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Ethics Case Analysis Paper Requirements
One of the requirements for graduation at Stritch School
of Medicine is completion of a paper analyzing a case that involves an ethical conflict,
dilemma, or problem you have experienced or witnessed. The case is to be analyzed following the framework from Guidelines
for Writing Up a Narrative Case Presentation. The paper is expected to be a minimum of 6
pages in length, contain at least 10 separate references to the literature, and follow
specific format rules that are standard for medical papers considered for publication.
The paper is due the beginning of
your fourth year: July 11, 2008.
The purposes of the paper are threefold. First, the paper serves to
demonstrate your ability to recognize ethical aspects of medical care and write a well
reasoned, researched paper. Second, the paper provides an opportunity for you to develop
your own ability to think about ethical problems and articulate your own independent
thinking. Third, the paper can illustrate one facet of what I hope is the kind of doctor
that Stritch educates: a woman or man who is profoundly aware of the moral nature of
medical practice, committed to a high ethical standard in personal practice, and dedicated
to a careful consideration of what it means to do right in the often confusing arena of
medical care.
Although the paper is not due until
July 11, 2008, it is not too early to
begin to consider some of the challenging cases you may have encountered in your clinical
rotations. This letter comes to you now so you can keep in mind some of the ethical
problems that you may have already encountered and to encourage you to put down the
details of the case or cases while they are still fresh in your mind. Remember that a case
need not involve some life-threatening conflict or some huge dilemma. The case may involve
the care of an individual without insurance, or how we inform patients about a procedure,
or the amount of information one gives a patient about a medication, etc.
The papers are expected to be well written, researched, and carefully
reasoned. Your paper is not something that should be done in several hours or tossed off
over a weekend. It is vital that the paper follow standard grammar and spelling and that
you proofread your work. The department faculty will help you consider which case to
choose or how to sharpen your thesis. This requirement of an ethics paper may be
considered simply as another hoop to jump through on your way to graduation. It can,
however, be the opportunity for you to show your ability to think, write, and argue in a
respectful manner on a topic crucial to patient care. These are all essential skills for a
physician.
Your Ethics Case Presentation: Guidelines for
Writing up a "Narrative Case Presentation"
What is narrative presentation of a case?
Saying that cases in clinical medical ethics should be
presented in narrative form is a fancy way of saying that we need to explain the case in
ordinary language and try to convey its story-like quality. Presenting the case
narratively is an attempt to trace and demonstrate the development of the themes that run
through the case and that characterize the conflicts involved.
Narrating the case is much like what we do if we need to
explain the case to a lay person. It is what we did all our lives before becoming
health-care professionals. That is, we expressed things in ordinary language, usually
beginning at some relevant point ("the beginning") and telling of the important
events at each stage ("the action") until a pinnacle in the story is reached
("the climax"). The pinnacle is usually the height of the conflict between the
main "characters" or the point at which one of the characters (e.g., the
physician) faces a dilemma. This climax is usually what occasions us to present a case for
discussion. We want to know how to resolve the conflict and help the characters achieve an
ethically acceptable "resolution" (the final stage of the story).
Why is narrative form important?
On the one hand, there are mundane reasons for
preferring a narrative account to a medical record (i.e., the chart) of "facts"
concerning the case. For instance, narrating the case tends to make it more approachable
to the non-specialist or non-professional. Specialists in various medical fields often
have their own jargon and abbreviations that are not readily accessible to other medical
specialists and health-care professionals must increasingly include lay persons in the
decision-making and review process (e.g., the patient, the patient's family, medical
ethics consultants, ethics committee members, etc.); Obviously, the more approachable
format makes the case more usable by this wider variety of persons.
Of greater philosophical import is the notion that facts
need to be interpreted and narrative form is the easiest way of including the reader in
that process. For example, large numbers of tests are often run on patients. Simply
reporting the results of all tests will frequently not give the reader insight into which
test results the health-care team is viewing as relevant or what conclusions they are
drawing from them. Thus, the reasoning of the health-care professionals from the facts is
hidden from us without a narrative account that thematicizes the thought process.
Further, the health-care institution can be viewed as the
junction of many stories. The first or primary story is usually told from the perspective
of the health-care team. It begins with the presentation of the patient for treatment and
includes whatever information concerning the patient's medical history is available. This
story features a climax and resolution in which the antagonist is the illness. This
antagonist is overcome or triumphs over the patient and the health-care team. In this
story, the health-care team aids the protagonist (the patient) by helping (beneficence)
him/her against the illness.
