ideal ethics answer

[mattg]

What is the ideal way to structure an answer to an ethical question?

I know there are several posts on ethics questions, but it seems that how to answer an ethical question varies between people... any ideas on what the best way to structure an answer to one is?

 

My current understanding is:

-Acknowledge the ethical conflict - state what it is and why it is an ethical issue

-Show that you understand and appreciate both sides of the issue - talk about each side and how it pertains to the patient, any legal implications, the patient's family, the doctor's integrity, society, etc. (?)

-Describe how you would handle it - what you would do, anyone you would ask advice from, etc., and also why you would do this

 

i dunno, I just kind of thought of that outline right now... I never really had a solid outline of how to answer ethical questions... any ideas?

[aKGDH]

Actually I think that's a pretty good outline. I would agree with it and most certainly follow it whenever possible for any ethical questions.

 

The questions are usually quite difficult though and coming up with an 'ideal' answer is next to impossible. So as long as an organized response is answered and reasonable, logical and appropriate decision-making is utilized, you can't go too wrong..

[mattg]

I agree that you can't plan for an ideal answer per se, but I think that a general structure can be applied to answering most, if not all, ethical questions. Just trying to get a discussion going with regards to what makes up an ideal *structure* for ethics answers.

[estairella]

Here is how I went about it for my MMI stations... pretty similar to what you did.

 

1. Acknowledge the ethical conflict. Identify the ethical principles involved

 

2 & 3. I would first argue the side I think is correct. Then I would provide a counter-argument, "on the other hand" or "however, others would say that". Finally, I would address the issues raised in the counter-argument and reaffirm that "based on this, I believe my initial argument is the appropriate way to address this"

 

Usually, they will then ask you follow-up questions. Something like "But what if [variable changed]". Obviously it depends on the situation, but usually you should stick with your original choice... better yet is if your original choice takes into account what they were going to ask.

 

If you change your answer based on a small change in detail, then it can seem like you're not really using an ethical framework to address issues, but instead you're going with your gut feeling.

[dreamer87]

Here is how I went about it for my MMI stations... pretty similar to what you did.

 

1. Acknowledge the ethical conflict. Identify the ethical principles involved

 

2 & 3. I would first argue the side I think is correct. Then I would provide a counter-argument, "on the other hand" or "however, others would say that". Finally, I would address the issues raised in the counter-argument and reaffirm that "based on this, I believe my initial argument is the appropriate way to address this"

 

Usually, they will then ask you follow-up questions. Something like "But what if [variable changed]". Obviously it depends on the situation, but usually you should stick with your original choice... better yet is if your original choice takes into account what they were going to ask.

 

If you change your answer based on a small change in detail, then it can seem like you're not really using an ethical framework to address issues, but instead you're going with your gut feeling.

 

good post!

[Guest viscous]

Here is how I went about it for my MMI stations... pretty similar to what you did.

 

1. Acknowledge the ethical conflict. Identify the ethical principles involved

 

2 & 3. I would first argue the side I think is correct. Then I would provide a counter-argument, "on the other hand" or "however, others would say that". Finally, I would address the issues raised in the counter-argument and reaffirm that "based on this, I believe my initial argument is the appropriate way to address this"

 

Usually, they will then ask you follow-up questions. Something like "But what if [variable changed]". Obviously it depends on the situation, but usually you should stick with your original choice... better yet is if your original choice takes into account what they were going to ask.

 

If you change your answer based on a small change in detail, then it can seem like you're not really using an ethical framework to address issues, but instead you're going with your gut feeling.

 

But that assumes that ethical principles are abstract ideals. What if in the follow up question, the changed variable is such that it necessitates that you change your decision in order to be more ethical? Maybe they want to see if the person is stubborn and cannot change his position if it needs to be changed due to new circumstances?

[UTPEOPLE]

But that assumes that ethical principles are abstract ideals. What if in the follow up question, the changed variable is such that it necessitates that you change your decision in order to be more ethical? Maybe they want to see if the person is stubborn and cannot change his position if it needs to be changed due to new circumstances?

 

If the variable is changed enough that the same approach doesnt work... Then it is a different ethical question all together. For example, you cant discriminate against older individuals for receiving organ donations, but you sure can discriminate against alcoholics....

