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Special Report

Table 1: The Four-quadrant Approach Medical Indications

Other approaches to healthcare ethics are also relevant to case analysis, for example, a virtue-based approach.7

Patient Preferences

Patient’s medical problem, prognosis, Does the patient have capacity? If so, goals of treatment, probabilities of what does he/she want? If not, has success, treatment options, patient benefits.

he/she expressed prior preferences? What is in his/her best interests?

Quality of Life What impairment/distress is the Contextual Features Are there family factors that may

patient experiencing? Will the quality influence decision-making? Are there of life post-intervention be acceptable religious, cultural or legal matters that to the patient? Are there plans for need to be taken into account? Are palliative care?

there conflicts of interest? Adapted from Jonsen et al., 2006.9 Also see McCarthy et al., 20106 and Sokol, 2008.10 The focus of this

conspire to make it impossible to adequately assess what are the best options for that patient in an urgent situation.

• •

When resources are inadequate and it is not possible to give patients and families what they want or need. This may be a hospice bed, equipment or staff.

When a patient lacks capacity and family and professionals have different views in terms of what is in his/her best interests. A person lacks capacity for a specific decision if they are unable to express an informed view on that issue within the required timeframe, as a result of persisting impaired cognition. To have capacity for a decision, a person must understand and retain the relevant information, in order to make and communicate a balanced decision.3

When a patient has capacity but communication barriers prevent adequate open discussion, for example, language barriers that lead to professionals becoming overly dependent on family members for giving information to the patient and in describing the patient’s wishes.

• • •

When patients refuse to share information with family members regarding their diagnosis or prognosis.

When patients or families request interventions that are illegal or considered unethical by professionals.

When patients and their families do not agree on the best course of action when facing decisions around life-prolonging treatments, particularly once capacity is lost or where patients have consistently left most decisions to their family members.

When professionals disagree about the right course of action in relation to patient treatment and care.

There are different approaches to the ethical analysis of practice situations that can help practitioners consider the pertinent concerns that help to make a reasoned decision. One such is the four-quadrant approach (see Table 1).

Each quadrant needs to be considered in relation to the case to help practitioners make ethical decisions. In terms of the values that underpin each quadrant or box, it has been suggested that the four quadrants can be supported by the four principles of biomedical ethics:4,5

respect for autonomy, beneficence, non-maleficence and justice. The medical indications category, for example, is underpinned by beneficence (do good) and non-maleficence (do no harm); patient preferences is underpinned by the principle of respect for autonomy; quality of life captures three principles of beneficence, non- maleficence and justice; and contextual features is underpinned by the principle of justice or fairness.6


approach is on the question ‘how should we live?’ and ‘what ethical dispositions or virtues are required to be an ethical practitioner?’ In ethical decision-making in cancer care it can be agreed that practitioners require a range of virtues, for example: professional wisdom to consider the salient points of a situation and to deliberate well, for example, balancing patient autonomy against distributive justice considerations when resources are scarce; moral courage to, for example, defend patient rights or to take a course of action that may be unpopular; compassion to respond appropriately to patient and family suffering; and, perhaps, respectfulness to demonstrate the value or worth of the person regardless of age, mental capacity status or any other factor. An important point to bear in mind is that a virtue ethics approach can accommodate different decisions, that is, two virtuous practitioners may come to different conclusions in terms of what to do in particular circumstances.

The following case represented a series of difficult decisions for practitioners but also for a neighbour and family member. Here we focus on one difficult decision that had to be made regarding the response of a hospice team. The case has been anonymised and included here with family consent.

Mrs Jackson – Overview of an Ethics Case Mrs Jackson is 92 years of age. She lives alone and has recently been diagnosed with breast cancer. Prior to her diagnosis, she had been independent and had enjoyed the company of friends and neighbours. She has no family in the UK and her son lives in Canada. She now appears low in mood and says that she does not wish to live any longer. She has refused all medical interventions and visits from professionals, including her GP who has known her for many years. She is eating little and relies on an elderly neighbour who visits her twice daily. Her neighbour, Mrs Brown, and her GP are aware that Mrs Jackson has a ‘living will’ saying she does not want hospital admission. One morning, Mrs Brown finds Mrs Jackson on the sofa. She is still fully dressed from the previous evening and incoherent. There are packets of soluble paracetamol around her. A copy of her living will is on the table beside her. Mrs Brown phones the GP and says that ‘something has to be done’. The GP is unable to visit as he has a morning surgery but phones the local hospice. He gives the details to one of the senior nurses who is to attend the morning admissions meeting. The nurse attends the meeting and has to decide whether and how she can make a case for Mrs Jackson’s admission to the hospice.

Using the four-quadrant approach as a framework, what aspects of the case does the hospice team need to consider? Should they offer her a hospice bed?

Medical Indications

The patient’s medical problem, prognosis, goals of treatment, probabilities of success, treatment options and patient benefits, etc. should all be considered.

The hospice team will require a good deal more information about Mrs Jackson’s diagnosis, prognosis and what might benefit her. For example, the label ‘breast cancer’ is unclear and they would want to know the staging, treatment options and current impact. Is it early or end-stage disease? Is it easily treatable (oral hormones) or not treatable? And is it currently asymptomatic or disabling?


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