So now that we've learned about what
ethics is, what medical ethics is,
the different approaches to ethics, and the fact
that in clinical medicine we may encounter dilemmas,
we need a framework for how
to solve those situations.
So, I'm going to
view medical ethics
and its approaches in this structured way
the same way I view clinical medicine.
We start with 3 main questions.
First is the diagnostic question.
What is wrong?
You know, what's the problem
that we have to deal with?
Next is the
So in clinical medicine, it's figuring
out the treatment for the patient.
In ethics, it's what are
our range of options?
What can be done
in this situation?
And then 3rd is the
So, using my clinical judgment when I'm
taking care of a patient, I figure out,
you know, this is my
recommended treatment for you.
This is what I think is going to be
best to take care of your problem.
The same thing in
We need the normative question of
here are the range of possibilities
of what can be done or
what should be done.
And that's going to, you know, rely on all these approaches
that we've talked about with regard to medical ethics.
So, let me give you a framework.
It's not complete,
but it's a good way to think about the different
ways of approaching ethical dilemmas.
So the first is
identify a concern.
And that maybe the moral sensitivity
that you've developed as a professional,
that moral intuition that says something is not
right here, it seems like it might be a dilemma,
maybe conflicting obligations,
something that needs solution.
So the next step is to define the dilemma. You
know, what are the competing obligations?
Are there values at stake that seem
to be in conflict in some way?
Just identifying them, just name them,
that's going to be your first step.
And then, you know, good
ethics relies on good facts.
So you need to understand the
situation as completely as possible.
You need to figure out who
the moral stakeholders are.
Who are the people that are going
to be affected by the decision,
by the action that needs
to be implemented?
One handy method that's been used in medical
ethics is something called the 4-topic method.
So let me just walk you
through those 4 topics.
The first just as we talked about with clinical
medicine starts with medical indications.
So what are we trying to achieve in the beneficent
way, you know in the best interest of the patient,
while also paying attention to
non-maleficence, not harming the patient.
What are the medical indications in
terms of the diagnosis, the treatment,
the chances of success of that treatment, and what
we are ultimately recommending to the patient?
That's the first step. Can
you identify all that?
In some patients, you're going to
have multiple medical problems
that you then need to figure out
a solution for each of those.
Next, you're going to think
about patient preferences
and this is going to harken back to the idea
of respect for persons, respect for autonomy.
So, knowing who the person is,
knowing what their value system is,
knowing whether or not they have the
ability to make their own decisions.
We're going to have a future lecture
about decision-making capacity
so we have to be able to inform the patient and
then they have to understand the information,
reason about it, and make a decision that fits
with, you know, who they are as a person.
And they're going to have various preferences
in terms of what we recommended medically
whether or not they want
to accept that or not.
One thing that they may want to consider in
making those decisions is quality of life.
So, what is their current quality
of life as a result of illness?
Are there things that provide impediments
to them living the life that they want to?
Are we concerned that, you know, they have a
disease process that might progress and get worse?
And then that's also going to
affect their quality of life.
Are there points where they would say "Well, this
quality of life is no longer acceptable to me
and maybe I don't want to pursue the
medical treatment that's being recommended
because it's going to
impact my quality of life?"
So that's another topic that we need to understand
all the facts working with the patient,
with their family, trying to understand it
from all the stakeholders' perspectives.
A 4th topic in thinking about this
framework is contextual features.
So, thinking about the
culture of the patient.
Do they have certain religious beliefs that might
inform how they think about their preferences?
Are there, you know, cultural
features in terms of our side?
You know, do we have to worry about conflicts of
interest in terms of how we're managing a case?
Do we need to think about
legal parameters such as,
you know, respecting
a patient's privacy?
All of those contextual features may feed in to
thinking about the dilemma in the fullest way possible.
Once you've integrated all of that
information, the next step is going to say
"Okay, well now
we need guidance.
You know, we need to figure out various approaches
that we can help to resolve this issue.
That will be harkening back to
the things we've talked about,
the principles, the 4 principles that
we've talked about in previous lectures.
It could be "How does this pertain to the virtues?
You know, if it's something like truth telling.
How do I adhere to the virtue of
honesty?" It may be the values.
Are there the values of the patient or the values that
I hold as a professional, or my own personal values?
Are those sources of guidance for how
to resolve this particular issue?
We talked about casuistry.
So there may be paradigm cases that we can say "Well,
this is how historically a case like this was handled.
Does it seem to work in this particular
case for the patient in front of me?"
There may be case law, you know, so there
may be legal decisions that we could say
"Well, this is how it was
decided in the court of law.
If we have to try to pay
attention to the law as well,
is that going to provide some guidance
to resolve this particular issue?"
And then lastly, from the profession, we're
going to have guidelines, codes of ethics,
ways to behave, ways to
think about an issue,
and are we adhering to those
You take the facts, you take
the sources of guidance,
and then you develop your differential
diagnoses with possible solutions.
So you're going to say "What
choices are possible?
You know, with the range of things
that we might be able to do,
list them all out whether they're, you
know, fantastic or you know rudimentary
but really try to make sure you've
listed all the possible choices.
Hopefully from using
your source of guidance,
you're going to arrive at something that
you think is the right thing to do.
What should be done? What are you obliged
to do in this particular situation?
When it's sort of a what we
called reflective equilibrium
trying to meld all of the
principles together for instance,
is there a way to try to reach a
consensus among those principles
that you're trying to follow all of them as best
as possible to then figure out the right action.
And then lastly, as I've talked about in other
lectures, ethics, medical ethics is practical.
There has to be something you
do at the end of the day.
So, what should be done should
help inform what will be done.
Now there may be constraints based on the
patient's circumstances or, you know,
really a need to respect autonomy that patients might
differ from what you think is the right thing to do.
So ultimately you will
have to do something.
What will be done, that's
what you follow through on.
You decide on that course of action
and clinical medicine is something
where if you're taking care of the person over time,
you're going to be seeing the results of that action.
So, decide on the course of action, follow
through on it, and then evaluate its outcome.
You can then, you know, help guide the future
care of that patient to know how that,
you know, solution
worked or did not work.
It could also help guide your future practice so
when you're taking care of patients in the future,
that idea of quality improvement
in terms of being a clinician
can we do better the next time
when we face a similar dilemma.
Those are all of the things you're
going to be trying to achieve
in this framework for
approaching ethical dilemmas.
I wish you goodluck in approaching
these dilemmas on your own
and hopefully this framework will
help you in solving some of them.