Ethical Frameworks

Outlines

Objectives. Introduction. Description of the four ethical frameworks based on UK-CEN (clinical ethics network).

Objectives

After completion of this lecture, the students should be able to: provides a brief description of some ethical

frameworks that have been developed as a way of approaching ethical dilemmas in patient care and used for case analysis.

Ethical frameworks based on UK-CEN (clinical ethics network) include:

1 2 3 4

The four quadrant approach

The four principles of biomedical ethics

CARE (Shneider and Schnell 2000)

The Ethox structured approach

1. The four quadrant approach

Consideration of the ethical issues in a case

using the four quadrant approach should be

worked throughout the following questions:

a) Indications

for

medical

intervention:-

establish a diagnosis, what are the options for

treatment, what are the prognoses for each

options.

1. The four quadrant approach

b)

Preferences

of

patient:-

is

the

patient

competent, so what does he / she want? If not

competent, then what is the patients best interest? c) Quality of life:- will the proposed treatment improve the patients quality of life? d) Contextual features:do religious, cultural,

legal factors have an impact on the decision?

 For example: Mrs. Hana is 56 years old and has a learning disability. She is admitted to hospital with an

ovarian cyst. The cyst is blocking her ureter and if left

untreated will result in renal failure. Mrs. Hana would need an operation to remove the cyst. Mrs. Hana has

indicated quite clearly that she does not want a needle

inserted for the anesthetic for the operation to remove the cyst- she is uncomfortable in a hospital setting and is frightened of needles.

 Cont. example: The clinician is concerned that if the cyst is not removed Mrs. Hana will develop renal failure and require dialysis

which would involve the regular use of needles and be very difficult
to carry out given her fear of needles and discomfort with hospitals. The anesthetist is concerned that if Mrs. Hana does not comply with

the procedure then she would need to be physically restrained. Mrs.

Hana niece visits her in the care home every other month. The niece is adamant that her aunt should receive treatment. Should the surgeon perform the operation despite Mrs. Hana objections?

 Interpretation according to the four quadrant framework:

a) Indications for medical intervention:- Mrs. Hana has been diagnosed with an ovarian cyst and so, the options for treatment should be considered. What is the prognosis with the operation, considered against the prognosis without treatment (or with ongoing dialysis)? If she does not have the operation and requires dialysis, is this going to be manageable; will she be able to get to hospital many times a week and will this interfere with work or caring commitments she may have?

 Interpretation according to the four quadrant framework: b) Preferences of patient:- Mrs. Hana has a learning disability. This does not mean that she is automatically incompetent to make a decision about her treatment. If she is incompetent (and this is not temporary incompetence) then, the decision about treatment should be taken in her best interests. It is in her medical best interests to have the operation but it is not in her interests to forcibly restrain her in order to carry out the treatment. These benefits and disadvantages need to be balanced to arrive at a decision about which course of

treatment to follow.

 Interpretation according to the four quadrant framework: c) Quality of life:- Will the operation improve the Mrs Hana quality of life? It is a one off treatment that, if all goes to plan, will return her to her previous standard of health. d) Contextual features:- Are there any religious or cultural factors that may be relevant? What care will she receive after the operation? To what extent will Mrs. Hana niece continue to provide support? It would be useful to know if there is any particular reason why Mrs. Hana is so frightened of needles and why she feels uncomfortable in hospitals?

2. The four principles of biomedical ethics

Four Principles is one of the most widely used frameworks and offers a broad consideration of medical ethics issues generally, not just for use in a clinical setting. The Four Principles are general guides that leave considerable room for judgment in specific cases. 1. Respect for autonomy: respecting the decision-making

capacities of autonomous persons; enabling individuals to make reasoned informed choices. 2. Beneficence: this considers the balancing of benefits of treatment against the risks and costs; the healthcare professional

should act in a way that benefits the patient.

2. The four principles of biomedical ethics

3.

Non maleficence: avoiding the causation of harm; the

healthcare professional should not harm the patient. All treatment involves some harm, even if minimal, but the harm

should not be disproportionate to the benefits of treatment.

