BackgroundAs moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research.MethodsA multiple-case study was conducted in a care organization for people with (...) intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level.ResultsAccording to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up.ConclusionsConcretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences. (shrink)

Zusammenfassung Krankenhäuser müssen sich an der ethischen Qualität ihrer Versorgung messen lassen. Es geht dabei um einen Zustand, in dem allgemein anerkannte moralische Normen in der Patient:innenversorgung konsequent berücksichtigt werden. Damit sind zwei Ebenen angesprochen: die der ethisch-normativen Deutung und die der Gestaltung intra- und interpersonaler Prozesse. Die Klinische Ethik ist die Disziplin, die in der Verbindung beider ihre zentrale Aufgabe sieht. Um sie zu erfüllen, muss Ethikarbeit auf der Basis komplexer Kompetenzen erfolgen. Neben fundiertem Ethikwissen ist das Beherrschen von (...) geeigneten Methoden für die Steuerung solcher Prozesse eine unabdingbare Voraussetzung. Dazu aber ist die Studienlage vergleichsweise dünn. Die vorliegende Arbeit greift dieses Desiderat auf und geht dabei von der Hypothese aus, dass die Systemik einen wichtigen Beitrag zu einer im obigen Sinne effektiven Ethikarbeit leisten kann. Die Darstellung gibt einen Einblick in das systemische Denken und diskutiert die Möglichkeiten, die systemisches Handwerkszeug für die Herausforderungen der Klinischen Ethik bereithält. Die Ausführungen laden dazu ein, über den Einfluss systemischer Grundannahmen und Methoden auf die Gestaltung einer effektiven Ethikarbeit nachzudenken. Darüber hinaus ruft dieser Beitrag dazu auf, die Beratungsmethodik als solche mehr in den Fokus zu rücken. (shrink)

In their recent work, Kok et al propose a theoretical framework for the evaluation of clinical ethical case interventions, in particular moral case deliberation (MCD).1 According to the authors, this framework provides ‘empirically accessible hypothesis that describe the relationship between MCD and care quality at the organisational level’.1 Evaluation of ethical interventions in healthcare is an important topic. As Donabedian has noted, evaluation can be understood as defining reasonable quality expectations and to check by means of empirical research whether and (...) to what extent these expectations have been met.2 If suitable for ethical interventions like MCDs, the carefully compiled framework by Kok et al would surely present a major step towards satisfying the requirements outlined by Donabedian. However, caution is in order whether this holds true. The authors start by observing that most of the recent research regarding the evaluation of MCD tends to follow a paradigm that can be outlined by two premises. First, focusing on quality is justified by the need to provide a rationale for an intervention’s consumption of resources.3 Second, this implies research that is usually centred around the quality …. (shrink)

Definition of the problemQuality of care also includes a professional approach to ethical challenges. This involves the moral interpretation of an issue and the management of intra- and interpersonal reflection processes. Combining both is the central task of clinical ethics consultation (CEC). Despite its importance only a few studies have dealt with the appropriate methods for steering reflection processes.ArgumentsCEC requires a theory-based and methodological approach. The argumentation shows the effects that systems theory and systemic methods have on the effectiveness of (...) CEC. The main methods such as clarification of mandates and handling complexity are presented, and their impact on dealing with ethical challenges is shown through the discussion of two cases.ConclusionThe paper provides insight into systems thinking. It discusses the influence that systemic tools have on dealing with typical challenges within clinical ethics counselling. It also shows how specific counselling methods impact a normative level. (shrink)

Measuring outcomes using quantitative analytic methods is the hallmark of scientific research in healthcare. For clinical ethics support services (CESS), tangible outcome metrics are lacking and literature examining CESS quality is limited to evaluation of single cases or the influence on individual healthcare professional’s perceptions or behaviour. This represents an enormous barrier to implementing and evaluating ethics initiatives to improve quality. In this context, Kok _et al_ propose a theoretical framework for how moral case deliberation (MCD) can drive quality at (...) an organisational-level, termed _morisprudence_ 1. By offering mechanistic insights into how MCD can lead to organisational learning and quality improvement (QI), they provide a roadmap for actionable items to measure quality. As conceptualised, _morisprudence_ follows accumulation of organisational practical wisdom from a repertoire of ‘paradigmatic’ MCDs, aiding identification of patterns of morally important features. Here, there are parallels between healthcare professionals’ clinical judgement, where past experience... (shrink)

There is a claim that clinical ethics support services (CESS) improve healthcare quality within healthcare organisations. However, there is lack of strong evidence supporting this claim. Rather, the current focus is on the quality of CESS themselves or on individual learning outcomes. In response, this article proposes a theoretical framework leading to empirical hypotheses that describe the relationship between a specific type of CESS, moral case deliberation and the quality of care at the organisational level. We combine insights from the (...) literature on CESS, organisational learning and quality improvement and argue that moral case deliberation causes healthcare professionals to acquire practical wisdom. At the organisational level, where improving quality is a continuous and collective endeavour, this practical wisdom can be aggregated into morisprudence, which is an ongoing formulation of moral judgements across cases encountered within the organisation. Focusing on the development of morisprudence enables refined scrutinisation of CESS-related quality claims. (shrink)

In their national follow-up study on ethics consultation in the U.S., Fox et al. report the worrying finding of a decline in efforts to evaluate ECs. Compared to the findings of Fox et...