In spite of an intensive discussion of ethical subjects, psychiatric departments rarely request clinical ethics support. However, during regular psychological supervisions subjects with an underlying ethical conflict are increasingly encountered. Based on the case study of a 39-year-old female patient suffering from personality disorder and her newborn child, the role of ethical consultation in psychiatric treatment and the decision making regarding health and welfare of child and mother will be presented. While discussing opportunities and limitations of psychological supervision as a (...) possible vehicle for clinical ethics support, it becomes obvious that during psychological supervision, ethical conflicts can also be reflected and treatment alternatives be evaluated. Psychological supervision finds its limits because of its more intuitive processes when the conflict escalates, when the patient cannot be involved and when institutional interests dominate. In these cases, the more structured and formalised process of clinical ethics consultation clearly offers advantages. (shrink)

Research in the field of Empirical Ethics (EE) uses a broad variety of empirical methodologies, such as surveys, interviews and observation, developed in disciplines such as sociology, anthropology, and psychology. Whereas these empirical disciplines see themselves as purely descriptive, EE also aims at normative reflection. Currently there is literature about the quality of empirical research in ethics, but little or no reflection on specific methodological aspects that must be considered when conducting interdisciplinary empirical ethics. Furthermore, poor methodology in an EE (...) study results in misleading ethical analyses, evaluations or recommendations. This not only deprives the study of scientific and social value, but also risks ethical misjudgement. (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)

An ethics reflection group is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of (...) 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services. (shrink)

In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?

Eine patientengerechte Versorgung ist ein hohes Ziel. Unangemessene Behandlung wie Unter- oder Überversorgung zu erkennen und zu vermeiden, stellt Ärztinnen/Ärzte und Pflegende am Krankenbett vor schwierige Entscheidungen. Hier ist die Entwicklung von praxistauglichen Orientierungshilfen angezeigt, die wissenschaftlichen Kriterien genügen und nicht allein auf Konsens beruhen. Die vorliegende Arbeit versucht, zentrale Normen zur Vermeidung von Über- und Unterversorgung zu formulieren und theoretisch zu fundieren. Dafür wird auf Basis einer Interessen-basierten Ethik eine Graduierung der Autonomie vorgenommen, indem zwischen schwacher und starker Autonomie (...) unterschieden wird. (shrink)

Moral Case Deliberations are reflective dialogues with a group of participants on their own moral dilemmas. Although MCD is successful as clinical ethics support, it also has limitations. 1. Lessons learned from individual MCDs are not shared in order to be used in other contexts 2. Moral learning stays limited to the participants of the MCD; 3. MCD requires quite some organisational effort, 4. MCD deals with one individual concrete case. It does not address other, similar cases. These limitations warrant (...) research into complementary ways of providing CES to healthcare professionals. Our research objective was therefore to develop a low threshold CES tool based on a series of MCDs on autonomy in long-term care. We used a qualitative research design in which we analyzed the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. In total 28 MCDs were analyzed by means of a thematic content analysis. In various rounds of development, the results of the analysis were combined with theoretical reflections on CES. Consequently, the tool was evaluated in three focus groups and adjusted. The CES tool, called ‘moral compass’, guides the users through a series of six subsequent questions in order to methodically reflect on their concrete moral dilemma, in the form of a booklet of 23 pages. It combines a methodical element that encourages and structures a reflection process with a substantive element, including norms, values, options, strategies, and insights regarding dealing with client autonomy. By using data from a series of MCDs, combined with theoretical reflections on MCD, ethics support and moral learning, we developed a thematic, low-threshold CES tool that supports healthcare professionals in daily practice in dealing with moral questions regarding client autonomy. It integrates examples and insights from earlier MCDs on the same topic. The moral compass is not a replacement of, but can be used complementary to MCD. The feasibility and impact of the moral compass need to be investigated in an evaluative follow-up study. The methodology presented in this paper may be used to develop moral compasses on different topics in various healthcare organizations. (shrink)

Internationally, the prevalence of clinical ethics support (CES) in health care has increased over the years. Previous research on CES focused primarily on ethics committees and ethics consultation, mostly within the context of hospital care. The purpose of this article is to investigate the prevalence of different kinds of CES in various Dutch health care domains, including hospital care, mental health care, elderly care and care for people with an intellectual disability. A mixed methods design was used including two survey (...) questionnaires, sent to all health care institutions, two focus groups and 17 interviews with managing directors or ethics support staff. The findings demonstrate that the presence of ethics committees is relatively high, especially in hospitals. Moral case deliberation (MCD) is available in about half of all Dutch health care institutions, and in two-thirds of the mental health care institutions. Ethics consultants are not very prominent. A distinction is made between explicit CES forms, in which the ethical dimension of care is structurally and professionally addressed and implicit CES forms, in which ethical issues are handled indirectly and in an organic way. Explicit CES forms often go together with implicit forms of CES. MCD might function as a bridge between the two. We conclude that explicit and implicit CES are both relevant for clinical ethics in health care. We recommend research regarding how to combine them in an appropriate way. (shrink)

