Springer 2007
Med Health Care and Philos (2008) 11:43–56 DOI 10.1007/s11019-007-9103-1
Scientific Contribution Implementing moral case deliberation in a psychiatric hospital: process and outcome Bert Molewijk,1,2,* Maarten Verkerk,3 Henk Milius,3 and Guy Widdershoven1 1 Department of Health, Ethics and Society/metamedica Faculty of Health, Medicine and Life Sciences, School of Public Health and Primary care (Caphri), Maastricht University, PO Box 616, 6200 MD, Maastricht, The Netherlands (*author for correspondence, E-mail:
[email protected]); 2GGnet, Mental Health Care Institution, Zutphen, The Netherlands; 3 Vijverdal Maastricht, Psychiatric Hospital, Maastricht, The Netherlands
Abstract. Background Clinical moral case deliberation consists of the systematic reflection on a concrete moral case by health care professionals. This paper presents the study of a 4-year moral deliberation project. Objectives The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of the evaluation of the moral case deliberation sessions, and (d) present the implementation process. Methods The implementation process is both monitored and supported by an interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists). Results Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects. Key words: clinical moral case deliberation, implementation, moral competency, responsive evaluation design, train-the-facilitator program
Introduction Moral case deliberation implies the methodological reflection on concrete moral cases among health care professionals, facilitated by an ethicist (Molewijk and Widdershoven, 2006; Abma and Widdershoven, 2006; Molewijk et al., 2007). This paper deals with the description and evaluation of a 4year moral deliberation project in a Dutch psychiatric hospital. The project aimed at implementing methods for moral case deliberation throughout the whole hospital by means of a train-the-facilitator program. Despite the rapidly increasing attention for such moral deliberation projects in the Netherlands, experiences with these projects, as well as scientific evaluation of these experiences, have not
been available for an international audience.1,2 The main goal of this paper is to offer a description of the moral deliberation project, and to present the results of the scientific evaluation of the moral case deliberation sessions, the train-the-facilitator program and the implementation process. Moral deliberation as a new development in Dutch healthcare
In The Netherlands, many clinical ethics committees within health care institutions are transforming their former distant expert role and their focus on policy and guidelines into that of a steering group which aims to develop the moral competencies of health care professionals, and to guarantee
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an ethics climate throughout the whole institution (Dartel, 1998). In 2005, a national survey of the Centre for Ethics in Health Care (CEG) demonstrated the underdeveloped status of ethics within Dutch health care institutions. The authors called for more attention for moral deliberation among health care professionals (CEG, 2005). At the same time, the Dutch Minister of Health Care signalled the need for more thoughtful consideration of the structure of moral deliberation within health care institutions (Min. VWS, 2005). Since 2004, and every 3 months, expert meetings on moral deliberation take place at the Department of Ethics at the Ministry of Health. National working conferences on moral deliberation for health care professionals are organized every six months. In concert with these developments, various health care institutions have started moral deliberation projects with or without the assistance of clinical ethicists from universities. A variety of rationales for these projects are mentioned, such as: improving the moral competencies of the health care professionals, improving the quality of care processes, increasing the transparency of decision-making processes, making explicit the rationale of professional behaviour, fostering a culture of critical yet constructive dialogue among multi-disciplinary professionals, and enhancing the quality of management. Methods of moral case deliberation
A moral case deliberation consists of a meeting with, on average, 10 health care professionals who systematically reflect on one of the moral issues that emerge within a concrete clinical case they have experienced themselves (Molewijk et al., 2007).3 Most issues concern the question ‘‘What do we consider as the morally right thing to do and how should we do it correctly?’’ The reflection, which takes 45 min to one day, is facilitated by an ethicist and structured by means of a selected conversation method (for examples of conversation methods see: Gracia, 2003; Manschot and Dartel, 2003; Steinkamp and Gordijn, 2003; Steinkamp and Gordijn, 2004; Molewijk et al., 2007). Methods are selected to suit the specific goal(s) of a moral case deliberation (among other reasons). For example, some methods (e.g. the dilemma method) focus on the moral case itself and work toward a wellconsidered decision, while other methods (e.g. the Socratic method) use the moral case as a means to enhance moral competencies of the health care professionals.
