Value Added by an Ethics Consult Is Reasoning Process

Abstract

Source: Tsai T-C, Harasym PH, Coderre S, et al. Assessing ethical problem solving by reasoning rather than decision making. Med Educ. 2009; 43(12): 1188– 1197; doi: 10.1111/j.1365-2923.2009.03516.xInvestigators from the University of Calgary in Canada and Taipei Medical University in Taiwan examined the ethical reasoning process of medical practitioners with different levels of training. The study group consisted of volunteers from both countries having different levels of expertise in ethics. The participants were divided into three groups: 1) “ethics experts” (physicians who had at least two years’ experience as ethics consultants, ethics committee members, or ethics teachers); 2) second-year residents; and 3) medical students. A set of 15 clinical vignettes served as scripts to trigger physician responses to common ethical dilemmas. Data consisted of physician responses and reasoning collected from participants’ analysis of “staged” interviews about a clinical vignette during which participants were encouraged to verbalize their thoughts as they worked through the ethical issues. The interview was taped and translated, and then reviewed by two coding experts, and the ethical decision-making scored on two domains: correctness of response and ethical reasoning.The study enlisted 49 participants (32 in Taiwan and 17 in Canada). Taiwanese participants included 15 medical students, 5 residents, and 12 ethics experts. Canadian participants included 7 medical students, 6 residents, and 4 ethics experts. The proportion of ethics cases with acceptable answers did not differ significantly between medical students, residents, and ethics experts in either country. With regard to ethical reasoning, however, ethics experts were more likely to display more organized knowledge and consider more relevant variables in arriving at their answers. The authors concluded that ethical problem-solving expertise was evident in the reasoning process applied to a case, rather than in the actual decisions that were made.Whereas the recommendations provided by an ethics consultant are usually helpful, it is the underlying reasoning process that adds value by giving validity and credibility to the suggestions presented to the family and attending physician. For many consultants, the reasoning process makes use of the principles of autonomy, justice, beneficence, and nonmalificence. Applying these principles facilitates consideration of multiple aspects of the case by the consultant and assists in determining the best interest of the patient. Consideration of these principles helps to identify the ethics applicable to different patients in various settings and make them understandable to both the family and the care team. An alternate popular method is the four-topics chart,1 a concise and useful way of organizing the decision-making process. The chart uses four categories — medical indications, patient preferences, quality of life, and contextual features — to assist the consultant in organizing a case, giving due consideration to the important specific aspects of the patient germane to the recommendations.While an ethics consultation may yield definitive recommendations, it is not unusual for the consultant to offer suggestions in the form of several options — “It is ethically permissible …”2 In such a scenario, there is some latitude in the decision-making process which allows the family and care team to choose among an array of ethical options, an approach they feel reflects the patient’s best interest and prior-expressed medical preferences. The authors of this article note that it is the reasoning process — not the specific recommendation — that reflects the differences in expertise among the participants of the study group.