Meeting the ethical needs of doctors

Making the (Business) Case for Clinical Ethics Support in the UK

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals.

Managing ethical issues in patient care and the need for clinical ethics support

OBJECTIVE

To investigate the range, frequency and management of ethical issues encountered by clinicians working in hospitals in New South Wales (NSW), Australia.

METHODS

A cross-sectional survey was conducted of a convenience sample of 104 medical, nursing and allied health professionals in two NSW hospitals.

RESULTS

Some respondents did not provide data for some questions, therefore the denominator is less than 105 for some items. Sixty-two (62/104; 60%) respondents reported occasionally to often having ethical concerns. Forty-six (46/105; 44%) reported often to occasionally having legal concerns. The three most common responses to concerns were: talking to colleagues (96/105; 91%); raising the issue in a group forum (68/105; 65%); and consulting a relevant guideline (64/105; 61%). Most respondents were highly (65/99; 66%) or moderately (33/99; 33%) satisfied with the ethical environment of the hospital. Twenty-two (22/98; 22%) were highly satisfied with the ethical environment of their department and 74 (74/98; 76%) were moderately satisfied. Most (72/105; 69%) respondents indicated that additional support in dealing with ethical issues would be helpful.

CONCLUSION

Clinicians reported frequently experiencing ethical and legal uncertainty and concern. They usually managed this by talking with colleagues. Although this approach was considered adequate, and the ethics of their hospital was reported to be satisfactory, most respondents indicated that additional assistance with ethical and legal concerns would be helpful. Clinical ethics support should be a priority of public hospitals in NSW and elsewhere in Australia.

The use of clinical ethics committees in infertility clinics

Clinical ethics committees (CECs) are increasingly used in UK health care (Slowther et al., 2004a). However, there has been little debate about their use in infertility units. Current HFEA guidance on CECs encourages their use in aiding ethical decision making but this is not required by the code of practice or obligated by law. It will be argued that the HFEA should strengthen its guidance on CECs by recommending that all infertility clinics should have a designated CEC (where possible) as a matter of good practice and such a recommendation should be formalised in the HFEA's Code of practice. The article will conclude with recommendations for a particular model of CECs in infertility units.

On the Ethics Committee: The Expert Member, the Lay Member and the Absentee Ethicist

This paper considers the roles and definitions of expert and lay members of ethics committees, focussing on those given by the National Research Ethics Service which is mandated to review all research conducted in National Health Service settings in the United Kingdom. It questions the absence of a specified position for the ‘professional ethicist’ and suggests that such individuals will often be lay members of ethics committees, their participation being a reflection of their academic interest and expertise.

The absence of a specified position for professional ethicists and the concomitant but implicit denial of ethical expertise appear to be an anomalous state of affairs if one considers that the training offered to members of ethics committees is often delivered by academic ethicists. It is suggested that this is based on a misunderstanding of the concept ‘ethical expertise’ and that properly understood the ethicist can assist the work of ethics committees by drawing on their expert knowledge.

Clinical Ethics Committees: a due process wasteland?

The development of clinical ethic support in the UK arguably brings with it a series of legal questions, which need to be addressed. Most particularly, these concern questions of due process and formal justice, which I argue are central to the provision of appropriate ethical advice. In this article, I will compare the UK position with the more developed system in the USA, which often provides a template for development in the UK. While it is not argued that the provision of clinical ethics support in the UK will necessarily follow the path mapped in the USA, there are lessons that can be learned from the US experience – particularly in terms of attention to process – from which UK clinical ethics support service might well benefit.

Teaching medical ethics to undergraduate students in post-apartheid South Africa, 2003 2006

The apartheid ideology in South Africa had a pervasive influence on all levels of education including medical undergraduate training. The role of the health sector in human rights abuses during the apartheid era was highlighted in 1997 during the Truth and Reconciliation Commission hearings. The Health Professions Council of South Africa (HPCSA) subsequently realised the importance of medical ethics education and encouraged the introduction of such teaching in all medical schools in the country. Curricular reform at the University of Stellenbosch in 1999 presented an unparalleled opportunity to formally introduce ethics teaching to undergraduate students. This paper outlines the introduction of a medical ethics programme at the Faculty of Health Sciences from 2003 to 2006, with special emphasis on the challenges encountered. It remains one of the most comprehensive undergraduate medical ethics programmes in South Africa. However, there is scope for expanding the curricular time allocated to medical ethics. Integrating the curriculum both horizontally and vertically is imperative. Implementing a core curriculum for all medical schools in South Africa would significantly enhance the goals of medical education in the country.

The need for a clinical ethics service and its goals in a community healthcare service centre: a survey

OBJECTIVES

To (1) assess whether according to healthcare providers, the creation of an ethics service responds to a need; (2) assess the importance of an ethics service for healthcare providers; (3) determine what ethics services should be offered and the preferred formats of delivery; and (4) identify key issues to be initially dealt with by the ethics service.

DESIGN

A survey of healthcare providers in Québec's Centre Local de Services Communautaires (CLSC), healthcare institutions dedicated to community health and social services.

FINDINGS

96 (95%) respondents agreed that an ethics service was needed, and on average the ethics service project was judged to be very important. Preferred formats for ethics consultation and education were identified, as well as key concerns such as the need of respect for the patient as a person, elder abuse and ethical issues in home care.

CONCLUSION

This survey is helping in the implementation of an ethics service and can guide others in similar healthcare institutions.