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Chapter 1 v
A Model for Ethical Problem-Solving
Learning Objectives
1. Apply a stepwlse process to systematically resolve an ethical
problem in a clinical case.
2. Dehneate the steps in a five-step model for ethical demmon-
making.
3. Dmtmguish between chmcal and situational information
necessary for sound ethical demmons.
4. Define ethical principles commonly encountered in clinical prac-
tice such as respect for autonomy, beneficence, nonmaleficence,
and veracity.
5. Analyze courses of action to determine which are morally
justifiable.
After the determination of the source and meaning of ethmal judgments, what kinds of actions are right, and how rules apply to specific situations, the question remains: What ought to be done in a specific case or situa-
tion? Physicians and other health professionals often go through the pro- cess of determining the correct action in a specific case unconsciously.
Furthermore, if asked, they would be hard-pressed to articulate just
what steps they went through to arrive at a sound and justifiable decision.
Tnere are many normative models for resolving ethical problems in the
19
health science hteratur@ but all require crmcal thinking and should result m a choice
that is morally justifiable. Decision-making, whether m ethics or any other area of
hfe, is often thought of entirely in terms of its anatomy or structure--that is, the steps
one should follow and the component parts of each step. However, ethical decision-
making is more than just following steps; it involves an appreciation of the complexity of the components of each step such as what really comprises gathering reformation
and how the steps relate to each other Xhe majority ofthts book addresses the "func-
tion" of how general ethical prmc@es apply to ethical problems in health care. Here,
a framework is offered that includes those principles and a stepwise process to sys-
tematmally resolve ethical problems m particular cases.
The Five-Step Model
3he five steps provide the structure for the decision-making process and are linear;
that is, they should be carried out m the order hsted below:
1 Respond to the "sense" or feeling that something is wrong 2 Gather reformation/assessment
3 Identify the ethical problem/moral diagnosis 4. Seek a resolutton
5. Work wtth others to determine a course of action.
3he steps in the model outline a process, a way of making judgments about what should
be done in a pamcular situation. Additional steps could be added and much elabora-
tion could be included within each step, but the basic framework is suftlcient to focus
moral judgments and simple enough to recall and apply in actual clinmal practice.
Application of the Model
The five-step structure will be applied to Case 1-1 to illustrate the process of
decision-making.
Case 1-1
Disclosure of a Terminal Diagnosis
Richard Dossey, a 68-year-old architect, was admitted to the oncology ser-
vice after having an emergency operation in another state while there on
vacation. According to Mr. Dossey, the surgeon at the hospital told him that
he had gastric cancer but assured him that "a few cycles of chemotherapy
should successfully treat the cancer." When he was stable enough to travel,
arrangements were made at the hospital where the operation took place to
have Mr. Dossey admitted to a hospital in his home town. Mr. Dossey then
flew home on a private jet accompanied by his wife.
Sashi Jajoura, MD, the oncologist who was now attending Mr. Dossey,
read the surgical report and was shocked to discover that there were
20 { Part I Ethics and Values in Medical Cases
igmficant lymph node metastases. She knew that despite attempts to lm-
!pÿove quahty of care, survival rates for gastric cancer remained poor--
!around 10% overall 5-year survival for patients with advanced disease,
ilÿositive margins after resection, and advanced age. In essence, postopera-
itive chemoradiotherapy might offer some additional time, but it was unlikely
that any therapy would result m a cure
Clearly, the reformation in the pathology report in Mr. Dossey's clinical
iÿ records from the hospital where he underwent the did meshoperation not
/ÿ with his reported understanding of his prognosis. Meanwhile, as Dr. Jajoura
!ÿ\ÿ determined the best course of palhatlve treatment for Mr. Dossey, he de-
veloped acute renal failure. A sonogram revealed bilateral hydronephrosis,
" probably caused by the primary tumor that had extended to the ureters,
During this crisis, Dr. Jaloura informed Mr. Dossey that he was acutely ill as
a result of kidney failure. She also informed him that the probable reason
for his kidney failure was the cancer.
Dr. Jaloura then discussed the plan of treatment with Mr. Dossey, pro-
posing that catheters be placed rote the ureters through small bilateral in-
cisions and a presurgical computed tomography (CT) scan. She explained
that, postoperatively, he would be a candidate for chemoradiotherapy.
