Journal of medical ethics, I978, 4 200-206

A clinical model for decision-making

Richard M Martin Medical College of Georgia, United States

Richard Martin's aim in this paper is to present acritical method of making ethical decisions in amedical context. He feels that such a reflective methodprovides the best means of making the appropriatedecisions in given situations. It is based on DrMartin's experience in applying ethical theory whilecollaborating with physicians in the daily course ofclinical practice. Through his giving of a functionaldefinition of medical ethics, his descriptionsof an analytical model, the significance of valuesfor clinical decision-making and the advocacy roleof medical ethicists and their relationships withclinicians, Richard Martin sets out his ownvalue-intention as regards an ideal decision process.He stresses that his argument is ofparticular importanceto his fellow ethicists who should continuously andvigorously examine the creative interaction offaithand fact in their own inquiry and action. DrMartin concludes by stating that physicians andethicists can work together to accomplish theircommon aim, which is, of course, the health andwell-being of the patient.

John Dewey traces the development of Westernethical thought in terms of what he calls a revol-utionary assertion 'that conduct is not truly conductunless it springs from the heart, from personaldesires and affections, or from personal insight andrational choice'.' The custom-directed moralityof a more ancient, homogeneous world has givenway to a more reflective, rationally critical approachdemanded by a new world filled with incompatiblevalues and unprecedented issues. In the place ofthe definitive casuistry of the old customarymorality, this reflective morality offers assistancein making personal choice more intelligent. Accord-ing to Dewey, it enables an individual to place hismoral conflicts into the larger context of generaltypes and intellectual precedents and make his'personal reflection more systematic and enlight-ened, suggesting alternatives that might otherwisebe overlooked, and stimulating greater consistencyin judgement'.1 Reflective morality does not seekto overcome the necessity of personal choice withready-made answers; it facilitates it. This develop-ment constitutes, in William Frankena's words, a'move from a rather irrational kind of inner directionto a more rational one in which we achieve anexamined life and a kind of autonomy, becomemoral agents of our own, and even reach a point

when we can criticise the rules and values of ourown society. .. 2The medical context of ethical decisions is, of

course, in flux. It is hardly a novel idea that most ofour easily accessible moral answers have been madeobsolete by the rapid development of technologyand the proliferation of its products. In fact, thisdecline of moral certainty in the face of the bio-technical revolution is a favourite lament of manywriters. However, if Dewey and Frankena are to betaken seriously, the decline is consonant with man'scoming of age morally, so to speak, and should bemet with enthusiasm, not lamentations. The new,iconoclastic occasions which unsettle old moralconclusions are stimulants to the reflective mindequipped with a critical ethical method.

This paper presents such a critical method. It hasbeen written because ethical decisions made in themedical context are important and a reflectivemethod provides the best means for making appro-priate ones. It is hoped that the method will helpfacilitate intelligent personal choice or, at the veryleast, prod the reader into public discussion of abetter one. The description of the method willconsist of:

i) A functional definition of medical ethics as theanalysis of decision in action and the advocacy ofcertain human values,2) A critical model for that analysis,3) A description of the significance of values forclinical decision-making,4) The advocacy role of medical ethicists and theirinterrelationships with clinicians.It is based on the writer's experience in applyingethical theory while collaborating with physiciansin the daily course of clinical practice in the wardsof the Departments of Medicine and Neurology atthe Medical College of Georgia.

A definition of medical ethicsIn a recent book edited by Irving S Cooper andothers, Harmon Smith states that, '[t]o examine life,in terms of the values which support and inform it,is to practise ethics'.3 Smith goes on to suggest twopoints which are important to the concept of ethicaltheory to be presented here: ethics is 'characterisedby a spirit of radical inquiry' into moral value as anessential element ofhuman action; and such inquiry

