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Ligtenberg W, Stolper M, Molewijk B. Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation. BMC Med Ethics 2024; 25:49. [PMID: 38702729 PMCID: PMC11067180 DOI: 10.1186/s12910-024-01039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/18/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. METHOD Based on experiences and research into MCD facilitators' needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. RESULTS The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. CONCLUSIONS This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools.
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Affiliation(s)
- Wieke Ligtenberg
- Department Ethics, Law & Humanities, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Margreet Stolper
- Department Ethics, Law & Humanities, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bert Molewijk
- Clinical Ethics Support, Center for Medical Ethics, Oslo, Norway
- Department Ethics, Law & Humanities, Amsterdam UMC, Ethics Support & Research Integrity, Amsterdam, The Netherlands
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Long S, Irving K, Murphy C. Is therapeutic lying contradictory to person-centred care? Toward understanding the connection. Aging Ment Health 2024; 28:520-530. [PMID: 37139937 DOI: 10.1080/13607863.2023.2202632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/04/2023] [Indexed: 05/05/2023]
Abstract
AIM There is a lack of clarity about therapeutic lying in the context of everyday dementia care. This study provides conceptual clarity on how the term is used and considers the concept in relation to person-centred care. METHODS Rodgers' (1989) evolutionary framework of concept analysis was employed. A systematic multiple database search was conducted and supplemented with snowballing techniques. Data were analysed thematically through an iterative process of constant comparison. RESULTS This study highlighted that therapeutic lying is intended to be used in the person's best interests for the purpose of doing good. However, its potential for doing harm is also evident. Its use in the literature has increased with the general trend towards becoming more accepted in the discourse. A continuum emerged depending on the degree to which a lie departs from the truth. Emerging guidelines were also evident as to when a lie could or could not be justified. CONCLUSION The term therapeutic lying, was contrasted with aspects of person-centred care and was found to be problematic. We conclude that there may be more pragmatic ways of constructing language around the care of people with dementia which could be less stigmatising.
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Affiliation(s)
- Shirley Long
- Nursing, Community Health Organisation, Dublin, Ireland
| | - Kate Irving
- School of Nursing, Dublin City University, Dublin, Ireland
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Kröger C, Molewijk B, Muntinga M, Metselaar S. The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations. BMC Med Ethics 2024; 25:4. [PMID: 38172942 PMCID: PMC10765795 DOI: 10.1186/s12910-023-00992-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/01/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice. METHODS We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation. RESULTS The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur. CONCLUSIONS The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.
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Affiliation(s)
- Charlotte Kröger
- Department of Ethics, Law and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1089a, Amsterdam, The Netherlands.
- Netherlands Defense Academy, Breda, The Netherlands.
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1089a, Amsterdam, The Netherlands
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Maaike Muntinga
- Department of Ethics, Law and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1089a, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, De Boelelaan 1089a, Amsterdam, The Netherlands
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Vrouenraets LJJJ, de Vries ALC, Arnoldussen M, Hannema SE, Lindauer RJL, de Vries MC, Hein IM. Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians. Eur Child Adolesc Psychiatry 2023; 32:2343-2361. [PMID: 36115898 PMCID: PMC10576681 DOI: 10.1007/s00787-022-02076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.
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Affiliation(s)
- Lieke Josephina Jeanne Johanna Vrouenraets
- Department of Medical Psychology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Emma Children's Hospital, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ramón J L Lindauer
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Vries ALC, Molewijk BC. GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care. PATIENT EDUCATION AND COUNSELING 2023; 114:107854. [PMID: 37356115 DOI: 10.1016/j.pec.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC). METHODS Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders' needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool. RESULTS The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges. CONCLUSION The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM. PRACTICE IMPLICATIONS GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.
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Affiliation(s)
- Karl Gerritse
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Casper Martens
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Medical Psychology, Amsterdam UMC location VUmc, location Vrije Universiteit Amsterdam, the Netherlands.
| | - Annelou L C de Vries
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Child and Adolescent Psychiatry, Amsterdam UMC location University of Amsterdam, the Netherlands.
| | - Bert C Molewijk
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
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Hem MH, Molewijk B, Weimand B, Pedersen R. Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review. Front Public Health 2023; 10:960815. [PMID: 36711422 PMCID: PMC9877517 DOI: 10.3389/fpubh.2022.960815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
Background Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness? Methods A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit. Results Twelve studies-both qualitative and quantitative-were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges. Conclusions Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.
