Ethics Analysis in Clinical Medicine Eugene Bereza, MD CM, CCFP Director Biomedical Ethics Unit Faculty of Medicine McGill University

GOAL Provide a practical tool for ethics analysis: 1.Clinically oriented 2.Systematic 3.Easy to remember 4.Application: *Clinical care *Teaching supervision *Resident Evaluation *Outline for responding to ethics questions

GOAL Appreciate ethical component of a clinical dilemma Practical resolution of a case

What can I do? What should I do?

Action Ethics Action

Clinical Ethics Clinical Ethics 1) Identify the ethical dilemma 2) Gather pertinent information 3) Analyze the information in context of the dilemma 4) Prioritize recommendations and articulate supporting argumentation

STEP 1 Identify the ethical dilemma Identify the ethical dilemma

1. Identify the dilemma – Identify the dilemma: – name the “rock” – name the “hard place” – Translate your choice of actions into a choice between competing values or principles

1. Identify the dilemma Four foundational principles of modern bioethics Autonomy Autonomy Non-maleficence Non-maleficence Beneficence Beneficence Justice Justice (Beauchamp & Childress) (Beauchamp & Childress)

Dilemmas often fall within a range of acceptable options on a continuum ? WORST BEST EVIL GOOD

1. Identify the dilemma GOOD #1 GOOD #2 GOOD #2

1. Identify the dilemma BAD#1 BAD #2 BAD #2

STEP 2 Gather pertinent information

2. Gather information BIOPSYCHO -Diagnosis- preferences of patient -Nature of disease- preferences of surrogate - Prognosis with Rx- preferences of caregivers - Prognosis without Rx SOCIAL SOCIAL - laws - codes of ethics - policies

STEP 3 Analyze the information in context of the dilemma Analyze the information in context of the dilemma

3. Analyze Generate all realistic optionsGenerate all realistic options For each option, access the underlying principles and consequences that support and undermine itFor each option, access the underlying principles and consequences that support and undermine it Compare & contrast the burdens/benefits of each optionCompare & contrast the burdens/benefits of each option Judge which option brings best consensus outcomeJudge which option brings best consensus outcome

3.Analyze Two Predominant Categories of Moral Reasoning Two Predominant Categories of Moral Reasoning 1.Deontological (reference to principles, values) 2.Teleological (reference to anticipated consequences)

3.Analyze Other Schools of Moral Reasoning Casuistry (balancing of principles and consequences in individualized context) Virtue ethics (reference to fundamental character) Communitarian ethics (reference to prioritization of collective as the target)

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