A 24 year-old graduate student develops a severe headache and a stiff neck and is brought to the ER by a friend. Physical exam shows a patient with a temperature of 103°F and a stiff neck. After obtaining informed consent, a spinal fluid exam reveals cloudy fluid with a white cell count of 2,000 and with bacteria suggesting pneumococcal meningitis. Antibiotics are recommended but the patient refuses. He offers no reason for his refusal.

Eric Swirsky, JD, MA Director of Graduate Studies Clinical Assistant Professor

Ethical Decision-making

Seven Step Decision-making Process

1. Identify the type of moral or ethical dilemma 2. Reflect on personal bias or assumptions 3. Gather relevant information 4. Consider stakeholder interests and values 5. Explore practical alternatives 6. Complete and justify the action 7. Evaluate the process and outcome

Case Example

A 24 year-old graduate student develops a severe headache and a stiff neck and is brought to the ER by a friend. Physical exam shows a patient with a temperature of 103°F and a stiff neck. After obtaining informed consent, a spinal fluid exam reveals cloudy fluid with a white cell count of 2,000 and with bacteria suggesting pneumococcal meningitis. Antibiotics are recommended but the patient refuses. He offers no reason for his refusal.

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

• Moral Distress

• Ethical Dilemma

• Moral Agency

• Locus of Authority

Step One — Identify the Type of Ethical Problem

• Gut reaction

• Identify personal assumptions, biases, emotions, and values

• Conflicting personal and professional values

• Impact on decision-making

Step Two – Reflect on Personal Bias

Medical Indications

The Principles of Beneficence and Nonmaleficence

1. What is the patient’s medical problem? history? diagnosis? prognosis?

2. Is the problem acute? chronic? critical? emergent? reversible?

3. What are the goals of treatment? 4. What are the probabilities of success?

Patient Preferences The Principles of Respect for Autonomy

1. What are the patient’s preferences for treatment? 2. Has the patient been informed of benefits and risks,

understood this information and given consent? 3. Is the patient mentally capable and legally

competent? Is there evidence of incapacity? 4. If incapacitated, who is the appropriate surrogate? Is

the surrogate using appropriate standards for decision making?

5. Has the patient expressed prior preferences, e.g., living will?

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

Quality of Life

The Principles of Beneficence, Nonmaleficence, and Respect for Autonomy

1. What are the prospects, with or without treatment, for return to normal life, and with what physical, mental, and social deficits might the patient experience even if treatment succeeds?

2. What ethical issues arise concerning improving or enhancing a patient’s quality of life?

3. Do quality of life assessments raise any questions regarding changes in treatment plans, such as foregoing life-sustaining treatment?

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

Contextual Features

1. Are there family issues that might influence treatment decisions?

2. Are there financial and economic factors?

3. Are there religious or cultural factors?

4. Are there limits to confidentiality?

5. How does the law affect treatment decisions?

6. Is clinical research or teaching involved? Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

• Which parties have an interest in the process?

• Which parties have an interest in the outcome?

• Who is directly involved in the case?

• Who is indirectly involved?

Step Four – Consider Stakeholder Interests and Values

• Doing nothing

• Time limited trials

• Be creative

• Respecting confidentiality

Step Five – Explore Practical Alternatives

The goal of analysis is to determine the range of ethically acceptable options and take action.

Use ethical theories or approaches to justify action

Step Six – Complete the Action

• What went well, and why do you think so?

• Most challenging aspects? Compare to other situations? What future applications?

• Who helped most? Feedback from patient, family, care team, others?

• What did you learn? What would you do differently?

Step Seven – Evaluate the Process and Outcome

Case Example

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

Ethical Decision-making

Seven Step Decision-making Process

Case Example

Step One — Identify the Type of Ethical Problem

Step Two – Reflect on Personal Bias

Step Three – Gather Info

Medical Indications

Patient Preferences

Quality of Life

Contextual Features

Step Four – Consider Stakeholder Interests and Values

Step Five – Explore Practical Alternatives

Step Six – Complete the Action

Step Seven – Evaluate the Process and Outcome

Case Example

1. Gather Information

2. Identify the Type of Ethical Problem

3. Use Ethical Theories to Analyze the Problem

4. Explore the alternatives

��5. Complete the action��6. Evaluate the process and outcome��

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