The Four Topics Chart:

A Tool for Clinical Ethics Case Analysis

Yati Soenarto
Wika Hartanti

Center for Bioethics and Medical Humanities

Faculty of Medicine, Public Health and Nursing

Bioethics Course for Health Professionals – HELP approach

The 2nd Series: Basic Biomedical Ethics
June 30th 2018
 Outlines

Introduction and Background

The 4 topics chart

Resolving ethical dilemma

Cases
 Introduction of Ethical Issues

Ethical Issues:
A problem or situation that requires a person or organization to choose between alternatives
that must be evaluated as right (ethical) or wrong (unethical).

Clinicians must understand ethical issues Clinicians mean:

such as: Physicians, surgeon, nurses, social
• Informed consent workers, psychologists, clinical ethicist,
• Truth telling member of ethics committee, medical
• Confidentiality technicians, chaplains, and other
• Privacy responsible for the welfare of patients.
• The Distinction between research and clinical
care
• End-of-life care Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical
Ethics: A Practical Approach To Ethical Decision in Clinical Medicine.
7th ed. Gavelston: Mc Graww Hill Medical.
 Four Principles in applying Ethics
in Profession:

Respect for
Beneficence
Autonomy
A practitioner should act in
The patient has the right to the best interest of the
refuse or choose their patient
treatment

Justice
Non maleficence Concern the distribution of
scarce health resources, and
“first, do no harm” the decision of who gets
what treatment

Beauchamp, Tom L and Childress James F. 2013. Principles of Biomedical Ethics. 7th ed. ed. New York. Oxford University Press.
Clinical Ethics
• Clinical ethics is a practical discipline that provides a
structured approach to assist physicians in identifying,
analyzing and resolving ethical issues in clinical medicine

• Clinical ethics relies upon the conviction that, even when

perplexity is great and emotions run high, physicians and
nurses, patients and families can work constructively to
identify, analyze and resolve many of the ethical problems
that arise in clinical medicine.

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History
• Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. (1998)

• By 3 clinical ethicists:
– Albert R. Jonsen (philosopher)
– Mark Siegler (physician)
– William J. Winslade (lawyer)

• Authors’ purposes:
1. to offer an approach that facilitates thinking about the complexities of the problems that
clinicians actually face
2. to assemble concise representative opinions about typical ethical problems that occur in the
practice of medicine.

Goal: an aid for clinicians to develop skills at analyzing the cases

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About the Method
A straightforward way to sort the facts and values of the case at hand into an orderly
pattern that will facilitate the discussion and resolution of the ethical problem.

The topics provide a systematic way to identify, analyze and resolve the ethical problems
arising in clinical medicine.

A useful organizing device for teaching and discussion. More important, however, is the
way in which a review of these topics can help to move a discussion of an ethical problem
toward a resolution.

Our method of analysis begins, not with the principles and rules, as do many other ethics
treatises, but with the factual features of the case

Abstract discussions of principles is avoided as is the tendency to think of only one

principle http://depts.washington.edu/bioethx/tools/ceintro.html
 ?
Providing a similar pattern for
Suggested to be used and
collecting, sorting, and
analyzed when ethical
ordering the facts of a clinical
problem are seen
ethical problem
The Four
Boxes

Helping clinicians understand

Contained relevant series of
where the moral principles
questions to gather
meet the circumstances of the
information
clinical case

Center of Bioethics- Washington (2017) Depts.Washington.edu/bioethx/ceintro.html

THE FOUR TOPICS CHART
(Jonsen et al, 2010)
The 4 Topics
• Medical Indications - All clinical encounters include a diagnosis, prognosis,
and treatment options, and include an assessment of goals of care

• Patient Preferences - The patient’s preferences and values are central in

determining the best and most respectful course of treatment.

• Quality of Life - The objective of all clinical encounters is to improve, or at

least address, quality of life for the patient, as experienced by the patient.

