Journal of evaluation in clinical practice · 2026
CALME: A Cognitive Loop for Ethical Deliberation During Clinical Action.
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Cadeau Comte Nina
Аннотация
RATIONALE, AIMS AND OBJECTIVES: Most established approaches to clinical ethics support deliberation before or after care, through processes such as informed consent, institutional guidance, ethics consultation and retrospective case review. Yet ethically significant decisions often arise during clinical action, when clinicians must respond under time pressure, manage competing technical demands and navigate asymmetries of knowledge and power. Although the literature on everyday ethics shows that routine practice is ethically dense, it does not provide a compact reasoning structure designed for use as care unfolds. This article develops such a structure.
METHOD (CONCEPTUAL): The framework was developed through conceptual analysis of the temporal and cognitive conditions of decision-making during clinical action. Five bodies of scholarship informed its design: reflective practice, the logic of care, everyday ethics, cognitive load theory, and naturalistic decision-making. Three hypothetical clinical cases were used to examine its internal coherence and illustrate how it could be applied.
RESULTS: CALME is a five-component cognitive loop: Context, Appraisal, Limits, Margin of manoeuvre and Evaluation. Its compact structure is designed to limit the effort required to search among possible actions, with the aim of preserving working memory for ethical attention. The Limits component makes competence, ethical justification, the patient's wishes and institutional constraints explicit. Margin of manoeuvre narrows the available actions to four categories: continue, adapt, defer or stop. Evaluation then returns the clinician to Context, allowing the loop to be repeated as action changes the situation.
CONCLUSIONS: In a form simple enough to remember and practical enough to use at the bedside, CALME gives explicit structure to ethical decision-making during clinical encounters. It offers clinicians what the everyday-ethics literature has not yet provided: not simply another account of the ethical density of routine practice, but a usable format for the reasoning that such density requires.
METHOD (CONCEPTUAL): The framework was developed through conceptual analysis of the temporal and cognitive conditions of decision-making during clinical action. Five bodies of scholarship informed its design: reflective practice, the logic of care, everyday ethics, cognitive load theory, and naturalistic decision-making. Three hypothetical clinical cases were used to examine its internal coherence and illustrate how it could be applied.
RESULTS: CALME is a five-component cognitive loop: Context, Appraisal, Limits, Margin of manoeuvre and Evaluation. Its compact structure is designed to limit the effort required to search among possible actions, with the aim of preserving working memory for ethical attention. The Limits component makes competence, ethical justification, the patient's wishes and institutional constraints explicit. Margin of manoeuvre narrows the available actions to four categories: continue, adapt, defer or stop. Evaluation then returns the clinician to Context, allowing the loop to be repeated as action changes the situation.
CONCLUSIONS: In a form simple enough to remember and practical enough to use at the bedside, CALME gives explicit structure to ethical decision-making during clinical encounters. It offers clinicians what the everyday-ethics literature has not yet provided: not simply another account of the ethical density of routine practice, but a usable format for the reasoning that such density requires.