ABC Toolbox
The ABC toolbox was developed in Singapore in 2013 by Michael Dunn to support clinical ethics decision-making on the frontline in time-limited settings. Originally developed as a teaching and learning tool for “in practice” ethical reflection amongst junior health professionals, it offers a straightforward, and easy to digest, approach to reasoning through ethical issues in clinical cases.
The ABC toolbox is part of the materials that support the Singapore Bioethics Casebook. Dunn has published some slides explaining the approach, which you can access here. You can also watch a video in which Dunn discusses the approach here.
The toolbox has three tools:
Toolbox A:
Analysing facts and values
All care encounters involve both facts and values. No amount of evidence (“what is the correct dosage of this medication?”) or legal knowledge (“what are the rights of patients concerning information about their care?”) will resolve a conflict between values (“what is good/right?”).
Once you have identified relevant facts, describe the values – the competing versions of good or right action – that are in conflict. Some values conflicts involve the interests of an individual patient or a smaller group versus the interests of a larger group; these conflicts are characteristic of decisions about how to allocate limited resources, for example. Other conflicts may involve values concerning what course of treatment is good or right for a single patient.
Toolbox B:
Balancing principles and intuitions
The ethical values that a healthcare professional should adhere to in the care of the sick are long-established and widely recognised. One influential account, developed in the USA by Beauchamp and Childress, is known as the four principles approach.
There are, of course, many other accounts of the ethical principles and values that are important in healthcare. In the ABC Toolbox framework, no pre-specified list of principles is given; these can be chosen flexibly from other established accounts of values in health care, as the decision-making context demands. To protect against bias, a broad, inclusive and ecumenical approach should be adopted here. It is better to include too many irrelevant principles than to risk excluding an important ethical value from consideration because those in the room have pre-determined views about which principles ought to be considered in such cases.
Separately from selecting relevant principles, people will also have gut reactions about what they believe ought to happen in each situation. This is true of the members of a clinical ethics service just as it is true of healthcare professionals themselves. These moral intuitions reflect the norms of our families, our traditions, our social environment, and our professional culture. Moral intuitions have a powerful emotional component; we can feel strongly that something is right or wrong, even if we have difficulty explaining why this is so.
Once again, in an ethically challenging situation, it is likely that principles will conflict with each other, and that principles and personal intuitions will also conflict. Resolving ethical conflicts involves applying principles to practice, and identifying trade-offs: in each situation, what are appropriate and inappropriate limits on autonomy in the interest of preventing harm, for example?
We also need to be prepared to challenge our own intuitions (or those of other people), and not act simply on gut instinct. This means more than simply developing rational arguments – the human mind is extremely good at finding arguments to justify our gut instincts. The goal of ethical reasoning is to reach broad, good-faith agreement with other people with integrity, on what course of action is consistent with ethically sound practice in the care of people who are sick. This process will, ideally, allay individual moral concerns. However, a perfect reconciliation of ethical principles and individual intuitions may not be possible.
Toolbox C:
Comparing cases
When Tools A and B have been used to advise on a course of action that addresses the ethical questions, it is useful to assess how this decision compares to other situations – to test the ethical defensibility of the conclusion drawn. Is advice being provided in the same way as has been provided in similar situations, and would we be happy to provide the same advice in the future when faced with similar situations?
Case comparison is based upon the importance of consistency in ethical decision-making. If we decide to make different decisions in similar situations, then we must be able to point to an ethically significant difference between the situations.
A practice of comparing cases can also help to direct the modification of ethical recommendations moving forward, in addition to being a prudent retrospective check on the consistency of ethical reasoning. When faced with a new situation, we can ask ourselves and the clinical team presenting a case: what has past experience taught us about this kind of situation? What is similar, and what is different, about the situation at hand?
Case comparison is common in many legal systems, particularly those in which a doctrine of precedent operates. This essentially means that previous court decisions will determine the decisions that are to be made in later, similar cases. We can see the value of case comparison by considering briefly some high-profile legal cases. In so doing, we can examine what seems to be two different decisions being made by the courts in clinical scenarios that looked, on the face of things, very similar.
Comparing Cases: Charlie Gard and Tafida Raqeeb
Charlie Gard was a young boy with severe neurological damage. He required ventilation with no prospect of recovery. The hospital staff wanted to discontinue ventilation and allow him to die, but his parents wanted to take him to another country for treatment. The court found in favour of the hospital and ventilation was withdrawn.
Tafida Raqeeb was a five-year-old girl who also had severe neurological damage and similarly required ventilation with no prospect of recovery. The hospital staff wished to withdraw ventilation and allow her to die, but her parents wanted to take her to another country for treatment. The courts found in favour of the parents and the parents took their daughter to a hospital in Genoa where she settled in well.
The two cases bear some clear similarities. Why, then, would a judge endorse one course of action in one case, and an entirely different course of action in the other? Judges perform case comparisons par excellence, because what they are interested in, apart from the law, are the details of the case. They ask what it is it about the details of this case that might lead to the application of the law in a different way. Good ethical reasoning places the same demands on us.
Some of the differences in these two cases which might account for the different decisions, which may or may not be morally relevant, are:
- Differences in age: Charlie Gard was one year old and Tafida is a few years older – is that morally relevant? Perhaps it isn’t morally relevant unless it is associated with something else.
- The specific diagnosis is different: Charlie had mitochondrial depletion syndrome, so he had a progressive neurological condition that was going to get worse. Tafida had an initial insult, a vascular bleed in her brain, so the specific diagnosis in each case was different. This may or may not be morally relevant.
- The trajectory of the conditions was different: Charlie Gard was going downhill rapidly. According to the law report, Tafida might live for another 10-20 years on ventilation. Perhaps that is a morally relevant difference.
- The parents had different reasons underlying their preferences: One of the reasons Tafida’s parents gave was that the concept of the sanctity of life was important to them, as part of their personal values, as part of their religious values, thus there was a value to maintaining the life of the loved one, because they were still there as a person, that life was precious to them, and it wasn’t up to the doctors, or the family, to make a decision about withdrawing treatment and allowing that life to end. In contrast, Charlie’s parents wanted a treatment they thought would cure their son, or at least make their son better, and they had agreed with the hospital that, if that treatment wasn’t available, then the burdens and benefits of treatment were such that they didn’t want to carry on treatment. So, once they lost the case in terms of being able to transfer Charlie to have the treatment they thought might make a difference, they weren’t then saying that they wanted Charlie to receive treatment, to be ventilated, until he died. So, the parents had different reasons. These are perhaps morally relevant reasons, and the values that inform the reasons would be morally relevant reasons for why the judge might come to a different decision.
- Differences in the level of suffering and awareness of pain: In Charlie’s situation, his doctors thought he might be aware of and able to experience pain, even though he might not be able to communicate this. In Tafida’s case, the court held that she might not be able to experience pain, so continuing treatment was not likely to cause her distress or pain; as such, when contrasting the burden of treatment compared to the benefit, the balance was viewed differently.
Click here to download a PDF with further information about ethical frameworks, including worked-through examples of how each of the different frameworks would approach the ethical analysis of a case.