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Affiliation(s)
- Marit Helene Hem
- Norwegian University of Science and Technology (NTNU) Social Research, Trondheim, Norway,Faculty of Health Studies, VID Specialized University, Oslo, Norway
| | - Bert Molewijk
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,Department Ethics, Law and Humanities, Amsterdam University Medical Centre (UMC) and Vrije Universiteit, Amsterdam, Netherlands
| | - Bente Weimand
- University of South-Eastern Norway, Faculty of Health and Social Sciences, Drammen, Norway,Division Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | - Reidar Pedersen
- Centre for Medical Ethics, Faculty of Medicine, University of Oslo, Oslo, Norway,*Correspondence: Reidar Pedersen ✉
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals' ethical challenges and norms regarding decision-making in gender-affirming medical care. BMC Med Ethics 2022; 23:139. [PMID: 36575401 PMCID: PMC9793857 DOI: 10.1186/s12910-022-00880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands. METHODS In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents' explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged. RESULTS Respondents' ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC's guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI. CONCLUSIONS This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.
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Affiliation(s)
- Karl Gerritse
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Casper Martens
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Marijke A. Bremmer
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Baudewijntje P. C. Kreukels
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Medical Psychology, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Fijgje de Boer
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Bert C. Molewijk
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
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Molewijk B. Materialising and fostering organisational morisprudence through ethics support tools. JOURNAL OF MEDICAL ETHICS 2022; 48:991-992. [PMID: 36384891 DOI: 10.1136/jme-2022-108692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
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de Snoo-Trimp J, de Vries A, Molewijk B, Hein I. How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool. BMC Med Ethics 2022; 23:96. [PMID: 36138384 PMCID: PMC9494804 DOI: 10.1186/s12910-022-00837-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
Background Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care. Methods The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care. Results Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. Discussion Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00837-1.
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Affiliation(s)
- Janine de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.
| | - Annelou de Vries
- Department of Child and Adolescent Psychiatry, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.,Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Irma Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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Metselaar S, van Schaik M, Widdershoven G. CURA: A clinical ethics support instrument for caregivers in palliative care. Nurs Ethics 2022; 29:1562-1577. [PMID: 35622018 PMCID: PMC9667086 DOI: 10.1177/09697330221074014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article presents an ethics support instrument for healthcare professionals
called CURA. It is designed with a focus on and together with nurses and nurse
assistants in palliative care. First, we shortly go into the background and the
development study of the instrument. Next, we describe the four steps CURA
prescribes for ethical reflection: (1) Concentrate, (2) Unrush, (3) Reflect, and
(4) Act. In order to demonstrate how CURA can structure a moral reflection among
caregivers, we discuss how a case was discussed with CURA at a psychogeriatric
ward of an elderly care home. Furthermore, we go into some considerations
regarding the use of the instrument in clinical practice. Finally, we focus on
the need for further research on the effectiveness and implementation of
CURA.
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Affiliation(s)
- Suzanne Metselaar
- Suzanne Metselaar, Department of Ethics,
Law & Humanities, Amsterdam University Medical Centers, De Boelelaan 1089a,
Amsterdam 1081 HV, The Netherlands.
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van Schaik MV, Pasman HR, Widdershoven G, Metselaar S. Participatory development of CURA, a clinical ethics support instrument for palliative care. BMC Med Ethics 2022; 23:32. [PMID: 35321698 PMCID: PMC8942152 DOI: 10.1186/s12910-022-00772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Existing clinical ethics support (CES) instruments are considered useful. However, users report obstacles in using them in daily practice. Including end users and other stakeholders in developing CES instruments might help to overcome these limitations. This study describes the development process of a new ethics support instrument called CURA, a low-threshold four-step instrument focused on nurses and nurse assistants working in palliative care.
Method We used a participatory development design. We worked together with stakeholders in a Community of Practice throughout the study. Potential end users (nurses and nurse assistants in palliative care) used CURA in several pilots and provided us with feedback which we used to improve CURA. Results We distinguished three phases in the development process. Phase one, Identifying Needs, focused on identifying stakeholder and end user needs and preferences, learning from existing CES instruments, their development and evaluation, and identify gaps. Phase two, Development, focused on designing, developing, refining and tailoring the instrument on the basis of iterative co-creation. Phase three, Dissemination, focused on implementation and dissemination. The instrument, CURA, is a four-step low-threshold instrument that fosters ethical reflection. Conclusions Participatory development is a valuable approach for developing clinical ethics support instruments. Collaborating with end users and other stakeholders in our development study has helped to meet the needs and preferences of end users, to come up with strategies to refine the instrument in order to enhance its feasibility, and to overcome reported limitations of existing clinical ethics instruments.
