(This presentation was given at the ESPHI conference in Washington, DC )

The ability to workup the ethical aspects of a case is an essential part of clinical reasoning The emphasis in the this workup is on a sensible progression from the facts of the case to a morally sound decision. An ethics workup (this one or a similar version) may be used by a variety of health professionals, such as physicians, nurses, social workers etc. With some adjustments, it may also be used by lay persons. Using the five principal steps of the ethics workup, health professionals holding a variety of philosophical and religious positions regarding ethics can share a basic framework for thinking about and discussing morally troubling cases:

1. What are the facts?
It is vitally important to clarify the facts of the case in order to anchor the decision. These facts are both medical and social. For example, both an estimate of prognosis and an understanding of the patient's home situation are often relevant to an ethical decision.
     Persons involved (who?)
     Diagnosis, prognosis, therapeutic options (what)
     Patients preferences, beliefs, values (what?)
     Chronology of events, time constraints on decision (when?)
     Medical setting (where?)
     Reasons supporting claims, goals of current care (why?)
Nurses and social workers may be instrumental in ensuring that the patient/family and other non-medical health professionals understand the medical facts and that the health care team understands pertinent non-medical information about the patient an family. 

2. What is the Issue?
It is necessary to identify the specific ethical issue in the case. The issue may not be ethical., but rather a diagnostic problem or a simple miscommunication. 

3. Frame the Issue:
Some health professionals will explore the issue using only one moral approach. Others will eclectically employ a variety of approaches. But no matter what one's underlying moral orientation, the ethical issue at stake in a given case can be framed in terms of several broad areas of concern, representing aspects of the case which may be on ethical conflict. It is therefore useful, if somewhat artificial, to dissect the case along the lines of the following areas of concern:

a) Identify the appropriate decision maker(s)

b) Apply the criteria to be used in reaching clinical decisions.

1) The specific biomedical good of the patient: One should ask: what will advance the biomedical good of the patient? What are the medical options and likely outcomes?
2) The broader goods and interests of the patient:
One should ask: what broader aspects of the patients good, i.e. the patients dignity, religious faith, other valued beliefs, relationships, and the particular good of the patients choice, are pertinent to the decision at hand?
3) The goods and interests of other parties: 
health professionals must also be attentive to the goods and interests of others, e.g. in the distribution of resources. One should ask: what are the concerns of other parties (family, health care professionals, health care institution, law, society, etc.) and what difference do they make, morally, in the decisions that need to be made about this case? In deciding about an individual case, however, these concerns should generally not be given as much importance as that afforded the good of the individual patient whom health professionals have pledged to serve.

The physician explains the medical options to the patient/surrogates and if indicated makes a recommendation. The patient/surrogate makes an uncoerced informed decision. Limits to patient surrogate autonomy include the bounds of rational medicine/nursing/social work, the probability of direct harm to identifiable third parties, and violation of the consciences of involved health care professionals. In problematic cases the interdisciplinary team may meet to ensure consistency in their recommendations to the patient/surrogate(s)

c) Establish the health care professionals' moral/professional obligations.
Each health care professional must decide what she/he owes the patient, herself/himself, the healthcare team, the health care institution, and other third parties. Conflicts may present.

4. Decide:
In clinical ethics, as in all other aspects of clinical care, a decision must be made. There is no simple formula. The answer will require clinical judgment, practical wisdom, and moral argument the health care professional must ask herself/himself: What should I do? Where can I get help? She/he must analyze the data, reflect on it morally, and draw a conclusion. She/he must be prepared to explain her decision and the moral reasons for it. Sources of justification include:
a) The nature of the health care professional-patient relationship, compatibility of recommended courses of action with aims of profession (internal morality of profession).

b) Approach to ethical inquiry: principle-abased ethics, virtue-based ethics, casuistry, feminist/caring/existentialist ethics, theological ethics.

c) Ethical relevant considerations: 

Balancing benefits and harms in the care of patient
Disclosure, informed consent, and shared decision making
The norms of family life
The relationships between clinicians and patients
The professional integrity of clinicians
Cost-effectiveness and allocations
Issues of cultural and religious variation
Considerations of power (Fletcher, Brody, Miller & Spencer)

d) Grounding and source of ethics: philosophical (based in reason), theological (based in faith), socio-cultural (based in custom)

5. Critique:
It is important to be able to critique the decision that has been made by considering its major objections and then either responding adequately to them or changing one's decision. The health care professional should also seek her/his colleagues' input when time permits. Some cases can even be taken to an ethics committee for further reflection. Retrospective analysis is also useful in preparing "for the next time" such a situation is encountered.