Eric Swirsky, JD, MA Director of Graduate Studies Clinical Assistant Professor Ethical Decision-making © 2017 Eric Scott Swirsky Seven Step

Eric Swirsky, JD, MA
Director of Graduate Studies
Clinical Assistant Professor

Ethical Decision-making

© 2017 Eric Scott Swirsky

Seven Step Decision-making Process

1. Identify the type of moral or ethical dilemma
2. Reflect on personal bias or assumptions
3. Gather relevant information
4. Consider stakeholder interests and values
5. Explore practical alternatives
6. Complete and justify the action
7. Evaluate the process and outcome

Case Example

A 24 year-old graduate student develops a severe
headache and a stiff neck and is brought to the ER by a
friend. Physical exam shows a patient with a
temperature of 103°F and a stiff neck. After obtaining
informed consent, a spinal fluid exam reveals cloudy
fluid with a white cell count of 2,000 and with bacteria
suggesting pneumococcal meningitis. Antibiotics are
recommended but the patient refuses. He offers no
reason for his refusal.

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

© 2017 Eric Scott Swirsky

• Moral Distress

• Ethical Dilemma

• Moral Agency

• Locus of Authority

Step One — Identify the Type of Ethical Problem

© 2017 Eric Scott Swirsky

• Gut reaction

• Identify personal assumptions, biases, emotions, and
values

• Conflicting personal and professional values

• Impact on decision-making

Step Two – Reflect on Personal Bias

© 2017 Eric Scott SwirskyStep Three – Gather Info

Medical Indications

The Principles of Beneficence and Nonmaleficence

1. What is the patient’s medical problem? history?
diagnosis? prognosis?

2. Is the problem acute? chronic? critical? emergent?
reversible?

3. What are the goals of treatment?
4. What are the probabilities of success?

Patient Preferences
The Principles of Respect for Autonomy

1. What are the patient’s preferences for treatment?
2. Has the patient been informed of benefits and risks,

understood this information and given consent?
3. Is the patient mentally capable and legally

competent? Is there evidence of incapacity?
4. If incapacitated, who is the appropriate surrogate? Is

the surrogate using appropriate standards for decision
making?

5. Has the patient expressed prior preferences, e.g.,
living will?

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

Quality of Life

The Principles of Beneficence, Nonmaleficence, and
Respect for Autonomy

1. What are the prospects, with or without treatment, for
return to normal life, and with what physical, mental,
and social deficits might the patient experience even if
treatment succeeds?

2. What ethical issues arise concerning improving or
enhancing a patient’s quality of life?

3. Do quality of life assessments raise any questions
regarding changes in treatment plans, such as
foregoing life-sustaining treatment?

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

Contextual Features

1. Are there family issues that might influence
treatment decisions?

2. Are there financial and economic factors?

3. Are there religious or cultural factors?

4. Are there limits to confidentiality?

5. How does the law affect treatment decisions?

6. Is clinical research or teaching involved?
Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.

© 2017 Eric Scott Swirsky

• Which parties have an interest in the process?

• Which parties have an interest in the outcome?

• Who is directly involved in the case?

• Who is indirectly involved?

Step Four – Consider Stakeholder Interests and Values

© 2017 Eric Scott Swirsky

• Doing nothing

• Time limited trials

• Be creative

• Respecting confidentiality

Step Five – Explore Practical Alternatives

© 2017 Eric Scott Swirsky

The goal of analysis is to determine the range of
ethically acceptable options and take action.

Use ethical theories or approaches to justify action

Step Six – Complete the Action

© 2017 Eric Scott Swirsky

• What went well, and why do you think so?

• Most challenging aspects? Compare to other
situations? What future applications?

• Who helped most? Feedback from patient, family,
care team, others?

• What did you learn? What would you do differently?

Step Seven – Evaluate the Process and Outcome

Case Example

A 24 year-old graduate student develops a severe
headache and a stiff neck and is brought to the ER by a
friend. Physical exam shows a patient with a
temperature of 103°F and a stiff neck. After obtaining
informed consent, a spinal fluid exam reveals cloudy
fluid with a white cell count of 2,000 and with bacteria
suggesting pneumococcal meningitis. Antibiotics are
recommended but the patient refuses. He offers no
reason for his refusal.

Siegler, M. Teaching Clinical Medical Ethics. PowerPoint presentation, MacLean Fellowship 2011-2012.