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CASE STUDIES
Department of Medical Education and 2Department of Medicine, Mount Sinai School of Medicine, New York, USA
Email: rosamond.rhodes@mssm.edu
Abstract
Because the process of moving from moral principles and facts to action-guiding moral conclusions
has not been articulated clearly enough to be useful in a practical way, we designed a systematic
approach to aid learners and clinicians in their application of ethical principles to the resolution of
clinical dilemmas. Our model for clinical moral reasoning is intended to provide a clear and replicable
structure that makes the thought process involved in reasoning about clinical cases explicit. In this
paper we present the model and demonstrate how it can be used in three clinical cases.
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Clinical Ethics
2007
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Number 2
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2007
Volume 2
Case 1
An 84-year-old man with end-stage metastatic colon cancer
was admitted to the hospital with persistent nausea and vomiting. An initial evaluation revealed a large bowel obstruction
due to the progression of the primary colonic mass. After placement of a naso-gastric tube for decompression, a surgical consult was requested to evaluate him for surgical palliation of the
obstruction. He had previously undergone a course of surgery
and chemotherapy, but the cancer recurred after three years.
Before this hospitalization, the patient had been living independently at home with his wife. The patient had designated his
wife as his health care proxy and he had also expressed his
desire to return home with his wife. The medical team wanted
to honour the patients wishes, but they were unsure whether
that included exposing him to the risk of surgery.
In this case beneficence was identified as the central
concept involved. It was, however, not at all obvious just
what course a commitment to beneficence directed. The
question that the team formulated was therefore, Should
surgery be performed or avoided for this man with endstage cancer patient and a bowel obstruction?. Because
the patients condition was acute, there was little time for
waiting or for gathering additional data.
After discussion of the patients prognosis, the treatment alternatives, and the likely consequences of each
option, it was clear that there was no distinctly best or
worst course for him. It seemed that none of the options
would assure that he could return home to a significant
period of the life he had enjoyed. The choice of which
route to follow turned on how one might rank the harms
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Case 2
A 78-year-old high-functioning woman with congestive heart
failure, chronic renal insufficiency, and decubitus ulcers was
admitted to the hospital because of an exacerbation of heart failure. She had been living with her sister for 30 years, and when
her illness recently worsened, her sister became her primary
care giver. The sister, who was also designated as the patients
health care proxy, was present in the hospital daily where she
made significant personal efforts to clean and debride her sisters
decubiti, using non-traditional and unsanitary methods. The
sister refused both nurse and physician requests to leave these
procedures to the hospital staff. The patient never made any
attempt to intervene with her sisters behaviour, and she did not
raise any objections to it.
The patient did not respond to the treatment for her heart
failure and her renal insufficiency worsened to the point of
uraemia requiring dialysis. In spite of treatment, the patients
mental status worsened from the uraemia. At this point the
patients prognosis was poor.
As the patient lay in bed obtunded, the sister refused to
allow the resident physicians to enter the room for an evaluation, although she did allow the attending senior physician. In
spite of maximal medical therapy, the patient eventually developed irreversible multi-organ failure due to her severe progressive cardiac and renal disease. After discussion with the medical
team, the sister agreed to pursue palliative care for the patients
shortness of breath and declining level of consciousness, which
she said was consistent with the patients prior wishes.
Using our systematic approach to clinical ethics, the
basic concepts involved in this case were identified as
beneficence, respect for autonomy, assess decisional capacity and surrogate decision making. Beneficence was noted
in the teams insistence that the patients welfare was
paramount. So long as first the patient, and later the sister,
had decisional capacity, respect for autonomy required
their decisions be accepted. Team members had raised
important questions about the patients decisional capacity
early on in her hospitalization, whether factors related to
her illness, such as depression, fear, anxiety and dependence, as well as her medical illness, may have impaired
her ability to meaningfully participate in the treatment
decision process. They also raised questions about the sisters involvement. Her behaviour suggested to them that
she may not have been acting in the patients best interest.
Even though the patient did not object to her sisters
interventions, the team considered whether they should
have allowed them. If the patient actually had decisional
capacity, the sisters behaviour could be accepted because
it was consistent with the patients stated preference. But
as the patients mental status declined, the sisters decisions became more of an issue. One concern was whether
or not the sister actually had decisional capacity herself.
Ultimately, the ethical question that they formulated
was, Should the medical team abide by the surrogates
decisions?. In this case, although there was clash between
the principles of beneficence and respect for autonomy, a
crucial dilemma concerned the capacity of both the
patient and her sister. Even after lengthy discussion of
whether or not the patient had capacity before she developed severe uraemia, and whether or not the sister had
decisional capacity, the answers remained in doubt. When
dealing with a surrogate decision, clinicians have to evaluate both the surrogate and the surrogates decisions. In this
case, the surrogate certainly demonstrated appropriate
concern for the patients well being, and while her strange
behaviour raised questions about her capacity, it did not
quite rise to the level of demonstrating a lack of capacity.
Because there was no medical intervention that could
have significantly reversed the patients inevitable decline,
the surrogates decisions would not change the outcome in
any appreciable way. Therefore, the group concluded that
any exemplary physician in such a situation should accept
the sister as an appropriate surrogate and abide by her
decisions.
