Introduction

Principles and practice

Casuistry, or case-based reasoning, is the preferred methodology for clinical ethics. Broadly speaking, this practice of thinking through the ethical aspects of medical decisions gives the particularities of each case primacy over appeals to principle. Emphasizing the details of and differences between cases in this way has proved to be a welcome heuristic against excessively abstract principles and impersonal institutional policies. Furthermore, case-based disquisition not only respects, but emerges out of, the experience-enriched perspectives good clinicians bring to their practice.

In the execution of moral deliberation, however, it can be difficult to discern whether principle-directed, or instead case-based, moral reasoning is being attempted. That is because both methodologies incorporate reference to model cases, albeit in very different ways. But arduous as it may be to disentangle these approaches, the utility of doing so is evident. For where the methodologies have been scrambled, cases will prove themselves resistant to our expectations about how they should be resolved, and will leave a residual puzzlement and dissatisfaction about their outcome. Furthermore, this lack of closure may precipitate premature calls for policy making.

Prior to yielding to pressures to promulgate policies, however, it is prudent to gain a better understanding of what values difficult cases bring into play. Doing so helps to predict when a prospective policy is liable to clash with the values of the broader community. To illustrate, let us explore why, after having successfully executed “long-term ventilation in a child with severe central nervous system impairment,” Drs. Perkin, Orr, and Ashwal continue to find the case an irritant.