[Ethical decisions in surgery. Foundations for a principle-oriented case discussion]

Due to advanced medical interventions, the multitude of beliefs in our society, and increasing economic pressure, difficult ethical decisions are also part of the surgical care of patients.

How can health care personnel address the ethical challenges in a structured, well-founded ethical manner?

Based on the four principles of biomedical ethics beneficence, nonmaleficence, respect for autonomy, and justice, we present a model for the step-wise ethical evaluation of difficult cases.

The principle-based model of ethical case discussions consists of five steps: 1) In the medical analysis of the case, the available management strategies are identified, including a detailed description of their benefits and risks. 2) The evaluation starts with the ethical obligations towards the patient: Which treatment strategy is in the patient's best interest? And: Which option does the patient prefer herself after appropriate disclosure? 3) Then it has to be examined whether obligations to third parties (family members, other patients, etc.) have to be taken into account. 4) In the synthesis, the individual evaluations are integrated into an overall assessment of the case; conflicting obligations have to be balanced based on good reasons. 5) A critical review of the case concludes the case discussion. The application of the model is exemplified based on a surgical case discussion.

Difficult ethical decisions can be supported by structured case discussions, in which all medical disciplines and professional groups involved in the care of the patient should participate.