ET AL.
Moral case deliberation differs significantly from clinical ethics consultation (Ranson et al., 2006).4 There are three central goals to moral case deliberation: (1) to let the health care professionals enhance their moral competencies, (2) to improve the ethical climate and decision-making processes by means of dialogue, and (3) to improve the moral quality of care and the care process. As a consequence, within a moral case deliberation, the ethicistÕs role is that of a facilitator who does not give substantial advice, and does not morally justify or legitimize a specific decision. With respect to ethics consultation, the ASBH taskforce on the Core Competencies for Health Care Ethics Consultation describes a more procedural and expert approach of the ethics consultant when discussing ‘‘the ethics facilitation approach.’’ A central goal of the ethics consultant is to answer the question ‘‘Who is the appropriate decision-maker?’’ in a morally and legally appropriate way (ASBH, 1998; Aulisio et al., 2003). It seems as if the ethics consultant focuses more on the answer to the question ‘‘What is morally right?’’ whereas the facilitator within the moral deliberation focuses more on the process by which the group members reach this answer on their own. Implementation of moral case deliberation: moral deliberation projects
Moral case deliberations can be part of a larger moral deliberation project, which takes usually two to four years (Molewijk et al., 2007). In general, a moral deliberation project aims at improving the overall ethics quality of (the organization of) care at three levels: (1) offering time, methods and facilitators to reflect on complex or problematic moral cases (case level), (2) improving the moral competencies of the employees of the health care institution (professional level),5 and (3) developing an integrated ethics policy and ethics climate throughout the whole organization (institutional level).6 The project we describe in this paper took place at Vijverdal, an academic psychiatric hospital in Maastricht. The director of the hospital and the chief of the medical staff ordered for a moral deliberation project to be managed by a senior ethicist from the University of Maastricht who would be hired for alternately one or two day(s) a week. Three phases of implementation were planned: (1) analysis of ethics documents and culture, and moral sensitization by means of various pilot activities, (2) transmission of moral expertise and competencies to health care professionals, and (3) forming an organizational structure and institutional policy in which moral
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deliberation activities could be embedded (inspired by Dartel, 1998). The central activities of the moral deliberation project in Vijverdal involved various ad hoc moral case deliberations with different teams of health care professionals, regular moral case deliberations with the overall management team (including the administration and the chief psychiatrists), a trainthe-facilitator program for three groups of about ten people, organizing institutional thematic conferences, ethical analysis of policy or philosophy of treatment documents, participant observation of the reorganization of treatment policies, writing ethics columns for the hospitalÕs newsletter, and giving ethics seminars. Due to the limited scope of this paper, we will focus on the moral case deliberations, the train-the-facilitator program, and the implementation process. Next section starts with a brief description of hermeneutic ethics as the theoretical background of both our approach to moral case deliberation and the overall research design (i.e. Responsive Evaluation). Successive sections describe the meaning of responsive evaluation, the research methods, presents both process and outcome. In the discussion section, the research process and the main results are critically discussed. The paper ends with suggestions for both the practice of and research on moral deliberation.
