Medicine, Health Care and Philosophy 6: 227233, 2003.

2003 Kluwer Academic Publishers. Printed in the Netherlands.

Ethical case deliberation and decision making

Diego Gracia
Department of Public Health and History of Science, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
(E-mail: dmgg@med.ucm.es)

Abstract. During the last thirty years different methods have been proposed in order to manage and resolve ethical
quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decisionmaking theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism,
Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate
methodology. This is due to the fact that moral decisions must take into account not only principles and ideas,
but also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is
considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of
others. The goal of this process is not the reaching of a consensus but the enrichment of ones own point of view
with that of the others, increasing in this way the maturity of ones own decision, in order to make it more wise
or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but
the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the
process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings,
values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to
reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting
them to give reasons for their own points of view. This method has been traditional in Western clinical medicine
all over its history, and it should be also the main procedure for clinical ethics.
Key words: clinical medicine, conflict of value, decision-making, deliberation, ethical problem, nosology, reason

Since the Hippocratic writings at the beginning of

Western medicine, ethics and clinical medicine have
been two inseparable concepts. This is due, in the first
place, to the fact that, as the author of the Hippocratic
writing The Physician points out, possessions very
precious (Hippocrates, 1981, p. 313) pass through the
hands of physicians. However, there is also another
reason, which is perhaps more important than the
first. And this is that medicine and ethics share the
same methodology. At first hearing, this may appear
strange but after calm reflection it ceases to do so.
An ever-surprising fact is that ethics methodology very
likely stems from clinical methodology, more specifically from the Hippocratic clinical methodology. Aristotle was the author of this modification. Son of a
doctor, always concerned about medical issues and a
tireless investigator into biological matters, Aristotle
very probably became interested in ethics through his
interest in medicine. In his Nicomachean Ethics, where
he describes the logics of practical reasoning, he is
not only thinking of ethics and politics but also, as
he himself points out, of technology, especially that
which in his age had become paradigmatic, the tchne
iatrik, medical technique, medicine. The theories

of deliberation, practical wisdom, intermediate point,

probable reasoning, decision making in uncertain situations, etc., are applied to medicine and ethics in the
same way (Aristotle, 1995, p. 295).
However, things have changed greatly since Hippocrates times, especially in the last few decades. This
is due to many reasons, the first one being the qualitative change in medical technology. Our technology
is no longer the tchne of Hippocrates or Aristotle. It
is something completely different. According to the
ancient Greeks the aim of technology was to change
the state of natural substances a mere change of accidents without altering the substance. It should also be
pointed out that ancient technology changed (accidentally) but did not transform (substantially). This was
the alchemists great challenge, they did not just want
to change reality but transform it, transmute it, transubstantiate it through the use of technical processes.
Their condemnation was unanimous. The technician
had to look for more humble objectives, such as those
of the carpenter or the ironmonger. Neither of them
produced the substances they worked with; wood or
iron. They did not aim to create wood or iron, only
to change its state as regards quantity, relation, etc.,

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in order to make a table, a chair or a coat of arms.

Aiming to substantially change nature was not only
thought to be practically impossible but also ethically
unacceptable. It would be like playing God.
Modern technology, however, has taken this great
leap, which for many centuries was thought to be
impossible. The alchemists were right when they
wanted to transmute metals as this has been achieved
by modern chemistry. The human being not only plays
God: he is in fact a little divinity, as Leibniz (Leibniz,
1995, p. 639) points out. Human beings cannot create
a new reality from nothing, as God does, but they
can transmute or transform it. Such is the origin of
modern technology. Human beings are not the servants
of nature but its masters; they have the power in their
hands to make and unmake, to manipulate everything,
including life and death. The old idea that transformation of nature is intrinsically perverse can no
longer be sustained. This ethical barrier has also fallen.
However, this does not mean that all ethical control
has been lost. Much to the contrary, it is now more
important than ever. Taking this into account, ethics
and technology, ethics and the technical aspects of
medicine, i.e., ethics and clinical medicine, meet again
through a different route. This new encounter compels
us to define the rules of the game, right from the start.