From the patient's perspective, the illness and the
current presentation at the hospital are usually seen as one episode in the larger story
of his or her life. This life includes dreams and goals, various significant
relationships, beliefs and values, and a medical history that must be interpreted within
the framework of this larger context, i.e., the patient's life. Within this context, an
illness may not be the enemy simpliciter to be defeated at all costs. For instance, a
patient might authorize treatments because they offer hope of a cure but might decline
these same treatments if he finds that they preclude a present quality of life that allows
for certain highly-valued daily activities. Further, the patient's sense of the
"dignity" that characterizes his or her life is quite varied from one story to
another. Thus, when the health-care team treats a patient only from the perspective of the
primary narrative, they fail to recognize that the same actions may be valued differently
in the patient's story. For example, what is beneficence in the primary narrative may be
paternalism from the patient's perspective.
In sum, narrating the case allows us to make sense of it
as if it were a novel. Simply reporting the facts often leaves us with the sense that
characters are performing inexplicable or seemingly irrational acts for which the
motivations are concealed. Narrative provides us with the motivations and reasoning of the
health-care workers and helps us to find our first clues to the larger narrative that
accounts for the actions and decisions of the patient. Once we frame the conflict within
these larger stories, we often find that resolution is a matter of improved communication.
What points should I keep in mind to improve my case
narrative?
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There is no simple formula to make us perfect
narrators of cases in clinical ethics any more than there is a rulebook that can make us
novelists. However, just as there are conventions of writing fiction, there are some
guidelines we should attempt to observe in writing case reports. For instance:
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Medical jargon and abbreviations can be employed but
translations usable by lay persons should be provided as well. Parentheses often come in
handy for this purpose. However, jargon should never be used simply for its own sake even
if you provide translations. This is also true of ethical jargon - use it when it can help
convey meaning, never for its own sake.
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Most case presentations begin the story with the
patient presenting for treatment. Keep in mind the larger narrative of the patient's life
and try to include, what, if any, of this story (the patient's larger history) is
available to those health-care workers initially treating the patient. In other words,
make sure you tell us what the treating physician knew about the patient at the time of
the initial contact. This larger story often continues to be incrementally revealed to the
health-care team. Include as much of this process of discovery in your report as is
available.
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Try to include the conclusions that the health-care
professionals are drawing from their diagnostic work and tell how much of this information
is conveyed to the patient. This is very important because the two stories may be
developing independently based upon different information and conclusions.
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No story is complete without an end. At various points
in every story, the characters base their actions on what they believe will be the
outcome. Medicine calls this outcome the prognosis. Surprisingly, this is often omitted
from case reports. This happens because health-care workers often try to act as if they
are dealing only with the empirical situation present at hand and not venturing into
future probabilities. However, in real life, we usually base our actions to some degree on
our expectations of the future. This is true in both the medical narrative and the
patient's life story. Hence, it is important to understand as much about the prognoses at
the decision-making points as we can and to know how much of that information was conveyed
to the patient/family.
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Often, conflicts seem unresolvable at first glance. We
look at the choices expressed by each party and it seems that they cannot be reconciled.
Often the choice of one of the parties seems irrational and unreasonable. In such cases we
must ask why they are making the choice they are. There are many possible motivations for
a decision but motivations often can be traced to the larger narrative context of the
patient's life. Asking the person directly why they have made the choice they have is
always the preferred course of action. However, sometimes that is not possible.
Attempt to provide as much of the patient's history as you deem may be relevant to
understanding their motivations.
Instructions for
Preparing Ethics Case Presentations
A. Select a Case: What constitutes an ethics case or issue?
Students often select cases in which there is a
conflict of opinion regarding the best course of action or treatment to
pursue. Such conflicts can arise between physicians and patients, among
members of the health-care team, between physicians and family members,
between patients and family members, and among family members. Conflicts of
this type can often be analyzed by focusing on the competing values of each
party (e.g., extending life versus minimizing suffering). Presentations of
cases involving conflicts can lead to discussions of such ethical issues as
autonomy, competence (decision-making capacity), informed consent,
paternalism, and the rights and responsibilities of physicians, patients,
and family members.
Cases can be presented
which do not involve any interpersonal conflicts. Students may wish to
present a case because they believe that a decision was incompatible with an
important ethical norm, value or principle. For example, decision makers who
seek to promote a patient's best interests (as perceived by the physician
and family) may neglect the patient's right to information regarding the
diagnosis, prognosis, and treatment alternatives. Thus, even though a
physician and a patient's family may agree that the patient will not be told
that she has cancer, the decision to withhold information may merit ethical
examination.
