Decision-making in clinical ( bio ) ethics : contemporary approaches

Taking decisions in the face of moral problems in clinical practice has become a very important aspect for all professionals involved in health care. This study considers this context of uncertainty, in which there are discussions regarding the real benefits and access to new technologies in health, and assumes that any resolution in clinical (bio)ethics results from the principle that respect for the human being is indispensable for correct actions. This article aims to 1) identify in literature some of the aspects that cause anguish in health care professionals and/or researchers in clinical practice, and 2) briefly present the reflections or correlated approaches used in the decision-making process in clinical (bio)ethics of identified cases. This study’s process refers to a review of scientific literature with a defined search strategy.

Decision-making in clinical (bio)ethics: contemporary approaches http://dx.doi.org/10.1590/1983-80422016242131 In the face of the changes that took place during the twentieth century and of the scientific and biotechnological advances -especially in research involving human beings -(bio)ethics emerged as an attempt to provide answers to arising challenges and transformations.Its origin explained the desire for ethics that is not limited to deontological concepts and moral relations of "good relationship", but that would allow reflection and debate regarding health and life sciences, restoring respect, care and protection not only of human beings themselves but of all living beings 1 .
In the mid-1970s, by recognizing that not everything that is scientifically possible is morally correct, the American oncologist and professor Van Rensselaer Potter coined the term "bioethics", conceiving it in one of his works as a "bridge" between the life sciences and the humanities 2,3 .As time went by, (bio)ethics became fundamental for dialogue between different knowledge, disseminating concepts of ethics, morality, religion, law, science, technics and decision-making, seeking to appreciate, describe and propose means capable of protecting everyone involved.
In general, decision-making sets/configures an extremely diverse area, as the decision-making process can be investigated at different levels of complexity, from neurosciences to applied social sciences, finding different concepts, many of which come from management sciences 4 .Significantly, and with specific relevance, are the initial contributions of Bethlem 5 , which initially characterized the decision-making process in a generic model consisting of four stages: 1) the decision to decide; 2) the definition regarding what one is going to decide; 3) the formulation of alternatives; and 4) the definition of the alternative considered most appropriate.The characterization made by Idalberto Chiavenato, which considered decision-making as the process of analysis and choice between several available alternatives to determine the course of action that a person should follow 6 , is also considered relevant.
From a health science perspective, -especially neuroscience and neuroethics 7 -, it is known that the basis of human neurobiological decision-making involves complex neural processes and biochemical events, which have been contemporaneously investigated in order to identify areas and cortical circuits responsible for all activities involved in the decision-making process 8,9 .Significantly, studies published in international scientific literature point to the prefrontal cortex as an important link in decision-making, given its importance in realizing projections and connections to different cortical areas of the central nervous system, also being influenced by them [10][11][12] , and intrinsically correlating with the process of evaluation and filtering emotional and social afferents, which form the basis of the decision-making process 13,14 .
Making decisions in the face of moral dilemmas in clinical practice has become an important issue for all professionals involved in health care, once it shows the ability -or lack of it -to recognize an ethical problem and to then make use of (bio)ethical tools appropriate to each situation at any health care level -primary, secondary, tertiary and quaternary.
In a context marked by significant uncertainty -in which the real benefits and access to new technologies in health are being discussed -and assuming that any decision on clinical (bio)ethics implies respect for human beings, this article aims to 1) identify in literature situations afflicting healthcare professionals and/or researchers in clinical practice; and 2) briefly present thoughts or approaches correlating to the decision-making process in clinical (bio)ethics regarding the identified situations.

Method
The path taken in this study includes a review of scientific literature with a defined search strategy.Initially the appropriate terms were identified in the Descritores em Ciências da Saúde -DeCS -(Health Sciences Descriptors) of the Biblioteca Virtual em Saúde -VHL (Health Virtual Library).The second phase included the completion of a search undertaken in the PubMed, Literatura Latino-Americana e do Caribe em Ciências da Saúde -LILACS (Literature in the Health Sciences in Latin America and the Caribbean) and Scientific Electronic Library Online -SciELO -databases using the descriptors in a combined form, as shown in Table 1.Considering the publication of articles in three languages (Portuguese, English and Spanish), the selected descriptors were: 1) "bioética" (bioethics; bioética); 2) "temas bioéticos" (bioethical issues; discusiones bioéticas); 3) "técnicas de apoio para a decisão" (decision support techniques; técnicas de apoyo para la decisión); 4) "teoria da decisão" (decision theory; teoría de las decisiones); 5) "ética clínica" (ethics, clinical; ética clínica).The articles that compose the sample of this study contemplated the following inclusion criteria: scientific articles published in the last ten years, with the end date defined as 31 st December 2014; publications in indexed journals; and availability of (free) access to the content in full for download.Articles presented only in summary/abstract format and publications that required access to content dependent on Programa de Comutação Bibliográfica -Comut -(Bibliographical Switching Program) were excluded at the discretion of the authors.
The third and final stage involved the selection of texts for inclusion in the review.Articles were chosen by the systematic reading of titles and abstracts, having as criteria the presence in the text of an approach focused on ethics/(bio)ethical practice.After analysing the obtained publications, fourteen articles were chosen, complemented by references and textbooks on related topics.

