Decision-Making Strategy for Clinical-Ethical Problems in Medicine

Medical education and training should prepare physicians to make decisions, because that is what they do routinely in medical practice. When physicians determine that a diagnostic procedure is warranted, or when they recommend a particular form of treatment, or even, when they assess whether and when a patient who telephones with a medical problem should be seen in the office (or in the emergency room), physicians are making decisions. None of these decisions is easy, because medicine is, as Osler described it, a science of uncertainty and an art of probability. Nevertheless, physicians generally reach clinical decisions and feel reasonably comfortable doing so. In contrast to clinical decisions, physicians find clinical-ethical decisions of the following sort extremely difficult: Should no-code orders be written (for example, on a patient with irreversible senile dementia and an acute, treatable pneumonia)? Should an infant with Down's syndrome and duodenal atresia be treated with maximal