Exploration of Clinical Ethics Consultation in Uganda: A case study of Uganda Cancer Institute

Introduction

Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESS) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence of mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda.

Methodology

This qualitative study utilized in-depth-interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers, who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook.

Results

There was no formal committee nor mechanism utilized to resolve ethical dilemmas at the UCI. The study uncovered six fora where ethical dilemmas were addressed: individual consultations, tumor board meetings, morbidity and mortality meetings, core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas.

Conclusion

The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

Toward a Social Bioethics Through Interpretivism: A Framework for Healthcare Ethics

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term "social bioethics." Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare.

Disparities in Clinical Ethics Consultation among Hospitalized Children: A Case-Control Study

OBJECTIVE

To identify sociodemographic factors associated with pediatric clinical ethics consultation (CEC).

STUDY DESIGN

Matched, case-control study at a single center, tertiary pediatric hospital in the Pacific Northwest. Cases (patients hospitalized January 2008-December 2019 with CEC) were compared with controls (those without CEC). We determined the association of the outcome (CEC receipt) with exposures (race/ethnicity, insurance status, and language for care) using univariate and multivariable conditional logistic regression.

RESULTS

Of 209 cases and 836 matched controls, most cases identified as white (42%), had public/no insurance (66%), and were English-speaking (81%); most controls identified as white (53%), had private insurance (54%), and were English-speaking (90%). In univariate analysis, patients identifying as Black (OR: 2.79, 95% CI: 1.57, 4.95; P < .001), Hispanic (OR: 1.92, 95% CI: 1.24, 2.97; P = .003), with public/no insurance (OR: 2.21, 95% CI: 1.58, 3.10; P < .001), and using Spanish language for care (OR: 2.52, 95% CI: 1.47, 4.32; P < .001) had significantly increased odds of CEC, compared with patients identifying as white, using private insurance, and using English for care, respectively. In multivariable regression, Black race (adjusted OR: 2.12, 95% CI: 1.16, 3.87; P = .014) and public/no insurance (adjusted OR: 1.81, 95% CI: 1.22, 2.68; P = .003) remained significantly associated with receipt of CEC.

CONCLUSIONS

We found disparities in receipt of CEC by race and insurance status. Further study is needed to determine the causes of these disparities.

Moral expertise revisited

In recent years, there has been a lively (bio-)ethical debate on the nature of moral expertise and the concept of moral experts. However, there is currently no common ground concerning most issues. Against this background, this paper has two main goals. First, in more general terms, it examines some of the problems concerning moral expertise and experts, with a special focus on moral advice and testimony. Second, it applies the results in the context of medical ethics, especially in the clinical setting. By situating the debate in the clinical setting, one arrives at some important conclusions to better understand the relevant concepts and vital problems in the general discussion on moral expertise and the requirements of who counts as a moral expert.

Addressing racism in the healthcare encounter: The role of clinical ethics consultants

Justice is a core principle in bioethics, and a fair opportunity to achieve health is central to this principle. Racism and other forms of prejudice, discrimination, or bias directed against people on the basis of their membership in a particular racial or ethnic group are known contributors to health inequity, defined as unjust differences in health or access to care. Though hospital-based ethics committees and consultation services routinely address issues of justice that arise in the course of patient care, there is variability in whether and how racism and other causes of health inequities are addressed. In this paper, we describe a novel structure and process for addressing health equity within clinical ethics consultation. In addition, we discuss the barriers and challenges to its success, many of which are rooted in the identities, norms and assumptions that underlie traditional clinical ethics consultation. We offer pragmatic recommendations and conclude with unresolved questions that remain as we work to adapt the structure of a clinical ethics consultation service to improve attention to issues of health equity and promote anti-racism in patient care and institutional policy.

Jewish Values in Medical Decision-making for Unrepresented Patients: A Ritualized Approach

Determining appropriate care for patients who cannot speak for themselves is one of the most challenging issues in contemporary healthcare and medical decision-making. While there has been much discussion relating to patients who left some sort of instructions, such as an advance directive, or have someone to speak on their behalf, less has been written on caring for patients who have nobody at all available to speak for them. It is thus crucial to develop clear and rigorous guidelines to properly care for these patients. The Jewish tradition offers an important perspective on caring for unrepresented patients and determining approaches to guide care providers. This article develops an understanding of fundamental Jewish principles that can provide clear guidance in navigating this challenge. It applies those values to a specific set of suggested behaviors, one of which adds a novel ritualized component to what has been recommended by bioethicists in the past.

