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Understanding "4-Box" Method

of Clinical Ethics:
Medical Indications

Case Presentation:
Maternal-Fetal Conflict
University of Washington School of Medicine

A 29-year-old woman had an obstetrical

ultrasound at 33 weeks to follow-up a
previous finding of a low-lying placenta.
Although the placental location was now
acceptable, the amniotic fluid index (AFI) was
noted to be 8.9 cm. Subsequent monitoring
remained reassuring until 38.5 weeks, when
the AFI was 6 cm.

Case Presentation:
Maternal-Fetal Conflict
The patient declined the recommendation to
induce labor, and also refused to present for
any further monitoring. She stated that she
did not believe in medical interventions.
Nevertheless, she continued with her prenatal
visits. At 41 weeks, she submitted to a further
AFI, which was found to be 1.8 cm. She and
her husband continued to decline the
recommendation for induced labor.

Case Presentation:
Maternal-Fetal Conflict
Which ethical duty takes precedence, the duty
to respect the patient's autonomous decision,
or the duty to benefit a viable fetus?
Is induction of labor a harmful intervention,
subject to the principle of nonmaleficence?

"4-Box" Method of Clinical Ethics

Medical Indications:

Client Preferences:

State the clients medical problem, history, and

diagnosis; is it acute, chronic, critical, emergent, and
reversible? Goals of treatment? Probabilities of
success? Plans in case of therapeutic failure? Potential
benefits of care? How can harm be avoided? Medical
risks if service is discontinued?

State the clients preferences. Do they have the

capacity to decide? If yes, are clients wishes
informed, understood, voluntary? If not, who is
substitute decision maker? Does the client have prior,
expressed wishes? Is clients right to choose being

Quality of Life:

Contextual Features:

Describe quality of life in clients term, clients

subjective acceptance of likely quality of life, and
views and concerns of care providers. Examine the
emotional factors influencing each individual, such as
exiting feelings, values, biases and prior experiences.

Any other family involved or significant relationships?

Any care plans put in place so far? Relevant social,
legal, economic, and institutional circumstances?
Other relevant features, e.g. religious & cultural
factors, limits on confidentiality, resource allocation
issues, legal implications, research or teaching
involved, provider conflicts of interest? Organizational
values to consider?

Definition of Medical Indications

Medical Indications are the facts, opinions,
and interpretations about the patient's
physical and/or psychological condition that
provide a reasonable basis for diagnostic and
therapeutic activities aiming to realize the
overall goals of medicine: prevention, cure,
and care of illness and injury.

The Ethical Principles of Beneficence

and Nonmaleficence
In medicine, benefit and harm have a specific
meaning: helping by trying to heal and doing
so as safely and painlessly as possible
Beneficence primarily means the duty to try to
bring about those improvements in physical or
psychological health that medicine can achieve
Nonmaleficence means going about these
activities in ways that prevent further injury or
reduce its risk

BenefitRisk Ratio
The principles of beneficence and nonmaleficence do
not merely instruct the clinician to help and do no
harm; they coalesce to guide the clinician's
assessment of how much risk is justified by the
intended benefit.
A physician must calculate this "ratio" and fashion it
into a recommendation to the patient who will, in
the last analysis, evaluate it in light of his or her own

A Clinical Approach to Beneficence

and Nonmaleficence
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
4. What are the probabilities of success of various
treatment options?
5. In sum, how can this patient be benefited by
medical and nursing care, and how can harm be

What is the patient's medical


What are the goals of treatment?

In what circumstances are medical

treatments not indicated?

What are the probabilities of success

of various treatment options?

How can this patient be benefited

by medical and nursing care, and
how can harm be avoided?