Process I
Michael A. Gillette, Ph.D.

An approach to medical ethics will only be useful if it can yield practical results in difficult cases. While the theoretical discussions that I have often presented in "Practical Ethics" are very important from an educational standpoint, it is equally important to show how theoretical considerations can be translated into useful information. In order for the philosophical issues discussed to become more than an academic exercise, a method of moving from the purely intellectual realm of philosophical thinking into the practical world of clinical decision making is required. I believe that a specific procedure is required in order to make this transition.

When considering particular medical ethics difficulties, there are five steps that I recommend as being useful to follow. These steps can be referred to as the five R's.

The Five R's
Review, Respond, Reduce, Recast, Resolve

1) REVIEW THE SITUATION, IDENTIFY THE PROBLEM, DEFINE THE AREA OF NEED:
This stage requires the gathering of information. Become familiar with the present situation and identify those factors which might be relevant.

a) Are there any genuine problems here? Do I perceive the possibility of confusion or disagreement? Are any "normal" procedures being ignored? What motivates concern in this case?

b) Is this problem medical, social, legal, or moral? Do I have the resources ne

2) RESPOND TO THE ISSUES:
List all possible responses to the situation. Identify all of the arguments that could be made in support of each possible response. Responses can either be an intuitive or answers that you believe to be obviously incorrect. Either way, your initial responses and arguments will be only starting points for further development, or targets for criticism.

3) REDUCE THE LIST OF POSSIBLE RESPONSES:
Eliminate excess arguments either by combining redundant views or by use of decisive counter arguments. Even views that appear correct should be subjected to criticism. Why would anyone respond in the ways listed in step two? Develop supporting positions and create counter-examples to all positions. Examine difficult ramifications of accepting possible views.

4) RECAST THE CONFLICT:
Once the central arguments and options for response have been identified and considered, recast the issue in order to clarify the operative concepts. Appeal to analogues that admit to clearer intuitions in order to place the present issue in a clear conceptual framework.

5) RESOLVE THE DISPUTE AND CLARIFY THE CONFUSION:
Once the issues have been identified, and analogous cases have been considered, identify acceptable responses to the issue and develop an action plan for implementing recommendations. If possible, construct a generalizable theory that accounts for the acceptable options and explain how exceptions might be accommodated without giving up on the ethical principles involved. Once this has been accomplished, create a universalizable view that will help in other cases. Show why your final position is not unique to the case at hand, or alternatively, show how this case is in fact morally unique.

Now, how do these steps actually work? Next month we will consider a specific case in order to demonstrate the process in action.