Evaluating the use of casuistry during moral case deliberation in the ICU: A multiple qualitative case study

Intensive care unit (ICU) professionals engage in ethical decision making under conditions of high stakes, great uncertainty, time-sensitivity and frequent irreversibility of action. Casuistry is a way by which actionable knowledge is obtained through comparing a patient case to previous cases from experience in clinical practice. However, within the field of study as well as in practice, evidence-based medicine is the dominant epistemic framework. This multiple case study evaluated the use of casuistic reasoning by intensive care unit (ICU) professionals during moral case deliberation. It took place in two Dutch hospitals between June 2020 and June 2022. Twentyfive moral case deliberations from ICU practice were recorded and analyzed using discourse analysis. Additionally, 47 interviews were held with ICU professionals who participated in these deliberations, analyzed using thematic analysis. We found that ICU professionals made considerable use of case comparisons when discussing continuation, withdrawal or limitation. Analogies played a role in justifying or complicating moral judgements, and also played a role in addressing moral distress. The language of case-based arguments is most often not overtly normative. Rather, the data shows that casuistic reasoning deals with the medical, ethical and contextual elements of decisions in an integrated manner. Facilitators of MCD have an essential role in (supporting ICU professionals in) scrutinizing casuistic arguments. The data shows that during MCD, actual reasoning often deviated from principle- and rule-based reasoning which ICU professionals preferred themselves. Evidence-based arguments often gained the character of analogical arguments, especially when a patient-at-hand was seen as highly unique from the average patients in the literature. Casuistic arguments disguised as evidence-based arguments may therefore provide ICU professionals with a false sense of certainty. Within education, we should strive to train clinicians and ethics facilitators so that they can recognize and evaluate casuistic arguments.

The structure of analogical reasoning in bioethics

Casuistry, which involves analogical reasoning, is a popular methodological approach in bioethics. The method has its advantages and challenges, which are widely acknowledged. Meta-philosophical reflection on exactly how bioethical casuistry works and how the challenges can be addressed is limited. In this paper we propose a framework for structuring casuistry and analogical reasoning in bioethics. The framework is developed by incorporating theories and insights from the philosophy of science: Mary Hesse's ideas on horizontal and vertical relations in analogical reasoning in the sciences, Paul Bartha's articulation model of analogical reasoning and Daniel Steel's insights on mechanism-based extrapolation in biomedical research. Adopting our framework results in two practical benefits: it sets methodological standards for analogical reasoning and enables us to compare and evaluate diverging lines of analogical reasoning in a systematic way. Adopting the framework also has theoretical benefits: it helps to understand how analogical reasoning can have moral normativity; it pinpoints exactly where moral principles or theories enter analogical reasoning; and it helps to understand why casuistry is an attractive method in bioethics and in applied ethics more generally.

Chapitre 3. La casuistique de la relation numérique du justiciable

The digital transformation of justice is the vector of profound change for the litigant. If it can have advantages (speed, accessibility, efficiency), it also presents risks, whether it is the dehumanization of justice or the risk of a digital divide. The study seeks to highlight all the ambivalence of the digital transition in the light of the diversity of litigants.

Reversible Splenial Lesion Syndrome as a Challenging Casuistry

The corpus callosum plays a vital role in brain function. In particular, in the trunk of the corpus callosum, in the course of various diseases, there may be temporary, reversible changes (reversible splenial lesion syndrome (RESLES)), as well as partially reversible and irreversible changes. This article discusses the differentiation of RESLES and other conditions with changes in the corpus callosum lobe, as well as the accompanying clinical symptoms. Moreover, a case report of a patient in whom the above changes appeared in the nuclear magnetic resonance (NMR) image is presented. A 20-year-old patient with the diagnosis of Ehlers-Danlos syndrome type VI was admitted to the psychiatric ward in an emergency because of psychomotor agitation, refusal to take food and fluids, delusional statements with a message, grandeur, and auditory hallucinations. In the performed magnetic resonance imaging (MRI) of the brain, the corpus callosum non-characteristic in T2-weighted images revealed a hyperintensive area, which was significantly hyperintensive in diffusion magnetic resonance (DWI) sequences and in apparent diffusion coefficient (ADC) sequences with reduced signal intensity and no signs of bleeding. The hypothesis of subacute ischemic stroke of the corpus callosum was presented. In the control MRI of the brain, changes in the corpus callosum completely regressed, thus excluding an ischemic etiology and favoring the diagnosis of RESLES. During hospitalization, the patient experienced significant fluctuations in mental status, with the dominant symptoms typical of the paranoid syndrome in the form of disturbances in the course and structure of thinking and perception, and a clear and stable improvement was obtained after the administration of long-acting intramuscular olanzapine. Taking into account the clinical and radiological picture, the age of the episode, the rapidity of the disease development, the persistence of its clinical symptoms after the withdrawal of radiological changes in the brain NMR image, as well as the significant improvement in the clinical condition after the introduction of antipsychotic drugs, the final diagnosis was made of schizophrenia.

