Development of Bioethics and Clinical Ethics in Bulgaria

Bulgaria at the onset of clinical ethics consultation

BACKGROUND

Over the years, Bulgarian bioethics has been mainly an academic enterprise and fallen short of providing health professionals with skills for ethical decision-making. Clinical ethics support (CES) was piloted by the author through two bottom-up models - METAP (Modular, Ethical, Treatment, Allocation of resources, Process) and MCD (Moral Case Deliberation).

AIMS

This paper aims to present and analyse developments in the area of clinical ethics and the first experiences in CES in Bulgaria.

METHODOLOGY

The project reported here included a review of relevant literature on CES methods and evaluation and a documentary review of data from two CES pilot projects: METAP and MCD.

RESULTS

Most of the 69 METAP ethics meetings reviewed were first time meetings (88,4%); the average duration was 36 min and the average number of participants was four (44,9%). The meetings were organized in response to cases of severely or critically ill patients. The ethical dilemmas included choice of treatment (31,9%) and conflicts with the patient or their relatives (23,2%). Consensus was achieved in 34,8% of the cases. The situation was clarified with the patient (27,5%) and within the team (15,9%). The rights and obligations of both sides were discussed in 7,2% of the cases. The experience of the members of the Bulgarian Association of Bioethics and Clinical Ethics (BABCE) with MCD was also presented to justify the inference about the applicability of the two CES models in a Bulgarian context.

CONCLUSION

Among Eastern European countries Bulgaria has made progress in CES. Both METAP and MCD have been found to be useful methods.

Designing a Clinical Ethics Education Program for Nurses Based on the ADDIE Model

BACKGROUND AND PURPOSE

The ADDIE (Analysis, Design, Development, Implementation, and Evaluation) model enables educators to create programs using a systematic approach designed to meet learner's needs. The purpose of this study was to develop and evaluate a clinical ethics education program for nurses to improve their ethical confidence, ethical competence, and moral sensitivity.

METHODS

The study was conducted in three steps. In the first step, a seven-session ethics program was developed using the ADDIE model. The themes of each session were as follows: (a) sharing individual ethical issues in clinical settings; (b) understanding a process involved in ethical decision-making; (c) identifying ethical issues in end-of-life care; (d) identifying ethical issues in family caregiving; (e) learning communication skills; (f) developing ethical leadership skills; and (g) reflecting to build self-awareness of the significance of practicing clinical ethics. The second step involved the delivery of the program. In the third step, using a mixed methods design, the effects of the program were evaluated through a quantitative survey administered both before and after completion of the program and focus group interviews.

RESULTS

The seven-session ethics program based on the ADDIE model improved ethical confidence, ethical competence, and moral sensitivity in nurses.

IMPLICATIONS FOR PRACTICE

The ADDIE model can be an effective tool in nursing education, offering an established structure for developing educational programs. In order to validate the effectiveness of the ethics program, it is necessary to conduct repeated measure studies and further studies at the institutional level.

Clinical Ethics Consultation in the Transition Countries of Central and Eastern Europe

Since 1989, clinical ethics consultation in form of hospital ethics committees (HECs) was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have been analyzed under the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries.