This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they (...) are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a “bottom-up” perspective might give healthcare personnel opportunities to think and reflect more than a “top-down” perspective. A “bottom-up” approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a “top-down” approach risks removing such moral responsibility. (shrink)

Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The (...) aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers’ experiences and perceived importance of outcomes of Moral Case Deliberation. (shrink)

Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Most participants report (...) positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices. (shrink)

Background: Moral Case Deliberation is one form of clinical ethics support described as a facilitator-led collective moral reasoning by healthcare professionals on a concrete moral question connected to their practice. Evaluation research is needed, but, as human interaction is difficult to standardise, there is a need to capture the content beyond moral reasoning. This allows for a better understanding of Moral Case Deliberation, which may contribute to further development of valid outcome criteria and stimulate the normative discussion of what Moral (...) Case Deliberation should contain. Objective: To explore and compare the content beyond moral reasoning in the dialogue in Moral Case Deliberation at Swedish workplaces. Methods: A mixed-methods approach was applied for analysing audio-recordings of 70 periodic Moral Case Deliberation meetings at 10 Swedish workplaces. Moral Case Deliberation facilitators and various healthcare professions participated, with registered nurses comprising the majority. Ethical considerations: No objection to the study was made by an Ethical Review Board. After oral and written information was provided, consent to be recorded was assumed by virtue of participation. Findings: Other than ‘moral reasoning’ (median (md): 45% of the spoken time), the Moral Case Deliberations consisted of ‘reflections on the psychosocial work environment’ to a varying extent (md: 29%). Additional content comprised ‘assumptions about the patient’s psychosocial situation’ (md: 6%), ‘facts about the patient’s situation’ (md: 5%), ‘concrete problem-solving’ (md: 6%) and ‘process’ (md: 3%). Conclusion: The findings suggest that a restorative function of staff’s wellbeing in Moral Case Deliberation is needed, as this might contribute to good patient care. This supports outcome criteria of improved emotional support, which may include relief of moral distress. However, facilitators need a strategy for how to proceed from the participants’ own emotional needs and to develop the use of their emotional knowing to focus on the ethically difficult patient situation. (shrink)

The attention for Moral case deliberation has increased over the past years. Previous research on MCD is often written from the perspective of MCD experts or MCD participants and we lack a more distant view to the role of MCD in Dutch health care institutions in general. The purpose of this paper is to provide an overview of the state of the art concerning MCD in the Netherlands. As part of a larger national study on clinical ethics support in the (...) Netherlands, we will focus on the prevalence and characteristics of MCD in Dutch health. A mixed methods design was used in which we combined two survey questionnaires, two focus groups and 17 individual interviews with top managers or ethics support staff. The findings demonstrate that the prevalence of MCD is relatively high in Dutch health care, especially in mental health care. Institutions with MCD differ from institutions without MCD concerning size, kind of problems and importance of ideological background. Characteristic of MCD is that it often exists for 3 years or more, has a high participation of health professionals and middle managers and is both organized scheduled as unscheduled. As well integration in existing policy as key persons emerge as important issues in relation to the positioning of MCD. We conclude that MCD is a part of an integrated ethics policy and serves as a catalyst for such an integrated ethics policy. (shrink)

In Moral Case Deliberation, healthcare professionals discuss ethically difficult patient situations in their daily practice. There is a lack of knowledge regarding the content of MCD and there is a need to shed light on this ethical reflection in the midst of clinical practice. Thus, the aim of the study was to describe the content of healthcare professionals’ moral reasoning during MCD. The design was qualitative and descriptive, and data consisted of 22 audio-recorded inter-professional MCDs, analysed with content analysis. The (...) moral reasoning centred on how to strike the balance between personal convictions about what constitutes good care, and the perceived dissonant care preferences held by the patient. The healthcare professionals deliberated about good care in relation to demands considered to be unrealistic, justifications for influencing the patient, the incapacitated patient’s nebulous interests, and coping with the conflict between using coercion to achieve good while protecting human dignity. Furthermore, as a basis for the reasoning, the healthcare professionals reflected on how to establish a responsible relationship with the vulnerable person. This comprised acknowledging the patient as a susceptible human being, protecting dignity and integrity, defining their own moral responsibility, and having patience to give the patient and family time to come to terms with illness and declining health. The profound struggle to respect the patient’s autonomy in clinical practice can be understood through the concept of relational autonomy, to try to secure both patients’ influence and at the same time take responsibility for their needs as vulnerable humans. (shrink)

Next SectionObjective The purpose of this article is to investigate the need for ethics support in Dutch healthcare institutions in order to understand why ethics support is often not used in practice and which factors are relevant in this context. Methods This study had a mixed methods design integrating quantitative and qualitative research methods. Two survey questionnaires, two focus groups and 17 interviews were conducted among board members and ethics support staff in Dutch healthcare institutions. Findings Most respondents see a (...) need for ethics support. This need is related to the complexity of contemporary healthcare, the contribution of ethics support to the core business of the organisation and to the surplus value of paying structural attention to ethical issues. The need for ethics support is, however, not unconditional. Reasons for a lacking need include: aversion of innovations, negative associations with the notion of ethics support service, and organisational factors like resources and setting. Conclusion There is a conditioned need for ethics support in Dutch healthcare institutions. The promotion of ethics support in healthcare can be fostered by focusing on formats which fit the needs of (practitioners in) healthcare institutions. The emphasis should be on creating a (culture of) dialogue about the complex situations which emerge daily in contemporary healthcare practice. (shrink)

