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Bioethics: Principles, Issues, and Cases, Third Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers. Lewis Vaughn is the author or coauthor of several books, including: Philosophy Here and Now (2013); Bioethics: Principles, Issues, and Cases, Second Edition (2013); Great Philosophical Arguments (2012); Classics of Philosophy (2011); Philosophy: The Quest for Truth, Eighth Edition (2012); How to Think About Weird Things: Critical Thinking for a New Age, Sixth Edition (2011); Doing Ethics. Bioethics: Principles, Issues, and Cases, Third Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers influential moral theories and the criteria for evaluating them. Description: Bioethics: Principles, Issues, and Cases, Fourth Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers influential moral theories and the criteria for evaluating them.
*Bioethics Principles Issues And Cases 4th Edition Pdf
*Vaughn Bioethics
*Bioethics Principles Issues And Cases 4th Edition Pdf
In Clinical Ethics, three clinical ethicists (a philosopher - Jonsen, a physician - Siegler, and a lawyer - Winslade) developed a method to work through difficult cases. The process can be thought of as the ’ethics workup,’ similar to the ’History and Physical’ skills that all medical students use when learning how to ’workup’ a patient’s primary complaints. While this method has deep philosophical roots, clinicians who use this method like the way it parallels the way they they think through tough medical cases.
We will introduce this method briefly here, offer the decision-making tool (the ’4 boxes’), and then discuss a sample case to illustrate the method. For a more in depth discussion of this method and for extensive examples of case analysis, students should refer to Albert Jonsen, Mark Siegler, & William Winslade’s Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. Seventh Edition. McGraw Hill, 2010. (see the Introduction from the 4th edition of the book)
Jonsen, Siegler and Winslade have identified four ’topics’ that are intrinsic to every clinical encounter. Focusing our discussion around these four topics gives us a way to organize the facts of the particular case at hand.
Medical Indications - All clinical encounters include a diagnosis, prognosis, and treatment options, and include an assessment of goals of care
Patient Preferences - The patient’s preferences and values are central in determining the best and most respectful course of treatment.
Quality of Life - The objective of all clinical encounters is to improve, or at least address, quality of life for the patient, as experienced by the patient.
Contextual Features - All clinical encounters occur in a wider social context beyond physician and patient, to include family, the law, culture, hospital policy, insurance companies and other financial issues, and so forth.
These four topics are present in every case. In the interest of consistency, the order of the review of topics remains the same (much like the review of systems in a complete H&P), yet no topic bears more weight than the others. Each will be evaluated from the perspective of the facts of the case at hand.
Once the details of a case have been outlined according to the four topics, there are a series of questions that the clinician should ask.
What is at issue?
Where is the conflict?
What is this a case of? Does it sound like other cases you may have encountered? (e.g., Is it a case of ’refusal of potentially life-sustaining treatment by a competent patient’?)
What do we know about other cases like this one? Is there clear precedent? If so, we call this a paradigm case. A paradigm case is one in which the facts of the case are clear cut and there has been much professional and/or public agreement about the resolution of the case.
How is the present case similar to the paradigm case? How is it different? Is it similar (or different) in ethically significant ways?
The resolution in any particular case will depend on the facts of that case, but will be influenced by how similar cases have been handled, debated, and adjudicated.
After analyzing a difficult case in this way, clinicians are usually able to think clearly about what is at issue and to identify the best course of action available to them. If a best course of action remains elusive, a formal ethics consultation is often the next step.
A case-based approach to ethical decision-making
Adapted from AR Jonsen, M Siegler, W Winslade, Clinical Ethics, 7th edition. McGraw-Hill, 2010.
MEDICAL INDICATIONS
The Principles of Beneficence and Nonmaleficence
*What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
*What are the goals of treatment?
*In what circumstances are medical treatments not indicated?
*What are the probabilities of success of various treatment options?
*In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy
*Has the patient been informed of benefits and risks, understood this information, and given consent?
*Is the patient mentally capable and legally competent, and is there evidence of incapacity?
*If mentally capable, what preferences about treatment is the patient stating?
*If incapacitated, has the patient expressed prior preferences?
*Who is the appropriate surrogate to make decisions for the incapacitated patient?
*Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of Beneficence, Nonmaleficence, and Respect for Autonomy
*What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
*On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
*Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
*What ethical issues arise concerning improving or enhancing a patient’s quality of life?
*Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
*What are plans and rationale to forgo life-sustaining treatment?
*What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness
*Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
*Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
*What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
*Are there financial factors that create conflicts of interest in clinical decisions?
*Are there problems of allocation of scarce health resources that might affect clinical decisions?
*Are there religious issues that might affect clinical decisions?
*What are the legal issues that might affect clinical decisions?
*Are there considerations of clinical research and education that might affect clinical decisions?
*Are there issues of public health and safety that affect clinical decisions?
*Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?
Case: John, a 32 year-old lawyer, had worried for several years about developing Huntington’s chorea, a neurological disorder that appears in a person’s 30s or 40s, resulting in uncontrollable twitching and contractions and progressive, irreversible dementia. It typically leads to death in about 10 years.
John’s mother died from this disease. Huntington’s is autosomal dominant and children of an affected person have a 50% chance of inheriting the condition. John had indicated to many people that he would prefer to die rather than endure the progression of the illness. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington’s. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.
How much weight should John’s preferences (especially his attempt to end his life) carry in managing his emergency and subsequent clinical care?
Review of Topics:
Medical Indications
There are 2 diagnoses/prognoses that merit consideration. The underlying chronic disease of Huntington’s is incurable and symptoms progress with a bleak long term prognosis. However, there are effective treatments available for the acute diagnosis of drug overdose including gastric lavage (pumping his stomach), emetics, antidotes, and/or activated charcoal (to prevent undigested drugs from entering his blood stream); supportive treatment following the initial treatment; and medications to ameliorate the underlying depression. How does the diagnosis of Huntington Disease affect our response to the acute condition? We know that the standard of practice is to assume that patients admitted for suicide attempts lack decisional capacity.
Patient Preferences
We know from the patient’s suicide note that he is refusing all medical treatment. However, what do we know about these statements of preference? Were they informed? Was the patient competent to make that decision? The answers to these questions remain unclear, but we do know that the patient does not have decision making capacity for the present decision of whether to proceed with the gastric lavage. Is there a surrogate decision maker available?
Quality of Life
Life with Huntington’s can be difficult. John was familiar with the quality of life associated with living with Huntington’s as he watched his mother die of this disease. On the other hand, John does have a supportive family and continues to be able to work for the time being. How should the diminished quality of life that is anticipated in the future affect current clinical management?
Contextual Features
Several factors in the context of this case are significant. While the patient has a legal right to refuse treatment, he is currently unconscious and his surrogate (his wife) is requesting treatment. There are also certain emergency room obligations to treat emergent conditions. How should the emergency staff weigh the various competing legal and regulatory duties?
Case Analysis:
John has indicated through his note that he refuses potentially life-sustaining treatment, but his competency to make decisions is questionable in the context of attempted suicide. Also at issue is the distinction between the acute and chronic conditions.
The precedent for cases such as this one is fairly clear. When the patient’s preferences are unclear or health care providers have reason to believe a patient’s decision-making capacity is compromised; the acute condition is easily treatable; and the harm of not treating is very great, emergency medical treatment of the immediate life-threatening condition is provided, creating an opportunity to talk with the patient about his preferences regarding his chronic condition at a later time and to treat any underlying depression that may have contributed to his suicide attempt.
Notice that the facts of this particular case determine whether the precedent case is applicable. If the medical team was familiar with this patient’s expressed preference to refuse any medical treatment and if the available treatment for the acute condition was considerably less certain to be effective, the case could be decided differently. The clinicians would look for a different precedent.
The following is an excerpt from Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Edition by Albert R. Jonsen, Mark Siegler, and William J. Winslade (1998). Copyright permission to reproduce this excerpt has been generously granted by McGraw-Hill. We encourage you to read this useful resource book, available now in the 7th Edition (2010).INTRODUCTION:CASE ANALYSIS IN CLINICAL ETHICS
Clinical ethics is a practical discipline that provides a structured approach to assist physicians in identifying, analyzing and resolving ethical issues in clinical medicine. The practice of good clinical medicine requires some working knowledge about ethical issues such as informed consent, truth-telling, confidentiality, end-of-life care, pain relief, and patient rights. Medicine, even at its most technical and scientific, is an encounter between human beings, and the physician’s work of diagnosing disease, offering advice, and providing treatment is embedded in a moral context. Usually, moral values such as mutual respect, honesty, trustworthiness, compassion, and a commitment to pursue shared goals, make a clinical encounter between physician and patient morally unproblematic. Occasionally, physicians and patients may disagree about values or face choices that challenge their values. It is then that ethical problems arise. Clinical ethics is both about the ethical features that are present in every clinical encounter and about the ethical problems that occasionally arise in those encounters. Clinical ethics relies upon the conviction that, even when perplexity is great and emotions run high, physicians and nurses, patients and families can work constructively to identify, analyze and resolve many of the ethical problems that arise in clinical medicine.
