A Clinician’s Approach to Clinical Ethical Reasoning
`Lauris C. Kaldjian, MD, PhD,1,2 Robert F. Weir, PhD,2,3 Thomas P. Duffy, MD 4
`1Division of General Internal Medicine, Department of Internal Medicine, 2Program in Biomedical Ethics and Medical Humanities, and
`3Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, USA; 4Department of Internal Medicine, Yale
`University School of Medicine, New Haven, CT, USA.
`
`We offer a systematic strategy that situates clinical ethical reasoning
`within the paradigm of clinical reasoning. The trajectory of this strategy
`parallels clinical reasoning: a plain statement of the initial problem,
`careful gathering of data, a differential diagnostic assessment, and ar-
`ticulation and confirmation of a justified plan. This approach pays spe-
`cial attention to the goals of medical care, because so much depends on
`whether or not physician and patient share the same goals. This ap-
`proach also addresses the heterogeneity of clinical problems that at
`first appear ethical and acknowledges the ethical pluralism that per-
`vades clinical ethics.
`
`KEY WORDS: clinical ethics; decision making; ethical analysis; profes-
`sional education; ethical pluralism.
`DOI: 10.1111/j.1525-1497.2005.40204.x
`J GEN INTERN MED 2005; 20:306–311.
`
`P hysicians can be more effective and confident in their re-
`
`sponses to ethical challenges in patient care if they learn
`to address these challenges in a systematic fashion. To be
`useful, a systematic approach to clinical ethical reasoning
`needs to be accessible to clinicians and should resonate with
`their style of clinical reasoning. We offer such an approach in
`this article (Fig. 1).
`The strategy of our approach is to incorporate existing
`bioethical concepts into the ‘‘thinking space’’ of a clinician by
`situating clinical ethical reasoning within the paradigm of clin-
`ical reasoning (Fig. 2). The method we propose partially resem-
`bles other approaches in clinical ethics,1–10 but
`it
`is
`distinguished by deliberately adopting the trajectory of clini-
`cal reasoning. By emulating clinical reasoning, our approach
`recognizes that ethical problems in clinical medicine usually
`do not arrive prediagnosed but emerge through a dynamic
`process of assessment. The differential diagnostic character of
`our approach also recognizes that problems which at first
`seem ethical may turn out to be primarily related to insuffi-
`cient communication, interpersonal conflict, or incomplete
`awareness of existing medical information and options.11–13
`Our approach also incorporates ethical pluralism14–16 in
`order to make diverse sources of ethical value explicit and to
`reflect the diversity clinicians bring to their ethical delibera-
`tions. We recommend 6 familiar sources of ethical value that
`can be used to support decision making in clinical ethics but
`also invite clinicians to incorporate their preferred sources into
`its scheme. Contrasting sources of ethical value expand the
`angle of moral vision, but a plurality of values can also cause
`tension: physicians may have to choose a single course of ac-
`tion in the face of multiple competing values.17
`
`Accepted for publication July 1, 2004
`The authors have no conflict of interest to report.
`Address correspondence and requests for reprints to Dr. Kaldjian:
`Department of Internal Medicine, SE605 GH, University of Iowa Carver
`College of Medicine, 200 Hawkins Drive, Iowa City, IA 52242 (e-mail:
`lauris-kaldjian@uiowa.edu).
`306
`
`To illustrate the use of our approach, we offer a patient
`case and unfold its discussion as the approach is presented: a
`68-year-old woman is admitted to the hospital with right-sided
`weakness and confusion. Her examination reveals unintelligi-
`ble vocalizations, intact pupillary reflexes, absent gag reflex,
`impaired swallowing, and right hemiparalysis. Magnetic reso-
`nance imaging of the brain shows acute infarction involving
`the left frontal, parietal, and temporal lobes. Supportive care is
`instituted, including intravenous hydration and a nasogastric
`feeding tube. The patient does not have an advance directive or
`medical power of attorney; her family decides that she should
`not be resuscitated in the event of cardiac arrest. Her mental
`status fluctuates; at times she is able to recognize her family.
