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Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible
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  1. Clare Delany1,2,
  2. Sharon Feldman2,
  3. Barbara Kameniar3,
  4. Lynn Gillam2
  1. 1Medical Education, The University of Melbourne, Melbourne, Victoria, Australia
  2. 2Children's Bioethics Centre, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
  3. 3Honorary, Faculty of Education, The University of Melbourne, Melbourne, Victoria, Australia
  1. Correspondence to Professor Clare Delany, Medical Education, The University of Melbourne, Melbourne, Victoria, Australia; c.delany{at}unimelb.edu.au

Abstract

In clinical ethics consultations, clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others. The reasoning process involves identifying and clarifying ethical values which are at stake or contested, and guiding clinicians, and sometimes patients and families, to think through ethically justifiable and available courses of action in clinical situations. There is, however, ongoing discussion about the various methods ethicists use to do this ethical deliberation work. In this paper, we make visible and accessible seven steps of facilitation used in the critical dialogue method of ethics consultation.

We describe how the facilitation techniques serve two overall purposes. First, to identify ethically justified responses to ethical questions. Second, to assist participants to gain greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.

By describing in detail facilitation steps for clinical ethics consultation, we aim to advance the scholarship of ‘clinical ethics facilitation methods’ and to demystify the ethical deliberation work undertaken by clinical ethicists.

  • Ethics Committees
  • Education
  • Ethics
  • Ethics- Medical

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

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Introduction

Ethical challenges brought to a clinical ethicist are always complex and concrete1 rather than theoretical and abstract.2 Clinical ethicists bring moral reasoning to bear3 on these types of concrete clinical ethical problems by undertaking ethical deliberation in collaboration with others.4 Ethical deliberation involves identifying and clarifying ethical values which are at stake or contested and guiding clinicians, and sometimes patients and families, in thinking through ethically justifiable courses of action in a given situation.5 Two established outcomes of clinical ethics consultations are: (a) to build or identify a principled resolution and possible actions to address an ethical problem,3 6 and (b) to enhance clinicians’ understanding of the ethical dimensions of a clinical problem so they can use their own moral agency to address it.7 8

In 1993, Margaret Urban Walker suggested that clinical ethicists achieve these types of outcomes by designing and constructing moral spaces within healthcare settings as moral architects. To earn the label of being a ‘moral’ space, Walker discussed how all three elements of a consultation—the design, the structure and the processes of engagement—must be aligned and directed towards stated outcomes of the deliberative process.9 How ethicists do this moral design and construction work, and ensure that what they do aligns with stated goals of the consultation, is the subject of ongoing discussion in the literature.

In this paper, we add to this discussion by making visible and accessible the facilitation steps used in a specific method of ethics consultation, the critical dialogue (CD) method. We show how the steps of the CD method are specifically designed and directed towards achieving the two outcomes of bringing moral reasoning to bear on ethical problems, and purposefully scaffolding moral agency and growth in those involved.9 10 In educational terms, scaffolding refers to the provision of a form of ‘temporary adaptive support’, purposefully designed to meet the demands of a specific task and with the intention of bridging a learner’s current abilities or capacities to ‘an anticipated future state’.11 In describing the steps of the CD method, we use the term scaffolding to denote a framework and language that an ethicist might use to facilitate and support deliberation about a moral dilemma.

In the CD method, critical denotes an intention to encourage clinicians, and others present at an ethics consultation, to think about and resolve moral questions associated with clinical care in a deliberative and analytical way, rather than relying on intuition or private conscience situated within their professional authority. This intention is oriented towards the outcome of building a principled resolution to an ethical problem.12 13 Dialogue is used to denote the process of collaborative communication between people to foster shared understanding14 of an ethical problem. This element is directed towards supporting the second outcome of enabling moral growth, specifically, greater moral clarity, understanding and confidence to respond to ethical challenges as independent moral agents.