Also, because Mr. Dossey°s creatmme and blood urea mtrogen (BUN) levels
were rising quickly, she asked him If he had prepared an advance directive
and if he had specifically thought about a do-not-resuscitate order should
his heart stop beating or if he should stop breathing.
Though stunned, Mr. Dossey said he would like to talk to his wife, his
adult son, and the pastor at his church about his prognosis and the proposed
treatment He then angrily burst out: "That surgeon lied to me!"2
The next day, Mr. Dossey told the clinical nurse specialist and the staff
nurses that he wanted to go home that day without treatment and without
any more diagnostic tests, saying, "I know the doctors aren't going to agree
with me, but I want to leave anyway." When the nurses asked his wife and
son about Mr. Dossey's decision, both responded in unison, "He has always
made his own decisions. We support him m this decision." Dr. Jajeura
asked Mr. Dossey to consent to the CT scan to determine the extent of the
cancer, but he refused and stood by his request to be discharged.3
Questions for Thought and Discussion
Reread Case 1-1 At what point In the case do you get a clear sense that some-
thing Is "wrong" ethically speakmgV
-ÿ What additional reformation or clarification would you hke to have about
Mr. Dossey's chmcal statusV Situational factorsV
' ÿ What fs the primary ethical problem in the casev : ÿ At this point m the case, what should Dr Jajoura do7
Chapter 1 A Model for Ethical Problem-Solving I 21
Commentary
2his case Is complex but reveals potential ethmal concerns. As the physician
revolved m the case, Dr. Jajoura will need to decide what she should do and why. ÿhe five-step model can help Dr. Jajoura and the other members of the health care team revolved in Mr. Dossey's care to work toward a justifiable
resolution.
1. Respond to the Sense That Something Is Wrong
3-he first step in the ethical decision-making process is to respond to the intuitive
sense that something is wrong in a given situation. Unhke obvlous physical signs
and symptoms that chniclans are used to looking for m patients to determine
what is wrong, such as a change in breathing pattern or a rise in blood urea
nitrogen (BUN) or creatimne, there are no objective signs that one is involved m
an ethical problem. It is obvious that urgent care areas such as the emergency
department and intensive care units can be fraught with stress and emotion.
It is obvious that Mr. Dossey's case is full of emotion: he was described as
stunned, angry, and determined. Dr. Jajoura was "shocked." Do these emotional
signs mdicate that an ethical problem is in progressÿ ÿlae answer, as is often the
case m ethics, is yes and no. Just because people are emotionally upset with each
other or under a lot of stress does not necessarily mean that an ethmal problem is
involved. However, heightened emotional sensitivity along with "stress and tension
intrapersonally or interpersonally.., and ineffective communication patterns such
as avoidance, nagging, or silence" are often warning signs that one is involved in
an ethical problem.4
In Mr. Dossey's case, Dr. Jajoura responded to her feeling that something
was not right as soon as she saw the dxscrepancy between his optimistic statement
that "the cancer should clear up" and the grim reality of his diagnosis. She pro-
posed an operation to correct the acute renal failure, and Mr. Dossey wanted to
be discharged without treatment. Dr. Jajoura may also feel angry and frustrated with her surgical colleague at the other hospital who seems to have withheld from Mr. Dossey the bad news about his prognosis. ÿihese negative emotions and in-
terpersonal conflicts are indications that an ethical problem may be present. ÿhis
first step in the decision-making process merely requires one to respond to the
feeling that something is wrong. One should then move on to the next step.
2. Gather Information
]-here is an old saw m ethics: "Good ethics begins with good facts." Clearly, to
make an informed decismn one must have the facts. To organize the numerous
facts in the situatmn in whmh Dr. Jajoura is revolved, one can classify them into
clinical and situational reformation,s
Clinical mformatmn deals with the relevant chmcal data for the case in ques-
tion. ÿIhe following types ofchnical questions are relevant when reviewing a case:
What is the medmal status of the patient or patients involved m the situation?
