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A systematic approach to clinical moral reasoning

Rosamond Rhodes and David Alfandre
Clinical Ethics 2007 2: 66
DOI: 10.1258/147775007781029582
The online version of this article can be found at:
http://cet.sagepub.com/content/2/2/66

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CASE STUDIES

A systematic approach to clinical moral reasoning

Rosamond Rhodes1 and David Alfandre2
1

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.

An understanding of the basic principles and concepts of

medical ethics is critically important for navigating the
ethical dilemmas that arise in clinical medicine. Yet clinicians also need to develop skills in recognizing ethical
problems in clinical practice and understanding how the
principles can be used to guide practice. In the medical
ethics literature, numerous authors offer advice on how to
resolve moral problems, some in terms of principles,1,2
some in terms of rules,3 some in terms of virtues4 and others in terms of the kinds of information that should be
collected.5 There have, however, been few attempts to
describe the process of moving from principles, rules,
virtues, and facts to action-guiding moral conclusions,6,7
and even there the details have not been articulated
clearly enough to be useful in a practical way. Because we
see a need for more guidance, we have designed a template for clinical moral reasoning that is intuitively compelling. It incorporates philosophical insights framed in a
structured thought process that is styled after the systematic approaches to medical thinking that clinicians are
trained to employ. We expect that this model will be useful for clinicians, ethics committee members, and in medical education with learners who are already familiar with
the basic concepts of medical ethics. This approach is
deliberately formulated to work with a range of similar
terms that convey the key concepts of medical ethics.
We have been using this model at the Mount Sinai
School of Medicine as a targeted educational intervention
specifically designed to help house staff members learn to
understand and manage clinical ethical dilemmas.
Medical teams identify cases that raise ethical issues and

Rosamond Rhodes PhD is Professor of Medical Education and Director

of Bioethics Education at the Mount Sinai School of Medicine and
Professor of Philosophy at The Graduate Center, CUNY. She writes on a
broad array of issues in bioethics. She co-edited The Blackwell Guide to
Medical Ethics (2007), Medicine and Social Justice: Essays on the Distribution
of Health Care (2002) and Physician Assisted Suicide: Expanding the Debate
(1998).
David Alfandre MD MSPH is a General Internist in the Department of
Medicine at the Mount Sinai School of Medicine. He divides his time
between patient care, research and resident teaching.

arrange a conference for their discussion. Typically, the

cases are chosen because the team experiences them as a
mess that cannot be resolved with the standard tools of a
medical armamentarium. Conference leaders distribute a
pocket-sized laminated index card with a template for our
model for clinical moral reasoning on one side and use it
to guide the medical team through the process of defining,
analysing, and resolving the ethical dilemma8 (Box 1).
The leaders role is also to clarify concepts, explain relevant legal constraints, and keep the discussion on topic so
that the conference can be concluded within its allotted
time.
At the beginning of a session, a conference leader
explains the goals, then a member of the team presents the
major clinical details of the case focusing on how they
relate to the moral problem. Other team members contribute information from their own experience with the
patient. The clinical chart is also available if needed.
During the discussion the leaders repeatedly draw
attention to the index card outline. Our faculty have
become familiar with the concepts over a long period of
working and teaching medical ethics together with different learner groups and in a variety of settings. Without
that background, however, the model does require some
explanation and justification. In what follows, we shall
explain the reasoning that lies behind each step in our systematic approach and elaborate on what each step entails.

Collect all relevant data that could

help to answer your question
The complete set of data should certainly include the
medical factors such as diagnosis, prognosis and treatment
options. It will also be crucial to ascertain the patients
preferences. Often it is important to be informed about
legal and institutional policy matters and familiar with
codes and principles of medical ethics and the relevant
guidelines from professional societies.9
Communication skills and moral imagination, in addition to medical skills, are important tools in gathering this
data. Careful listening and attending to the responses of
the patient and family helps to inform a deep understand-

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Box 1 How to approach a clinical ethical dilemma*

Collect all relevant data that could help to resolving your

question.
Identify the basic principles involved and explain how
they relate to the case.
Consider whether principles conflict in this situation or
whether there is uncertainly about what a particular
principle (e.g. beneficence, respect for autonomy) directs
you to do.
Formulate a question that reflects the conflict.
Decide which principle should have priority in this case
and support that choice with factors relevant to the case,
or find an alternative that avoids the dilemma.
When uncertainty persists, note whether there is some
missing information that would help you to resolve the
dilemma. Which information? How will it help to resolve
the dilemma?
Evaluate your decision by asking if it is what a consensus
of exemplary doctors would agree to do.
Plan the practical steps that you should take, focusing on
the details of the case and the future issues that you
foresee.

