Bioethics Mediation Research Articles

Toward a new clinical pragmatism: method in clinical ethics consultation.

In this paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist's perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending on the demands of the specific case, and should avoid attempts to identify a 'true' methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism's emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism's relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation.

Conflict Management in the ICU.

To provide a concise review of data and literature pertaining to the etiologies of conflict in the ICU, as well as current approaches to conflict management. Detailed search strategy using PubMed and OVID Medline for English language articles describing conflict in the ICU as well as prevention and management strategies. Descriptive and interventional studies addressing conflict, bioethics, clinical ethics consultation, palliative care medicine, conflict management, and conflict mediation in critical care. Relevant descriptions or studies were reviewed, and the following aspects of each manuscript were identified, abstracted, and analyzed: setting, study population, aims, methods, results, and relevant implications for critical care practice and training. Conflict frequently erupts in the ICU between patients and families and care teams, as well as within and between care teams. Conflict engenders a host of untoward consequences for patients, families, clinicians, and facilities rendering abrogating conflict a key priority for all. Conflict etiologies are diverse but understood in terms of a framework of triggers. Identifying and de-escalating conflict before it become intractable is a preferred approach. Approaches to conflict management include utilizing clinical ethics consultation, and palliative care medicine clinicians. Conflict Management is a new technique that all ICU clinicians may use to identify and manage conflict. Entrenched conflict appears to benefit from Bioethics Mediation, an approach that uses a neutral, unaligned mediator to guide parties to a mutually acceptable resolution. Conflict commonly occurs in the ICU around difficult and complex decision-making. Patients, families, clinicians, and institutions suffer undesirable consequences resulting from conflict, establishing conflict prevention and resolution as key priorities. A variety of approaches may successfully identify, manage, and prevent conflict including techniques that are utilizable by all team members in support of clinical excellence.

Do we understand the intervention? What complex intervention research can teach us for the evaluation of clinical ethics support services (CESS)

BackgroundEvaluating clinical ethics support services (CESS) has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS.Main bodyIn this paper, we argue that a first necessary step for progress is to better understand the intervention(s) in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a first step, we introduce principles of “complex intervention research” and show how CESS fulfil the criteria of “complex interventions”. In a second step, we develop a generic “conceptual framework” for “ethics consultation on request” as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of “bioethics mediation” to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: “proactive ethics consultation” and “moral case deliberation” and discuss implications for evaluating both types of CESS.ConclusionTo make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer “good” CESS.

Bioethics Mediation: A Practical Approach to Physician Assistant Ethics Education.

Bioethics Mediation: A Practical Approach to Physician Assistant Ethics Education.

Bioethics Mediation in Health Care Settings: An Innovative Approach to Shaping Shared Solutions in Ethics Disputes

Bioethics Mediation in Health Care Settings: An Innovative Approach to Shaping Shared Solutions in Ethics Disputes

Conflict Resolution in the Clinical Setting: A Story Beyond Bioethics Mediation

Rarely do ethics consults focus on genuine moral puzzlement in which people collectively wonder what is the right thing to do. Far more often, consults are about conflict. Each side knows quite well what is “right.” The problem is that the other side is too blind or stubborn to recognize it. And so the ethics consultant is called, perhaps in the hope that s/he will throw the weight of ethics toward one side and end the controversy so everyone can get on with other business. Perhaps the greater problem in these scenarios is that even if one side “wins” by gaining the power to dictate what happens next, the toxicity permeating the relationships often markedly worsens and other conflicts erupt, major and minor. Accordingly, where an ethics consultant cannot or should not declare an obvious winner on substantive grounds, the challenge often becomes largely procedural: how shall the situation be addressed in a way that acknowledges the legitimacy of diverse voices and strives to preserve, perhaps even to rebuild, the relationships on which good healthcare depends? At that point thoughtful negotiation and creative problem-solving are generally preferable to entrenched combat. This is the point at which “clinical-setting mediation” or other conflict management tools, such as coaching or facilitation, might be invoked. This article focuses on mediation. This paper broadens the conversation to encompass the conflict that permeates healthcare generally. Conflict resolution skills can readily address disputes and tensions throughout healthcare and, in the process, provide a kind of preventive ethics. Part I illustrates these broader conflict resolution opportunities by describing a recent mediation regarding a difficult discharge negotiation. Part II then outlines broader opportunities for conflict resolution across the spectrum of healthcare and describes several initiatives in that direction, particularly from the legal community. Finally, Part III discusses several ways in which clinical-setting mediation, as described in this article, differs significantly from bioethics mediation as it is often described in the literature, and offers a few suggestions for ethics committees interested in providing conflict resolution services.

Identifying Sources of Clinical Conflict: A Tool for Practice and Training in Bioethics Mediation

Bioethics mediators manage a wide range of clinical conflict emanating from diverse sources. Parties to clinical conflict are often not fully aware of, nor willing to express, the true nature and scope of their conflict. As such, a significant task of the bioethics mediator is to help define that conflict. The ability to assess and apply the tools necessary for an effective mediation process can be facilitated by each mediator's creation of a personal compendium of sources that generate clinical conflict, to provide an orientation for the successful management of complex dilemmatic cases.

