Perspective Six-step framework for ethical decision making Journal of Health Services Research & Policy 2014, Vol 19(1) 62–64 ! The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1355819613511599 jhsrp.rsmjournals.com Gavin Enck Abstract The expectation, from the ethos of medicine and society, is that a practitioner should make the correct ethical decision in the clinical setting. Yet there is little help for them as to a process for making ethical decisions. A structured six-step framework may assist. It is not an algorithm to arrive at a determinate answer in all situations and ethical issues but instead offers a process that indicates the most relevant information and biomedical considerations a practitioner needs to be aware of and helps to make ethics issues more manageable. The issues practitioners face are complex and resistant to reduction; it is hubris to pretend otherwise. Yet, the difficulty of these issues warrants practitioners relying on a framework to guide them in the process of making ethical decisions. Keywords decision aids, decision quality, patient-centered care, Patient-Reported Outcome Measure (PROM) Introduction The expectation, from the ethos of medicine and society, is that a health care practitioner should make correct ethical decisions. As a practitioner, imagine encountering the following scenarios: Case 1: A 43-year-old man with gastric cancer and metastatic liver disease is in your medical centre. He has an advanced directive and his sister is his medical power of attorney, but his mother comes to the medical centre asking about his condition. She is unaware of her son’s condition and while she is high functioning, she has dementia and short-term memory problems. Case 2: The parents of a 12-year-old girl with a terminal glioblastoma multiforme request that you do not tell the patient that she is terminal and being transferred to hospice care. However, the patient currently has cognitive capacity and keeps asking you and other staff about her condition and plans of care. Case 3: The spouse of a terminally ill woman is a former law enforcement officer. He is attentive and loving, but you notice that tucked in the small of his back is a concealed weapon. This medical centre, like most medical centres, has strict prohibitions against carrying even permitted weapons in the facility. These types of scenarios are a regular occurrence. While there is much literature that provides broad, biomedical ethical approaches towards resolving an issue or an ethical justification for a resolution, there are few resources available offering a framework which walks a practitioner through the practical process of addressing an ethics issue. In my experience, it is not that practitioners are unable to make an appropriate decision. Rather, it is that they are often overwhelmed by the process – the information, ethical considerations and potential courses of action – when attempting to address an ethics issue. However, many experienced practitioners and clinical ethicists are not overwhelmed when handling ethics issues because they follow a step-by-step procedure that makes addressing these issues manageable. Such a step-by-step procedure is nothing new: it relies on the literature of biomedical ethical accounts for approaching such issues, decision making and their own experiences. So, what is the practical information, considerations and options that are available to practitioners when making a clinical ethics decision? Clinical Ethics Fellow, The University of Texas MD Anderson Cancer Center, Texas, USA Corresponding author: Gavin Enck, The University of Texas MD Anderson Cancer Center, 1400 Pressler, Houston, TX 77030-3722, USA. Email: genck@mdanderson.org Enck Before offering a six-step framework, it needs to be clearly stipulated that my goal is not to imply that it is a broad biomedical ethical account of how practitioners should approach ethical issues. Instead, the framework is merely an amalgamation of the best parts of these approaches codified into a practical procedure to guide practitioners. In addition, it is not an algorithm which always arrives at a determinate answer. In the clinical setting, ethics issues are complex and resistant to simple reductions. There is often a range of appropriate solutions rather than a single one, so any algorithm which posits the ability to provide a determinate answer, for all situations and cases, is not feasible. 63 integrity and conscientiousness – stipulate that practitioners have a fiduciary responsibility to patients. More importantly, these biomedical ethical principles and ideals underwrite the relevant ethical considerations in an assessment of an ethical issue. Relying on a slightly modified version of Jonsen, Siegler and Winslade’s terms, these ethical considerations are medical indications, patient’s preferences, interests and values, quality of life and contextual aspects of the situation.5 These ethical considerations are used in the assessment of an ethical issue which is a situation in which conflict occurs between patients, lay carers, practitioners or the health care institution involving values, preferences or professional responsibilities.4,5,8 Concepts of biomedical ethics In moral philosophy, the study of normative ethics often takes the central questions to be, but not limited to, ‘how ought a person act’ or ‘what sort of person am I to be?’1,2 These questions, in turn, are often specified further in regards to intricate and sophisticated theories of right action, with a focus on ‘what properties make an action right’ or ‘what are the limitations on these actions?’ The focus is on elucidating a justification (or exposing the lack of) on the theoretical grounds from which moral agents act. Yet, moral philosophy does not (nor should it be required to) provide a method for making an ethical decision. At least one reason that moral philosophy need not offer a method of ethical decision making is because, in everyday life, people’s common understanding of ethics – of what are right, permissible or wrong actions – manages quite well. For the most part, the majority of people do not wantonly murder, rape and steal. Yet, in some situations, people’s preferences, interests and values do conflict, and deciding the most appropriate action is often difficult. In part, the difficulty is that rational and reasonable people do often disagree in profound ways on what are the right, permissible or wrong actions in certain situations (e.g. killing one person to save five). This does not mean, as a cynic would hold, that there is no such thing as morality but that the world in which we live in is complicated. As Aristotle remarks about the complexity of ethics, ‘Our discussion will be adequate if it has as much clearness as the subject matter admits of’.3 While the complexity of ethics for those working in health care is great, a distinct advantage is that biomedical ethical concepts clearly stipulate the obligations, responsibilities and conduct of practitioners. It is reasonable