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Bioethics 1.02

2 Sem/A.Y. 2015-2016

Ethical Decision-Making
Dr. Vinna Marie Tenorio-Quiones

A.

B.

C.

OUTLINE
Meta-Ethics
a. Casuistry
b. Principlism
Normative Ethics
a. Normative Theory
b. Virtue Ethics
c. Deontology
d. Consequentialism
Analyzing a Case

November 5, 2015
Arguments against Principlism

Not absolute
o How would you know which principle weighs more
than the other does?

Not capable of determining what action should be taken

Does not specifically say which is appropriate in a

consistent and universal fashion.
NORMATIVE THEORY

LEVELS OF MORAL DISCLOSURE

META-ETHICS

What PRINCIPLE makes actions morally right?

(ACTION THEORY)
What kinds of CONSEQUENCES are good or valuable?
(VALUE THEORY)
What kinds of TRAITS are praiseworthy?
(VIRTUE THEORY)

A. CASUISTRY
When we try to discuss medical cases related to ethics, we try
to analyze them in different ways. One way by which we do that
is to look at them as cases and try to compare them with cases
that we have seen previously.

Moral Determinants of an Act = Principle (VALUE), Intrinsic

Good (ACT), and Good Character (AGENT)
A.

VIRTUE ETHICS

Judgment of actions based on AGENTs moral character

AGENT = Man should possess Character Traits that
should be manifested in actions, regardless if they bring
desirable or undesirable consequences
o Courage
o Generosity
o Compassion

Paradigm Case
o Cases related to abortion and TBS. People complain
or file a lawsuit related to abortion or TBS. The
lawyers could also look at the decision of the
Supreme Court based on these landmark cases and
use them as paradigm cases. They could compare
what they have, the case that they have now, to these
cases. Similar to what the lawyers do, sometimes
they mention all the previously decided upon cases
and they mention the merits of these cases so that
they can win their arguments. Similarly, in medical
ethics, we do that.
o (If) you know a case in medicine that has been
decided upon favorably or unfavorably, you can follow
that decision.
In matters of ethics, similar cases should be treated
similarly and decided upon in the same way.

Arguments against Casuistry

May pay attention to certain features and ignore others

o Ex. Roe Vs Wade case (decision for abortion)

Stakeholder being considered was the mother;

no consideration was given for the unborn child

No mechanism that will restore a conflict of interpretation

B.

PRINCIPLISM

These principles can be used to guide you in making decisions.

Beneficence
o To do good or provide a benefit (Consequentialism)

Non-maleficence
o To do no harm

Autonomy
o Self-governance or non interference

Justice
o Fairness

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EXAMPLE 1: Youre a very honest person, you dont want to lie.

One day, a person runs amok and starts looking for your mom.
He comes to your house with a machete and asks, Where is
your mom?! She owes me money, and I want to KILL HER!
EXAMPLE 2: Your broken-hearted friend recently had a haircut,
showed to you, and asked, Do I look good?
Will this (VIRTUE of Honesty) apply when deciding on this
case?
IN THE END, there is a higher level of basis for decisionmaking, which is based on the CONSEQUENCES.

Aristotle: Virtue is a mean between extremes of excess and

deficiency.
o Foolhardiness > COURAGE > Cowardice
o Extravagance > GENEROSITY > Stinginess
o Selflessness > CHARITY > Selfishness
o Craftiness > PRUDENCE > Ignorance

Arguments Against Virtue Ethics

Criterion for rightness is vague

Plausibility of a purely, character-based criterion of

rightness.

Virtuous character may still act wrongly (subjective).

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Bioethics 1.02 Ethical Decision-making

B.

DEONTOLOGY

Greek deon = duty/obligation, logos = study

A collection of sayings attributed to a religious leader
Judgment of actions based on the ACT
o Certain types of actions are intrinsically good, or
intrinsically evil, irrespective of their consequences.
o Is lying good or bad? We cannot generalize that. In
certain instances, you do lie (referring to the above
Examples)

How do we know what is ethically correct?

o RELIGIOUS ANSWERS

Church tradition/experience

Scripture
o SECULAR ANSWERS

Logic and Reason

Observation and Experience

Intuition and Social Agreement

What is the source of duty?

o RELIGIOUS ANSWERS

Divine Law

Divine Will
o SECULAR ANSWERS

Universal: Natural Law, Hypothetical Contract

Relativist: Personal Cultural background,

Preferences, Social Contract

Arguments Against Deontology

Ignores outcomes

No guidance on maximizing benefits and minimizing harm

to meet the claims of the need of many.
C.