The clinical method

Clinic comes from the Greek word klne, the meaning
of which becomes clear when we think of other words
that derive from it such as inclination, triclinic,
climate or climacteric. The most usual meaning
of klne was bed. Clinical also derives from klne,
a clinical activity is one carried out at the patients
bedside. It is always a specific, individual activity,
its aim being to diagnose and treat a certain, specific
patient. It is different from nosology or the study of
the so-called morbid species, or universal diseases.
The study of a morbid species such as pulmonary
tuberculosis is not the same as the diagnosis and
treatment of a specific patient with tuberculosis. The
species is universal whilst the patient is particular. The
same difference exists between them as that which
exists between a botanical or zoological species and
a specimen of one. Nevertheless, the categorisation
of diseases as species is much more problematic and
disputable than that of animals and plants because a
patient may have several morbid species, but an animal
or plant specimen can only be of one species.
In any event, Western medicine in its origins
decided that there are morbid species and specific
patients, and that the same difference exists between
them as exists between natural species and individuals

or specimens. This is the origin of expressions still

used today such as the natural history of diseases.
Western medicine opted for understanding disease as a
natural occurrence, attempting to interpret it by using
the same categories as in nature, especially living
nature.
Such is the origin of the standard distinction
between nosology and clinical medicine, which all
health professionals learn in the first years of their
training. Nevertheless, there is one thing that is not
taught, although it is of utmost practical importance,
i.e., the different logic of these two types of knowledge. The reasoning of nosology and that of clinical
medicine is completely different and has been different
since the origin of Western medicine. The logics of
nosology cannot be claimed by those of clinical medicine, nor vice versa. The classical theory, in effect
from ancient Greek times until the 17th century, was
that the same difference existed between clinical medicine and nosology as that between primary substance
or ousa and secondary substance or t t estn. In
Latin the first is substantia, and the second essentia.
Substance is particular whilst essence is universal.
They differ in the same way as a human being differs
from humanity. All human beings form part of the
same species and therefore we share the same specific
essence, even though we may have individual variations. Essence, therefore, is what makes us part of
the human species. Aristotle defined the human species
as zon lgon chon; translated into Latin as animal
rationale. This is the essence of a human being and
consequently, of the human species. An individual is
a member of the human species if he or she possesses
these two characteristics, i.e., he is animal and he is
rational.
For ancient people species had reality, but this
reality is not the same as that of individuals. We are
aware of the reality of individuals through senses,
their properties and characteristics. In contrast, the
reality of species, i.e., of the universal essence, is not
directly accessible by senses, only by understanding,
by reason. Reason is what differentiates the common
and specific from the individual, and in this way penetrates into the essence of things. By being universal,
knowledge of essences is by definition certain. There
is no room for doubt here. For this reason, Aristotle
assigned this type of knowledge to the category of
epistme, science. Here science means necessary,
universal knowledge; therefore certain. In medicine
this type of knowledge is proper to nosology, therefore knowledge of morbid species is universal and
certain, i.e., scientific. On the other hand, knowledge
of a specific individuals disease is always uncertain,
as it depends on our capability to interpret signs and
symptoms of this specific reality, and this is always

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limited. In classic thinking concretion is always more

