Guide to ethical decision-making for the critically ill: the three R's and Q.C

Ethical decision-making for the care of the critically ill and injured has never been more difficult than it is today. Major technologic advances prolong life but often provide questionable benefit in human terms. Both the ethical commitment to the individual patient and the competition for access to expensive and scarce health resources prompt the search for clinically useful and operationally appropriate criteria for decision-making. The mnemonic 3 R's and Q.C. was evolved as a practical tool by which the ethical basis for interventions may be tested. The first tier, the 3 R's, is likely to resolve the vast majority of ethical issues. These are appropriately addressed at the bedside by clinicians who determine whether a proposed intervention is Rational, Redeeming, and Respectful. When the ethical issues cannot be resolved at the bedside on the basis of the 3 R's, a second tier of testing of Quality of Life and Cost (Q.C.) is triggered. This addresses decision-making which is not exclusively or even primarily in the skill domain or authority of most physicians. It calls for assistance by those who represent a broader base of societal involvement including multidisciplinary experts in ethics and law who serve as consultants or who are organized into medical center-wide ethics committees.