USING THE CASEBOOK
Teaching and Learning Guide
Welcome to the Teaching and Learning Guide!
This section of the website is designed to offer you a structured way of teaching and learning using all the different materials in the casebook.
Various Pathways
How you use the casebook is up to you. If you are dipping in, or looking for material about specific care situations or ethical and legal issues, the search function on the homepage keywords can help you find items of interest.
If you are looking for a more structured approach, this Teaching and Learning Guide will describe different ways of working through the casebook, depending on your needs.
Please click on one of the following links to find out more about how to use this casebook to cater to your needs.
Leading a teaching session for colleagues
How to do it
Teaching in health and care settings happens in formal and informal ways: through grand rounds, seminars and other formal presentations; through journal clubs and other informal discussions; through “show one, do one, teach one” skills-building; and through being a good role model and mentor.
Teaching is supported learning. This section of the Guide is designed for professionals who want to use this casebook to support learning by others, in how to think through difficult decisions in practice. You do not require any prior training or experience in ethics and law to use the casebook as a teaching tool.
We recommend two approaches for using this guide in a teaching session. The first approach uses a difficult case to illustrate a specific ethical challenge you want to explore. The second approach uses a difficult issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice. Please click on the link below for further information about how to make use of these different approaches.
Difficult Case Approach
A look at the approach
This approach focuses on one case that illustrates a specific ethical challenge you want to explore. It is a useful approach for a relatively short teaching session.
Before your teaching session
Step 1: Choose the case that best fits your practice setting. You can modify the details of the case to fit the needs of your audience; for example, you may find it helpful to change a patient’s diagnosis to match the conditions typically seen by your audience. You can also use a case as a model for developing your own unique teaching case.
Step 2: Identify the questions that you want to explore during your teaching session. You may want to use or adapt the reflection questions at the end of the case, or, if you have the opportunity to do so, to ask your audience members for questions of special concern to them.
Step 3: Read the case closely, identifying the ethical issues the case presents, so that you are prepared to discuss these issues. Ethical uncertainty often reveals itself when different people express different values and concerns, or assert different sources of authority, so pay close attention to what the different characters in your case are saying and doing.
Step 4: Identify the arguments that you want your audience to consider as they work through how to resolve the ethical uncertainty presented by the case. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop such arguments. You might find the videos on the third tab useful in your teaching session. The videos could be shown in the class to your colleagues to model a way of reasoning through a case, or you could use them to help to prepare your own structure for the teaching session. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 5: Consider whether and how you will use the commentaries and practitioner perspective on your case, and the backgrounders relevant to your case, during your teaching session. You could draw on these materials to identify ethical arguments and/or relevant factual information. Alternatively, you could distribute the case, commentaries, and practitioner perspective to audience members as a set of readings for discussion.
During your teaching session
Step 6: Present the case, or your modified version of it, making use of the video as you think is appropriate. Asking a participant to read the case aloud, or for several to read the parts of the different characters in the case, are good ways to encourage participants to engage with the case and the issues.
Step 7: Present the questions and arguments you want your audience to consider, giving them opportunities to suggest their own questions and arguments. Because care professionals often use cases to explore challenging situations, be prepared to explain what is similar, and different, about using a case to explore ethical challenges in care practice. Further information about this method is outlined in the ‘Toolbox for ethical thinking’ in the second tab above.
Step 8: Discuss the questions and arguments with reference to the case, and conclude by identifying lessons or other insights that participants can take with them into the real world of practice.
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Resolving the conflict requires that someone recommend an ethical course of action, and that others reach agreement on whether to adopt this course of action, or propose something different.
Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of the process of an ethics teaching session – See Steps 4 and 7 of the difficult case approach. Here is a step-by-step approach to working with your colleagues to develop an ethical argument:
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some conflicts in values involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way. Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The videos on the third tab provide worked examples of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. The current video focuses on an ethical issue arising in a hospital setting. (There are two forthcoming animated videos that will focus on both the hospital and community settings.)
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
Difficult Issue Approach
A look at the approach
This approach focuses on an issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice. It is a useful approach for a workshop that includes sufficient time for discussion of a number of cases, and for skills-building activities.
Before your teaching session:
Step 1: Choose the cases that best illustrate the issue you plan to explore. You can use the ‘Browse by topic’ link in the Casebook to select cases that address particular ethical issues. As with the ‘difficult case’ approach, you can modify the details of the cases to fit the needs of your audience, or use the cases in the casebook as models for developing your own teaching cases.
