4 Box Model for Clinical Decision Making

Remember the 4 Cs:

  1. Clinical indication (Principle of Benevolence and Non-maleficence)
  2. Choice of patient (Principle of respect for Autonomy)
  3. Contextual features (Principle of Loyalty and Fairness)
  4. Condition (quality) of life (Principle of Benevolence, Non-maleficence and respect for Autonomy)
  5. A 5th box can be added: Catholic perspective
four box model ethics


Clinical indications

18 yr old male with blood mixed sputum in cough and fever for 2 week and findings suggestive of right sided exudative pleural effusion
Patient needs chest tube or pigtail catheter insertion and aspiration of pus
Choice of patient

Only IV antibiotics
No chest tube
Patient refuses
Mother and relatives wants indicated treatment
Condition (Quality) of life

At Present not good
May be improved with treatment as it is curable with antibiotics and aspiration of Pus
Contextual features

Taking consent from mother and counselling the patient

Marugg L, Atkinson MN, Fernandes A. The five-box method: The “four-box method” for the Catholic physician. Linacre Q. 2014 Nov;81(4):363-71. doi: 10.1179/2050854914Y.0000000032. PMID: 25473133; PMCID: PMC4240053.

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