The quality of bioethics debate: implications for clinical ethics committees

Reimagining Thriving Ethics Programs without Ethics Committees

With the increasing professionalization of clinical ethics, some hospitals and health systems utilize both ethics committees and professional clinical ethicists to address their ethics needs. Drawing upon historical critiques of ethics committees and their own experiences, the authors argue that, in ethics programs with one or more professional clinical ethicists, ethics committees should be dissolved when they fail to meet minimum standards of effectiveness. The authors outline several criteria for assessing effectiveness, describe the benefits of a model that places primary responsibility for ethics work with professional clinical ethicists-the PCE-primary model, and offer suggestions for alternative ethics program structures that empower healthcare professionals to contribute to ethics work in ways more tailored to their strengths and skills while minimizing the shortcomings of ethics committees.

Training clinical ethics committee members between 1992 and 2017: systematic scoping review

INTRODUCTION

Clinical ethics committees (CECs) support and enhance communication and complex decision making, educate healthcare professionals and the public on ethical matters and maintain standards of care. However, a consistent approach to training members of CECs is lacking. A systematic scoping review was conducted to evaluate prevailing CEC training curricula to guide the design of an evidence-based approach.

METHODS

Arksey and O'Malley's methodological framework for conducting scoping reviews was used to evaluate prevailing accounts of CEC training published in six databases. Braun and Clarke's thematic analysis approach was adopted to thematically analyse data across different healthcare and educational settings.

RESULTS

7370 abstracts were identified, 92 full-text articles were reviewed and 55 articles were thematically analysed to reveal four themes: the design, pedagogy, content and assessment of CEC curricula.

CONCLUSION

Few curricula employ consistent approaches to training. Many programmes fail to provide CEC trainees with sufficient knowledge, skills and experience to meet required competencies. Most programmes do not inculcate prevailing sociocultural, research, clinical and educational considerations into training processes nor provide longitudinal support for CEC trainees. Most CEC training programmes are not supported by host institutions threatening the sustainability of the programme and compromising effective assessment and longitudinal support of CEC trainees. While further reviews are required, this review underlines the need for host organisations to support and oversee a socioculturally appropriate ethically sensitive, clinically relevant longitudinal training, assessment and support process for CEC trainees if CECs are to meet their roles effectively.

Lessons learned from implementing a responsive quality assessment of clinical ethics support

BACKGROUND

Various forms of Clinical Ethics Support (CES) have been developed in health care organizations. Over the past years, increasing attention has been paid to the question of how to foster the quality of ethics support. In the Netherlands, a CES quality assessment project based on a responsive evaluation design has been implemented. CES practitioners themselves reflected upon the quality of ethics support within each other's health care organizations. This study presents a qualitative evaluation of this Responsive Quality Assessment (RQA) project.

METHODS

CES practitioners' experiences with and perspectives on the RQA project were collected by means of ten semi-structured interviews. Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of the decisions.

RESULTS

The main findings illustrate the relevance of the RQA with regard to fostering the quality of CES by connecting to context specific issues, such as gaining support from upper management and to solidify CES services within health care organizations. Based on their participation in the RQA, CES practitioners perceived a number of changes regarding CES in Dutch health care organizations after the RQA: acknowledgement of the relevance of CES for the quality of care; CES practices being more formalized; inspiration for developing new CES-related activities and more self-reflection on existing CES practices.

CONCLUSIONS

The evaluation of the RQA shows that this method facilitates an open learning process by actively involving CES practitioners and their concrete practices. Lessons learned include that "servant leadership" and more intensive guidance of RQA participants may help to further enhance both the critical dimension and the learning process within RQA.

Clinic, courtroom or (specialist) committee: in the best interests of the critically Ill child?

Law's processes are likely always to be needed when particularly intractable conflicts arise in relation to the care of a critically ill child like Charlie Gard. Recourse to law has its merits, but it also imposes costs, and the courts' decisions about the best interests of such children appear to suffer from uncertainty, unpredictability and insufficiency. The insufficiency arises from the courts' apparent reluctance to enter into the ethical dimensions of such cases. Presuming that such reflection is warranted, this article explores alternatives to the courts, and in particular the merits of specialist ethics support services, which appear to be on the rise in the UK. Such specialist services show promise, as they are less formal and adversarial than the courts and they appear capable of offering expert ethical advice. However, further research is needed into such services - and into generalist ethics support services - in order to gauge whether this is indeed a promising development.

