This page contains a Flash digital edition of a book.
Special Report

Difficult Decisions in Cancer Care – Conducting an Ethics Case Analysis Ann Gallagher1

and Craig Gannon2

1. Reader in Nursing Ethics, Faculty of Health and Medical Sciences, Division of Health and Social Care, University of Surrey; 2. Consultant, Palliative Care, Princess Alice Hospice


In everyday oncology practice, practitioners make a wide range of ethical decisions. Many of these decisions will seem straightforward, with those involved agreeing on the right course of action. Other decisions will be difficult, with conflicting perspectives regarding the wishes, needs and best interests of patients. This article suggests an ethical framework to facilitate the decision-making of practitioners in relation to challenging practice situations. We provide an anonymised ‘ethics case’ to examine one difficult decision made by a hospice team. The four-quadrant approach can be used to facilitate reflection and collaborative decision-making.

Keywords Difficult decisions, ethics, cases, oncology practice, ethical framework

Disclosure: The authors have no conflicts of interest to declare. Acknowledgement: The contribution of this article was facilitated by the European Oncology Nursing Society (EONS) who selected the topic area and invited the contribution from the authors. The authors would like to thank the son of ‘Mrs Jackson’ for his consent to discuss this case. Received: 13 January 2011 Accepted: 22 February 2011 Citation: European Oncology & Haematology, 2011;7(2):101–5 Correspondence: Ann Gallagher, Reader in Nursing Ethics, International Centre for Nursing Ethics, Division of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford GU2 7TE, UK. E:

Numerous complex and emotive life choices punctuate the cancer journey. Difficult decisions are unavoidable. Practitioners have an important role in providing information and support to help patients and families make decisions. They also contribute to decisions in terms of care and treatment and make decisions that determine their actions and omissions. The process and impact of decision-making that stems from the ethical aspects of care and treatment can be challenging and practitioners may have to negotiate differences of values and perspectives. In practice and educational contexts it can be helpful to construct complex practice situations as ‘ethics cases’ and to use an ethical framework to analyse the concerns that arise.

Here we introduce one framework for the analysis of ethics cases – the four-quadrant approach – and apply this to one practice situation.

An Ethics Case

When we discuss examples or cases from practice it is not possible to present all of the detail. Therefore, we are selective in including and excluding aspects. This is particularly so when we use cases in discussion of ethical aspects of cancer care. The term ‘case’ can have a broad definition as, for example, ‘a person, a family or a group… a short description of a situation, an event or a piece of work.1


‘ethics case’ such as those presented in professional education or in clinical ethics committees is likely to have particular features. Such cases are constructed in a particular way and generally have the following components.1


There is a ‘plot’ involving some ethical transgression, dilemma, problem or difficult decision.



The case outline is driven by plot, that is, what is done and what happens. There is usually little information about character or context.


The action usually takes place over a short period of time but there may be a summary in terms of what happened over a longer time. There is generally little information about what happens before or afterwards.


The case often ends with a question, e.g. ‘what should the practitioner do?’ Sometimes the ending is given and the reader is invited to say how the practitioner ‘should have acted’.2

Crucially, for our purposes here, the practitioner’s actions are based on a decision.

In providing care and treatment for people who have cancer, practitioners have to make a wide range of decisions. These decisions may relate to a patient’s care and treatment. They may involve information-giving, for example, how much information? To whom? When? Where and how? Practitioners will be involved in discussions with patients and families in terms of treatment and care options. This can also include the move from treatment to palliative care. Decisions become more difficult, raising challenging ethical matters, in the following circumstances:

When patients refuse care or treatment that professionals think they need, or when patients or families request interventions that seem ‘futile’.

When there is a lack of continuity of care, lack of advance care planning and lack of essential documentation. These factors may


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68