ZusammenfassungMedizinethische Entscheidungsfindungsmodelle müssen nachweisen können, weshalb die mit ihnen getroffenen Entscheidungen richtig oder zumindest „belastbar“ sind. Hierfür sind theoretische Rechtfertigungsansätze aus der Ethik unverzichtbar. Der Klinischen Ethik wird aber mitunter ein Mangel an theoretischer Fundierung vorgeworfen. Um diesem Vorwurf entgegenzutreten, soll unter Bezugnahme auf ein Projekt der Klinischen Ethik („METAP“) die ethische Unterstützung in Form der ethischen Fallbesprechung und der Ethikkonsultation mittels Prinzipienethik und Diskursethik gerechtfertigt werden. Prinzipienethik und Diskursethik können einander über das Medium der ethischen Fallbesprechung oder Ethikkonsultation fruchtbar (...) ergänzen. So können einige theoretische und praktische Schwächen der beiden Ansätze durch den jeweils anderen abgefedert werden. Die Diskursethik übernimmt bspw. die Sicherung der ethischen Gültigkeit von moralischen Entscheidungen bzw. Handlungsnormen und vermindert dadurch ein Rechtfertigungsdefizit, welches bei einem rein prinzipienorientierten Verfahren auftritt. Umgekehrt antwortet die Prinzipienethik u. a. auf Fragen der ethischen Angemessenheit und dient v. a. der adäquaten Einzelfallentscheidung. Durch die Integration des einen Ansatzes in den anderen ist eine umfassendere Rechtfertigungsleistung erzielbar als bei einem alleinigen Einsatz von Prinzipienethik oder Diskursethik. Selbst wenn einige Herausforderungen bestehen bleiben und auch das integrierte Modell moralische Dissense nicht immer verhindern kann, vermag es durch seine „doppelte“ Absicherung (Prinzipien und Diskurs) ein praktisches Vertrauen in die getroffene ethische Entscheidung zu stärken und so der Klinischen Ethik mehr „Robustheit“ zu geben, als sie bisher besitzt. (shrink)

Eine patientengerechte Versorgung ist ein hohes Ziel. Unangemessene Behandlung wie Unter- oder Überversorgung zu erkennen und zu vermeiden, stellt Ärztinnen/Ärzte und Pflegende am Krankenbett vor schwierige Entscheidungen. Hier ist die Entwicklung von praxistauglichen Orientierungshilfen angezeigt, die wissenschaftlichen Kriterien genügen und nicht allein auf Konsens beruhen. Die vorliegende Arbeit versucht, zentrale Normen zur Vermeidung von Über- und Unterversorgung zu formulieren und theoretisch zu fundieren. Dafür wird auf Basis einer Interessen-basierten Ethik eine Graduierung der Autonomie vorgenommen, indem zwischen schwacher und starker Autonomie (...) unterschieden wird. (shrink)

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We undertook a systematic review of (...) the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards. (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)

Initiating clinical ethics support in psychiatry and maintaining its continuity appear to be easy. This is contradicted by the observed delay or lack of CESiP, e.g. ethics consultation. On the basis of a published literature search and the discussion of practical experiences over 2.5 years 10 tasks and relating challenges of initiating and maintaining CESiP are formulated and illustrated by examples. Referral to experiences is grounded on the systematic documentation of ca. 100 CESiP activities. The tasks and challenges illustrate how (...) CESiP was initiated and maintained in child and adolescent, adult and forensic psychiatry. Each example is followed by a “rule of thumb” that was found useful in our centre. Discussion: Suggestions I–III are of organisational nature, IV–X have explicit ethical content concerning the ethos or professionalism of the ethics consultant and CES practice. Their realisation requires a minimum of stability of CESiP and considerable consultancy experience. (shrink)