[estairella]

But that assumes that ethical principles are abstract ideals. What if in the follow up question, the changed variable is such that it necessitates that you change your decision in order to be more ethical? Maybe they want to see if the person is stubborn and cannot change his position if it needs to be changed due to new circumstances?

 

If the variable is changed enough that the same approach doesnt work... Then it is a different ethical question all together. For example, you cant discriminate against older individuals for receiving organ donations, but you sure can discriminate against alcoholics....

 

I do believe that for most ethical situations there is an appropriate framework that TAKES INTO ACCOUNT changing variables. UTPEOPLE's example is a perfect one:

 

Ethical situation: If you had 1 liver but 2 people who needed transplants, a 60-yo (first in line) and a 20-yo (second in line), who would you give it to?

Not so great answer: It would be unethical to discriminate against the older person simply due to his age, therefore he should receive it because he was first in line.

 

Follow-up: Okay, let's change the situation. What if they were both 20 yo's but the one who was first in line was an alcoholic.

Not so great response: Umm.. okay well IN THIS CASE you can discriminate, because it's okay to discriminate against alcoholics. So the second guy should get it!

 

See, the problem here is you're not answering by presenting an ethical framework, you've jumped DIRECTLY TO the response.

 

There are two ethical principles here. One is that of justice - a fair distribution of our limited healthcare resources; in this case, viable livers for transplantation. Justice would dictate that whoever was first in line should get the transplant (the most 'fair'). The other is that of beneficence - what would provide the most benefit. The 20 yo MAY benefit more than the 60 yo (more QALY) and the non-alcoholic LIKELY WILL benefit more (more QALY). So in the above, you are saying in one situation, justice is more important and in another situation, beneficence is more important. This is what I mean by inconsistency.

 

Now the appropriate way to do it:

 

Ethical situation: If you had 1 liver but 2 people who needed transplants, a 60-yo (first in line) and a 20-yo (second in line), who would you give it to?

Great answer: In this case, beneficence outweighs justice regarding who should receive an organ transplant. While it may not be fair that some people will wait on the list a long time while others get off it shortly, intuitively, it makes even less sense for an organ to go to the first one on the list - if the organ is not type-matched, there is a high probability it will be rejected, and this is an immense waste of an already-limited resource. How old these patients are would not weigh into my decision, instead, I would do a thorough clinical assessment of their physical and psychological status as well as the stage of their liver disease to best assess who would benefit the most (survive the most years) from receiving this transplant. I would make my decision based on this assessment alone

 

Follow-up: Okay, let's change the situation. What if they were both 20 yo's but the one who was first in line was an alcoholic.

Great answer #2: As I previously mentioned, I would look to see who would benefit most from receiving this implant. One may conjecture that - depending on the severity of the first patient's alcoholism - he would be a poor candidate, both because of his poor compliance and the risks of subsequent harm to the transplanted liver due to alcohol, but once again, I would need to do an appropriate assessment before making my decision.

 

PS. Yes I know that you wouldn't be put on a waiting list in the first place if you were a chronic alcoholic, but it's for the same reasons I outlined - not because we are discriminating against alcoholics for being alcoholics, but because statistically, they have a poor prognosis with a liver transplant.

[Guest viscous]

I do believe that for most ethical situations there is an appropriate framework that TAKES INTO ACCOUNT changing variables. UTPEOPLE's example is a perfect one:

 

Ethical situation: If you had 1 liver but 2 people who needed transplants, a 60-yo (first in line) and a 20-yo (second in line), who would you give it to?

Not so great answer: It would be unethical to discriminate against the older person simply due to his age, therefore he should receive it because he was first in line.

 

Follow-up: Okay, let's change the situation. What if they were both 20 yo's but the one who was first in line was an alcoholic.

Not so great response: Umm.. okay well IN THIS CASE you can discriminate, because it's okay to discriminate against alcoholics. So the second guy should get it!

 

See, the problem here is you're not answering by presenting an ethical framework, you've jumped DIRECTLY TO the response.

