Ethics AnalysisEthics Analysis in in

Clinical Medicine Clinical Medicine

Eugene Bereza, MD CM, CCFPEugene Bereza, MD CM, CCFP

Director Director Biomedical Ethics UnitBiomedical Ethics Unit

Faculty of MedicineFaculty of MedicineMcGill UniversityMcGill University

GOAL

Provide a Provide a practicalpractical tool for ethics analysis: tool for ethics analysis:

1.1. Clinically orientedClinically oriented2.2. SystematicSystematic3.3. Easy to remember Easy to remember 4.4. Application:Application:

*Clinical care*Clinical care*Teaching supervision*Teaching supervision*Resident Evaluation*Resident Evaluation*Outline for responding to *Outline for responding to

ethics questionsethics questions

GOALGOAL

Appreciate ethical component Appreciate ethical component of aof a

clinical dilemmaclinical dilemma

Practical resolution of a casePractical resolution of a case

What What cancan I do? I do? What What shouldshould I do? I do?

Action Ethics Action

Clinical EthicsClinical Ethics

1) 1) Identify the ethical dilemmaIdentify the ethical dilemma

2) 2) Gather pertinent informationGather pertinent information

3) 3) Analyze the information in context of the dilemmaAnalyze the information in context of the dilemma

4) 4) Prioritize recommendations and articulate Prioritize recommendations and articulate supporting argumentationsupporting argumentation

STEP 1STEP 1

• Identify the ethical dilemmaIdentify the ethical dilemma

1. 1. Identify the dilemmaIdentify the dilemma

– Identify the dilemma:Identify the dilemma:– name the “rock”name the “rock”– name the “hard place”name the “hard place”

– Translate your Translate your choice of choice of actionsactions into into a a choice between competing choice between competing valuesvalues or or principlesprinciples

1. 1. Identify the dilemmaIdentify the dilemma

Four foundational principles of modern bioethicsFour foundational principles of modern bioethics

• AutonomyAutonomy

• Non-maleficenceNon-maleficence

• BeneficenceBeneficence

• JusticeJustice

(Beauchamp & Childress)(Beauchamp & Childress)

Dilemmas often fall within a range of Dilemmas often fall within a range of acceptable options on a continuumacceptable options on a continuum

?

WORST BESTEVIL GOOD

1. 1. Identify the Identify the dilemmadilemma

GOOD #1GOOD #1 GOOD GOOD

#2#2

1. 1. Identify the Identify the dilemmadilemma

BAD#1BAD#1 BAD #2BAD #2

STEP 2STEP 2

• Gather pertinent information

2. 2. Gather informationGather information

BIOBIO PSYCHOPSYCHO- DiagnosisDiagnosis - preferences of patient- preferences of patient- Nature of diseaseNature of disease - preferences of surrogate- preferences of surrogate- Prognosis with Rx- Prognosis with Rx - preferences of caregivers- preferences of caregivers- Prognosis without Rx- Prognosis without Rx

SOCIALSOCIAL- laws- laws

- codes of ethics- codes of ethics- policies- policies

STEP 3STEP 3

• Analyze the information in context of the dilemmaAnalyze the information in context of the dilemma

3. 3. AnalyzeAnalyze

• Generate all Generate all realistic optionsrealistic options

• For each option, access the underlying For each option, access the underlying principlesprinciples and and consequencesconsequences that support and undermine itthat support and undermine it

• Compare & contrast the Compare & contrast the burdens/benefitsburdens/benefits of each option of each option

• JudgeJudge which option brings best which option brings best consensusconsensus outcome outcome

3.3. AnalyzeAnalyze

Two Predominant Categories of Moral ReasoningTwo Predominant Categories of Moral Reasoning

1.1. Deontological Deontological (reference to principles, values)(reference to principles, values)

2.2. TeleologicalTeleological(reference to anticipated consequences)(reference to anticipated consequences)

3.3. AnalyzeAnalyze

Other Schools of Moral ReasoningOther Schools of Moral Reasoning

CasuistryCasuistry(balancing of principles and consequences in (balancing of principles and consequences in

individualized context)individualized context)

Virtue ethics Virtue ethics (reference to fundamental character)(reference to fundamental character)

Communitarian ethicsCommunitarian ethics

(reference to prioritization of collective as the target)(reference to prioritization of collective as the target)

STEP 4STEP 4

• Prioritize recommendations and articulate Prioritize recommendations and articulate supporting argumentationsupporting argumentation

4. Prioritize recommendations and articulate supporting argumentation

1. WHAT

(thesis)

2. WHY(reasoned argumentation invoking the balancing of competing values,

principles, and consequences)

3. HOW(who, where, when …)

4. QUALIFIERS(unique aspects of particular case which limit ability to generalize)