Learning from Covid

Mrs. Clark's case was an ordinary consult in an extraordinary time. She was refusing dialysis, but the psychiatric unit had concluded that she lacked capacity for such decision-making. The only difference between Mrs. Clark's current hospitalization and the last two was that it was April 2020 and a virus called Covid-19 had overtaken our hospital. As the chief of Montefiore Medical Center's bioethics service, when I received a consult before the virus, I always saw the patient. Whether the patient had been in a vegetative state for a day or for years, it didn't matter. I would lay my hand on a leg or an arm and observe. But Covid-19 enforced physical boundaries between my team and our patients; I would not be able to meet Mrs. Clark. Our hospital responded to the attack on human connection by getting creative. We asked ourselves, which tools are still available to us? Answering this involved, in part, finding new ways for our team of clinical ethicists to support the clinicians caring for Mrs. Clark.

Counter-Transference and the Clinical Ethics Encounter: What, Why, and How We Feel During Consultations

One of the more draining aspects of being a clinical ethicist is dealing with the emotions of patients, family members, as well as healthcare providers. Generally, by the time a clinical ethicist is called into a case, stress levels are running high, patience is low, and interpersonal communication is strained. Management of this emotional burden of clinical ethics is an underexamined aspect of the profession and academic literature. The emotional nature of doing clinical ethics consultation may be better addressed by utilizing concepts and tools from clinical psychology. Management of countertransference, the natural emotional reaction by the therapist toward the patient, is a widely discussed topic in the psychotherapeutic literature. This concept can be adapted to the clinical ethics encounter by broadening it beyond the patient-therapist relationship to refer to the ethics consultant's emotional response toward the patient, the family, or other members the healthcare team. Further, it may aid the consultant because a recognition of the source and nature of these reactions can help maintain 'critical distance' and minimize bias in the same way that a psychologist maintains neutrality in psychotherapy. This paper will offer suggestions on how to manage these emotional responses and their burden in the clinical ethics encounter, drawing upon techniques and strategies recommended in the psychotherapeutic literature. Using these techniques may improve consultation outcomes and reduce the emotional burden on the clinical ethicist.

Taxonomizing Views of Clinical Ethics Expertise

Our aim in this article is to bring some clarity to the clinical ethics expertise debate by critiquing and replacing the taxonomy offered by the Core Competencies report. The orienting question for our taxonomy is: Can clinical ethicists offer justified, normative recommendations for active patient cases? Views that answer "no" are characterized as a "negative" view of clinical ethics expertise and are further differentiated based on (a) why they think ethicists cannot give justified normative recommendations and (b) what they think ethicists can offer, if they cannot offer recommendations. Views that answer "yes" to the orienting question are characterized as a "positive" view of clinical ethics expertise. Positive views are distinguished according to four additional questions. First (P1), how are those recommendations generated? Second (P2), what is the nature of the recommendations? Third (P3), we ask, how are the recommendations justified? And finally (P4), how are the recommendations communicated?

Discovering What Matters: Interrogating Clinician Responses to Ethics Consultation

Against the background assumptions that (a) knowing what clinical ethics consultation represents to those with whom ethics consultants work most closely is a necessary component for being responsible in the practice of ethics consultation, and (b) the complexities of soliciting and understanding colleague evaluations require another inherent responsibility for the methods by which ethics consultations are evaluated, in this article we report our experience soliciting, analyzing, and trying to understand retrospective evaluations of our Clinical Ethics Consultation Service. These evaluations were collected through a quality assessment effort at our institution. Drawing from the qualitative elements of our survey instrument, we describe unexpected variations among the requests for ethics consultation and the retrospective reports from those colleagues making the requests. Focusing on just one aspect - the reason for request - raised several core questions about how we should evaluate those retrospective reports, what could be learned from the differences that we were now encountering, and what we could learn about the process of evaluating our practices. Working through these questions, we suggest several issues to consider in ongoing efforts to describe and evaluate clinical ethics consultation: the role of time and memory in evaluating retrospective evaluations, the importance of attending to the language of moral shift or disruption with which our colleagues describe their experiences, and how to understand the role of ethics consultation in creating 'moral space' (a la Margaret Urban Walker's conception) for colleagues to process their moral experiences.

Growing an ethics consultation service: A longitudinal study examining two decades of practice

BACKGROUND

Little is known about what factors may contribute to the growth of a consultation service or how a practice may change or evolve across time.

METHODS

This study examines data collected from a busy ethics consultation service over a period of more than two decades.