Almost any case contains ethical issues because the norms of
the doctor-patient relationship are, ideally, based on ethical principles
and motivations. To identify ethical issues, students can select a case and
observe how the physician-patient relationship is conducted. Particular
attention can be given to how the attending and house staff interact with
the patient, what and how information is conveyed, how and by whom treatment
decisions are made, and how the patient's decision-making capacity is
assessed. If a surrogate decision maker is involved, students might consider
the following questions: How and by whom was it decided that the patient
lacked decision-making capacity? How was the surrogate selected? Was
sufficient information given to the surrogate? Was sufficient consideration
given to the patient's values and best interests in the decision-making
process?
Students are encouraged to discuss the decision-making process with the
attending, house staff and the patient or family. Such cases can facilitate
an exploration during ethics conferences of the proper role of each party in
treatment decisions, effective methods of communication, and means to
minimize conflicts through better communication.
B. What information should I present? There should be five topics
covered in your case presentation:
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The Narrative of the
Case: The
student should attempt to present all relevant medical and social facts
about the patient. Ethically sound decision-making is based on good
medical care and a good factual basis regarding patient care. Much
relevant information is easily obtainable from the patient's chart.
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The Language and Issues
of the Case: Cases are often discussed in terms of a particular topic, e.g.,
informed consent, the decision-making capacity (competence) of the
patient, forgoing life-sustaining treatment, physician-assisted suicide,
etc. The reasons for choosing one course of action over another are often
explained in terms of one of the prima facie duties of physicians to
patients, respect for autonomy, nonmaleficence, beneficence, or justice.
You should not jargonize your write up unduly. However, you should be able
to identify the topic under which your case falls and to identify the
duties to the patient that are involved in the case.
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Perspectives and Key
Points of View:
This is probably the single most important part of any case analysis. You
should go person by person and explain how each saw the situation. Very
often, you will find that one or more of the points of view are not well
understood by you or others involved in the case. Attempting to understand
the reasons and preferences of the parties involved can help to identify
important conflicts and their sources. On the other hand, seemingly
unresolvable conflicts can be resolved when a sincere effort is made to
understand the underlying reasons and values.
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Facilitating Resolution:
What approaches might have been taken to bring about case resolution?
e.g., family and caregiver conference? Ethics case consultation? A
discussion among certain members of the health-care team? Is there any way
you could have contributed to the solution?
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What actually happened?
Please be sure to include the outcome of the case.
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Commentary:
Your commentary should
highlight the professional duties that physicians have to patients and how
these duties were respected or compromised in the case resolution.
ETHICS PAPER STUDENT GUIDELINES
In preparing your case analysis, follow the process of moral reasoning
introduced using the format of the Instructions for Preparing Ethics Cases Presentations.
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Paper must be a minimum of 6 and a maximum of 10 pages. It must be
typed, double spaced, on 8-1/2" X 11" paper. Include your name, address, phone number and
Loyola mailbox number on the title page.
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Criteria for Using the instructions for Preparing Ethics Cases
Presentations:
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Address each section of the instructions for Preparing Ethics Cases
Presentations. Use sub-headings to delineate the sections in your paper.
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Present medical and social facts of the case (the narrative).
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Identify the language and issues of the case.
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Explore the perspective of the patient, attending physician and other
pertinents to the case.
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Identify several possible courses of action or ways to try to resolve
the case.
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Incorporate an ethical justification for the recommended course of
action, drawing on the duties of the physicians to patients, such as beneficence,
non-maleficence, justice, and autonomy. Explain how your solution tries to reconcile
or fails to reconcile the perspectives in conflict in the case.
Incorporate relevant medical and bioethics literature in your
discussion. Paper must cite at least ten references. Use the reference system and format
of the New England Journal of
Medicine.
Use correct grammar and spelling. This is an essential part of this
paper. Poor grammar and spelling will result in a failing grade.
If you are aware of the outcome of the case that you discuss, it may be
worthwhile to discuss what actually happened and any follow-up information you have
available.
DUE DATE: Papers are due
July 11, 2008 at 4:00pm. Failure to meet the deadline will result in a grade of
"FAIL." No exceptions will be made. A remediated "Fail" will be reported as "P*."
Submit TWO copies of your paper to the Neiswanger Institute
for
Bioethics & Health Policy office,
Bldg. 120, Room 280, on or before the due date.
GRADING: Papers will be graded Pass/Fail. Poorly written papers that do
not meet the guidelines will receive a failing grade.
Click
here
 to view a sample case
presentation paper.
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