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

Motta, Luís Claudio de Souza; Oliveira, Lucas Nicolau de; Silva, Eugenio; Siqueira-Batista, Rodrigo

doi:10.1590/1983-80422016242131

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Research articles • Rev. Bioét. 24 (2) • May-Aug 2016 • https://doi.org/10.1590/1983-80422016242131 copy

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

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

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.

Bioethics; Clinical ethics; Decision-making

Descriptors and search strategies	Databases consulted

	PubMed	Lilacs	SciELO
Bioethics + decision support techniques	3	102	0
Bioethics + decision theory	12	0	0
Bioethics + ethics, clinical	2	27	0
Bioethical issues + decision support techniques	1	0	0
Bioethical issues + decision theory	0	0	0
Bioethical issues + ethics, clinical	4	1	0
Total	152 publications

Title	Method(s)	Major conflicts / consideration on clinical (bio)ethics
Ética na decisão terapêutica em condições de prematuridade extrema [Ethics in therapeutic decisions in extreme prematurity conditions] ¹⁵	• Qualitative study, critical review of literature	• Uncertain prognosis of infants born extremely premature and ethical considerations regarding autonomy and therapeutic decisions
		• The increasing technological advancement in health care and the need for humane intervention - as a (bio)ethics imperative – in the routine of neonatal units
		• Artificial maintenance of vital functions in the context of lack of reasonable recovery expectations
Implantação de comitês de bioética em hospitais universitários brasileiros: dificuldades e viabilidades [Bioethics committees deployment in Brazilian university hospitals: problems and viabilities] ¹⁶	• Qualitative study, case report	• Contextualisation of the development and proposal of bioethics committees in Brazil
	• Scenario: hospital complex of a Brazilian public university	• Little understanding by health professionals regarding the basic (bio)ethical knowledge and ability to deal with moral issues in clinical and care environments
Modelos de tomada de decisão em bioética clínica: apontamentos para abordagem computacional [Decision-making models in clinical bioethics: notes for a computational approach] ¹⁷	• Qualitative study, literature review	• Rise of the applicability of computer systems in clinical practice
	• Qualitative study, literature review	• Presentation of artificial neural networks as computer support to decision-making in clinical (bio)ethics
Tomada de decisão em bioética clínica: casuística e deliberação moral [Decision-making in clinical bioethics: casuistry and moral deliberation] ¹⁸	• Qualitative study, update article	• Presentation and discussion of two procedures for decision-making in clinical (bio)ethics: casuistry and moral deliberation by Diego Gracia
Conflitos éticos na comunicação de más notícias em oncologia [Ethical conflicts in the communication of bad news in oncology] ¹⁹	• Qualitative and exploratory study with semi-structured interviews	• Difficulties experienced by oncologists in the process of communicating bad news
	• Participants: 15 clinical oncologists and surgeons	• Ethical problems arising from tensions between paternalism and respect for patient autonomy
	• Scenario: Municipality of Rio de Janeiro
Cuidados paliativos em pacientes com HIV: princípios da bioética adotados por enfermeiros [Palliative care of patients with HIV: bioethical principles adopted by nurses] ²⁰	• Qualitative and exploratory study	• Appreciation of the principles of respect for autonomy, beneficence, non-maleficence and justice in the practice of palliative care for patients with HIV
	• Participants: 12 nurses
	• Application of structured form and thematic categorical analysis (Bardin)	• Physicians’ difficulty to safely decide when to offer palliative care and the perpetuation of a long process of dysthanasia of patients with HIV
	• Scenario: Infectious diseases clinic and specialised medical service from a public hospital in the city of João Pessoa / State of Paraiba
Bioética clínica e sua prática [Clinical bioethics and its practice] ²¹	• Qualitative study, update article	• Debate on methodological tools that aid in clinical practice and better decision-making
	• Qualitative study, update article	• Presentation of methods for decision-making in clinical (bio)ethics based on the proposals of Diego Gracia, Albert Jonsen and James Drane
Acerca da bioética da beira do leito [About bedside bioethics] ²²	• Qualitative study • Scenario: university hospital in the municipality of São Paulo	• Doctor-patient relationships and the ethics of interaction at the bedside as challenges
		• (Bio)ethics at the bedside as a comparative examination of multiple consequences of assistance and success in the reconciliation and sharing of clinical decisions
Bioética e nutrição em cuidados paliativos oncológicos em adultos [Bioethics and nutrition in cancer palliative care for adults] ²³	• Qualitative study, literature review	• The importance of nutritional treatment in the palliative care of cancer patients
	• Qualitative study, literature review	• Describes the (bio)ethical dilemma between palliative care and nutrition in cancer patients
The principle of respect for autonomy: concordant with the experience of oncology physicians and molecular biologist in their daily work? ²⁴	• Qualitative, empirical study	• (Bio)ethical reflection of a principlist character
	• Phenomenological hermeneutic approach with methods of moral philosophy, through semi-structured interviews	• Vulnerability and external constraint of circumstances experienced as factors that influence patients to consent to any form of treatment
	• Participants: 12 Danish oncologists and molecular biologists	• Circumstances in which the principle of respect for autonomy is not respected and oncologists and molecular biologists decide to include or not patients in treatment
Bioética clínica: contribuições para a tomada de decisões em unidades de terapia intensiva neonatais [Clinical bioethics: contributions to decision-making in neonatal intensive care units] ²⁵	Qualitative study, update article	• Decision-making for neonatal ICU admission based on the principle of distributive justice
	Qualitative study, update article	• Dilemma of NICUs professionals in relation to decision-making regarding who and how should be benefit with available public resources
O médico frente ao diagnóstico e prognóstico do câncer avançado [The physician in the face of the diagnosis and prognosis of advanced cancer] ²⁶	• Quantitative, empirical, study using a multiple-choice questionnaire	• Not providing information of the diagnosis of severe terminal illness as a form of medical paternalism.
	• Participants: 38 medical specialists working with oncology	• (Bio)ethical conflicts involving beneficence and respect for the autonomy of the patient experienced in medical practice
	• Scenario: Hospital de Base do Distrito Federal [Brasilia Base Hospital]
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
	• Qualitative study, update article	• (Bio)ethics and the four skills cited as fundamental to sharing the medical decision-making process

