The deliberative method, step by step
- Procedure
Deliberating means analysing a case on three levels, facts, values and duties, to choose the course of action that least harms the conflicting values.
What it is
Deliberation is an orderly exchange of reasons, alone or in a group, to reach a reasonable and prudent decision. The method proposed by the Spanish bioethicist Diego Gracia, widely used by ethics committees in Spanish-speaking countries, moves through three levels: first the clinical facts, then the values in conflict, and finally the duties, that is, what ought to be done. Its central idea is that there are almost never only two ways out: between the two extremes, which save one value by sacrificing another, there are intermediate courses, and the optimal one is usually among them. The «How to work through an ethics case» page compares it with the four boxes; this one explains it step by step.
What it must include
- The complete, checked facts, including the voice of the patient or their representative.
- The chosen moral problem, stated as a conflict between values.
- The two extremes and at least several intermediate courses.
- The chosen course, the reason for it and the result of the consistency tests.
- Who decides and how it is recorded.
How it is done
- The person who must decide presents the case: medical record, family data and social setting.
- Discuss the clinical facts: diagnosis, prognosis and options, with the rigour of a clinical meeting.
- Identify the moral problems the case raises for each participant, phrased as questions.
- The person responsible for the case chooses the moral problem that worries them most, to be analysed.
- Identify the values in conflict in that problem (for example, life and autonomy).
- Look for the extreme courses of action: those that promote one value at the cost of the other.
- Look for every possible intermediate course between the two extremes.
- Choose the optimal course: the one that least harms the conflicting values.
- Consistency tests: is it legal? Would it be defended in public? Would the same decision be made after a few hours or days?
- Final decision by the person who consulted, with the recommendation written down and recorded in the medical record.
In clinical practice
- A capable patient refuses surgery with a good prognosis: the extremes are operating against their will or simply discharging them; intermediate courses include exploring their reasons, giving time, offering alternatives and a second opinion.
- A family asks to hide a diagnosis: between lying and telling everything at once there are courses such as asking the patient how much they want to know and supporting the family.
- Scarce resource: between «first come, first served» and «only the best prognosis» there are public criteria combining need, expected benefit and justice.
- The committee recommends; the decision belongs to whoever is responsible for the case, together with the patient.
Common mistakes
- Discussing values before the clinical facts are clear.
- Framing the case as a two-option dilemma and choosing one of the extremes.
- Confusing one's own values with the patient's, or leaving the patient out of the deliberation on values.
- Seeking certainty: deliberation seeks prudence, not a single truth.
- Not writing down the recommendation and its reasons.
Test yourself
Think of the answer, then tap the question to see it.
What are the three levels of the deliberative method, and in what order are they covered?
Facts, values and duties, in that order. Values rest on the facts, and duties seek to realise the values in conflict.
Why are the extreme courses of action sought?
To open up the range of options: the extremes save one value by sacrificing the other, and they serve as reference points for finding intermediate courses.
What characterises the optimal course of action?
It realises all the values in conflict or harms them as little as possible; it is almost always an intermediate course.
What are the three consistency tests for a decision?
Legality (is it legal?), publicity (would it be defended in public?) and time (would it be made the same after a few hours or days?).
Connections
Educational content on ethics and health law; not legal advice. Laws and case law change: each page links the official text and says when it was last checked. For a real case, read the text in force and ask a lawyer or the medical ethics tribunal.
Sources: ¿Qué es la deliberación en clínica? (Comprender los cuidados paliativos) (Sociedad Española de Cuidados Paliativos (SECPAL), 2022); Introduction to Clinical Ethics (the four topics method) (University of Washington, Department of Bioethics & Humanities, 2018).
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Representative model, for educational purposes only.