PHI 413V Grand Canyon University Applying the Four Principles: Case Study This assignment will incorporate a common practical tool in helping clinicians be

PHI 413V Grand Canyon University Applying the Four Principles: Case Study This assignment will incorporate a common practical tool in helping clinicians begin to ethically analyze a case. Organizing the data in this way will help you apply the four principles of principlism.

Based on the “Case Study: Healing and Autonomy” and other required topic study materials, you will complete the “Applying the Four Principles: Case Study” document that includes the following:

Part 1: Chart

This chart will formalize principlism and the four-boxes approach by organizing the data from the case study according to the relevant principles of biomedical ethics: autonomy, beneficence, nonmaleficence, and justice.

Read “Teaching Clinical Ethics Using the Four Topic Method” (attached). Use the example provided in the article to guide you in the completion of the chart in the topic assignment.

Part 2: Evaluation

This part includes questions, to be answered in a total of 500 words, that describe how principalism would be applied according to the Christian worldview.

———————————————————————————————————————

This assignment should consist of completing a chart using the four-box method as a way to organize a case according to the four principles of Principlism. As you fill in each box in section once, be sure there is a clear connection to the items you include in the box and one or more of the principles in the box’s heading.

Bullet points are typically used to complete the boxes in Part I. Make a brief comment in parentheses to show how the information you include relates to the principles for that box. For example:

“I include this item in this box” (this supports the autonomy of the patient)
Do not include lengthy descriptions of what, for example, “autonomy” is. Give concrete information in each box. For example, in box one, medical indications, the diagnosis current state of the patient must be included.

Remember to support your responses with the topic study materials.