problematic than abstraction. As regards specific individuals, science is never appropriate, only opinion
(dxa). Therefore, the logics of nosology are not
the same as the logics of clinical medicine. The
logics of nosology, according to the ancients, are
apodictic and demonstrative; they have a true
value similar to those of mathematical theories. There
is little room for error and even less for uncertainty.
On the other hand, the logics of clinical medicine
are those of uncertainty. We shall never be able to
exhaust the wealth of a specific reality, and therefore
our judgements on it shall be at the most probable. Against the apodicticity of nosology there is the
probability of clinical medicine. That is why uncertainty always rules in clinical medicine. Certainty is
impossible. Consequently, one can or should never
expect that ones conclusions are certain; they can
only be reasonable. Coming to a reasonable decision
involves always carefully weighing up the main intervening factors, in order to be as reasonable as
possible. The Greeks named this reasonable weighing
up boleusis, deliberation. And the reasonable
decision arrived at after prolonged deliberation they
named as being wise or prudent. When epistme
says demonstration, dxa adds deliberation, and
when epistme says certain, dxa says wise or
prudent. Deliberation and practical wisdom are
the two basic conditions for practical reasoning, in
the same way as demonstration and certainty are
those for theoretical reasoning. For the ancients,
the paradigmatic example of theoretical reasoning
was mathematics. In contrast, practical reasoning
was concerned with ethics, politics and techniques in
general.
We can now understand why clinical medicine
and ethics have shared the same logic throughout
their history: because both used a similar type of
reasoning, the two main characteristics being deliberation and practical wisdom compared to demonstration and science. Nobody expects that their clinical
decisions will be absolutely certain, and that they
will not need future rectification. Whats more, in
medicine it is quite possible that two wise and experienced professionals, deliberating on the same case,
will reach different diagnostic, prognostic and therapeutic decisions. Always admitting more than one
solution is characteristic of wise reasoning. One or
more decisions can be reached on the same event,
all of them prudent, and not only different but even
opposing. This is characteristic of clinical medicine
and also of ethics.
This way of thinking did not begin to change until
the 17th century, due to works by Empiricist philosophers such as Locke and doctors such as Sydenham.

229

Empiricism showed that Aristotles analysis of practical reasoning was much more consistent than that
of the speculative reasoning, and therefore that his
practical wisdom theory was more coherent than his
science doctrine. According to the empiricists all
empirical knowledge is imperfect, and this imperfection increases when the formulation of universal
propositions are attempted, which is what science
does. On this point, about the truth of science Aristotle
was mistaken. There is no absolutely true empirical
knowledge. This only applies to relations of ideas,
in the so-called analytical judgements, which are
proper to non-experimental sciences, such as logic
and, perhaps, mathematics. Nosology is an experimental science and therefore by definition it is uncertain. Nosology shares the same fate as clinical medicine: furthermore, it may and should be conceived as
universalised clinical medicine, i.e., as the universalisation of the specific data collected during the clinical
process. Nosology is arrived at, therefore, through
clinical medicine, and consists of the generalisation
of data acquired in the clinical process. From the
17th century, therefore, purely nosologic or essential
procedure had given way to a very different procedure
of a nosographic or descriptive character. Since the
17th century up to the present time there have been
repeated attempts to reintroduce essential, speculative
knowledge into both medicine and ethics. There have
been three significant movements in this respect: 17th
century Rationalism, 18th century Idealism, and 19th
century Positivism. All three movements attempted to
re-establish empirical knowledge on certain, scientific
bases, and all three have failed in this attempt. Never
has there been such an apparent awareness of this
failure as in the 20th century, and more specifically,
in the last few decades. In spite of the fact that there
are still many dogmatic doctors, anti-dogmatic awareness in medicine has never been so apparent as it is
today. And in spite of the fact that there are still many
dogmas in ethics and bioethics, never has there been
the possibility for extensive, shared deliberation on
these issues in search of reasonable, wise decisions,
as there is today.

The method of clinical ethics

Moral judgements, as well as medical ones, are primarily empirical and specific. They comply with the
principle that the specific reality is always richer
than our intellectual thinking and therefore surpasses
it. Thus, the decision-making procedure is not a
pure mathematical equation, but a careful, thoughtful
analysis of the main factors involved. This is what
is technically known as deliberation. There is clin-

