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Teaching ethics in the clinic. The theory and practice of moral case deliberation
  1. A C Molewijk1,2,
  2. T Abma1,
  3. M Stolper1,
  4. G Widdershoven1
  1. 1
    Department of Health, Ethics and Society/Metamedica Faculty of Health, Medicine and Life Sciences School for Public Health and Primary Care (Caphri), Maastrict University, Maastrict, The Netherlands
  2. 2
    GGNet, Institute for Mental Health Care, Warnsveld, The Netherlands
  1. A C Molewijk, Department of Health, Ethics and Society/Metamedica Faculty of Health, Medicine and Life Sciences School for Public Health and Primary Care (Caphri), Maastrict University, PO Box 616, 6200 MD, Maastrict, The Netherlands; b.molewijk{at}zw.unimaas.nl

Abstract

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 (teaching) 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.

  • education
  • pragmatic hermeneutics
  • dialogical ethics
  • moral case deliberation
  • moral competencies
  • responsive evaluation
  • implementation
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Teaching medical ethics gets increasing attention because of the upcoming framework of core-competencies within current educational programmes for healthcare professionals. Yet, traditional ways of teaching medical ethics have some limitations. The abstract knowledge of textbook ethics makes professionals feel alienated from their own moral experiences, expertise, and insights. Professionals may learn ethical concepts and principles, but are not adequately trained and motivated to apply this abstracted knowledge in their own clinical practice. Even teaching programmes that focus less on knowledge transmission of ethical theories (eg casuistry), seem to pay little attention to the training of moral competencies, virtues and to dialogue and deliberation among practitioners. In these approaches the analysis of the case itself and required analytical skills are central. In order to focus more on collective situational and competency learning, an alternative way of teaching medical ethics has been developed, namely moral case deliberation.

Moral case deliberation consists of a collaborative, systematic reflection on a real clinical case (see Appendix A for an example). The reflection takes 45 minutes to 1 day and is structured by means of one of a variety of conversation methods.1 2 Methods are chosen depending on the purpose of the moral case deliberation and can focus on the process (eg individual self-reflection, teambuilding, training attitude or skills) or the product (eg solutions, compromises, answers, actions). The ethicist functions as a non-directive facilitator as opposed to an expert and concentrates on the quality of the deliberation process and the meaningfulness of the moral issues. By means of moral case deliberation, professionals develop moral skills and an appropriate, reflective attitude.

Moral case deliberations are ideally not unique events, but a regular and structural part of the professional training on the work floor within healthcare institutions. This fits well with trends in education and organisational learning. Within these disciplines the transmissional view on information processing and learning as a cognitive act has been criticised.36 Alternative ideas emphasise the context-bound nature of learning in relationships between people.7

In The Netherlands several healthcare institutions have started moral case deliberation projects on the work floor in collaboration with ethicists.8 This has resulted in a practical guidebook for moral case deliberation.1 At a national level the Dutch Minister of Health has advised healthcare institutions to implement moral case deliberation in the clinic.9 In 2004, the University of Maastricht and Hans van Dostel (Leiden University) established an expert platform on Moral Case Deliberation with the Ethics Department of the Ministry of Health. Since 2005, these parties started to organise annual working conferences on the methods and implementation of moral case deliberation.

In order to illustrate moral case deliberation we present a practical example. It concerns a three-year project within a chronic care division in a psychiatric hospital in The Netherlands. The division management requested moral case deliberation to enhance the competence of professionals, to stimulate reflection on the quality of care and to develop a culture of openness and transparency10 (Annual Report of Division of Chronic Mental Health Care, Mental Health Care Institution, Den Bosch, 2004). In response a project plan was developed between the university and division members. A project-group and a steering committee composed of staff members to middle and top-managers were installed. Teaching activities included clinical site visits, monthly moral case deliberation sessions with two permanent multi-disciplinary groups with members from different teams, reading and discussing papers, interactive presentations and joint writing. The project was monitored and evaluated through the method of responsive evaluation in order to adjust and improve the teaching activities undertaken.