Step 2: Identify the questions that you want to explore during your teaching session. As with the ‘difficult case’ approach, you can use or adapt the reflection questions at the end of your selected cases, or ask your audience members in advance for questions of special concern to them.
Step 3: Read your selected cases closely, identifying how they illustrate the issue you are exploring. Pay attention to how the characters in the cases express ethical uncertainty.
Step 4: Identify the arguments that you want your audience to consider as they explore the difficult issue by means of the selected cases. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop such arguments. You might find the videos on the third tab useful in your teaching session. The videos could be shown in the class to your colleagues to model a way of reasoning through a case, or you could use them to help to prepare your own structure for the teaching session. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 5: Consider how you will use the commentaries and practitioner perspective on your selected cases. Are the backgrounders relevant to these cases, during your teaching session? You can draw on these materials to identify ethical arguments and/or relevant factual information. Alternatively, you could distribute the case, commentaries, and practitioner perspective to audience members as a set of readings for discussion.
During your teaching session
Step 6: Present the selected cases, or modified versions of them, using the animated video in the second tab as you think appropriate. Ask participants to read each case aloud, or for several participants to read the parts of the different characters in each case since they are good ways to encourage participants to engage with the cases and the common issue. If you are presenting to a large group, you may want to divide the audience into smaller groups for discussion of individual cases, and then reconvene to summarise the different cases and compare how the common issue was reflected in each case and resolved by the group.
Step 7: Present the questions and arguments you want your audience to consider, giving them opportunities to suggest their own questions and arguments. Because care professionals may also use cases to explore challenging situations, be prepared to explain what is similar, and different, about using a case to explore ethical challenges in care practice. Further information about this method is outlined in the ‘Toolbox for ethical thinking’ in the second tab above.
Step 8: Discuss the questions and arguments with reference to the cases, and conclude by identifying lessons or other insights that participants can take with them into the real world of practice. If time permits, a skills-building exercise (for example, on how to resolve a family conflict about decision-making on behalf of a patient who lacks decision-making capacity) can help reinforce these lessons by providing practical guidance that participants can apply.
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of the process of an ethics teaching session – referenced in Steps 4 and 7 of the difficult issue approach. Here is a step-by-step approach to working with your colleagues to develop an ethical argument:
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some values conflicts involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way.
Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The videos on the third tab provide worked examples of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. The current video focuses on an ethical issue arising in a hospital setting. (There are two forthcoming animated videos that will focus on both the hospital and community settings.)
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
Having a group discussion with colleagues
How to do it
Ethical issues are commonly addressed within group discussions that take place amongst practitioners. Sometimes these discussions can be formal, for example when you a multi-disciplinary team meeting or a staff handover meeting is scheduled. At other times, these discussion can take place in informal settings: over lunch, coffee, or in the corridor of your workplace in between other meetings.
Ethically difficult care situations are the kind of topics that might often be discussed in these formal or informal group settings as you face uncertainty about how to make difficult decisions for a specific patient, or for patients in general. The unstructured nature of these discussions, in comparison to a teaching seminar, means that it can often be difficult to think about how conversations about ethics in practice can help to identify important learning points for how to make difficult decisions in everyday practice.
We believe that a carefully facilitated approach to talking about ethics in these formal and informal group discussions is useful to embed good ethical practice in care work.
How you facilitate a discussion of this kind will depend on what you aim to achieve. We recommend two approaches for structuring a group discussion with colleagues. The first approach uses a difficult case to illustrate a specific ethical challenge you want to explore. The second approach uses a difficult issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice. Please click on the link below for further information about how to make use of these different approaches.
Difficult Case Approach
A look at the approach
This approach focuses on one case that illustrates a specific ethical challenge involving a particular patient that you want to explore in discussion with your colleagues. This step-by-step guide can be adopted formally in a group meeting, or as a rule of thumb in informal conversations that you have with colleagues.
Step 1: Choose a case that best fits the situation of the patient for whom you are struggling to make a difficult decision. You can modify the details of the case to fit the circumstances; for example, you may find it helpful to change a patient’s diagnosis or living arrangements to match the conditions you are facing.
Step 2: Identify the questions that you want to explore during your discussions. You may want to use or adapt the reflection questions at the end of the case, or to use this opportunity to ask your colleagues for questions of special concern to them.
Step 3: In a team meeting, identify a facilitator who will chair the discussion and ensure that the analysis is conducted in a structured way. Identify ground rules amongst the group members; how will you manage disagreement? Will you work as individuals, in small groups, or as one large group in the process of developing an ethical argument? Will specific individuals be asked to undertake particular tasks in leading parts of the discussion?