CONSEQUENTIALISM

Judgment of actions based on OUTCOME

o Always act in a way that brings about the best
consequence. It does not matter what those acts are,
the end justifies the means.
Value Theory = tells us whether an action is right or wrong
based on an outcome
UTILITARIANISM

The greatest good for the greatest number of

people

Example in practice is doing triage in the

emergency room

EXAMPLE 1: You are in a situation where you are driving a

train. The track forks, and in one part of the fork are 5 persons,
on the other, 1 person. You lose your brakes and you have to
choose: Save the 5 and ram 1, or Save the 1 and ram the 5
others.
CONSEQUENTIALISTS: Save the most number of persons.
However if the 1 person has the potential to save the world, and
the 5 are ex-convicts (consider the number of families whose
lives are going to be destroyed), how will you choose now?
EXAMPLE 2: You have one vial of medicine for Ebola. Using
the full contents of the bottle will surely save 1 person, but

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dividing the contents can probably prevent disease from

occurring in 10 persons. How will you use the medicine?
Arguments Against Consequentialism

Violates Individual rights

Hard to measure the goodness or value of

consequences

No standard of assessment in calculating good

consequences.
ANALYZING A CASE
Mr. Parker is an 89-year-old man with Parkinsons disease,
hypertension, renal insufficiency, and urinary incontinence. 6
days PTA ER due to respiratory distress
Physical
Exam:
Minimally
responsive,
afebrile,
normotensive, tachycardic to 114 bpm, and tachypneic to 38
breaths/min. (+) for left-sided rales.
Laboratory tests: Increased WBC (17x103 L) Creatinine
(2.1 mg/dL) CXR left lower lobe consolidation.
5 yrs PTA, patient diagnosed with Parkinsons disease.
6 mos. PTA he was diagnosed with mild dementia. Was
unable to ambulate independently and used a wheelchair
outside the house, but he still enjoyed reading, watching TV,
and seeing his grandchildren.
Mr. Parker had an advance directive authorizing his physician
to issue a Do Not Resuscitate/Do Not Intubate (DNR/DNI)
order, he was placed on bi-level positive airway pressure
(BIPAP), given IV antibiotics, and transferred to ICU for further
observation.
In the ICU, the patients respiratory status
stabilized, gradually weaned off BIPAP. ICU physicians
concluded that Mr. Parkers new worsened mental status was
due to the pneumonia.
Renal insufficiency was stable with a creatinine of 2 mg/dL.
ICU discharge plan was for antibiotics and supportive care.
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On the day of transfer to the medicine service, a 2 -year
resident finds the patient comatose and in mild respiratory
distress off BIPAP.
Patients daughter just arrived at the hospital and tells Dr.
Rivero that she wants everything done for her father. This
approach would conflict with the patients advance directive,
tells the daughter that they could meet later in the day to
discuss the daughters concerns. Mr. Parker appointed his
son, Mr. Kingston, as the health care proxy.
Px decided on the DNR/DNI order last year after an extended
hospitalization for pneumonia. Does not wish heroic measures
if he has no reasonable chance of meaningful recovery. The
daughter, a health care administrator at a hospital a few hours
away, reiterates her concern that more could be done for her
father. Tells resident that her father needs stronger antibiotics,
a breathing tube to help his breathing, and dialysis to help his
kidneys.

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Bioethics 1.02 Ethical Decision-making

to be done with his life. All you need to do is
follow what was written.

STEP 1. Collect all RELEVANT DATA (medical and nonmedical) that should be evaluated
2.
Table 1. Key medical information

Patients diagnoses

Parkinsons disease,
hypertension, renal
insufficiency, urinary
incontinence, pneumonia
Almost all of the patients major
organs are involved.

Prognosis

Poor

Baseline mental and

physical function and
decision-making capacity

Comatose

STEP 3. Consider whether principles CONFLICT OR

whether there is UNCERTAINTY about what a particular
principle directs you to do.

(+/-) Healthcare proxy

[agent appointed by the
patient to make health care
decisions should he/she lose
the ability to do so]

Son is the appointed proxy

Presence or absence of
family relationships

Son and daughter are present

Determine the patients

previously stated wishes
about his/her health care

Mr. Parker had an advance

directive authorizing his
physician to issue a do not
resuscitate/do not intubate
(DNR/DNI) order.
Patient decided on this order a
year ago after extended
hospitalization for pneumonia.
Mr. Parker does not wish for
heroic measures to be done,
but at present this conflicts with
the concern of his daughter to
be more aggressive with
treatment.

