Ethical Dilemmas usually involve making difficult decisions. Decision making often requires recommendations by the clinician or provide information about the patient’s best interest. Criteria frequently used to determine best interest of the patient includes1:
- Determining what the patient finds acceptable or unacceptable regarding quality of life
- Reviewing the benefits and risks of each reasonable intervention
- Characterizing the risk and the degree of suffering and pain associated with an intervention
- Giving the expected prognosis with and without treatment
Healthcare professionals that limit ethical decision making to one framework may cause conflict with the patient and their loved ones. Multiple ethical frameworks should be considered, particularly in complex clinical situations.
The most common framework for medical ethical reasoning in the United States is called principlism. It includes the four guiding principles in medical ethics1:
- Respect for Autonomy
Principlism decision making becomes stuck when principles contradict each other.1 For example, a patient with end-stage cancer may have the personal belief that he or she must be told so that he/she can make decisions and use remaining time well. However, the patient’s family may insist that the patient not be told because they believe that knowledge will rob him or her of the will to live. In such a situation, the principles of respect for autonomy and principle of non-maleficence are at odds. So, who decides what happens with the patient?
Jonsen’s “Four Box Model” for clinical ethical decision making, helps clinicians prioritize the ethical principles of the clinical situation. This model balances medical decision-making elements that are important to health professionals with those patient-centered elements that are important to patient.1
Table 2: Four Box Model2
Beneficence and Nonmaleficence
- What is the patient’s medical problem? History? Diagnosis? Prognosis?
- Is the problem acute? Chronic? Critical? Emergent? Reversible?
- What are the goals of treatment?
- What are the probabilities of success?
- What are the plans in case of therapeutic failure?
- In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
Respect for Autonomy
- Is the patient mentally capable and legally competent? Is there evidence of incapacity?
- If competent, what is the patient stating about preferences for treatment?
- Has the patient been informed of benefits and risks, understood this information, and given consent?
- If incapacitated, who is the appropriate surrogate? Is the surrogate using appropriate standards for decision making?
- Has the patient expressed prior preferences, e.g., Advanced Directives?
- Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
- In sum, is the patient’s right to choose being respected to the extent possible in ethics and law?
Quality of Life
Beneficence, Nonmaleficence and Respect for Autonomy
- What are the prospects, with or without treatment, for a return to normal life?
- What physical, mental, and social deficits is the child likely to experience if treatment succeeds?
- Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
- Is the patient’s present or future condition such that his or her continued life might be judged undesirable?
- Is there any plan and rationale to forego treatment?
- Are there plans for comfort and palliative care?
Loyalty and Fairness
- Are there family issues that might influence treatment decisions?
- Are there provider (physicians and nurses) issues that might influence treatment decisions?
- Are there financial and economic factors?
- Are there religious or cultural factors?
- Are there limits on confidentiality?
- Are there problems of allocation of resources?
- How does the law affect treatment decisions?
- Is there any conflict of interest on the part of the providers or the institution
Utilitarian/consequentialist view stress acting in ways that maximize the balance of benefits and burdens.1 For example, a utilitarian approach to deciding whether or not to offer cardiopulmonary resuscitation to a patient would weigh the likelihood of survival and subsequent quality and quantity of life against potential suffering and costs.
Deontological view is that some duties transcend calculations of net benefit.1 For example, palliative care involves clinicians arguing for withholding or withdrawal of treatment based on a utilitarian assessment of futility, but the family members argue for continued treatment out of a sense of familial duty.
Communitarian view emphasizes communal values, the common good, social goals, traditional practices, and cooperative virtues.1 For example, communitarians argue in favor of universal access to health care because it improves the quality of life for the entire community.
Principle of double effect (PDE) stipulates that3:
- the action taken is morally good or neutral
- the intended outcome is important enough to justify the unlikely but possible bad effect
- efforts are undertaken to minimize risk of the bad effect
- the unintended effect is not the means to achieve the desired effect
PDE is often used in the decision to give enough pain medicine at the end of life to relieve pain, even though it may suppress respiration. There is generally ethical consensus about the standard treatment of pain at the end of life. The position of the Catholic Church and the Supreme Court is that aggressive treatment of pain at the end of life is legally and morally acceptable.3 Even if death is hastened by the medication, provided that the intention of the action is to relieve pain and not to cause death.
Rights-based approaches emphasizes the rights of individuals.1 For example, patients who are near the end of their lives have the right to participate and benefit from appropriate research.
Ethics of caring (or feminist ethics) holds that natural caring for others is the basis for moral behavior. It stresses caring relationships with others not based on individual rights, but rather on a strong sense of being responsible.1 For example by explicitly taking the patient and his or her family as the unit of care, not just the patient.
Virtue ethics focuses on the moral character which informs behavior.1 The virtues emphasized in hospice and palliative care practice include compassion/empathy, faithfulness, justice/advocacy, and practical wisdom.
Ethical relativism holds that morality is relative to the norms of one's culture. There are no absolute truths. What is morally right or wrong varies from person to person or from society to society. Variances in culture and society influence whether an act is moral.
Whatever approach is taken, utilizing the different perspectives and skills of the interdisciplinary team members to address ethical issues is needed.