The four quadrant approach

In 2008, Daniel Sokol wondered why the four quadrant approach had not enjoyed the popularity he had expected it to in the nearly 30 years since it had been first presented.4 He noted that, while the book in which the idea had been first described was in its 6th edition, he could find only one academic paper describing its use.

Ten years hence, with the book now in its 8th edition, the literature is less of a wasteland when it comes to discussions and mentions of this approach to medical ethics decision-making.5–13 (Notably, one of these examples is dated earlier than Sokol’s review: presumably he did not find it because they refer to it by a different name: the ‘four box approach’.) Sokol’s clear, reflective analysis, with useful, practical examples, may have helped to give the approach some popularity.

It is interesting to note the types of places that the four quadrant approach appears. The papers above are aimed at people such as nurses, consultants, paediatricians and medical students; these people are all practising (or at least, soon to be practising) clinicians. There is even a book that applies the method to veterinary practice.14 The approach is particularly popular in the military, appearing in the (since withdrawn, with a new version as yet forthcoming at the time of writing) Ministry of Defence’s ‘Clinical Guidelines for Operations’.15 It is the military’s method of choice for helping medical personnel to consider and deal with ethical issues, both in the abstract (ie, in classroom discussions and conferences) and on the ground, that is, in real life scenarios.

Clearly, then, it is considered by some to be of practical use, either in the teaching or conduct of medical ethics. While there is conceivably a gulf between a tool’s perceived practical use and its actual practical use, it is beyond the scope of this paper to consider in further depth whether these users are right to view the four quadrant approach as being practically useful. The first quadrant’s emphasis on clinical, medical factors makes a practical application unsurprising, so we will assume that users see the applications of the approach more or less straightforwardly. My central question, then, is whether the four quadrant approach is sufficiently theory-sensitive. In the absence of more feedback data and measurements of the actual effects of the four quadrant approach (though some efforts to this end have already occurred16), I will consider more abstractly whether the approach confers greater moral and/or theoretical legitimacy on the training than a more theoretical approach to begin with. Since the military has adopted the approach as its key way of negotiating medical ethical dilemmas, this discussion should be of particular interest to military medical personnel.

Is the four quadrant approach theoretically robust?

Given the criticism levelled at the much more mainstream ‘four principles’17 approach as risking ‘sterility and uniformity of approach’18 and being ‘algorithmic [and] robotic’,19 the four quadrant approach would likely garner similar criticism from more theoretical moral philosophers. These criticisms accuse the four principles approach of leaving no room for judgement, and that, applied unthinkingly, the approach can lead to deleterious results. They echo Millian concerns about values and beliefs deteriorating into ‘dead dogma’20 if they are not perpetually and robustly challenged. What starts as a shorthand way of applying moral theory turns into an unacceptable shortcut.

If we take this complaint seriously, the four quadrant approach appears, prima facie, to be as guilty as the four principles approach, if not more so. Where the four principles approach asks us to analyse moral problems in terms of four very broad categories or value theories, the four quadrant approach appears to ask us to do so sequentially, given the clear advantages of starting in the first quadrant. As well as using the quadrants sequentially, it is important to use them comprehensively: it should be concerning to us if there are cases where the approach is interpreted as stating that, once the problem appears to be resolved, there is no need to move to later quadrants (should there be any left). For one, and as Sokol states: ‘no quadrant will single-handedly settle the case’.4 But on top of this, we will see shortly that using all the quadrants is key to the approach’s usefulness over the four principles approach, and frees it from accusations of being too robotic.