Theoretical background of moral deliberation: hermeneutic ethics The theoretical background of moral deliberation as viewed by the moral deliberation group of the University of Maastricht is hermeneutics ethics. The Greek verb hermeneuein means interpreting. According to hermeneutic philosophy, human life is essentially interpreting the world and giving meaning to it. Interpretation takes place through story telling. In stories, our experiences are at first vague and ambiguous, and then take on a clearer and more articulate form (MacIntryre, 1981). Stories make explicit the implicit meaning of lived experience. In stories the pre-narrative structure of life is transformed into a narrative structure (Ricoeur, 1983). Stories also contain a moral view of the world and present those who participate in a situation, their relationships, and their responsibilities (Walker, 1998). Stories try to clarify moral problems and moral responsibilities, and invite others to reflect on these clarifications and interpretations. From a hermeneutic perspective, moral deliberation as a process can make use of stories of
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participants in a practice. In our moral deliberation project we invite participants to bring cases they have experienced in practice. These cases are written down as stories, and in every group meeting a case is selected and discussed by the group. From a hermeneutic perspective, understanding is always partial. One can never fully grasp the meaning of a situation, in the same way that one cannot see an object completely or absolutely (Merleau-Ponty, 1945). The story about a situation is always told from a certain perspective. The possibility of various perspectives is not something we learn through theoretical reflection, yet it is forced upon us in practice when we realize that the object is different from what we had assumed. Because understanding always takes place within a specific perspective, it can be enlarged by a change of perspective. Again, this change is not something we rationally decide on; it is something we go through when our expectations are not being met. Moral deliberation groups are processes in which the perspectives of the participants are enlarged by the mutual confrontation of the participantsÕ views. This leads to a merger of perspectives, in which individual views are changed into a common interpretation. In hermeneutics, this process is seen as a fusion of horizons (Gadamer, 1960; Widdershoven, 2005). From a hermeneutic perspective, ethics is not a matter of individual argumentation, but, essentially, a process of joint moral learning. The outcome is not theoretical knowledge about ethical principles and maxims, but practical knowledge about what is good in the specific situation (Lave and Wenger, 1991; Leader, 1994; Widdershoven, 2005; Verkerk and Nijhof, 2001). Aristotle coined the term phrone`sis to describe the specific character of moral knowledge. From a hermeneutic perspective, knowing what is good in the situation requires experience. In the moral deliberation groups, participants have experience with handling problems in practical situations. Without such experience, the deliberation would easily result in theoretical discussions. The group process also aims to foster experience. By discussing problems and exchanging viewpoints, the participants become more experienced in dealing with moral issues. The theoretical notions of hermeneutic ethics served as a foundation for our moral deliberation projects. They also played a role in the evaluation of these projects. We assumed that what was good in our projects was not given beforehand by the perspective of the ethicists and researchers, but could only be developed in interaction with participants in practice. Therefore, we made use of an interactive, dialogical research design of evaluation.
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In the context of this design, various qualitative and quantitative research activities took place.
Responsive evaluation as overall research design The overall research design we used in order to evaluate the moral deliberation project is called responsive evaluation (Guba and Lincoln, 1989; Abma and Widdershoven, 2005). In a responsive approach, stakeholders participate actively in the evaluation process: they are involved in the formulation of questions, the selection of participants, and the interpretation of findings (Greene, 1988; Widdershoven, 2001). Stakeholders become active and equal partners in the deliberative process of evaluation (Abma, 2005). Stakeholders are groups of people within the hospital whose interests are at stake; each stakeholder group has its own interests and values.7 Responsive evaluation fits well with our theoretical view of hermeneutic ethics. It shares (with hermeneutic ethics) the emphasis on the emergence of meaning through processes of dialogue.8 The essence of responsive evaluation is negotiation (Stake, 1975; Stake and Trumbell, 1982; Guba and Lincoln, 1989; Shulha and Cousins, 1997; Koch, 2000; Abma and Widdershoven, 2005). Evaluation criteria for single moral case deliberations and moral deliberation projects are derived from the various stakeholders, and gradually emerge in conversation with and among stakeholders. Both the identification of issues and the conditions for negotiation are (co-)created during the interaction between the researchers and the stakeholders within the hospital. The inquirer (i.e. the ethicist), instead of predetermining the evaluation by forming evaluation criteria in advance, acknowledges the plurality of meaning in practice (Rosen, 1991). Methodologically, the acknowledgement of plurality implies the research design gradually emerged from the collaboration of the stakeholders and the researchers (Abma, 2005). The multiple roles of the inquirer include those of interpreter, educator, facilitator, and Socratic guide (Schwandt, 2001), but also that of actor, experimenter, observer, and theorist (Verkerk, 2004, p. 372). Within this project, the ethicist serves both as a facilitator in moral case deliberations and as an evaluator of the moral deliberation project. In both roles, the attitude and activities are similar. As a facilitator of a moral case deliberation meeting, the ethicist helps the participants to make explicit their views, exchange perspectives, and learn from one
ET AL.
another. As a responsive evaluation researcher, the ethicist elicits the views of stakeholders, and fosters dialogue between and among them about the value of the project and its further development. During a moral case deliberation, the ethicist refrains from giving expert advice. In the same way, in his capacity of researcher, he does not act as the leader of the project, but encourages the stakeholders to take responsibility for the course of the project altogether.
