Juggling law, ethics, and intuition: practical answers to awkward questions.

Part of the fascination of medical ethics derives from the interplay of different perspectives and principles in the search for morally coherent solutions to ethical dilemmas. Practical problem solving involves verifying the facts in as accurate a manner as possible before weighing up the different values and interests to reach an acceptable balance. Although there may be various ways of doing this, modern methodologies are likely to come up with similar solutions. This is because most of us draw upon the same shared pool of established values although we may quote different justifications for respecting them. For the practical decision maker as opposed to the theoretician, legal boundaries and societal mores also increasingly limit the range of choices that can be made even before we begin to examine the ethical arguments. Indeed, in some situations, the legally viable options are so clearly and unambivalently stated that it may seem superfluous to look beyond them if the aim is to provide practical advice. The obligation to look beyond statute and legal precedents, however, springs from the need to ensure that ethical advice is morally consistent and justifiable in different contexts, regardless of whether the law has pronounced upon all the relevant scenarios. Practical ethical advice must also be consistent with society's changing expectations, especially in areas where the law is open to interpretation. The risks of relying on unscrutinised past medical practice and ambiguous legislation concerning organ retention, for example, were highlighted by the public inquiries at Bristol and Alder Hey. (1,2) Furthermore, although account must be taken of general societal expectations, British medicine is practised in a diverse and multicultural setting where individual patients' preferences about who decides what for whom may vary. Some patients choose to waive certain of their legal and ethical rights when treatment decisions are made (which can involve complications about whether they can validly decide not to have certain crucial information without knowing how crucial it is). Among other things, this paper is about the need for practical guidance to focus strongly on the individual circumstances of each case as well as taking account of the law, ethical theories, and the requirement for medical decisions to be consistent, clinically sound, and evidence based.

The vast majority of practical ethical dilemmas in medicine involve staple examples of conflicting moral imperatives. Nevertheless, medical technology can produce new twists on classic dilemmas and so systems of problem solving should be adaptable to foreseeable future problems. They should be able to address in a consistent way exceptional as well as routine questions. Unlike the neat dimensions of textbook dilemmas, real life problems can be "rather messy concoctions of many details, some salient, others obscure, but all calling for attention". (3) The reasoning applied to them must be logical and philosophically sound but also robustly practical and flexible. Human emotions are obviously complex and sometimes undisciplined but they cannot be excluded from the picture. Respecting patients' autonomy involves respecting their intentions--if knowable--which can be a different matter from respecting the words spoken. A very common dilemma, for example, centres around the thriving, self confident, and content patient, apparently fully recovered from mental illness, who probably knows but prefers to ignore that this happy state depends on clandestine medication administered by relatives. Whether patients' self deception and collusion must automatically be challenged, and whether it benefits or harms them to do so, might conceivably have different answers in different contexts. Undoubtedly, we need pure, clear lines of ethical reasoning for the establishment of norms and standards but real life dilemmas often tend to involve ambiguities, inconsistencies, mutually incompatible desires, and ragged edges. Frequently not all the pieces of the jigsaw are available because information has been withheld or lost or misinterpreted through human error. Flexibility, interpretation, and some juggling skills may be required and they are also part of the British Medical Association (BMA) approach.

COMPONENTS OF THE BMA'S METHODOLOGY

In some respects, the BMA's methodology has much in common with a four principles approach. It is based on the premise that moral solutions cannot be reduced to a set of one size fits all rules and algorithms. Context is important. The association does not provide "answers" to doctors' dilemmas but rather sets out the legal and moral arguments, indicating what appears most ethically justifiable in a specific context. By disentangling the morally relevant issues of the dilemma from the clutter of information surrounding them, the BMA seeks to highlight the competing interests that need to be balanced in a particular situation. Although staple questions recur, ready made answers cannot necessarily be applied, precisely because the requirements of some or all of the individuals concerned can vary from case to case. Thus, as with the four principles approach, potential solutions depend on the weight and priority given to particular values in the context of individual cases. In every dilemma, it is crucial first to clarify the facts and details. Within the BMA's methodology, it is then generally necessary for us to consider:

l. The law, including the implications of human rights legislation;

2. Established professional guidance;

3. Relevant legal and ethical definitions of "harm" and "benefit" in particular contexts;

4. Doctors' traditional values and duties;

5. The available clinical evidence base, especially for innovative practices;

6. Community values in terms of issues such as patient autonomy and its limits, the need for transparency, protection of vulnerable individuals, and the need to accommodate cultural and religious diversity;

7. The need for consistency--not just with existing advice and policies but also looking ahead to identify future ethical dilemmas.

For the most part, these components are self explanatory but it may be worth focusing on why factors such as the law, professional guidance, and traditional values feature prominently in the BMA's methodology. Interpretation of what constitutes a "benefit" or "harm" is likely to be central to any problem solving methodology but …