Other known models of ethics consultation draw predominantly from ‘top down’5 methods of facilitation, where the ethicist explicitly brings moral authority to the ethics consultation15; for example, by drawing from principlism16 or other ethics frameworks such as the four-box method17 and/or applying their knowledge and expertise in ethical theory and deliberative judgement to assist in the resolution of the ethical question or conflict. The ‘CASES approach’18 and the Nijmegen method19 are good examples of a top-down approach to ethical reasoning. While these facilitation methods recognise and respect the moral intuitions and expertise of all participants, they are oriented towards the first outcome of clinical ethics consultation, to achieve a principled resolution informed by a predetermined set of principles brought to the consultation by the ethicist.

Ethics consultation methods oriented towards the second outcome of enhancing clinicians’ moral understanding of the ethical dimensions of a clinical problem focus on creating moral spaces which enable participants to draw from and apply their own moral agency to address ethical concerns.7 8 ‘Bottom up’5 approaches involve the ethicist situating her own ethics knowledge and expertise within the experiences and knowledge of staff and patients,3 20 and the particular health institution work context.9 The ethicist purposefully avoids prescribing particular ethical principles or imposing her own values and ethical priorities, and instead supports clinicians to identify and express their values (emotional, religious, personal, professional).6 7 21 22 The dilemma method of moral case deliberation (MCD) is a good example of this approach. It describes specific steps an ethicist should follow to assist clinicians to reflect on their own moral experiences.23 In MCD, the facilitator or participants can refer to ethical theories and concepts; however, existing ethical knowledge is neither the starting point nor the basis on which judgements are made.23 While this approach can also achieve the outcome of building or identifying a principled resolution and possible actions to address an ethical problem, the basis of the resolution may differ from that identified in a top-down approach.

The genesis of the CD method in our clinical ethics service

The CD method has been developed and refined over a period of 15 years of running a clinical ethics service within a large paediatric hospital in Melbourne, Australia.12 13 The method was developed through a process of regular reflection about the methods and outcomes of each consultation. Post consultation reflections included noting the level and type of engagement of attendees; identifying challenges that people had in articulating ethical concerns; comparing the ethical issue or question which emerged from the ethics consultation to the ethical question framed in the referral (in some cases they were quite different); and discussing ethics concepts and theories which were used or could have been used to shed light on and clarify ethical questions.

Over time, these reflections highlighted two recurring themes underlying the ethics facilitation process. The first was the importance of the ethicist-facilitator creating a space for discussion which enabled participants to reflect on and formulate their own ethical concerns, rather than having the ethical framing of the situation set for them. The second was the need for the ethicist to be prepared to take the lead and summarise concerns raised, and/or to add in ethics concepts and ideas to clarify and frame participants’ contributions. These two reflective themes informed each of the steps of the CD method described below.

The types of referrals received by the service include moral uncertainty about treatment pathways, disagreement between parents and clinicians, resistance or refusal of recommended treatment from either the child or parents and disagreement among members of the treating teams. Referrals come from a wide range of clinical departments and relate to both chronic and acute conditions, some life limiting or life threatening, others less severe.13 Consultations at our service include individual ethics consultations between an ethicist and clinician; an ethicist attending a multidisciplinary team (MDT) meeting; and committee-based ethics consultations via a Clinical Ethics Response Group (CERG) meeting. The CERG at the hospital is made up of 50 members representing medical, nursing, allied health, pastoral care and law.13 However, CERG consultation meetings are attended by a subset of the CERG membership (at least one, and usually two to four from each membership category), in addition to clinicians involved in the care of the patient. A typical CERG consultation would therefore involve 15–18 attendees, though some are smaller, and some are quite a bit larger, where multiple clinical teams are involved. A clinical ethicist chairs the CERG consultation, facilitates the discussion, synthesises and summarises the conclusions reached and then prepares summary notes to be distributed to those who attended. The summary notes are then uploaded to the patient’s electronic medical record. The same process is used for an ethics MDT consultation, with the only difference being the number of participants (an ethics MDT involves only the multidisciplinary clinical team and the ethicist, not CERG members).

The service also has other roles beyond ethics case consultation for clinicians, including policy advice and organisational ethics, mediation, and engagement with patients and families. In our clinical ethics service, families do not attend CERG or MDT meetings, but an ethicist can organise to meet with parents before the CERG meeting. At other times the ethicist may specifically be requested to do so by the referring clinician or team, or the parents themselves. The service receives an average of 70 referrals per year (this figure is over the period 2019–2023), with approximately 50% of these being for a CERG or MDT ethics consultation with clinicians.