This paper focuses on what professionals actually learned as part of the moral case deliberation project. Its central aim is to present a contextual approach to teaching ethics. We start with a description of the theoretical background of our approach. Next, the method of evaluation will be elucidated. After the presentation of the results, we will reflect on the strengths and weaknesses of moral case deliberation.

THEORETICAL BACKGROUND: PRAGMATIC HERMENEUTICS AND DIALOGICAL ETHICS

The background of our approach to teaching ethics is a combination of pragmatic hermeneutics and dialogical ethics. Both approaches stress the importance of practical processes of meaning-making, always related to concrete problems. They require openness towards the views of others. Important vehicles for meaning-making are stories, by which people interpret and understand their situation and try to find out which actions are suitable. In stories, our experiences are at first vague and ambiguous, and then get a more prominent form.11 Stories make explicit the implicit meaning of lived experience. In stories, the pre-narrative structure of life is transformed into a narrative structure.12 13 14 Pragmatic hermeneutics and dialogical ethics are in line with narrative ethics in their interest in stories. They differ in that they emphasise the need for deliberation and dialogue as a way of making sense of stories and coming to joint interpretations.15

Pragmatic hermeneutics is critical of all attempts to frame the problem in terms of strictly defined principles and to solve it through abstract procedures. Ethical problems in healthcare are always complex and concrete.16 One should investigate what the situation means for those who are practically involved in it. How do they define the issue? What solutions do they envisage? What problems do they encounter? Pragmatic hermeneutics is sceptical about interpretations which are general and ahistorical. In trying to make sense of a situation, one should be aware of its intricacy and of its historical and contextual background. Pragmatic hermeneutics urges participants in a practice to be open to the contextuality and contingency of the situation. It invites people to interpret their situation not within a fixed and rigid set of principles but to be flexible and open to new possibilities.

Dialogical ethics focuses on processes of joint learning. Learning means extending one’s perspective, or broadening one’s horizon.17 This typically takes place in a dialogue. In a conversation, we can be confronted with unexpected statements or utterances. In such a case, dialogical understanding means that one tries to see the point the other makes. It means being open to what the other has to say, being prepared to accept it as relevant and valid for oneself. To quote Gadamer: “Openness to the other, then, involves recognising that I myself must accept something against me, even though no one else would bring this up.”(Gadamer, p343).17

METHOD: RESPONSIVE EVALUATION

Working from this theoretical background, we developed a moral case deliberation project at a chronic care division in a psychiatric hospital. The project was evaluated by a team of two evaluators. One conducted the research activities. The other also coordinated the project and moderated the regular meetings with two moral case deliberation groups.

The evaluators followed a responsive evaluation approach.6 1820 The term negotiation characterises the essence of responsive evaluation. Evaluation criteria are derived from the issues of various stakeholders and gradually emerge in conversation with and among stakeholders. Besides the identification of issues, conditions are created for the interaction between stakeholders. In this instance, the evaluators identified the following stakeholders: hospital and division management, healthcare professionals and staff members.

Research activities included six in-depth interviews with key-figures about their expectations of moral deliberation within the institution at the start of the project. The participants also responded to a regular evaluation survey (n = 57) after every moral deliberation session and a final evaluation survey (n = 11). Furthermore, both evaluators visited a clinical site (ie one of the units of the division) in order to participate within regular work activities and to raise several moral issues that came out of the observations during the visit. Since the evaluators also acted as moderators of the moral case deliberation sessions they gathered a lot of inside information about the group dynamics and actual learning processes of the participants. This participant observation information was systematically recorded in a logbook. In addition two focus groups were organised with the participants in the moral case deliberation sessions. In these focus groups, participants shared their experiences with the project as a whole and with the deliberation sessions in particular, and discussed whether or not the sessions had helped them in their clinical practice. The participants also responded to controversial statements derived from the interviews with key-figures as part of the dialogue between stakeholder groups.

