Reconsidering ‘ethics’ and ‘quality’ in healthcare research: the case for an iterative ethical paradigm

Abstract

BackgroundUK-based research conducted within a healthcare setting generally requires approval from the National Research Ethics Service. Research ethics committees are required to assess a vast range of proposals, differing in both their topic and methodology. We argue the methodological benchmarks with which research ethics committees are generally familiar and which form the basis of assessments of quality do not fit with the aims and objectives of many forms of qualitative inquiry and their more iterative goals of describing social processes/mechanisms and making visible the complexities of social practices. We review current debates in the literature related to ethical review and social research, and illustrate the importance of re-visiting the notion of ethics in healthcare research.DiscussionWe present an analysis of two contrasting paradigms of ethics. We argue that the first of these is characteristic of the ways that NHS ethics boards currently tend to operate, and the second is an alternative paradigm, that we have labelled the ‘iterative’ paradigm, which draws explicitly on methodological issues in qualitative research to produce an alternative vision of ethics. We suggest that there is an urgent need to re-think the ways that ethical issues are conceptualised in NHS ethical procedures. In particular, we argue that embedded in the current paradigm is a restricted notion of ‘quality’, which frames how ethics are developed and worked through. Specific, pre-defined outcome measures are generally seen as the traditional marker of quality, which means that research questions that focus on processes rather than on ‘outcomes’ may be regarded as problematic. We show that the alternative ‘iterative’ paradigm offers a useful starting point for moving beyond these limited views.SummaryWe conclude that a ‘one size fits all’ standardisation of ethical procedures and approach to ethical review acts against the production of knowledge about healthcare and dramatically restricts what can be known about the social practices and conditions of healthcare. Our central argument is that assessment of ethical implications is important, but that the current paradigm does not facilitate an adequate understanding of the very issues it aims to invigilate.

The co-construction of medical disposals in emergency medicine consultations

“…We argue that although the participants recorded may have reacted to the use of the recording equipment, in particular the camera, we feel any reaction will have been of significantly less magnitude in comparison to studies using interview methods where researchers have "an active and ongoing part in soliciting reports" (Potter & Shaw, 2018: 189). We have written elsewhere (Stevenson et al 2015) on the ethical dilemmas of this research and we will not discuss this in any detail here. All participants were given a range of options in relation to sharing the data collected which ranged from using anonymised extracts to sharing original data for the purposes of education and research.…”

Ethics by Design. Exploring Experiences of Harmony and Dissonance in Ethical Practice.

“…The application of approaches that are cyclical, integrative, use both qualitative and quantitative methods, and focus on the engagement and empowerment of people (Khanlou & Peter, 2004) towards transformational change are often significantly different to those traditionally adopted across health and care. Similarly, the use of iterative and emergent methodological approaches frequently do not match the benchmarks with which research ethics committees are familiar (Stevenson et al 2015). However, this is not limited to the health context alone, even across academic institutions processes for ethical review can differ significantly (Farrimond, 2013;Vadeboncoeur et al, 2016).…”

“…Research is defined by the Health Research Authority (2009) as the quest "to derive generalisable new knowledge", typically requiring clear research questions, a defined methodology, and usually requiring Research Ethics Committee (REC) approval. The ethical framework that provides governance for all studies involving NHS patients, staff, and/or taking place on NHS premises is largely designed to assess clinical or quantitative research and can seem inharmonious with qualitative approaches to research (Stevenson et al, 2015). Banks (2013) acknowledges the difficulties in adapting and aligning qualitative social research approaches with the processes and procedures of institutional ethical review.…”

“…Similarly, NHS ethics is framed around the protection of participants and the mitigation of risk. The Health Research Authority (HRA) that governs NHS ethics stems from historical cases of misconduct and clinical trials, (Stevenson et al, 2015) aiming to do no harm which in turn has cultivated a risk-averse working culture. Research that is bound by ethical governance and only explicit in word but not in action is in Tonkinwise' (2004) view unethical as it automates a human response resulting in "unconscious" behaviours, creating an unsustainable "way of being".…”

The gift in A&E: re-framing the medical case presentation through Mauss

“…This question led to a research design intended to find out how junior doctors did their work, rather than specifically the difficulties they faced, a move intended to study their involvement in decision-making rather than their 'novice' status. Our study was a pilot exercise, to establish how work practices in an A&E department could be studied empirically, since this setting poses particular challenges (Stevenson et al, 2015).…”