Putting it all Together

An Introduction to Doing Medical Ethics
Michael A. Gillette, Ph.D.

In addition to the orienteering analogy regarding the discussion of ethical issues, it is also important to identify a series of specific requirements for doing ethics well. Like all activities, the process of ethical evaluation and decision making is based on a desire to achieve certain specific goals. In order to achieve the desired goals, a set of requirements will become necessary. In other words, once we know what it is that we are trying to do when we consider ethical issues, it will become clear that certain actions will be consistent with our goals and certain actions will not. This is where casuistry and theory come together. We can reason on the basis of our experience, as casuistry demands, but we cannot ignore the basic goals which we are trying to achieve. These goals are given voice through theoretical discourse.

Take football, for example. If I am an NFL coach whose team is losing by one point with ten seconds left in the game and I find myself on the opposing team's fifteen yard line, the only option I have is to try for a field goal. It would not be rational to try to run the ball into the end-zone, or to try a passing play. Assuming that I have a healthy kicker available to me, I must kick the field goal. This is clear to me not only because I know what the odds are of scoring the requisite number of points to win the game given each of my options, but because I know that I want to win the game. If my goal is to lose, then I will force my team to fumble. If my goal is to make my players happy, then I will send in the bench-warming substitute. But if I want to win, I will put in my best kicker and tell him to kick.

In this example my practical experience with regard to kicking, passing and running plays the role of casuistically generated information. The desire to win, however, is a goal that is not learned through experience. Winning is analogous to the theoretical underpinnings of my moral view such as wanting to respect persons or maximize happiness.

In ethics, like football, I need to combine experience with theory. I need to know theoretically what I wish to do, and experientially how best to do it. Once I know what it is that I am attempting to achieve, I will necessarily see the importance of specific restrictions on my actions. If I want staff to live under policy, then I must make that policy clear and fair. If I want to defend my choices, then I must make sense when challenged. I argue that the goals of ethics are uncontroversial, and that they condition our actions just as clearly as the goal of winning conditions the actions of NFL football coaches. The figure on the next page expresses the relationship between the reasons for doing applied medical ethics and the requirements of doing ethics well.

Applied Ethics: Reasons and Requirements

Reasons For Doing Applied Ethics

• We want to develop the skills necessary to solve certain problems in satisfying and reasonable ways.
  
  
• We want to be able to express clearly why we have chosen to act in certain ways so as to defend our decisions in a satisfying manner (both for us and for those who disagree with us) when challenged.
  
  
• We want to be able to convince others that our choices are correct in an attempt to develop a consistent and sensible policy.
  
  
• We want to be able to use the answers that we have developed in some cases to help avoid additional problems, and to help answer any new problems that do arise in the most efficient way possible.
  
  

Requirements Of Doing Applied Ethics

• It must be possible to express the reasons for making a particular choice. Ad-hoc judgments fail to achieve goals two through four from above, even if they do achieve goal one.
  
  
• The conclusions reached must follow from the reasons given in a rationally acceptable way. All arguments must satisfy the logical requirement of soundness in order to achieve goals one through four.
  
  
• The reasons which are given must not depend upon unacceptable types of discrimination or double standards. Such illicit reasons will fail to achieve goals two and three.
  
  
• Once we accept a certain ethical position, we must follow the dictates of that position in all similar cases. Failure to do so will result in the inability to achieve goals two through four, and probably goal one as well.
  

The preceding discussion of strategies in ethical decision making can now be boiled down into a specific procedure that takes all of these points into account. When approaching an ethical problem it is important to determine the specific area of confusion or conflict, determine whether any background ethical assumptions impact on available options, evaluate available options, and justify a particular choice. This process can be summarized into the five Rs.
 

Making Ethical Decisions: A Procedural Approach:
The Five Rs - 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.

• Are there any genuine problems here? Do I perceive the possibility of confusion or disagreement? Are any oenormalî procedures being ignored? What motivates concern in this case?
   
• Is this problem medical, social, legal, or moral? Do I have the resources needed to solve the problem? Who/what are my additional resources?
  

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.

Although much more can and must be said about the details of ethical evaluation, this chapter is designed as an introduction only. It will serve our present purposes to attempt to show with a case study how this process-oriented discussion of medical ethics can be put to practical use.