Medical decision-making: an argument for narrative and metaphor

This study examines the processes of decision-making used by intensive care (critical care) specialists. Ninety-nine specialists completed a questionnaire involving three clinical cases, using a novel methodology investigating the role of uncertainty and temporal-related factors, and exploring a range of ethical issues. Validation and triangulation of the results was done via a comparison study with a medically lay, but highly informed group of 37 law students. For both study groups, constructing reasons for a decision was largely an interpretative and imaginative exercise that went beyond the data (as presented), commonly resulting in different reasons supporting the same conclusions and similar reasons supporting opposite conclusions. The skills of ethical imagination and interpretation were related to an individual's prior lived experience, construed in the broadest sense. Application of these skills of ethical imagination and interpretation always occurred, to some degree, in a state of uncertainty and almost always involved temporal relationships. Using these results, a theory of ethical decision-making is proffered. Three levels or types of reasoning processes may be present. Type I decision-making involves the application of rules, usually in a deductive fashion. Type II decision-making is characterised by a process where a plurality of reasons are balanced, weighed and sifted with each other. Type III decision-making is intimately linked with respondents lived experiences and 'crafts' the content of type I and II reasoning processes, via the application of ethical imagination and interpretation. Relationships between these three types of reasoning processes, and with narrative ethics, are also discussed.