethics, Principles of Biomedical Ethics by Beauchamp and Childress adapts this method for biomedical ethics. Our proposal for “weighing” and “balancing” of moral considerations is not as elaborate, or deeply philosophical as the approach posed by these authors, but it is, we believe, more easily used by clinical ethicists and clinicians. We do not seek any sort of equilibrium; clinical medicine is too messy to offer ideal solutions. Rather we are looking for the set of circumstances that draw down the scale toward one or another option. In other words, we search for a reasoned conclusion based on medical facts and ethical considerations that leads to a good or better decision, all things considered.
There are clearly some very important ethical principles, such as benevolence/nonmalevolence and respect for persons. It might be said that they are very “weighty.” However, we do not believe that a principle or norm in itself has “weight.” Rather, we propose that principles “gain weight” in application to the ethical reasoning about a particular case. Thus, while beneficence/nonmaleficence, the primary ethical principles of medical indications, is a very “weighty” or highly important principle—as its endurance throughout medical history demonstrates—it carries much less “weight” in a case where no known form of treatment can effect a cure. Or, more precisely, its weight is converted from the heavy obligation to apply curative interventions to the duty of providing comfort as an enhancement of quality of life.
All four topics and the principles associated with them contribute to the resolution of the problem. It is a mistake to leap into one topic or to grasp one principle as the obvious solution: all elements of the case, that is, all relevant circumstances and principles, are weighed. The resolution is always formulated “on the whole” or “all things considered.” It is also “probably the right course,” but its probability is tested by this weighing process. We are constantly reminded of Dr. William Osler’s sage observation, made more than 100 years ago but still relevant: “medicine is a science of uncertainty and an art of probability.”
Cases that present ethical problems may originate as disagreements between parties who all seek the best outcome for the patient, rather than adversarial opposition. These disagreements can often be settled by quiet, thoughtful exchange of views. In our experience, a simple checklist will aid clinicians to uncover the source of disagreement: (1) Have I failed to communicate effectively with the patient and family? (2) Has communication with patient and family been muddled by diverse providers? (3) Is the patient’s decisional capacity compromised by fear or pain? (4) Does the patient lack trust in me as an individual or toward medicine and its institutions? (5) Are the patient’s values and beliefs so different than mine that we are not pursuing a common goal? If still unable to reach agreement, it may be useful to resort to explicit mediation techniques.
CB. Bioethics Mediation: A Guide to Shaping Shared Solutions. New York, NY: United Hospital Fund of New York; 2004.
One final step remains in our practical approach. After an ethical problem is identified and assessed, a resolution must be reached. This resolution usually takes the form of a considered opinion by the clinician that can be formulated into a recommendation to the patient or other decision makers in the case. The resolution will be based on an assessment of the facts of the case in relation to the ethical principles relevant to the case. However, this assessment can also be tested by comparing it with similar cases. It is certainly true that in medicine every case is unique, and every patient “a statistic of one.” Nevertheless, the case at hand will have similarities with other cases. The other cases may have been thoughtfully considered—and even adjudicated in the law—and may provide guidance for assessing the present case. Such cases are called “paradigm cases.” Reference to paradigm cases does not prove that a case is correctly assessed; rather paradigm cases are examples of serious assessments in prior, similar cases, to which the current case can be compared, in order to guide the clinician in this case. The present case may have circumstances that make it more complex than previous cases; or it may represent a novel problem due to innovative technology. Clinical ethicists should be familiar with these paradigm cases and be able to discern how they differ from or agree with the current case.
Each chapter of this book begins with some general considerations about the topic and the ethical principle most relevant to that topic. Then, the clinical situations that generate ethical problems associated with that topic are stated and illustrated by cases. A short distillation of current opinion on this problem from the bioethical literature follows.
We conclude with a recommendation that the three authors formulate from our extensive experience as clinicians and clinical ethics consultants.