`On hospital day 4 she pulls out her nasogastric tube and it is
`reinserted. On hospital day 6, the attending physician recom-
`mends insertion of a percutaneous endoscopic gastrostomy
`(PEG) tube for longer-term enteral feeding. The patient’s family
`objects, requesting ‘‘comfort measures only.’’ The physician
`explains that the prognosis is too uncertain to justify a shift to
`palliative care and emphasizes the need for nutritional support
`while neurological rehabilitation is attempted and the progno-
`sis clarified. The family disagrees and requests that the patient
`be discharged home where they are willing ‘‘to let her go.’’
`
`APPROACH
`1. State the Problem Plainly
`
`This first step identifies what has triggered the perception that
`an ethical problem exists. Like the ‘‘chief complaint’’ that be-
`gins an evaluation in clinical medicine, the problem stated in
`straightforward terms helps focus attention on the problem
`with as little prejudgment as possible.
`Case: The physician believes a PEG tube should be in-
`serted, but the family disagrees.
`
`2. Gather and Organize Data
`
`a. Medical Facts. The principal medical facts of the situation
`must be defined, including the patient’s condition, diagnosis,
`prognosis, mental and emotional status, and decision-making
`capacity, as well as the benefits and burdens of treatment op-
`tions and their probabilities of success.
`Case: The patient has had an acute stroke resulting in
`aphasia, impaired swallowing, hemiparalysis, and fluctuating
`mentation. Her prognosis is unclear. She does not have deci-
`sion-making capacity. PEG tubes have known risks, but they
`avoid the discomforts and limitations of nasogastric tubes.
`
`b. Medical Goals. Articulating the goals of care facilitates dis-
`cussion that is oriented by concrete and feasible objectives.
`Common goals include preventing disease, curing disease, re-
`storing function, relieving pain, prolonging life, and comforting
`suffering. It is important to distinguish between disagreements
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`1. State the problem plainly
`
`2. Gather and organize data
`
` a. Medical facts
`
` b. Medical goals
`
` c. Patient’s goals and preferences
`
` d. Context
`
`3. Ask: Is the problem ethical?
`
`4. Ask: Is more information or dialogue needed?
`
`5. Determine the best course of action and support it with reference to one or more
`
` sources of ethical value:
`
`Ethical principles
`
`Rights
`
`
`
`Consequences
`
`
`
`Comparable cases
`
`
`
`
`
`
`
`
`
`
`Beneficence, nonmaleficence, respect for autonomy, justice
`
`Protections that are independent of professional obligations
`
`Estimation of the goodness or desirability of likely
` outcomes
`
`Reasoning by analogy from prior cases
`
`Professional guidelines
`
`
`
`
`e.g., AMA Code of Ethics, ACP Ethics Manual, BMA
` Handbook
`
`Conscientious practice
`
`
`
`
`Preserving the personal and professional integrity of
` clinicians
`
`6. Confirm the adequacy and coherence of the conclusion
`
`FIGURE 1. A clinician’s approach to clinical ethical reasoning.
`
`about goals versus disagreements about different ways to ac-
`complish the same goal. Medical goals have received consid-
`erable attention in end-of-life care discussions18–21 but should
`not be limited to this setting.
`Case: Medical goals include relieving discomfort, maximiz-
`ing neurological recovery, and prolonging life in order to clarify
`the prognosis.
`
`c. Patient’s Goals and Preferences. The medical goals of care
`need to be placed in the context of the patient’s assessment of
`the benefits and harms posed by treatment options. A patient’s
`values and beliefs will define his or her personal goals and de-
`termine how best to achieve them.20,22 Discussion of goals
`may prevent misunderstandings that arise when individual
`diagnostic or therapeutic decisions are isolated from the over-
`all clinical situation (the ‘‘big picture’’). Refusal of medical ad-
`vice should be a red flag inviting deeper exploration of the
`patient’s goals and preferences and should not automatically
`be interpreted as a lack of decision-making capacity. When a
`patient lacks decision-making capacity, advance directives
`and valid surrogate decision makers should guide the deter-
`mination of the patient’s wishes and best interests.
