Clinical Ethics Consultation

Theories and Methods, Implementation, Evaluation

John-Stewart Gordon, Jan Schildmann

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317165064
• Edition: 1
• Topic: Medicine
• Subtopic: Ethics in Medicine

This volume brings together researchers from different European countries and disciplines who are involved in Clinical Ethics Consultation (CEC). The work provides an analysis of the theories and methods underlying CEC as well a discussion of practical issues regarding the implementation and evaluation of CEC. The first section deals with different possible approaches in CEC. The authors explore the question of how we should decide complex cases in clinical ethics, that is, which ethical theory, approach or method is most suitable in order to make an informed ethical decision. It also discusses whether clinical ethicists should be ethicists by education or rather well-trained facilitators with some ethical knowledge. The second chapter of this book focuses on practical aspects of the implementation of CEC structures. The analysis of experienced clinical ethicists refers to macro and micro levels in both developed and transitional countries. Research on the evaluation of CEC is at the centre of the final chapter of this volume. In this context conceptual as well as empirical challenges with respect to a sound approach to judgements about the quality of the work of CECs are described and suggestion for further research in this area are made. In summary this volumes brings together theorists and healthcare practitioners with expertise in CEC. In this respect the volume serves as good example for a multi- and interdisciplinary approach to clinical ethics which combines philosophical reasoning and empirical research.

Chapter 1
Introduction

Jan Schildmann, John-Stewart Gordon and Jochen Vollmann

Clinical Ethics Consultation – A Brief Introduction

Clinical ethics consultation1 (CEC) has been implemented in many hospitals and other clinical settings. A representative survey conducted in the United States indicates that CEC services are available in more than 80 per cent of hospitals.2 In Europe the UK Clinical Ethics Network lists almost 100 CEC structures on their website (www.ethics-network.org.uk) and latest available data from Germany show that there are CEC structures in more than 300 health care institutions.3 The steady rise of new diagnostic and treatment options and questions regarding an ethically justified application (and limitation) of these possibilities has been cited as one important trigger for this development. The diversity of values in modern society and its various communities as well as the legal and ethical emphasis of patients’ autonomy are other important factors in this respect. Following the implementation of the first CEC structures in US hospitals in the 1970s two decades passed before CEC was implemented in health care institutions in Europe. Differences such as cultural characteristics, legal aspects and the funding of the health care systems not only between the USA and Europe but also between the European countries mean that CEC had to be adapted to the specific contexts. This is especially valid for the very recent development of the implementation of CEC structures in the so-called ‘transitional countries’ in Eastern Europe, of which there are a number of case studies presented in this book.

CEC – whether it takes place in the USA, in one of the European countries or in any other part in the world – is a multi- or even interdisciplinary enterprise. Medical ethicists, physicians, philosophers, nurses, social scientists, theologians and many more professions contribute to CEC. The diverse disciplinary background of those doing CEC may be one reason for the variety of CEC services we encounter in practice. Differences not only relate to organizational aspects but also to the theoretical and methodological premises of CEC and the aims of the different services. Until now there has been little detailed description of the above-mentioned aspects of CEC in the literature and even less systematic analysis of the similarities and differences of the existing CEC structures. The time-consuming practice of setting up and doing CEC may be one reason contributing to the relative scarcity of literature on CEC. In the multidisciplinary field of clinical ethics it seems also a task on its own to describe one’s CEC activities in a way that is accessible and intelligible to others. This may be even more valid for CEC structures which seem to be somewhat intermediate between the realm of philosophical ethical reflection and the world of busy clinical practice.

Information about CEC with respect to its theoretical premises, methodology and the aims of CEC structures is important for a number of reasons. First of all such descriptions can facilitate the discussion of those involved in CEC and thereby stimulate our thinking about our own concepts and practice regarding CEC. Secondly, descriptions of the practice of CEC and its underlying foundations are the necessary basis for a comparative analysis. Such an analysis again may lead to the important issue of evaluation of CEC. Many CEC structures which have been implemented in recent years receive considerable funding for staff and for educational purposes and it is very likely that at some stage these services will be called upon to account for the impact they have on daily clinical practice.