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A clinical model for decision-making 201

is profitably exercised by comparative analysis of'belief and behaviour', that is, by asking if anaction is appropriate for the agent's values andintentions.3The spirit of radical inquiry basic to ethics

provides an epistemological approach which canhelp to make decisions more systematic and en-lightened in several ways. It helps to identify anddefine the issues that are important to those whomust decide and, thereby, focus their attention onthem. It exposes the process of decision-making,itself, and provides a clearer understanding of itsstructure, its component parts and the character oftheir dynamic interaction. Critical analysis stimu-lates inquiry and offers a model by which most thatis significant, both in the context and for theinquirer, is brought to light, and by which theconsequences of the decision in action may behonestly evaluated. Ethics makes its special con-tribution to reflection by exposing the significanceof his own value complex to the decision-maker andproviding him access to the norms and principleswhich support and inform his decisions.One way that ethics makes this special contri-

bution is illustrated by Smith's suggestion that theinquiry is an assessment of the 'coherence and com-prehensiveness between ... character and conduct,belief and behaviour, affirmation and action'.3Ethical reflection presupposes that each decisionin action is an expression of an ideologicalintention. It represents the momentary fulfilment ofa moral ideal which, because of the inescapable com-plexity of situation and value structures, is, itself,incomplete and ambiguous. An important functionof a critical ethical theory is to ask if this momentaryexpression is, indeed, a fulfilment of the ideal, thatis, if it fits with the moral intention in its substanceand consequence. It asks if the decision in action isappropriate for the ideological purposes ofthe agent.In the course of this assessment of appropriateness,the rigorous inquiry contributes to a critical aware-ness of the moral ideal, itself. The nature andfunction of general principles are examined alongwith their more specific constituent rules and codes.Ethics asks questions such as what principle is thestandard for the decision? Why is it given priorityover others ? Is the rule system coherent and con-sistent with the implications of the principle ?Exposed in such a way, even basic moral values,themselves, are made the subject of analysis andcriticism.

It is important for any definition of ethics to notethat the rigorous character of this inquiry requiresuniversal application of its intensive analysis. Allcategories of human decision are to be assessed bythe same standards. In fact, the critical intention ofethics demands that even its own motivating andinforming sources be explored. Of what value is allthis intensive inquiry? Why is reflection preferableto custom? After all, it is a painstaking task that

people normally avoid, prefering a kind of moralreflex based upon an intuitive feel for the 'rightthing' which seems to be universally available.The answer to such questions reveals a telling

point about ethics. As is true of every category ofhuman reflection it subjects to analysis, ethicalinquiry is motivated and sustained by ideologicalintentions, that is, it serves certain human purposesand moral values. When ethicists are asked why thedecisions of physicians should be so rigorouslyexamined, we respond with Frankena and Deweythat it is necessary because mere moral reflex isinadequate for the complexities of our contexts ofdecision. For example, we argue that all the newpossibilities created by advancements in medicaltechnology have made the simpler, more custom-oriented sorts of decision-making obsolete; or thatthe immense sigificance of the decisions ofphysicians for the lives of their patients demandsthe most serious kind of deliberation. We maintainadamantly that less desirable ways of deciding notonly do not work well enough, are inadequate, butthat they probably are morally suspect. This papermakes it apparent that I generally agree with thesearguments. I believe in the examined life, rigorousethical inquiry, and the other tenets of the ethicist'sfaith. It is for me a means of fulfiling certainnormative ideals, certain principles and moral valueswhich make sense of my universe and direct thecourse of my action.

This affirmation is important, not only as aconfession of faith, but because it demonstrates anessential element in a functional definition of ethics:ethics is practised by ethicists who are no lessaffected by their own motives, purposes and com-mitments than other mortals; or, perhaps moreappropriately put, ethicists also enjoy the benefits ofmeaning and direction provided by their values.Ethical analysis provides us with the means foradvocacy of those values and ideals which inform usabout our lives and support the decisions we make.Ethical theory is morally significant because it helpsto reveal our normative intentions and the means bywhich our ideals can be fulfilled in action.