Results
Articles were subjected to a classification of analytical nature, from which a demonstrative chart (Table 2) was drafted.The chart, in which titles were arranged in ascending order by year of publication, includes the level of knowledge regarding the discussions on the subject of study.• Not providing information of the diagnosis of severe terminal illness as a form of medical paternalism.
• (Bio)ethical conflicts involving beneficence and respect for the autonomy of the patient experienced in medical practice From cure to palliation: concept, decision and acceptance 27 • Qualitative empirical, study, with a questionnaire • Participants: Swedish 1,672 medical professionals and nurses from 10 different specialties, chosen at random • Different perceptions of professionals regarding transition concepts between curative treatments and palliative care, and the respective influence of these distinctions in care strategies • Disagreements between professionals on the team regarding the decision-making concerning the interruption of curative treatment and the start of palliative care • Ethical reflection and analysis on the principles of virtue ethics, professional deontology, consequentialism and casuistry Informed consent and refusal of treatment: challenges for emergency physicians 28 • Qualitative study, update article • Informed consent as a legal right and morally recommended process that enabled patients to be able to participate in the decision process regarding their care • (Bio)ethics and the four skills cited as fundamental to sharing the medical decision-making process

Discussion
Considering the fourteen selected articles, the results demonstrate that the main discussions regarding (bio)ethical issues 29,30 experienced in different health care settings or clinical research are diverse and relate to the debate regarding the autonomy of the subjects involved; the issues referring to beneficence, non-maleficence and justice -concepts prima facie of the principlist school of thought -; the difficulty of access to health goods and services; the vulnerability of the subjects regarding health care; the conflict to share or not clinical diagnoses and bad news directly with patients and/or their families; the obstacles in the doctor-patient or patient-health professional relationship; the issue of informed consent; the dilemma of end of life and maintenance or interruption of the technologies used in critically ill or terminal patients admitted in ICU; the decision-making process not being shared among health teams; and referential from the bioethics of protection vs. the bioethics of intervention.
In the examination of the articles selected and presented in Table 2, it was possible to list some of the aspects glimpsed as relating to decision-making in clinical (bio)ethics, discussed below.

Perceptions regarding conflicts in the diversity of everyday health care practices
The NICUs are health care structures recognized in contemporary societies, especially in Brazil, as essential to the care of new-borns (NB), since they are configured as a space for the care of infants with immediate or potential threat to life 31 .Without proper strategic planning in this sector, NICUs professionals are faced with a (bio)ethical dilemma: how to decide Decision-making in clinical (bio)ethics: contemporary approaches http://dx.doi.org/10.1590/1983-80422016242131 on the choice of which NB should benefit -and howfrom the resources available for neonatal care 25 ?
Although the decline in mortality of live births in extreme prematurity is evident, prolonged time in the very stressful environment of the NICU, the various moments of manipulation and even the resuscitation interventions expose the premature NB to unwanted stimuli that later will be expressed in abnormal brain and sensory development, hearing and vision loss, and language disorders 15 .
It is recognized that artificial life support without reasonable recovery expectations -in cases of severely compromised new-borns -sets (bio)ethical dilemma in clinical practice of NICU professionals, given the possibility of prolonging the suffering of the sick individual and also of their families, putting into question the very protection of human dignity of new-borns in intensive care 15,32 .
Given the above, in the case of neonatology, respect for autonomy appears as a bridge to the consideration of shared decision.Although these patients are unable to decide about their lives, the protection of their dignity involves sharing the decisions of the health team with the patient's parents, who are legally authorized to give consent for performing certain type of treatments 25,32 .Ribeiro and Rego 25 in this case also include in their thinking bioethics of protection and the capabilities approach of Nussbaum 33 as a State responsibility to meet fairly the needs of vulnerable people in their care.

