++++++++++++++++++++++++++++++++++The Four Topics Chart

Medical Indications

Preferences of Patients

The Principles of Beneficence and Non-maleficence

  1. What is the patient’s medical problem? Is the problem acute? chronic? critical? reversible? emergent? terminal?

  2. What are the goals of treatment?

  3. In what circumstances are medical treatments not are the probabilities of success of various treatment options?

  4. In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?

The Principle of Respect for Autonomy

  1. Has the patient been informed of benefits and risks of diagnostic and treatment recommendations, understood this information, and given consent?

  2. Is the patient mentally capable and legally com-petent or is there evidence of incapacity?

  3. If mentally capable, what preferences about treat-ment is the patient stating?

  4. If incapacitated, has the patient expressed prior preferences?

  5. Who is the appropriate surrogate to make deci-sions for an incapacitated patient? What stan-dards should govern the surrogate’s decisions?

  6. Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Quality of Life

Contextual Features

The Principles of Beneficence and Nonmaleficence and Respect for Autonomy

  1. What are the prospects, with or without treatment, for a return to normal life and what physical, mental, and social deficits might the patient ex-perience even if treatment succeeds?

  2. On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?

  3. Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?

  4. What ethical issues arise concerning im-proving or enhancing a patient’s quality of life?

  5. Do quality-of-life assessments raise any questions that might contribute to a change of treatment plan, such as forgo-ing life-sustaining treatment?

  6. Are there plans to provide pain relief and provide comfort after a decision has been made to forgo life-sustaining interventions?

  7. Is medically assisted dying ethically or legally permissible?

  8. What is the legal and ethical status of suicide?

The Principles of Justice and Fairness

  1. Are there professional, interprofessional, or busi-ness interests that might create conflicts of interest in the clinical treatment of patients?

  2. Are there parties other than clinician and patient, such as family members, who have a legitimate interest in clinical decisions?

  3. What are the limits imposed on patient confiden-tiality by the legitimate interests of third parties?

  4. Are there financial factors that create conflicts of interest in clinical decisions?

  5. Are there problems of allocation of resources that affect clinical decisions?

  6. Are there religious factors that might influence clinical decisions?

  7. What are the legal issues that might affect clinical decisions?

  8. Are there considerations of clinical research and medical education that affect clinical decisions?

  9. Are there considerations of public health and safety that influence clinical decisions?

  10. Does institutional affiliation create conflicts of interest that might influence clinical decisions?



01. Beneficence

 Nonmaleficence (primum non nocere, or "do no harm")

02. Respect for patient autonomy



Distributive justice

Respect for the law. 

Ethical dilemmas arise when there is a potential conflict between two principles or values.

Physicians resolve these dilemmas by gathering additional information; conducting meetings with other healthcare professionals, patients, and families; and applying an informed judgment in individual situations.

In some circumstances, physicians may seek the involvement of the institutional ethics committee or the judicial system.

Ethical decisions are called at both the level of the individual patient-clinician relationship and at the level of the allocation of resources.


1. https://depts.washington.edu/bioethx/topics/index.html



Physicians enter the doctor-patient relationship with a professional identity that obliges them to give priority to the patient’s interests, to devote themselves to the competent care of the patient, to preserve confidentiality, and to communicate honestly and compassionately. Physicians must aim, in the words of Hippocrates, “to help and do no harm”.

In the usual course of a therapeutic relationship, clinical care and ethical imperatives run smoothly together. The reason for this is that generally the patient and clinician share the same goal, namely, to resolve the medical problems and needs of the patient. For example, a patient presents with a distressing cough and wheezing and wants relief; a physician responds to the patient and utilizes the correct means to diagnose and treat. In this situation, the treatment for, say, a mild asthma attack, is effective and the patient is satisfied. In other cases, this simple scene becomes complicated. The patient’s wheezing may be caused by a tumor obstructing the airway. This disease may be life threatening; the treatment may be complex and may prove unsuccessful. On other occasions, the smooth course of the doctor-patient relationship may be interrupted by what we call an ethical question: a doubt about the right action when ethical responsibilities conflict or when their meaning is uncertain or confused. For example, the physician’s duty to cure is countered by a patient’s refusal of indicated treatment, or the patient’s need for treatment cannot be met because of inability to pay. The principles that usually bring the clinician and the patient into a therapeutic relationship seem to collide. This collision blocks the process of deciding and acting required for clinical care. Sometimes, confusion and conflict can become extreme and distressing for all parties. This book aims to elucidate the ethical dimensions of clinical care when doubt about right action blocks decisions. In such cases, we attempt to formulate recommendations about how that doubt might be resolved.

