(Dilemmas in Clinical Medicine Frequently Asked Questions)

Case reports should be drawn from the student's own experience during the Medicine clerkship; the report should be kept to a maximum of two sides of a single sheet of paper and, as long as it is legible, may be handwritten.

The case should be selected from the student's experience on the clinical rotation, since ethical analysis should be a routine part of medical management. The student should be familiar with all aspects of the patient's medical condition as this is necessary for a meaningful analysis. The case should pose an ethical dilemma for the physicians on the case (that is, a difficult decision involving ethical issues or principles). This ordinarily represents a conflict over values; patient and family, patient and physician, etc. Specifically, you should exclude cases that focus on clearly inappropriate, unprofessional, or immoral behavior.

There is sometimes a tendency to focus upon high profile issues involving seriously ill hospitalized patients (such as withdrawal of life sustaining treatment). While such cases certainly may present serious ethical dilemmas, one must not lose sight of dilemmas in less dramatic settings. Chronic illness, or well-patient encounters are often the backdrop for dilemmas relating to the Doctor-Patient Relationship, particularly in the ambulatory setting. These dilemmas can be just as vexing, and are certainly more common.

The write-up itself should begin with a brief summary of the medical facts of the case. This summary should be brief, although the student should be sufficiently familiar with the case to answer more detailed questions at the time of the presentation in class. Particular attention should be paid to clinical details which relate to the ethical issue (eg. mental status or prognosis).

Following the clinical data, the dilemma itself should be identified. This can usually be summed up in one or two sentences.

The student should then outline his or her plan for resolving the dilemma. This might take any number of forms. One approach is to appeal to certain principles of biomedical ethics. In some cases there are accepted principles and guides to behavior which directly bear upon the problem at hand and facilitate resolution. Autonomy, beneficence, nonmaleficence, justice, veracity, and confidentiality are often cited in this regard. One should be cautious with this approach however. There are often many principles one could cite and there may be no clear way to prioritize them.

Another approach utilizes a checklist which is applied to any specific case. Such lists include general questions which are applicable to most, if not all cases. For example:

1. What is the relevant medical information? (medical options, prognosis with and without treatment, etc.)
2. Who is the appropriate decision maker? (in regard to value judgments, not technical medical matters)
3. Is the patient capable of making medical decisions?
4. If not, WHO is the appropriate surrogate for the patient, and HOW does that person go about making the decision?
5. Are there any advance directives?
6. Are there any IMPORTANT legal constraints upon the decision?

Carefully answering these questions will often provide the resolution to the dilemma, since important aspects of them are often overlooked by those caring for the patient.

Finally, one can also inspect the case for key words and phrases which ought to "trigger" a more intensive analysis. When someone mentions one of them, it should trigger an immediate response from you. Such triggers are often slogans, stated forrhetorical value, and are commonly areas of dispute or confusion. These are generally topics about which much is written in the literature, and this may be useful in the case analysis.

Examples of such triggers include:

Key phrases of this sort are commonly the focus of articles in the medical literature, and are thus easily searchable.

Ultimately, the best case discussions are those that utilize any number of the above tools. A flexible, eclectic approach permits the analyst to adapt the approach to the information he or she is given. In some cases, an accepted principle resolves the dilemma; in other cases, carefully working through the checklist reveals a flaw in the medical presumptions; in yet others, a key player makes reference to a slogan to which the analyst can respond. Although not required for the write-ups, citations are welcome, particularly when the student has found them helpful in discussing the case.