`Case: The patient lacks decision-making capacity and has
`no advance directives; her husband (with family) is her surro-
`gate decision maker. He believes that she would prefer to die
`comfortably at home rather than have a PEG tube inserted and
`struggle through the uncertain outcome of her stroke.
`
`d. Context. Patients bring to the medical encounter a personal
`context that may bear heavily on their perceptions, preferenc-
`es, and understanding of options. They may be influenced by
`family bonds, social or economic circumstances, prior health
`care experiences, a history of racial discrimination, or religious
`traditions. Physicians have contexts that are shaped by pro-
`fessional culture, economic conditions, legal obligations, and
`health care systems, and they work alongside clinicians in
`other health disciplines who have their own moral standing.
`Case: The family appears to have the patient’s best interests
`in mind. No institutional or economic constraints on the deci-
`sion-making process are evident. In the state where the patient
`resides, statutory law leaves open the possibility of legal lia-
`bility for withholding life-supporting therapy, because the pa-
`tient does not have an advance directive and is not deemed
`terminally ill or permanently unconscious.
`
`3. Ask: Is the Problem Ethical?
`
`As with assessment in clinical medicine, this is a process of
`sifting and weighing that culminates in an interpretation of the
`problem that was stated plainly at the start. The task is to de-
`termine whether the problem is primarily ethical, that is,
`whether it involves moral questions related to values, princi-
`ples, commitments, obligations, rights, and so on. A differen-
`tial diagnostic evaluation includes the possibilities of poor
`
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`Clinical Reasoning
`
`Clinical Ethical Reasoning
`
`Problem
`
`Problem
`
`History
`
`Exam
`
`Data
`
`Medical
`Facts
`
`Medical
`Goals
`
`Patient
`Goals
`
`Context
`
`Differential Diagnosis,
`Clinical Assessment
`
`Differential Diagnosis,
`Ethical Assessment
`
`Further
`Diagnostic
`Evaluation
`
`Treatment
`Plan
`
`Further
`Information &
`Dialogue
`
`Best Course
`of Action
`
`FIGURE 2. Comparison between clinical reasoning and clinical ethical reasoning.
`
`communication, strained interpersonal relationships, or in-
`complete exploration of medical alternatives. If the problem is
`ethical, it should be defined in order to confirm (or question) a
`shared understanding of the problem. Possible conflicts be-
`tween competing values should also be identified.3,4,23,24
`Case: The disagreement between physician and family re-
`garding the insertion of a PEG tube is an ethical problem in-
`volving competing assessments of what is in the patient’s best
`interests.
`
`4. Ask: Is More Information or Dialogue Needed?
`
`Problems that appear to be ethical frequently arise because a
`clinical decision is premature. This error in clinical medicine
`occurs when clinicians leap to incorrect conclusions because
`of insufficient data. The physician may need to collect more
`information about a patient’s goals, search the medical liter-
`ature to explore medical alternatives, engage administrators
`and insurers, or take steps to repair misunderstandings or re-
`store trust. Narrative approaches to ethics emphasize the in-
`
`sights that come through understanding the unique details of
`each patient’s story.25,26 Some ethical and nonethical prob-
`lems will resolve solely with the addition of more information or
`dialogue.
`Case: The physician should consult experts and literature
`regarding prognosis in patients with middle cerebral artery in-
`farcts and the effectiveness of PEG tubes in stroke rehabilita-
`tion. The necessity of a PEG tube at this exact juncture should
`be probed. Dialogue with the family should explore the grounds
`of their belief that the patient would not want a PEG tube.
`
`5. Determine the Best Course of Action and
`Support Your Position with Reference to One or
`More Sources of Ethical Value
`
`a. Principles. The ‘‘four principles’’ have arguably become the
`most common ethical currency in North American and British
`biomedical ethics.5,10,15 Ethical principles are general obliga-
`tions that guide our actions; they should be followed, but need
`not be absolutely binding. Though their limitations are real,27
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`principles help us bridge the gap between moral rules and the
`complex realities of human life.28
`
`Beneficence. This is the obligation to act for (and maxi-
`mize) what is beneficial to the patient. The benefit of greatest
`interest to clinicians is health.
