Mind the gap: the lack of common language in healthcare ethics

Ethics consultation services provide support to staff, patients, and family members who find themselves in morally difficult situations in healthcare settings. Not unlike other clinical consultation services, ethics consultation activities should be well documented. Good documentation allows for evaluation of the consultation process and the ability to refer back to consults when needed, and provides data for future research in healthcare ethics (HCE). In our exploration of existing HCE documentation systems, we identified two main points of interest. First, HCE information documentation systems are powerful tools for providing information on ethics consultation services.These documentation systems can be used to produce detailed reports on various HCE activities both institutionally and cross-institutionally. Second, our findings indicate greater agreement in the language and terminology of HCE needs to be established. Cultivation of such common language is needed in order to develop a standard healthcare ethicists can use to document and categorize consults. Standardization of language would allow data to be readily comparable and lead to more consistency in documentation of ethics consultations. Ultimately, standardization of documentation can also constitute a standard of practice for HCE in general.The development of such standards is essential for any developing profession, and will be required for HCE as it moves in towards professionalization in Canada.     

Certifying clinical ethics consultants: who pays?

The movement advocating the formal certification of clinical ethics consultants may result in major changes to the field of clinical ethics consultation by creating a new standard of care. The actual certification process is still in the development phase, but unanswered questions include: What will certification cost, and, Who will pay? Currently there is little salary support for ethics consultants and no regulation requiring healthcare institutions to offer clinical ethics consultation. Without the support of healthcare administrators and accreditation bodies, this may remain unchanged. Healthcare administrators may be unwilling to pay for certification or professional services if accreditation bodies do not require healthcare institutions to provide certified ethics consultants' services. If consultants will not be reimbursed or paid, they may not seek certification. If certified consultants are required, healthcare administrators may look for ways to cover the costs for providing this service, including insurance or third-party reimbursement and direct billing of patients for consultations, which may affect who performs and who participates in ethics consultation. However, this is less than ideal, as bioethicists believe ethics consultation should be available to all as part of providing safe, quality ethical care and support and guidance for patients, families, and healthcare staff. Going forward, bioethicists should study quality improvement, patient safety, and cost-savings resulting from certification-eligible clinical ethics consultants' activities. Administrators and financial personnel can be surveyed regarding their support for the certification process. Bioethicists should enlist the help of patient rights and safety advocacy groups, professional medical associations, and healthcare administrators. Bioethicists should invite accreditation bodies, healthcare administrators, and financial personnel to collaborate in the development of the certification process. Without their support, certification may be of value only to the bioethics community, and may have little standing in actual clinical healthcare institution settings.     

The Emergence of Clinical Research Ethics Consultation: Insights From a National Collaborative

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards (IRBs), to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation (REC) services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying ethical commentaries to highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research.     

New Ways of Making Babies: The Case of Egg Donation (Book)

This research was undertaken to explore audience members learning ethics from two national museum exhibitions: The Return of Sherlock Holmes (RSH) and Human Body Exploration (HBE) in Taiwan. Based on literature review of ethics for museums, there are four dimensions related to exhibition ethics: environment, marketing, education, and services. Therefore, the purpose of this research was to examine the relationships within the dimensions of environment, marketing, education, and services of exhibition ethics and to understand the differences in exhibition ethics between RSH and HBE. The total number of valid questionnaires was 191 for RSH and 152 for HBE. The research method analysis of variance was applied to examine whether there were significant differences between individual's basic data and four different dimensions of exhibition ethics in museums.

As survey data revealed, exhibition ethics had significant relationships with four dimensions (serviceability, education, environment, and marketing) and significant differences to the demographic variable, such as age. We suggest that exhibition agents should emphasize exhibition contents more than relative commodities, thereby possibly attracting audiences to visit the museum exhibitions. In addition, the exhibitions that were related to sensible issues should be divided into different levels regulated in terms of audience age and the degree to which parents, teachers, or narrators at the museum could negatively influence a younger visitor's perception of an exhibition and thereby museums. Finally, during busy periods, the museums should control visitor numbers to maintain visiting quality. Therefore, the museums should be able to create added value to attract more audience members to visit the exhibition.     