• (Bio)ethical conflicts end of life
In the examination of the elements of the selected articles, it was possible to detect strains in multidisciplinary teams providing care to patients with advanced and / or terminal diseases 34 , especially in the context of palliative care.According to the World Health Organization, palliative care corresponds to the active and total care of patients whose pathogenesis is no longer responsive to curative treatment alternatives.The approach of care is different because it proposes to improve the quality of life for patients as well as of their families or guardians 35,36 .
By proposing improved quality of life, nutrition per se is also pertinent to palliative care, which is necessary in different therapeutic approaches, including feeding through catheter or ostomy.Besides, it has important preventive significance, providing means and routes to feed, reducing adverse effects caused by chemo-toxic treatments and slowing anorexia-cachexia syndrome 23 .
Benarroz et al. 23 depict specifically the (bio) ethical concerns and conflicts with which nutrition professionals deal in the daily oncological palliative care of adults.It is clear that food will not always promote comfort and well-being.On the contrary, undesirable effects of nutritional techniques -in particular, the artificial -are sometimes exacerbating, damaging the primary goal of palliative care.In the referenced article, (bio)ethics participation in nutritionist clinical practice included the principlist aspect, which offered (bio)ethical arguments for dialogue between health staff, patients and family members 23 .
Palliative care was also addressed in the care of patients with HIV in a recent study 20 aimed to investigate which principles of (bio)ethics were considered by nurses in their practice.From the analysis of the empirical material emerged two main categories, which refer to principlist bioethical reflections: 1) respect for the autonomy of patients with HIV under palliative care, allowing them to exercise their right to participate in decisions; and 2) appreciation of the principles of beneficence, non-maleficence and justice in the practice of palliative care for patients with HIV, providing humane conduct to patients and protecting them from possible harm during hospitalization 20 .
In research conducted with twelve Danish physicians and molecular biologists specialised in oncology, there was also reference to Beauchamp's and Childress' principlism.Interestingly, though participants affirmed that respect for the autonomy of cancer patients should always be based on the desires and knowledge of the patient regarding their illness, the behaviour that was usually adopted was to decide without consulting patients or family members when they were considered to lack the necessary competence to make decisions 24 .
In another study 27 it was noted that the decisions regarding treatment options were not always shared between the team and the patient and family, even lacking discussion between the parties involved.At other times, such decisions were characterized as the role of physicians themselves.Moreover, when the teams did not clarify the disease process to the patients and family members, the stress related to accepting the disease was evident.In the study, four (bio)ethics theories were used for the analysis of conflicts and improvement of decision-making: 1) the ethics of virtues; 2) deontology; 3) consequentialism; and finally, 4) casuistry as a strategy for comparison of moral cases and conclusion of events.and morally recommended process that enabled patients to be able to participate in making decisions regarding the care they would receive.From an ethical point of view, four functional skills were identified as fundamental in sharing the medical process of decision-making in clinical emergencies and imminent risk of death situations: 1) the patient's ability to understand information relevant to the decision of his/her treatment; 2) the ability of those involved to appreciate the significance of each information for each situation faced; 3) the ability of health professionals to use reason to contribute to the logical process of treatment options; and 4) the patient's ability to express his/her choice 28,36,37 .

• (Bio)ethical conflicts and communication of bad news in oncology
One of the identified studies, conducted in the Federal District with physicians who provided care to patients with malignant neoplasm 26 , highlighted that informing patients and their families of the diagnosis has been recognized as one of the pillars of the doctor-patient relationship, promoting assurance and providing patients with the possibility of exercising autonomy.In the cases of restricted diagnostic information -prohibited by the Code of Medical Ethics, except when information is likely to bring more harm to the patient -the authors stressed situations related to physicians' "paternalistic" behaviour (to protect patients from suffering), minimizing the occurrence of distress in hopeless contexts (non-maleficence).
Using semi-structured interviews, Geovanini and Braz 19 conducted a study with oncologists focusing on ethical conflicts in the communication of bad news in oncology.The main conflicts were related to fair moral propriety regarding the use of truth in the communication and management of medical relationships with patients' families.The most obvious difficulty faced by respondents related to the unpredictability of the consequences of decisions taken and therefore the behaviour of some in not communicating properly with those involved, culminating in paternalistic attitudes that interfere with the full exercise of patient autonomy 19 .