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ical deliberation, which the health professional carries

out every time he treats a patient, and there is ethical
deliberation. Ethical deliberation is not an easy task.
In fact, there are many people who do not know
how to deliberate, and then there are others who
consider deliberation to be unnecessary or even unimportant. That which occurs in clinical deliberation
also occurs in ethical deliberation. Some professionals
make decisions quickly, as a reflex reaction and do not
go through the long patient evaluation process. This is
often justified appealing to the so-called good clinical eye. Just as some professionals think they have a
good clinical eye, others think they have good moral
instinct (Gracia, 1991, pp. 910). These professionals
think they already know the answer, and there is no
need for deliberation. This is usually due to fear or a
lack of confidence as regards the deliberation process.
For this reason, practicing deliberation may be said to
be a sign of psychological maturity. Those dominated
by anxiety or unconscious emotions, do not deliberate
on the decisions they make, but act automatically, on
an impulse, as a reflex reaction. Only those who are
able to control their feelings of fear or anxiety will
have the integrity and presence of mind that deliberation requires. Our emotions cause us to make extreme
decisions, complete acceptance or refusal, love or hate,
and turn conflicts into dilemmas, i.e., into problems
with only two solutions, these also being extreme
and opposed (Gracia, 2001, pp. 223232). Reducing
problems to dilemmas is generally due to anxiety.
Deliberation attempts to analyse problems in all their
complexity. This means weighing up the principles
and values involved as well as the circumstances and
consequences of each case, and thus enable all, or
at least most, of the possible courses of action to be
determined. As a general rule there are always five
or more possible courses of action; if less are determined then the analytical process is likely to be flawed.
Furthermore, the best course of action is not generally one of the extremes; it is one that is midway or
close to it. The result of a deliberation process, therefore, is usually very different from that of dilemmatic
procedures. As Aristotle said, virtue is usually at an
intermediate point.
The deliberation process requires careful listening
(anxiety prevents a person from listening to another,
precisely because they are afraid of what the other
might say), an effort to understand the situation at
hand, analysis of the values involved, rational argument of the possible courses of action and of the most
appropriate one, non-directive advice and help even if
the chosen option by he or she who has the right and
duty to make this choice, does not coincide with that
which the professional considers to be the correct one,
or else referral to another professional.

Deliberation in itself is a method, a procedure.

Therefore, correct deliberation must go through certain
established stages. Critical analysis of bioethical cases
should always consist of the following basic steps:
1. Presentation of the case by the person responsible
for making the decision.
2. Discussion of the clinical aspects of the medical
record.
3. Identification of the moral problems that arise.
4. The person responsible for the patient chooses the
moral problem that concerns him or her and that
he or she wishes to analyse.
5. Determination of the values in conflict.
6. Tree of courses of action.
7. Analysis of the best course of action.
8. Final decision.
9. Decision control consistency: Check the consistency of the decision made by putting it to the
legality test (is this a legal decision?), the publicity test (would you be prepared to defend it
publicly?), and to the consistency in time test
(would you arrive at the same decision in a few
more hours or a few more days time?).
It is always desirable to follow some kind of procedure,
whether it is this or another one. Ethical problems are
always connected to conflicts of value, and values are
supported by facts. Therefore, the procedure must start
with a detailed study of the clinical facts. The clearer
these are the more accurate the identification of value
conflicts will result. A good medical record is always
the basis of a good clinical round, and also of an ethical
round.
The most complex point of the above procedure is
point seven deliberation on the morally most appropriate course of action. Assessing the quality of a
course of action consists of two stages: 1. Checking its
compliance to the principles at issue and 2. Assessing
the likely consequences. Extreme principlists often
claim that decisions should be made based on absolute, immutable principles. Extreme consequentialists,
on the other hand, consider that the correctness of an
act may only be measured by its consequences. Both
theories have been, and are, defended in Ethics, but
they are clearly extreme standpoints, and as such a
long way from being that of the majority. Some authors
refer to some kind of common sense or common
moral sense and claim that there are universal deontological principles such as do not kill or do not
lie. However, these authors consider that there are
exceptions to all principles, and these are justified
by the circumstances of each case and the likely
consequences.
There is no known deontological principle that can
be said with absolute certainty to have or probably