22 { Parÿ 1 Ethics and Values in Medical Cases
Medical history? Diagnosis? Prognosisÿ What drugs are involved, and what are
thexr actions, side effects, and so on? What is the patient's probable hfe expec-
tancy and general condition if treatment is given? What is the patient's probable
life expectancy and general condition if treatment is not givenÿ What are the
risks and side effects of the proposed treatmentÿ
In Mr. Dossey's case, the climcal informatlon appeared to be unambiguous.
His cancer was inoperable, it had metastamzed and was now causing acute renal
failure--a hfe-threatening con&tion. Because of the acute problem, Dr. Jajoura
asked him if she could perform a diagnostic test, a CT scan, to determine the
extent of the cancer. However, this reformation would not change his poor prog-
nosis and would only assist in determining appropriate treatment for the renal
failure. Mr. Dosseywill certamly die in the Immediate future if he does not receive
treatment to reheve the blockage of the ureters--the cause of the acute renal fail-
ure. The risks of performing an operation to reheve the blockage would also have
to be considered. Even if the likelihood that the treatment would relieve the im-
mediate problem was great, the underlying condition would not change At that
point, Mr. Dossey would have to consider the risks and burdens of radlauon and
chemotherapy treatment options.
As much as possible, it is important to clarify the relevant clinical informa-
tion in the case before moving on to a more in-depth analysis of the moral rele-
vance of these facts.
Situational information includes data regarding the values and perspectives of
the principals revolved; their authority; verbal and nonverbal commumcatlon in-
cluding language bamers; cultural and religious factors; setting and time con-
straints; and the relationships of those immediately revolved in the case. In other
words, even if the climcal "facts" of a case are held constant, changes m the situ-
auonal or contextual factors such as the values of a key principal m the case could
change the ethmal focus or intensity of the ethical conflict. Of all the situational data mentioned, the most important is the identification and understanding of the
value judgments involved in a case. An extensive discusmon of value judgments
can.be found in Chapter 2.
ihe mare players m this case are Mr. Dossey, his wife and son, Dr. Jajoura,
members of the nursing staff, and, from a distance, the surgeon who first cared for
Mr. Dossey and supphed the less-than-honest news about his prognosis. All the
individuals revolved m the case possess values about many things, including values
about health, honesty, professmnal competence, and loyalty, to name a few.
We know that Mr. Dossey has a wife and son. Did they completely understand
the seriousness of Mr. Dossey's condmon? What were their positionsÿ Did they
agree with one another? What are the views of the other mdwiduals revolved m the
case such as the nursing staff or Mr. Dossey's pastor? How do these views compare
and contrast?
We know that responsibility for the care of Mr. Dossey rested with various
members of the health care team Each member's responslblhties are &stmct, yet
overlap. As part of the reformation-gathering step, it is important to sort out the
various responsibilities, not for blame-placing purposes but for identifying moral
Chapter 1 A Model for Ethical Problem-Solving I 23
accountabdity. For example, Dr. Jajoura may not be the one who presented the
less-than-accurate view of Mr Dossey's diagnosis, but she is the one who has to
break the bad news at this point If she wants to honestly present treatment options
to her patient and obtain vahd consent ÿhese are only some of the facts that affect
an ethical decision from all of the reformation provided m the case. Once the facts
are outlined, one can examine them to see whether the case has the characteristics
of an ethical problem.
3. Identify the Ethical Problem/Moral Diagnosis
As has been noted in the Introduction, ethms deals with a wide range of Impera-
tives and obligations regarding human dignity and conduct. ÿhe distinct character-
istms of moral evaluation, also mentioned m the Introduction, apply to this third
step of the five-step model, that is, they must be ultimate, possess universahty, and
treat the good of everyone alike Ethmal princ@es are relevant sources of ethical guidance and can serve to help identify the types of ethical problems in a case. ÿhe
values, rights, duties, or principles that are in conflict should be Identified. The
ethical principles most often revolved m complex cases such as Dr Jajoura's situa-
tion are (1) respect for patient autonomy, (2) beneficence and nonmaleficence, and (3) veracity. In this volume we wdl treat justice, fidelity, and avoidance ofkilhng as possible principles as well. Separate chapters are presented in Part 2 of this book to develop each of these pnnclples.