 

There are two ethical principles here. One is that of justice - a fair distribution of our limited healthcare resources; in this case, viable livers for transplantation. Justice would dictate that whoever was first in line should get the transplant (the most 'fair'). The other is that of beneficence - what would provide the most benefit. The 20 yo MAY benefit more than the 60 yo (more QALY) and the non-alcoholic LIKELY WILL benefit more (more QALY). So in the above, you are saying in one situation, justice is more important and in another situation, beneficence is more important. This is what I mean by inconsistency.

 

Now the appropriate way to do it:

 

Ethical situation: If you had 1 liver but 2 people who needed transplants, a 60-yo (first in line) and a 20-yo (second in line), who would you give it to?

Great answer: In this case, beneficence outweighs justice regarding who should receive an organ transplant. While it may not be fair that some people will wait on the list a long time while others get off it shortly, intuitively, it makes even less sense for an organ to go to the first one on the list - if the organ is not type-matched, there is a high probability it will be rejected, and this is an immense waste of an already-limited resource. How old these patients are would not weigh into my decision, instead, I would do a thorough clinical assessment of their physical and psychological status as well as the stage of their liver disease to best assess who would benefit the most (survive the most years) from receiving this transplant. I would make my decision based on this assessment alone

 

Follow-up: Okay, let's change the situation. What if they were both 20 yo's but the one who was first in line was an alcoholic.

Great answer #2: As I previously mentioned, I would look to see who would benefit most from receiving this implant. One may conjecture that - depending on the severity of the first patient's alcoholism - he would be a poor candidate, both because of his poor compliance and the risks of subsequent harm to the transplanted liver due to alcohol, but once again, I would need to do an appropriate assessment before making my decision.

 

PS. Yes I know that you wouldn't be put on a waiting list in the first place if you were a chronic alcoholic, but it's for the same reasons I outlined - not because we are discriminating against alcoholics for being alcoholics, but because statistically, they have a poor prognosis with a liver transplant.

 

Ok. Lets say then you are given a totally different 3rd question involving ethics for which you determine that justice would be given more priority over beneficence after following a certain framework, would not that be taken as being inconsistent too? In other words, what would allow you to determine which principle takes priority over other as you go from one case to another?

[estairella]

Ok. Lets say then you are given a totally different 3rd question involving ethics for which you determine that justice would be given more priority over beneficence after following a certain framework, would not that be taken as being inconsistent too? In other words, what would allow you to determine which principle takes priority over other as you go from one case to another?

 

In the situation of organ transplant, the only time justice would prevail over beneficence is if a) it's mandated by law or beneficence is equal (if identical twins both need a liver to live 10 more years each, you would give it to the one who's been waiting longer). In neither of those cases is there an ethical conflict (though you might argue doing what's ethically right and doing what's legally right is a conflict of its own.. but that might be moral lol).

 

If you are given a completely different situation, then you have to come up with a framework that addresses that particular situation and all related situations. For example, let's say you're a family doctor and some patients want to take up more of your time. Do you let them? Really, you could argue either way.

 

You can argue that it's more ethical if everyone gets their equal share of healthcare resources (i.e. justice) so you give a maximum of 15 minutes to everyone. After all, if you gave some people more time, you take away that time from other patients (who might need it just as much). The interviewer would likely follow-up with, "well what if someone really needed more time to address their problem" - you can say, well they have to rebook a longer appointment to keep the system fair or they can be referred to a specialist if that's what they need or if it's an emergency they should go to the ER.

 

You can also argue that it's more ethical if, based on certain evidence-based criteria/symptoms, you triaged your patients into low, medium and high-need (beneficence). This would maximize the efficacy of what you're doing. The interviewer might follow-up with "but what if someone came in with a common cold, but had a more serious problem that you could have found out if you spent 15 minutes instead of 5 minutes". You would explain that you want to maximize health for your entire population of patients, and following this system will statistically be the most beneficial - so even if you cannot say you provided the best possible care for any individual patient, overall you provided the best care to all your patients.

 

Since there's no "right" ethical answer in this case (that I'm aware of), by choosing and sticking with an argument (and being able to defend it), you look like you've thought this through. If you switch back and forth, even with the best of intentions, you look like you're just kind of on the fence (or you just don't know). That's my opinion, in any case.

[Thio]

Those are some awesome ideas and outlines for ethically related questions, good stuff !