Systematic Approaches to Ethics Cases / Moral Reasoning

Isabel Legarda MD

DEONTOLOGY (from Greek “deon” meaning duty)

What it is: an approach to ethical analysis that focuses on duties and obligations and requires
that patients be treated as ends in themselves / that no patient ever be treated as a means
to an end; often considered rule-based, with rules that must be universally applicable (e.g. do
not steal, do not kill, be true to your word).

Questions to ask when applying this approach:

• What are our obligations as clinicians to patients? To family members?
• What ethical decision would result in the patient being treated as most people would
wish to be treated in this particular case?

Well-suited for: patient-centered care; end-of-life issues; cases involving patient autonomy

Further reading:
pp. 12-15 of Heubel F and Biller-Adorno N (2005). The contribution of Kantian moral theory
to contemporary medical ethics: a critical analysis. Med Health Care Philos 8(1):5-18.

CONSEQUENTIALISM / UTILITARIANISM

What it is: an approach to ethical analysis that considers the greatest benefit that can be
achieved for the greatest number of stakeholders

Questions to ask when applying this approach:

• What action or decision benefits the greatest number of people?
• What is the desired big-picture outcome?
• What would happen if nothing were done?

Well-suited for: public health crises; disaster medicine; vaccine policies; challenges with
rationing and resource allocation

Further reading:
Beauchamp TL and Childress JF (2013). Principles of Biomedical Ethics. New York: Oxford UP,
354-361.
VIRTUE ETHICS

What it is: the use of character traits, and common judgments about the actions of
exemplars considered to have “good” character, to inform ethical decision-making

Questions to ask when applying this approach:

• What would a “good doctor” do in this situation?
• What clinical/ethical decision would result in the expression of key virtues in medical
practice: respect for others, compassion, kindness, honesty, diligence?

Well-suited for: a variety of clinical situations, but can be limited by vagueness, lack of
consensus about the ideals to apply, and lack of clarity or specificity about the best action to
take

Further reading:
Oakley, J (2012). A virtue ethics approach. In Kuhse H and Singer P (eds.), A Companion to
Bioethics (2nd ed.). Malden, MA: Blackwell Publishing, 91-104.

Pellegrino, E.D. 2002. Professionalism, Profession and the Virtues of the Good Physician. The
Mount Sinai Journal of Medicine, New York 69(6):378–84.

PRINCIPLISM

What it is: a top-down approach to ethical analysis – the one most commonly taught in
clinical medicine – in which respect for patient autonomy, beneficence, nonmaleficence, and
justice must be prioritized in clinical and ethical decision-making

Questions to ask when applying this approach:

• What are the patient’s values and wishes, and does the clinical decision align with
them?
• What will benefit the patient most?
• What will cause the least harm to the patient?
• What is the fairest outcome for those upon whom the final decision has an impact?
• In what ways will this decision have an impact on the overall system?

Well-suited for: a wide variety of clinical situations, but may be shown to have limitations
when honoring one principle conflicts with another

Further reading:
Taylor, RM (2013). Ethical principles and concepts in medicine. Handb Clin Neurol 118:1-9.
NARRATIVE ETHICS

What it is: a ground-up approach to ethical analysis that attempts to arrive at an ethical
decision or resolution by considering the complex underlying stories that have formed the
stakeholders’ views, values, and responses to a given situation

Questions to ask when applying this approach:

• Who are the stakeholders in the dilemma?
• What does each person strongly desire? Why?
• What is each person most afraid of? Why?
• What things matter most to each person?

Well-suited for: complex situations involving multiple involved stakeholders; critical care
situations in which parties are in conflict; difficult care situations in which loved ones feel
overwhelmed, underinformed, or lost about the “right” decision

Further reading:
https://www.hmpgloballearningnetwork.com/site/altc/content/the-power-stories-narrative-
ethics-long-term-care

https://journalofethics.ama-assn.org/article/ethical-force-stories-narrative-ethics-and-
beyond/2014-08

https://www.thehastingscenter.org/publications-resources/special-reports-2/narrative-
ethics-the-role-of-stories-in-bioethics/

FEMINIST ETHICS

What it is: an approach to ethical analysis that centers the needs and concerns of women,
recognizes the ways in which their interests are repeatedly and systematically neglected or
devalued, and strives to resist and rectify ways in which systemic injustices or disadvantages
have seeped into their individual experience

Questions to ask when applying this approach:

• How have societal or medical systems caused women particular inequities here?
• What does this woman need most?
• What would enable her to heal and flourish?

Well-suited for: ethical situations involving reproductive autonomy; cases in which women
may be disempowered by family dynamics, culturally derived priorities, legal constraints, or
inadequate resources; trauma

Further reading: https://plato.stanford.edu/entries/feminism-ethics/

CARE ETHICS

What it is: an approach to ethical analysis that focuses on interpersonal relationships and the
expression of benevolence through action as the basis of moral decision-making

Questions to ask when applying this approach:

• On whom does the patient depend most? For what?
• Who depends on the patient? For what?
• What are the patient’s greatest vulnerabilities?
• What would best safeguard the interests of individuals involved?
• What is the most compassionate action in this case?

Well-suited for: elder care; maternal care; pediatrics; trauma

Further reading:
Tronto, JC (2005). An ethic of care. In Cudd, AE and Andreasen, RO (eds.). Feminist theory: a
philosophical anthology. Malden, MA: Blackwell Publishing, 251-263.

Pellegrino, E.D. 2002. Toward a reconstruction of medical morality. The Journal of Medical
Humanities and Bioethics 8(1):7-18.

CASUISTRY

What it is: a ground-up approach to ethical analysis – the one we apply every session in this
course – in which examination of concrete cases allows for moral reasoning “by analogy”

Questions to ask when applying this approach:

• What comparable situations have occurred before?
• How were previous cases similar? How different?
• What were the clinical and ethical outcomes of past cases?
• What aspects of the current cases favor or argue against going in a particular
direction?

Well-suited for: a wide variety of clinical situations, but may be shown to have limitations in
pluralistic settings or be insufficiently conclusive or critical

Further reading:
Arras, JD (2012). A case approach. In Kuhse H and Singer P (eds.), A Companion to Bioethics
(2nd ed.). Malden, MA: Blackwell Publishing, 117-125.