Moral Case Deliberation Research Articles

Chapitre 3. Moral case deliberation in an academic hospital in the Netherlands

In this article we describe the process of developing an ethics support service in a Dutch academic hospital by means of implementing moral case deliberation (MCD). In MCD, health care professionals discuss their moral issues pertaining to a real case in order to come to mutual understanding and/or a shared idea of what is best to do and in which way. MCD is inspired by the philosophy of dialogical and hermeneutic ethics. Equal dialogue and critical constructive reflection are both important aims and means of MCD. This requires equality of perspectives, time to deliberate about values and considerations, and active involvement of all participants (ownership). However, within the context of an academic hospital, these conditions are not evident, given the prevalence of power and hierarchy, the need for efficiency and time management, and the emphasis on experts' advice instead of joint responsibility. This paper introduces the core features of the philosophical background of MCD and describes ways of dealing with some tensions between MCD's philosophical inspirations and the practical context of an academic hospital while implementing MCD. The paper shows that these philosophical inspirations can be helpful in the cooperation with an academic hospital when implementing MCD together. This joint process of making MCD meaningful and useful for the practice while dealing with different tensions, is as important as offering high quality MCD sessions.

Emotions and Clinical Ethics Support. A Moral Inquiry into Emotions in Moral Case Deliberation

Emotions play an important part in moral life. Within clinical ethics support (CES), one should take into account the crucial role of emotions in moral cases in clinical practice. In this paper, we present an Aristotelian approach to emotions. We argue that CES can help participants deal with emotions by fostering a joint process of investigation of the role of emotions in a case. This investigation goes beyond empathy with and moral judgment of the emotions of the case presenter. In a moral case deliberation, the participants are invited to place themselves in the position of the case presenter and to investigate their own emotions in the situation. It is about critically assessing the facts in the case that cause the emotion and the related (moral) thoughts that accompany the emotion. It is also about finding the right emotion in a given situation and finding the right balance in dealing with that emotion. These steps in the moral inquiry give rise to group learning. It is a process of becoming open towards the perspectives of others, leading to new insights into what is an appropriate emotion in the specific situation. We show how this approach works in moral case deliberation. A physician presents a situation in which he is faced with a pregnant woman who is about to deliver multiple extremely premature infants at the threshold of viability. The moral deliberation of the case and the emotions therein leads to the participants' conclusion that "compassion" is a more adequate emotion than "sadness". The emotion "sadness" is pointed towards the tragedy that is happening to the woman. The emotion "compassion" is pointed towards the woman; it combines consideration and professional responsibility. Through the shift towards compassion, participants experienced more creativity and freedom to deal with the sad situation and to support the woman. The paper ends with an analysis and reflection on the deliberation process. In the conclusion we argue for more attention to emotions in clinical ethics support and offer some directions for doing this in the right way.

"Here's my dilemma". Moral case deliberation as a platform for discussing everyday ethics in elderly care.

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on good care’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’.

Client Participation in Moral Case Deliberation: A Precarious Relational Balance

Moral case deliberation (MCD) is a form of clinical ethics support in which the ethicist as facilitator aims at supporting professionals with a structured moral inquiry into their moral issues from practice. Cases often affect clients, however, their inclusion in MCD is not common. Client participation often raises questions concerning conditions for equal collaboration and good dialogue. Despite these questions, there is little empirical research regarding client participation in clinical ethics support in general and in MCD in particular. This article aims at describing the experiences and processes of two MCD groups with client participation in a mental healthcare institution. A responsive evaluation was conducted examining stakeholders’ issues concerning client participation. Findings demonstrate that participation initially creates uneasiness. As routine builds up and client participants meet certain criteria, both clients and professionals start thinking beyond ‘us-them’ distinctions, and become more equal partners in dialogue. Still, sentiments of distrust and feelings of not being safe may reoccur. Client participation in MCD thus requires continuous reflection and alertness on relational dynamics and the quality of and conditions for dialogue. Participation puts the essentials of MCD (i.e., dialogue) to the test. Yet, the methodology and features of MCD offer an appropriate platform to introduce client participation in healthcare institutions.