Mediation Training for the Physician: Expanding the Communication Toolkit to Manage Conflict

Good communication is critical to the practice of medicine. This is particularly true when outcomes are unpredictable and/or patients lack the capacity to participate in medical decision making. Disputes may develop that cannot be addressed using basic communication skills. Conflict of this nature can burden patients, families, and medical staff and may result in increased suffering for all parties. Many physicians lack the necessary communication tools to handle difficult conversations. Training in bioethics mediation provides physicians with skills that can promote healing by empowering participants to engage in effective discourse and break down barriers to find common ground. Mediation training for physicians can expand their capacity to connect with patients and enhance their ability to identify potential conflict early on, in order to collaborate more effectively. Competency in the processes of negotiation and conflict resolution should therefore be seen as essential elements of medical training.

Patient-Centered Care and the Mediator’s Skills

Bioethics mediation training offers knowledge and skills valuable for clinical ethics consultants who are engaged in high conflict situations. Furthermore, clinicians with this training can support organizational efforts to create a culture that is centered on the values, needs, and care preferences of patients and their families, rather than on those of the clinician or organization. Patient-centeredness is a hallmark of quality and an essential component for patients' safety. Clinicians with mediation training have the communication skills to address the myriad needs of patients and their loved ones, needs that are challenging to meet in inpatient hospital settings. The author illustrates principles of mediation such as validating patients' emotions, revealing the interests of all stakeholders, and shaping a shared solution to demonstrate how these skills have broad applicability in patient care settings.

Neglected Ends: Clinical Ethics Consultation and the Prospects for Closure

Clinical ethics consultations (CECs) are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of adverse, lingering sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”

Conflict Resolution in the Clinical Setting: A Story Beyond Bioethics Mediation.

Because ethics consults are often more about conflict than moral puzzlement, the skills of conflict resolution and communication facilitation are now deemed a core competency for ethics consultants. Those skills range beyond the traditional ambit of "bioethics mediation," as illustrated here by a recent mediation regarding a difficult discharge. As conflict permeates healthcare, often spawning downstream ethical issues, conflict resolution services might be deemed a genre of preventive ethics suitably offered by ethics committees. If so, a strong distinction must be made. "Bioethics mediation" as historically defined is a curious amalgam between a consultant who recommends, and a mediator who facilitates consensus among the parties at the table. On closer examination this approach is problematic, particularly in the clinical setting. A mediator who acts as consultant, telling parties what they should do or directly circumscribing the limits of an "acceptable" decision, quickly becomes just another pair of fists in the fight. At that point the odds for reaching genuine agreement, as opposed to a transient acquiescence, diminish markedly. Accordingly, those who undertake conflict resolution in the clinical setting need to distinguish quite sharply between facilitative mediation, versus a consultant's role.

The four-principle formulation of common morality is at the core of bioethics mediation method.

Bioethics mediation is increasingly used as a method in clinical ethics cases. My goal in this paper is to examine the implicit theoretical assumptions of the bioethics mediation method developed by Dubler and Liebman. According to them, the distinguishing feature of bioethics mediation is that the method is useful in most cases of clinical ethics in which conflict is the main issue, which implies that there is either no real ethical issue or if there were, they are not the key to finding a resolution. I question the tacit assumption of non-normativity of the mediation method in bioethics by examining the various senses in which bioethics mediation might be non-normative or neutral. The major normative assumption of the mediation method is the existence of common morality. In addition, the four-principle formulation of the theory articulated by Beauchamp and Childress implicitly provides the normative content for the method. Full acknowledgement of the theoretical and normative assumptions of bioethics mediation helps clinical ethicists better understand the nature of their job. In addition, the need for a robust philosophical background even in what appears to be a purely practical method of mediation cannot be overemphasized. Acknowledgement of the normative nature of bioethics mediation method necessitates a more critical attitude of the bioethics mediators towards the norms they usually take for granted uncritically as valid.

Moving ‘Beyond Neutrality’ and Cross-cultural Training: Using World Café Dialogue to Address End-of-life Care Inequalities

In this article I discuss how World Café Dialogues can be used to unveil structural and cultural violence that drive the behaviors that maintain end-of-life care inequalities, especially among minorities, in acute healthcare hospitals. Conflict practitioners are rarely included in conversations of end-of-life care inequalities and when included it is to “solve a problem” through bioethics mediation or provide training in cross-cultural competence. I argue that conflict practitioners need to broaden their approach to conflict and use their skills to surface unequal power structures and implicit beliefs that maintain the unjust status quo in end-of-life care disparities.