APA style is not required (except for resources), but must have solid academic writing. Applying the Four Principles: Case Study
Part 1: Chart (60 points)
Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet
points or a well-structured paragraph in the box. Gather as much data as possible.
Medical Indications
Patient Preferences
Beneficence and Nonmaleficence
Autonomy
Quality of Life
Contextual Features
Beneficence, Nonmaleficence, Autonomy
Justice and Fairness
©2019. Grand Canyon University. All Rights Reserved.
Part 2: Evaluation
Answer each of the following questions about how principlism would be applied:
1. In 200-250 words answer the following: According to the Christian worldview, which of the four
principles is most pressing in this case? Explain why. (45 points)
2. In 200-250 words answer the following: According to the Christian worldview, how might a
Christian rank the priority of the four principles? Explain why. (45 points)
References:
©2019. Grand Canyon University. All Rights Reserved.
CLINICAL REVIEW
© 2015 Human Kinetics – IJATT 20(6), pp. 10-13
http://dx.doi.org/10.1123/ijatt.2014-0118
Teaching Clinical Ethics
Using the Four Topic Method
Mike J. Ediger, DHSc • Whitworth University
A
thletic training and sports medicine are
branches of health care, presenting a
unique set of ethical problems when
making clinical decisions. Very few health
professionals face the potential threats and
difficulties in maintaining doctor–patient confidentiality, the possible impediments to obtaining informed
consent, and the temptation or requirement to use
the application of medical arts for enhancing athletic
performance or potentially-dangerous behavior.1 As
a health care profession, athletic training demands
foundational behaviors of professional practice such
as primacy of the patient, a team approach to practice,
legal and ethical practice, advancing knowledge in the
field, cultural competence, and professionalism.2 The
ability to be part of a health professional team and
effectively manage the sometimes difficult interplay
between the unique aspects of competitive sports and
medicine often only comes with experience.
When athletic training students are involved with
injury evaluations but are not intentionally challenged
to consider the many variables that go into making
difficult clinical decisions, their growth as professionals
will be stunted. Even though clinical educators may
be diligent at discussing the decisions with students,
if students are not versed at identifying and analyzing
all of the variables, they may be left understanding the
decision yet not possessing the tools to work through
a case on their own. If athletic training students are
expected to one day become excellent clinical decision-makers and engage in interprofessional practice,
they must understand the biomedical principles that
provide uniformity and unity among health care pro10  NOVEMBER 2015
fessionals and create the foundation of ethical decision-making in clinical practice.
The Four Topic Method: A Practical
Approach to Ethical Decision-Making
In Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine3, Jonsen, Siegler, and Winslade
present a practical approach to ethical decision-making
in clinical medicine, and build on the philosophical
study of underlying principles in biomedical ethics
(autonomy, beneficence, nonmaleficence, and justice)
originally devised by Beauchamp and Childress in their
textbook, Principles of Biomedical Ethics. Jonsen et al.
acknowledge the work of Beauchamp and Childress,
and then direct readers on how these general principles
intersect with the specific circumstances of a clinical
case. The authors suggest that every clinical case is
to be analyzed based on a systematic review of four
basic topics: medical indications, patient preferences,
quality of life, and contextual features (see Table 1).
While the book was written for clinical medicine, it can
also provide athletic training educators and students a
framework that can be applied to a real or theoretical
case analysis, providing a practical guide to ethical
clinical decision-making in athletic training settings.
Because each injury situation will present a unique
set of ethical and clinical variables, the scope of this
article will not fully explore every possible issue in each
of these topics. However, hopefully it can serve as a
guide to stimulate further discussion and exploration of
these issues between clinical athletic trainers, athletic
training educators, and athletic training students. There
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
Table 1 The Four Topics Chart,3
with Example Questions Adapted for Athletic Training
Medical Indications
Patient Preferences
The principles of beneficence and nonmaleficence
• What is the athlete’s injury or problem?
• Is the problem acute, chronic, or critical?
• What is the history, diagnosis, and prognosis?
• What are the subjective and objective signs or symptoms?
• What therapeutic interventions may be appropriate?
• What does research or evidence suggest in terms of
treatment or intervention?
• What are the medical facts based on this particular
case?
The principle of respect for autonomy
• Has the athlete been informed of the indications, risks,
and benefits?
• What are the athlete’s wishes for treatment, therapy, or
return to competition?
• Is the athlete competent?
• Is the injury or pain severe enough to interfere with the
athlete’s decision-making capacity?
• Is the desire to compete clouding the athlete’s judgment?
• Is the athlete feeling pressure related to opinions or attitudes of others?
• Is the athlete’s right to choose being respected to the
extent possible?
Quality of Life
Contextual Features
The principles of beneficence and nonmaleficence and
respect for autonomy
• How might the injury or problem be impacting the
athlete in other areas of life?
• How might the injury impact the athlete’s relationship to the team, coaches, or others?
• Will the injury create any academic impediments if
the athlete is in school?
• Are there any short- or long-term health risks?
• Are there any physical, mental, or social implications
that are secondary to the original injury?
• Does the injury impact identity, self-worth, or cause
depression?
• Are there biases that might prejudice the athletic
trainer’s evaluation of what is right for the athlete?
The principles of loyalty, justice, and fairness
• Are there other parties who are stakeholders in the clinical decision?
• What are the limits of, or imposed restrictions on, confidentiality?