* This model has developed through ongoing

conversations of the ethics faculty and through the efforts
of the faculty and Ethics Fellows involved in the design and
implementation of our ethics assessment activities,
COMPASS-1&2. We are particularly grateful for the input
of: Steven Birnbaum, Erica Friedman, Nada Gligorov, Joseph
Goldfarb, Kurt Hirschhorn, James Hitt, Ian Holzman,
Thomas Kalb, David Muller, Richard Stein, Christine Vitrano

ing of the facts in the particular context. Discussion of the

full context of the data is necessary for developing an
appreciation of the needs of the patient and family.
Information that is not addressed during the initial clinical
case presentation is added as it becomes important to the
discussion. Typically, an assessment of the patients capacity or the identification of a health care proxy are part of
the data set that could be important in resolving the clinical moral dilemma. Details of the social history, including
descriptions of the richness or absence of family relationships, baseline mental and physical function, and the
home environment should also be incorporated into this
portion of the discussion.

nently in their case. Relating the principles to the case

encourages clarification of the concepts and promotes
understanding of just why the concept is an important
component of clinical medical ethics.

Consider whether principles conflict

in this situation, or whether there is
uncertainly about what a particular
principle directs you to do
Once the principles are clearly identified and understood,
it is easy to appreciate why the case presents a moral
dilemma. This piece of the exercise allows participants to
recognize that moral problems frequently involve two
important principles of medical ethics that cannot both be
satisfied at once. It also allows participants to see how the
clash between principles gives rise to moral conflict when
two important principles direct physicians to opposing
courses of action. Sometimes, however, it may be unclear
as to what a single principle (e.g. beneficence) requires in
the situation. Requiring the team to explicitly identify the
conflict begins the process of reasoning to a resolution and
delineates the parameters for the conversation that follows.

Formulate a question that reflects the

conflict
According to our template, the next step which is analogous to the identification of a chief complaint in clinical
medicine requires the team to identify the main ethical
question. This helps them to focus the discussion on the
key dilemma, that which forms the crux of the problem. A
clearly formulated question guides the crucial discussion
that follows. Once the several relevant principles are identified and discussed, formulating a question is usually
rather straightforward. Occasionally, in an especially complex case, two or three dilemmas may be involved, so several different questions may have to be formulated.

Box 2 Some principles / duties / concepts of medical ethics

Identify principles, duties and

concepts involved, and explain how
they relate to the case
Asking participants to identify the principles that are at
issue helps them to appreciate the conflict and to focus on
the controversy raised by the case. For easy reference and
to help participants recall important concepts and duties
of medical ethics, we provide a list on the flip side of the
index card (Box 2). This list is neither intended to be in
any way definitive nor intended to connote any theoretical commitment to one sort of entity over another, but
merely to serve as a shorthand reminder of an assortment
of concepts, principles, rules, virtues, duties and hazards.
The items on the list were chosen for their salience and
frequent relevance in clinical medicine. Typically, a team
is able to identify two or three concepts that arise promi-

Duty to provide care

Assess decisional capacity
Confidentiality
Assess surrogate appropriateness
Truth telling
Respect for autonomy (patient goals)
Minimize harms
Beneficence/caring (team goals)
Duty to warn
Non-judgmental regard
Professionalism
Trust/fiduciary responsibility
Informed consent
Justice (fair allocation of scarce resources)
Justified paternalism
Futility (furthers no goals)
Note conflict of interest
Professional competence
Evidence-based practice
Responsibilities to peers and institutions

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Decide which principle should have

priority in this case, and support that
choice with factors relevant to the
case, or find an alternative that avoids
the dilemma

sulting with peers and adhering to the basic principles of

medical ethics which constitute the ethical standard of
care. Physicians who make this question a touchstone of
their clinical practice exemplify medical professionalism.