3-he principles that are m conflmt in the case at a minimum are respect for au-
tonomy, which, m this case, implies the pauent's right to make an informed deci-
sion about his treatment, and veracity, nonmaleficence, and beneficence, raising
the question of the obhgations of the physician to be honest and to prevent harm and do good when possible Because the patmnt's preferences or wishes take prior-
ity over other parties revolved, his wishes should be conmdered first. Generally, the wishes of competent, informed patients should be respected and followed, that is,
the lmphcauon of the principle of respect for autonomy Xherefore, ascertaining the
patient's competency Is important Is Mr. Dossey capable of making demsions?
he fact that his creatinme and BUN levels were rising qmckly may have affected his central nervous system and affected his abihty to make a competent decismn.
Xhough determination of competency is a legal determmatmn, the parties revolved
with Mr. Dossey could have informally validated his ability to understand the m- formation presented to him, to appreciate that the information apphed to his case,
to state the benefits and burdens of treatment and nontreatment options presented,
and to demonstrate a logmal coherence between his wlshes and the predictable
outcomes. For example, it would be illogical for Mr. Dossey to say, "I really want
to be &scharged without any treatment, but I want to do everything to prevent my
death "A competent person would understand that discharge without treatment is
tantamount to death.
Nonmaleficence is the principle underlying the original surgeon's decision to
withhold the truth from Mr. Dossey He wanted to avoid the psychological trauma that the bad news would bring Nonmaleficence also motivates Dr. Jajoura's con-
wctmn that she should strive to protect Mr. Dossey from unnecessary harms
24 { Part I Ethics and Values in Medical Cases
2he immediate harm from acute renal failure is of greatest concern, espemally
since it is a harm that can probably be corrected. 2he long-term harms from meta-
static disease can be ameliorated but not eliminated. Assuming she was not will-
ing, like the original surgeon, to treat Mr. Dossey without informing him of his
situation, the duty to protect her patient from harm could lead Dr. Jajoura to try one more time to reach Mr. Dossey about the seriousness of his present status
Perhaps she would even consider seeking the family's support in convincing him
about the treatability of the acute renal failure. At a minimum, treatment of the
acute problem could buy more time for the family and the patient to grasp the poor prognosis and determine ifpalhatlve radiation or chemotherapy is worth the ben- efits and burdens involved or ffhospice care is the right choice at this time.
Also at stake is the principle ofveramty, the moral notion that one is obligated to speak truthfully, espemally in situations in which one is m a role in whmh one cannot keep silent. 2his principle separates Dr. Jajoura and the original treating physmian. Mr. Dossey was not adequately informed about his prognosis. Clearly,
the surgeon who initially treated him was not honest about his diagnosis and prog- nosis. Dr. Jajoura did offer information about the prognosis, but did Mr. Dossey really hear anything after that? When Mr. Dossey fully grasped the truth, he became angry. Furthermore, the revelation about the gravity of his diagnosis
and the deception might have caused him to mistrust other health care profes-
sionals including Dr. Jajoura. She believes that she is obligated to tell the truth to Mr. Dossey about his diagnosis and prognosis so that she can propose treatment
options to him. She may also believe that Mr. Dossey will benefit from open dis- cussion of his prognosis--it could avoid anxiety from not knowing his situation In
that case, the principle of beneficence would support disclosure even if Dr. Jajoura did not accept the principle of veracity.
At this point we can move to the fourth step m the solving of the problem at hand by exploring various courses of action, whmh reqmres both determining
which principles are involved and what their implications are.
4. Seek a Resolution
Tne working phase of decision-making is, indeed, proposing more than one course
of acuon and examining the ethmal jumfication of various actmns. Many people
try to avoid this step m the decision-making process and at the same ume reduce
stress by settling for the first option that comes to mind or what at first appears to be the safe choice.
