Two approaches have dominated Western thinking about medical ethics: consequentialism and deontology.¹

CONSEQUENTIALISM

A philosophical approach that judges the correctness of an action based on the effect it will likely have. The focus is on the consequences of an action. Advocates, including utilitarian philosophers, argue for actions that seek the greatest happiness for the greatest number of people.

DEONTOLOGY

A philosophical approach that argues that actions have intrinsic moral worth. Supporters purport that certain universal truths and rules should be followed, regardless of their consequence.

FOUR PRINCIPLES

Most people feel that four principles should guide approaches to care and decision making:

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  Beneficence: Provide care that benefits the patient

  
  
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  Maleficence: Avoid causing harm

  
  
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  Autonomy: When possible, individuals should decide for themselves what is in their best interests

  
  
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  Justice: Relates to fairly distributing services and resources

DECISION MAKERS

The legally authorized decision maker is determined by the patient’s age and the capacity for an individual to make a decision.

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  Adult patients: Patients >18 years old can make decisions for themselves if they have decision-making capacity. An adult can identify a decision maker in the event he or she does not have decision-making capacity. Surrogate decision makers should make decisions based on substituted judgment when possible.

  
  
  
  
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    Decision-making capacity: A clinical determination that an individual can 1) understand and communicate about the medical situation; 2) manipulate information about the situation and consider the consequences of alternatives; 3) make a choice among the alternatives

    
    
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    Competence: Typically considered a legal term reflecting the ability of an individual to make a decision

    
    
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    Power of attorney: A legal document giving decision-making authority for the patient to an individual

    
    
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    Legal surrogate: A person legally charged with acting on behalf of another person

    
    
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    Substituted judgment: A decision made on behalf of another person based on knowledge about what the person would decide if he or she could speak for himself or herself

  
  
  
  
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  Pediatric patients: For patients <18 years old, parents or the patient’s legal guardian is the legal decision maker and should make decisions based on the best interest standard. However, the state can intervene when parents make decisions that place the child’s health, well-being, or life in jeopardy. The American Academy of Pediatrics supports involving developmentally appropriate patients in clinical decision making, provided that his or her views will be considered.²

  
  
  
  
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    Best interest standard: The decision pursued should be the one most favorable for the child.³

    
    
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    Exceptions: In certain state-determined clinical situations (e.g., issues related to sexually transmitted infections or pregnancy), the patient can make his or her own decisions. States also have unique laws that determine who is eligible to be an emancipated or mature minor and therefore make his or her own medical decisions.

    
    
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    Patient assent: Patient approval or agreement about decisions.

  
  

SHARED DECISION MAKING

Although the patient or his or her family member may be the legal decision maker, experts advocate using a process of shared decision making, particularly for value-laden decisions. Shared decision making seeks to arrive at appropriate choices for patients and families through consideration of available options and the patient’s and family’s values. In shared decision making, communication exchange is bidirectional and comprehensive. Clinicians share medical information with families, and families share their values, attitudes, and preferences with the health care team. With shared decision making, patients and the family determine their role in decisions; that is, some people may choose to make decisions without guidance from clinicians, whereas others may request the clinicians make the final choice based on knowledge of the patient’s and family’s values and goals.⁴

DO NOT ATTEMPT RESUSCITATION (DNAR)

There is a presumed desire for resuscitation, including cardiopulmonary resuscitation.⁵ Absent an order not to attempt resuscitation, it should be attempted in all patients. Competent adults and their surrogates (e.g., parents of pediatric patients) may refuse medical care, including resuscitation.

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  Bilateral DNAR: The medical team and patient and family both agree that treatment limitation is appropriate.

  
  
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  Unilateral DNAR: An order placed based on the direction of the medical team. Only some states have laws supporting this controversial approach.

FUTILITY

Futility is sometimes used as a justification not to offer potential treatments felt not to be in the patient’s interests.⁶ There are variable ways to define futility:

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  Futility by condition: Treatment for a particular diagnosis is felt to never be successful

  
  
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  Qualitative futility: Treatment preserves a patient in a state that by some would be considered unalterable; dependence on intensive medical care will never cease

  
  
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  Quantitative futility: In the last “X” years, treatment for a given condition has been unsuccessful

  
  
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  Physiologic futility: Proposed treatment is not able to meet intended physiologic goals

Because of the many definitions of futility and the need to consider every intervention in terms of the goals of the patient and family, there is movement away from using the concept of futility to support decisions about the use of potentially inappropriate care.⁷