CLINICAL ETHICS

Clinical ethical dilemmas: convergent and divergent views of two scholarly communities

A M Stiggelbout¹, A S Elstein², B Molewijk¹, W Otten¹ and J Kievit¹

¹ Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
² Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois, USA

Correspondence to:
Correspondence to:
Dr Anne M Stiggelbout
Department of Medical Decision Making, Leiden University Medical Center, P O Box 9600, 2300 RC Leiden, The Netherlands; a.m.stiggelbout{at}lumc.nl

Objective: To survey members of the American Society for Bioethics and Humanities (ASBH; n = 327) and of the Society for Medical Decision Making (SMDM; n = 77) to elicit the similarities and differences in their reasoning about two clinical cases that involved ethical dilemmas.

Cases: Case 1 was that of a patient refusing treatment that a surgeon thought would be beneficial. Case 2 dealt with end-of-life care. The argument was whether intensive treatment should be continued of an unconscious patient with multiorgan failure.

Method: Four questions, with structured multiple alternatives, were asked about each case: identified core problems, needed additional information, appropriate next steps and who the decision maker should be.

Observations and results: Substantial similarities were noticed between the two groups in identifying the core problems, the information needed and the appropriate next steps. SMDM members gave more weight to outcomes and trade-offs and ASBH members had patient autonomy trump other considerations more strongly. In case 1, more than 60% of ASBH respondents identified the patient alone as the decision maker, whereas members of SMDM were almost evenly divided between having the patient as the solo decision maker or preferring a group of some sort as the decision maker, a significant difference (p<0.02). In case 2, both groups agreed that the question of discontinuing treatment should be discussed with the family and that the family alone should not be the decision maker.

Conclusion: Despite distinctively different methods of case analysis and little communication between the two professional communities, many similarities were observed in the actual decisions they reached on the two clinical dilemmas.

Abbreviations: ASBH, American Society for Bioethics and Humanities; ICU, intensive care unit; SMDM, Society for Medical Decision Making

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