Medizinethische Entscheidungsfindungsmodelle müssen nachweisen können, weshalb die mit ihnen getroffenen Entscheidungen richtig oder zumindest „belastbar“ sind. Hierfür sind theoretische Rechtfertigungsansätze aus der Ethik unverzichtbar. Der Klinischen Ethik wird aber mitunter ein Mangel an theoretischer Fundierung vorgeworfen. Um diesem Vorwurf entgegenzutreten, soll unter Bezugnahme auf ein Projekt der Klinischen Ethik („METAP“) die ethische Unterstützung in Form der ethischen Fallbesprechung und der Ethikkonsultation mittels Prinzipienethik und Diskursethik gerechtfertigt werden. Prinzipienethik und Diskursethik können einander über das Medium der ethischen Fallbesprechung oder Ethikkonsultation fruchtbar (...) ergänzen. So können einige theoretische und praktische Schwächen der beiden Ansätze durch den jeweils anderen abgefedert werden. Die Diskursethik übernimmt bspw. die Sicherung der ethischen Gültigkeit von moralischen Entscheidungen bzw. Handlungsnormen und vermindert dadurch ein Rechtfertigungsdefizit, welches bei einem rein prinzipienorientierten Verfahren auftritt. Umgekehrt antwortet die Prinzipienethik u. a. auf Fragen der ethischen Angemessenheit und dient v. a. der adäquaten Einzelfallentscheidung. Durch die Integration des einen Ansatzes in den anderen ist eine umfassendere Rechtfertigungsleistung erzielbar als bei einem alleinigen Einsatz von Prinzipienethik oder Diskursethik. Selbst wenn einige Herausforderungen bestehen bleiben und auch das integrierte Modell moralische Dissense nicht immer verhindern kann, vermag es durch seine „doppelte“ Absicherung (Prinzipien und Diskurs) ein praktisches Vertrauen in die getroffene ethische Entscheidung zu stärken und so der Klinischen Ethik mehr „Robustheit“ zu geben, als sie bisher besitzt. (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)

BackgroundOver the years, Bulgarian bioethics has been mainly an academic enterprise and fallen short of providing health professionals with skills for ethical decision-making. Clinical ethics support (CES) was piloted by the author through two bottom-up models – METAP (Modular, Ethical, Treatment, Allocation of resources, Process) and MCD (Moral Case Deliberation).AimsThis paper aims to present and analyse developments in the area of clinical ethics and the first experiences in CES in Bulgaria.MethodologyThe project reported here included a review of relevant literature on (...) CES methods and evaluation and a documentary review of data from two CES pilot projects: METAP and MCD.ResultsMost of the 69 METAP ethics meetings reviewed were first time meetings (88,4%); the average duration was 36 min and the average number of participants was four (44,9%). The meetings were organized in response to cases of severely or critically ill patients. The ethical dilemmas included choice of treatment (31,9%) and conflicts with the patient or their relatives (23,2%). Consensus was achieved in 34,8% of the cases. The situation was clarified with the patient (27,5%) and within the team (15,9%). The rights and obligations of both sides were discussed in 7,2% of the cases. The experience of the members of the Bulgarian Association of Bioethics and Clinical Ethics (BABCE) with MCD was also presented to justify the inference about the applicability of the two CES models in a Bulgarian context.ConclusionAmong Eastern European countries Bulgaria has made progress in CES. Both METAP and MCD have been found to be useful methods. (shrink)

Although clinical ethics consultation has existed for more than 40 years in the USA and Europe, it was not available in Bulgaria until recently. In introducing clinical ethics consultation into our country, the Modular, Ethical, Treatment, Allocation of resources, Process methodology has been preferred because of its potential to be used in resource-poor settings and its strong educational function. This paper presents the results of a METAP evaluation in a hospital palliative care ward in the town of Vratsa. The evaluation (...) was based on Beauchamp and Childress’ four principles of biomedical ethics and involves implementation of specific instruments for clinical ethics decision-making. Research tasks emphasised analyses of ethics meetings in the ward. Data were processed by SPSS v.24 using descriptive statistical analysis. Altogether, 32 ethics meetings of an average duration 20.63 min were conducted on cases involving critically ill patients. Most of the participants expressed satisfaction with the ethics process. The principlist approach supported resolution of conflicts between autonomous patients and their relatives, clarified definitions of “medical benefit” and “social good,” and enabled assessments of the risk of unequal treatment. Even as the specific research tasks were achieved, further participant follow-up is necessary to identify any improvement in healthcare personnel’s ethical competence. METAP worked well in end-of-life care settings. Participants experienced several benefits, including improved team communication, better understanding of patient preferences, and confidence in the correctness of decisions. Despite the significant educational potential of METAP, the need for additional and ongoing ethics training of health professionals should not be underestimated. (shrink)