Some of the courses of action that are open to Dr. Jajoura are: (1) if she faces
her moral choice before she has revealed his true situation, she could continue the
original plan of deceiving him; (2) she could, by declaring him incompetent or simply ignoring his competence, treat him against his will to eliminate the risk of life-threatening renal failure; (3) she could let Mr. Dossey leave and call the next day to see if he has changed his mind keeping the door open to treatment of the acute renal failure; (4) she could propose hospice care for Mr. Dossey in his home,
thereby honoring his wishes. The actions actually fall into the categories of directly overriding Mr. Dossey's autonomy, treating him as nonautonomous, honoring
Chapter 1 A Model for Ethlcal Problem-Solving I 25
Mr. Dossey's autonomy but still trying to change his mind, completely honoring
his decision by ordering hospice services (thus confirming the decision to stop curative treatment for the acute renal failure), and offering symptom management and assistance with end-of-life care.
To determine which options are morally justifiable, one must project the prob- able consequences of each action and the underlying retention of the action as well
as whether there are moral duties that prevail Independent of the consequences.
his process involves the apphcation of the ethical principles presented earlier and the ethical theories described below. By following this process, one can reject some
options immediately because they would result in harm or would conflict with an-
other basic ethical principle.
Choosing the first option would be hard to reconcile with the principle of veracity but could be supported by more consequence-oriented ethics that stress
beneficence and nonmaleficence. Two major versions of consequence-oriented
ethics were presented in the Introduction: utilitarianism and Hippocratic ethics.
Hippocratic ethics would focus on the principles of beneficence and nonmalefi-
cence, but only insofar as the action affects the patient.
Utlhtarianism differs from Hippocratic ethics not In focusing on the prin-
ciples of beneficence and nonmaleficence, but in which consequences are relevant.
It holds that we should choose the option that would bring about the greatest good for the greatest number. For example, if Dr. Jajoura were a utihtarlan, she mÿght
agree with the original surgeon that Mr Dossey would be better off if he were deceived, but she might still fear that others 0ncludmg his family) would learn from this experience that doctors lie to patients. If she was worried that the long-
term bad consequences for other patients--developing fear that doctors cannot be
trusted--would outweigh any benefits for Mr. Dossey, she might decÿde against
the first option.
By contrast, the Hippocrauc form of consequentialism factors In only the
consequences for the individual patient. Dr Jajoura might still reject the first option if she thought Mr. Dossey himself would be harmed by the continuing deception, if, for example, she feared he would soon find out he was getting worse
and faced the additional problem of not being able to talk openly with his doctor and family about his impending death. Thus, consequentlalists--those who focus
only on principles of beneficence and nonmaleficence--can either accept or reject
the first option depending on how they assess the consequences and whose con- sequences they include.
Option two may involve a variation on optmn one--ignoring respect for au-
tonomy. In some cultures, physicians have had the power simply to treat a patient
in the way that they think is best for the patient, ignormg the patient's autonomy. If Dr. Jajoura is driven by beneficence for the patient, she might conclude that this is a viable strategy. It could solve the renal failure problem but could make
Mr. Dossey upset. It would also be illegal in our society, assuming Mr. Dossey
was competent to consent or refuse consent. On the other hand, if Dr. Jajoura
really believed Mr. Dossey was incompetent to consent, she could pursue the
course of trying to get him declared incompetent, thus acting on the principle of
26 [ Part 1 Ethics and Values in Medical Cases
beneficence, whmh may be the only relevant principle left for one who, lacking competence, has no possibility of autonomous decision-making. Dr. Jajoura should
realize, however, that if Mr. Dossey ,s declared incompetent, someone will be ap-
pointed his guardian--probably his wife or son--and they may make the same
choice for him that he was gomg to make.
Options three and four both follow a different strategy, one based on a belief that Mr. Dossey is an autonomous agent and that his autonomy must be re-
spected Respect for autonomy is a prmmple that leaves patients free to follow
their own life plans even ffsometimes domg so does not result in what is best for
the patient. ÿIlae principle of veracity also supports some version of open disclo-
sure. Respecting autonomy and the related principle ofverac,ty will prohibit de-
ception m Mr. Dossey's case. Such respect, however, does not rule out reasonable
attempts to persuade a patient to follow a course that the doctor beheves to be
best One could leave Mr. Dossey to his own choice and sull follow up at some
time in the near future to see if he has changed his mind. At that time one could
again offer hospice care, which would be conmstent with respecting autonomy
and veracity. "Ibis might also avoid some harm due to other courses and lead to
giving Mr. Dossey as much benefit as possible. It is poss,ble, however, that the
conflict between such respect for autonomy and the more consequence-oriented
prinmples of beneficence and nonmaleficence cannot be resolved. In that case
Dr. Jajoura will have to decide whether she is to be graded by a consequence- oriented ethic or one that holds that m the end the duty to respect the pat, ent's
autonomy must prevail.