The dialogical process between various stakeholder groups mainly took place within the meetings of the moral case deliberation groups, the project-group and the steering committee. The participants in these groups responded to the stakeholder issues and data gathered by the interviews, participant observation, focus groups and surveys at several moments in time during the project. This helped the evaluators to gain a broad spectrum of perspectives on the project within the institution, but it also fostered the implementation of findings. It is known that stakeholder participation and communication are key factors for implementation of evaluation findings.21 22

TEACHING MORAL CASE DELIBERATION IN A PSYCHIATRIC HOSPITAL

Soon after the project had been started, research activities made it apparent that healthcare professionals experienced several problems. They did not feel secure enough to openly share professional doubts and feared these were seen as signals of professional weakness. Stressful and complex cases (eg violence, coercion, patients with double diagnoses, uncertainty about justification of mild paternalism) led to feelings of emotional burn out. Professionals also reported they lacked words, competencies and structured meetings to constructively reflect on these cases. As one of the healthcare professionals said:

“There are many moments in which I feel morally uncomfortable with the situation, without being able to express for which reasons the dilemma came into existence in the first place. It would be wonderful if we could recognise the elements of our dilemmas, share them with our colleagues, and get to learn how we could transform powerless feelings into concrete and constructive ways of dealing with those dilemmas.”

These issues, including the requests of the division management, were formulated as learning goals within the project plan. During the interim and annual project reports, and the meetings of the project group and the steering committee, these learning goals were evaluated and if necessary adjusted. Concrete examples of what participants learned during the moral case deliberation project are described below.

What moral questions?

Twenty moral case deliberation sessions in one year with an average of seven participants led to a division-related database of approximately 100 moral cases of which about 20 were extensively discussed, recorded and analysed. The moral questions of the cases were categorised into: client-centred, professional-centred, and organisational-centred moral questions.23

Some examples of client-centred questions:

  • A long-term patient has real difficulties with cleaning his room and becomes anxious. Should I help him and clean his room for him or should I demand that he cleans his own room?

  • A Korsakov patient has been on the waiting list for admission to the hospital for a long time but the treatment facilities are not yet well-developed. Should I still refer him, or should I persist and ask the therapists to develop the treatment facilities first?

Professional-centred issues include, for example:

  • A nurse-trainee does not seem to be functioning well. How much time and how many opportunities should I give him before we decide that he is not able to continue his nursing education?

Organisation-centred moral questions consist of the following:

  • Smoking is by law prohibited in all hospitals. Patients at the long-term care division live within the hospital. Should we respect the law or allow the patients to smoke in “their” home?

  • A long-term patient has been away for a long time because of his psychiatric treatment elsewhere, which is still not finished. How long should we keep his place open at the long term facility?

Which moral competencies?

The ethicists in the project divided the moral competencies the professionals learned into knowledge, attitude and skills. Instead of teaching moral theories, professionals were taught how to deal with clinical ethical issues in real life situations. With respect to knowledge, the ethicists showed how to recognise moral issues and how to formulate moral questions or moral dilemmas. The ethicists discussed questions such as: What are values and norms and how are they related? What are differences between a dialogue and a debate? In which different ways can one determine what is morally good? The ethicists only brought in ethical concepts when they were actually relevant for the topic of the case deliberation. So, within the teaching activities, knowledge played a minimal role and the knowledge taught was instrumental for the teaching of attitudes and skills. Knowledge itself was not the main goal of teaching.

With respect to the attitude of professionals, they learned how to actually have or create a moral dialogue with their colleagues. They were enabled to postpone their initial judgments, their desire to convince the other, to run for the practical answer without a well thought-out analysis of the question itself, and to focus on “the” only right answer or action. They learned to critically reflect on the actual underlying moral questions, to listen actively by means of questioning, to respect other or even opposite viewpoints on the case, and to distance themself from moral dilemmas that initially paralysed them. During the responsive evaluation research process, the participants formulated their changing attitude as follows:

  • I learned to see our common professional behaviour as more special and complex

  • I’m aware of the normative dimension of my professional attitude

  • Team decisions are made less on an ad-hoc basis and are better considered

  • I learned to give words to uneasiness which increased my constructive attitude

  • I realised that others are also uncertain about what is morally good, that there is not just one simple moral answer that is right; I felt less insecure about sharing my questions

  • I learned to learn from people who do not agree with me

  • I felt less emotionally distressed since I could more easily distance myself from, and reflect upon my moral dilemmas: Dilemmas no longer control or capture me

With respect to participants’ skills, healthcare professionals learned communication skills (eg non-judgemental listening, asking fundamental questions), reasoning skills (eg logic, connection between moral values and norms, inductive versus deductive reasoning) and moral skills or virtues (eg postponing moral judgments, creating dialogue instead of convincing the other). Given our pragmatic hermeneutic and dialogical approach to ethics, communication skills and moral virtues are particularly important. Reasoning skills are relevant, but need to be alongside communication and moral virtues, especially within clinical contexts.24 Based of the evaluation questionnaires, participants reported they learned the following:

  • I’m able to recognise moral dilemmas as such, which makes many cases less emotionally overwhelming

  • I can postpone initial judgments

  • I learned to ask questions

  • I learned that there is a limit to my professional responsibility

  • I’m more clear about my professional limits and better able to ground them

  • It has become easier for me to refine the questions of the patients

How did the participants value the learning process?

Ongoing research gave the ethicists the opportunity to monitor the way healthcare professionals evaluated the moral case deliberation project. The learning activities were evaluated on a scale of 1—10 and averaged at eight or higher. The professionals felt the moral case deliberations were a necessary activity since they do not normally have the time to reflect on what they are doing. They also felt that instead of teaching knowledge, their own cases and their own expertise were appealed to. The participants from the structural moral case deliberation groups felt more secure and were able to increase their competencies regarding dealing with moral questions and dilemmas. At the end of the project, the participants concluded that the moral deliberation should take place even closer to the place where they actually work with their own team. As one participant aptly put it:

“Learning to deal with moral issues is tough, but trying to implement moral case deliberation within our own units is even tougher. We feel like we need more support, both from the ethicist, from the university and from our own managers.”

Overall, during the moral case deliberation project, a dynamic and interactive cooperation emerged between the ethicists and the stakeholders within the psychiatric hospital. Healthcare professionals were involved as co-owners which helped to facilitate the implementation of moral case deliberation. A large amount of context-based data has been collected: with respect to the learning of moral competencies; with respect to professionals’ concrete moral cases; and with respect to the implementation process of moral case deliberation in the clinic. In retrospect we conclude that the moral deliberation approach has been beneficial in the setting described. Yet, knowledge, attitudes and skills are not the only, and maybe not even the most important, outcome indicators and success factors. The project described has been successful, because practitioners got engaged in the process and invited us to their wards. This important lesson is, however, hard to demonstrate, because it requires closer monitoring of the whole process and illuminative description of the learning history at the site.

DISCUSSION

Moral case deliberation, as applied in our project, is based on a pragmatic-hermeneutical dialogical approach to ethics and gets constructed with, and within, the actual clinical work environment. Moral case deliberation fits well within new experiential learning paradigms in which the in-company training of competencies plays a central role. The method of responsive evaluation has been useful to study and facilitate the learning and implementation process. Healthcare professionals continuously experience complex moral cases in which “the moral questions” or “the relevant facts” are not as clear-cut as in many medical ethics textbooks. Moral case deliberation can serve as a way to deal with concrete problems and to train moral competencies at the same time. As a consequence, methods for moral case deliberation are now also introduced in various educational and teaching programmes in The Netherlands, for instance in medical education and in education for nurses and psychologists. The relatively simple structure of the moral case deliberation methods helps to structure the often confusing and complex moral cases. The structure of moral case deliberation is also helpful for regulating the complex dynamics of the groups. Furthermore, due to the contextual approach, the implementation process becomes smoother as stakeholders become co-owners. Of course, the process of implementation is never easy. A problem we encountered was that the moral deliberation group tended to become somewhat detached from the wards. Introducing ward-visits solved this. From this we learned that we have to do better at taking the relation to the wards into account in future projects.