• Contextual Features - All clinical encounters occur in a wider social context

beyond physician and patient, to include family, the law, culture, hospital
policy, insurance companies and other financial issues, and so forth.
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 • MEDICAL INDICATION • PATIENT PREFERENCES

Principles of beneficence & non maleficence Principles of respect for other/ autonomy
1. Medical problems? 1. Good informed consent,
2. Goal of treatment? understood?
1. Diagnosis 2. Mentally capable, legally competent? 1. Patient
3. Circumstances, medical treatment, non 3. Preferences of patients/ family 2. Family
2. Treatment
indicated? stating 3. Team
3. Prognosis 4. Probability of success of treatment? 4. Patients expression before
5. Benefited by medicine and nursing Appropriate surrogate
5. Patient unwilling to medicine,
care, harm can be avoided? treatment?
QUALITY OF LIFE CONTEXTUAL FEATURES
Principles of beneficence, non maleficence & Principles of Justice & Fairness
respect autonomy 1. Conflict of interest?
1. Medical treatment – physical, mental, 2. Fairness preferences?
social, deficit? 3. Patient confidentiality?
1. Before 4. Financial factors? 1. Support system
2. During 2. Quality of life, before and after? 5. Allocations of scarce resources? 2. Cost availability
3. Providers evaluation? Bias? 6. Religious issues? 3. Special
3. After 4. Ethical issues & patient quality of life? 7. Legal issues? circumstance
5. Quality of life assessment – life 8. Research & education?
sustaining treatment? 9. PH issues?
6. Plans & rationale? 10. Interest of hospital? Effect or patient
welfare? (Jonsen, et al, 2010)
7. Legal & ethical status of suicide?
Medical Indication
• This topic comprises the usual content of a clinical discussion: the diagnosis and
treatment of the patient's pathological condition.

• The ethical discussion will not only review the medical facts, but also attend to the
purposes and goals of any indicated interventions.

• A clear view of the possible benefits of intervention is the first step in assessing the
ethical aspects of a case.

• Most relevant ethical principles: Beneficence and Non Maleficence

• Medical indications are particularly prominent in following clinical ethics cases:

1. Nonbeneficial (or futile) treatment
2. Cardiopulmonary resucitation (CPR) and do-not-resucitate (DNR) orders
3. The Determination of Death
 The Four Topics Chart
1. MEDICAL INDICATION
THE PRINCIPLE OF BENEFICENCE AND NON-MALEFICENCE:
• What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible?
Emergent? Terminal?
• What are the goals of treatment?
• In what circumstances are medical treatments not indicated?
• What are the probabilities of success of various treatment options?
• In sum, how can this patient be benefited by medical and nursing care, and how can harm be
avoided?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
Patient Preferences
• Express choices of the patient about their treatment, or
the decisions of those who are authorized to speak for t h e
patient when the patient is incapable of doing so.
• Reflect patients experiences, beliefs, values
• In all medical treatment, the preferences of the patient, based on
the patient's own values and personal assessment of benefits and
burdens are ethically relevant.
• Most relevant principle: Respect for Autonomy
“Respect for persons affirms that each and every person has moral
value and dignity in his or her own right”
 The Four Topics Chart
2. PATIENT PREFERENCES
THE PRINCIPLE OF RESPECT FOR AUTONOMY
• Has the patient been informed of benefits and risks, understood this information, and given consent?
• Is the patient mentally capable and legally competent, and is there evidence of incapacity
• If mentally capable, what preferences about treatment is the patient stating?
• If incapacitated, has the patient expressed prior preferences?
• Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
 Quality of Life
• The object of all medical intervention is to restore, maintain or improve quality of life. Thus,
in all medical situations, the topic of quality of life must be raised.

• This topic, which is less well worked out in the literature of medical ethics than the two
previous ones, is perilous because it opens the door for bias and prejudice. Still, it must be
confronted in the analysis of clinical ethical problems.

• Describes features of the patient’s life prior to and following treatment.

• Refers to degree of satisfaction that people experience and value about their lives as a whole and
in its particular aspects, such as physical health.

• Most relevant principles: non maleficence, beneficence, respect for autonomy. Non maleficence
shoud be considered first before Beneficence.
 The Four Topics Chart
3. QUALITY OF LIFE
THE PRINCIPLES OF BENEFICENCE AND NONMALEFICENCE AND RESPECT FOR AUTONOMY
• What are the prospects, with or without treatment for a return to normal life, and what physical, mental and social deficits might the
patient experience even if treatment succeeds?
• On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a
judgement?
• Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
• What ethical issues arise concerning improving or enhancing a patient’s quality of life?
• Do quality of life assesment raise any questions regarding changes in treatment plans, such as forgoing life-sustining treatment?
• What are plans and rationale to forgo life-sustaining treatment?
• What is the legal and ethical status of suicide?