In this paper, we focus on the steps of the CD method used within the context of CERG and MDT ethics consultations. The CD method informs all other types of ethics consultations, but the steps are used more flexibly depending on the needs of the individual clinician, clinical team, or patient and family. This paper does not set out to compare or evaluate our method against other similar methods.23 24 Rather, we aim to make visible and accessible our ethics facilitation processes, including how they are designed to achieve outcomes of both moral resolution and support for moral agency in others. Our purpose is to contribute to and stimulate ongoing dialogue about the facilitation practices and goals of ethics consultations.

CD method: steps of facilitation

The CD method (figure 1) involves a series of seven steps. We have purposefully represented five of the steps as overlapping to show that moral thinking and deliberation do not necessarily occur in a strictly chronological order. Instead, each consultation discussion involves a particular combination of narratives about facts and circumstances of the clinical situation. The values, experiences and ethical concerns expressed during the meeting determine the flow of dialogue and ethical deliberation.9

Figure 1

Critical dialogue method: steps of facilitation.

Step 1: setting the scene (opening statement)

The ethicist’s opening statement or introduction begins with an overview of the goals of the discussion and a description of the steps of the enquiry. This enables participants to tune into the process by knowing what to expect in the time available and also to distinguish an ethics consultation from other clinical meetings where hierarchies may set the tone of the discussion and even determine who gets to speak and what type of contribution they can make.25 A key aim of this first step is to create a safe space in which participants can feel confident that their firm or tentative opinions are a valid contribution to the discussion. Making the consultation process steps transparent is a deliberate strategy to curate and establish a community of people coming together for the purpose of collaborative enquiry.26 (See box 1 for example opening statements.)

Box 1

Opening statement examples

The purpose of the clinical ethics consultation meeting is to conduct a thorough ethical analysis of the case at hand. The goal is not to make binding decisions for clinicians, but to consider the range of perspectives and experiences in the room as part of the process of identifying ethically justified and available options for proceeding.

As a group, our tasks are to:

  • Articulate the nature of the ethical issue/s or question/s involved.

  • Identify the range of possible options for proceeding from this point.

  • Identify and weigh up the ethical pros and cons of each option.

  • Identify options which are clearly ethically appropriate, or not.

In the time we have available, we will aim to:

  • Listen actively (including to hear both the content and the emotion within contributions).

  • Think critically (to consider the meaning and implications of what is being said rather than judging or evaluating the information).

  • Be comprehensive.

  • Identify and consider seriously the full range of possible views and positions.

We encourage you to bring your views and perspectives from your different clinical backgrounds and experiences.

The opening statement may also anticipate and distinguish between different types of listening that may be required in step 2. For example, empathic listening27 (involving cognitive understanding of what is being communicated in addition to a sensitivity to the speaker’s emotional state) and evaluative listening27 (involving a conscious attempt to critically consider the meaning and implications of a message being conveyed). The chair may also note the need to avoid making early assumptions about the meaning of facts and opinions.

Step 2: listening actively and without interruption

In the CD model, listening is a crucial aspect of creating a safe moral space. It requires the ethicist to model and enable a listening atmosphere which can shape the participatory nature of the dialogue within the consultation. Listening actively refers to being both curious and receptive to the speaker; the content of what they are saying, and feelings being conveyed.28

It means being open to the possibility of ‘unforeseeable’ or unexpected incoming opinions, interpretations and perspectives.29 Informed by narrative theory,30 active listening recognises that the clinician presenting a case is telling a story, and making meaning of the situation as they narrate it. They are not presenting neutral facts. Listening within an ethics consultation is different from listening to help or to solve a problem or conflict, as many health professionals have been trained to do. Instead, it requires a type of disciplined ‘self-forgetting’, or an awareness and then setting aside of one’s own concerns, prejudices and assumptions to create a more deeply receptive space.26

Listening without interruption or attentive silence31 sets a particular moral tone for the discussion. It demonstrates respect for the narrator’s own formulation of the situation, nurtures their moral agency21 and promotes thoughtful narration. As part of the process of active listening, in this step the ethicist may summarise what the clinician has said or ask questions that seek to clarify stated facts, issues and needs (box 2). This also models for others present, practical ways to listen and attend to each other.32

Box 2

Statements and questions which demonstrate active listening

  • What I have heard you raise is…

  • The way you described it, what happened is…

  • This is what I heard you say…have I got that right?

