Ethics Toolkit

Creating the Ethics Deliberating Process

Post-acute and long-term care is a complex healthcare environment. As with any such clinical environment, multiple factors can trigger requests for ethical consultation.  What appears at first to be an ethical dilemma may actually turn out to be an interpersonal dispute among family members or between staff and family members. Thus, for all participants to focus on the central ethical concerns and to clarify the expectations of an ethics deliberation process, an important first is defining the ethical question.

Broadly defined, clinical ethical dilemmas arise when there are conflicts between different ethical principles and values in a person’s life. A well-designed ethics deliberation process should lead to answers to the following questions: 

• What is the ethical dilemma(s) in this case? Is there an ethical issue?
• What are the alternative courses of action? What are the benefits and burdens of each? To whom? 

While it may be possible to identify the ethical dilemma(s) in a case immediately, it is possible that this question cannot be answered until a thorough analysis of the case is performed.

Using a systematic approach to identify these principles and conflicts can help to clarify an ethical question and the expectations for the ethics consultation. In the same way clinicians use frameworks to guide clinical questions for evidence-based medicine, a similarly systematic approach serves to organize the relevant medical facts, and the beliefs, principles, or standards that inform decision making. There are a number of good models for ethical deliberation.  Here we consider two different and potentially complementary models, the CASES approach and the Four-Topics Model. 

The CASES Approach

The CASES Approach was developed by the National Center for Ethics in Health Care to standardize ethics consultation and deliberation throughout the Veterans Administration (VA) system, but it is applicable to other settings as well.  

The first step is to Clarify the request. The consultant or individual tasked with initially evaluating the request should gather information from the requester to determine whether the situation constitutes a genuine ethical dilemma or would be better served in another venue or process. While a thorough analysis may be necessary to thoroughly understand the underlying ethical dilemma(s), this may be sufficient to frame the initial questions.

The next step is to Assemble the relevant information, which requires both identifying the types of information necessary and the sources of information. If the ethical dilemma(s) and related questions have not been fully identified before, this may provide the additional information to do so.

Once the necessary information is gathered, it should be Synthesized, allowing for the identification of the relevant ethical principles in conflict. This will help determine whether a formal meeting—depending on the institutional process—is needed and should help lay out the applicable ethical dilemmas.  For an ethics consultant, this should lay the groundwork for further deliberation and identification of subsequent actions. For an ethics committee or similar group, this should provide adequate information to stimulate discussion and generate potential solutions or other actions.

The next step is to Explain the synthesis to key participants, provide additional resources, and delineate acceptable and alternative actions to resolve the ethical conflict. Depending on the institutional policies and procedures, the result of the process, whether a consultation or formal ethics committee meeting, should be documented in the health record and, if it exists, in the minutes or consultation record.

Thereafter, it is important to Support the ethics deliberation process by following up with participants, evaluate the outcome of the process, identify any opportunities for improvement, and adjust the process as necessary.

Here is a summary of the CASES Approach:

A fuller description and explanation of the CASES Approach can be found here: http://bioethics.pitt.edu/sites/default/files/CEP/Dober%2C%20VHA%20Integrated%20Ethics.pdf.

The Four Topics Model

The “Four Topics Model” of Jonsen, Siegler, and Winslade, is a case- and principlist-based approach that allows the organization of necessary clinical facts and issues germane to the case into four categories: medical indications, patient preferences, quality of life, and contextual features. (Although this model stands on its own, it might also be applied as a complement to the CASES model, particularly for the “Assemble” step.)  

Each topic in the four quadrants provides a systematic way of collecting and organizing information relevant to the ethical principles being considered. For instance, under “medical indications,” questions allow for consideration of facts dealing with beneficence and non-maleficence. The category of “Patient Preferences” contains questions helping to establish patient autonomy. “Quality of Life” further elucidates information, clarifying the patient’s perspective on values and preferences, which may bring more focus to the principles of beneficence and non-maleficence. Finally, “Contextual Features” contains questions that allows for the consideration of information related to justice, fairness, loyalty and other potential factors that must be considered. 

Table 1.

Adapted from: Jonsen AR, Siegler M, Winslade WJ. eds. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 9e. McGraw-Hill Education; 2022. Accessed August 26, 2024. https://accessmedicine.mhmedical.com/content.aspx?bookid=3130&sectionid=262031316

Once the facts of the case are organized, it is important to identify the ethical dilemma(s), if any. As noted above, it is useful to consider two sets of questions: 

• What is the ethical dilemma(s) in this case? Is there an ethical issue?
• What are the alternative courses of action? What are the benefits and burdens of each? To whom? 

Generally, ethical conflicts are expressed as opposing ethical principles, such as autonomy versus non-maleficence or autonomy versus justice. One must keep in mind that there may be more than one ethical quandary to resolve, and a given ethical conflict may have more than one ethically acceptable solution. Likewise, there may be areas beyond the four prima facie ethical principles to consider, such as considerations of community, moral injury, and other factors.