The sequential approach to the quadrants is a double-edged sword. On the one hand, the decision whether to move on requires a degree of judgement in itself: namely, the judgement that the case truly is resolved by the quadrants already used up. On the other hand, ignoring remaining quadrants seems like an obvious way to forget about potentially important moral features of a case. The use of such an approach should serve to remind those without formal ethics training what kinds of things can be morally relevant, rather than lure them into the trap of thinking that the situation may be resolved at too early a stage. This may depend on the case at hand; a case may appear to be satisfactorily resolved by, say, the autonomy type considerations in the second quadrant. It is nevertheless possible that there will be relevant considerations from the later quadrants. If a patient with capacity refuses treatment, we might think that autonomy considerations are the end of the story. But there may still be contextual factors (per quadrant four) that affect the treatment of this patient: a patient with an infectious disease may have their freedom of movement restricted, for example. This contextual factor means that autonomy considerations are not the whole of the picture. It is therefore worth checking the other quadrants before concluding that one is satisfied with the answers provided by prior quadrants.

Indeed, the saving grace of the four quadrant approach comes in this fourth quadrant. The fourth quadrant asks the user to consider ‘contextual features’ of the case at hand. Sokol describes this quadrant as follows: ‘It is, in effect, a hotchpotch of potentially relevant issues, reflecting the wealth of considerations that might affect an ethics case analysis. I do not see this as a major problem’.4 He is right that the presence of such a ‘mop-up’ element, in which the user can consider any further issues pertaining to the case is not a major problem. Far from being a problem, this invitation to consider wider features not covered in the previous three quadrants is what rescues the four quadrant approach from the charge of being algorithmic and robotic and allows users to exercise their own ethical judgement. The fourth quadrant thus, at least in this way, elevates itself above the four principles approach, and gives more scope for the user to ethically analyse the case according to principles not explicitly prescribed by the quadrants.

This provides a very good reason to use the approach in a way that emphasises the equality of all the quadrants, much like the proposed equality of the four principles in Beauchamp and Childress’s approach (notwithstanding Gillon’s comment that of these principles, autonomy should be the ‘first among equals’21). So, while it might make sense to use the quadrants in a certain order, they must each be considered, and the fourth quadrant serves as a final ‘human’ check that the algorithm (1) appears to cover all relevant ethical issues and (2) appears to have been correctly applied.

A caveat

This paper has so far made the case that the four quadrant approach has genuine theoretical advantages, and is therefore in fact quite far from reaching the status of cargo cult in the hands of the military. There are nevertheless important steps that should be taken to ensure that continued use of this approach is sensible.

It has been several years since the military has adopted this technique as a practical way of applying medical ethics. Given that the role of ‘military medical/healthcare ethicist’ is to date a non-existent one, it is incumbent on both ethicists and military medical/healthcare personnel to meet in the middle: to devise ways of working that are robust with respect to moral theory, but that are sufficiently sensitive to the realities of professional life as to be practically useful.

It is laudable that organisations like healthcare services and the military (and the parts of those organisations that overlap) aim to provide ethical training and guidance for their personnel. It is especially good that this training is underpinned by ethical theory, where approaches are taken that have their basis in robust theorising that withstands philosophical scrutiny. The potential pitfall, however, lies where the practical application of this theory is divorced from the scrutiny of that theory over a sustained period of time. It is good to begin with a basis in theory, but it will be useful for those applying these tools to return to the theory, or to those conducting the theory, from time to time, to report their results and their use of the theory, so that theoreticians can consider whether the application is really working. I propose more of this symbiotic, two-way relationship, so that the approach can have more of a grounding in what matters and what works at a theoretical level, lest teachings that appear practical become wrong-footed.

There may always be a distance between professionals who study ethics theoretically, and those who practice it. But there will always be people in the middle of that dichotomy, at various stages: clinicians with Masters degrees in healthcare ethics; philosophers stationed in medical schools like the author of this paper and philosophers stationed in philosophy departments but with clear agendas for generating practical, useful arguments. (Philosopher Peter Singer is a good example: ‘It’s nice when your colleagues in philosophy departments appreciate what you are doing, but I also judge the success of my work by the impact my books, articles, and talks have on the much broader audience of people who are interested in thinking about how to live ethically’.22) These people will be particularly key in bridging theory and practice.