Ethical Considerations in the Treatment of Head and Neck Cancer

David P. Schenck, PhD

Disclosures

Cancer Control. 2002;9(5) 

In This Article

Ethical Decision-Making Model

A simple yet effective algorithm for approaching biomedical ethical decisions is presented in the Figure.

Algorithm for biomedical ethical decision making. This scheme is an adaptation of a method for analyzing and working up clinical ethical problems used in the Schools of Medicine and Nursing at Georgetown University.

The first task in the ethical decision-making process is to ascertain the medical facts of the case. The second step is to assess relevant nonmedical issues, which is more challenging. It is here that we must attempt to come to some understanding of the state of mind of patients, their view of their illness history, their relationships with others and their social situations, the spiritual aspects of their lives, and any other factors that will help in understanding the context in which they will have to make a decision.

These steps are followed by an assessment of the goods important in the case. The most immediate concern is obviously what is good for the patient medically, but that is followed closely by an attempt to understand the patient's overall good -- ie, psychological good, good in terms of family and relations, spiritual good,and good in terms of the patient's preceding life history and values. While ensuring the good of the patient is the primary goal, it is insufficient by itself, for the goods of others must also be considered; acting for the good of the patient would be inappropriate if that would mean a lack of respect for the goods of others. Physicians, hospitals, and other health care providers cannot be expected to violate their own values or stated policies.

The principles that apply in the case at hand are then examined, specifying what a given principle means in this case and balancing it against the moral claims of each of the others.[22] This exercise may not be sufficient to guide us to a resolution of an ethical problem, however, especially if we refuse to accept autonomy as a de facto trump principle. By themselves, principles can become mere abstractions, perhaps even sterile nostrums for dealing with complex issues. Medicine, if anything, is a human and humane practice; it concerns not only the care of others, but also the relationship of the healer with the sufferer.[27] Thus, the nature of that relationship is extremely important. Virtue ethics, another bioethical approach that has received increased attention in recent years, addresses the nature of the relationship between patient and healer, with particular attention to the character of the physician. Pellegrino and Thomasma[23] have presented a detailed analysis of how they interpret the virtues that are essential to medical practice. These virtues include phronesis, compassion, fidelity to trust, integrity, self-effacement, justice, fortitude, and temperance.

Phronesis is prudence, the kind of prudence that is defined as practical wisdom. It is the ability to choose right action with respect to all of the other virtues. Prudence is the virtue that shapes and guides the other virtues used in disposing one towards right action and good ends. It helps the agent address complex circumstances and discern the right and good in particular acts. In medicine, this means effecting a right and good healing action that is not only correct in terms of medical science, but also morally good in terms of all the interests of patients -- their values, aspirations, needs, and beliefs. The character of physicians then depends on their ability to exercise prudence in the proper application of other virtues and principles.

Whether principles or virtues are considered first in approaching an ethical decision is irrelevant. It might seem preferable to work through clarification and balancing of the principles with one another first and then reflect on a tentative decision based on that examination through a thoughtful application of the virtues. The reverse may be just as effective. In any case, a consideration of the virtues in combination with principles achieves several objectives. It enriches the discussion of the case, focusing our attention on the human dimension of the situation and, chiefly through the careful use of prudence, it serves as a guide to a proper understanding and application of principles. While there is always room for error in trying to do the right thing, and while there is often no "right"answer to bioethical dilemmas, the approach described here, followed by a comparison of the case at hand with any prior similar cases, provides more guidance than reliance on principles and rules alone.

The following two cases examine the dynamics of principles and virtues in the context of different individuals and circumstances.

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