`
`Nonmaleficence. This is the obligation to avoid causing
`harm to the patient. Harm may occur by intention or negli-
`gence, and it may be physical, psychological, social, financial,
`or spiritual.29
`
`Respect for patient autonomy. This is the obligation to re-
`spect a patient’s preferences and decisions according to their
`beliefs and values. Patients with decision-making capacity are
`presumed to be autonomous; those without this capacity re-
`quire surrogate decision makers. When patient autonomy con-
`flicts with physician advice, it is important to understand that
`acting for a patient’s good (beneficence) includes respecting
`that patient’s assessment of his or her own good.30 Respect for
`patient autonomy should avoid imposing unrealistic expecta-
`tions on patients who sometimes do not know what they think
`or want.31
`
`Justice. This is the obligation to be fair and impartial and
`to treat similar people in similar situations the same way.
`Another meaning of justice is to give to each person their
`‘‘due’’ as persons endowed with human dignity.32 Injustice in
`medicine occurs when clinicians discriminate against persons
`or groups on the basis of criteria that are generally believed to
`be inappropriate (e.g., gender, ethnicity, age, wealth, or reli-
`gious belief).
`Case: Both the physician and the family are trying to max-
`imize the patient’s good and avoid harm, but their contrasting
`definitions of benefit and harm lead to competing conclusions.
`The physician views the possibility of neurological improve-
`ment as a benefit and premature death as a harm. The family
`views comfort care as a benefit and the prolongation of suffer-
`ing as a harm. The family shows respect for patient autonomy
`through their substituted judgment based on prior knowledge
`of the patient’s values; the physician relies on a best-interests
`standard that carries a presumption of treatment in the ab-
`sence of a clear expression by the patient to the contrary.
`Questions of justice might arise if treatment decisions discrim-
`inated against the patient on the basis of financial status, cog-
`nitive capacity, and so forth.
`
`b. Rights. These are claims made against others (or society) to
`express ethical values we prize the most.33 We invoke rights in
`medical practice (e.g., the right to informed consent) and in
`society (e.g., human rights). Rights demand a reciprocal re-
`sponse: if we say a patient has a right, it implies that health
`care providers have an obligation to respond to that right.
`There is a contrast between negative rights (the right to be left
`alone) and positive rights (the right to be assisted in some way)
`and between moral rights (common to all humans) and legal
`rights (variable among societies).
`Case: Both the physician and family could frame their po-
`sitions in terms of rights, the former emphasizing the patient’s
`positive right to treatment and life, the latter emphasizing the
`patient’s negative right to refuse treatment.
`
`c. Consequences. Ethical reasoning based on consequences
`assumes that a course of action is right or wrong depending on
`
`the balance of its anticipated consequences, good and bad;
`this is the basis of utilitarianism.34 Outcome variables relevant
`to clinical ethics include factors related to the patient (mortal-
`ity, morbidity, suffering, disability, and cost) and interests re-
`lated to patients’ families, clinicians, hospitals, and other third
`parties. Because consequentialist reasoning is based on pre-
`dicted outcomes, prognostic uncertainties will
`lessen the
`strength of its conclusions.
`Case: Both the physician and family rely on possible out-
`comes, the former emphasizing the possibility of a net positive
`outcome through neurological improvement, the latter focus-
`ing on the possibility of a net negative outcome through pro-
`longed suffering.
`
`d. Comparable Cases. When referring to comparable cases,
`we reason by analogy.35 This kind of case-based reasoning is
`routine in clinical medicine and reflects the physician’s habit
`of comparing an unknown case to cases previously encoun-
`tered. In ethics, we may be aware of paradigmatic cases—from
`our own clinical experience, professional literature, or impor-
`tant court cases (e.g., Quinlan, Conroy, Cruzan)—against which
`we compare a present case. Reasoning proceeds from the cir-
`cumstances and conclusions of a clearer case to the circum-
`stances of a less certain one: if the two cases are sufficiently
`alike to justify comparison, their similar circumstances may
`justify similar conclusions.