This book is titled Clinical Ethics. Clinical ethics is a structured approach to ethical decisions in clinical medicine. Clinical ethics is part of the discipline called bioethics. Bioethics is an academic enterprise that draws upon various disciplines such as moral philosophy, cognitive psychology, communication skills, clinical medicine, and health law. The scholars called bioethicists must master this interdisciplinary field. Clinicians in their daily practice of medicine need not become bioethics scholars; they usually can manage with a basic understanding of certain key ethical issues like informed consent, surrogate decision making, and end-of-life care. They should be able to identify the ethical question and to reach a reasonable conclusion and recommendation for action. In this book, we provide a method to identify the ethical dimensions of patient care and to analyze and resolve ethical problems. This method is useful for structuring the questions faced by any clinician as she or he cares for patients.

Jonsen  AR. The Birth of Bioethics. New York, NY: Oxford University Press, 1998.
Jonsen  AR. A Short History of Medical Ethics. New York, NY: Oxford University Press, 1999.

Ethical cases must have some method to collect, sort, and order the facts and opinions raised by the case. Four topics for organizing ethical reasoning: medical indications, patient preferences, quality of life, and contextual features.

Topics provide a pattern for collecting, sorting, and ordering the facts of a clinical ethical problem. Each topic can be filled with the actual facts of the clinical case that are relevant to the identification of the ethical problems. The contents of all four topics viewed together form a comprehensive picture of the ethical dimensions of the case. Clinical reasoning begins with the facts of the case and moves toward a presumptive diagnosis by sorting those facts into reasonable patterns of causality. Similarly, clinical ethical reasoning starts with the facts. A statement of the ethical problem in a case follows a clear and complete collection of the facts of the case.

Bioethics scholars generally identify four ethical principles that are particularly relevant to medical care: the principles of beneficence, of nonmaleficence, respect for autonomy, and justice. Some bioethicists would add to these four principles others such as empathy, compassion, fidelity, integrity, and other virtues. The bioethical literature explains these principles at length (see Beauchamp, Childress below). In this book, we explain them only briefly. We direct our reader’s attention to how these general principles relate to the concrete circumstances of a clinical case, and how they serve as guides to action in specific circumstances.

Those charts display the particular questions that can be raised about each of the topics and that can be asked to determine the circumstances of each clinical case. Because the charts display these topics in quadrants, many users of this book have come to speak of “THE FOUR BOXES.” We accept that terminology because it helps to explain how the four topics should be used in a clinical consultation. Each topic is, in a way, a “box” into which the circumstances of the case can be sorted and evaluated.

The four topics are: (1) Medical indications (MI) refer to the diagnostic and therapeutic interventions that are being used to evaluate and treat the medical problem in the case. (2) Patient preferences (PP) state the express choices of the patient about their treatment, or the decisions of those who are authorized to speak for the patient when the patient is incapable of doing so. (3) Quality of life (QL) describes the degree of satisfaction, pleasure, and well-being or the degree of distress and malfunction that people experience in their life prior to and following treatment. (4) Contextual features (CF) identify the social, institutional, financial, and legal settings within which any particular case of patient care takes place, insofar as these influence medical decisions.

All of the following are true of the Principles of Medical Ethics, except

The correct answer is A.

A. Beneficence and nonmaleficence are synonyms






01. Communication and interpersonal skills

Cultural competence

Human Sexuality

Sexual Disorders



Patient interviewing, consultation, and interactions with the family (patient-centered
communication skills)
Use of an interpreter
Medical ethics and jurisprudence, include issues related to death and dying palliative
Consent/informed consent to treatment, permission to treat (full disclosure, risks and
benefits, placebos, alternative therapies, conflict of interest, and vulnerable populations)
Determination of medical decision-making capacity/informed refusal
Involuntary admission
Legal issues related to abuse (child, elder, and intimate partner)
Birth-related issues (eg, prenatal diagnosis, abortion, maternal-fetal conflict)
Death and dying and palliative care
Physician-patient relationship (boundaries, confidentiality including HIPAA, privacy, truth-
telling, Telling Bad news

other principles of medical ethics, eg, autonomy, justice, beneficence)
Impaired physician, including duty to report impaired physician
Negligence/malpractice, including duty to report negligence and malpractice
Physician misconduct, including duty to report physician misconduct

In medicinereferral is the transfer of care for a patient from one clinician to another.[1]
Cultural issues not otherwise coded
Systems-based practice (including health systems, public health, community, schools)
and patient safety (including basic concepts and terminology)


The Profession of Medicine - Its Aims and Obligations

01. Responsibility and Privilege

04. Cultural and Linguistic Competence

Difficult Patients and Difficult Situtations

There are six core competencies required of physicians to deliver high quality medical care

practice-based learning and improvement (Competence (medical knowledge))

interpersonal and communication skills,


and systems-based practice.1


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