Methods: research activities The research activities were performed by the senior ethicist, a junior researcher from the university who was not actively involved in the moral deliberation project, and three Master students of the health care sciences faculty. In line with the Dutch Medical Research Involving Human Subjects Act (WMO), this research was exempted from a formal IRB review. Quantitative research activities included the Maastricht evaluation questionnaire for anonymous9 participants of every moral case deliberation (see Appendix A).10 This two-page questionnaire consisted of closed and open questions. It contained items about the demographic characteristics of the respondents, the role of the facilitator, the lessons participants learned (or did not learn), the influence on participantsÕ professional behaviour, and the perceived goals of moral case deliberation. Furthermore, halfway during the implementation project, a brief survey was sent to all stakeholders involved at that moment. This survey focused on strong and weak points of the implementation process, and on how the stakeholders valued their experiences with the moral deliberation activities. Within both the questionnaire and the survey, respondents scored the items on a 1–10 scale (1 for ‘‘very bad quality’’ and 10 for ‘‘very good quality’’). We made use of three kinds of qualitative research activities (Hull et al., 2001; Marshall and Koenig, 2001). In the first place, the junior researcher from the university performed in-depth interviews with various stakeholders within the psychiatric hospital about their expectations of and experiences with moral deliberation, both at the start of the project (before the sensitization phase) and during the implementation of the train-the-facilitator program (i.e. transmission phase). These interviews were analyzed, and results were discussed with key-figures as part of the dialogue between stakeholder groups. Second, by acting both as a facilitator of the moral
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deliberation group and as a trainer during the trainthe-facilitator program, the ethicist gathered inside ethnographic information about the group dynamics, and the actual learning and implementation processes of the participants (Geertz, 1973; Hammersley and Atkinson, 1995). This participant observation information was systematically recorded in a logbook. Finally, qualitative explorative analyses were performed by using hospital and treatment policy documents, as well as extensive reports of the moral case deliberation sessions, train-the-facilitator sessions, and the project group meetings. During these meetings, participants not only shared their experiences with the (training of) moral deliberation sessions, but also with the project as a whole; they also had to note in particular whether or not the meetings had helped them in their clinical practice.
Results: outcome and process This section deals with the results of both our qualitative and quantitative research. We will start with the outcome of the moral case deliberation sessions (The evaluation of the moral case deliberation sessions). Subsequently, we will present the results of the brief survey that was performed halfway during the implementation project (Brief survey halfway during the implementation process). Finally, some of the qualitative data are reported (Evaluation of the train-the-facilitator
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program as a means for implementation). In presenting these qualitative data, we will focus on those that reflect the implementation process and, in particular, the train-the-facilitator program. The evaluation of the moral case deliberation sessions
Nine moral case deliberation sessions were planned with different groups. In total, 69 out of 95 participants filled in the evaluation questionnaire (response rate: 73%). Table 1 presents the demographic and educational background information of the participants (see Table 1). The senior ethicist facilitated eight sessions, and the junior researcher one session. Themes of the moral case deliberations are reflected in the following questions that were used: When is coercion in psychiatry morally acceptable? What should be the limit of care giving or professional help? Should we report illegal activities of our outpatients, knowing that their mental health will worsen if they are punished? Is it morally acceptable that we close the treatment relationship? Should we prevent a patient from getting pregnant? Should we deliver psychiatric care that is not covered by insurance? Should we permit (or even assist) a patientÕs suicide by allowing her to refuse food?