The role of hospital (bio)ethics committees and commissions
Differently from hospital ethics committees and commissions -that are always composed exclusively of members of one corporation -bioethics committees are necessarily multiprofessional and multidisciplinary, because they propose to deal with more specific references: those of bioethics itself.Although they initially emerged in the United States in the period from 1960 to 1970, since 2005 these committees are now recommended by UNESCO, as stated in Article 19 of the Universal Declaration on Bioethics and Human Rights 38 .In fact, they allow for more extended discussion of more difficult clinical cases from the point of view of decision-making in situations of moral conflict.Through them, forums that involve not only health professionals, but also professionals from other fields and representatives of users and community, were created.
The proposal of the committees is to become an open space focused on dialogue, valuing all individuals involved in the search for conflict resolution in the context of health institutions and improving the care provided to patients.These forums enable cases that require ethical evaluation to be addressed, allowing the opportunity to search for the role of patients and their representatives, as well as offering a greater repertoire of (bio)ethical actions to health professionals and managers 16 .However, these committees and commissions are not intended to eliminate the responsibility of health professionals -or clinical teams -regarding the decisions to be taken in each case 39 .
Interestingly, despite the importance of such committees and commissions, the study considered in this article points to the difficulties still encountered in the implementation of such forums assisting clinical (bio)ethics decisions.Marinho et al. 16 recounts the experience with the implementation of these committees in four health units in Brazilian public universities: they were created through a bottom-up initiative, this means, an initiative starting with the professionals involved with medical education in the hospital, but without effective participation of the unit's managers, little involvement and participation of students from other areas of health, and the absence of some professionals 16 .

Computer support to decision-making in clinical (bio)ethics
The computational approach has become valuable tool to aid decision-making, with applications in the fields of industry, various engineering, finance, commerce, agriculture, health and scientific research itself 17 .
After World War II, artificial intelligence (AI) developed significantly 17,40,41 , seeking to systematize and replicate human intellectual tasks.In this process, the applications of connectionist AI focused on the Drane uses the principles of autonomy and beneficence, besides using as a base a set of moral values captured from the description of the relevant clinical factors, to guide the reflection.The systematization of proposed ethical methodology is structured in three phases: 1. Descriptive, which serves to guide the identification of relevant factors; 2. Rationale, which is used to direct the reasoning about the relevant facts; 3. Volitional, which refers to the factors considered that served as a basis for decision-making: ordering of goods, principles and decision-making.
Schramm considers that both theoretical reasoning (descriptive and comprehensive) and practical reasoning (applied) are indispensable tools of (bio) ethics, and proposes the use of "tools" in light of practical reasoning: 1. Moral intuition; 2. Exemplification of facts and concrete situations as arguments; 3. Use of analogies, facilitating the search for the best arguments; 4. Slippery slope argument; 5.The role of "devil's advocate" or debating with oneself; 6. Search for commitment and critical evaluation of the proposed solution.
From this perspective, a recent study has proposed the use of machine learning algorithms for the development of computer systems to support decision-making in clinical (bio)ethics, incorporating aspects related to the decision-making process, the initial prototype, Bio-Oracle (Bio from "bioinformatics" and Oracle from "Organizer of the Rational Approach in Computational Learning Ethics"), is under development 17 .

Decision-making in clinical (bio)ethics: the methods
The relationship between doctor and patient is often uneven: the first has knowledge concerning the problem afflicting the last.The professional is responsible for the diagnosis, prognosis and treatment options.On the other hand, the patient only has the ability to decide based on a clear and true communication performed by the doctor.Thus, the attitudes of health professionals become critical to the positioning of their patients: who can either be treated as a subject of his/her own life or as an object of therapeutic interventions 22,48 .
In this context, the proposal of clinical (bio)ethics covers all situations that require decision-making in the everyday life of the various health professions or in particular situations in ethics committees.Indeed, Table 3 presents methods developed by different authors with the objective of guiding the analysis of conflicts and moral dilemmas that arise in clinical practice, and of assisting the decision-making process.
In addition to the methods presented, other procedures for decision-making in clinical (bio)ethics, which are also recognized in the literature, are proposed: 1) casuistry and 2) moral deliberation.Casuistry is considered by Albert Jonsen and Stephen Toulmin 51 as a valid tool for discussing (bio) ethical problems in clinical practice.Specifically Moskop 28 studied, in US emergency departments, the use of informed consent as a legal right Decision-making in clinical (bio)ethics: contemporary approaches http://dx.doi.org/10.1590/1983-80422016242131

Table 1 .
Descriptors used, search strategies and number of citations obtained

Table 2 .
Distribution of titles, authors, year of publication, methods, conflicts and considerations regarding clinical (bio)

ethics identified in selected articles Title Method(s) Major conflicts / consideration on clinical (bio)ethics
15

making in clinical (bio)ethics: contemporary approaches
• Little understanding by health professionals regarding the basic (bio)ethical knowledge and ability to deal with moral issues in clinical and care environments Decisionhttp://dx.doi.org/10.1590/1983-80422016242131 17 19 20

Table 3 .
Auxiliary methods for decision-making in clinical (bio)ethics by the author