  • It sounds like this has a number of complex features, including

  • I’m hearing that there is some frustration, anger, confusion, uncertainty…

  • Can you explain what that would be like for the patient in this situation…

  • Could you tell us more about…

  • Could you explain what you meant by…

The ethicist moves into step 3 by inviting others to ask questions or contribute their perspectives or experiences about the situation. This prompt to expand ‘the story’ or contribute additional information is key to creating a receptive and safe space for others to share their perspectives and experiences.

Step 3: gathering information and perspectives

In this step, the ethicist explicitly invites others to contribute to the background or narrative of the case to promote shared understanding through sharing of perspectives.33 Differences in understanding of the facts sometimes come to light at this stage. This is an important advantage of the CD method, since such differences need to be brought to light and resolved to create the shared understanding that is needed for an ethically appropriate outcome to be reached. To encourage diverse contributions, care is taken to model a disposition of curiosity about different types of information that are brought forward. This may involve slowing down any propensity of participants to place a particular value or ethical significance on one aspect of information. The ethicist’s role is to ensure attendees feel safe to bring their views and experiences, to actively think for themselves as individual moral agents and also to think collaboratively with others.

This step represents a type of distributed enquiry process about an ethical problem so that the ethical issue is seen from multiple angles and perspectives (including clinical, practical, relational, experiential and cultural). The specific goals in this step are to bring to light facts, perspectives and experiences related to the ethical issue, and to raise participants’ awareness of their personal preconceptions, biases and tacit assumptions which might prevent full understanding of the situation.14 Participants may be encouraged by the ethicist to ask the referring clinician questions about the case as it has been presented. Jonsen’s four-box approach34 comprises useful domains of enquiry, which the ethicist may use to assist in categorising and making sense of shared information.

The facilitation approach used in step 3 is similar to the methodology of conducting semistructured qualitative interviews, where the researcher brings a research topic structure, but privileges the interviewee’s unique experience and concern about the situation under discussion.35 Although a clinical ethicist brings normative ethics concepts, values and principles through which the information discussed is ultimately filtered, as in qualitative interviews, this remains as a subtle and flexible structure which guides rather than specifically directs the gathering of information.

One paradoxical effect of this collective and open approach to gathering information about the ethical concern is that it may result in people feeling more confused about the situation and the nature of the ethical challenge it presents. Chalmers36 writes about this effect as confusion at a higher or more sophisticated level. For example, clinicians may initially believe the problem they are bringing to the ethics consultation is a question of whether or not to continue treatment or how to weigh up benefits and burdens. However, during the information gathering phase, it may become apparent that the initial formulation of the ethics concern may be less important than the effect of past experiences of the patient/family resulting in mistrust of clinicians, or there may be cultural and religious values that need to be addressed.

Although bringing in extra information and perspectives can confuse or unsettle6 37 participants’ considered views, it also has the effect of promoting ‘deeper and broader, less superficial and more sophisticated, more coherent and less contradictory’ thinking.26 In response to this effect, the ethicist may need to synthesise the ethical concerns expressed, and move the discussion towards clarifying and articulating ethics questions that are considered to be the most important.

At this time, the ethicist’s role shifts to gathering up the various concerns and experiences raised, and beginning to connect them to foundational ethical values or exploring how they intersect with each other. The ethicist may also draw from ethical theory and concepts to highlight the possible moral significance of what is being discussed. This facilitation step of synthesising and introducing ways of making sense of the problem works to cumulatively advance how the whole group understands and takes account of the ethical dimensions of a problem.26

In this step, the ethicist may also highlight points of disagreement about clinical or other factual aspects of the case to clarify what is agreed or contested (eg, in relation to the risks/benefits of a proposed clinical treatment), or to generate a clear picture and meaning of various clinical concerns presented. Clarifying what has been said so far also enables the referring clinician to amend their narrative. Examples of these synthesising and clarifying statements are listed in box 3.

