â€œFour Topics Approachâ€ To Ethical Decision Making
Four Topics Approach
Emile Nighthorse is a 77-year-old man who has been hospitalized on a ventilator with a serious kidney disease that will require him to have dialysis indefinitely. Additionally, he has severe dementia and he does not understand his condition or even where he is. The physician has determined that his dementia is getting more severe and he is showing signs of multi-system failure. It is unlikely, he will ever be stable enough to be discharged from the hospital but that he will likely live another few months on a ventilator.
There is no ‘Advance Directive’ and no evidence of his wishes. He has an estranged wife of 50 years and 2 children, all of whom live in another city. He has an adult friend, Ben, who visits him daily and have been close friends since his wife left 10 years ago. Ben asks the physician to discontinue dialysis and the ventilator. The wife says she doesn’t care but the children insist everything should be done. To save their father, neither of which are willing to come to the hospital to visit him. What does the physician do?
TABLE 2-1 Four Topics Method for Analysis of Clinical Ethics Cases
Medical Indications: The Principles of Beneficence and Nonmaleficence
What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
The condition of the patient is chronic and is non-curative.
What are the goals of treatment?
The treatment is aimed to achieve the maintenance of the patient (Toh et al., 2018).
In what circumstances are medical treatments not indicated?
Physiological conditions refer that the condition is non-curative.
What are the probabilities of success of various treatment options?
The probabilities of success of the treatment are scientific and ethically it is futile.
In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?
The treatment of the patient is aimed to achieve the maintenance of the patient and to save a life.
Patient Preferences: The Principle of Respect for Autonomy
Has the patient been informed of benefits and risks, understood this information, and given consent?
The patient was informed and the consent was conveyed, though it has to be decided by the decision-maker (Toh et al., 2018).
Is the patient mentally capable and legally competent, and is there evidence of incapacity?
The patient has been suffering from dementia and is not mentally competent.
If mentally capable, what preferences about treatment is the patient stating?
If incapacitated, has the patient expressed prior preferences?
The patient has expressed the preferences to the friend.
Who is the appropriate surrogate to make decisions for the incapacitated patient?
Usually, a wife and children are surrogate to make decisions for incapacitated patients (Toh et al., 2018).
Is the patient unwilling or unable to cooperate with medical treatment? If so, why?
The patient is incapacitated therefore, medical treatment is being decided by the relatives and physicians (Toh et al., 2018).
Quality of Life: The Principles of Beneficence and Non-maleficence and Respect for Autonomy
What are the prospects, with or without treatment, for a return to normal life, and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
With or without treatment, no wishes are being displayed by the patient. The children want to continue the treatment for the betterment of the patient's life (Pozgar, 2019). Shortfalls may be observed to be severe conditions of dementia and kidney disease may also proliferate.
On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
There were no patient’s desires and preferences shown. The children can judge that the treatment given was appropriate or not. Lastly, the physicians applying the principles of non-maleficence would result in no harm by the treatment (Toh et al., 2018).
Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
Ethically, physicians can terminate treatment however, the physician in the cases where the patient has no neurological responses may ignore the preference of the patient.
What ethical issues arise concerning improving or enhancing a patient’s quality of life?
Ethical issues such as no important and noteworthy goal other than maintenance are existing in this state. The patient is mentally incapacitated whose preferences are not expressed, so physicians are acting for the best recommendations as per law.
Do quality-of-life assessments raise any questions regarding changes in treatment plans, such as forgoing life-sustaining treatment?
Life-sustaining treatment plans are preferred by the physicians however if the result is futile, physicians are no longer under obligation to initiate or continue the management of the patient (Toh et al., 2018).
What are the plans and rationale to forgo life-sustaining treatment?
First of all, the patient's desires and preferences are favored unless the patient is mentally incapacitated. Physicians can terminate the treatment if the result is negative and if there is no hope of recovery (Pozgar, 2019). However, some laws allow the patient and physician to intervene in the treatment plan.