Step 4: Present the case, or your modified version of it. Asking a participant to read the case aloud, or for several to read the parts of the different characters in the case, are good ways to encourage participants to engage with the case and the issues.
Step 5: Begin your analysis of the case. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop an argument to address the ethical question you are focusing on. You might find the videos on the third tab useful to see how ethical arguments are developed in care practice. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 6: Draw attention to the commentaries and practitioner perspective on your case as appropriate, and the backgrounders relevant to your case. You could use these to identify counter-arguments, or to see how others have worked through the question and the conclusions that they came to.
Step 7: Discuss the questions and arguments with reference to the case, and then connect these arguments back to the specific difficult decision that you are facing in the care of your patient. Conclude your discussion by identifying lessons or other insights that participants can take home.
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Resolving the conflict requires that someone recommend an ethical course of action, and that others reach agreement on whether to adopt this course of action, or propose something different. Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of the process of a group discussion focused on an ethically difficult decision in a patient’s care. Here is a step-by-step approach to working with your colleagues to develop an ethical argument. This is useful in fulfilling Step 5 of the difficult case approach.
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some values conflicts involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way.
Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The videos on the third tab provide worked examples of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. The current video focuses on an ethical issue arising in a hospital setting. (There are two forthcoming animated videos that will focus on both the hospital and community settings.)
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
Difficult Issue Approach
A look at the approach
This approach focuses on an issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice. It is a useful approach for an extended discussion that includes sufficient time for working through a number of cases and for developing general ethical guidelines in a care setting. This step-by-step guide can be adopted formally in a group meeting, or as a rule of thumb in informal conversations that you have with colleagues.
Step 1: Choose the cases that best illustrate the issue you plan to explore in discussion with your colleagues. You can use the ‘Browse by topic’ link in the Casebook to select cases that address particular ethical issues. As with the ‘difficult case’ approach, you can modify the details of the case to fit the circumstances; for example, you may find it helpful to change a patient’s diagnosis or living arrangements to match the conditions you are facing.
Step 2: Identify the questions that you want to explore during your discussions. You may want to use or adapt the reflection questions at the end of the case, or to use this opportunity to ask your colleagues for questions of special concern to them.
Step 3: In a team meeting, identify a facilitator who will chair the discussion and ensure that the analysis is conducted in a structured way. Identify ground rules amongst the group members; how will you manage disagreement? Will you work as individuals, in small groups, or as one large group in the process of developing an ethical argument? Will specific individuals be asked to undertake particular tasks in leading parts of the discussion?
Step 4: Present the cases. Asking a participant to read the case aloud, or for several to read the parts of the different characters in the case, are good ways to encourage your colleagues to engage with the central issue.
Step 5: Begin your analysis of the cases. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop an argument to address the ethical question you are focusing on – although the video only focuses on one case. You might find the videos on the third tab useful to see how ethical arguments are developed in care practice. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 6: Draw attention to the commentaries and practitioner perspective on issues relating to the one that concerns you, and any relevant backgrounders. You could use these to identify counter-arguments, or to see how others have worked through the question and the conclusions that they came to.
Step 7: Discuss the questions and arguments with reference to the issue you are discussing. Conclude your discussion by identifying main lessons or other insights that participants can take home. Consider whether your discussions could be developed into a more formal guideline to support ethical decision-making on this issue.
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Resolving the conflict requires that someone recommend an ethical course of action, and that others reach agreement on whether to adopt this course of action, or propose something different. Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of the process of an ethics teaching session – referenced in Step 5 of the difficult issue approach. Here is a step-by-step approach to working with your colleagues to develop an ethical argument:
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some values conflicts involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way. Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The following video provides a worked example of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. This video focuses on an ethical issue arising in a hospital setting. (There is a forthcoming video that will focus on both the hospital and community settings.)
You may wish to present the video to your colleagues in the teaching session, by way of modelling how an ethical issue can be analysed. Alternatively, you might use the video in order to prepare for the session, using the structure of the analysis to shape your own presentation.
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
Learning in your own time
How to do it
Ethically challenging situations can arise all the time in care work. Often there is limited support available to address ethical questions in your practice, or limited time to devote to thinking these questions through. You might find that ethically difficult decisions keep you awake at night, or that they are distracting you from your work. In light of this, you might find yourself looking for support on how to make difficult decisions in care practice in your own time. Recognising that people need assistance in this self-reflective process, we have designed this component of the guide to assist you in reflecting on ethically challenging situations, and to provide learning support in making difficult decisions that you might be struggling with.