Several issues for discussion, research and improvement remain. One may question whether there is a link between moral case deliberation, the learning of moral competencies and the quality of care. In the case under consideration the professionals became more sensitive for moral dilemmas and they were better able to structure and analyse moral problems. Yet, more attention should be paid to conceptual clarification and empirical measurement of the learning of moral competencies (eg the improvement of various kinds of moral skills).25 Furthermore, it is plausible that the development of professionals’ moral competencies affects the quality of care, but it is as yet unknown which part of the quality of care actually improves and what the effect will be in the longer run. One way to improve the quality of care is by including patients and their moral cases within the moral case deliberation.18 26 27 Another way is to arrange a structural connection between the moral case deliberations and the hospital’s quality of care policy. Qualitative and quantitative research is needed in order to support, approve and further develop the relationship between moral case deliberation and the quality of care.28

Another issue concerns the role of the ethicist in moral case deliberation. Should ethicists persist in a procedural moderator role or should there be room for ethicists to bring in their moral judgements when situations are considered morally wrong? Within a pluralistic liberal society, the question emerges of how to define what is morally wrong. Should ethicists justify or criticise substantial decisions of the healthcare professionals? Should they ultimately leave the hospital and let the healthcare professionals do their own moral case deliberations? Ethicists and healthcare professionals who are involved within moral case deliberation projects need to find balanced and reasoned answers to those role questions. The theoretical background of pragmatic-hermeneutics and dialogical ethics provides a framework for dealing with those questions in a non-dogmatic way.

Acknowledgments

This research has been possible due to a grant from the division of chronic care from the Reinier van Arkel Groep, a Dutch mental health care institution in Den Bosch. We wish to thank all participants within the moral case deliberation project for our instructive and ongoing collaboration.

APPENDIX A

Example of a moral case deliberation method

As mentioned, there are various divergent methods for a moral case deliberation.1 2 The methods are inspired by different moral theories and reflect divergent understandings of moral problems and ways of dealing with them. For example, the Hermeneutic method is especially process oriented and focuses on multiple interpretations of text and form. Its main goals are meaning-pluralism, comprehension and understanding. The Socratic Dialogue can be both process and product oriented, and consists of philosophical research on conceptual and argumentative presuppositions in real cases. Its goals are conceptual clarification, finding conceptual consensus, and critical reflection on the logic of someone’s thinking process. The Dilemma method is mainly product oriented (stepwise problem solving) and tries to ground the decision making process by means of inventory the various values and norms of the involved stakeholders. Below you will find a brief description of the Dilemma method (inspired by D Bavdvin and by Graste.29).

Description of steps within the Dilemma method

Goal: list and structure perspectives, values, norms in dilemma (analytical goal) in order to prepare the decision-making process (no guarantee for problem solving or consensus!). Experiencing a dilemma is feeling that you are being forced to do either A or B. It is not logically possible to do both (A and B). Not doing A or B causes a moral burden or a moral damage.

1. Moral case is presented

2. [Formulation of a general moral question]

3. Short formulation of a dilemma (of the case presenter!)

a. Should I do A or B?

b. Concrete as possible

c. Prevent abstract concepts

d. Prevent implicit normative formulations

4. Possibilities for clarification & questions

5. Scheme with ‘perspectives’, ‘values’, ‘norms’ (see table 1)

Table 1 Scheme with perspectives, values and norms of an example case

a. Position dilemma in scheme (<)

b. Connect values/norms to original dilemma (A or B)

6. List all possible alternatives (without discussing feasibility)

7. Make individual round (write down first)

a. I think the right thing to do is …

b. Because

c. Therefore I’m not able to do …

d. How can I cope with or decrease moral burden/damage?

e. Which virtues are necessary to do the right thing?

8. Discuss possible group consensus or decision (‘weigh’ values & norms)

9. Make practical appointments and plan date to evaluate those appointments

REFERENCES

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Footnotes

  • Competing interests: None.

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