The authors have two purposes in writing this book: first, to offer an approach that facilitates thinking about the complexities of the problems that clinicians actually face and, second, to assemble concise representative opinions about typical ethical problems that occur in the practice of medicine. We think it is more important that clinicians develop skill at analyzing the cases they encounter rather than merely have a book in which ’to look up answers.’ Our hope is that every clinician will acknowledge that ethics is an inherent aspect of good clinical medicine and that, ideally, every clinician will become as proficient at clinical ethics as clinical medicine. Our book is intended not only for clinicians and students who provide care to patients, but also for others whose work requires an awareness and sensitivity to the ethical issues raised in clinical care, such as hospital administrators, hospital attorneys, members of institutional ethics committees, quality reviewers and administrators of health plans. In the complex world of modern health care, all of these persons are responsible for maintaining the ethics that lie at the heart of quality care.
Many books on health care ethics are organized around moral principles, such as respect for autonomy, beneficence, non-maleficence and fairness, and the cases are analyzed in the light of those principles. Our method is different. While we appreciate the importance of principles, we believe that the practitioner approaching a case needs a method that better fits the realities of the clinical setting and the reasoning of the clinician. Clinical situations are complex since they often involve a wide range of medical facts, a multitude of circumstances and a variety of values. Often decisions must be reached quickly. The authors believe that clinicians need a straightforward way to sort the facts and values of the case at hand into an orderly pattern that will facilitate the discussion and resolution of the ethical problem.
We suggest that every clinical case, when seen as an ethical problem, should be analyzed by means of four topics. These four topics are
*Medical Indications
*Patient Preferences
*Quality of Life
*Contextual Features, that is, the social, economic, legal, and administrative context in which the case occurs.
Every case can be viewed in terms of these four topics; no case can be adequately discussed without reference to them. Although the facts of each case differ, these four topics are always relevant. The topics organize the varying facts of the particular case and, at the same time, the topics call attention to the moral principles appropriate to the case. It is our intent to show readers how the topics provide a systematic way to identify, analyze and resolve the ethical problems arising in clinical medicine.
Clinicians will recall the method of case presentation that they learned at the beginning of their professional training. They were taught to ’present’ a patient by stating in order the patient’s history, including the chief complaint, the history of the present illness, past medical history, family and social history, followed by physical findings and laboratory data. These are the topics that an experienced clinician uses to reach a diagnosis and to formulate a case management plan. While the particular details under each of these topics differ from patient to patient; the topics themselves are constant and always relevant to the task of arriving at a case management plan. Sometimes one topic, for example, the patient’s family history or the physical examination, may be particularly important or, conversely, may not be relevant to the problem at hand. Still, clinicians are expected to review all topics in every case. Our four topics -- (1) Medical Indications, (2) Patient Preferences, (3) Quality of Life, and (4) Contextual Features--are the ethical equivalents of these familiar clinical topics.
These topics help clinicians understand where the moral principles meet the circumstances of the clinical case. The general headings of the topics describe the major features that define the ethics of clinical medicine; each of these features takes on specific, concrete form from the circumstances of the particular case. In a given case, a patient comes to a physician, complaining of feeling ill. Medical Indications include a clinical picture of polydipsia and polyuria, nausea, fatigue and some mental confusion, with laboratory studies showing hyperg
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Bioethics: Principles, Issues, and Cases, Third Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers. Lewis Vaughn is the author or coauthor of several books, including: Philosophy Here and Now (2013); Bioethics: Principles, Issues, and Cases, Second Edition (2013); Great Philosophical Arguments (2012); Classics of Philosophy (2011); Philosophy: The Quest for Truth, Eighth Edition (2012); How to Think About Weird Things: Critical Thinking for a New Age, Sixth Edition (2011); Doing Ethics. Bioethics: Principles, Issues, and Cases, Third Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers influential moral theories and the criteria for evaluating them. Description: Bioethics: Principles, Issues, and Cases, Fourth Edition, explores the philosophical, medical, social, and legal aspects of key bioethical issues. Opening with a thorough introduction to ethics, bioethics, and moral reasoning, it then covers influential moral theories and the criteria for evaluating them.
