Ethical decision-making in clinical contexts

Ethical decision-making under conditions of clinical uncertainty can be both complex and difficult. In this issue, particular complexities and difficulties arising in three clinical scenarios are helpfully discussed with a view to their practical as well as ethical resolution. The most generic of these scenarios, discussed by Winkler et al (see page 647, Editor's choice) is when a patient ‘requests active treatment with the goal of life-prolongation while the physician suggests best supportive care only’. The authors, recognising that resolution of this conflict ‘requires both medical expertise and value judgements’, propose ‘an ethical algorithm with five guiding questions’ which reflect criteria related to the ‘effectiveness’ and ‘benefit-harm ratio of the intervention’, ‘the patient's understanding of his or her medical situation’ and, in certain circumstances, the ‘resources required for the treatment’. This paper, which also includes useful discussion of the concepts of futility and denial, offers an ethically sophisticated but accessible decision model which deserves to be seriously considered by clinicians in the circumstances it addresses.

A more specific decision-making scenario, concerning decompressive craniectomy for patients with traumatic brain injury, is discussed by Honeybul and colleagues and in Madder's commentary (see pages 657 and 662). The authors describe the problematic weighing of potential benefits and risks related to this controversial albeit ‘technically straightforward’ surgical procedure, but go on to ask whether or not a patient might wish it to be carried out, given that while ‘many patients go on to make a good long term functional recovery’, a ‘significant number survive but are left with severe neurocognitive impairment’. The difficulty about answering this question, of course, is that ‘the patients themselves will be in no position to participate in any discussion regarding treatment options’. Consequently, the authors argue, ‘the fundamental question is what we would want for ourselves if we …