Four quadrant approach

Professor Heather Draper, Catherine

Hale, Lt Cdr Alan Brockie
 Who are these slides for?
• These slides introduce the four quadrant
approach (4QA) to making ethical decisions
• They can be used to familiarise yourself with
this tool, or to present the tool to others to
use – perhaps in conjunction with some of our
case studies as a group work exercise.
• Anyone is free to use them. We ask only that
you preserve the accreditation in full.
 What is the 4QA?
• The 4QA has been adopted by UK Defence Medical
Services as a useful way working through an ethical issue
in clinical practice1
• It is not a theory or principle or formula. It is more of a
tool for organising your thoughts
• Here we are using a slightly modified representation of
the 4QA based on the work conducted to evaluate it use
by the military2
1.Ministry of Defence. Joint Service Publication ( JSP 999). Clinical Guidelines for 14
Operations. Section 5: Pathways 7 Version Change 3 September, London: MoD, 2012.
2. Bernthall, EMM, Russell, RJ Draper, H A qualitative study of the use of the four
quadrant approach to assist ethical decision-making during deployment. JR Army
Corps 2014 160; 96-202
• The 4QA was adapted by Sokel3 from the ‘four
topics approach’ to assist ethical decision-
making in palliative care4.
• It assumes a reasonable amount of time for
discussion and this time may not be available in
kinetic situations.
3. Sokol DK. The ‘four quadrants’ approach to clinical ethics case
analysis: an application and review. J Med Ethics 2008;34:513–16.
4. Schumann JH, Alfandre D. Clinical ethical decision making: the four
topics approach. Semin Med Pract 2008;11:36–42.
• In a training context, we suggest that groups
are given a case to tackle, literally draw the
four quadrants on a large flip chart/white
board and discuss what information or
considerations should go in each of the
quadrants.
• It is important, however, that they follow all
three steps, rather than jumping straight to
Step 2
 Step 1 – asking the right question
• Identifying THE ethical issue is not always straightforward
• There might also be more than one
– We may need to discuss which is the most important or
pressing question. We may need to repeat the process for
each question
• Ethical questions generally include ethical terms e.g.
‘ought’; ‘should’
– ‘Can I give this patient a blood transfusion?’ vs ‘Should give
this patient a blood transfusion?’
• Of course what you ought to do depends on what you
can do: no obligation to do the impossible
– ‘ought implies can’
 Quadrant 1
Medical Implications

• This is probably the easy bit

• It tells you what you CAN do
– NB this helps to define the scope of your moral responsibilities
• Sets out options and potential outcomes
• “good ethics start with good facts”
• Sometimes disagreements over the best medical
management present as ethical issues and can be
resolved at this point.
• Puts everyone on the same starting page
• Opportunity to revisit the question
 However
• Q1 assumes that the medical indications are clear
• Whereas often ethical issues arise because of
uncertainty
• And also what seems likely turns out not to be
• And sometimes this resolves the ethical issue
– E.g. Patient dies unexpectedly
• And sometimes it changes the question
– E.g. Patient unexpectedly survives withdrawal of care:
now what?
• This may mean going back to step one
 The order matters

• The order imposes a hierarchy of values based at

least partly on predominant western ethical norms,
with respect for autonomy driving Q2 & Q3.
• This is not JUST a ‘fact gathering’ exercise (though
this has been found to be useful).
 Quadrant 2
Patient Preferences
• Can put an end to the matter
– Refusal of consent by a competent patient has to be respected; go
no further?
– Previously stated wishes; go no further?
• Go no further?
– Assumes autonomy trumps other concerns
– Have sufficient evidence of wishes
• Might not be known
– Adult without capacity & no one available to provide information
• Might not exist - minors
– Though parental wishes might be relevant, assuming parents
present
– And parents acting in the best interests of minor
 Privileging autonomy: why?
Respect for persons Maximises welfare
• Tied to Kantian • Tied to consequential
understanding of moral reasoning; its the best
responsibility way to achieve benefit
• Absolute • NOT absolute
• Autonomy only
• Reflects law (by and large)
– And professional codes privileged whilst it
• Need to buy into maximises benefit
deontological thinking • Need to buy into
consequential thinking
Moral theory is not ‘pick and mix’
 Quadrant 3
Quality of Life

• Supposed only get here if the patient unable to express a

preference (including through others)
– Assumes patient best judge, if able to judge, including of their
QoL
– But patient’s preferences could be unreasonable
• Reasons for privileging autonomy may now start to bite
• Aspect of first do no harm / beneficence
• Likely to be informed by Q1
• People disagree on what gives life quality
• People disagree especially about the relationship between
quality of life and value of life.
 Quadrant 4
Contextual Factors

• This includes practically any other consideration

– Resource limitations
– Cultural differences or other personal biases
– Impact on others, including medical team
– ‘We’re deployed military personal operating within military
constraints’
– It’s a humanitarian disaster/complex emergency
– It’s Ebola we’re dealing with
• Q4 helps with transparency but provides no mechanism
for weighing factors in the balance i.e. arriving at
Step 3
Step 3 - What have we decided to do and
why?
• Note that this step contains two parts
– Ethical decisions
– Actions
• It allows you to and agree and summarise, for
the patient’s record, what the important
ethical considerations in the case are
which enables you to justify
• What should be done