*Bioethics Principles Issues And Cases 4th Edition Pdf
*Vaughn Bioethics
*Bioethics Principles Issues And Cases 4th Edition Pdf
In Clinical Ethics, three clinical ethicists (a philosopher - Jonsen, a physician - Siegler, and a lawyer - Winslade) developed a method to work through difficult cases. The process can be thought of as the ’ethics workup,’ similar to the ’History and Physical’ skills that all medical students use when learning how to ’workup’ a patient’s primary complaints. While this method has deep philosophical roots, clinicians who use this method like the way it parallels the way they they think through tough medical cases.
We will introduce this method briefly here, offer the decision-making tool (the ’4 boxes’), and then discuss a sample case to illustrate the method. For a more in depth discussion of this method and for extensive examples of case analysis, students should refer to Albert Jonsen, Mark Siegler, & William Winslade’s Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. Seventh Edition. McGraw Hill, 2010. (see the Introduction from the 4th edition of the book)
Jonsen, Siegler and Winslade have identified four ’topics’ that are intrinsic to every clinical encounter. Focusing our discussion around these four topics gives us a way to organize the facts of the particular case at hand.
Medical Indications - All clinical encounters include a diagnosis, prognosis, and treatment options, and include an assessment of goals of care
Patient Preferences - The patient’s preferences and values are central in determining the best and most respectful course of treatment.
Quality of Life - The objective of all clinical encounters is to improve, or at least address, quality of life for the patient, as experienced by the patient.
Contextual Features - All clinical encounters occur in a wider social context beyond physician and patient, to include family, the law, culture, hospital policy, insurance companies and other financial issues, and so forth.
These four topics are present in every case. In the interest of consistency, the order of the review of topics remains the same (much like the review of systems in a complete H&P), yet no topic bears more weight than the others. Each will be evaluated from the perspective of the facts of the case at hand.
Once the details of a case have been outlined according to the four topics, there are a series of questions that the clinician should ask.
What is at issue?
Where is the conflict?
What is this a case of? Does it sound like other cases you may have encountered? (e.g., Is it a case of ’refusal of potentially life-sustaining treatment by a competent patient’?)
What do we know about other cases like this one? Is there clear precedent? If so, we call this a paradigm case. A paradigm case is one in which the facts of the case are clear cut and there has been much professional and/or public agreement about the resolution of the case.
How is the present case similar to the paradigm case? How is it different? Is it similar (or different) in ethically significant ways?
The resolution in any particular case will depend on the facts of that case, but will be influenced by how similar cases have been handled, debated, and adjudicated.
After analyzing a difficult case in this way, clinicians are usually able to think clearly about what is at issue and to identify the best course of action available to them. If a best course of action remains elusive, a formal ethics consultation is often the next step.
A case-based approach to ethical decision-making
Adapted from AR Jonsen, M Siegler, W Winslade, Clinical Ethics, 7th edition. McGraw-Hill, 2010.
MEDICAL INDICATIONS
The Principles of Beneficence and Nonmaleficence
*What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
*What are the goals of treatment?
*In what circumstances are medical treatments not indicated?
*What are the probabilities of success of various treatment options?
*In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
PATIENT PREFERENCES
The Principle of Respect for Autonomy
*Has the patient been informed of benefits and risks, understood this information, and given consent?
*Is the patient mentally capable and legally competent, and is there evidence of incapacity?
*If mentally capable, what preferences about treatment is the patient stating?
*If incapacitated, has the patient expressed prior preferences?
*Who is the appropriate surrogate to make decisions for the incapacitated patient?
*Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
QUALITY OF LIFE
The Principles of Beneficence, Nonmaleficence, and Respect for Autonomy
*What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
*On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
*Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
*What ethical issues arise concerning improving or enhancing a patient’s quality of life?
*Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
*What are plans and rationale to forgo life-sustaining treatment?
*What is the legal and ethical status of suicide?
CONTEXTUAL FEATURES
The Principles of Justice and Fairness
*Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
*Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
*What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
*Are there financial factors that create conflicts of interest in clinical decisions?