Table 1. Evaluation of the moral case deliberation sessions N = 69 Sex Age
Degree of education
Primary professional occupation
Past experiences with moral case deliberation (MCD)
Valuation of MCD experiences Overall importance of MCD Interested in future participation
46% female (N = 32) 52% male (N = 36) Between 18 and 30 years Between 31 and 40 years Between 41 and 50 years Between 51 and 66 years Secondary education Higher education University degree Nurse (assistant) Psychologist or therapist Physician Manager or chief Other occupation No experience 1–3 MCD 4–9 MCD 68% (N = 47) 100% (N = 69) 96% (N = 66)
9% (N = 6) 13% (N = 9) 45% (N = 31) 33% (N = 23) 14% (N = 10) 32% (N = 22) 54% (N = 37) 17% (N = 12) 36% (N = 25) 13% (N = 9) 19% (N = 13) 15% (N = 10) 36 (52%) 30 (44%) 03 (4%) 7.62 (6–9; st. dev 0.82) 7.86 (6–9; s.d. = 0.86)
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Under which circumstances can we morally accept euthanasia? Is it morally acceptable to provide more care (i.e. more money) to certain patients than the average coverage of the health insurance company and, thereby provide less care (i.e. less money) to other patients? Overall, participants evaluated the moral case deliberation positive to very positive with a mean score of 7.68 (answers ranged from 4 to 10; s.d. = 1.0). With respect to the quality of six central tasks of the facilitator of the moral case deliberation, participants were positive to very positive with respect to all features (see Table 2). Table 3, second column, shows how participants valued the importance of the goals of moral deliberation in general. Remarkable are the high scores (‡8.0) for goals like: ‘‘to get knowledge and insight in moral issues,’’ ‘‘to pay attention to reasons and arguments,’’ and ‘‘to improve mutual understanding.’’ Also, notable is a very high score (‡9.5) for ‘‘to activate my job motivation.’’ Relatively low scores (£6.5) were given for the goals: ‘‘to deliver an answer or solution to the moral problem’’ and ‘‘to reach consensus within the group’’ (see Table 3). Table 2. Evaluation of six central features of facilitator N = 69
Valuation [range] (s.d.)
Introduction and explanation Ordering session Listening and understanding Critical reflection Encouraging Expertise
7.8 7.6 7.9 7.5 7.6 7.8
[5–10] [5–10] [6–10] [5–10] [5–10] [4–10]
(0.9) (1.0) (0.7) (1.0) (0.9) (1.0)
ET AL.
The third column reflects the extent to which these goals were met during this specific moral case deliberation. Participants gave relatively high scores (‡7.5) for the goals: ‘‘to get knowledge of and insight in moral issues,’’ ‘‘to pay attention to reasons and arguments,’’ and ‘‘to improve mutual understanding.’’ These three goals correspond with the three goals that received the most importance scores. Relatively low scores (£6.5) were given for the goals: ‘‘to influence my behaviour with respect to the case,’’ ‘‘to deliver an answer or solution to the moral problem,’’ ‘‘to reach consensus within the group,’’ and ‘‘to frees my mind’’ (see Table 3). The fourth column describes the difference between importance of the goal and goal reached. The fact that the importance of the goal structurally received a higher mean than goal reached could have been influenced by the fact that some goals could not be reached within a single moral case deliberation (see Table 3). The Maastricht evaluation questionnaire also consisted of some open questions (see Appendix A). Below we present a summary of answers to three open questions: ‘‘What did you miss during this moral case deliberation?’’ How to draw more general conclusions Reflection on the topic on a higher abstract level How to reach a consensus after enumeration of different perspectives Concrete steps Time to continue ‘‘What have you learned during this moral case deliberation session?’’11 How different our perspectives are with respect to the same situation
Table 3. Importance of general goals of moral deliberation and extent to which these goals were met
To To To To To To To To To To To To To To To
get knowledge of and insight in moral issues influence my attitude with respect to the case influence my behaviour with respect to the case improve my skills in dealing with moral issues deliver an answer or solution to the moral problem reach consensus within the group pay attention to reasons and arguments pay attention to feelings improve mutual understanding improve mutual cooperation activate my job motivation frees my mind make me a better professional improve quality of (organisation of) care indirectly better ground decisions and reflect more on them
Importance of goal
Goal reached?