Based on Dr. Riveros assessment of the patients present

comatose mental status, she concludes that Mr. Parker is
unable to meaningfully and rationally participate in
decisions about his medical care and, therefore, lacks
decision-making capacity.

STEP 2. IDENTIFY ETHICAL PRINCIPLES and/or related

concepts involved, and explain how they are relevant to the
case.

1.

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Autonomy/Respect for persons

Applies primarily because the patient has

already issued a statement of what he wants

Acknowledge that in end of-life care situations, the family

members also are in need of care.
Beneficence in this case also applies to the patients close
family members because it is not just the patient who is in
need of care; it is not just the patient who will benefit from
the decision that you will make.
Remember that when treating a patient like the one in this
case (e.g. in the ICU), you also have an entire family to look
after.
STEP 4. Formulate a question that reflects the dilemma.

Because when you formulate a question, it will be a lot

easier for you to come up with an answer.
In the case, the question they thought of was: What are the
physicians obligations when a family disagrees about
the prior stated wishes of an incapacitated family
member?
o There is a prior wish and disagreement in the family.
As a physician, what are your obligations to both the
patient and his family?

STEP 5. Decide which PRINCIPLE should have PRIORITY

and support that choice with factors relevant to the case, OR
find an ALTERNATIVE clinical course of action that avoids
the dilemma.

The 2 most prominent ethical principles that can be used in

deciding this case are:

Beneficence

In this case, the patient already knows what

he feels would be most beneficial for his case,
knowing what kind of disease/condition he
has.

Only the patient himself can decide what

would be most beneficial for him.

If its possible, avoid the dilemma. If you really cant, try to

see which principle trumps the other. You have to:
o analyze the data that you have
o try to review your case
o talk to other people about the case
o document these thoughts (so that it can be used
when presenting the case to a hospital ethics
committee)
Requires objective data analysis; a doctors intuition is not
enough
CASE: The chart should include the patients DNI/DNR
request that would go to the medical record so that in the
end, you will be acquitted and have no liability because its
all reported and has been discussed. Once you reach a
decision, you as a physician will present this to the family in
a family conference. For this patient, there should be a
neurologist, pulmonologist, ICU specialist, and a

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Bioethics 1.02 Ethical Decision-making

nephrologist representing the medical field, and with the

daughter and son representing the family as well as a
layperson or somebody who will put their two cents, a priest
(if Catholic), a minister or a pastor or any other leader from
a denomination that can represent so that their values can
also be heard.
o Doctor must provide explicit and transparent reasons
to support the choice that can be articulated to the
patient, the family, and medical colleagues and that
can be documented in the medical record.
Daughters personal values about her fathers illness vs.
Mr. Parkers personal values.
Based on discussion with the son, -- Mr. Kingston (the son)
would agree with the proposed treatment plan (which is not
to be aggressive).
Dr. Rivero concludes that, without compelling reasons to
override the patients prior stated wishes, respecting the
patients autonomy takes precedence over
beneficence, as the care the patient would have chosen is
the care that has been proposed.
Thus, the team should continue with comfort care including
antibiotics, oxygen, frequent suctioning, and opioids for
respiratory distress. To do otherwise would contradict Mr.
Parkers autonomous decisions. At the same time, Dr.
Rivero realizes it will not be easy to adhere to this treatment
plan without the daughters cooperation (as he has
somebody on the team whos not on the same page).

Based on Virtue Ethics

In context with the case, by choosing NOT to treat the patient

aggressively you...
1) Show compassion. Thats what the patient asked for.
2) Are socially responsible because the patient will not
end up in a persistent vegetative state (PVS) and the
family is not forced to spend for treatment that may end
up being futile.
3) Show commitment, as you are trying to provide the
best possible care.
4) Are being true to the patient and to what you feel is the
right thing, thus displaying integrity.
Based on Deontology

STEP 6. When uncertainty persists, DETERMINE WHETHER

THERE IS MISSING INFORMATION that would help in
resolving the dilemma. Which information? How will it help?

This provides a feedback loop

o New information changes the clinical ethical picture
Process back to the original step OR may yield insight
that will be useful in the analysis of the dilemma.

It says whether you miss something and when

you try to review your case, it might yield insight
that will be used in the analysis of the dilemma.
o In the patients case, when Dr. Rivera tried to talk to
the daughter about comfort care especially for dying
patients, the daughter angrily interrupted him saying
she wasnt ready to talk about it. You detect a certain
amount of guilt or perhaps, trying to hold on of what
she has. So now you know what you wanted to do
and what the problem with the daughter is. You then
try to see whether your decision will actually be the
same with other physicians. If youre the attending,
you can try to get a consensus among other
physicians who were probably able to handle cases
similar to yours and see what their insight is.

