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January 1998
Assumptions and practice in clinical medical ethics.
Baker AB; Anaesth Intens Care 1997; 25:528-534.
[ see abstract below ]
One of the difficulties with discussions of medical ethics is the principles (fundamental truths) that are said to underlie all ethical reasoning. That is not to say that I believe that non-maleficence, beneficence, autonomy, justice etc. are bad ideas. However, the requirement that these beliefs be taken as truths upon which a hierarchy of reasoning is built can lead to contradictory or unnecessarily limited conclusions.
In a recent issue of Anesthesia and Intensive Care Medicine, Professor AB Baker from the University of Sydney liberates these ideas from traditional hierarchical constraints. He replaces discussion of
"principles" with examination of "assumptions". By reframing basic ideas as sensitive to time and place, he places the focus of the discussion squarely where it belongs: on the perspectives of the patient, family and physician involved in a particular ethical dilemma. He describes 6 basic assumptions (in favor of Life, Autonomy, Beneficence, Equity, Truth and Law) and points out some of the places where correlates of these assumptions overlap or contradict each other. It is often in the areas of overlap or contradiction that important perspective on a particular set of circumstances may be found.
The second half of the paper provides a practical outline of a structured approach to ethical decision-making. Professor Baker recommends that the decision-making process follow a general pattern so
that critical steps are not omitted and that each of the 6 basic assumptions is reviewed for each patient. The stages that he outlines are:
1. Medical Probabilities: the "facts" of the case, several medical opinions and explicit acknowledgement of bias and uncertainties.
2. Medical Practicalities and Possibilities: the options and their perceived odds of success.
3. Ethical Practicalities and Possibilities: including a careful discussion, without trying to prioritize them, of the assumptions and their correlates.
4. Clarification of Values and Choices: arrange the information in some order of priority
5. Justification of Decision: "often the act of documentation crystallizes views or values..."; this stage should if possible be followed by at least 24 hours of reflection before any action is taken
6. Physician Review: the treating physician reviews the decision to be sure it is consistent with their values
7. Action: by those who have taken part in the decision process
8. Reflection: and review of the entire process by the patient, family and health care staff to ensure that remaining doubts and concerns are addressed.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
An orderly scheme of action is proposed to allow for the practical solution of clinical ethical problems. This scheme depends on understanding and discussion, between patient and doctor, of the ethical assumptions involved in any dilemma. Instead of the more usual ethical principals, arguments are presented for six basic ethical assumptions (and their associated corollaries) in favour of Life, Autonomy, Beneficence, Equity, Truth, and Law. Because these assumptions are dependent on the different personal viewpoints of the people involved and not immutable principles, such ethical assumptions are able to be set in different hierachical orders on different occasions permitting in most cases a particular solution specific for that dilemma.
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