Box 3

Gathering information

  • We have heard from the surgeon, but I’m wondering what the nurses who have been involved with this family can contribute from their perspective.

  • So far, we have mostly heard information about X. What about Y?

  • The social worker has talked about… [the family’s living arrangement] … and this perhaps provides some explanation for what we heard about… [turning up for appointments]. Does anyone have other information or ideas about… [this issue of non-attendance]?

  • What is known about… [the child’s view]?… [Has anyone spoken separately to the child?]

  • It sounds like one of the difficulties in this case is… [disagreement between clinicians and…, some uncertainty about prognosis/concern about limits of care].

  • As we’ve talked about the situation, an important distinction has emerged between x and y ways of understanding … [the family’s reason for refusing treatment], which makes a difference to our ethical thinking about the situation.

  • From the discussion so far, it appears there are different clinical views about… [the level of risk involved in one of the treatment options, the extent to which the patient understands the long-term effects of the procedure].

  • So far, a lot of concern has been expressed about… [the patient’s difficult living situation], which relates to the ethical question of… [how beneficial the treatment would be for the patient in the long-term].

Step 4: closing in on the ethical question(s)

In the same way that a hypothesis drives the nature and methods of a science experiment, formulating ethics questions works to focus the direction and nature of the ethics deliberation.38 The ethicist may formulate an ethics question or invite others to do so. The ethicist’s task is to ensure that ethics questions are framed to be practically normative. That is, they capture the core ethical issue to be addressed, and they prompt consideration of ethically permissible, obligatory or justifiable actions or decisions.

At this stage, a clinician may not have a clear ethical question related to their concern and may instead revert to describing the ethical complexity of the situation. To ensure the discussion moves from what has been ethically challenging to what should be done and/or how, the ethicist may need to suggest an ethics question or questions as a starting point (box 4). The ethicist can then invite attendees to refine the question(s) to ensure it captures the ethical challenges they are experiencing.

Box 4

Honing in on key ethics questions

  • Are there any aspects of the case discussion so far that raise a specific ethical question?

  • On the basis of the discussion so far, I’m going to suggest that the key ethical question here is… [whether the option of amputation rather than limb-saving reconstructive surgery should even be offered to the patient]. Does that sound like a reasonable formulation?

  • We started with the ethical question of … [whether this patient should be placed on the waiting list for transplant] but now we seem to have identified a more fundamental ethical question of …[whether the patient has actually had a chance to make a fully informed and considered decision].

Step 5: identifying ways of responding

In this step, the role of the ethicist is to move the conversation beyond why something is ethically challenging towards possible responses for resolving a clinician’s concrete ethical concern. This starts with identifying all possible and available courses of actions. While the ethicist has an active role in shaping and guiding the discussion, in the CD method, this is not a task done by the ethicist separate from participants. Instead, this step is a collaborative endeavour, which involves acknowledging the thinking, emotions and culture of those who must make the hard treatment decisions.38

One way of moving the thinking towards possible actions is to suggest worst case scenarios by posing ‘what if’ questions (box 5). Proposing extreme solutions is another way to assist in identifying what is clearly on or off the table as an ethically justified response, and so encourage clinicians to start thinking about feasible and ethically balanced options for proceeding that lie between the two extremes. It can subtly nudge participants to begin considering and evaluating competing ethical values, which is the focus of step 6. In this step, the ethicist encourages attendees to think about and suggest possible pathways that are somewhere in the middle, as well as more nuanced or complex options, such as start with A, but if that does not help, then move to B.

Box 5

Identifying possible options

  • This is clearly a very complex situation, with many uncomfortable interactions between clinicians and family members, but now we need to decide what is the ethical way forward. Would someone like to suggest what options are ethically on the table? [Is notification to Child Protection one of the options?]