Training in clinical ethics consultation: the Washington Hospital Center course

How can one be trained to enter the evolving field of clinical ethics consultation? The classroom is not the proper place to teach clinical ethics consultation; it is best done in a clinical setting. The author maps the elements that might be included in an apprenticeship, and sets out propositions for debate regarding the training needed for clinical ethics consultants and directors of clinical ethics consultation services. I was invited to be an observer of the first Intensive Course in Clinical Ethics at the Washington Hospital Center (WHC). I had no input into the planning. Having been present at a meeting of the Clinical Ethics Consultation Affinity Group of the American Society of Bioethics and Humanities (ASBH) when the issue of a lack of training programs was discussed, I was acutely aware of the need. Knowing how popular the various four-day intensive courses in bioethics have been, held at Georgetown University first, and then in Seattle and locations in the Midwest, it seemed time to have a four-day intensive course that was devoted to clinical ethics. The differences between bioethics and clinical ethics is substantial and largely unappreciated by those in bioethics. So when the WHC team agreed to take on the task of offering an intensive in clinical ethics, it was an important step for the field.     

Political and interpersonal aspects of ethics consultation

Previous papers on ethics consultation in medicine have taken a positivistic approach and lack critical scrutiny of the psychosocial, political, and moral contexts in which consultations occur. This paper discusses some of the contextual factors that require more careful research. We need to know more about what prompts and inhibits consultation, especially what factors effectively prevent house officers and nonphysicians from requesting consultation despite perceived moral conflict in cases. The attitudes and institutional power of attending medical staff seem important, especially where innovative interventions raise ethical questions. Ethics consultants also need to address the thorny problems of the origin(s) of the consultant's authority, whistleblowing, conflicts of interest that affect the consultant, persistently poor communications in hospitals, systemic inequity in the availability or quality of services for some, and the standing of the consultant's recommendations, including their appearance in the patient's medical record.     

Ethics Consultation and Autonomy

Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons they serve. This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist.     

A systematic review of activities at a high-volume ethics consultation service

We describe the ethics consultation service (ECS) at the Cleveland Clinic and report on its activities over a 24-month period in which 478 consultations were performed.To our knowledge, this is the largest case series of ethics consultations reported to date. Established more than 25 years ago, the ECS at the Cleveland Clinic is staffed by multiple consultants with advanced training in bioethics. Several of these ethicists work closely with specialized clinical units and research departments, where they participate in multidisciplinary meetings and provide specialized assistance. This combination of historical experience, large numbers of consultation requests, and specialized clinical ethicists suggests that the experience at the Cleveland Clinic may be helpful to ethicists and others who may be considering how to structure and sustain a vibrant ECS. Our results highlight the diversity of activities performed by a high-volume ECS at a tertiary care facility. Our hope in sharing the inner workings of the ECS at the Cleveland Clinic is to promote dialogue on common practices and approaches across medical institutions that support ethics consultation.     

“The Notion of Neutrality in Clinical Ethics Consultation”

Clinical ethics consultation (CEC), as an activity that may be provided by clinical ethics committees and consultants, is nowadays a well-established practice in North America. Although it has been increasingly implemented in Europe and elsewhere, no agreement can be found among scholars and practitioners on the appropriate role or approach the consultant should play when ethically problematic cases involving conflicts and uncertainties come up. In particular, there is no consensus on the acceptability of consultants making recommendations, offering moral advice upon request, and expressing personal opinions. We translate these issues into the question of whether the consultant should be neutral when performing an ethics consultation. We argue that the notion of neutrality 1) functions as a hermeneutical key to review the history of CEC as a whole; 2) may be enlightened by a precise assessment of the nature and goals of CEC; 3) refers to the normative dimension of CEC. Here, we distinguish four different meanings of neutrality: a neutral stance toward the parties involved in clinical decision making, toward the arguments offered to frame the discussion, toward the values and norms involved in the case, and toward the outcome of decision making, that is to say the final decision and action that will be implemented. Lastly, we suggest a non-authoritarian way to intend the term “recommendation” in the context of clinical ethics consultation.     

