Framework to Solve an Ethical Dilemma

00:00 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.

00:18 So, I'm going to view medical ethics and its approaches in this structured way the same way I view clinical medicine.

00:26 We start with 3 main questions.

00:29 First is the diagnostic question. What is wrong? You know, what's the problem that we have to deal with? Next is the therapeutic question.

00:37 So in clinical medicine, it's figuring out the treatment for the patient.

00:41 In ethics, it's what are our range of options? What can be done in this situation? And then 3rd is the normative question.

00:49 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.

00:56 This is what I think is going to be best to take care of your problem.

01:01 The same thing in medical ethics.

01:04 We need the normative question of here are the range of possibilities of what can be done or what should be done.

01:10 And that's going to, you know, rely on all these approaches that we've talked about with regard to medical ethics.

01:18 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.

01:27 So the first is identify a concern.

01:30 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.

01:47 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.

02:02 And then, you know, good ethics relies on good facts.

02:06 So you need to understand the situation as completely as possible.

02:10 You need to figure out who the moral stakeholders are.

02:14 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.

02:25 So let me just walk you through those 4 topics.

02:28 The first just as we talked about with clinical medicine starts with medical indications.

02:34 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.

02:43 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.

03:04 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.

03:11 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.

03:19 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.

03:33 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.

03:40 One thing that they may want to consider in making those decisions is quality of life.

03:44 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.

04:01 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.

04:24 A 4th topic in thinking about this framework is contextual features.

04:28 So, thinking about the culture of the patient.

04:32 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.

04:59 Once you've integrated all of that information, the next step is going to say "Okay, well now we need guidance.

05:06 You know, we need to figure out various approaches that we can help to resolve this issue.

05:13 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.

05:19 It could be "How does this pertain to the virtues? You know, if it's something like truth telling.

05:25 How do I adhere to the virtue of honesty?" It may be the values.

05:30 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.

05:44 So there may be paradigm cases that we can say "Well, this is how historically a case like this was handled.

05:50 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.

06:02 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 professional guidelines? You take the facts, you take the sources of guidance, and then you develop your differential diagnoses with possible solutions.

06:31 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.

06:46 Hopefully from using your source of guidance, you're going to arrive at something that you think is the right thing to do.

06:52 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.

07:14 And then lastly, as I've talked about in other lectures, ethics, medical ethics is practical.

07:21 There has to be something you do at the end of the day.

07:23 So, what should be done should help inform what will be done.

07:28 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.

07:40 So ultimately you will have to do something.

07:43 What will be done, that's what you follow through on.

07:47 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.

07:58 So, decide on the course of action, follow through on it, and then evaluate its outcome.

08:04 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.

08:12 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.

08:25 Those are all of the things you're going to be trying to achieve in this framework for approaching ethical dilemmas.

08:31 I wish you goodluck in approaching these dilemmas on your own and hopefully this framework will help you in solving some of them.