Intended for healthcare professionals

Observations Ethics Man

How to think like an ethicist

BMJ 2010; 340 doi: (Published 23 June 2010) Cite this as: BMJ 2010;340:c3256
  1. Daniel K Sokol, honorary senior lecturer in medical ethics, Imperial College London
  1. daniel.sokol{at}

    A search for method in the madness of medical ethics

    Structure. That is the key. Structure. Did John steal the stethoscope? Go through each of the five components of theft: appropriation, of property, belonging to another, dishonestly, with the intention to permanently deprive. If a single element is missing, there is no theft. Was Tracy negligent when she failed to intubate the young child? Go through the elements of negligence: loss, duty of care, standard of care, breach, causation, and remoteness. Throughout the last year at law school we were told to “think like lawyers.” We had to lose the deep rooted instinct to judge the morality of a person’s act and replace it with a dispassionate legal dissection of the facts at hand.

    When training in medical ethics I was never told to “think like an ethicist.” There is no universally accepted way to do ethics, and at times the words from a Dilbert comic strip posted on the notice board of a bioethics department ring worryingly true. Having received the advice he wanted to hear, Dilbert muses that “90% of happiness is finding the right ethicist.”

    If I were asked to train BMJ readers to be medical ethicists (the kind that I would like my doctor to consult if morally perplexed), structure would feature early in the syllabus. The method would be the “four quadrants” approach, developed by the Americans Albert Jonsen, Mark Siegler, and William Winslade in the early 1980s.1 It is lesser known than the “four principles” approach,2 and less versatile, but it is more straightforward to use and more attuned to the clinical context. A brief demonstration (which is based on an example given in Jonsen and colleagues’ book) follows.

    Lucy is an 8 year old girl with a diagnosis of acute myeloid leukaemia. Three months after a course of chemotherapy she relapsed. A transplantation of bone marrow from her older sister was performed. Again, she soon relapsed. Although the oncologist told Lucy’s parents that further chemotherapy would provide scant benefit, they insisted on more. The medical team attempted a course of experimental chemotherapy, which unfortunately did not slow the progress of the disease. Lucy, a once cheerful patient, is now despondent. She asks, “Why must I keep doing this?”

    The temptation to “jump in” with gut reactions must be resisted. Good ethics starts with good facts. The first quadrant of our analysis, therefore, is clinical indications. What is Lucy’s likely prognosis? What is the treatment goal, and how likely are we to attain it? If the proposed treatment does not work, what is plan B? This quadrant clarifies the medical situation and seeks to highlight the harms and benefits of any proposed intervention. Doctors should feel on familiar territory here. The ideal scenario is that the medical team, after reviewing the situation, agrees on the clinical “ought.” Of course, in reality, the medical situation may be messy, with various unknowns and disagreements.

    Once the medical indications are clear—or as clear as they can be—the next quadrant looks at the patient’s preferences. Is Lucy competent to take part in decisions about her care? If so, has she been informed of the situation, and what are her thoughts on the matter? Lucy’s remark suggests that someone needs to talk to her about her future care. Keeping her in the dark runs counter to the principle of respect for autonomy and may lead Lucy to feel isolated or abandoned. If dealing with an incompetent adult we would consider prior preferences, including any advance statements.

    Next, we consider the third quadrant: quality of life. What will the effect of any proposed intervention be on Lucy’s quality of life? How will further aggressive treatment, for example, affect her mental, physical, and social wellbeing? Again, there is no certainty in this assessment, but it is an important factor in deciding what is in Lucy’s best interest. An intervention may be medically indicated because it will prolong life. This quadrant will question the value of such an extension. For Lucy, palliative care may be more appropriate.

    Then we turn to the final quadrant: contextual features. This is a hotch-potch category, containing all other relevant factors. In Lucy’s case, we would explore the views and feelings of her parents and sister and any underlying religious or cultural issues. Clinicians, too, have prejudices and biases that can affect their decision making, whether they are based on religion, past experience, self interest, or hospital politics. This is also the place to consider the delicate issue of resource allocation and any pertinent legal rules or professional guidelines.

    That, in a nutshell, is the four quadrants approach: start with clinical indications and move on to examine patient preferences, then quality of life, and finally contextual features. It is no panacea, however. Sound judgment and an open mind are needed to balance the various considerations raised in the analysis. A solution will not always emerge from the foggy moral landscape; but more often than not it will clear some of the haze and expose the mines strewn along the way. Like any skill, it gets easier with practice.

    In the 13th century the surgeon Lanfranc wrote that “no one can be a good physician who has no idea of surgical operations, and a surgeon is nothing if ignorant of medicine.” In 2010 physicians and surgeons operate in a morally laden clinical environment, and neither group can be truly at ease without a method to examine the ethical issues in their practice. The four quadrants of ethics should be as familiar to doctors as the four quadrants of the abdomen.


    Cite this as: BMJ 2010;340:c3256