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Related Topics
Clinical EthicsReview - Clinical Ethics
A Practical Approach to Ethical Decisions in Clinical Medicine
by Albert R. Jonsen, Mark Siegler, and William J. Winslade
McGraw-Hill, 2002
Review by Lawrence D. Hultgren, Ph.D.
Nov 17th 2005 (Volume 9, Issue 46)

The ambiguous term 'clinical ethics' can refer either to the ethical analysis of clinical decisions or to the inclusion of ethical considerations in the care of the patient. For some, this has created 'two cultures' of bioethicists: those philosophers and theologians who are primarily interested in analyzing and interpreting clinical decisions, and physicians and other health care providers who are actively engaged in making those decisions. In their classic work Clinical Ethics, first published in 1982, Drs. Albert Jonsen, Mark Siegler, and William Winslade acknowledged their normative perspective that, "[m]edicine, even in its most technical and scientific levels...is embedded in a moral context" (1). Now in its fifth edition, the authors reaffirm their commitment to anchor ethical decision making in clinical practice and not in arm chair philosophy. "Clinical ethics," they conclude, "is a practical discipline that provides a structured approach for identifying, analyzing, and resolving ethical issues in clinical medicine" (1).

In its original publication in 1982, this clinician's coat-pocket-sized book on ethics targeted specialists in internal medicine with its proposal of a method of ethical analysis that would be closer to the practice of physicians than to the speculation of the philosophers. That method is the now classic "The Four Topics Method," which responds to cases by examining, in order, medical indications, patient preferences, quality of life, and contextual features. In subsequent editions, ethical issues in adult medicine and pediatrics were addressed. Now the scope has broadened even more, and the authors in their thinking and writing have targeted other professionals, including "health care providers, nurses, social workers, medical technicians, as well as chaplains and administrators" (4). Specifically excluded, however, are practitioners in obstetrics and reproductive medicine since the ethical "problems there involve an enigmatic third party" (4).

For those who want "to go to the answer" or who are an "in the box" kind of thinker, the four part ("box") case method seems ideal. It offers a "straightforward method of sorting out the pertinent facts and values of any case into an orderly pattern that facilitates the discussion and resolution of ethical problems" (2). This technique for analyzing ethical issues, according to the authors, corresponds to the way clinicians are taught to analyze medical issues. Thus it helps clinicians understand how seemingly abstract ethical principles connect with the concrete circumstances of patient care. This attempt at a rapprochement between the theoretical and the practical is initially illustrated in the book by examining the now classic case of Donald "Dax" Cowart, the burn victim who related his experience in the videotape Please Let Me Die and the documentary Dax's Case.

Following an introduction, the book is divided into four parts each devoted to one of the four topics. In each chapter, major concepts are defined, paradigmatic cases are presented, and resolutions are suggested. Not only do the authors give their own beliefs, but they offer as well current opinions of medical ethicists and references to relevant articles and texts. A "Locator" is even included at the back of the book so that a clinician or reader can use more easily use the text as a reference source.

The four topics method of analysis begins not with a series of a priori statements about what ought to be done but with the clinical diagnosis of the concrete problem. Chapter One, "Indications for Medical Intervention," reaffirms the dictum that good clinical ethics will depend upon good clinical facts -- clarity about the patient's medical condition. Specific medical interventions discussed in the first chapter include cardiopulmonary resuscitation (CPR) and Do Not Attempt Resuscitation (DNAR) orders. Inappropriate treatments are briefly covered as well, especially as they revolve around the often ambiguous notion of medical futility. The chapter closes with a brief treatment of the care of a dying patient and the definition of death, either by cardiorespiratory criteria or brain criteria.

The second topic, and chapter, essential to the analysis of a clinical ethical problem, is "Patient Preferences." Once the medical indications are clarified and the patient is told what can be done, it is up to the patient to decide what of what can be done ought to be done. Both the ethical and legal facets of the physician-patient relationship are discussed, and the authors, echoing Immanual Kant and J. S. Mill, conclude that, "[c]onstraint of a person's free choices is morally permissible only when one person's preferences and actions seriously infringe on the rights and welfare of another" (48). Featured in this chapter is an exploration of the way patient preferences ought to be expressed through the process of informed consent. The authors argue that, with respect to disclosure, "[t]he reasonable person standard may be ethically sufficient, but the subjective standard is ethically ideal" (52).

Chapter Three discusses "Quality of Life" within the context of clinical care and not as an abstract concept. The authors reaffirm their belief that evaluation of quality of life, however difficult, is always relevant to appropriate patient care: "The most fundamental goal of medical care," they suggest, "is the improvement of the quality of life for all those who need and seek care" (105). Helpfully distinguishing between the "personal evaluation" and the "observer evaluation" of the patient's quality of life, this chapter explores the ethical and legal implications of this concept for difficult end of life issues such as foregoing treatment, euthanasia and assisted suicide, and suicide.

Chapter Four, "Contextual Features," reviews the social, legal, economic, and institutional factors that impinge on clinical and ethical decision making. It offers brief discussions of the ethical issues involving (1) physician responsibilities beyond those to the patient; (2) physician's confidentiality; (3) the economics of health care, including organizational ethics; (4) "rationing" scarce health care resources; (5) religious belief; (6) legal concerns; (7) clinical research; (8) clinical teaching responsibilities; (9) occupational medicine; and (10) public health. An examination of the goals of (11) ethics committees and (12) ethics consultation concludes the chapter and book.

Given the joint authorship of this book by an ethicist, a physician, and a lawyer, and the growing success of "The Four Topics Method," it is not too surprising that, in this latest edition, the authors offer their methodology as a way to improve patient care literally at the bedside. They suggest that it be used as a heuristic for healthcare providers, patient, and family as they determine the ethical dimensions of a patient's care. Thus a pullout card of the four topics chart is included at the end of the book for quick reference. However slight, this decentering of clinical ethics from the original clinician thrust of the text, focusing on the physician-patient relationship, opens the door to future discussions about the relation between ethical theory and moral practice.

Blending elements of casuistry with principle-based reasoning, this new edition of the now classic Clinical Ethics offers, as its subtitle claims, "A Practical Approach to Ethical Decisions in Clinical Medicine." Eschewing the academic, this book delivers on its promise and responds to the needs and convenience of practicing clinicians.

 

2005  Larry D. Hultgren

Larry Hultgren describes himself as follows:

A.B. Grinnell College majoring in Philosophy and Religion; Ph.D. Vanderbilt University in Philosophy. Currently Professor of Philosophy at Virginia Wesleyan College, Norfolk, VA. Since I am at a liberal arts college, my teaching runs the gamut of philosophy offerings. I am especially interested in interdisciplinary pursuits, and I direct the college's Social Ecology Program and our innovative PORTfolio Project, which attempts to bring the liberal arts to life for our students by connecting the classroom with real world experiences. I also serve on the Bioethics Committee of the Children's Hospital of the King's Daughters in Norfolk, VA, and serve on the Board of Directors of the Bioethics Network of Southeast Virginia.


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