An analytical modelWith this definition of ethical theory in mind, thedescription of a decision model may be presentedwhich serves this dual function of analysis andadvocacy. The reader who is familiar with theChristian ethical theory of Waldo Beach willrecognise the strong influence of his schema for'double contextualism' upon the graphic represen-tation. It should be added that the writer has revisedand elaborated his schema in order to emphasisecertain elements which are of particular importancein the medical context. The most significantsuggestions for this revision and elaboration came

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202 RichardM Martin

from Max Weber's Verstehen methodology, particu-larly his discussions of the role of value-orientation.4

This analytical model is based upon the principlethat the optimal decision is one which is appropriatefor both the objective context and the evaluatingsubject. It is optimal because it recognises theinevitable interplay between what one supposes tobe the actual circumstances, viable options andprobable consequences, and his own value-ladenapproach to facts. A theory based upon thatprinciple affords a rigorous system by which everyelement of significance to decision might be exam-ined. Figure i will be used to help demonstrate amodel of this system.The interaction in decision-making includes, first

of all, an objective context, a complex of observedphenomena. This object is composed of a conglo-meration of things, places and episodes of humanbehaviour, some of which represent some sort ofrecognisable interrelationship, many of which seemnot to be connected at all. These are the data whichwe might refer to as facts (Fig. i.i). They are bits ofinformation which we observe or have reported tous about what is happening and recognise as beingsomehow important for understanding the event -who is involved, where, when and how the eventsproceed. These data constitute much of the empiri-cal knowledge available to the decision-maker, thecollection of things and events to which he ascribesmeaning and in the face of which he acts.The objective information also includes the values

at stake in the observed interactions (Fig. 1.2). Thefactual events occur as human beings make decisions

ix.. Factswho, what,where, when,how

and act to fulfil their own moral ideals, their ownintentions. In order to take full account of theavailable empirical information, the observer mustask why some action-events occurred and notothers? What caused, that is, motivated anddirected what happened? Human agents actuallycreate historical events as they apply their valuestructures to provide meaning and direction for theirworld. Such value structures include, at least, eachindividual's specifically personal ideology, interestsand desires, behavioural norms and role-expectationsprescribed by his social interrelationships, and acultural identity which provides a world view andcontent for his ultimate concerns. The object ofanalysis can hardly be understood unless the norma-tive postulates of these human agents are treated tothe same rigorous assessment as other pertinentdata.

This objective context of fact and values at stakeis significant for the act of decision because itenters into an epistemological and normative inter-action with the decision-maker. This evaluatingsubject contributes his intellect to the process of dataassessment (Fig. I.3). The decision-maker possessesa rational ability, that is, he is capable of mentallyprocessing data by using concepts and organisingthem into manageable patterns. He has cultivatedthis rational ability even further by providing itwith more refined and directive concepts and modelsthrough some specific training. This intellectualaspect of the evaluating subject is shaped andfocused by patterned exercise so that it can makeexclusive abstractions from the overwhelming mass

1.3. Intellectreason, technxicalskills, logic

OBJECTIVECONTEXT

1.2. ValUeS

social, andcultural

Responsiveiz i~tionInteracto'

EVALUATINGSUBJECT

1.4. Valuesego - ideal, socialnorms, culturalprinciples

1.5. Understandinga. Observationand selection

b. Organisationand interpretation

""

i.6. Responsible decision 4

Reflection/revision|

Appropriate Action

Fig I The structure of decision and action.

\

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A clinical model for decision-making 203

of experiential data and make sense of his worldwith ideal constructs. He approaches the objectwith his own particular rationality, special technicalskills and logic.As the term implies, the evaluating subject also

possesses his own value structures (Fig. I.4). Theydetermine his concern, approach and managementof the objective context. He comes to the contextwith a cause supported and informed by an egoideal, that is, his own understanding of what he isand ought to be, by social rules, roles and norms,and by moral and philosophical principles whichcharacterise his culture.

This intellect-value complex makes action possibleby making sense of the objective data and providingform and content for action. The moral intention ofthe subject-values distinguishes certain relevantdata as significant and the subject-intellect createsconceptual patterns useful for fulfilling that inten-tion. Without these the object would remain a chaosof uninteresting, unimportant and useless data.To make decisions, then, the evaluating subject