We have at this pomt identified several possible courses of act*on and the
lmphcations of various ethical principles for each of those courses.
5. Work with Others to Determine a Course of Action
No one makes declsmns alone m a health care setting. The same is true for ethical
decisions. A better declsmn can be reached if the people who are legitimately in-
volved have the opportunity to discuss thmr perceptions, values, and concerns
openly. Referring back to the first step of the decision-making model, the response
to the sense that something is wrong is a subjective one that is limited by one's
intuition and is informed by many factors such as culture, gender, class, race, and
ethmcxty, to name a few. To help broaden our limited perspectives, it Is important
to share views and insights with others involved m a case. Who should be part of
the team or group to resolve ethical problems? In an acute-care setting, that will
usually involve members of the health care team who provide direct care to a pa-
tient and family. A care conference or other form of team meeting in whmh goals
of treatment are discussed could be the place where collaborative decisions are
made and concerns aired even if those concerns are not specifically labeled as eth-
real ones. In a complex case such as this, Dr. Jajoura should also call on the input
of the institutional ethms committee that usually has representatives from a variety
of disciplines such as nursing, social services, pastoral care, and medicine. One
should seek the counsel of an ethics committee when the goals of care are con-
fused or there is a sense ofconflmting duties, or when those involved would benefit
Chapter 1 A Model for Ethical Problem-Solving I 27
from a facihtated discussion. By sohclting &fferent points of view and discussing
concerns in a mutually respectful environment where all voices can be heard, they
can reach a more comprehensive demmon that is ethmallyjustifiable.
It is apparent that the duty-based principles such as respect for autonomy and
veracity push us very hard to disclose Mr. Dossey's diagnosis and honor his deci-
sion if it is indeed substantially autonomous. On the other hand, the Hippocratic
form of a consequence-based ethic provides the most plausible basis for overrid-
ing his decision to refuse treatment for an acute health problem that could prob-
ably be reversed. 7here are many cases m ethics that lead to relatively clear
resolutions. At times, reasonable people can come to the same resolutmn but sup-
port their decision with entirely different principles or theories. Mr. Dossey's
case, however, does not lead to a defimtive resolution because of the facts of the
case and the individuals involved. Health professionals encounter all of these
types ofethmal problems from the clear-cut to the vague and messy. ÿ-he demsion-
making model is one tool to help determine justifiable options whether the case is simple or complex.
Notes
1 Pumlo, Ruth Ethical Dimensions m the Health Professaons, 3d ed PhAadelphxa: W. B. Saunders, 2005; Fletcher, John C., ed. Fletcher'sIntrodumon to ChmcalEthlcs, 2d ed Fredermk, MD: Umverslty Publishing Group, 2005, Haddad, A, and M. Kapp. Ethzcal and Legal Problems m Home Health Care Norwalk, CT' Appleton and Lange, 1991; Rule, James T., and Robert M Veatch. Ethical Questaons m Denttslry, 2d ed. Chmago. Quintessence Books, 2004
2 Leong, Trevor. "Chemotherapy and Radiotherapy in the Management of Gastrm Cancer." Current Opanzons an Gastroenterology 21 (2005). 673-678.
3 Haddad, Amy. "ÿhe Anatomy and PhysMogy of Ethical Decision Making m Oncology." JolÿrnalofPsychosoctaI Oncology 11 (No. 1, 1993). 69-82.
4 Salladay, Susan, and Amy Haddad. "Point-Counterpoint Techmque m Assessing Hidden Agendas." Damensaons ofCÿ atzcal Care Nÿtrsÿng 5 (No. 4, 1986): 238-243.
5 Haddad and Kapp. Ethacal and Legal Problems in Home Health Care, p 13
28 { Part 1 Ethics and Values in Medical Cases