THE ROLE OF EMOTIONS IN MORAL CASE DELIBERATION: THEORY, PRACTICE, AND METHODOLOGY

In clinical moral decision making, emotions often play an important role. However, many clinical ethicists are ignorant, suspicious or even critical of the role of emotions in making moral decisions and in reflecting on them. This raises practical and theoretical questions about the understanding and use of emotions in clinical ethics support services. This paper presents an Aristotelian view on emotions and describes its application in the practice of moral case deliberation. According to Aristotle, emotions are an original and integral part of (virtue) ethics. Emotions are an inherent part of our moral reasoning and being, and therefore they should be an inherent part of any moral deliberation. Based on Aristotle's view, we examine five specific aspects of emotions: the description of emotions, the attitude towards emotions, the thoughts present in emotions, the reliability of emotions, and the reasonable principle that guides an emotion. We then discuss three ways of dealing with emotions in the process of moral case deliberation. Finally, we present an Aristotelian conversation method, and present practical experiences using this method.

Organizing moral case deliberation Experiences in two Dutch nursing homes

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other.

Moral margins concerning the use of coercion in psychiatry

In the closed wards of mental health institutions, moral decisions are made concerning the use of forced seclusion. In this article we focus on how these moral decisions are made and can be improved. We present a case study concerning moral deliberations on the use of seclusion and its prevention among nurses of a closed mental health ward. Moral psychology provides an explanation of how moral judgments are developed through processes of interaction. We will make use of the Social Intuitionist Model of Jonathan Haidt that emphasizes the role of emotions, intuitions and the social context in moral judgments and reasoning. We argue that this model can help to explain social dynamics in the context of enforced seclusion. In the discussion we explore how moral psychology can be complemented with the normative perspective of dialogical ethics to develop strategies for improving psychiatric practices. We conclude that social processes play an important role in moral deliberations and that moral development can be fostered by bringing in new perspectives in the dialogue. Moral case deliberation provides a practical tool to systematically organize moral reflections among nurses on the work floor.

Editorial: All you need is love?

In a country renowned for its contribution to the establishment of nursing as a profession, we are reeling from yet another report of poor care. The UK Health Service Ombudsman report ‘Care and compassion?’ detailed 10 investigations into the care of older people in the National Health Service (NHS). The report discussed the absence of the most fundamental aspects of care for older people. The journalist, Jenni Russell, recently shared her experiences of the NHS in a Sunday newspaper. She described how a friend’s father had moved ‘from an environment where staff were rude and mean to a micro civilisation where the ethos was kindness. ‘‘Honestly, he genuinely felt loved there’’’. Russell described the activities that contributed to this elderly gentleman feeling loved. She wrote ‘The nurses mushed up his food so that he could eat despite his mouth cancer; they were cheerful and tactful about his need for bedpans and bed baths; they talked to him with affection, took messages and rang his family with bulletins whenever they were asked to, even in the middle of the night. Even though he died from a hospital infection, the family has no regrets.’ The attitudes and behaviour of nurses and other staff can make a significant contribution to patient well-being and dignity. However, explanations for good and poor care go beyond individual behaviour. The review of organizational ethics by Riitta Suhonen and colleagues informs us of the state of research in this important area. Elleke Landeweer’s exploration of moral decision-making in relation to seclusion in mental health demonstrates the value of inter-disciplinary perspectives. Insights from the social intuitionist model help to explain the dynamics of enforced seclusion. Moral case deliberation is discussed as a practical tool to organize the moral reflections of nurses. The interaction between individual and organizational factors is explored in Sandra Pereira’s systematic review relating to burnout in palliative care. The research of Sandra van der Dam and her co-authors explore the contribution of moral case deliberation in improving the quality of care. They conclude that two implementation strategies – existing communication structures and a mixed moral case deliberation group – can complement each other. A second article on the topic of clinical ethics is by Iva Sorta-Bilajac. This study assessed nurses’ and physicians’ ethical dilemmas in clinical practice in Croatia. Findings suggest that nurses and physicians experienced similar ethical dilemmas and that the usage of clinical ethics consultations is low. Fang Pengqian and co-researchers surveyed health professionals’ attitudes towards information disclosure to cancer patients in China. Respondents placed a high value on patients’ desire and priority to know the truth. They recommend that health professionals should learn more about informed consent compatible with Chinese culture. An Iranian study of placebo use by nurses, conducted by Hamid Reza Koohestani, concludes that most nurses had used placebo and view this as ethically permissible. These studies suggest the need to consider contentious ethical issues in specific cultural contexts. The qualitative study reported by Christina Karlsson and Ingela Berggren explores nurses’ perceptions of factors that contribute to patients’ experiencing a ’good death’ in their own home. They conclude that good