The Art of the Chart Note in Clinical Ethics Consultation and Bioethics Mediation: Conveying Information that Can Be Understood and Evaluated

Unlike bioethics mediators who are employed by healthcare organizations as outside consultants, mediators who are embedded in an institution must be authorized to chronicle a clinical ethics consultation (CEC) or a mediation in a patient's medical chart. This is an important privilege, as the chart is a legal document. In this article I discuss this important part of a bioethics mediator's tool kit in my presentation of a case illustrating how bioethics mediation may proceed, and what this approach using both bioethics and mediation may add.

A Response to Dubler’s Commentary on “Surmounting Elusive Barriers: The Case for Bioethics Mediation”

Dubler's commentary focuses on knowledge of clinical medicine and "institutional savvy" as pieces of the skill set required of bioethics mediators. Here, I describe why, as a practical matter, such requirements are unlikely to be achieved by a meaningful number of aspirants. Simultaneously, I examine the reasons why Dubler's criteria are inherently risk-laden and would be better addressed as a dialogue among experienced practitioners regarding the merits of alternative stylistic approaches, rather than as universal threshold criteria for the practice of bioethics mediation.

Surmounting Elusive Barriers: The Case for Bioethics Mediation

This article describes, analyzes, and advocates for management of clinical healthcare conflict by a process commonly referred to as bioethics mediation. Section I provides a brief introduction to classical mediation outside the realm of clinical healthcare. Section II highlights certain distinguishing characteristics of bioethics mediation. Section III chronicles the history of bioethics mediation and references a number of seminal writings on the subject. Finally, Section IV analyzes barriers that have, thus far, limited the widespread implementation of bioethics mediation.

Commentary on Bergman: “Yes … But”

In "Surmounting Elusive Barriers: The Case for Bioethics Mediation," Bergman argues that professionals trained in bioethics, reluctant to acquire the skills of mediation, would better be replaced by a cadre of mediators with some bioethics knowledge, to which I respond, "yes ... but."

Bioethics mediation: a guide to shaping shared solutions

tions that are frequently encountered in everyday practice. Essential communication skills are emphasized as well as documentation of the situation in the medical record, keeping both free of emotion, while relaying essential information to all members of the healthcare team. The techniques presented can be used in the clinical setting to identify parties involved in the conflict; understand the interests of the participants; level the playing field to minimize disparities of power, knowledge, skill, and experience; maximize options for resolution of the conflict; search for common ground; ensure that consensus can be justified as a “principled resolution”; help implement the agreement; and conduct followup. Under certain circumstances these strategies could enhance the autonomy of the patient, support shared values of the patient and family, and strengthen the implementation of the healthcare plan. When a common ground cannot be found, it is typical to call the bioethics committee; however, not all disagreements involve ethical issues. The communication strategies outlined in this book will assist healthcare professionals to identify and resolve the discord. The book can also be used as a teaching guide to help facilitate communication skills and knowledge of bioethics mediation. Role-playing situations can help the novice feel more comfortable in situations involving conflict.

Bioethics mediation: The role and importance of nursing advocacy

Ethics consultations are utilized in health care to identify and manage conflict, difficult decision-making, and ethical issues. In bioethics mediation, a more updated approach using interpersonal, mediative, conflict management, and dispute resolution skills is merged with ethical principles to manage dilemmas arising in healthcare settings. This article argues, based on a professional obligation to advocate for the good of the client, that nurses must assume leadership roles in mediation processes. Nurses can initiate and fully participate in formal bioethics mediation and other mediative interventions. Nurse administrators can work to evolve existing ethics consult models to mediation models. Nonetheless, mediative efforts of individual nurses must be grounded in realization of the multifactorial nature of conflict and dilemma in healthcare settings. Multidisciplinary mediative interventions, framed by sound institutional policies, may best serve the complex needs of ethically vulnerable clients. To best advocate for these at-risk clients, nurses must assume various leadership roles in mediation processes.

A Commentary on Caplan and Bergman: Ethics Mediation — Questions for the Future

Previous articleNext article No AccessA Commentary on Caplan and Bergman: Ethics Mediation — Questions for the FutureRobert Arnold, Mark Aulisio, Ann Begler, and Deborah SeltzerRobert ArnoldUniversity of Pittsburgh Search for more articles by this author , Mark AulisioMetroHealth Medical Center in Cleveland, Ohio Search for more articles by this author , Ann BeglerPennsylvania Joint State Government Advisory Committee Search for more articles by this author , and Deborah SeltzerRand-University of Pittsburgh Health Institute Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Volume 18, Number 4Winter 2007 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/JCE200718404 Citations: 2Citations are reported from Crossref © 2007 The University of Chicago. All rights reserved.PDF download Crossref reports the following articles citing this article:Edward J. Bergman Surmounting Elusive Barriers: The Case for Bioethics Mediation, The Journal of Clinical Ethics 24, no.11 (Dec 2022): 11–24.https://doi.org/10.1086/JCE201324102 Mark P. Aulisio “Facilitated Consensus,” “Ethics Facilitation,” and Unsettled Cases, The Journal of Clinical Ethics 22, no.44 (Dec 2022): 345–353.https://doi.org/10.1086/JCE201122406