Abuse and misuse of prescription opioids: is it only an Ameri- can problem? An observational study on an Italian casuistry

Medical use of prescription opioids has steadily increased since the 1990s, particularly in the U.S.A. and Canada, along with abuse of these substances and significant increases in rates of addiction and death related to prescription opioids. The American authorities speak of an "addiction epidemic" and are launching a series of countermeasures to better address the problem. In Europe, there is an increasing use of prescription opioids and related problems, but the European context is much less dramatic than the American and Canadian ones. Never-theless, based on the data, it cannot be ruled out that a similar crisis will occur on the Old Continent. The aim of this study is to analyze the Italian context to better understand whether there is a possibility of an addiction epidemic. Twenty-four cases of death of people under treatment with pre-scription opioids have been retrospectively analyzed. Toxicological samples were collected with routine methods during the autopsy, followed by systematic screening for substances by diverse methods. Volatile compounds were identified using gas chromatography-flame ionization detection (GC-FID). Medical drugs and drugs of abuse were identified via the use of gas chromatography-mass spectrome-try (GC-MS) and liquid chromatography-tandem mass spectrometry (LC-MS-MS). Of a total of 24 subjects, 14 died due to an overdose of Tramadol, while 7 died due to an overdose of Buprenorphine and 3 dues to a Fentanyl overdose. The most used drug was Tramadol. Histological examination was performed with hematoxylin/eosin staining, though no significant findings emerged apart from widespread edema and focal sclerosis of the myocardium, and interstitial and alveolar edema of the lungs. Our data show that attention must be paid to prescription opioids. European institutions, as soon as possible, must implement preventive measures that avoid the recurrence of the North American situation.

Clinical decision-making: the case against the new casuistry

Albert Jonsen and Stephen Toulmin have argued that the best way to resolve the complex issues in medical settings is to focus on the actual details of cases and then determine what to do in the given cases. This approach to medical decision-making, labeled "casuistry," has met with much criticism. In response, Carson Strong has attempted to save much of Jonsen and Toulmin's version of casuistry. This analysis reveals that Strong's recent salvage efforts fail to deflect the major criticisms. The upshot of this analysis is that Jonsen and Toulmin's version of casuistry is not an appropriate framework from which to resolve complex issues in clinical settings.

The casuistic method of practical ethics

This essay concerns itself with the methodology of practical ethics. There are a variety of methods employed in ethics. Although none have been firmly established as dominant, it is generally agreed that casuistry, or the case-based method, is one important strategy commonly used for resolving ethical issues. Casuists compare the case under consideration to a relevantly similar (analogous) precedent case in which judgements have already been made, and they use these earlier judgements to determine the proper resolution of the present case. In this article, I try to provide a better understanding of the nature of contemporary casuistry. To accomplish this, I explain (in the first section) the basic features of casuistic reasoning. The second section focuses on the logic of casuistry. By assessing casuistic reasoning from the logical viewpoint, casuistry can be reconstructed as a logically correct method of reasoning. The third section looks at casuistry from the epistemic point of view and investigates the justificatory force of casuistic reasoning. Finally, in the fourth section, I show the usefulness of formal casuistry.

