Understanding Ethical Issues: The Clinical Ethics Model
Issue 3, April 2001
"Clinical ethics is a practical discipline that provides a structured approach to decision making that can assist physicians and family members to identify, analyse, and resolve ethical issues in clinical medicine."
—Jonsen, Siegler & Winslade
Healthcare professionals frequently contact The Nathaniel Centre asking for advice on a particular issue in clinical practice, or an issue concerning treatment options for a family member. We thought it would be helpful, therefore, to provide a brief outline of a model to assist these readers understanding of some of the ethical issues in healthcare practice. This particular model comes from Jonsen, Siegler & Winslade's book, "Clinical Ethics".
Ethical issues, which are an inherent part of medical practice, are embedded within a particular context. That context can be broken up and analysed for the purposes of discussion and clarification and in order to achieve a reasonable and practical process of consensus, and, if possible, resolution. An appreciation of the various elements within the complexity of an ethical issue enables the healthcare professional to be more effective in this process of resolution. The clinical ethics provides a structured approach to decision making and assists the healthcare professional and those they care for to identify, analyse and resolve ethical issues. The use of this or a similar clinical ethics model is not a ready-made formula providing answers to complex questions but rather is meant to assist the clinician working with family members and other healthcare professionals in reflecting on the various layers in a specific ethical issue. Because ethical issues centre on competing goods there are times when a particular issue cannot be resolved even though a point of consensus may still be reached.
Jonsen, Siegler and Winslade, describe four essential features of the clinical ethics model which highlight and help to identify and understand a particular ethical issue - the Medical Indications; the Patient Preferences; Quality of Life Issues, and Contextual Features. While all of these features are relevant to every case, often a specific feature will be especially significant and provide the key to the process of understanding.
Medical Indications – the content of the clinical discussion
The starting point for any ethical discussion is to focus on the patient's background or narrative. Medical indications help to establish the content and parameters of the discussion and greatly assist in the process of resolution once there is a clear understanding by all parties of what these indications are. Helpful questions to ask in order to establish an adequate and relevant history include: What are the clinical facts? What are the probable outcomes of treatment? And, what are the possible benefits, together with, the possible burdens of the specific interventions?
Patient Preferences – Values, Goals, Desires
The patient's history and medical indications alert us to the patient's preferences, that is, his or her values, goals and desires, and his or her personal assessment of the benefits and burdens of any proposed treatments or interventions. Questions that help to establish a clear understanding of a patient's preferences include: What are the patient's goals? What does the patient want? Has the patient been provided sufficient information? Does the patient understand this information? If the patient is not able to communicate his or her preferences then who has the authority to act on his or her behalf?
The usual means of establishing a patient's preferences is through the process of free and informed consent, which shows respect for the autonomy and innate dignity of the patient. [In the Catholic moral tradition this principle is a corollary of the principle of a well-formed conscience.] As a process it should be initiated early and is not achieved in an instant or in a single conversation. Neither can it be initiated when a case has unravelled. Frequently unresolved ethical issues in clinical practice reveal a lack of due process in obtaining informed consent. [This issue of The Nathaniel Report contains a more complete article on "Informed Consent"]
Quality of Life Issues – the object of any medical intervention: To restore, maintain or improve the quality of a patient's life
Illness and disease have the potential to reduce an individual's quality of life. The object of any medical intervention is to restore, maintain or improve the quality of a patient's life. Particular goals of care, such as adequate pain relief and physiotherapy, are illustrations of improving quality of life. Nevertheless, the use of the concept of quality of life in clinical ethics is open to considerable bias and prejudice and must therefore be employed with great care. Jonsen, Siegler and Winslade distinguish between two uses of the phrase "quality of life". The "subjective satisfaction expressed or experienced by an individual in his or her physical, mental and social situation"; and, "the subjective evaluation by an onlooker of another's subjective experiences of personal life." They rightly caution the clinician or observer in applying quality-of-life judgements in clinical decisions.
Contextual Features – the limits and features of a particular case
The context establishes the limits and conditions of a particular case. Every case is located in a larger context of variables. Patient care is simultaneously influenced, positively and negatively, by the constraints of the context. Contextual features include: Cultural values; personal narrative; legal and financial issues; the family context; social arrangements; institutional and spiritual issues.
Discussion/Resolution – Clinical ethics in practice
Claude Monet, one of the founders of Impressionist painting, has left some wonderful writing on his painting style. He once wrote, "The fragment gives insight into the whole, the total picture. The shadow brings insight to the light." In examining a particular ethical issue, it is frequently the "fragment" that gives insight into the process of resolution and understanding because its significance has been overlooked. In examining a patient's narrative or history, in careful listening to the patient's preferences, quality of life and contextual features the significance of the "fragment" is re-established thereby opening the way for possible resolution and/or consensus.
The establishment of goals of care is, ideally speaking, an interdisciplinary process. Multiple teams, working in isolation, with their own specific focus, can complicate the process of resolution of an ethical issue. Given that fragmented care can in fact compound the particular issue at hand, frequently the use of the clinical ethics model in practice involves facilitates the reestablishment of good lines of communication and clear goals of care. In this process the ethicist acts as a facilitator for the good of the individuals concerned.
Rev Michael McCabe, PhD
The Nathaniel Centre