*Are there problems of allocation of scarce health resources that might affect clinical decisions?
*Are there religious issues that might affect clinical decisions?
*What are the legal issues that might affect clinical decisions?
*Are there considerations of clinical research and education that might affect clinical decisions?
*Are there issues of public health and safety that affect clinical decisions?
*Are there conflicts of interest within institutions or organizations (e.g. hospitals) that may affect clinical decisions and patient welfare?
Case: John, a 32 year-old lawyer, had worried for several years about developing Huntington’s chorea, a neurological disorder that appears in a person’s 30s or 40s, resulting in uncontrollable twitching and contractions and progressive, irreversible dementia. It typically leads to death in about 10 years.
John’s mother died from this disease. Huntington’s is autosomal dominant and children of an affected person have a 50% chance of inheriting the condition. John had indicated to many people that he would prefer to die rather than endure the progression of the illness. He was anxious, drank heavily, and had intermittent depression, for which he saw a psychiatrist. Nevertheless, he was a productive lawyer.
John first noticed facial twitching 3 months ago, and 2 neurologists independently confirmed a diagnosis of Huntington’s. He explained his situation to his psychiatrist and requested help committing suicide. When the psychiatrist refused, John reassured him that he did not plan to attempt suicide any time soon. But when he went home, he ingested all his antidepressant medicine after pinning a note to his shirt to explain his actions and to refuse any medical assistance that might be offered. His wife, who did not yet know about his diagnosis, found him unconscious and rushed him to the emergency room without removing the note.
How much weight should John’s preferences (especially his attempt to end his life) carry in managing his emergency and subsequent clinical care?
Review of Topics:
Medical Indications
There are 2 diagnoses/prognoses that merit consideration. The underlying chronic disease of Huntington’s is incurable and symptoms progress with a bleak long term prognosis. However, there are effective treatments available for the acute diagnosis of drug overdose including gastric lavage (pumping his stomach), emetics, antidotes, and/or activated charcoal (to prevent undigested drugs from entering his blood stream); supportive treatment following the initial treatment; and medications to ameliorate the underlying depression. How does the diagnosis of Huntington Disease affect our response to the acute condition? We know that the standard of practice is to assume that patients admitted for suicide attempts lack decisional capacity.
Patient Preferences
We know from the patient’s suicide note that he is refusing all medical treatment. However, what do we know about these statements of preference? Were they informed? Was the patient competent to make that decision? The answers to these questions remain unclear, but we do know that the patient does not have decision making capacity for the present decision of whether to proceed with the gastric lavage. Is there a surrogate decision maker available?
Quality of Life
Life with Huntington’s can be difficult. John was familiar with the quality of life associated with living with Huntington’s as he watched his mother die of this disease. On the other hand, John does have a supportive family and continues to be able to work for the time being. How should the diminished quality of life that is anticipated in the future affect current clinical management?
Contextual Features
Several factors in the context of this case are significant. While the patient has a legal right to refuse treatment, he is currently unconscious and his surrogate (his wife) is requesting treatment. There are also certain emergency room obligations to treat emergent conditions. How should the emergency staff weigh the various competing legal and regulatory duties?
Case Analysis:
John has indicated through his note that he refuses potentially life-sustaining treatment, but his competency to make decisions is questionable in the context of attempted suicide. Also at issue is the distinction between the acute and chronic conditions.
The precedent for cases such as this one is fairly clear. When the patient’s preferences are unclear or health care providers have reason to believe a patient’s decision-making capacity is compromised; the acute condition is easily treatable; and the harm of not treating is very great, emergency medical treatment of the immediate life-threatening condition is provided, creating an opportunity to talk with the patient about his preferences regarding his chronic condition at a later time and to treat any underlying depression that may have contributed to his suicide attempt.
Notice that the facts of this particular case determine whether the precedent case is applicable. If the medical team was familiar with this patient’s expressed preference to refuse any medical treatment and if the available treatment for the acute condition was considerably less certain to be effective, the case could be decided differently. The clinicians would look for a different precedent.