The great number of CEC activities in many European countries during the last decade, the few existing possibilities to discuss the conceptual and practical aspects of this work, and the scarcity of literature, were our main reasons for organizing the conference, Clinical Ethics Consultation: Theories & Methods – Implementation – Evaluation, which took place from 11–15 February 2008 at the Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum. The main aim of the project was to provide a forum for researchers from different European countries and disciplines who are involved in CEC and to facilitate discussion on the theories and methods underlying CEC as well as the exchange of ideas regarding the issues of implementation and evaluation of CEC. This book contains a selection of presented papers. All chapters have been peer-reviewed with a focus on interdisciplinary perspectives on theoretical and practical aspects of CEC.

Part I: Theories and Methods

The appropriateness of different theories and methods is at the centre of current interdisciplinary debate on CEC. In the first section of this book philosophers and medical ethicists provide their accounts of theoretical and methodical aspects of CEC. The envisaged roles, qualifications and tasks of the clinical ethicist indicate clearly that the questions and answers on theories and methods are also relevant for the practice of CEC.

The first chapter in this section, by John-Stewart Gordon, is concerned with a particular approach to ethical problem-solving called ‘ethics as a method’. The first part contains an analysis of three ethical approaches – principle ethics, casuistry, and mid-level ethical theories – with regard to their strengths and weaknesses concerning CEC. The second part provides an account of a dynamic method of ethical decision-making, which generally appeals to Aristotle’s concept of ethical reasoning and presents a brief framework on ethical decision-making in CEC. The third part deals with the appropriate role of an ethicist in the context of CEC.

Uwe Fahr and Markus Rothhaar argue in Chapter 3 that empirical research is important for the development of ethics consultation, but it also poses a challenge. In their chapter, they present different conceptual constellations based on different models of the relationship of ethics and empiricism in medicine and bioethics. By means of conceptual analysis they explore the significance of empirical social research for ethics consultation and its future development. The authors come to the conclusion that social science research and approaches which form the basis for norms must be separated. They must be converged within the context of inter- and trans-disciplinary research, in order to enable studies on clinical ethics consultation. In particular, the development of suitable evaluation instruments and their requirements presupposes the development of philosophical social science models of consultation.

In Chapter 4 Guy Widdershoven and Bert Molewijk claim that clinical ethics has been developed, not as a theoretical endeavour, but as a practical process of dealing with ethical issues in health care, engaging practitioners in adopting new views and vocabularies. However, according to them, it is possible, and necessary, to reflect on the foundations of clinical ethics from a philosophical point of view. Based on the conceptual foundation and their longstanding experience with CEC in practice they reflect on clinical ethics from a hermeneutic perspective. Philosophical hermeneutics stresses that ethics is a form of practical understanding. This ideally takes place in a dialogue in which experiences are exchanged and perspectives merged. Moral deliberation is presented as an example of clinical ethics as dialogue and presupposes that the participants have moral knowledge, and aims to develop this knowledge further. According to hermeneutic philosophy, the ethicist should act as a facilitator, fostering the process of moral deliberation. However, according to their view, hermeneutic philosophy does not provide a set of instructions for clinical ethics; it rather explains what the practice of clinical ethics is about. It helps ethicists and other participants in practice to focus on practical experiences as a source for moral inquiry.

Uwe Fahr argues in Chapter 5 that by using the theory of discourse ethics one can better understand what ethics consultation is about. Discourse ethics is able to explain the ethical foundation of ethics consultation. It shows that one has to differentiate between practical discourse and ethical theory. It may be that the arguments of discourse ethics, trying to make plausible that ethics has a cognitive basis, are untrue. Nonetheless, if one accepts the claim that ethics has a cognitive basis, one can, according to Fahr, use the difference between ethical discourse and ethical theory to claim that one does not need an ethical theory in order to structure one’s method in case deliberation. Using the complex justification model of discourse ethics, Fahr’s aim is to argue that the main point in establishing ethics consultation and practical discourses is to institutionalize them. If they are established according to the contra-factual presuppositions inherent in the communication community it becomes more probable that agreement about general norms can be reached.