What is the legal and ethical status of suicide?
It is legally allowed in various countries and states including but not limited to California, Colorado, New Jersey and Montana. It is still not permitted legally in other than 9 states.
Contextual Features: The Principles of Justice and Fairness
Are there professional, inter-professional, or business interests that might create conflicts of interest in the clinical treatment of patients?
If the patient has some legal surrogate then he/she can conflict in decision making (Pozgar, 2019).
2. Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
In case the patient is mentally incapacitated then physicians and the relations can decide on behalf of the patient keeping the ethics of beneficence and no-maleficence (Toh et al., 2018).
What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
The Health Insurance Probability and Accountability Act 1996 includes the standards, possibility and limits of privacy. Physicians may share the registers for discussion while managing without patient approval. The HIPPA does not deliberate the validity of sharing private material with other individuals at risk.
Are there financial factors that create conflicts of interest in clinical decisions?
Patients social and financial state is very important in making decisions such as non-affordability of expensive procedures recommended by the physicians may not be incorporated by the patients due to lack of financial resources (Bryan et al., 2019).
5. Are there problems of allocation of scarce health resources that might affect clinical decisions?
Non-availability of funds to carry out clinical procedures such as surgeries in the critical care units. No availability of appropriate equipment, skilled staff and professions also affect the clinical decisions. If a therapy necessary for the patient is not available in the facility, the nurses or the professions may not be able to accommodate the patient and its outcome in loss of life.
6. Are there religious issues that might influence clinical decisions?
The difficulty of education related to faith and religiousness in health care practice expresses to the statement that patient and physician morals can occasionally interconnect in a way that clues up to clash and ethical distress (Bryan et al., 2019).
What are the legal issues that might affect clinical decisions?
Numerous decisions such as decisions by the court including the legal permission of assisted suicide may encounter within patient and doctor. The doctor may or may not be willing to accept the decision but it limits him to follow the legal instructions (Pappas, 2015).
Are there considerations of clinical research and education that might affect clinical decisions?
Some studies have proved that the education, awareness and the research have a profound effect on the quality of life of a patient and it helps in prompt recovery.
9. Are there issues of public health and safety that affect clinical decisions?
Yes, various decisions such as conflicts of interest exist for example, when a hospital facility allows for an abortion or other clinical procedure and the surgeons are not willing to do so. If a patient does not aware of the disease and the treatment and desired to retain the condition that may become fatal for the person.
10. Are there conflicts of interest within institutions and organizations (e.g., hospitals) that may affect clinical decisions and patient welfare?
The risk occurs when independent witness would enquire whether surgeons are excessively influenced by reflections of noteworthy particular interest.
The decision making is directly linked with the policies and the standards of a healthcare facility. The four topics method is an effective and well-organized technique for the physicians and the nurses to decide the illnesses of the patient (Toh et al., 2018). As it has been shown that the decision making is affected by the socio-economic status of the patients, rules of a healthcare facility, court decisions and the treatment plans (Pozgar, 2019). The four topics method is an operative strategy in the healthcare facilities to improve the health of the patient. It effectively describes the principles of the beneficence, justice and the non-maleficence in healthcare decisions.
Pozgar, G. D. (2019). Legal and ethical issues for health professionals. Jones & Bartlett Learning.
Toh, H. J., Low, J. A., Lim, Z. Y., Lim, Y., Siddiqui, S., & Tan, L. (2018). Jonsen’s Four Topics Approach as a Framework for Clinical Ethics Consultation. Asian Bioethics Review, 10(1), 37-51.
Pappas, S. C. (2015). Ethical issues in end-stage liver disease: a framework for assessment and the challenges. In Complications of Cirrhosis (pp. 347-353). Springer, Cham.
Bryan, D. S., & Angelos, P. (2019). How to Solve Ethical Conflicts in Everyday Surgical Practice: A Toolbox. In Surgical Ethics (pp. 305-311). Springer, Cham.
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