The following is an excerpt from Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 4th Edition by Albert R. Jonsen, Mark Siegler, and William J. Winslade (1998). Copyright permission to reproduce this excerpt has been generously granted by McGraw-Hill. We encourage you to read this useful resource book, available now in the 7th Edition (2010).INTRODUCTION:CASE ANALYSIS IN CLINICAL ETHICS
Clinical ethics is a practical discipline that provides a structured approach to assist physicians in identifying, analyzing and resolving ethical issues in clinical medicine. The practice of good clinical medicine requires some working knowledge about ethical issues such as informed consent, truth-telling, confidentiality, end-of-life care, pain relief, and patient rights. Medicine, even at its most technical and scientific, is an encounter between human beings, and the physician’s work of diagnosing disease, offering advice, and providing treatment is embedded in a moral context. Usually, moral values such as mutual respect, honesty, trustworthiness, compassion, and a commitment to pursue shared goals, make a clinical encounter between physician and patient morally unproblematic. Occasionally, physicians and patients may disagree about values or face choices that challenge their values. It is then that ethical problems arise. Clinical ethics is both about the ethical features that are present in every clinical encounter and about the ethical problems that occasionally arise in those encounters. Clinical ethics relies upon the conviction that, even when perplexity is great and emotions run high, physicians and nurses, patients and families can work constructively to identify, analyze and resolve many of the ethical problems that arise in clinical medicine.
The authors have two purposes in writing this book: first, to offer an approach that facilitates thinking about the complexities of the problems that clinicians actually face and, second, to assemble concise representative opinions about typical ethical problems that occur in the practice of medicine. We think it is more important that clinicians develop skill at analyzing the cases they encounter rather than merely have a book in which ’to look up answers.’ Our hope is that every clinician will acknowledge that ethics is an inherent aspect of good clinical medicine and that, ideally, every clinician will become as proficient at clinical ethics as clinical medicine. Our book is intended not only for clinicians and students who provide care to patients, but also for others whose work requires an awareness and sensitivity to the ethical issues raised in clinical care, such as hospital administrators, hospital attorneys, members of institutional ethics committees, quality reviewers and administrators of health plans. In the complex world of modern health care, all of these persons are responsible for maintaining the ethics that lie at the heart of quality care.
Many books on health care ethics are organized around moral principles, such as respect for autonomy, beneficence, non-maleficence and fairness, and the cases are analyzed in the light of those principles. Our method is different. While we appreciate the importance of principles, we believe that the practitioner approaching a case needs a method that better fits the realities of the clinical setting and the reasoning of the clinician. Clinical situations are complex since they often involve a wide range of medical facts, a multitude of circumstances and a variety of values. Often decisions must be reached quickly. The authors believe that clinicians need a straightforward way to sort the facts and values of the case at hand into an orderly pattern that will facilitate the discussion and resolution of the ethical problem.
We suggest that every clinical case, when seen as an ethical problem, should be analyzed by means of four topics. These four topics are
*Medical Indications
*Patient Preferences
*Quality of Life
*Contextual Features, that is, the social, economic, legal, and administrative context in which the case occurs.
Every case can be viewed in terms of these four topics; no case can be adequately discussed without reference to them. Although the facts of each case differ, these four topics are always relevant. The topics organize the varying facts of the particular case and, at the same time, the topics call attention to the moral principles appropriate to the case. It is our intent to show readers how the topics provide a systematic way to identify, analyze and resolve the ethical problems arising in clinical medicine.
Clinicians will recall the method of case presentation that they learned at the beginning of their professional training. They were taught to ’present’ a patient by stating in order the patient’s history, including the chief complaint, the history of the present illness, past medical history, family and social history, followed by physical findings and laboratory data. These are the topics that an experienced clinician uses to reach a diagnosis and to formulate a case management plan. While the particular details under each of these topics differ from patient to patient; the topics themselves are constant and always relevant to the task of arriving at a case management plan. Sometimes one topic, for example, the patient’s family history or the physical examination, may be particularly important or, conversely, may not be relevant to the problem at hand. Still, clinicians are expected to review all topics in every case. Our four topics -- (1) Medical Indications, (2) Patient Preferences, (3) Quality of Life, and (4) Contextual Features--are the ethical equivalents of these familiar clinical topics.
These topics help clinicians understand where the moral principles meet the circumstances of the clinical case. The general headings of the topics describe the major features that define the ethics of clinical medicine; each of these features takes on specific, concrete form from the circumstances of the particular case. In a given case, a patient comes to a physician, complaining of feeling ill. Medical Indications include a clinical picture of polydipsia and polyuria, nausea, fatigue and some mental confusion, with laboratory studies showing hyperg
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