Difference
8.1 7.3 7.1 7.5 6.4 6.2 8.0 7.9 8.0 7.9 9.7 6.7 7.3 7.7 7.7
7.7 6.9 6.2 7.1 5.7 5.8 7.9 7.4 7.8 7.3 7.0 6.3 6.7 7.0 7.4
0.4 0.4 0.9 0.4 0.7 0.4 0.1 0.5 0.2 0.6 2.7 0.4 0.6 0.7 0.3
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Contact with others about moral dilemmas creates room for making choices Learned to get to know and respect other peopleÕs considerations Experience more space and passion for caring and the care process A good dialogue facilitates good implementation of the decision Learned to widen and deepen my opinion Reflect on division of roles (between managers and professionals) How complex a single case can be The difficulty of listening without passing judgment ‘‘How will this moral case deliberation influence your daily work?’’ By inspiring better communication and more openness within a team By showing how management and care-givers can become partners By encouraging to ask more critical questions instead of running around By showing how there can be more room for reflection and distance By pointing to more respect for and awareness of different perspectives By inspiring more dialogue between managers and professionals about marketing By pointing to a better framing of the question(s) (of both colleagues and patients) Overall, the responses to the evaluation questionnaire showed that almost all participants of the moral case deliberation sessions were enthusiastic about the session, and positive about the five tasks of the ethicist as facilitator. We found correspondence between the importance of the goals of moral deliberation in general and the extent to which these goals were met: respondents scored high rates for getting knowledge of and insight in moral issues, paying attention to reasons and arguments, and improving mutual understanding. The open questions revealed that the participants sometimes missed concrete suggestions for follow-up on the moral case, and methods for reaching consensus after exploration of various perspectives on the case. Among the lessons learned that participants reported, we note their becoming aware of the difficulty of listening without judging, the complexity and multidimensionality of a single case, and the improvement of communication and decision-making. Brief survey halfway during the implementation process
Halfway during the implementation process, we executed a brief three-page survey to find out how
participants evaluated the project (Molewijk, 2004). The primary goal of the survey was to collect information on how to continue the implementation process. A secondary goal was to attract attention to the project, and to involve as many people as possible. The survey was distributed to all participants who were aware of the moral deliberation project (by means of interviews, clinical ethics conferences, and moral case deliberation). Table 4, Appendix B, shows the results of this survey. (It must be noted that the three respondents who gave an unsatisfactory mark had not participated in a moral case deliberation.) Central lessons the respondents learned during the moral case deliberations were: to reflect on oneÕs own behaviour and thinking to improve the quality of care to acknowledge and integrate multiple perspectives to become aware of presuppositions and assumptions to practice early thorough reflection for preventing needless team discussions later to learn how to think critically and systematically to achieve multi-disciplinary communication to avoid time pressure and fixation on solutions When asked what they had missed so far, the respondents reported: introduction and background information on moral deliberation structural knowledge of moral deliberation
Table 4. Results of survey halfway during the implementation process N = 122 Response
40% (N = 49)
Valuation of moral deliberation so far General importance of moral deliberation Interested in participation in near future Interested in organizing deliberations Interested in becoming a facilitator Moral deliberation should be used for: Feedback of colleagues and Professionalization Reflecting on a concrete case Increasing ethics knowledge Determining policy (statements) Team-building processes
7.0 (range 4–8)* 7.4 (range 4–10) 96% (N = 47) 42% (N = 21) 29% (N = 10) 60% (N = 29) 51% 40% 34% 32%
(N (N (N (N
= = = =
25) 20) 17) 16)
*The three respondents who gave an unsatisfactory mark had not participated in a moral case deliberation.