• What is the coach’s attitude toward the injury or treatment plan?
• What is the athlete’s role on a team?
• Does the athlete play a particular position, or does the
time of season have any impact on the decision-making
process?
• Was it a nonathletic-related injury that will impact athletic participation or have financial implications (insurance coverage)?
• Are there religious issues that may impact treatment?
• Is the athlete a minor, or should parents be consulted?
will certainly be overlap between the four topics, but
it is recommended that the ethical analysis of clinical
decisions follow the same order in all cases: (1) medical
indications, (2) patient preferences, (3) quality of life,
and (4) contextual features.3
Note: For the context of this article, patients will
be referred to as athletes, since most athletic training
education takes place at the collegiate setting.
Topic 1: Medical Indications
Medical indications simply refers to the indications for
or against a particular medical intervention, and recognizes the principle of beneficence and nonmaleficence.
In this step, athletic trainers are to evaluate the medical
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
facts of a particular case in light of the individual, not
in light of what decision would best benefit the team or
allow the athlete to return to play most quickly. In the
broadest scope of medical ethics, this incorporates the
principles of beneficence and nonmaleficence, or how
the medical intervention brings benefit to the athlete
without doing any harm. Through clinical examination,
the athletic trainer will take the athlete’s history and
attempt to determine the diagnosis and prognosis.
Other considerations regarding this topic include:
Which therapeutic interventions may be appropriate to
evaluate and treat the injury, and what does evidence
or research suggest might be the best treatment? Pure
medical ethics condemn any action during this step
dictated by interests or pressures not related to the goal
NOVEMBER 2015  11
of good health or beneficience.4 This does not mean
performance or participation will not be taken into
account as a treatment plan is developed, however,
it is a secondary issue and will be considered later.
Helping students identify medical indications might be
the most objective step, and one that athletic training
clinicians and educators do very well.
Topic 2: Patient Preferences
Patient preferences recognizes the principle of respect
for autonomy, and highlights the importance for any
athlete to have input into their care, treatment, and
return to activity. Important considerations may also
include the athlete’s competence and if they are free
from feeling pressure from others. Observance of an
athlete’s preferences hinges on the athlete’s decision-making capacity, or competence, and it must
be voluntary and cannot be made under pressure or
coercion. Herein lies the potential for both internal
and external barriers to recognizing an athlete’s preferences in the athletic setting.
When an athlete is injured, internal obstacles to
autonomous decision-making may be presented; the
athlete suffers pain, and potentially loses the ability to
compete and excel.5 A motivated athlete may view the
appropriate medical decision as interference to getting
back to play. The internal desire to return to competition can inhibit the ability to hear and comprehend a
rational discussion of risks and benefits. In these cases,
the athlete may make a decision that will allow them
to play rather than making a decision based truly on
the medical indications.
External barriers to informed consent and athlete
autonomy can be both blatant and subversive. Bunch
and Dvonch5 state that the assumption that injured
athletes, especially those involved in team sports, are
self-controlled decision-makers allowed to make autonomous decisions, is simply untrue. Instead, they describe
a decision-making process that is subject to group input,
a situation called a “constellation of consent”. Injured
athletes may have a constellation of people who have
a vested interest in their health and ability to compete.
Athletes may view playing through an injury as a badge
of honor, as dedication to the team, and, at times, an
expectation of the team. However, only the athlete
assumes the risks, which they may minimize to justify
getting back as quickly as possible so as to not let everyone down. For these reasons, medical decisions made
to assist an athlete’s return to competition based solely
12  NOVEMBER 2015
on the player’s desire to compete, in hindsight, could be
construed as coercive and negligent by anyone in the
constellation, and could have significant legal implications.4,6 As an advocate for the athlete, the athletic trainer
must sometimes protect athletes from themselves.
While athlete autonomy is primary and should never
be summarily dismissed, medical ethics will occasionally allow a form of weak paternalism. In the case of
an injured or overwhelmed athlete, cautious, beneficence-based paternalism may be an acceptable position
when making clinical or return-to-play decisions.5 The
question really becomes how far can athletic trainers
let medical self-determination or athlete autonomy go
when the athlete is under extreme pressure, internal or
external, to play with an injury?7
Topic 3: Quality of Life
Quality of life recognizes that any injury, especially
when severity is not initially known, may pose both
real and perceived threats to the athlete’s lifestyle, and
represents the principles of beneficence, nonmaleficence, and respect for autonomy. In addition, quality
of life will mean different things to different people,
and each athlete must be allowed to fully articulate
what is acceptable for them. The athletic trainer must
also be careful not to let personal bias prejudice the
evaluation of a situation and how the athlete is advised.
Careful consideration should be given to any potential
short- or long-term health risks due to the injury, with
or without intervention. What physical, mental, and
social deficits might the athlete experience if away from
their team or sport for a significant amount of time?
What academic impediments may be experienced
based on the injury? The goal of the athletic trainer
is to ensure the athlete’s health and well-being and to
minimize the pain and suffering. However, the goal
of the athlete might not always align with the athletic
trainer, where pain and suffering are often acceptable
by-products of athletic participation and competition.