to think that their conduct is governed by certain principles, rules and ideals.4–7 The bioethical principles of beneficence, non-maleficence and respect for patient autonomy and justice – as well as the ideals of human excellence or virtues of compassion, trustworthiness, The six steps of the framework The relevant ethical considerations can be allocated within a six-step framework that facilitates the making of an ethics decision by outlining, in a clear and structured manner, the practical information, considerations and options.4,5,8–11 This will allow practitioners to work through an ethics problem in a manner that is more manageable, limits the scope of the ethics issues and (hopefully) prevents them from being overwhelmed in the process. This six-step process is as follows: Information Obtain as much information as possible about the patient’s medical and social history: diagnosis, prognosis, goals of care, treatment plan and the primary and/or consulting services involved. Identification Assess whether this is an ethics issue or if it is a legal, institutional or social issue better addressed by other services or departments. Clarification Does the practitioner and other members of the team know and understand all the necessary and relevant medical information? Does the patient and/or their family know and understand all the necessary and relevant medical information? Are there other options readily available, e.g. switching services, departments or transferring the patient? Is a trial period possible? Is it an ethical issue or dilemma? Frame as an ethical question. Assessment Assess the considerations of medical indications, patient’s preferences, interests, values and their quality of life. Recommendation Make a recommendation all parties can understand. 64 Journal of Health Services Research & Policy 19(1) Documentation Document the recommendation in the patient’s records. Follow up. Feedback: ask for comments, suggestions and thoughts about the ethical issue or dilemma, recommendation or decision-making process. issues. It does not always provide a determinate answer but it is at least one way they can avoid being overwhelmed when encountering an ethics issues. Although ethical issues in clinical settings are complex and resistant to reduction, it does not follow that we cannot strive to provide practitioners with a framework for guidance. Acknowledgements How the framework can help I thank Christina Guajardo and Brittany Campbell for editorial advice and Jessica A Moore for academic advice. Using this six-step framework, let us return to the three scenarios presented earlier. It offers a structured process that assists a practitioner: Funding Case 1: At the clarification step, a practitioner could ask the patient whom in his family he has told about his condition. By asking the patient, it is possible to discover a reason, preference or indication of a personal value that could be useful for determining disclosing this information. Moreover, if he says he does not want you to tell his mother – and since she is not his medical power of attorney, surrogate decision maker, or caregiver and thus does not have an ethical right to that information – the practitioner clearly does not have an obligation to disclose the son’s condition to his mother. Case 2: At the clarification step, the ethical problem is categorized as an ethical dilemma and then framed as a question: ‘Given the parents’ preferences and the patient’s age and prognosis, is it ethically justifiable to not inform the patient that her condition is terminal?’ One relevant ethical consideration for answering this question is to consider the patient’s preferences, interests and values. While the patient is only 12 years old, her preferences, interests and values do matter. Consider that even if her parents were to consent to a particular treatment, a practitioner would want to obtain assent for the treatment from the patient.12–14 Therefore, in this scenario, a practitioner needs to assess the benefits, harms, risks and burdens of the parents’ preferences for not telling the patient against the obligation to respect and inform the patient of this information. Case 3: The first step, identification, is the important step here. While this patient’s spouse is attentive and loving, the possession of a concealed weapon is an institutional safety issue rather than an ethical issue. Yet, a practitioner should take steps to address the concealed weapon, such as notifying security personnel to inform the patient of the institution’s rules rather than trying to address this issue on their own. This six-step framework is but one structured method for practitioners to rely on when encountering ethics This work was supported by the Section of Integrated Ethics in cancer care at the University of Texas MD Anderson Cancer Center. References 1. Copp D (ed.) The Oxford handbook of ethical theory. Oxford: Oxford University, 2006. 2. Schneed JB. The misfortunes of virtue. In: Virtue ethics. Oxford: Oxford University Press, 1997, pp.178–200. 3. Aristotle. The complete works of Aristotle: The revised Oxford translation, Barnes B (ed). Princeton: Princeton University Press, 1984 (NE 1.3 1094b12–13). 4. Beauchamp T and Childress JF. Principles of biomedical ethics, 6th ed. Oxford: Oxford University Press, 2009. 5. Jonsen AR, Siegler M and Winslade WJ. Clinical ethics: a practical approach to ethical decisions in clinical medicine, 7th ed. New York, NY: McGraw-Hill Medical, 2010. 6. McCammon SD and Brody H. How virtue ethics informs medical professionalism. HEC Forum 2012; 24: 257–272. 7. Pellegrino ED and Thomasm DC. The virtues in medical practice. Oxford: Oxford University Press, 1993. 8. Dubler NN and Liebman CB. Bioethics mediation. Nashville, TN: Vanderbilt University Press, 2011. 9. Fox E, Bottrell MM, Berkowitz KA, et al. Integrated Ethics: an innovative program to improve ethics quality in health care. Innovation J 2010; 15: 1–36. 10. National Center for Ethics in Health Care. United States Department of Veteran Affairs. Integrated ethics, http:// www.ethics.va.gov/integratedethics/ (2013, accessed April 2, 2013). 11. Fox E. Evaluating ethics quality in health care organizations: looking back and looking forward. AJOB Primary Res 2013; 4: 71–77. 12. Kenny N, Downie J and HarrisonC. Respectful involvement of children in medical decision making. In: Singer PA and Viens AM (eds) The Cambridge textbook of bioethics. Cambridge: Cambridge University Press, 2008. 13. American Academy of Pediatrics. Informed consent, parental permission, and assent in pediatric practice. Pediatrics 1995; 93: 314–317. 14. Canadian Paediatric Society and Bioethics Committee. Treatment decisions regarding infants, children, and adolescents. Paediatr Child Health 2004; 9: 99–103. Copyright of Journal of Health Services Research & Policy is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission. However, users may print, download, or email articles for individual use.
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