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Affiliation(s)
- Malene Vera van Schaik
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands.
| | - H Roeline Pasman
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands
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Gerritse K, Hartman LA, Bremmer MA, Kreukels BPC, Molewijk BC. Decision-making approaches in transgender healthcare: conceptual analysis and ethical implications. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:687-699. [PMID: 34008081 PMCID: PMC8557156 DOI: 10.1007/s11019-021-10023-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/01/2021] [Indexed: 05/10/2023]
Abstract
Over the past decades, great strides have been made to professionalize and increase access to transgender medicine. As the (biomedical) evidence base grows and conceptualizations regarding gender dysphoria/gender incongruence evolve, so too do ideas regarding what constitutes good treatment and decision-making in transgender healthcare. Against this background, differing care models arose, including the 'Standards of Care' and the so-called 'Informed Consent Model'. In these care models, ethical notions and principles such as 'decision-making' and 'autonomy' are often referred to, but left unsubstantiated. This not only transpires into the consultation room where stakeholders are confronted with many different ethical challenges in decision-making, but also hampers a more explicit discussion of what good decision-making in transgender medicine should be comprised of. The aim of this paper is to make explicit the conceptual and normative assumptions regarding decision-making and client autonomy underpinning the 'Standards of Care' and 'Informed Consent Model' currently used in transgender care. Furthermore, we illustrate how this elucidation aids in better understanding stakeholders' ethical challenges related to decision-making. Our ethical analysis lays bare how distinct normative ambiguities in both care models influence decision-making in practice and how foregrounding one normative model for decision-making is no moral panacea. We suggest that the first steps towards good decision-making in gender-affirming medical care are the acknowledgement of its inherent normative and moral dimensions and a shared, dialogical approach towards the decision-making process.
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Affiliation(s)
- Karl Gerritse
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands.
- Department of Ethics, Law and Humanities, Amsterdam UMC, location VUmc, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
- Department of Psychiatry, Amsterdam UMC, Location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands.
| | - Laura A Hartman
- Department of Ethics, Law and Humanities, Amsterdam UMC, location VUmc, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
- The Netherlands Centre for Ethics and Health (CEG) and the Council of Public Health & Society (RVS) The Netherlands, Parnassusplein 5, 2511 VX, Den Haag, The Netherlands
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
- Department of Psychiatry, Amsterdam UMC, Location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC, location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC, Location VUmc, de Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - Bert C Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, location VUmc, de Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands
- Faculty of Medicine, Center for Medical Ethics, Institute of Health and Society, University of Oslo, Kirkeveien 166, 0450, Oslo, Norway
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Fischer-Grönlund C, Brännström M, Zingmark K. The 'one to five' method - A tool for ethical communication in groups among healthcare professionals. Nurse Educ Pract 2021; 51:102998. [PMID: 33639607 DOI: 10.1016/j.nepr.2021.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/24/2022]
Abstract
Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.
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Affiliation(s)
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology, Sweden.
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Vrouenraets LJJJ, Hartman LA, Hein IM, de Vries ALC, de Vries MC, Molewijk BAC. Dealing with Moral Challenges in Treatment of Transgender Children and Adolescents: Evaluating the Role of Moral Case Deliberation. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2619-2634. [PMID: 32592076 PMCID: PMC7497454 DOI: 10.1007/s10508-020-01762-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 05/10/2023]
Abstract
Treatment teams providing affirmative medical transgender care to young people frequently face moral challenges arising from the care they provide. An adolescent's capacity to consent, for example, could raise several issues and challenges. To deal with these challenges more effectively, several Dutch treatment teams started using a relatively well-established form of clinical ethics support (CES) called Moral Case Deliberation (MCD). MCD is a facilitator-led, collective moral inquiry based on a real case. This study's purpose is to describe the teams' perceived value and effectiveness of MCD. We conducted a mixed methods evaluation study using MCD session reports, individual interviews, focus groups, and MCD evaluation questionnaires. Our results show that Dutch transgender care providers rated MCD as highly valuable in situations where participants were confronted with moral challenges. The health care providers reported that MCD increased mutual understanding and open communication among team members and strengthened their ability to make decisions and take action when managing ethically difficult circumstances. However, the health care providers also expressed criticisms of MCD: some felt that the amount of time spent discussing individual cases was excessive, that MCD should lead to more practical and concrete results, and that MCD needed better integration and follow-up in the regular work process. We recommend future research on three matters: studying how MCD contributes to the quality of care, involvement of transgender people themselves in MCD, and integration of CES into daily work processes.
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Affiliation(s)
| | - Laura A Hartman
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert A C Molewijk
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
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