To proceed, they decided to focus on improving communication with the surrogate. This approach was deemed
preferable to more strong-arm confrontational techniques
to achieve the best possible outcome, which would not
make much of a difference in the ultimate result. The
team reasoned that disrupting the enduring relationship
between the patient and her sister would do more harm
than good and interfere with the trust in clinicians that
was essential to providing any beneficial interventions for
the patient.
Case 3
A 56-year-old woman who was employed as a home health aide
was admitted to the hospital with a cocaine-associated myocardial infarction. Three months earlier she had been admitted
with the same diagnosis. No grossly evident heart damage was
detected. The inpatient medical team was, however, concerned
that the patients cocaine use exposed her clients to harm. They
were also concerned that notifying her employer would violate
their patients confidentiality.
Further information was presented about the extent of
the patients drug use and the likelihood of her using
cocaine in the future. She was thought to have a drug
abuse illness because she had continued her use of cocaine
despite missing work and sustaining a previous myocardial
infarction.
Confidentiality and duty to warn, particularly in the
case of a health care professional, were identified as the
key principles involved. It was noted that the well-recognized importance of safeguarding the patients confidentiality-protected health information conflicted with the
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importance of protecting the patients wards from the possibility of her potentially negligent behaviour. The extensive discussion of the principles and their relevance to this
case made the source of the dilemma very clear. The special opportunities for abuse that arise from providing
health care in the unsupervised home setting were also
noted as being particularly relevant to this case. Using the
card to guide the discussion, the group formulated their
question: In order to mitigate harm, should the medical
team notify the patients employer about her cocaine use
when the patient does not want that information disclosed?.
The patients goal was to return to her work. She did
not want to directly address her substance abuse and she
wanted to keep her medical problems confidential. Yet the
medical team wanted to ensure the safety of her wards.
They were also sensitive to the importance of safeguarding
the patients confidentiality and to the fact that revealing
confidential information could undermine her willingness
to pursue needed treatment in the future.
The team also noted that many people who work as
home care providers are not actually professionals in the
sense of having participated in a special educational programme, being licensed by the state, and being accorded
the powers and privileges of a health care professional, or
even having an agency employer. Because this seemed to
be a key point in determining a course of action, the team
resolved to investigate the matter in detail with the
patient. It was decided that if she was, in fact, a health
care professional, that they would have a professional duty
to report her drug use to the State, but that reasons for
reporting would be far less compelling if she was not a
health care professional.
Another critical concern was the assessment of the
danger to our patients patients. The team identified two
components of this issue. Because they envisioned that the
patient could be working without direct supervision or
oversight in the home of someone who could be significantly impaired, and therefore vulnerable to neglect or
abuse, they were concerned about the danger that their
patient could present to the health and well being of her
charge(s) just by being in the home. They were also concerned about whether their patients drug use would affect
her behaviour or impair her judgement while at work. To
make a decision about reporting the patient or safeguarding her confidentiality, they decided that both of these
issues had to be explored further and that any exemplary
physician should take that path. Once they knew more of
the details about the patients use of cocaine and the situation in which she was employed they would be in a better
position to reach a decision. Yet, even after fact finding,
because the information was likely to remain incomplete
and somewhat unreliable, it would be hard to have confidence in any decision.
Further investigation revealed that the patient was
not a health professional in any official sense and she did
not work for any health care agency. She was therefore not
subject to the professional standards expected from
Clinical Ethics
2007
Volume 2
Conclusions
Our systematic approach to clinical moral reasoning is
specifically designed as a guide for health professionals and
ethics committee members. It is structured to function as a
tool for navigating the common ethical dilemmas that
arise in the inpatient and outpatient clinical setting by
providing a clear and replicable structure that makes
explicit a thought process that was previously only intuitive. Although conference participants had sometimes
reached similar conclusions about what to do prior to the
conference and without the aid of the systematic
approach, the model explained why the conclusion was
appropriate to the case and provided confidence in the resolution.
We expect that learning to use the model will facilitate participants ability to navigate future ethical dilemmas, provide them with a basis for assessing their intuitive
convictions about other cases, and become a means for
approaching the dilemmas that they find most puzzling. In
these ways, we expect that our template for clinical moral
reasoning will provide clinicians with a structure on which
to build and be useful to them in the future when they
encounter complicated clinical ethics dilemmas.
References
1 Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th edn.
New York: Oxford University Press, 2001
2 R Gillon. Education and debate, Medical ethics: four principles plus
attention to scope. BMJ 1994;309:184
3 Gert B, Culver R, Clouser KD. Bioethics: A Systemic Approach. New
York: Oxford University Press, 2006
4 Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. New
York: Oxford University Press, 1993
5 Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 6th edn. New
York: McGraw-Hill, 2002
6 Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. San
Francisco: Lippincott, 2005
7 Kaldjian L, Weir R, Duffy T. A clinicians approach to clinical ethical reasoning. J Gen Intern Med 2005;20:30611
8 The following faculty members have served as leaders of these clinical conferences: David Alfandre, Thomas Kalb, David Muller,
Rosamond Rhodes and Richard Stein
9 In conversation, Robert Baker pointed out the importance of consulting professional codes and ethics statements
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