Casuistry as common law morality

This article elaborates on the relation between ethical casuistry and common law reasoning. Despite the frequent talk of casuistry as common law morality, remarks on this issue largely remain at the purely metaphorical level. The article outlines and scrutinizes Albert Jonsen and Stephen Toulmin's version of casuistry and its basic elements. Drawing lessons for casuistry from common law reasoning, it is argued that one generally has to be faithful to ethical paradigms. There are, however, limitations for the binding force of paradigms. The most important limitations--the possibilities of overruling and distinguishing paradigm norms--are similar in common law and in casuistry, or so it is argued. These limitations explain why casuistry is not necessarily overly conservative and conventional, which is one line of criticism to which casuists can now better respond. Another line of criticism has it that the very reasoning from case to case is extremely unclear in casuistry. I suggest a certain model of analogical reasoning to address this critique. All my suggestions to understand and to enhance casuistry make use of common law reasoning whilst remaining faithful to Jonsen and Toulmin's main ideas and commitments. Further developed along these lines, casuistry can appropriately be called "common law morality."

[Research Biomedical Ethics and Practical Wisdom]

As is well known, in the field of Biomedical Ethics some methodological proposals have been put forward. They try to provide some guidelines in order to take proper decisions. These methodologies are quite useful insofar as they supply reasons for action, but they are essentially insufficient. In fact, taking a good decision requires a special skill that goes beyond sheer technique, and this skill is traditionally called practical wisdom. Not in the usual and more outlying sense of sheer caution, but in the more central one of phronesis or prudentia. Although it is not a new notion, it usually appears blurred in biomedical decision-making theory, playing the wrong role, or in a marginal or indefinite way. From this postulate, we will try to make a double analysis. First, we will try to show the need for a proper understanding of the core role that phronesis plays in decision making. Second, we will try to get the original meaning of Aristotelian phronesis back. For reasons of space, in this paper the second question will be just partially addressed.

What really separates casuistry from principlism in biomedical ethics

Since the publication of the first edition of Tom Beauchamp and James Childress's Principles of Biomedical Ethics there has been much debate about what a proper method in medical ethics should look like. The main rival for Beauchamp and Childress's account, principlism, has consistently been casuistry, an account that recommends argument by analogy from paradigm cases. Admirably, Beauchamp and Childress have modified their own view in successive editions of Principles of Biomedical Ethics in order to address the concerns proponents of casuistry and others have had about principlism. Given these adjustments to their view, some have claimed that principlism and casuistry no longer count as distinct methods. Even so, many still consider these two conceptions of bioethical methodologies as rivals. Both accounts of the relationship between casuistry and principlism are wrong. These two conceptions of methodology in biomedical ethics are significantly different, but the differences are not the ones pointed out by those who still claim that they are distinct positions. In this article, I explain where the real similarities and differences lie between these two views.

[Death with dignity - dignity life. A debate]

Since 2010 in the Autonomous Community of Andalusia passed into law ″derechos y garantías de la dignidad de las personas en el proceso de muerte″. At national level, in Spain, it's disputed the need to legalize this delicate aspect therefore already been made some projects for legalization. This advised to review the pros and cons of some legislative implementation experiences and case mix in countries where it has already occurred. This paper undertakes the study of the implementation of the Death with Dignity Act in Oregon and highlight is what were the immediate consequences and risks that has produced a law of this nature.

Casuistry and the moral continuum. Evaluating animal biotechnology

While the science of animal biotechnology is advancing at a rapid pace, the ethical discussion about the boundaries the public might want to set is at the most nascent stage. There is a tendency in the public debate for opponents to favor an all-out ban on the science, while proponents want to grant it carte blanche. I argue that a more nuanced position on animal biotechnology considers individual projects to be located on a moral continuum, where some are clearly morally justified, others morally impermissible, and some lie in the ethical gray-zone. To begin to define this continuum, we use the bioethical method of casuistry to analyze one case at the end of moral permissibility, and we contrast it with a case that is located at the opposite end of the moral spectrum. I advocate this approach to assessing the moral merit of biotechnology projects because of its attention to the details of individual cases--the protocols, ends, and methods--on which an accurate moral judgment necessarily rests.

Overview of psychiatric ethics IV: the method of casuistry

OBJECTIVE

The aim of this paper is to describe the method of ethical analysis known as casuistry and consider its merits as a basis of ethical deliberation in psychiatry.