must interact with the data to help create the objectand formulate an appropriate course of action. Hemust understand the data and what it means for hismoral ideal (Fig. I.5). The interest of the decision-maker is first expressed in his recognition that he isconfronted by a situation that either threatens hismoral ideal or gives him an opportunity to fulfil it.As this general sense of concern develops, heproceeds to more specific assessment of the occasionby selecting those data which his concern, purpose,and previous experience determine to be significant,that is, useful. In essence, he pursues his ideal by aprocess of unilateral selection, and the significanceand meaning he finds in events are based upon hisown value-orientation. He, then, organises the datainto familiar conceptual patterns which he createsby purposeful abstraction, the construction ofheuristic concepts, and the use of conventionalassumptions ofproximate causation. Having reducedthe plethora of data to manageable proportions andbestowed order to an otherwise chaotic collection ofdissociated events, the subject can convert theinformation into useful knowledge for practicaldecision (Fig. i.6). At last, he is ready to act. Thisinterpretation for action occurs as he assesses hisportrait of the context, its constraints and possi-bilities for fulfilment, and formulates a responsewhich will take greatest advantage of the perceivedsituation. As the consequences of his decision beginto become apparent, he enters a continuing processof reflection upon its actual efficiency. By thisreflection, he tries to determine if his expectationsand intentions are being realised and whether or nothis creative understanding or tactics might need tobe revised. He asks questions about cost and benefitfor his ideal, about how well his own action answersthe threat or maximises the opportunity for mani-festing his moral ideal, his 'good'.

This description of the process of decision foraction is presented not only because decision seemsto function that way, but also because it containscertain elemental considerations which ought to betaken into account in ethical theory. It is basedupon the idea that a decision should be responsibleto both context and moral ideal, that is, that it shouldbe appropriate for an object which includes factsabout observable events and value-orientationswhich help to create the events, and for an evaluatingsubject who is a complex of intelligence and value-affirming intention and is at once struggling tomaintain familiar manifestations of his moral idealand to advance toward its ultimate fulfilment.

The significance ofvalues for clinical decision-making

If this model is applied to the clinical decisionsphysicians must make, it become obvious that theyare involved in the same creative, evaluative processeven within the narrow limits of their practice. Theirdecision-making process also helps to demonstratethis abstract model with more specific clarity. Figure2 illustrates their clinical decisions.The object in which the physician finds his

limitations and possibilities usually has to do with apatient in his context. The physician meets hisfacts in the form of a bundle of symptoms such aspains or confusion and/or signs such as an abnormalreflex or high blood pressure in a history of physicaland social complaints, in a physical examination,etc., (Fig. 2.I). In spite of the fact that the scopeof available data is limited to the general area of anindividual's health problems, the amount ofinformation that the concern of the patient, theskill of the clinician, and the wonders of medicaltechnology can in concert create, is considerable.

In his interrelationship with the physician, thepatient exercises a multitude of individual interests.He is concerned about more needs, problems andopportunities than, for example, his backache. Hehas moral and religious structures which greatlyinfluence the meaning of his pain and what he willdo to resolve it (Fig. 2.2). He has a particular worldview and philosophy of life by which he understandshis own being and ultimate reality. The physicianis confronted by an acting person for whom themeaning of his illness and the significance of thephysician have been formulated by some value-orientation, and who is striving for fulfilment of hisaction-intention.The physician's job is to evaluate the patient;

that is, he must ascribe meaning and significance tothe chaos of data presented to him and formulate aresponse. The understanding the physician musthave of his patient so that successful treatment mayoccur comes only when the clinician-agent wilfullyinteracts with each unique patient context.The physician's tools for making sense of clinical

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2o4 RichardM Martin

2.I. Factssymptoms,signs, history,etc.

PATIENT

2.2. Valuesindividual interestsmoral/religiousstructures, worldview

2.3. Intellectprofessionalknowledge,scientific skills

ResponsiveInteraction'

A::,:;2.5. Understanding

PHYSICIAN a. History andexamination

b. Differentialdiagnosis

2.4. Valuespersonal interests.professional codesand role-expectations,moral principles,world view

2.6. Responsible Diagnosis <

Follow-up/revision

Appropriate Treatment

Fig 2 The structure of clinical decision and action.