4. Justice: distributing benefits, risks and costs fairly; the notion that patients in similar positions should be treated in a similar manner. To get some feel for how the Four Principles could be used by a clinical ethics committee, consider the previous history of Mrs. Hana as a theoretical case study.

2. The four principles of biomedical ethics

Interpretation of the ethical issues using the Four Principles framework

1. Respect for autonomy: The principle of respect for autonomy

entails taking into account and giving consideration to the patients views on his/ her treatment. Autonomy is not an all or nothing

concept. Mrs. Hana may not be fully autonomous (and not legally
competent to refuse treatment) but this does not mean that ethically her views should not be considered and respected as far as possible. She has expressed her wishes clearly; she does not want a needle inserted for the anesthetic.

2. The four principles of biomedical ethics

Interpretation of the ethical issues using the Four Principles framework An autonomous decision does not have to be the correct decision from an objective viewpoint otherwise individual needs and values would not be respected. However an autonomous decision is one that is informed has Mrs. Hana been given enough information, in a manner that she can comprehend? 2. Beneficence: The healthcare professional should act to benefit his/her patient. This principle may clash with the principle of respect for autonomy when the patient makes a decision that the healthcare professional does not

think will benefit the patient is not in her best interests.

2. The four principles of biomedical ethics

In the same example, should consider both the long term and short term effects of overriding Mrs. Hana views. In the short term, Mrs. Hana will be frightened to have a needle inserted in her arm and to be in hospital this may lead her to distrust healthcare professionals in the future and to be reluctant to seek medical help. In the long term, there will be a benefit to Mrs. Hana in having her autonomy overridden on this occasion. Without treatment she will suffer serious and long-term health problems that would require greater medical intervention (ongoing dialysis) than the treatment required now (operation). The benefits of acting beneficently would need to be weighed against the no benefits of failing to respect Mrs. Hana autonomy.

2. The four principles of biomedical ethics

3. Non maleficence: Do no harm to the patient. Here, Mrs. Hana would be harmed by forcibly restraining her in order to insert the needle for anesthesia. On the other hand if she is not treated now she will require ongoing dialysis a number of times per week. If she does not comply with dialysis it would be impractical to administer and may require restraint.

Which course of action would result in the greatest harm? This

assessment relies on assumptions: how successful is the operation likely to be; how likely will Mrs. Hana comply with dialysis?

4. Justice: It would be relevant to consider cost effectiveness of the

treatment options for Mrs. Hana, and the impact of the decision about her treatment has on the availability of treatment for others (awaiting dialysis).

3. CARE (Shneider and Schnell 2000)

This framework is drafted for individuals but could be used by an ethics committee. 1. 2. What are my Core beliefs and how do they relate to this situation? How have I Acted in the past when faced with similar situations? (What

do I like about what I have done, what do I not like?)

3.

What are the Reasoned opinions of others about similar situations?

(What does our culture say about this situation?) 4. What has been the Experience of others in the past when faced with

similar situations? (What do I like about what they have done, what do I
not like?).

4. The Ethox structured approach

Flow Chart for Ethox Framework

What would constitute an appropriate decision-making process? Remember: Who is to be held responsible? When does a decision have to be made? Who should be involved? What are the procedural rules?

What are the clinical and other relevant facts of the case?

What are the morally significant features of each option? Remember: Patient preferences. Capacity. Best interests. Consequences.

List options
What does law/guidance say about each option?

Choose an option

4. The Ethox structured approach

Flow Chart for Ethox Framework (cont.)

Choose an option When choosing an option remember to consider: How does this case compare with others similar to it? Is meaning of key ethical terms in this argument clearly understood? Is the argument put forward valid? What are the consequences? Does this option respect the persons involved? What are the implications if this option should be made a general rule? Evaluate your argument Identify strongest counter argument Can you rebut this counter argument? Review recommendations in light of what happens and learn from it.

Make Recommendations

Thank You !!!