GUIDELINES FOR ETHICAL DECISION MAKING
It is important for the individual physician to find or de-velop guidelines for decision making that can be applied consistently in facing ethical dilemmas. Guidelines con-sisting of several logical steps can aid the practitioner in analyzing and resolving an ethical problem. The approach that follows incorporates elements of several proposed schemes and is affirmed by ACOG.
· Identify the decision makers. The first step in addressingany problem is to answer the question, “Whose decision is it?” Generally, the patient is presumed to have the au-thority and capacity to choose among medically accept-able alternatives or to refuse treatment. An individual’s capacity to make a decision depends on that individual’s ability to understand information and appreciate the im-plications of that information when making a personal decision. If a patient is thought to be incapable of mak-ing a decision or has been found legally incompetent, a surrogate decision maker must be identified.
· In the ab-sence of a durable power of attorney, family members have been called on to render proxy decisions. In some situations, the court may be called on to appoint a guardian. A surrogate decision maker should make the decision that the patient would have wanted or, if the pa-tient’s wishes are not known, that will promote the best interests of the patient. The physician has an obligation to assist the patient’s representatives in examining the issues and reaching a resolution.
· Collect data, establish facts. It is important to be as objec-tive as possible when collecting the information on which to base a decision. Consultants may be called upon to ensure that all available information about the diagnosis, treatment, and prognosis has been obtained.
· Identify all medically appropriate options. Using consulta-tion as necessary, identify all of the options available, including those raised by the patient or other con-cerned parties.
· Evaluate options according to the values and principles in-volved. Start by gathering information about the valuesof the involved parties, the primary stakeholders, and try to get a sense of the perspective each is bringing to the discussion. The values of the patient generally will be the most important consideration as decision mak-ing proceeds. Then, determine whether any of the options violates ethical principles that all agree are im-portant. Eliminate those options that, after analysis, are found to be morally unacceptable by all parties. Finally, reexamine the remaining options according to the interests and values of each party. Some alterna-tives may be combined successfully.
· Identify ethical conflicts and set priorities. Try to define theproblem in terms of the ethical principles involved (e.g., beneficence versus respect for autonomy), and weigh the principles underlying each of the arguments made. Studying a similar case may be helpful. In doing so, the physician should look for important differences and similarities between this and other cases.
· Select the option that can be best justified. Try to arrive at arational resolution to the problem, one that can be jus-tified to others in terms of widely recognized ethical principles.
· Reevaluate the decision after it is acted on. Repeat the evalu-ation of the major options in light of information gained during the implementation of the decision. Was the best possible decision made? What lessons can be learned from the discussion and resolution of the problem?