László Kovács, in Chapter 6, makes the case that conscience is a fundamental point of reference even though it is little understood in clinical ethics. Using conscience in moral decision-making is the subject of much debate. Some ethicists suggest unifying medical services by establishing treatment standards, pushing the fallible conscience into the role of personal opinion. Others insist upon the beneficial role of conscience in moral decision-making. Such controversies focus mainly on the content of professional conscience and neglect the dynamics of it. In Kovács’ view, CEC is challenging to the use of conscience by its very existence, but depending on the way of implementation and the basic attitudes of ethics consultants it can also improve physicians’ professional commitment. CEC should not be seen as a ‘better alternative’ than conscience to solving moral discrepancies, but as a means to strengthen the medical professional’s conscience for clinical decision-making.

Christiane Stüber, in Chapter 7, examines the professional ethics of health care professionals and their relationships of trust with patients in German hospitals through the lens of moral philosophy. After discussing two contemporary theories of trust, the concept of the ‘decent agent’ is introduced to explore to what extent medical staff can reasonably be expected to comply with professional norms. Stüber argues that CEC can provide an appropriate setting for medical staff to reflect upon the contents of traditional professional norms and their contemporary relevance for good patient care. CEC will have a positive effect on the maintenance of hospital patients’ trust in medical staff, and will strengthen professionals’ confidence in their own capacity to live up to professional norms.

Part II: Implementation

Setting up CEC structures in health care institutions is not an easy task. On this background the second section of this book not only provides insight in experiences of ethics consultants from five different countries but also touches on the important question of factors which positively support the process of implementation of CEC structures on different levels.

In Chapter 8, Jochen Vollmann provides an overview of factors relevant to the process of implementation of CEC. Based on his longstanding practical experience as a clinical ethics consultant and on his own research, Vollmann focuses on the interplay between the level of clinical case analysis and the organizational level. To make CEC a lively, accepted and valuable contribution, the so-called ‘bottom-up’ and ‘top-down’ approaches should both be present in institutions in which CEC structures are set up. In addition it is necessary to define the aims of CEC for each institution to make sure that the implemented CEC structure is sufficiently specific for the respective purpose and mission. As pointed out by the author the implementation of CEC is also affected by the political and societal contexts – an aspect which is illustrated by the development of CEC structures in the so-called ‘transitional countries’ of Eastern Europe.

Beate Herrmann, in Chapter 9, claims that in the context of clinical ethics consultation, the primary task of the consultant is often seen as moderating and mediating the communication between different agents in order to facilitate discussion and to achieve a consensus. Against this widely held position, it is argued that the term ‘ethics consultancy’ refers to the fact that it is not simply a question of those involved reaching a general consensus about further action or about one particular course of action. Rather, this consensus should be ‘ethically qualified’ in a more closely defined sense. Herrmann gives a definition of the ethical expertise of the moral philosopher in the context of clinical ethics consultation. Therefore, she outlines a typology of competences and presents their usefulness for the consultation processes. In this regard the relationship of ethical expertise and moral judgement will be examined in detail.

In her chapter, Nunziata Comoretto stresses that CEC is still a new phenomenon in Italy. However, the Institute of Bioethics of the Catholic University of the Sacred Heart is the oldest such institute within a medical school in Italy. It performs CECs at a tertiary-care academic centre in Rome. Since the beginning of the consulting activity, defining a decision-making approach for CEC has been one of the most important problems to solve. Their methodology can be labelled as a casuistic approach, supported by a person-centred ethical theory. According to their experience, ethical theory has a key role in solving clinical ethics problems, as a framework to provide the appropriate description of an action. Ethical theory is also a common starting point to explain the source of moral disagreement and almost always to resolve the dispute. The main hypothesis is that decision-making in clinical ethics could be better achieved not merely by applying a methodology, but by developing ethical virtues, especially the virtue of prudence. Further, ethical decision-making in the clinical context cannot be independent of a strong physician-patient relationship, which is based on mutual trust. In that perspective, ethical theory, according to her view, gives a strong foundation to ethical action, and the philosophy of medicine to relational ethics.