We recommend two approaches for using this guide when you are learning in your own time. The first approach uses a difficult case to illustrate a specific ethical challenge you want to reflect on. The second approach uses a difficult issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice that you might be experiencing. Please click on the link below for further information about how to make use of these different approaches in your own learning.
Difficult Case Approach
A look at the approach
This approach focuses on one case that illustrates a specific ethical challenge that you might be having in providing care for a particular patient. This step-by-step guide can be adopted as you learn in your own time.
Step 1: Choose a case that best fits the situation of the patient for whom you are facing ethical uncertainty. You can modify the details of the case to fit the circumstances; for example, you may find it helpful to change a patient’s diagnosis or living arrangements to match your situation.
Step 2: Identify the questions that you want to explore. You may want to use or adapt the reflection questions at the end of the case, or to identify a different issue that better captures your own difficulty.
Step 3: Read the case closely, identifying the ethical issues the case presents. Ethical uncertainty often reveals itself when different people express different values and concerns, or assert different sources of authority, so pay close attention to whether part of your difficulty lies in the fact that your view of the issue in the case differs from colleagues that you are working with.
Step 4: Begin your analysis of the case. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop an argument to address the ethical question you are focusing on. You might find the videos on the third tab useful to see how ethical arguments are developed in care practice. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 5: Take a look at the commentaries and practitioner perspective on your case, and the backgrounders relevant to your case. You could use these to identify counter-arguments, or to see how others have worked through the question and the conclusions that they came to. To what extent is your analysis aligned with those of the commentary and perspective writers?
Step 6: Consider your arguments with reference back to your own case. Are you happy that you have now found a good path to addressing the difficulty you were facing, and can you identify whether your analysis has any other implications for the care of other patients you are involved in?
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Resolving the conflict requires that someone recommend an ethical course of action, and that others reach agreement on whether to adopt this course of action, or propose something different. Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of self-reflective learning that is focused on an ethically difficult decision you are making as part of a patient’s care. Here is a step-by-step approach to developing an ethical argument. This is useful in fulfilling Step 4 of the difficult case approach.
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facs and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some values conflicts involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way. Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The videos on the third tab provide worked examples of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. The current video focuses on an ethical issue arising in a hospital setting. (There are two forthcoming animated videos that will focus on both the hospital and community settings.)
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
Difficult Issue Approach
A look at the approach
This approach focuses on an issue (such as a values conflict within a family, or how to make decisions on behalf of people lacking mental capacity) that is a common feature of ethically challenging situations in practice. Upon reflecting on the situations that you are finding ethically challenging in your own practice, you might realise that it is a general issue, rather than a specific case, that is the source of your difficulty.
Step 1: Choose the cases that best illustrate the issue that is causing you ethical uncertainty. You can use the ‘Browse by topic’ link in the Casebook to select cases that address particular ethical issues. As with the ‘difficult case’ approach, you can modify the details of the case to fit the circumstances; for example, you may find it helpful to change a patient’s diagnosis or living arrangements to match your situation.
Step 2: Identify the questions that you want to explore. You may want to use or adapt the reflection questions at the end of the case, or to identify a different issue that better captures your own difficulty
Step 3: Read the cases closely, identifying how the issue manifests itself differently across the cases. Ethical uncertainty often reveals itself when different people express different values and concerns, or assert different sources of authority, so pay close attention to whether part of your difficulty lies in the fact that your view of the issue in the case differs from colleagues that you are working with.
Step 4: Begin your analysis of the cases. The ‘Toolbox for ethical thinking’ in the second tab of this page offers help in how to develop an argument to address the ethical question you are focusing on – although these videos only focus on one case. You might find the videos on the third tab useful to see how ethical arguments are developed in care practice. The current video is focused on a hospital setting. (Two forthcoming animated videos will focus on both the hospital and community settings.)
Step 5: Take a look at the commentaries and practitioner perspective on your cases, and the backgrounders relevant to your issue. You could use these to identify counter-arguments, or to see how others have worked through the question and the conclusions that they came to. To what extent is your analysis aligned with those of the commentary and perspective writers?
Step 6: Consider your arguments with reference back to how the issue has arisen in your own practice. Are you happy that you have now found a good path to addressing the difficulty you were facing, and can you identify whether your analysis has any other implications for the care of other patients you are involved in? How might you share these implications with your colleagues, and might it be possible to engage your colleagues in discussion about this issue at a subsequent time?