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have no exceptions, unless this principle is formulated purely analytically and consequently tautologically. This is an error of logic that often occurs
in ethics. Analytical judgements are those in which
the conclusion is already contained in the premises:
that is why they say nothing new but just repeat that
which we already know from the premises. Analytical judgements are named as such because they were
assumed as being independent of or prior to empirical experience. On the other hand, synthetic judgements come about as a result of interaction between
experience and human intelligence. These days most
philosophers do not agree with this, due to the fact
that they think that the so-called analytical judgements are also based on experience. They are only
different because that which is asserted in them is often
included in the subject, so they are always and necessarily tautological. Therefore, always necessarily true.
For example, in the judgement that cruelty is always
morally reprehensible, cruelty already has a negative
moral quality; what is more, if we were capable of
imagining a circumstance in which cruelty did not
have a negative moral connotation, judgement of it
would not be analytical, and it could not be precise.
Acts of cruelty by a mentally deranged person or a
sleepwalker for example would be considered as not
subjectively reprehensible (because the subject lacked
the voluntariness to commit this act). However they
are objectively reprehensible because the act in itself is
still wrong. But here is where the true difficulty arises.
Kant clearly saw that only bad will is bad without
qualification (Kant, 1995, p. 1062). Bad will can
never be good will, because of its subjective nature.
However if we take the voluntariness away from the act
and focus on its objective dimension, it is impossible
to consider it as being always morally reprehensible.
Sometimes a person may lie, or may kill, even an innocent person. It is true that these circumstances make
the case more serious and moral justification much
more difficult, but it cannot be said that there is not or
cannot be a situation that would make it morally justifiable. Amongst other things, because we do not know
all the possible situations and therefore, we cannot
claim that these justifying circumstances did not exist
or never could exist. History is a good witness in this
cause. And even if it were not, the logical principle
that absolute or unconditioned universality and necessity, which are characteristic of analytical judgement,
cannot be applied to synthetic judgements which moral
judgements are, would still prevail.
The practical consequences of all of the above is
that moral deliberation should take place in two stages.
The first stage is to check that the course of action
obeys the deontological principles. The second stage
is to evaluate the circumstances and consequences in

231

order to determine if these allow or require an exception to the principles. The primary obligation is to
comply with the principles and he/she who wishes
to make an exception takes on the burden of the
proof, and therefore must prove that the exception
may and should be made. This is just a mere exception, not another principle. An exception is always
exceptional, and ceases to be so when it becomes a
principle. It is true that there is a risk of escalating
exceptions into principles. This abuse is not justified
by theory. Theory only says that there are circumstances that allow certain exceptions to principles. In
medicine, there are situations that justify breaching
the principle of veracity. This is the origin of the socalled white lie, or of the exception to informed
consent known as therapeutic privilege. Telling the
truth in all circumstances is, at the least, irresponsible.
Ethics that articulate principles and consequences go
by the name of ethics of responsibility. Bioethics is
practised by the majority of its cultivators (although
not all, because there still exist strict deontological
stances that consider certain deontological principles
to be absolute and with no exceptions, and strict
teleological viewpoints for which the correctness of
an act is measured only by the maximisation of its
consequences) according to the categories characteristic of the ethics of responsibility.
In practice the following steps may be taken to
assess the ethical quality of a course of action:
I. Check the compliance of the course of action with
moral principles:
1. Analyse the principles involved in the case:
autonomy, beneficence, nonmaleficence, justice.
The principles of nonmaleficence and justice
have a public nature, and therefore determine
our duties towards each and every human being,
both as regards their biological life (principle
of nonmaleficence) and their social life (principle of justice). These principles define duties
that may be demanded of every one equally, and
may even be coerced. For this to be possible,
these principles must be formulated in a way
acceptable to everyone or the majority, and
consequently acquire a legal form. On the other
hand, the principles of autonomy and beneficence are of a private nature and each person
must manage them according to his/her own
beliefs or life ideals. The first two principles
corresponded to that referred to as the minimalist ethics and the latter two to the maximalist
ethics.
2. Identify conflicts between values or principles.
The duties related to the minimalist ethics are
more limited or restricted than those of the