data include, obviously, a highly developed intellect(Fig. 2.3). The years of required education andtraining have provided him with professionalknowledge about where the back is, what it doesand what makes it hurt. He possesses a vast array ofscientific skills and techniques which enable himchemically and physically to probe and repair backsand many other parts of the body. He knows names,concepts, systems, and intellectual approaches bywhich he can abstract, order, and manipulate dataabout the patient with great empirical success.As any other evaluating subject, the physician has

value-orientations to support and inform him in hiswork (Fig. 2.4). His own idiosyncratic interests, hispersonal likes, desires, and objects of affection helpto provide him with an image ofan ideal self and, bygeneralisation, the kind of person he thinks hispatient ought to be. For example, he might want tohelp people be like he is, clean, truthful, altruistic,well-educated and articulate, healthy, and hard-working. He ascribes meaning and significance to hispatient's situation according to his own criteria andgoals. He is, also, a part of a set of social systemsand a member of reference groups which providehim with functionally specific norms and role-expectations. Being a physician instructs him thathe is expected to exhibit active concern for illnesswherever he finds it and employ all the resources athis disposal to achieve a successful resolution forevery patient. His professional code of ethicsdemands that, above all personal interest, he devoteshimself to the welfare of his patient, the generalgood of society, the scientific advance of medicine,

and the integrity of his profession.5 His cultureprovides him with moral principles, religious tenets,and a general world view in a kind of superordinatemeaning-structure which helps to answer ultimatequestions of significance. These are final authoritieswhich test the rules of fact and behaviour and bywhich understanding and response are oriented andlegitimated. The physician makes his final appealfor his evaluation of the patient to fundamentalbeliefs like the truth of the scientific method, thesanctity of the quality and extent of human life,and the moral imperative of the 'golden rule'.5 Suchgeneral expressions of cultural value serve as moralprinciples which are manifested in particularsituations as functionally specific rules and norms,and which determine priorities among competinggoods and truths. These various structures of value-orientation enable the believer-physician to under-take decisive interaction with the patient becausethey provide defining purpose, significance for dataselection, and reflective criteria; they provide theaction-intention.The clinical setting has its own special terms for

the understanding and action process, but its basicfunctions remain intact (Fig. 2.5). The observationof the patient-context and selection of significantdata occur in medicine as history-taking, review ofsystems, physical examination, and laboratory tests.By these procedures, the physician submits thechaos of information about the patient to a stan-dardised, well-practised pattern of inquiry which iscarefully designed to elicit those data which fit arelatively small number of possible explanations for

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A clinical modelfor decision-making 205

rather specific clinical problems. The physician islooking for a way to categorise these problemsin terms of a familiar syndrome or disease. His firstaction-intention is to find a single, treatable lesion.From the moment he first meets the patient, thephysician begins to organise the data into a differen-tial diagnosis, that is, a list of likely possibilitieseach of which is used as a working hypothesis toguide clinical investigation. This process continuesas he tests and eliminates his suspicions, and amendsand reorders his differential until he is reasonablysatisfied with an explanatory theory. The result isan interpretation of the patients' problems in termsof a diagnosis, the meaning of which includes some-thing of the nature of the disease and its causalrelationship with some event or agent along with ageneral idea of its course and outcome (Fig. 2.6).Once the diagnosis is made, the physician canprescribe the appropriate treatment according to hisknowledge of conventional medical practice. Thetreatment will usually be one alternative amongseveral which might range from chemotherapy tosurgery, from a couple of weeks of bedrest tolaminectomy. His choice may be made on the basisof what he last read, how he feels about surgeons, orhis own years of experience and training. Thereflection on the results of the decision, the treat-ment, comes in the form of follow-up during aperiod of relatively close scrutiny of the patient'sprogress. If improvement of the symptoms andsigns can be seen, the patient will continue theprescribed course to completion. Ifthere is deteriora-tion or no improvement the treatment is changedand, in some ambiguous cases, even a new diagnosismay be sought.The responsible decision and appropriate action

