As a teacher of family medicine, I frequently tell resident physicians to accept that there may be more than one way to manage a clinical situation. When several alternatives are available for care, I suggest they assume that all of them have some truth but that none have all the truth. Which alternative they choose to treat a patient is less important than for them to choose 1 alternative and then to observe the patient closely and reevaluate as necessary.
That statement reflects my feelings about clinical ethics. In this article, I describe how I, as one family physician, approach the clinical ethics situations encountered in my work. Rather than review every important ethical issue in family medicine, I discuss several leading clinical ethics methods and how I use them in practice.
When approaching a clinical ethics problem, I remember 3 lists of clinical tenets. The first is the 4 major goals of medicine1: to cure illness, improve health, decrease suffering, and prolong life.
The second is 4 questions I ask myself when seeing a patient: What does this patient want from me today? What other medical care does this patient need from me—either today or in the future? What preventive care should I offer this patient? What psychosocial issues might I help this patient and family handle so that they feel better?
The third is the 6 components of the patient-centered clinical method2 promoted by the Department of Family Medicine at the University of Western Ontario, London, Ontario: explore both the disease and the illness experiences, understand the whole person, find common ground regarding management, incorporate prevention and health promotion, enhance the patient-doctor [sic] relationship, and finally, be realistic.
These lists have at least 4 things to do with clinical ethics decision making. First, they highlight the importance of open and honest communication.2-4(pp104-128)5 Decisions cannot be made unless it is clear to all parties involved what is being decided: what the options are, what the consequences are, and what those consequences mean for everyone. Most ethical dilemmas vanish when patients, families, and health care personnel have fully disclosed and listened to each other's perceptions, feelings, expectations, fears, worries, motives, etc. Some ethical conflicts are unavoidable, but many are preventable and easily solved by working with patients and families and clarifying what everybody understands.6 Furthermore, even in today's managed care environment, such communication not only is the right thing to do, it also saves time, money, and effort.
A clinical example of how clear communication helped me resolve an ethical problem is the case of a 64-year-old Latina woman with diabetes mellitus and chronic renal failure, who suffered a cardiac arrest during a dialysis session that left her receiving mechanical ventilation and in a nearly persistent vegetative state. After 2 weeks, her intensive care physicians wanted to withdraw dialysis and respiratory support, thinking these treatments had become futile. Her family, however, refused, saying they wanted "everything done." After several discussions with all of the patient's family together, including her husband, her mother, and her 8 children, some of whom were office workers who had been educated in the United States and others who were agricultural workers who spoke only Spanish, there was consensus to withdraw care. Once each family member's personal values, fears, and guilt were addressed with the whole family, it was possible to discuss what the patient might want. She died on December 12, the Feast of Our Lady of Guadalupe, in a room filled with candles.
Second, these clinical tenets demonstrate that getting the facts straight and developing a clinical narrative7-8 are central to what I do. What are the patient's issues? What does the patient want from me? What do I want for the patient? What has happened to the patient before, what is happening to the patient now, and how can I guide what could or should happen in the future? What are the details? Are other parties involved in the case? What are their issues, and what do they want?
The "4-box" method of clinical ethics analysis advocated by Jonsen et al9 is one outstanding and simple way to organize such a clinical narrative. What are the medical indications for different treatment options in this case? What are the patient (or family, surrogate, or both) preferences regarding treatment? What quality-of-life issues are pertinent to the patient's care decisions? What other contextual features—such as religious, financial, or legal matters—are relevant to the case?
Narrative ethics has been especially helpful when planning life-support and terminal care treatment.10 The proper medical decision becomes clear once a patient's whole life—her experiences, motives, interests, etc—are clearly reflected back to her, to me, to other health care professionals, and to the patient's family and community. Brody's question,11 "What, all things considered, ought to be done?" in a case can only be answered after all things have been considered—ie, after all the facts are revealed and the real story is told.
Third, the 3 lists noted earlier all have to do with the care of a patient. An ethic of care12-13 that emphasizes the relationships in clinical situations and the needs and concerns of the persons involved in these relationships is key. How can I care for patients without trying to see myself—or a friend or member of my family—in their position? How would I want to be treated—as opposed to what treatment would I want performed—if I were the patient? Am I caring for my patients as I go about the work of providing medical care?
Clinical examples of how an ethic of care has helped me resolve ethical conflicts include patients with diminished capacity to make medical decisions, such as a 57-year-old man with diabetes mellitus and organic brain syndrome, in whom chronic renal failure developed to the point that he needed dialysis. Unfortunately, it was impossible to know whether the patient understood what we were telling him about dialysis; multiple conversations with him were inconsistent and confused, and he would never sit still for more than 5 minutes before wheeling off to steal someone's food or go "visiting" around the nursing home where he had lived for the past 8 years. Finally, after carefully weighing all the benefits and burdens of dialysis, his family and his many friends among the nursing home staff agreed that tying him down for a procedure he did not understand, 3 hours at a time for 3 days a week, would not be the right way to care for him. The man died in his sleep about 2 months later.
Fourth, I have freely chosen these lists to guide my professional activity as a practitioner and teacher of family medicine. Consequently, if I am to remain true to myself and my chosen profession, I must consistently follow these clinical tenets and my discipline's defining principles.4(pp13-28) Furthermore, if I want to be a good person and a good physician as I follow these tenets and principles—if I want to know which actions are good, and if I want to possess a character such that I will actually be able to perform them—I must also try to be virtuous. To be virtuous, as nobly expressed by Pellegrino and Thomasma,14 is to habitually exercise the virtues, such as fidelity to trust, compassion, justice, fortitude (courage), temperance, integrity, self-effacement, and phronesis (prudence).
