Feature

Practical Ethical Reasoning

A jigsaw of ethical choices provides a guide for people making difficult decisions.

David Seedhouse

A consultant oncologist asks for advice. He has promised the family of a non-English speaking patient he won't tell her she has cancer -- and now she needs a bone marrow transplant. What do you suggest?

You are in a hospital management meeting. A proposal to close the long-stay geriatric ward has just been tabled. You are appalled -- but what do you say?

You are in court. Your hospital has asked for permission to treat a 12-year-old girl's leukaemia -- treatment her parents have declined on religious grounds. The judge makes you the responsible physician. What do you do?

You might react instinctively. You might follow hospital policy (if there is any, and if you agree with it). You might ask other people for help -- your lawyer? Your defence union? A respected colleague? An ethicist? You might try to apply ethical principles. You might sketch out ad hoc responses to each case. Or you might make use of the Ethical Grid.

If you follow policy you will probably know neither who set it nor their reasons. If you ask others for help you pass the buck. If you apply principles you cannot challenge their legitimacy. And if you try to solve ethical problems from scratch you will make inconsistent decisions. By using the Ethical Grid, you can avoid each of these problems. What's more, its regular use fosters comprehensive, confident decision-making in situations where it is all too easy to drown in ambivalence.

Boxes and Layers

The Ethical Grid is a decision-making device made up of boxes set out in four layers. It was first published 10 years ago and has since become widely used in practice and teaching. It is meant to remind clinicians (and others) of the range of considerations which might affect their clinical deliberations, to simplify ethical analysis and to encourage clear explanations of any judgements reached. When using the grid, a doctor should aim ultimately to select the box or boxes which best solve the problem in hand.

The grid acts as a reminder that when tackling ethical issues there are at least four aspects to consider, from the outermost layer of the grid through to the innermost layer: practicalities, outcomes and priorities, moral duties and basic purpose.

Each box of the grid should be thought of as detachable, as if made up of separate plastic chips or wooden blocks. By choosing some boxes, and discarding others, a doctor will have undertaken an extensive decision-making process and will be able to refer to the chosen boxes as a record of her analysis.

For example, if you were to advise the oncologist worried about revealing the truth to his patient, a guide through the grid could start with the outer layer:

Is this a resource issue? No. Will the action be effective? No answer possible until an action has been proposed. What are the risks? There is a risk of family disharmony. There is a risk that the doctor or hospital might face legal action. There is a risk that the patient will find out anyway -- and many more risks that need to be spelt out if the problem is to receive proper consideration. What does the law say? Is the evidence disputed? Do other people have wishes he ought to take into account? The deliberation should continue until the prevailing circumstances are as clear as possible.

What about the layer dealing with outcomes and priorities? Who is the primary focus of concern? The patient? The group, and if so what is the group in this case? The doctor? The hospital? The public interest? Decide this and the oncologist will have moved a good way toward a solution -- but to do so he will probably have to visit the inner layers first.

Should he keep his promise to the family? Will this minimise harm (and what does harm mean in this case?)? Is he obliged to pursue the most positive outcome (and what might this be?). Must he tell the truth (and if so what truth and to whom should he tell it?).

What clues do the boxes in the innermost layer provide? You might suggest to the oncologist that in this case the answer lies in this layer. For example, you might ask -- do you keep the truth from all your patients? Assuming he does not, you might then inquire whether there are special circumstances which permit you to treat this patient unequally? You might also ask how deception creates autonomy for the patient? How does it give control to the family? What are the fundamental needs in this case? Which needs is the oncologist best equipped to serve? Whose wishes are most important -- the relatives or the patient's (in other words, whose intellectual autonomy should be the first consideration?)?

You would -- as a competent ethical advisor -- press on with such questions until the oncologist began to form a definite view about what to do -- and then you would use the grid to challenge that view. The grid should not be used to support preferences but to assess them with a critical eye.

Eventually you would have helped the oncologist arrive at a selection of boxes which provide a defensible answer to the case -- and a basis for consistent future policy-making in similar circumstances. You might end up with:

• The Law
• Respect Persons Equally
• Tell the Truth
• Most Beneficial Outcome for the Patient

These boxes represent a decision to tell the patient she has cancer, and also that the oncologist has previously kept this information from her. The doctor might argue that the law requires informed consent to medical interventions (the law), that informed consent to a bone marrow transplant must include the reason for it (the law, tell the truth), that he generally tells the truth to patients (tell the truth, respect persons equally), and that the main focus of his concern as an oncologist is the cancer sufferer, not her wider family (most beneficial outcome for the patient or individual).

This may not be the right answer -- ethical analysis does not work like this -- and it is possible to use the grid to arrive at counter positions. But this is merely a reflection of the plurality of the social world -- not an objection to the grid itself. What matters most is that the ethical analyst has undertaken a detailed review of the problem, and explicitly arrived at a plausible position which he is able to defend against challenges (including challenges from the patient and her family).

More Tough Reasoning

What do you do in the hospital meeting where the geriatric ward is endangered? How do you respond to the court order? Do you treat the girl even if she says no? Do your force her to accept medication even if she is terrified? What do you do?

There are no easy or instant answers to such medical problems -- and neither the grid nor any other approach to ethical reasoning can offer quick solutions. However, where there is time to reflect there is great value in exploring the grid.

In each case -- in keeping with the grid's recommended use -- you need to achieve a good general understanding of the situation, and then address a clear and specific question. Perhaps -- in the case of the girl whose parents do not want you to treat her -- it will be: do I carry out the court order?

Ideally you should set out your preference as a hypothesis, perhaps: I should obey the order and treat the girl whatever she or her parents want, and then try to use the grid to criticise your point of view (if possible with the support of people whom you expect to have divergent views).

You should inspect each layer, identifying (and defining) the key boxes. For example, what are the risks? What is the certainty of the evidence (how likely is a cure? How much damage will involuntary treatment cause to the girl and her family?). What primary benefit are you seeking? Who should define this? What is your main concern -- the girl, the family, or yourself? What is your predominant moral obligation? What are you trying to achieve -- disease cure? Health? Longer life? Quality of life? What is your basic purpose?

You should -- at the end of your thinking -- have a set of boxes which sum up your decision, extensive notes of your reasoning process and -- most important of all -- a feeling that you have done the best you can to treat the matter with the intellectual seriousness it deserves.

Which boxes would you select, and why?

The Ethical Grid has recently been republished in the second edition of Ethics: The Heart of Health Care, John Wiley, Chichester, 1998. Wooden Grids for teaching purposes are available from David Seedhouse.

David Seedhouse is in the Department of Psychiatry at the University of Auckland.