SOFIA

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====== Peter Singer (CTB:3-5) – metodologias bioéticas ======

There are a number of different bioethical methodologies that have been advanced for the incorporation of bioethics into clinical practice. Broadly speaking, there are four such approaches (Agich, 2005 ).

The first is practical or applied ethics, or even an applied philosophy of medicine. This approach addresses ethical issues that arise in practice through the application of aspects of particular ethical theories, or specific notions/concepts (e.g., double effect, treatment versus enhancement distinction, etc.), to concrete clinical or research cases. The focus is not instance, what considerations would make an action good or a policy right. For more on this approach, see Caplan ( 1983 ), Beauchamp ( 1984 ), and Young ( 1986 ).

The second is principlism. This approach seeks to provide ethical guidance in clinical practice through a specified number of moral principles. By applying general principles to ethical problems, it is argued that such principles do a better job of obtaining the right answer concerning what one morally ought to do compared to trying to reason through what to do in each instance. The most famous versions of bioethical principlism are articulated by Beauchamp and Childress ( 2001 ), with the principles of autonomy, beneficence, non-malfeasance, and justice, or, for instance, some catholic healthcare institutions, which adopt a theologically based form of principlism. While principlism has been notably criticized for being too blunt an instrument in trying to apply a few ethical principles to all problems in all circumstances, and thus being too insensitive to the complexities and tensions inherent in morality, some forms of this approach are more multifaceted and responsive to the intricacies of moral considerations related to medicine. For more on this approach, see Clouser and Gert ( 1990 ), Daniels ( 1996 ), Richardson ( 2000 ), and Beauchamp and Childress ( 2001 ).

The third is casuistry. This case-based approach addresses ethical problems by guiding clinicians through specific issues via paradigm cases that have come up in clinical education or practice – something analogous to the use of case-based reasoning in the process of differential diagnosis. As opposed to theory-laden or top-down approaches, which apply general frameworks or concepts to particular issues when they arise, casuistry provides a bottom-up approach where clinicians use case-based reasoning to identify the morally relevant features of a situation and relate it to the specific circumstances of a previous case and its resolution. Given the prominent use of cases in clinical practice (e.g., case reports in journals, case conferences and rounds, etc.), clinicians may find this approach an appealing way to deal with ethical problems (for some of the reasons we have highlighted in the previous section). However, as a standalone bioethical methodology, the approach has been criticized for not providing a clear method for working through ethical issues. For more on this approach, see Jonsen ( 1991 ), Kopelman ( 1994 ), and Jonsen and Toulmin ( 1998 ).

The fourth is combination of techniques for identifying and resolving ethical conflicts, disagreements, and related problems. This approach treats the ethical issues that arise in clinical practice as those similar to inter-personal issues alleviated through techniques such as conflict resolution, mediation, negotiation, and arbitration. This approach has been criticized by some on the basis that, in treating ethical issues as just another set of considerations that can cause disagreement, it fails to adequately address the source of moral conflict or why we have good reasons to act one way as opposed to another in favor of securing consensus amongst participants. Admittedly, compromise plays an important role in clinical practice; however, achieving agreement for its own sake fails to appreciate sufficiently what is distinctive about moral considerations and how greater attention to resolving ethical issues can improve clinical practice. For more on this approach, see West and Gibson ( 1992 ), Dubler and Marcus ( 1994 ), and Reynolds ( 1994 ).

We believe none of these methodologies gets everything right. Since the aim of the book is not to argue for which methodology, or combinations of methodologies, is correct, we recommend that clinicians will most benefit from borrowing the best of each methodology in an effort to better recognize and resolve ethical issues in practice.