An athletic trainer must realize that injuries can affect
not only an athlete’s physical health and performance
on the field of competition, but also enjoyment of social
roles, intellectual functioning, emotional states, and a
sense of life-satisfaction or personal well-being.
Topic 4: Contextual Features
Contextual features recognizes that most athletic injuries are clearly embedded within a larger context of
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
factors. Clinical decisions are rarely made in a vacuum
and often require input from several individuals to
determine the course of action (e.g., athlete, athletic
trainer, coach, parents, and physician).7 Contextual
features bring into play the principles of justice and
fairness within the context of injury. Is the athlete the
best or worst player on the team, and what impact
might or should this have? Is the team in the off-season, preseason, or competing for a championship? Are
there provider issues, such as a specific team physician, specialist, or family physician that the athlete or
family wants to be consulted? Are there financial and
economic factors? Is the injury nonathletic-related,
which may or may not have insurance implications?
Are there confidentiality limits with personal issues,
such as an eating disorder or an abortion, which the
athlete may come to you for help but does not want
the coach to know? In every limiting medical condition, the relevance of the contextual features must
be determined and assessed. Skill in recognizing and
understanding these features, and learning how to diplomatically manage each, will be crucially important in
making ethical clinical decisions. Ultimately, the ability to navigate and anticipate some of the contextual
complications may dramatically influence the support
or resistance an athletic trainer may face in working
toward resolution with all of the parties involved.
The Four Topic Method
as a Pedagogical Tool
Peer and Schlabach8 state that cognitive understanding
of ethics in clinical education is critical for students to
establish the foundational behaviors of professional
practice. One of the difficulties in teaching clinical decision-making is that students are often not fully involved
in the decision-making process in their clinical experience, and replicating the process in the classroom can
be difficult. The Four Topic Method may bridge this
gap, allowing both clinical and classroom educators an
organizational tool to intentionally challenge students
to identify variables involved with injury management
situations. Clinical Ethics: A Practical Approach to Ethical
Decisions in Clinical Medicine3 may also be an excellent
text for a senior seminar or reading group. After being
presented with case studies, students could brainstorm
variables relevant to each of the four topics. Then,
working groups could carefully analyze, evaluate, and
present these variables to class members. This same
process could be used with clinical instructors when
INTERNATIONAL JOURNAL OF ATHLETIC THERAPY & TRAINING
evaluating current injuries seen in the training room.
This systematic, integrated, and ongoing practice of
working through clinical dilemmas will ultimately
help students establish the foundational professional
behaviors required to become ethical decision-makers
in daily practice.
Athletic training education must help students
become ethical decision-makers and prepare them
for interprofessional practice with the general medical
community. The Four Topic Method is an organized
model for clinical decision-making that is grounded
in principles of biomedical ethics. Using this method
in the clinic or classroom will intentionally and deliberately challenge students to critically analyze clinical
scenarios and help them master the foundational
behaviors revealed in the ethics of professional practice. If students can recognize the appropriate medical
indications, give athletes’ preference and quality of
life desires appropriate consideration, and learn to
recognize associated contextual features, they can
more objectively and effectively advocate for athletes’
health and well-being through competent and ethical
clinical decisions. 
References
1. Bernstein J, Perlis C, Bartolozzi AR. Normative ethics in sports medicine.
Clin Orthop. 2004;(420):309–318. PubMed doi:10.1097/00003086200403000-00044
2. National Athletic Trainers’ Association. Athletic training educational
competencies. 5th ed. Carrollton, TX: National Athletic Trainers’
Association; 2011. Available at http://www.nata.org/sites/default/
files/5th_Edition_Competencies.pdf.
3. Jonsen AR, Siegler M, Winslade WJ. Clinical ethics: A practical approach
to ethical decisions in clinical medicine. 7th ed. New York, NY: McGrawHill; 2010.
4. Liotard P. Sport medicine: to heal or to win? UNESCO Cour.
2000;53(9):37–39.
5. Bunch WH, Dvonch VM. Informed consent in sports medicine.
Clin Sports Med. 2004;23(2):183–193. PubMed doi:10.1016/j.
csm.2004.01.004
6. McCrory P. No pain, no gain. The dilemma of a team physician.
Br J Sports Med. 2001;35(3):141–142. PubMed doi:10.1136/
bjsm.35.3.141-a
7. Gould MT, Hansted KT. The fix is in: legal and malpractice standards regarding the treatment of athletic injuries. Clin Sports Med.
2003;22(3):631–638. PubMed doi:10.1016/S0278-5919(03)00020-6
8. Peer KS, Schlabach GS. Ethics education: the cornerstone of
foundational behaviors of professional practice. Athl Ther Today.
2007;12(1):2–6.
Mike Ediger is an associate professor and department chair of Health
Sciences, Whitworth University, Spokane, WA.
Malissa Martin, EdD, ATC, CSCS, Rocky Mountain University of Health
Professions, is the report editor for this article.
NOVEMBER 2015  13
Copyright of International Journal of Athletic Therapy & Training is the property of Human
Kinetics Publishers, Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder’s express written permission. However, users
may print, download, or email articles for individual use.
Applying the Four Principles: Case Study
Part 1: Chart (60 points)
Based on the “Healing and Autonomy” case study, fill out all the relevant boxes below. Provide the information by means of bullet
points or a well-structured paragraph in the box. Gather as much data as possible.
Medical Indications
Patient Preferences
Beneficence and Nonmaleficence
Autonomy
Quality of Life
Contextual Features
Beneficence, Nonmaleficence, Autonomy
Justice and Fairness
©2019. Grand Canyon University. All Rights Reserved.
Part 2: Evaluation
Answer each of the following questions a…
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