Ethics consultation in institutions of the healthcare system has been given a standard form based on three pillars: education, the development of guidelines and concrete ethics consultation in case conferences. The spread of ethics committees, which perform these tasks on an organizational level, is a remarkable historic achievement. At the same time it cannot be denied that modern ethics consultation neglects relevant aspects of care ethics approaches. In our essay we present an “ethics of care” approach as well as an (...) empirical pilot project—“Ethics from the bottom up”—which organizes ethics consultation based on this focus. Findings and philosophy of the project will be discussed as far as relevant for ethics consultation in the healthcare system. (shrink)

Teaching responsible conduct of research (RCR) to PhD students is crucial for fostering responsible research practice. In this paper, we show how the use of Moral Case Deliberation—a case reflection method used in the Amsterdam UMC RCR PhD course—is particularity valuable to address three goals of RCR education: (1) making students aware of, and internalize, RCR principles and values, (2) supporting reflection on good conduct in personal daily practice, and (3) developing students’ dialogical attitude and skills so that they can (...) deliberate on RCR issues when they arise. What makes this method relevant for RCR education is the focus on values and personal motivations, the structured reflection on real experiences and dilemmas and the cultivation of participants’ dialogical skills. During these structured conversations, students reflect on the personal motives that drive them to adhere to the principles of good science, thereby building connections between those principles and their personal values and motives. Moreover, by exploring personal questions and dilemmas related to RCR, they learn how to address these with colleagues and supervisors. The reflection on personal experiences with RCR issues and questions combined with the study of relevant normative frameworks, support students to act responsibly and to pursue RCR in their day-to-day research practice in spite of difficulties and external constraints. (shrink)

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as (...) such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience. (shrink)

In healthcare practice, care providers are confronted with tragic situations, in which they are expected to make choices and decisions that can have far-reaching consequences. This article investigates the role of moral case deliberation in dealing with tragic situations. It focuses on experiences of care givers involved in the treatment of a pregnant woman with a brain tumour, and their evaluation of a series of MCD meetings in which the dilemmas around care were discussed. The study was qualitative, focusing on (...) the views and experiences of the participants. A case study design is used by conducting semi-structured interviews with health care professionals who both played a role in the treatment of the patient and attended the MCD. The results show that MCD helps people to deal with tragic situations. An important element of MCD in this respect is making explicit the dilemma and the damage, demonstrating that there is no simple solution. MCD prompts participants to formulate and share personal experiences with one another and thus helps to create a shared perception of the situation as tragic. The article concludes that MCD contributes to the sharing of tragic experiences, and fosters mutual interaction during a tragedy. Its value could be increased through explicit reflection on the aspect of contingency that characterises tragedy. (shrink)

The role of religion in clinical ethics consultations is contested. The religion of the ethics consultant _can be_ an important part of the consultation process and improve the quality of a consultation. Practicing neighbor love leads to empathy, which not only can improve the quality of ethics consultations but also creates a space for religion to be part of, but not imposed on, the consultation. The practice of empathy will build trust, rapport, and an intersubjective connection that improves the quality (...) of the consultation. (The views expressed are the author’s and not representative of any institution or employer). (shrink)

Background With the increasing ethical challenges and dilemmas faced by nurses due to various disasters such as COVID-19 worldwide, there is a need for a new public health ethics education curriculum to strengthen competencies for ethical responses in the nursing field. Objectives This study was aimed to identify the impact of a teaching method utilizing news articles and panel discussion material in the public health ethics education program on nursing students’ thinking regarding ethical issues. Design This was an exploratory study (...) to identify the thinking styles inherent in ethical reflection by analyzing the reflection contents written by nursing students using text mining techniques. Participants 73 among the students taking a nursing ethics course at a university in Seoul, South Korea, voluntarily participated in this study after providing informed consent. Methods The public health ethics program was conducted with sessions held once a week for a total of 7 weeks, and reflections written by nursing students were collected as text files during session 5 to 7. In this study, data preprocessing process, keyword analysis, and LDA topic modeling were sequentially conducted utilizing the R program according to the data analysis procedure of text mining techniques. Ethical considerations This study was conducted under ethics approval from the institution where participants were recruited. Findings and discussion The results of this study show that the teaching method utilizing news articles enhanced rational ethical deliberation from the cognitive aspect, whereas the teaching method utilizing panel discussion material strengthened the response to emotions on a more internal level. Conclusions The teaching method utilizing news articles and panel discussion materials in public health ethics education is expected to be mutually complementary and effective, so further studies are recommended. (shrink)

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly—often with lingering effects such as healthcare providers’ disengagement and moral distress (McAndrew et al. Journal of (...) Trauma Nursing 18(4):221–230, 2011), compromised inter-professional relationships (Rosenstein and O’Daniel American Journal of Nursing, 105(1):54–64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1–11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486–490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results. (shrink)