A traditional approach to teaching medical ethics aims to provide knowledge about ethics. This is in line with an epistemological view on ethics in which moral expertise is assumed to be located in theoretical knowledge and not in the moral experience of healthcare professionals. The aim of this paper is to present an alternative, contextual approach to teaching ethics, which is grounded in a pragmatic-hermeneutical and dialogical ethics. This approach is called moral case deliberation. Within moral case deliberation, healthcare professionals (...) bring in their actual moral questions during a structured dialogue. The ethicist facilitates the learning process by using various conversation methods in order to find answers to the case and to develop moral competencies. The case deliberations are not unique events, but are a structural part of the professional training on the work floor within healthcare institutions. This article presents the underlying theory on ethics and illustrates this approach with an example of a moral case deliberation project in a Dutch psychiatric hospital. The project was evaluated using the method of responsive evaluation. This method provided us with rich information about the implementation process and effects the research process itself also lent support to the process of implementation. (shrink)

The notion that it is useful to specify norms progressively in order to resolve doubts about what to do, which I developed initially in a 1990 article, has been only partly assimilated by the bioethics literature. The thought is not just that it is helpful to work with relatively specific norms. It is more than that: specification can replace deductive subsumption and balancing. Here I argue against two versions of reliance on balancing that are prominent in recent bioethical discussions. Without (...) meaning to address the substance or the overall merits of either view I criticize, I attack Gert, Culver and Clouser's implicit reliance on some overall dimension of balancing as a basis of resolving conflicts among norms and Beauchamp and Childress's residual acceptance of 'justified balancing'. The former authors' description of resolving conflicts depends upon a type of value commensurability that (as they otherwise seem to admit) does not obtain, while the latter authors' role for justified balancing would be better served by continued specification. (shrink)

Approaches to clinical ethics dilemmas that rely on basic principles or rules are difficult to apply because of vagueness and conflict among basic values. In response, casuistry rejects the use of basic values, and specification produces a large set of specified rules that are presumably easily applicable. Balancing is a method employed to weigh the relative importance of different and conflicting values in application. We argue against casuistry and specification, claiming that balancing is superior partly because it most clearly exhibits (...) the reasoning behind moral decision-making. Hence, balancing may be most effective in teaching bioethics to medical professionals. (shrink)

In 1982, Jonsen, Siegler and Winslade published Clinical Ethics, in which they described the “four quadrants” approach, a new method of analysing clinical ethics cases. Although the book is now in its 6th edition, a literature search has revealed only one academic paper demonstrating the method at work. This paper is an attempt to start filling this gap. As a way of describing and testing the approach, I apply the four quadrants method to a detailed clinical ethics case. The analysis (...) is interspersed with reflections on the method itself. It is hoped that this experiment will encourage ethicists and clinicians to devote more attention to this neglected approach. (shrink)

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

While much attention has been given to the use of principles in biomedical ethics and increasing attention is given to alternative theoretical approaches, relatively little attention has been devoted to the critical task of how one resolves conflicts among competing principles. After summarizing the system of principles and some problems in conceptualizing the principles, several strategies for reconciling conflicts among principles are examined including the use of single-principle theories (pure libertarianism, pure utilitarianism, and pure Hippocratism), balancing theories, conflicting appeals theories, (...) and lexical ordering. Then a mixed strategy is proposed in which consequentialist principles are balanced between themselves as are nonconsequentialist principles, after which the result of balancing the nonconsequentialist principles is lexically ranked over the result of balancing the consequentialist ones. Finally, strategies involving specifying and rule generation are discussed concluding that most current specification and rule-generating theories must involve some degree of lexical ordering of principles. (shrink)

Background: Clinical ethics consultation services have been established in many countries during recent decades. An important task is to discuss concrete clinical cases. However, empirical research observing what is happening during such deliberations is scarce. Objectives: To explore clinical ethics committees’ deliberations and to identify areas for improvement. Design: A pilot study including observations of committees deliberating a paper case, semistructured group interviews, and qualitative analysis of the data. Participants: Nine hospital ethics committees in Norway. Results and interpretations: Key elements (...) of the deliberations included identifying the ethical problems; exploring moral values and principles; clarifying key concepts and relevant legal regulation; exploring medical facts, the patient’s situation, the therapists’ perspective, analogous clinical situations, professional uncertainties, the patient’s and relatives’ perspective, and clinical communication; identifying the involved parties and how to involve them; identifying possible courses of action, and possible conclusion and follow-up. The various elements were closely interwoven. The content and conclusions varied and seemed to be contingent on the committee members’ interpretations, experience and knowledge. Important aspects of a clinical ethics deliberation were sometimes neglected. When the committees used a deliberation procedure and a blackboard, the deliberations tended to become more systematic and transparent. Many of the committees were insecure about how to include the involved parties and how to document the deliberations. Conclusion: Clinical ethics committees may provide an important arena for multidisciplinary discussions of complex clinical ethics challenges. However, this seems to require adequate composition, adoption of transparent deliberation procedures, and targeted training. (shrink)