CONCLUSIONS

Casuistry approximates the legal arguments of common law. It examines ethical dilemmas by adopting a taxonomic approach to 'paradigm' cases, using a technique akin to that of normative analogical reasoning. Casuistry offers a useful method in ethical reasoning through providing a practical means of evaluating the merits of a particular course of action in a particular clinical situation. As a method ethical moral reasoning in psychiatry, casuistry suffers from a paucity of paradigm cases and its failure to fully contextualize ethical dilemmas by relying on common morality theory as its basis.

Overview of psychiatric ethics III: principles-based ethics

OBJECTIVE

The aim of this paper is to consider the application of principle-based medical ethics to psychiatry.

CONCLUSIONS

Principles-based medical ethics is a useful tool for resolving ethical dilemmas in psychiatry in that clinical aspects of ethical dilemmas can be better articulated then in other methods . The ethical dilemmas unique to psychiatry, such as those related to impairment of autonomy, present a challenge to the method. After considering a case example, we conclude that psychiatrists can best utilise a principles based approach to ethical dilemmas when they combine this with a level of critical reflection in the light of other ethical theories, such as virtue ethics, as well as close consideration of the clinical and social context of the ethical dilemma.

Bioethics as a second-order discipline: who is not a bioethicist?

A dispute exists about whether bioethics should become a new discipline with its own methods, competency standards, duties, honored texts, and core curriculum. Unique expertise is a necessary condition for disciplines. Using the current literature, different views about the sort of expertise that might be unique to bioethicists are critically examined to determine if there is an expertise that might meet this requirement. Candidates include analyses of expertise based in "philosophical ethics," "casuistry," "atheoretical or situation ethics," "conventionalist relativism," "institutional guidance," "regulatory guidance and compliance," "political advocacy," "functionalism," and "principlism." None succeed in identifying a unique area of expertise for successful bioethicists that could serve as a basis for making it a new discipline. Rather expertise in bioethics is rooted in many professions, disciplines and fields and best understood as a second-order discipline.

Principlism revisited: response to Simon Waltho

We respond to the comments provided on our paper 'Principles help to analyse but often give no solution-secondary prevention after a cardiac event' by Simon Waltho, and highlight points of clarification.

Balancing in Ethical Deliberation: Superior to Specification and Casuistry

Approaches to clinical ethics dilemmas that rely on basic principles or rules are difficult to apply because of vagueness and conflict among basic values. In response, casuistry rejects the use of basic values, and specification produces a large set of specified rules that are presumably easily applicable. Balancing is a method employed to weigh the relative importance of different and conflicting values in application. We argue against casuistry and specification, claiming that balancing is superior partly because it most clearly exhibits the reasoning behind moral decision-making. Hence, balancing may be most effective in teaching bioethics to medical professionals.

Integrating evidence into clinical practice: an alternative to evidence-based approaches

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient.

Bioethics as politics: the limits of moral expertise

The increasing reliance upon, and perhaps the growing public and professional skepticism about, the special expertise of bioethicists suggests the need to consider the limits of moral expertise. For all the talk about method in bioethics, we, bioethicists, are still rather far off the mark in understanding what we are doing, even when we may be going about what we are doing fairly well. Quite often, what is most fundamentally at stake, but equally often insufficiently acknowledged, are inherently political, essentially contested visions of the most compelling and attractive forms of life for individuals and social organization. The current situation in bioethics parallels similar debates in eighteenth-century jurisprudence, especially Jeremy Bentham's withering critique of the prevalent forms of judicial argument and his own, equally unsuccessful, attempt to develop a decision-making procedure in ethics that would operate on a plane above politics. The risk, both then and now, is that we will fail to appreciate the wide range of reasonable disagreement that will remain past the point of extended reflection and discussion.

Moral reasoning--the unrealized place of casuistry in medical ethics

If the practice of ethics consists of the justifiable application of moral principles, then the challenge will always be to ensure, first, that the principles are well chosen and, second, that their application to the case in point is overtly justifiable. In this editorial, having briefly mentioned “principlism”, which itself involves the application of ethical principles in practice, we shall make the case for casuistry (case-based) reasoning.