for the physician requires applying his specialepistemological skills and value-intention to con-tribute meaning and significance to the clinical dataso that he may understand the objective reality ofthe patient and interact with its demands. Withoutthe value-intention of the physician, the data wouldbe mere information, unorganised, meaningless, andpointless for the purposes of decision. At the sametime, the patient who confronts the physician isobjectively real; he is independent, factual contextwithout whom the physician's evaluation would bedisembodied, abstract and useless. For a decisionto be appropriate for this kind of interaction, thephysician must use all his effort and skills to under-stand the patient as a particular, historical individualwho creates his own world by value-intention. Thephysician needs to realise that the patient's value-orientations and how they support and inform himmay be different from his own. Once the physicianunderstands the character and significance of hisown value-orientation and that of his patients, hecan make his 'personal reflection more systematicand enlightened, suggesting alternatives that mightotherwise be overlooked, and stimulating greater

consistency in judgement'.I He may 'even reach thepoint when [he] can criticise the rules and values of[his] own society' . . .2

The role of advocacy in medical ethics and theethicist's interrelationship with cliniciansMy explanation of this analytical model includes arather obvious statement ofmy own value-intentionas regards an ideal decision process. It is repletewith what I believe ought to be the purpose, datacriteria, and eventual result of action. Words like'appropriate' and 'responsible' are not value-freeterms. What is at stake is my own value system, myown supposition of meaning and significance. Weethicists must never allow ourselves to forget touncover our own unrecognised postulates. We mustrigorously examine the creative interaction of faithand fact in our own inquiry and action. Thiscritical ethical theory is important to me because itserves my advocacy for medical decisions whichappreciate the essential function of value-orientationand the historical uniqueness of individual patientsand physicians, and which fulfil my own moralprinciples and philosophical presuppositions.There is always some question as to whether the

clinician will cooperate with the ethicist. While theymay share common value structures, the ethicist'sdemands for critical reflection are often inconvenientand may even threaten territorial imperatives, idealself images, or even professional relationships. Afterall, most clinical decisions are based upon proceduresand expectations which enjoy extensive conventionalauthority.The clinician makes his own demands upon those

he will allow into his practice, especially people whoare not members of his profession. On a personallevel, he requires that his associates stand the testof his own self image; that is, that they are intelli-gent, honest, hard working, and demonstrate a realconcern for the needs of the patient and his ownprofession. On a more professional level, the cliniciandemands expertise, that is, that associates know theirbusiness. He will not trust an ethicist who seemsinept. Finally, he requires that the expertise of anyassociate be applicable to the fulfilment of his ownintention, that is, the successful diagnosis andtreatment of his patient's problems.The success of the ethicist's advocacy is made

possible because he can contribute to an idealclinical intention with which he can generallyconcur. Ethical theory can help provide a moreaccurate understanding of clinical data about thepatient through an appreciation of formativeintentions and value-orientations in that context. Itcan help to point out the issues and possibilities fordecision and action. Ethical theory can help clarifywhat the physician's value-structures are like andprovide a means of systematically assessing theiradequacy for fulfilling his moral ideal. It helps the

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clinician to formulate diagnosis and treatment whichare most likely to be successful, that is, achieve thebest results for his patient. The ethicist has con-fidence that th!s kind of analytical assistance serveshis own intention because he shares most of thephysician's cultural principles and social norms; andhe believes that, when these common value-orienta-tions are fully understood and acted upon, his ownmoral ideal will be fulfilled. Physician and ethicistscan work together to accomplish their commongoal, that is, the health and well-being of thepatient.

References'Dewey, John (I974). Reflective morality and ethical

theory, in Introductory Readings in Ethics, Frankena,William K and Granrose, John T (eds), pp. i6, 23.Englewood Cliffs, New Jersey, Prentice-Hall Inc.

2Frankena, William (1973). Ethics. Englewood Cliffs,New Jersey, Prentice-Hall Inc.

"Smith, Harman C (I974). Some ethical considerationsof cerebellar stimulation as an innovative therapyin humans, in The Cerebellum, Epilepsy, andBehaviour, Cooper, Irving S, Rikler, Manuel andSnider, Ray S (eds), pp. 343-344. New York,Plenum Press.

4Weber, Max (I949). The Methodology of the SocialScience, Shils, Edward A and Finch, Henry A(Translators). New York, Free Press.

5Judicial Council (I958), American Medical Association,Principles of Medical Ethics, Sections I-4 andPreamble.

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