The ambiguous term ‘clinical
ethics’ can refer either to the ethical analysis of clinical decisions or to
the inclusion of ethical considerations in the care of the patient.  For some, this has created ‘two cultures’ of
bioethicists: those philosophers and theologians who are primarily interested
in analyzing and interpreting clinical decisions, and physicians and other
health care providers who are actively engaged in making those decisions.  In their classic work Clinical Ethics,
first published in 1982, Drs. Albert Jonsen, Mark Siegler, and William Winslade
acknowledged their normative perspective that, "[m]edicine, even in its
most technical and scientific levels…is embedded in a moral context"
(1).  Now in its fifth edition, the
authors reaffirm their commitment to anchor ethical decision making in clinical
practice and not in arm chair philosophy. 
"Clinical ethics," they conclude, "is a practical
discipline that provides a structured approach for identifying, analyzing, and
resolving ethical issues in clinical medicine" (1).

In its original publication in
1982, this clinician’s coat-pocket-sized book on ethics targeted specialists in
internal medicine with its proposal of a method of ethical analysis that would
be closer to the practice of physicians than to the speculation of the
philosophers.  That method is the now
classic "The Four Topics Method," which responds to cases by
examining, in order, medical indications, patient preferences, quality of life,
and contextual features.  In subsequent
editions, ethical issues in adult medicine and pediatrics were addressed.  Now the scope has broadened even more, and
the authors in their thinking and writing have targeted other professionals,
including "health care providers, nurses, social workers, medical
technicians, as well as chaplains and administrators" (4).  Specifically excluded, however, are
practitioners  in obstetrics and
reproductive medicine since the ethical "problems there involve an
enigmatic third party" (4).

For those who want "to go to
the answer" or who are an "in the box" kind of thinker, the four
part ("box") case method seems ideal.  It offers a "straightforward method of sorting out the
pertinent facts and values of any case into an orderly pattern that facilitates
the discussion and resolution of ethical problems" (2).  This technique for analyzing ethical issues,
according to the authors, corresponds to the way clinicians are taught to
analyze medical issues.  Thus it
helps  clinicians understand how
seemingly abstract ethical principles connect with the concrete circumstances
of patient care.  This attempt at a
rapprochement between the theoretical and the practical is initially
illustrated in the book by examining the now classic case of Donald
"Dax" Cowart, the burn victim who related his experience in the
videotape Please Let Me Die and the documentary Dax’s Case.

Following an introduction, the book
is divided into four parts each devoted to one of the four topics.  In each chapter, major concepts are defined,
paradigmatic cases are presented, and resolutions are suggested.  Not only do the authors give their own
beliefs, but they offer as well current opinions of medical ethicists and
references to relevant articles and texts.  
A "Locator" is even included at the back of the book so that a
clinician or reader can use more easily use the text as a reference source.

The four topics method of analysis
begins not with a series of a priori statements about what ought
to be done but with the clinical diagnosis of the concrete problem.  Chapter One, "Indications for Medical
Intervention," reaffirms the dictum that good clinical ethics will depend
upon good clinical facts — clarity about the patient’s medical condition.  Specific medical interventions discussed in
the first chapter include cardiopulmonary resuscitation (CPR) and Do Not Attempt
Resuscitation (DNAR) orders. 
Inappropriate treatments are briefly covered as well, especially as they
revolve around the often ambiguous notion of medical futility.  The chapter closes with a brief treatment of
the care of a dying patient and the definition of death, either by
cardiorespiratory criteria or brain criteria.

The second topic, and chapter,
essential to the analysis of a clinical ethical problem, is "Patient
Preferences."  Once the medical
indications are clarified and the patient is told what can be done, it
is up to the patient to decide what of what can be done ought to be
done.  Both the ethical and legal facets
of the physician-patient relationship are discussed, and the authors, echoing
Immanual Kant and J. S. Mill, conclude that, "[c]onstraint of a person’s
free choices is morally permissible only when one person’s preferences and
actions seriously infringe on the rights and welfare of another"
(48).  Featured in this chapter is an
exploration of the way patient preferences ought to be expressed through the
process of informed consent.  The
authors argue that, with respect to disclosure,  "[t]he reasonable person standard may be ethically
sufficient, but the subjective standard is ethically ideal" (52).

Chapter Three discusses
"Quality of Life" within the context of clinical care and not as an
abstract concept.  The authors reaffirm
their belief that evaluation of quality of life, however difficult, is always
relevant to appropriate patient care: 
"The most fundamental goal of medical care," they suggest,
"is the improvement of the quality of life for all those who need and seek
care" (105).  Helpfully
distinguishing between the "personal evaluation" and the
"observer evaluation" of the patient’s quality of life, this chapter
explores the ethical and legal implications of this concept for difficult end
of life issues such as foregoing treatment, euthanasia and assisted suicide,
and suicide.   

Chapter Four, "Contextual
Features," reviews the social, legal, economic, and institutional factors
that impinge on clinical and ethical decision making.  It offers brief discussions of the ethical issues involving (1)
physician responsibilities beyond those to the patient; (2) physician’s
confidentiality; (3) the economics of health care, including organizational
ethics; (4) "rationing" scarce health care resources; (5) religious
belief; (6) legal concerns; (7) clinical research; (8) clinical teaching
responsibilities; (9) occupational medicine; and (10) public health.  An examination of the goals of (11) ethics
committees and (12) ethics consultation concludes the chapter and book.  

Given the joint authorship of this book by an
ethicist, a physician, and a lawyer, and the growing success of "The Four
Topics Method," it is not too surprising that, in this latest edition, the
authors offer their methodology as a way to improve patient care literally at
the bedside.  They suggest that it be
used as a heuristic for healthcare providers, patient, and family as they determine
the ethical dimensions of a patient’s care. 
Thus a pullout card of the four topics chart is included at the end of
the book for quick reference.  However
slight, this decentering of clinical ethics from the original clinician thrust
of the text, focusing on the physician-patient relationship, opens the door to
future discussions about the relation between ethical theory and moral
practice.

Blending elements of casuistry with
principle-based reasoning, this new edition of the now classic Clinical
Ethics offers, as its subtitle claims, 
"A Practical Approach to Ethical Decisions in Clinical
Medicine."  Eschewing the academic,
this book delivers on its promise and responds to the needs and convenience of
practicing clinicians. 

© 2005  Larry
D. Hultgren

Larry Hultgren
describes himself as follows:

A.B. Grinnell College majoring in Philosophy and
Religion; Ph.D. Vanderbilt University in Philosophy. Currently Professor of Philosophy
at Virginia Wesleyan College, Norfolk, VA.
Since I am at a liberal arts college, my teaching runs the gamut of philosophy
offerings. I am especially interested in interdisciplinary pursuits, and I
direct the college’s Social Ecology Program and our innovative PORTfolio
Project, which attempts to bring the liberal arts to life for our students by
connecting the classroom with real world experiences. I also serve on the
Bioethics Committee of the Children’s Hospital
of the King’s Daughters in Norfolk, VA, and serve on the Board of Directors
of the Bioethics Network of Southeast Virginia.

Categories: Philosophical, Ethics