`Case: The case of Claire Conroy (Supreme Court of New Jer-
`sey, 1985) is analogous, involving an 84-year-old woman with
`severe impairments whose nephew sought to have her naso-
`gastric feeding tube removed. The court emphasized that pa-
`tients retain the right to decline any medical treatment,
`including technological feeding, when they lose decision-mak-
`ing capacity.
`
`e. Professional Guidelines. Although consensus is lacking on
`some issues, professional ethical guidelines serve as impor-
`tant references. Examples include the American Medical As-
`sociation’s Code of Ethics, the American College of Physicians’
`Ethics Manual, and the British Medical Association’s Hand-
`book of Ethics and Law.10,36,37
`Case: General guidelines about withholding life-sustaining
`treatments from incapacitated patients are available.
`
`f. Conscientious Practice/Physician Integrity. Conscientious
`practice reminds us that physicians have their own ethical
`integrity that warrants respect.38,39 Patients, colleagues, or
`administrators should not be allowed to compromise a
`physician’s integrity, which is both personal (the beliefs and
`values we bring to the practice of medicine) and professional
`(the beliefs and values the practice of medicine requires of us).
`Physicians may act according to conscience and decline par-
`ticipation in decisions that are considered unacceptable. Phy-
`sicians who disengage from a patient’s care should arrange a
`transfer of care in order to avoid the ethical and legal violation
`of patient abandonment.
`Case: If the physician’s recommendation to support the pa-
`tient with PEG tube feeding represents a fundamental com-
`mitment to the patient’s best interests, complying with the
`family’s request to forgo life-supporting treatment may com-
`promise the physician’s integrity. Intractable disagreement be-
`tween the physician and family might warrant transferring the
`patient’s care to another physician or consideration of judicial
`review.
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`6. Confirm the Adequacy and Coherence of the
`Conclusion
`
`In clinical medicine, the correctness of a diagnostic conclusion
`is tested by using the criteria of adequacy (the diagnosis ac-
`counts for all the patient’s findings) and coherence (the pa-
`tient’s
`findings
`are
`consistent with
`the
`described
`pathophysiology of the hypothesized disease state). Clinical
`ethical reasoning may not be able to achieve this degree of
`confirmation, but a conclusion should be as adequate and co-
`herent as possible. Failure to fulfill these criteria in clinical
`medicine forces the physician to question the diagnosis being
`entertained and consider a shift in clinical reasoning. Similar-
`ly, when clinical ethical reasoning produces conclusions that
`do not fit the known factors of a patient’s case or are incoher-
`ent, additional ethical analysis or consultation is needed.
`Case: The physician’s insistence on nutritional support
`during a period of rehabilitation is ethically justified on the
`basis of the physician’s assessment of benefits, harms, rights,
`possible outcomes, and conscientious practice. Even so, each
`of these sources of ethical value is open to more than one in-
`terpretation, as evidenced by the contrasting position of the
`family. The physician’s assessment adequately engages the
`ethical issues at stake using values that form a coherent eth-
`ical picture. The physician’s assessment does not ‘‘prove’’ that
`a position is right or ‘‘solve’’ a problem; rather, it justifies a
`course of action by articulating an adequate and coherent eth-
`ical explanation.
`
`CONCLUSION
`
`This approach to ethical reasoning incorporates existing
`knowledge in a systematic fashion through an organizational
`strategy that is familiar to clinicians. It is intended neither to
`replace basic curricula in ethics40–43 nor to deny the range of
`knowledge, skills, and attitudes that make education in clin-
`ical ethics complete.44–47 By capitalizing on the way clinicians
`think, we believe this approach provides a practical means to
`articulate ethical justifications for challenging clinical deci-
`sions. Such articulation allows the ethical basis of a difficult
`decision to become transparent.48 Transparency, in turn, al-
`lows clinicians to communicate and document an explanation
`for a course of action, and it is likely to facilitate consensus
`based on a shared understanding of values and goals or, at
`least, clarify causes of lingering disagreements. A practical and
`systematic approach to clinical ethical reasoning thereby not
`only enhances the clarity and content of ethical decisions, but
`also facilitates dialogue and cooperation between the partici-
`pants who will live with the decisions that are made.
