Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such support. Physicians (...) in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (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)

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)

Dealing with soldier enhancement can be challenging for military physicians. As research on the ethics of soldier enhancement is mostly theoretical, this study aims to gain insights into the actual moral issues military physicians encounter, or expect to encounter. To that end, we carried out a qualitative study involving six focus groups of Dutch military physicians (n = 28) in operational roles. The participants voiced their concerns about moral issues concerning soldier enhancement. Based on the group discussions, and using inductive (...) thematic analysis, we ascertained three major themes: (1) Doing no harm in soldier enhancement: uncertainty and high stakes; (2) Dependency relationships and conflicting moral responsibilities; and (3) The risk of ethical slippery slopes. Our findings illustrate that dealing with these moral responsibilities requires considerable skill and acuity to weigh up for all the situated complexities and dependency relationships that go beyond abstract rules or moral principles. A care-ethical approach that acknowledges the contextual and relational aspects of moral complexities along with peer consultation and joint reflective dialogue on moral issues can help military physicians deal with soldier enhancement responsibly. (shrink)

Background The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit (...) staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. Methods A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. Results All 178 respondents (response rate: 25–32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to ‘team cooperation’, ‘team solidarity’ and ‘work ethic’. Lessons learned were mostly related to ‘quality of care’ and ‘professional qualities’. Conclusions Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals’ dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. Trial registration The trial was registered on The Netherlands Trial Register, number NL9177. (shrink)

The legalization of cannabis in Canada instantiates principles of harm-reduction and safe supply. However, in-depth understanding of values at stake and attitudes toward legalization were not part of extensive democratic deliberation. Through a qualitative exploratory study, we undertook 48 semi-structured interviews with three Canadian stakeholder groups to explore opinions and values with respect to the legalization of cannabis: (1) members of the general public, (2) people with lived experience of addiction and (3) clinicians with experience treating patients with addiction. Across (...) all groups, participants tended to be in favor of legalization, but particular opinions rested on their viewpoint as stakeholders. Clinicians considered the way legalization would affect an individual’s health and its potential for increasing rates of addiction on a larger scale. People with lived experience of addiction cited personal autonomy more than other groups and stressed the need to have access to quality information to make truly informed decisions. Alternatively, members of the public considered legalization positive or negative in light of whether one’s addiction affected others. We elaborate on and discuss how scientific evidence about drug use impact values relates and how can different arguments play in democratic debates about legalization. (shrink)

Much of what we know and see of ethics support, in literature and during trainings, workshops and conferences, derives from clinical ethicists working at academic medical centers. Besides the probl...

This study explores the impact of participation in a series of moral case deliberations (MCD) on the moral craftsmanship (MCS) of Dutch prison staff. Between 2017–2020, ten MCDs per team were implemented in three prisons (i.e., intervention group). In three other prisons (i.e., control group) no MCDs were implemented. We compared the intervention and control group using a self-developed questionnaire, administered before (pre-measurement) and after the series of MCDs (post-measurement). Results After the MCDs, participants scored significantly higher on 7 of (...) the 70 items related to MCS. On some items there were significant impact differences between the various professional disciplines. Discussion Possible explanations for a relatively low impact are discussed. A shorter and validated questionnaire is needed in order to further study the MCS of professionals and the impact of Ethics Support Services (ESS). Conclusions There was a positive development on some elements of MCS after participation in a series of MCDs. (shrink)

The prevalence of Clinical ethics support services is increasing. Yet, questions about what quality of CES entails and how to foster the quality of CES remain. This paper describes the development of a national network, which aimed to conceptualize and foster the quality of CES in the Netherlands simultaneously. Our methodology was inspired by a responsive evaluation approach which shares some of our key theoretical presuppositions of CES. A responsive evaluation methodology engages stakeholders in developing quality standards of a certain (...) practice, instead of evaluating a practice by predefined standards. In this paper, we describe the relationship between our theoretical viewpoint on CES and a responsive evaluation methodology. Then we describe the development of the network and focus on three activities that exemplify our approach. In the discussion, we reflect on the similarities and differences between our approach and other international initiatives focusing on the quality of CES. (shrink)

Background Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist (...) care providers when dealing with moral challenges around decision-making competence in transgender adolescent care. Methods The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care. Results Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. Discussion Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support. (shrink)