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Clinical ethical dilemmas: convergent and divergent views of two scholarly communities
  1. A M Stiggelbout1,
  2. A S Elstein2,
  3. B Molewijk1,
  4. W Otten1,
  5. J Kievit1
  1. 1Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
  2. 2Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois, USA
  1. 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}


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.

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

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  • Competing interests: None declared.

  • Ethical approval: The institutional review boards at the University of Chicago at Illinois, Illinois, USA, and the Leiden University Medical Center, Leiden, The Netherlands, reviewed and approved the study.