  • Does anyone think it is reasonable to… [do exactly what the parents are asking for]?

  • What if… [the patient continues to insist that no information about her medical condition can be passed on to her partner, despite all efforts at counselling and education. In the end, would we think it ethically justified to breach her confidentiality?]

  • Many different attempts have been made to… [accommodate the patient’s religious beliefs]. Are we now at the point where… [we are not ethically obliged to offer more substantial accommodations]?

Step 6: identifying and weighing up ethical pros and cons of each possible response

Step 6 involves guiding attendees to identify which values are being promoted or diminished in the various proposed actions, so that ethical pros and cons can be identified and specified. The ethicist may ask for more detail about risks and benefits of different options or they may probe their impact (clinical, physiological, psychological, emotional, cultural) in the short term and the long term, and for different people involved. These types of considerations might not have been articulated in ethical terms before. For example, this might be where the consequences to a child of not proceeding with recommended treatment move from being stated in clinical/physiological terms to more overtly ethical terms such as subjective or objective burdens or harms, or what a decision means for a child’s interests.

To assist attendees to consider ethical dimensions, the ethicist may introduce established ethics knowledge and deliberative tools. For example, the ethicist may refer to standard approaches to some clashes between values, such as how the autonomy of a competent adult patient who is refusing treatment ultimately carries greater ethical weight than the benefits that clinicians believe treatment would bring.39 Or that when maintaining confidentiality clashes with preventing serious avoidable harm to another person, confidentiality has less ethical weight.39 In the paediatric context, if parents refuse medical treatment for a child, preventing serious harm to the child is considered to outweigh respect for parents’ wishes. Concepts such as the Zone of Parental Discretion40 and the Harm Principle41 are examples of ideas to guide ethical deliberation in these situations. In these ways, the ethicist shepherds the discussion so that it does not end up with an outcome that is clearly contrary to basic accepted normative standards. The aim of the ethics consultation is to identify ethically justifiable courses of action. The ethicist could also invite those present to think about other situations with the same ethical structure, to assist their thinking. However, many cases do not fall readily within a standard type, so a key task of the ethicist is to guide and facilitate a discussion about how to balance competing ethical considerations for the specific case at hand.

This is arguably the most difficult part of ethical deliberation, and the one where there is least guidance in the ethics literature. The ethicist may revisit the ethical concerns framed earlier in the discussion in somewhat general terms and start to anchor possible responses to ethical values so that clinicians can see how future actions promote or neglect some ethical values. The ethicist may also introduce ‘top-down’ framing of the ethical dilemma to demonstrate a principled, ethically justifiable resolution. The goal, however, is not to simply provide one specific solution but to prompt discussion of this reasoned approach and encourage consideration of alternative ethically justifiable or permissible resolutions. In the CD method, the ethicist does not attempt to over-ride or insist on a particular normative approach or solution, but instead to encourage and support clinicians to engage in valid and well-founded ethical deliberation and reasoning.

In this step, the ethicist may also ask each attendee to state their own intuitive sense of where the balance lies, and then guide the group to identify and discuss what reasons could be given for these intuitions.42 The intuitions can be delinked from the people who shared them, and put on the table as ideas for everyone to discuss, as an imaginative strategy43 which allows for more critical reflection. In formulating reasons, the group will be looking for features of the situation which would make one value carry more or less ethical weight or importance than others. Using comparisons with other situations where the balancing is more clear-cut may also be helpful.

In bringing this step to a close, the ethicist may synthesise the discussion, frame the practical actions or decisions in ethical terms and begin summing up and concluding while also providing attendees one further opportunity to clarify and refine the agreed responses or decisions (box 6).

Box 6

Identifying and weighing up values

  • We’ve talked about the risks of x…realistically, what is the probability that one of those complications could occur, and how dangerous would that be to the patient if it did happen?

  • The balance of risks and benefits is clearly a major ethical concern. Let’s go around the room and ask for people’s intuitions about where the balance lies. Then we can try to establish how these intuitions relate to the facts in front of us, and the ethical values we are working with.