It is reasonable to presume that all team members share a

commitment to the principles of medical ethics.
Nevertheless, they may prioritize them differently or see
the relevance of some as more important than others in
the case at hand. They may also have different views about
the place of the patients preferences in determining how
to proceed. Recognizing that members of the team may
give priority to different values and that the clinicians
ranking may be different from the patients is a vital feature of this exercise. Participants should note that the
medical teams primary goal may be different from that of
the patient or family and that the team and the family may
share goals yet disagree on how to achieve them. This
insight is an important starting point for the medical
teams clear and ongoing communication with the patient
and family and with one another.
It is useful to see choosing the goal to pursue as a process of communicating together to reach an acceptable
course in a difficult and unfolding situation rather than as
an exercise in dispute resolution between antagonistic and
opposing parties. In most cases, the patient, the family and
the medical team all want the same thing: the patients
good. There may, nevertheless, be legitimate disagreement
about what that entails. Reaching agreement about what
to do requires all of those involved to come to share reasons for following a particular course. Consensus can only
be achieved through a free and open discussion where
everyone has the opportunity to explain their concerns,
ask questions, challenge assumptions, introduce previously
overlooked factors, offer suggestions, and consider options.
Such a process may sometimes yield a creative solution
that avoids sacrificing either side of the dilemma.
When uncertainty persists, note whether there is some
missing information that would help you to resolve the
dilemma. Which information? How will it help to resolve
the dilemma?
There will be times when no consensus on how to proceed emerges from the discussion. Then, as in a situation
where the diagnosis remains elusive, the team has to consider what further information could be useful in answering the outstanding questions and make efforts to obtain
it. Some missing but crucial information may be medical
(e.g. the diagnosis, life expectancy with such a condition),
other required information may be personal or social (e.g.
are there any long-term care facilities near the family
home that will provide both tube feeding and ventilator
support). When pieces of information are critical to the
case, a decision cannot be reached without them.

Plan the practical steps that you

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

Evaluate your decision by asking what

a consensus of exemplary doctors
would agree to do
Clinicians justify their treatment decisions by referring to
the standard of care. The same should hold true with the
ethical choices that clinicians are required to make.
Questions of clinical medical ethics are not resolved by an
individual consulting his/her heart of hearts, but by conClinical Ethics

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It is important for the participants to appreciate that they

need to do the right thing and that they also have to do it
in the right way. Once a course of action is agreed upon, it
is time for planning just how to proceed. Forethought is
required to plan for the anticipated eventualities and complications. For example, the appointment of a proxy by a
patient with a deteriorating medical condition or a discussion of blood transfusions with a pregnant Jehovahs
Witness could be important steps in ensuring that the
patients goals are achieved. The ability to communicate
effectively with patients, families and colleagues is also an
important part of this process.

Putting the model to work

To illustrate how our model can be employed, consider
these examples from actual case conferences. The first
illustrates conflicting direction from a single principle; the
second the resolution of a clash between two important
principles; the third a case where the dilemma could not
be resolved without additional information.

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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and benefits of each path. Surgery might give the patient

the best chance of returning home for a significant period
of time, but it could also hasten his death or leave him to
endure complications and a prolonged dying process.
Rejecting surgery would involve a sooner death than he
might have with a successful surgery. Appreciating that
there were no optimal alternatives and that there were no
clear medical reasons for ranking one alternative over the
other made it easy for the team to accept the idea that the
resolution of this case turned on a ranking of the personal
priorities of those who were most immediately affected by
the decision. They concluded that the options had to be
explained to the patient and his wife and that the couple
had to be offered the teams support in which ever option
they chose.
This case illustrates how several different answers may
be ethically acceptable and there need not be a single
right answer.

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

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providers in fiduciary relationships with patients, and the

team had no duty of professional oversight that required
reporting her drug use. Upon questioning, the patient
explained that her work involved taking care of an elderly
man who lived with his extended family. She also confided
that she used cocaine only at weekend parties. Based on
that information about the patients drug use pattern and
her work situation, the team concluded that it was reasonably safe to maintain the patients confidentiality. The
team continued with the practical strategy of recommending that the patient obtain treatment for her substance
abuse problem, and offering assistance in providing access
to such services.

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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