Ethics in nursing homes: Experience and casuistry

The purpose of the study was to further explore the methods that nurses use to solve ethically difficult care situations in nursing homes while the aim of this article was to present a model for nursing practice in such situations. Fourteen nurses from three nursing homes in Norway were observed and interviewed in order to discern the strategies they used to deal with ethically difficult care situations. To analyse this information, we used a constant comparative method until a grounded theory emerged. The nurses' principal strategy was to apply earlier experiences while striving for the best outcome for the elderly patients. This article discusses this strategy and compares it to a theory of ethics called casuistry. We suggest that by using the method of experiences combined with casuistry in a more systematic way, nurses can develop acceptable solutions for difficult care situations in nursing homes.

Does empirical research make bioethics more relevant? "The embedded researcher" as a methodological approach

What is the status of empirical contributions to bioethics, especially to clinical bioethics? Where is the empirical approach discussed in bioethics related to the ongoing debate about principlism versus casuistry? Can we consider an integrative model of research in medical ethics and which empirical methodology could then be valuable, the quantitative or the qualitative? These issues will be addressed in the first, theoretical part of the paper. The concept of the "embedded researcher" presented in this article was stimulated by the two questions, (1) how can we safeguard that our research will yield valid and meaningful results to practice? and (2), how can we convince clinical colleagues that medical ethics offers relevant contributions to the analysis and solution of problems? One tentative answer has been our effort to elaborate a coherent methodological research approach in the field of end-of-life issues integrating qualitative and quantitative as well as casuistic methodologies. This development is characterized in the second part describing the ECOPE Study (short title) "Ethical Conditions Of Passive Euthanasia." The achievements and limitations of the suggested approach of the "embedded researcher" are discussed referring to 3 examples of our joint studies about ethical issues concerning (1) critical decision-making in neonatology (2) limitation of treatment in intensive care (3) problems with doctor-patient conversation at the end-of life in oncology. Conclusions from our studies are put to discussion in the final part of the paper about how to further develop research in the field of end-of-life care and, maybe, clinical bioethics as a whole.

Medical ethics and double effect: the case of terminal sedation

The use of terminal sedation to control the intense discomfort of dying patients appears both to be an established practice in palliative care and to run counter to the moral and legal norm that forbids health care professionals from intentionally killing patients. This raises the worry that the requirements of established palliative care are incompatible with moral and legal opposition to euthanasia. This paper explains how the doctrine of double effect can be relied on to distinguish terminal sedation from euthanasia. The doctrine of double effect is rooted in Catholic moral casuistry, but its application in law and morality need not depend on the particular framework in which it was developed. The paper further explains how the moral weight of the distinction between intended harms and merely foreseen harms in the doctrine of double effect can be justified by appeal to a limitation on the human capacity to pursue good.

Methods and principles in biomedical ethics

The four principles approach to medical ethics plus specification is used in this paper. Specification is defined as a process of reducing the indeterminateness of general norms to give them increased action guiding capacity, while retaining the moral commitments in the original norm. Since questions of method are central to the symposium, the paper begins with four observations about method in moral reasoning and case analysis. Three of the four scenarios are dealt with. It is concluded in the "standard" Jehovah's Witness case that having autonomously chosen the authority of his religious institution, a Jehovah's Witness has a reasonable basis on which to refuse a recommended blood transfusion. The author's view of the child of a Jehovah's Witness scenario is that it is morally required-not merely permitted-to overrule this parental refusal of treatment. It is argued in the selling kidneys for transplantation scenario that a fair system of regulating and monitoring would be better than the present system which the author believes to be a shameful failure.

Disability or end-of-life? Competing narratives in bioethics

Bioethics, and indeed much ethical writing generally, makes its point through narratives. The religious parable no less than the medical teaching case uses a simple story to describe appropriate action or the application of a critical principle. While powerful, the telling story has limits. In this paper the authors describe a simple teaching case on "end-of-life" decision making that was ill received by its audience. The authors ill-received example, involving the disconnection of ventilation in a patient with ALS (Lou Gherig's Disease) was critiqued by audience members with long-term experience as ventilation users. In this case, the supposedly simple narrative of the presenters conflicted with the life histories of the audience. The lessons of this story, and the conflict that resulted, speak critically to the limits of simple teaching cases as well as the strengths of narrative analysis as a tool for the exploration of bioethical case histories.