`
`Dr. Kaldjian is supported by funding from the Robert Wood
`Johnson Foundation as a Generalist Physician Faculty Scholar.
`
`REFERENCES
`
`1. Jonsen AR, Siegler M, Winslade WJ. Clinical Ethics. 4th ed. New York,
`NY: McGraw-Hill; 1998.
`2. Siegler M. Decision-making strategy for clinical-ethical problems in
`medicine. Arch Intern Med. 1982;142:2178–9.
`3. Thomasma DC. Training in medical ethics: an ethical workup. Forum
`Med. 1978;1:33–6.
`4. Doukas DJ. The design and use of the bioethics consultation form. Theor
`Med. 1992;13:5–14.
`
`5. Gillon R. Medical ethics: four principles plus attention to scope. BMJ.
`1994;309:184–8.
`6. McCullough LB. Addressing ethical dilemmas: an ethics work-up. New
`Physician. 1984;33:34–5.
`7. Finnerty JJ, Pinkerton JV, Moreno J, Ferguson JE. Ethical theory and
`principles: do they have any relevance to problems arising in everyday
`practice? Am J Obstet Gynecol. 2000;183:301–8.
`8. Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians. 2nd ed. Phil-
`adelphia, PA: Lippincott Williams & Wilkins; 2000:7–10.
`9. Miller FG, Fletcher JC, Fins JJ. Clinical pragmatism: a case method of
`moral problem solving. In: Fletcher JC, Lombardo PA, Marshall MF, Mill-
`er FG, eds. Introduction to Clinical Ethics. 2nd ed. Frederick, MD: Uni-
`versity Publishing Group; 1997:21–38.
`10. British Medical Association. Ethics Today: The BMA’s Handbook on
`Ethics and Law. 2nd ed. London: BMJ Publishing Group; 2004:6–12.
`11. Kelly SE, Marshall PA, Sanders LM, Raffin TA, Koenig BA. Under-
`standing the practice of ethics consultation: results of an ethnographic
`multi-site study. J Clin Ethics. 1997;8:136–49.
`12. DuVal G, Sartorius L, Clarridge B, Gensler G, Danis M. What triggers
`requests for ethics consultations? J Med Ethics. 2001;27(suppl I):
`i24–i29.
`13. Fetters MD, Brody H. The epidemiology of bioethics. J Clin Ethics. 1999;
`10:107–15.
`14. Brody BA. Life and Death Decision Making. New York, NY: Oxford Uni-
`versity Press; 1988:9–11.
`15. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed.
`New York, NY: Oxford University Press; 2001.
`16. Pellegrino ED. The metamorphosis of medical ethics: a 30-year retro-
`spective. JAMA. 1993;269:1158–62.
`17. Nagel T. The fragmentation of value. In: Engelhardt HT, Callahan D, eds.
`Knowledge, Value and Belief. Hastings-on-Hudson, NY: Institute of So-
`ciety, Ethics and the Life Sciences; 1977:279–94.
`18. Tulsky JA, Chesney MA, Lo B. How do medical residents discuss re-
`suscitation with patients? J Gen Intern Med. 1995;10:436–42.
`19. Tulsky JA, Fischer GS, Rose MR, Arnold RM. Opening the black box:
`how do physicians communicate about advance directives? Ann Intern
`Med. 1998;129:441–9.
`20. von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in
`end-of-life care: communication and relational skills. JAMA. 2000;284:
`3051–7.
`21. Goold SD, Williams B, Arnold RM. Conflicts regarding decisions to limit
`treatment: a differential diagnosis. JAMA. 2000;283:909–14.
`22. Pellegrino ED. The internal morality of clinical medicine: a paradigm for
`the ethics of the helping and healing professions. J Med Philos. 2001;
`26:559–79.
`23. Siegler M, Pellegrino ED, Singer PA. Clinical medical ethics. J Clin
`Ethics. 1990;1:5–9.