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maximalist ethics, but they are generally more

exacting, consequently in a situation of conflict
they usually take priority over the obligations
of maximums. Moral conflicts often arise as
a consequence of the conception of what is
public and what is private. For example, artificial
contraception has been characterised as a public
duty of nonmaleficence, included as an offence
in the Criminal Code, whereas these days it is a
duty of private management (in accordance with
the principles of autonomy and beneficence).
II. Evaluate the likely consequences:
1. Evaluate the circumstances of a particular case
and the likely consequences of the decision. This
evaluation can never be all-inclusive, however it
should be carried out very carefully. In ethics, as
in law, circumstances may be aggravating, extenuating or exempting. When there are exempting
circumstances, the obligation is overridden by
the specific circumstance. The reason is always
the same: because in these circumstances it
appears that the indiscriminate application of the
principle is incompatible with the respect due
to human beings. There are times, for example,
when telling the truth would clearly be offensive.
2. Determine if an exception to the principles may
and should be made. The exception is justified as long as we have reason to believe that
the application of a norm or principle would
undermine the dignity of a human being. In the
case of public duties that have become legal,
exception may be granted by the judge or by
the law, legalising or decriminalising the rule in
certain circumstances. This is what has happened
for example with regard to abortion in Spanish
legislation and as regards euthanasia in Dutch
legislation. It is important to point out that these
legalisations do not define the moral rightness or
wrongness of such acts; they just state that in
certain circumstances these acts are considered
to be of private management and not, as was
previously the case, of public management. It
should also be remembered that the most difficult part always falls to the person who wishes to
make the exception, as this person has the burden
of proof or the responsibility of proving that the
exception is possible and necessary.
Experience has demonstrated that by following the
above procedure many moral conflicts can be resolved,
or if the problems are not completely resolved at least
situations may be clarified.
Finally, it should be remembered that the aim of
this process is not to make decisions. It does not have

executive or decision-making properties, but consultative ones. Moral decisions cannot be easily transferred. Over the wide range of privately managed
duties it is the patient, the doctor responsible, the
family member, or the health manager who has the
right and obligation to make his/her own decisions.
The deliberation rounds cannot exonerate them from
this responsibility. What it can and tries to do is help
them in this process, in the conviction that in this way
it contributes to improving the quality of healthcare
and professional and user satisfaction with the health
system. Public managed duties, on the other hand, may
only be demanded by others if they have become legal
rules. The jury in some cases, the judge in others will
deliberate and pass sentence. In this case deliberation
has a decision-making character. In any event, deliberation must not be confused with decision-making. One
person or a group of persons different from those who
have to make the decision may deliberate. A significant
example of this are healthcare ethics committees.
One last comment is that, as has just been hinted,
deliberation may be individual or collective. As Aristotle says, we enlist partners in deliberation on large
issues when we distrust our own ability to discern.
(Aristotle, 1995, p. 295). The same takes place in
ethics as in clinical medicine. The most complex cases
are presented at a clinical round so that they can be
analysed by more than one professional. The same
thing happens at a Court of Justice when appeals are
considered by more than one judge, as it is thought that
serious cases should not be judged by just one person.
There is no reason why ethical deliberation should be
different from other kinds of deliberation. The health
professional carries out his own deliberation when he
has made decisions regarding a patient. The doctorpatient relationship is a deliberative process (Emanuel
and Emanuel, 1992, pp. 22212226). Healthcare ethics
committees also deliberate (Couceiro, 1999, pp. 239
310 and 3290-334). Their function is very similar
to that of clinical sessions: analysis of the complex
problems and help with the most difficult decisions.
Clinical and ethical deliberation is the core of clinical
activity.

Note
1. This paper is based on and adapted from: Gracia D.: (2001),
La deliberacin moral: El mtodo de la tica clnica, Med
Clin (Barc) 117, 1823. This was the introductory chapter
of a series of articles that were published under the title
Bioethics for clinicians in the same journal during the
second half of the year 2001 and January 2002. The author
would like to thank the Foundation for Health Sciences for
the permission to use this previous paper in the present one.

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Emanuel, E.J. and L.L. Emanuel: 1992, Four Models of the
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Gracia, D.: 1991, Procedimientos de decisin en tica clnica.
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Gracia, D.: 2001, Moral Deliberation: The Role of Methodologies in Clinical Ethics, Med Health Care Philos 4 (2),
223232.

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