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical
Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
Contextual Features
• Every medical case is embedded in a larger context of persons, institutions, financial
and social arrangements
• At the same time, the context itself is affected by the decisions made by or about the
patient
• the relevance of the contextual features must be determined and assessed. These
contextual features may be crucially important to the understanding and resolution
of the case
• The way in which professional, familial, religious, financial, legal, and institutional
factors influence clinical-decisions
• The principles of justice and fairness
– Justice Refers to Those moral and social theories that attempt to distribute the benefits and burdens of a
social system in a fair and equitable way among all participants in the system.
– Fairness demands that transactions and relationship give to each participant that which they deserve and
reasonably expect. In addition, it is obviously unfair to exploit by deceit, manipulation, or discrimination.
 The Four Topics Chart
4. CONTEXTUAL FEATURES
THE PRINCIPLES OF JUSTICE AND FAIRNESS
• Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
• Are there parties other than clinicians and patients, such as family members, who have an interest in clinical decisions?
• What are the limits imposed on patient confidentiality by the legitimate interest of third parties
• Are there financial factors that create conflicts of interest in clinical decision
• Are there problems of allocation of scarce health resoursces that might affect clinical decision
• Are there religious issues that might affect clinical decisions?
• What are the legal issues that might affect clinical decisions?
• Are there considerations of clinical research and education that might affect clinical decisions?
• Are there issues of public health and safety that affect clinical decisions
• Are there conflict interest within institutions and organizations (e.g., hospitals) that may affect clinical decisions and patient welfare

Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision in Clinical Medicine. 7th ed. Gavelston: Mc
Graww Hill Medical.
Resolving the Ethical Dilemma
Ethical Decision Making Worksheets:

• Step 1 – Identify the facts (the 4 topics chart)

• Step 2 – Determine the ethical principles in conflict
• Step 3 – Explore the options
• Step 4 – Act on your decision and evaluate
Step 2:
Determine the Ethical Principles in Conflict
• Identify ethical issues
• What ethical principles are in conflict?
• Identify and explain the issue for each
conflicting principles
• Refer to the relevant code of ethics
when necessary
Step 3: Explore options
• Explore options and consider their strengths and
weaknesses
• Brainstorm and discuss options alone or with
peers. Be creative and use your imagination.
• Consider a compromise, predict the outcomes
for each alternatives.
• Question whether the alternatives fit the
patient/family values, or meet the
policy/regulation
Step 4: Act on Your Decision and Evaluate
• Develop an action plan
– Considering all the information you have, choose the best option
– Develop an action plan
– Present your suggested alternative and action plan to patient/family and those involved
– Re-examine the alternatives if other factors come to light, or there is changes, or if agreement
cannot be reached
– Determine when to evaluate the plan
– Document and communicate the plan
• Evaluate the plan
– What was the outcome of the plane?
– Are changes necessary?
– Document the evaluation
• Self-evaluate your decision
– How do you feet about the decision and outcome?
– What would you do differently/the same next time?
– What have you learned from this process and outcome?
 References
• Aksoy, Sahin, and Ali Tenik. 2002. “The ‘Four Principles of Bioethics’ as Found in 13th Century Muslim Scholar
Mawlana’s Teachings.” BMC Medical Ethics 7: 1–7.
• Albert R.Jonsen, Mark Siegler, William J.Winslade. 2010. Clinical Ethics: A Practical Approach To Ethical Decision
in Clinical Medicine. 7th ed. Gavelston: Mc Graww Hill Medical.
• Beauchamp, Tom L and Childress James F. 2013. Principles of Biomedical Ethics. 7th ed. ed. New York. Oxford
University Press.
• Carrese, Joseph A. et al. 2015. “The Essential Role of Medical Ethics Education in Achieving Professionalism: The
Romanell Report.” Academic Medicine 90(6): 744–52.
• Lombarts, Kiki M.J.M.H., Thomas Plochg, Caroline A. Thompson, and Onyebuchi A. Arah. 2014. “Measuring
Professionalism in Medicine and Nursing: Results of a European Survey.” PLoS ONE 9(5).
• MacKenzie, C. Ronald. 2007. “Professionalism and Medicine.” HSS Journal 3(2): 222–27.
• Van Rostenberghe, Hans et al. 2014. “Autonomy in Refusing Life Saving Interventions: Religious and Cultural
Misconceptions.” Education in Medicine Journal 6(1): 70–73.
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