`24. Forrow L, Arnold RM, Frader J. Teaching clinical ethics in the residency
`years: preparing competent professionals. J Med Philos. 1991;16:
`93–112.
`25. Jones AH. Literature and medicine: narrative ethics. Lancet. 1997;349:
`1243–6.
`26. Charon R. Narrative medicine: a model for empathy, reflection, profes-
`sion, and trust. JAMA. 2001;286:1897–902.
`27. DuBose ER, Hamel R, O’Connell LJ, eds. A Matter of Principles? Fer-
`ment in U.S. Bioethics. Valley Forge, PA: Trinity Press International;
`1994.
`28. Callahan D. Ethics without abstraction: squaring the circle. J Med Eth-
`ics. 1996;22:69–71.
`29. Weir RF. Abating Treatment with Critically Ill Patients: Ethical and Legal
`Limits to the Medical Prolongation of Life. New York, NY: Oxford Univer-
`sity Press; 1989:349–54.
`30. Farley MA. Compassionate Respect: A Feminist Approach to Medical
`Ethics and Other Questions. New York, NY: Paulist Press; 2002.
`31. Schneider CE. The practice of autonomy and the practice of bioethics.
`J Clin Ethics. 2002;13:72–7.
`32. Outka G. Social justice and equal access to health care. J Rel Ethics. 1974;
`2:11–32.
`33. Freeden M. Rights. Minneapolis: University of Minnesota Press; 1991.
`34. Smart JJC, Williams B. Utilitarianism: For and Against. Cambridge,
`England: Cambridge University Press; 1982.
`35. Jonsen AR, Toulmin S. The Abuse of Casuistry: A History of Moral Rea-
`soning. Berkeley: University of California Press; 1988.
`36. AMA Council on Ethical and Judicial Affairs. Code of Medical Ethics:
`Current Opinions with Annotations. Chicago, IL: American Medical As-
`
`310
`
`

`

`JGIM
`
`Kaldjian et al., Clinician’s Approach to Clinical Ethical Reasoning
`
`311
`
`sociation; 1998. Available at: http://www.ama-assn.org/ama/pub/cat-
`egory/2498.html. Accessed January 6, 2005.
`37. Ethics manual. Fourth edition. American College of Physicians. Ann In-
`tern Med. 1998;128:576–94. Available at: http://www.acponline.org/
`ethics/ethics_man.htm. Accessed January 6, 2005.
`38. Thomasma DC. Beyond medical paternalism and patient autonomy: a
`model of physician conscience for the physician-patient relationship.
`Ann Intern Med. 1983;98:243–8.
`39. Wardle LD. Protecting the rights of conscience of health care providers.
`J Legal Med. 1993;14:177–230.
`40. Perkins HS. Teaching medical ethics during residency. Acad Med. 1989;
`64:262–6.
`41. Culver CM, Clouser KD, Gert B, et al. Basic curricular goals in medical
`ethics. N Engl J Med. 1985;312:253–6.
`
`42. Miles SH, Lane LW, Bickel J, Walker RM, Cassel CK. Medical ethics
`education: coming of age. Acad Med. 1989;64:705–14.
`43. Fox E, Arnold RM, Brody B. Medical ethics education: past, present,
`and future. Acad Med. 1995;70:761–9.
`44. Barnard D. Residency ethics teaching: a critique of current trends. Arch
`Intern Med. 1988;148:1836–8.
`45. Jacobson JA, Tolle SW, Stocking C, Siegler M. Internal medicine res-
`idents’ preferences regarding medical ethics education. Acad Med. 1989;
`64:760–4.
`46. Pellegrino ED, Siegler M, Singer PA. Teaching clinical ethics. J Clin
`Ethics. 1990;1:175–80.
`47. Gillon R. Thinking about a medical school core curriculum for medical
`ethics and law. J Med Ethics. 1996;22:323–4.
`48. Brody H. Transparency: informed consent in primary care. Hastings
`Cent Rep. 1989;19:5–9.
`
`311
`
`