Does this action represent the kind of person I am or who I

want to be?
Does it represent my institutions reputation or the vision of
the kind of physician it wants me to be?
Core Values of UERM
o Integrity
o Commitment
o Social Responsibility
o Compassion

Rules and Rights

Philippine Medical Association Code of Ethics
o Section 1. - A physician should be dedicated to
provide competent medical care with full professional
skill in accordance with the current standards of care,
compassion, independence and respect for human
dignity.

Based on Consequentialism

What is the outcome?

o Adherence to patients request
o Decrease in patient suffering
o Less burden for the patient and family

STEP 6. PLAN THE PRACTICAL STEPS that you should

take, focusing on the details of the case and the future
issues that you foresee.

STEP 7. EVALUATE YOUR DECISION by asking if it is what

a consensus of exemplary doctors would agree to do. Talk to
friends who were able to handle similar cases.

If you have a plan, put it in the medical records, have everybody

signed that they agree to what you are trying to do, so that
legally speaking you will not be held liable.

Adequate doctor-patient or doctor-family communication

In these emotionally charged situations, the communication

and interpersonal skills of the physician are called upon

Must be an effective and empathic communicator

Proper balance of clinical and humanistic elements of

doctoring

Personal and professional values of a physician and the

values of a patient or family member can conflict respect
the patients/family members choices even if the physician
disagrees.

Let patients or families articulate their values.

This step is a consideration of what is the ethical standard of

care. In ethics, there really is no standard of care.

Summary of Practical Guidelines in Ethical DecisionMaking (from p. 39, Bioethics and Legal Ethics Manual)

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Bioethics 1.02 Ethical Decision-making

Four Topics That Are Basic And Intrinsic To Every Clinical
Encounter:
MEDICAL INDICATIONS
All clinical encounters include a review of diagnosis and
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treatment options
Beneficence and Non-maleficence

What is the patients medical problem? History?

Diagnosis? Prognosis?

Is the problem acute? Chronic? Critical? Emergent?

Reversible?

What are the goals of treatment?

What are the probabilities of success? What are the

plans in case of therapeutic failure?

In sum, how can this patient be benefited by medical and

nursing care, and how can harm be avoided?

PATIENT PREFERENCES
All clinical encounters occur because a patient presents
before the physician with a compliant. The patients values
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are integral to the encounter.
Respect for Patient Autonomy

Is the patient mentally capable and legally competent? Is

there evidence of capacity?

If competent, what is the patient stating about

preferences for treatment?

Has the patient been informed of benefits and risks,

understood this information, and given consent?

If incapacitated, who is the appropriate surrogate? Is the

surrogate using appropriate standards for decision
making?

Has the patient expressed prior preferences (eg,

advance directives)? Is the patient unwilling or unable to
cooperate with medical treatment? If so, why?

In sum, is the patients right to choose being respected to

the extent possible in ethics and law?

CONTEXTUAL FEATURES
All clinical features occur in a wide context beyond physician
and patient, to include family, the law, hospital policy,
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insurance companies, and so forth.
Loyalty and Fairness

Are there family issues that might influence treatment

decisions?

Are there provider (physician, nurse) issues that might

influence treatment decisions?

Are there financial and economic factors?

Are there religious or cultural factors? Are there limits on

confidentiality?

Are there problems of allocation of resources?

How does the law affect treatment decisions?

Is clinical research or teaching involved?

Is there any conflict of interest on the part of the providers

or the institution?

LECTURE OBJECTIVES
To identify ethical issues given a medical case
To analyze clinical situations and apply the ethical
theories/principles to make a decision.

REFERENCES
1 Salazar N.A., et al. (2015) Biomedical and Legal Ethics
Manual.
2 Quiones, V.M. (2015) Ethical Decision-making. Lecture

QUALITY OF LIFE
The objective of all clinical encounters is to improve, or at least
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address, quality of life for the patient.
Beneficence, Non-maleficence, and Respect for Patient
Autonomy

What are the prospects, with or without treatment, for a

return to normal life?

What physical, mental, and social deficits is the patient

likely to experience if treatment succeeds?

Are there biases that might prejudice the providers

evaluation of the patients quality of life?

Is the patients present or future condition such that his or

her continued life might be judged as undesirable?

Is there any plan and rationale to forgo treatment?

Are there plans for comfort and palliative care?

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