Working with Mental Health Service Users to Change Mental Health Services

During the last ten years in the UK, service user consultation and collaboration has gradually entered the vocabulary of people providing and purchasing mental health services. However, we are not convinced that much needed change in mental health services will be achieved as a function of increased commitment to market consumerism. We argue here that service user consultation and collaboration should take account of the effects of social inequalities on mental health and on mental health services. This perspective highlights the need for fundamental change in mental health services, and helps us to appreciate the strength of resistance to change, and to understand some of the dynamics involved. We describe here how this perspective has motivated and shaped our own efforts to collaborate responsibly with service users to change mental health services.     

The personal is the organizational in the ethics of hospital social workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper, we present findings about clinical ethics from in-depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

The Personal Is the Organizational in the Ethics of Hospital Social Workers

Understanding the social context of clinical ethics is vital for making ethical discourse central in professional practice and for preventing harm. In this paper we present findings about clinical ethics from in depth interviews and consultation with 7 members of a hospital social work department. Workers gave different accounts of ethical dilemmas and resources for ethical decision making than did their managers, whereas workers and managers agreed on core-guiding ethical principles and on ideal situations for ethical discourse. We discuss the research team's initial interpretations, the relevance of the extant ethics literature to organizational structures and dynamics, and alternative perspectives on clinical ethics.     

The clinical ethicist at the bedside

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.     

Truly intensive clinical ethics immersion at the Washington Hospital Center

Opportunities for practical, hospital-based training in those skills demanded by clinical ethics consultation (CEC) have been limited. Given the number of individuals who provide part-time CEC, greater access to condensed, practical training such as the clinical ethics immersion course offered by the Washington Hospital Center, is necessary. Two participants in the initial cohort evaluate their CE training at a busy, urban referral center, exploring prior expectations, perceptions of its utility and suggestions for improvement. Such training will prove valuable not only for bioethicists who lack practical CEC experience "at the bedside" but also for ethics consultants whose ethics services have a low consult volume who wish to sharpen their skills.     

How mediation (and other) approaches may improve ethics consultants' outcomes

Articles in this issue of JCE recommend a number of approaches to clinical ethics consultation. Given these various approaches, how should ethics consultants proceed?     

Ethics Consultation Quality Assessment Tool: A Novel Method for Assessing the Quality of Ethics Case Consultations Based on Written Records

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool (ECQAT). ECQAT enables raters to assess the quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation (ethics question, consultation-specific information, ethical analysis, and conclusions and/or recommendations), established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT, the resulting product, and recommended future testing and potential uses for the tool.     

BOOK REVIEW

In this brief note, we respond to Gottlieb and Lasser's (2001/this issue) critical commentary on our work on narrative research ethics. We argue that their concern for privileging voices needs to be balanced against the risk of exploiting some research participants, that conflicts of interest are best resolved through appropriately prioritizing ethical principles and in consultation with others, and that the researcher's ability to protect participants from harm can be enhanced through appropriate clinical training and access to clinical expertise. We welcome Gottlieb and Lasser's specific recommendations for ethical practice in narrative research and encourage further ethical reflection by other researchers in this area.     

Ethics Consultant: Problem Solver or Spiritual Counselor?

The primary goal of ethics consultation should be to provide effective assistance to patients and families in obtaining care that is duly responsive to their rights and their needs. The consultation reported by Mark Bliton fails in this regard because it never ascertains why the consultation was called; makes little attempt to ascertain the motives of those involved; avoids exploration of the ethical concerns of family, attending or staff; makes no connection with institutional policies or practices; uncritically adopts and serves the medical treatment ethos; and substitutes fellowfeeling for compassionate action.