Bioethics: A brief review

Medical and life sciences research is a key driver in development, which leads to better quality of life. These pursuits can lead to discrimination, human rights violation, and injustice. The field of bioethics explores the ethical issues arising due to these advances in research and encompasses social, judicial, and environmental aspects affecting human beings. This brief review discusses the origin of bioethics, its principles, various international organizations, and their network involved in the development and propagation of guidelines on conducting biomedical research.

Disciplining bioethics: towards a standard of methodological rigor in bioethics research

Contemporary bioethics research is often described as multi- or interdisciplinary. Disciplines are characterized, in part, by their methods. Thus, when bioethics research draws on a variety of methods, it crosses disciplinary boundaries. Yet each discipline has its own standard of rigor—so when multiple disciplinary perspectives are considered, what constitutes rigor? This question has received inadequate attention, as there is considerable disagreement regarding the disciplinary status of bioethics. This disagreement has presented five challenges to bioethics research. Addressing them requires consideration of the main types of cross-disciplinary research, and consideration of proposals aiming to ensure rigor in bioethics research.

Bioethics and the reinforcement of socio-technical expectations

Over the past few years, considerable interest has been paid to the way in which social expectations (hopes, hypes, fears) about new genomic technologies help shape, and in themselves are shaped by, emerging technologies, regulatory regimes and social concerns. In comparison, little attention has been paid to the role of expectations in related, but non-scientific discourses, such as bioethics. Drawing on a review of publications addressing the ethical issues associated with pharmacogenetics, this paper presents a detailed critique of bioethicists' contribution to these debates. The review highlights how, almost a decade after bioethical debate around pharmacogenetics started, and in contrast to the profession's self-perception as a form of regulator, bioethicists still largely restrict themselves to reviews of possible ethical issues raised by this technology, rather than critiquing others' positions and arguing for specific points of view. In addition the paper argues that bioethicists tend to: accept unquestioningly scientists' expectations about the development and ethical issues raised by pharmacogenetics; ignore contributions from bioethicists who do question these expectations; and engage in an ethical debate, the boundaries of which have been laid down and defined by academic and industry scientists. The paper concludes by offering some possible explanations for why the bioethical discourse has taken this form.

Refining deliberation in bioethics

The multidisciplinary provenance of bioethics leads to a variety of discursive styles and ways of reasoning, making the discipline vulnerable to criticism and unwieldy to the setting of solid theoretical foundations. Applied ethics belongs to a group of disciplines that resort to deliberation rather than formal argumentation, therefore employing both factual and value propositions, as well as emotions, intuitions and other non logical elements. Deliberation is thus enriched to the point where ethical discourse becomes substantial rather than purely analytical. Caution must be exercised to avoid this formal permissiveness from accepting empty and incorrigible statements that are but flatus voci since they can neither be supported nor falsified. It is therefore suggested that deliberation in bioethics should comply with three sets of conditions: (1) Be understandable, truthful, honest and pertinent, as suggested by communicative ethics; (2) Allow for second order, thick judgements as suggested by pragmatism; (3) Abide by additional criteria as here proposed: Doxastic propositions should be bolstered by a cognitive element; statements should be specific and proportional to the issue at hand, and they should be arguable and coherent.

The use of clinical ethics committees in infertility clinics

Clinical ethics committees (CECs) are increasingly used in UK health care (Slowther et al., 2004a). However, there has been little debate about their use in infertility units. Current HFEA guidance on CECs encourages their use in aiding ethical decision making but this is not required by the code of practice or obligated by law. It will be argued that the HFEA should strengthen its guidance on CECs by recommending that all infertility clinics should have a designated CEC (where possible) as a matter of good practice and such a recommendation should be formalised in the HFEA's Code of practice. The article will conclude with recommendations for a particular model of CECs in infertility units.