Toolbox for ethical thinking
Ethically challenging situations often feature disagreement about the right thing to do. Resolving the conflict requires that someone recommend an ethical course of action, and that others reach agreement on whether to adopt this course of action, or propose something different. Proposing an ethical course of action involves explaining why this action is ethical; this explanation is known as an ethical argument. Good ethical arguments can help resolve individual ethical uncertainty – what should I do when I am faced with this situation? – even if there is no disagreement between the people involved.
Developing an ethical argument is a central part of self-reflective learning that is focused on an ethically difficult decision you are making as part of a patient’s care. Here is a step-by-step approach to developing an ethical argument.
Step 1: Confirming whether your question is an ethical question
Ethical questions are concerned with what we should do when there are good reasons for more than one course of action, when no single course of action is clearly ‘right’. (Sometimes, the ethical course of action will be the ‘least worst’ option.)
‘What should I do?’ is an ethical question. This question is not the same as:
- What am I legally permitted to do?
- What do policies or regulations require of me?
- What do most people think I should do?
- What does the clinical evidence suggest?
- What is the way we are accustomed to act in this situation?
It can be difficult to completely separate ethical questions from legal, policy, or clinical questions; good ethics depend on clarity about relevant facts. The reflection questions that follow the cases in this casebook include both ethical questions and questions about medical and legal facts that are relevant to this type of case.
When you have more than one ethical question, analyse each question individually.
Step 2: Making an ethical argument
The ABC Toolbox is a short, structured approach to thinking through ethical questions in care settings. Using the ABC Toolbox requires no formal training in ethics.
Tool A: Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (‘what is the correct dosage of this medication?’) or legal knowledge (‘what are the rights of patients concerning information about their care?’) will resolve a conflict between values (‘what is good/right?’). The facts are often relevant to making the ethically right decision, but the facts alone cannot tell us what we should do.
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict in your ethical question. Some values conflicts involve the interests of an individual or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate resources, for example. Other conflicts may involve values held by the same person; when that person is unable to make a decision for himself or herself, which values should guide the decision-maker?
Tool B: Balancing principles and intuitions
The ethical values that a care practitioner should adhere to in the care of the sick are long-established and widely recognised. Four Principles that reflect these values and that have been highly influential in clinical teaching and practice, and related areas of law are:
- Respect patients as persons (autonomyor self-determination)
- Do no harm to patients (non-maleficence)
- Do good for patients (beneficence)
- Act fairly (justice)
Do these principles capture the range of values that you have identified using Tool A, or are there additional principles that, in your view, reflect values implicit in your duties as a care provider? The answer to this question might differ depending on whether you are providing care in a hospital or in a community setting – and you need to think carefully about what these principles require of you in different care environments.
To what extent, if any, should your personal values influence how you interpret your professional duties? We all have gut reactions about what we believe we ought to do in a situation. These moral intuitions reflect the norms of our families, our cultural traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
In an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in a given situation, what are appropriate and inappropriate limits on self-determination in the interest of preventing harm, for example? We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. The goal of ethical reasoning is to reach agreement on a course of action that is consistent with ethically sound practice in the care of the sick. This process will, ideally, allay individual moral concerns; however, a perfect reconciliation of professional principles and individual intuitions may not be possible.
Tool C: Comparing cases
When we have used Tools A and B to make a decision that we think is ethically justified, it is useful to assess how this decision compares to other situations. Have we decided to act in the same way as we have acted previously in similar situations, and would we be happy to make the same decision in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help us to make ethical decisions, in addition to being a prudent retrospective check on the consistency of our reasoning. When faced with a new situation, we can ask, what has my past experience taught me about this kind of situation? What is similar, and what is different, about the situation at hand? Case studies about fictional patients, families, and professionals, based on real situations, can support ethical decision-making in this way. Case studies that include multiple perspectives and voices can also help a professional to step outside his or her own experience and ask, ‘Imagine if I were this character (the patient, a family member, a different family member, a member of a different profession) – what would this situation look like to me? What personal values, professional principles, or moral intuitions might be in play? Would I be inclined to make a different decision?’
The ABC Toolbox in practice
The videos on the third tab provide worked examples of how the ABC Toolbox can be applied to think through difficult ethical decisions in a particular case. The current video focuses on an ethical issue arising in a hospital setting. (There are two forthcoming animated videos that will focus on both the hospital and community settings.)
ABC Toolbox
This video, in three parts, provides a demonstration of the use of the ABC Toolbox to think through an ethical question in the care of an elderly person in the community.
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
ABC Toolbox: Part 1
ABC Toolbox: Part 2
ABC Toolbox: Part 3
Case Summary
This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences and ethics of seeking judicial intervention in the best interests of a child.