Nino Chikhladze and Nato Pitskhelauri present the first of two case studies on CEC implementation in the above-mentioned ‘transitional countries’. They describe developments at the macro level, such as the establishment of the National Council on Bioethics, as well as legal developments related to the establishment of clinical ethics committees. Despite these changes with respect to the framework, the authors observe little implementation of CEC structures in Georgia. Lack of information about patients’ rights and scarce opportunities for training in medical ethics for health care professionals are among a number of factors cited by the authors as possible explanations for the discrepancy between the perceived need for CEC and the limited number of activities in the field so far.

Ana Borovecki’s is the second case study from Eastern Europe. Borovecki deals with the need for CEC as it has been described in the literature and the challenges with respect to the implementation of the respective structures. In her analysis Borovecki describes the loss of trust in medical practice, corruption and low educational levels of patients as characteristics of a society in which the implementation of CEC may be nothing more than ‘a tool for alibi ethics or a tool for crisis management’. As a measure of preventive ethics the potential challenges to CEC are explored and possible strategies for the implementation of CEC are described.

Margreet Stolper et al. have developed a range of CEC initiatives in different clinical settings. In contrast to the situation of the ‘transitional countries’, the implementation of CEC has a rather long tradition in the Netherlands. However, the authors describe their concept of moral case deliberation. The method is characterized by a systematic reflection on moral questions generated in clinical practice in order to increase the moral competency of health care professionals. The training of moral case deliberation facilitators as well as aspects of organizational challenges are at the centre of this case study.

Daniel Strech argues that the topic of allocation of resources should have a place in the field of CEC. Following a summary of empirical research on the practice of bedside rationing in various countries the author suggests that CEC as a transparent and structured approach to resource allocation may support clinicians who are confronted with these tough decisions. Following this line of argument, Strech presents a framework ‘clinical ethics consultation and bedside rationing’ which focuses on the possible tasks for CEC in the context of scarce resources at the hospital level.

Part III: Evaluation of Clinical Ethics Consultation

In many cases the demand for implementation of CEC structures has been accompanied by a call for evaluation of these interventions. The final section of this book presents original work and a systematic review on evaluation of CEC. The methodical challenges related to the evaluation of an ethical intervention and possible approaches to handle normative and empirical challenges form part of all contributions in this section.

Silviya Aleksandrova examines the evaluation of physicians’ experiences with CEC structures. In her report of a cross-sectional survey conducted in four hospitals in Bulgaria, Aleksandrova presents findings on the current practice of physicians’ decision-making with respect to ethical challenges. In addition to this valuable information, which may serve as a baseline for the potential contribution of CEC with respect to decision-making in clinical practice, the study gives a picture of physicians’ expectations regarding the competences of clinical ethics consultants.

Georg Bollig examines the ethical challenges in nursing homes as well as the strategies used to deal with these issues in Norway. In general, eliciting information about the practice in a particular field is a prerequisite when planning an evaluation study. This is particularly true if the field is rather new as is the case for CEC in nursing homes. Based on his research, Bollig distinguishes ‘everyday ethical issues’ (e.g., eliciting informed consent) and ‘big ethical issues’ such as end-of-life decisions. The author suggests the implementation of ‘ethics peer groups’ as well as external ethics consultation to facilitate minor and major ethical conflicts in nursing homes.

Jan Schildmann and Jochen Vollman provide an overview on methodological aspects of the evaluation of CEC. The authors point out that many evaluation studies provide little information on common quality criteria of empirical research such as validity or reliability of the measurement instruments used to determine the outcomes of CEC. In addition the chapter explores conceptual difficulties with respect to the use of outcome criteria in quantitative studies. These studies are designed to provide generalizable data on the impact of CEC, an intervention that deals with highly individual and context-sensitive aspects of clinical practice. The a...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• List of Tables and Figure
• List of Contributors
• 1 Introduction
• PART I THEORIES AND METHODS
• PART II IMPLEMENTATION
• PART III EVALUATION OF CLINICAL ETHICS CONSULTATION
• Index