Team members perspectives on conflicts in clinical ethics committees

Abstract

Background: Clinical ethics committees have been broadly implemented in university hospitals, general hospitals and nursing homes. To ensure the quality of ethics consultations, evaluation should be mandatory. Research question/aim: The aim of this article is to evaluate the perspectives of all people involved and the process of implementation on the wards. Research design and participants: The data were collected in two steps: by means of non-participating observation of four ethics case consultations and by open-guided interviews with 28 participants. Data analysis was performed according to grounded theory. Ethical considerations: The study received approval from the local Ethics Commission (registration no.: 32/11/10). Findings: ‘Communication problems’ and ‘hierarchical team conflicts’ proved to be the main aspects that led to ethics consultation, involving two factors: unresolvable differences arise in the context of team conflicts on the ward and unresolvable differences prevent a solution being found. Hierarchical asymmetries, which are common in the medical field, support this vicious circle. Based on this, minor or major disagreements regarding clinical decisions might be seen as ethical conflicts. The expectation on the clinical ethics committee is to solve this (communication) problem, but the participants experienced that hierarchy is maintained by the clinical ethics committee members. Discussion: The asymmetrical structures of the clinical ethics committee reflect the institutional hierarchical nature. They endure, despite the fact that the clinical ethics committee should be able to detect and overcome them. Disagreements among care givers are described as one of the most difficult ethically relevant situations and should be recognised by the clinical ethics committee. On the contrary, discussion of team conflicts and clinical ethical issues should not be combined, since the first is a mandate for team supervision. Conclusion: To avoid dominance by physicians and an excessively factual character of the presentation, the case or conflict could be presented by both physicians and nurses, a strategy that strengthens the interpersonal and emotional aspects and also integrates both professional perspectives.

Evaluating assessment tools of the quality of clinical ethics consultations: a systematic scoping review from 1992 to 2019

“…(a) the personal and professional attributes of CEC members [7,16,79,[81][82][83][84][85][86] and the composition, training, experience [70,[78][79][80] and skillset of the team [69, 78-81, 83, 86-96] carrying out the CECons (92-94); (b) the approach adopted and if it considered the ethical, legal, moral, financial, clinical and professional issues holistically and objectively, and whether the process considered prevailing sociocultural and practical issues [5,14,73,88,[99][100][101]105] in a confidential manner [15,79,90,103,108]. Also considered was if the CECons was timely [31,79,109,110], well-documented, structured, accessible [5,9,31], clearly communicated [5,77,79,91,92,99,[111][112][113][114][115][116]…”

“…Feedback from patients and family members [14,69,74,91,92,114,130,131] iv. Input from healthcare professionals [5,14,15,33,72,74,80,85,87,90,91,98,103,111,112,114,118,119,127,130] v. Evaluations by senior clinicians [82,84,93,102,104,127] vi. Evaluations by administrators or organizational representatives [77] Assessments methods also include:…”

“…Longitudinal assessments that take place over many years [72] ii. Single time point assessments a. focus group interviews [14,74,76,77,84,87,90,92,98,103,127,130] b. questionnaires [33,72,74,79,85,91,92,102,111,112,114,119,127] iii. Specific appraisal of CECons decisions a. case report analysis [5,15,77,93,100,101,104,106,108,114,122,128,129,132] b. impact of CECons decisions such as via randomized controlled trials where an intervention group who received CECons were compared to a control group who did not [30,74,75,99,121,122] iv.…”

“…The CECons process was assessed through the approaches they employed such as whether all relevant information had been gathered [5,14,[99][100][101][102][103] and that all ethical [5,14,73,79,90,[99][100][101][102][103][104][105][106] and moral issues [100,102] were considered and analyzed together holistically [100,102] in an objective [103] and accountable manner [107] whilst maintaining confidentiality [15,79,90,103,108].…”

Living bioethics, clinical ethics committees and children's consent to heart surgery

“… 43 Second, in hermeneutic or interpretive injustice, CECs can be locked into cycles of misunderstanding, mistakes, impatience or embarrassment. 44 Lay members may routinely be interrupted, talked over, dismissed or challenged by higher status members. Leading members tend to insist on ‘high’, meaning academic-style, standards of debate.…”