Casuistry: The second common approach to ethical decision making

Alternative Ethical

Casuistry Direct analysis of particular cases

Uses previous paradigm cases to infer ethical action in a current case Analogues in common law and case law Values practical knowledge’ rather than theory (pretheoretical) Privileges experience

Narrative Ethics Supplements principles by emphasizing importance of full context Gathers views of all parties to provide more complete basis for moral justification Story and narrator substitute for ethical justification, which emerges naturally Privileges stories

Virtue-Based Ethics Emphasizes the moral agent, not the situation or the action Right motives and character reveal more about moral worth than right actions Character more important than conformity to rules.

The strength of this approach is that a dilemma is examined in a context -specific manner and then compared with an analogous earlier case. The funda- mental philosophical assumption of this model is that ethics emerges from human moral experiences. Casuists approach dilemmas from an inductive position and work from the specific case to generalizations, rather than from generalizations to specific cases (Beauchamp & Childress, 2009).

Concerns have also been raised regarding the use of a casuistic model for ethical decision making. As a moral dilemma arises, the selection of the paradigm case may differ among the decision makers and thus the interpretation of the appropriate course of action will vary. In nursing, there are few paradigm cases of ethical issues on which to construct a decision making process. Further- more, other than the reliance on previous cases, casuists have no mechanisms to justify their actions. The possibil- ity that previous cases were reasoned in a faulty or inac- curate manner may not be fully considered or evaluated (Beauchamp & Childress, 2009).

Feminist Ethics Views women as embodied, fully rational, and having experiences relevant to moral reasoning emphasizes view of the disadvantaged-women and other underrepresented groups Emphasizes importance and value of openness to different perspectives Concerned with power differentials that create oppression Emphasizes importance of attention to the vulnerable and to resulting inequalities Privileges power imbalances Care-Based Ethics Emphasizes creating and sustaining responsive connection with others Emphasizes importance of context and subjectivity in discerning ethical action Sees individuals as interdependent rather than independent; focuses on parties in a relationship Privileges relationships.

Artnak and Dimmitt (1996) applied the casuistic model to an analysis of a complex case, concluding that the use of this approach allows fuller consideration of the contextual particulars ofthe case and provides a systematic approach for organizing and analyzing the facts of the case. An adaptation of this approach has been developed by Jansen and colleagues (2010), sometimes referred to as the “four box” approach. These authors have advocated clustering patient information according to four key topics-medical indications, patient preferences, quality of life, and contextual features-and then using that information to resolve a dilemma.

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Narrative Ethics. Because neither of these theoretical approaches have been seen as fully satisfactory, altern a- tives have emerged (see Box 13-3). Narrative approaches to ethical deliberation have evoked considerable interest (Charon & Montello, 2002; Nelson, 2004; Rorty, Werhane, & Mills, 2004). Narrative ethics emphasizes the particulars of a case or story as a vehicle for discerning the meaning and values embedded in ethical decision making. The argument is that all knowing is bound up in a narrative tradition and that all participants in ethical deliberations need the coherence and singular meaning given to a particular situation that only narrative knowledge can provide. Narrative ethics begins with a patient’s story and has some similarities with casuistry in its inductive particularistic approach.

Critics of this approach have argued that although narrative is a necessary element in ethical analysis, it cannot supplant principle- or theory- based ethics (Arras, 1997; Childress, 1997). There is, howevet~ recognition that careful consideration of patient’s stories can enlarge and enrich ethical delibera- tions. In commenting on narrative versus principle-based approaches, Childress (1997) noted that “We need both in any adequate ethics” (p. 268). As with casuistry, narrative-based approaches appeal to nurses, who find much of the meaning in their work through entering into the stories of their patient’s lives.