David Thomasma	Diego Gracia	Albert Jonsen	James Drane	Fermin Schramm
Thomasma proposes the establishment of priorities when indicating the best course of action or making decisions:	Gracia recommends a thorough analysis of the clinical history in question, prior to applying the method:	Jonsen considers that moral issues should be analysed based on the clinical history (and not, initially, on the principles):	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:	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. Describe all the facts of the case;	1. Identification of the problem;	1. Stating the case, the moment at which all clinical data necessary for moral analysis is presented;	1. Descriptive, which serves to guide the identification of relevant factors;	1. Moral intuition;
2. Describe the relevant values for all involved;	2. Analysis of the facts: the clearer they are, the easier the ethical analysis will be;	2. Moral review or discussion, based on four categories: medical criteria, patient preferences, quality of life and socioeconomical factors;	2. Rationale, which is used to direct the reasoning about the relevant facts;	2. Exemplification of facts and concrete situations as arguments;
3. Determine the main value at threat;	3. Identification of the implied values, identification of conflicting values, reformulation of the problem;	3. Moral advice stage: it is the physician duty to recommend the treatment, but the patient has the right to accept it or not.	3. Volitional, which refers to the factors considered that served as a basis for decision-making: ordering of goods, principles and decision-making.	3. Use of analogies, facilitating the search for the best arguments;
4. Determine possible courses of action that can protect the largest number of values;	4. Identification of the fundamental conflict;			4. Slippery slope argument;
5. To elect a course of action;	5. Resolution on the fundamental conflict;			5. The role of “devil’s advocate” or debating with oneself;
6. To defend this course of action based on the core values.	6. Decision-making;			6. Search for commitment and critical evaluation of the proposed solution.
	7. Assurance Criteria (defend it publicly and verify whether the decision is wrongful.

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E-mail: bioetica@portalmedico.org.br

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[1] Correspondência Luís Claudio de Souza Motta – Centro Universitário Serra dos Órgãos (Unifeso), Curso de Graduação em Medicina e Curso de Graduação em Fisioterapia. Av. Alberto Torres, 111, Alto CEP 25964-004. Teresópolis/RJ, Brasil.