A qualitative study of the use of the four quadrant approach to assist ethical decision-making during deployment

Abstract

The 4QA is a useful tool within an operational setting but amending its diagrammatic presentation could improve its effectiveness. Pre-deployment training should include practising using the quadrant as described in Clinical Guidelines for Operations. This is particularly important as the participants relied heavily on experience to help them make ethical decisions, and this experience may not be available in future operations outside Afghanistan.

‘A band of brothers’—an exploration of the range of medical ethical issues faced by British senior military clinicians on deployment to Afghanistan: a qualitative study

“…The most straightforward decisions were those that the participants were familiar with making in their non-deployed role and when a patient's eligibility for treatment complied with the MRoE. The impact of experience echoes the findings of an earlier evaluation of the 4QA approach, in which clinicians appeared to view more familiar ethical decisions as clinical ones, even though it was an ethical one 14. The concerns around quality of care are consistent with previous studies 18 19…”

“…There are three steps to address an ethical issue11 23—moral perception, moral reasoning and moral action. Moral perception recognises that the case presents a moral or ethical question and is the first stage of 4QA 11 14. Moral reasoning considers the issue within a relevant moral framework.…”

“…However, none of the participants referred to BMA's4 guidance, even though it is aimed specifically at doctors in their position. Participants reported relying on previous experience, and this has been identified elsewhere 14. Relevant and high-quality training in ethical decision-making is necessary to help clinicians feel confident to deal with ethical issues on deployment.…”

“…Our participants spoke of engaging their clinical team in discussion. Participants in this study, like those from a previous study,14 referred to the pro forma of 4QA as a useful navigation tool that enabled them to check that they had gathered all of the information necessary to arrive at a decision. This is in line with the perceptions of 4QA of Tsai and Harasym 50.…”

“…The four quadrants are ‘ medical indications ’, ‘ patient preferences ’, ‘ quality of life ’ and ‘ contextual features ’ 10–13. Research14 suggests that the 4QA can be a useful tool to collect relevant information to assist ethical decision-making and identifies that participants rely on their previous deployment knowledge to make ethical decisions. However, military clinicians may not be able to rely on previous experience in future contingency operations where the characteristics, environment, circumstances and type of deployment are less likely to have been previously experienced.…”