RESULTS

We report a number of longitudinal findings that represent significant growth in the volume of ethics consultation requests from 19 in 1990 to 551 in 2013, as well as important changes in the patient population for which ethics help is requested. The findings include (1) a steady growth in requests from primary care providers (e.g., physicians and nurses), as well as increases in ancillary services (e.g., social workers); (2) a decrease in length of stay (days) before ethics help is requested; (3) an increase in the reasons that individuals ask for help from ethics; (4) an upsurge in consults requests from areas outside the intensive care unit (ICU); (5) a decrease in patients that died during hospitalization (e.g., live discharges); and (6) growth in the numbers of patients lacking decision-making capacity.

CONCLUSIONS

We believe the increases in consult requests reflect appropriate and necessary growth because recent consultations have also been associated with consultations requiring (7) additional interventions and (8) reasonably high time intensity scores.

Development of Bioethics and Clinical Ethics in Bulgaria

BACKGROUND

Bioethics and clinical ethics emerged from the classical medical ethics in the 1970s of the 20th century. Both fields are new for the Bulgarian academic tradition.

AIM

The aims of this paper were to demarcate the subject fields of medical ethics, bioethics, and clinical ethics, to present the developments in the field of medical ethics in Bulgaria, to delineate the obstacles to effective ethics education of medical professionals, and to present the results of the application of an adapted bottom-up methodology for clinical ethics consultation in several clinical units in Bulgaria.

MATERIALS AND METHODS

Extended literature review and application of an adapted METAP methodology for clinical ethics consultation in six clinical units in the Northern Bulgaria between May 2013 and December 2014.

RESULTS

Teaching of medical ethics in Bulgaria was introduced in the 1990s and still stands mainly as theoretical expertise without sufficient dilemma training in clinical settings. Earlier studies revealed need of clinical ethics consultation services in our country. METAP methodology was applied in 69 ethics meetings. In 31.9% of them non-medical considerations affected the choice of treatment and 34.8% resulted in reaching consensus between the team and the patient. Participants' opinion about the meetings was highly positive with 87.7% overall satisfaction.

CONCLUSION

Development of bioethics in Bulgaria follows recent worldwide trends. Several ideas could be applied towards increasing the effectiveness of ethics education. Results of the ethics meetings lead to the conclusion that it is a successful and well accepted approach for clinical ethics consultation with a potential for wider introduction in our medical practice.

Clinical Ethics Consultants are not "Ethics" Experts-But They do Have Expertise

The attempt to critique the profession of clinical ethics consultation by establishing the impossibility of ethics expertise has been a red herring. Decisions made in clinical ethics cases are almost never based purely on moral judgments. Instead, they are all-things-considered judgments that involve determining how to balance other values as well. A standard of justified decision-making in this context would enable us to identify experts who could achieve these standards more often than others, and thus provide a basis for expertise in clinical ethics consultation. This expertise relies in part on what Richard Zaner calls the "expert knowledge of ethical phenomena" (1988, 8).

Expertise, Ethics Expertise, and Clinical Ethics Consultation: Achieving Terminological Clarity

The language of ethics expertise has become particularly important in bioethics in light of efforts to establish the value of the clinical ethics consultation (CEC), to specify who is qualified to function as a clinical ethics consultant, and to characterize how one should evaluate whether or not a person is so qualified. Supporters and skeptics about the possibility of ethics expertise use the language of ethics expertise in ways that reflect competing views about what ethics expertise entails. We argue for clarity in understanding the nature of expertise and ethics expertise. To be an ethics expert, we argue, is to be an expert in knowing what ought to be done. Any attempt to articulate expertise with respect to knowing what ought to be done must include an account of ethics that specifies the nature of moral truth and the means by which we access this truth or a theoretical account of ethics such that expertise in another domain is linked to knowing or being better at judging what ought to be done and the standards by which this "knowing" or "being better at judging" is determined. We conclude with a discussion of the implications of our analysis for the literature on ethics expertise in CEC. We do think that there are clear domains in which a clinical ethics consultant might be expert but we are skeptical about the possibility that this includes ethics expertise. Clinical ethics consultants should not be referred to as ethics experts.

A Pilot Evaluation of Portfolios for Quality Attestation of Clinical Ethics Consultants

Although clinical ethics consultation is a high-stakes endeavor with an increasing prominence in health care systems, progress in developing standards for quality is challenging. In this article, we describe the results of a pilot project utilizing portfolios as an evaluation tool. We found that this approach is feasible and resulted in a reasonably wide distribution of scores among the 23 submitted portfolios that we evaluated. We discuss limitations and implications of these results, and suggest that this is a significant step on the pathway to an eventual certification process for clinical ethics consultants.