In many ways, the ethics of virtue directs both my general orientation to patient care and my predisposition to considering other methods of resolving ethical conflicts. I found the virtue of prudence especially valuable in the case of "Baby A." During routine ultrasonography in early pregnancy, Baby A was found to have a mass adjacent to the neck and jaw. Once informed, the parents, a young immigrant Latino couple, missed all follow-up appointments and avoided the public health nurse sent to contact them. They returned for care only when the mother began having irregular contractions. A second ultrasonograph confirmed the growth of a large mass, which now appeared to obstruct the pharynx. Consequently, they were referred to our affiliated university tertiary care center, 160 km away, for delivery and resuscitation. The parents, however, despite the fact that they obviously understood the clinical situation, refused the referral. In a conversation with them, it emerged that a combination of anger, guilt, denial, deep depression, and great fear—both of having a deformed infant and attracting the attention of the Immigration and Naturalization Service—motivated their refusal. After their psychosocial needs were prudently addressed, the parents were able to accept the transfer. Baby A was delivered by cesarean section and had a tracheostomy performed by pediatric surgery on the maternal abdomen before delivery of the shoulders. He continues to be observed at the university for the management of a large, complex cystic hygroma but is otherwise well.
I occasionally encounter cases with ethical dilemmas that I am unable to resolve solely by reflecting on the lists described earlier. Communication, getting the story straight, considerations of care, and discerning what actions are most virtuous are all inadequate. In some of these cases, to get myself "unstuck," I may consult the medical or clinical ethics literature or a respected colleague. By applying the methods of casuistry15-17—ie, by formally analyzing how my case compares with similar precedent cases and examining their solutions—I am able to reach the best decision based on the real, practical, and collective wisdom of my colleagues and community. Such formal comparative case analysis has been especially helpful in evaluating issues of futility regarding the benefits specific patients might receive from cardiopulmonary resuscitation, mechanical ventilation, a feeding tube, or aggressive surgical intervention.18
In other cases, my only hope to get unstuck is to perform a clear, objective analysis, considering the scope and balancing the weight of the principles of respect for autonomy, beneficence, nonmaleficence, and justice.19 An example of how formal, principled analysis has helped me resolve a clinical ethics dilemma is the case of a 37-year-old man with advanced laryngeal cancer who initially consented to a second course of chemotherapy and the placement of a feeding tube and then withdrew consent. His oncologist and otolaryngologist wished to proceed with treatment over his objections, but in talking with him, it was clear that he knew what he was doing. His chances for survival were slim, even with aggressive treatment. His goal was to be able to eat and stay out of the hospital for as long as possible, even if it meant dying sooner. He acknowledged feeling depressed about his situation ("Who wouldn't be?"), but he was certain about his desires and his reasons. The combined scope and weight of his autonomy and the potential good and bad of the medical interventions resulted in a clear recommendation to not treat. The man died several months later, still at peace with his decision.
Toward the beginning of After Virtue,20 MacIntyre laments that many contemporary moral discussions are "interminable"—ie, they are endless arguments pitting conflicting positions held by different parties—each of whom believes his or her method and position are undisputedly correct—against one another.
All methods of ethics have their proponents and their critics. All have some truth; none have all the truth. They all influence and enrich each other. Thinking about principles helps me act more virtuously21; considering aspects of care improves the quality of my communication2-5,13, 22; and narrative ethics and casuistry, both of which start with closely examining the details of a case, have many similarities.7-8,16-18
As a family physician, my clinical approach to patients is to consider all of their health care issues, to assess all simultaneously, to continually reprioritize my and my patients' goals for them, and to be eclectic and integrative in their management. Unlike a specialist who is "vertically" expert in a few areas, I am "horizontally" knowledgeable about many but expert about none. I cannot afford to be too much of an expert in one area because it might dilute my ability to be knowledgeable and thoughtful about many. My expertise is the ability to provide practical, continuous, and comprehensive care to my patients: to see them with a wide-angle lens, to view their situation from various perspectives, and to consider many options for action.
Some may ask whether my approach to ethical decision making is the same as wide, reflective equilibrium—the formal, detailed process of reflecting on an ethical question through numerous theories and finding a solution that fits—or is in equilibrium with—all of them.23-24 As a practicing primary care physician who is reflective about ethics—but not always in a personal state of theoretical equilibrium—I cannot say. My approach is consistent with the rest of what I do clinically. It is not a "situation ethics" in the sense that I purposely ignore all rules, principles, and methods that might apply to a case and examine it in a vacuum but, rather, an "ethics of the situation." That is, after briefly considering several methods, I choose the one that bests illuminates what to do in a specific case, depending on the ethical question, the clinical details, the personalities and needs of the patient and family, and so on.
Just as I advise the residents, I tell myself to accept that there are alternative methods to making a clinical ethics decision. The important thing is to choose one of them, observe events closely, and reevaluate as necessary.
Sometimes I need to try another approach. Sometimes I need to ask for help. But if I remember my 3 lists of clinical tenets; if I communicate clearly, get the facts of the story straight, and am caring about my care; and if I exercise the virtues for the good of my patient; and if I also use the literature and collective wisdom of my colleagues and community thoughtfully and consider principles appropriately—things always seem to work out well. It may not be elegant, but it is one family physician's approach.