  • One option that has been identified is… [talking with the child alone]. Let’s put that on the table and talk it through. How would that actually play out and what would be the impacts of it? If you embark on that course of action, how will you manage if… [the child tries to pull away when you come to take blood]?

  • What would… [continuing with treatment as the surrogate decision-maker requests] look or feel like for a patient? Are we really prepared to say that… [it is acceptable for the patient to go through that experience]?

  • So the bottom line question is how much subjective harm/bad experience is ethically acceptable to expose the child to, for the sake of allowing parents to feel they have done everything possible for their child?

  • It sounds like… [the risk of continuing with treatment A for this patient at this stage of their life is too high when compared with the benefits it will bring]. Have I read the room correctly on that?

OR

  • From my understanding of the discussion, the parents’ request for their child are thought by many or all in this room to be suboptimal, but there is not a strong view that they are causing such significant harm that you would override them.

Step 7: ethically justified outcomes

In this final step, the ethicist summarises what has been discussed including identifying agreed and ethically justified available options. In many cases, a single ethically appropriate response emerges from the discussion. In other discussions, it becomes apparent that there may be more than one ethically justifiable action to take. The ethicist may briefly return to some of the earlier information presented about the case, to make sure the group considers whether the normative conclusions reached are justifiable and feasible, and whether they address previously raised concerns (box 7).

Box 7

Prompts to reach ethical conclusions

  • So this is where we have got to …

  • We identified 3 possible ways forward from here, and after thorough consideration of the ethical pros and cons of each, we came to the view that x is most ethically appropriate, because…

  • It looks to me that we have noted some key ethical concerns and considerations [a,b,c] and identified two possible options [x, y] that look ethically feasible. This suggests that it would be ethically appropriate to do either. We did agree that doing z would not be ethically justifiable.

  • Is this an accurate summary of our discussion?

  • If you don’t agree, it’s important to say so.

  • So the plan is to…

Conclusions

In this paper, we have detailed the facilitation steps of our ethics consultation method—the CD method—and linked them to outcomes of identifying morally defensible and principled decisions and actions, and moral growth for those who attend the consultation. The need for this type of transparent alignment between facilitation methods and expected outcomes has previously been highlighted as important for clinical ethics work9 and is also a well-established concept in educational literature.44

With reference to ethicists as moral architects, each facilitation step aims to contribute to the design of a moral space which enables values and perspectives to be articulated, organised and then anchored to and weighed against values which encompass health ethics, cultural, religious and other values to determine an ethically justifiable response. The facilitation steps particularly focus on supporting and actively scaffolding participants’ knowledge and contributions as moral agents. Actively involving participants in the process is a crucial part of the ethics consultation process, so that any decisions and actions that are reached reflect participants’ own moral agency (rather than only the ethicist’s considered normative opinion). This approach aims to facilitate moral growth in all people involved in the process so they leave the meeting not just with a considered, ethically justified way forward in a case, but have also grown/learnt in various ways that will change how they think and engage with ethical challenges in the future.

The moral growth we have in mind is not limited to learning more sophisticated skills of logical or persuasive reasoning based on top-down application of codified theories and principles. Instead, the moral growth we envisage involves a disturbance, through collaborative discussion, of settled morality or routine processes of thinking about right and wrong responses to patient care embedded within the social, bureaucratic and cultural milieu of the hospital.45 We claim the CD method facilitates moral growth for attendees because their capacity to think and reason is taken seriously, and as a consequence, they are more likely to continue to participate in interpersonal negotiation and discussion of ethical values and moral norms including an openness to revising moral ideas.44

Finally, recognising similarities between clinical ethics facilitation processes and practices which seek to scaffold moral agency in others, opens up the future possibility of drawing from valuable literature about pedagogical approaches to scaffolding development and learning. This, in turn, can advance the scholarship of clinical ethics facilitation methods and demystify ethicists’ ‘moral space’ design and construction work.

Data availability statement

Data sharing not applicable as no datasets generated and/or analysed for this study.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.

References

Footnotes

  • Contributors All authors substantially contributed to the conception or design of the work, including drafting of the work or revising it critically for important intellectual content: SF, BK and LG. Final approval of the version to be published: SF, BK and LG. CD is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.