Enacting Ethics: Bottom-up Involvement in Implementing Moral Case Deliberation

In moral case deliberation (MCD), healthcare professionals meet to reflect upon their moral questions supported by a structured conversation method and non-directive conversation facilitator. An increasing number of Dutch healthcare institutions work with MCD to (1) deal with moral questions, (2) improve reflection skills, interdisciplinary cooperation and decision-making, and (3) develop policy. Despite positive evaluations of MCD, organization and implementation of MCD appears difficult, depending on individuals or external experts. Studies on MCD implementation processes have not yet been published. The aim of this study is to describe MCD implementation processes from the perspective of nurses who co-organize MCD meetings, so called ‘local coordinators’. Various qualitative methods were used within the framework of a responsive evaluation research design. The results demonstrate that local coordinators work hard on the pragmatic implementation of MCD. They do not emphasize the ethical and normative underpinnings of MCD, but create organizational conditions to foster a learning process, engagement and continuity. Local coordinators indicate MCD needs firm back-up from management regulations. These pragmatic action-oriented implementation strategies are as important as ideological reasons for MCD implementation. Advocates of clinical ethics support should pro-actively facilitate these strategies for both practical and ethical reasons.

Ethik in der medizinischen Aus- und Weiterbildung

Ethics education is a topic of growing importance in the medical curriculum. Medical ethics can be defined as the skilled professional discourse on moral issues in patient care, medical research and the health-care system. Ethical competence comprises conscientiousness and the ability to give reasons for intuitive moral convictions. In the curriculum, course content and didactic approaches should be aimed at all levels (cognitive, affective, practical), as discussed in this paper. Case based seminars are the gold standard of ethics education. The teacher's responsibility is rooted in their character as role models during case discussions. Ethics education should continue throughout the curriculum. In Germany the compulsory subject "history, theory, ethics of medicine" is predominant in the curriculum, but courses vary greatly between different universities. Further research is needed in the fields of adequate assessment formats and evaluation of final outcomes of ethics education. Interprofessional ethics education (undergraduate and postgraduate) is a major challenge for the future, especially since services for clinical ethics consultation and moral case deliberation are becoming more established in German hospitals.

Teaching ethics in the clinic. The theory and practice of moral case deliberation

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...

Implementing moral case deliberation in Dutch health care; improving moral competency of professionals and the quality of care

between evaluative meetings. Results: Both qualitative and quantitative results of the 220 questionnaires of 50 MCDs showed that the MCDs were regarded as very useful. Most participants saw the relevance of MCD for their daily work high and judged the quality of the dialogue positively. Their open, straight, constructive communicating and moral sensitivity increased; their presuppositions, prejudices and automatic responses decreased. Discussion: Future implementation research has to find out what the long term impact will be on the quality of care. Therefore, the next step in this project will focus on (methodology for) research on the follow up of outcomes of MCD and the integration of these outcomes with institutional policy issues.

Implementing moral case deliberation in a psychiatric hospital: process and outcome

Clinical moral case deliberation consists of the systematic reflection on a concrete moral case by health care professionals. This paper presents the study of a 4-year moral deliberation project. The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of the evaluation of the moral case deliberation sessions, and (d) present the implementation process. The implementation process is both monitored and supported by an interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists). Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects.

Moreel beraad en goede zorg voor ouderen veronderstellen <f"TimesAigu">e<f"TimesNRMT">n versterken elkaar

Caring is inherently a moral practice. Those who are involved in the care for the elderly give meaning to their views on good (organisation of) care, implicitly or explicitly. The meaning of good care is directly attached to a specific context and a specific moment; it is neither fixed nor static. In this paper, good care is understood as dialogic: the meaning of good care arises out of and by means of dialogue between the stakeholders. Ethics can play a crucial role in shaping this dialogue. Unfortunately, many people see ethics primarily as a discipline which develops abstract moral theories and generate ethicists for formal ethics committees in order to prescribe protocols and guidelines. Dialogical ethics, with its theoretical bases in pragmatic hermeneutics, is opposed to this view of ethics. Moral Case Deliberation is a good example of dialogical ethics in which the ethicist applies various conversation methods in order to support health care professionals to reflect on their moral questions. Starting point is the moral expertise of the health care professionals themselves; the ethicist functions as a facilitator. Moral Case Deliberation contributes both to reflect as to shape good care (executed by good professionals within a good health care organisation). This paper describes the meaning of a Moral Case Deliberation and a Moral Deliberation Project. Additionally, it reflects on the underlying view on dialogical ethics, the justification of Moral Deliberation and some possible goals of Moral Deliberation. With this paper, the authors argue that Moral Case Deliberation both presupposes and strengthens good elderly care.