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implementation of moral deliberation concrete suggestions about how to go on with moral deliberation in oneÕs own ward Overall, the survey made clear that the respondentsÕ experiences with moral deliberation activities during the first phase of the project (i.e. the sensitization phase) were mostly satisfactory. The survey also showed that respondents aimed at several goals at the same time when participating in moral case deliberations. Furthermore, the survey results could also be used for practical purposes: we approached those respondents who reported that they were interested in receiving training as facilitators for further inquiry and a formal (selection) interview. Evaluation of the train-the-facilitator program as a means for implementation
This sub section deals with qualitative data regarding the process of implementation; these data were gathered by means of two rounds of interviews, participant-observation during moral case deliberation sessions and train-the-facilitator sessions, and the explorative analysis of the reports of these sessions. During the interviews, the questions were focused on the implementation of the moral deliberation project in general, and the train-thefacilitator program in particular.12 Overall, the respondents were enthusiastic about the train-the-facilitator program. Most respondents asked for an extension of the program and wanted more training possibilities (also within their own teams). They felt that the project was well linked to the inherent moral dimension of their work. Respondents said that the project functioned as a constructive and systematic answer to a culture in which decisions and solutions are often presented too quickly. Because of the pragmatic and creative way of dealing with the situation, the dialogue between the moral deliberation project group and the employees of the hospital continued. The implementation process was put under pressure by sudden financial problems of the institution for two years during the project (2004–2006). Employees at all levels felt that they had to survive, and discussing moral issues started to be regarded as luxury. Participants had little energy, patience and distance to reflect on their work; they were not motivated for doing something ‘‘extra.’’ Interviews with stakeholders further showed that employees became less motivated regarding participation in initiatives of the management to improve the quality of care. Employees
ET AL.
also reported that the quality of care and their work environment was damaged in so many (essential) ways that it felt odd to seriously reflect on morally good care. We introduced a pause for the third train-the-facilitator program, and we decided to reflect more on the actual moral issues that emerged out of the financial crises. For example, a moral case deliberation was organized to involve the board of directors, the management team and the chief psychiatrists, who were called to reflect on the issues of tension between ‘‘good care’’ and ‘‘paid care,’’ and the responsibility of the various stakeholders. In this way, the employees of the hospital learned that the financial crisis had a moral dimension too, and that the project could deal with the crisis by reflecting on those issues. With respect to the train-the-facilitator program, some respondents said that the mix of caregivers and managers within a group sometimes caused a feeling of vulnerability or insecurity among some care-givers because of the misbalance of power and their fear of negative consequences.13 Managers felt that moral deliberations should focus more on solutions and decision-making rather than reflection and awareness of the multiple dimensions of a moral case. Some managers also wanted to use the moral case deliberation sessions in an instrumental way: in the context of the meeting, the manager might be able to make his or her decisions more easily. The focus on decisions sometimes decreased the quality of the dialogue (i.e. people had more difficulty with postponing their judgments and demonstrating an openness to the issues at stake). Respondents differed with respect to the question whether managers should become facilitators or not. Proponents of this suggestion said that managers usually have the skills and authority to moderate a meeting, while opponents warned of an abuse of power and a narrow, instrumental use of the moral deliberation meetings. A psychiatric nursing specialist, John, who completed the train-the-facilitator program, constitutes a ‘‘best practice’’ example of the train-the-facilitator program. After receiving his certificate, John started to organize moral case deliberations on a structural basis in different wards. As a staff member of the nursing team, he managed to make moral case deliberation something owned by the team, rather than something that external people from the university arrange ‘‘for the sake of the project.’’ Not only did he facilitate moral case deliberations, he also wrote about his experiences in the hospital newsletter and made reports on the moral case deliberations. He had the courage and ambition to
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learn, and continually ask for feedback by submitting several questions for the bi-monthly meetings with all the certified candidates. His function as a nursing specialist allowed him to fulfil a more coordinative role within the hospital. As a consequence, we invited him to be a member of the steering group. In the near future this group will take over the primary responsibilities of the project manager from the university, and transform the status of ‘‘a temporary project’’ into a structural part of the hospitalÕs quality policy. Although the content and structure of the trainthe-facilitator program was rated relatively high, its implementation faced some serious constraints (attributed to both the program itself and to external causes such as political and financial changes within the hospital). The basic idea that the actual implementation of the program did not take place during the training hours but afterwards (i.e. during the exercises within each team), had not been easily comprehended. We learned that the conditions for the latter were not sufficiently prepared and guaranteed. Some candidates were trained to become a facilitator without having the opportunities or requests to actually facilitate moral case deliberations. Furthermore, it was unclear what the consequences would (or should) be if candidates did not show up, did not prepare their homework, or did not exercise within their own work environment. Another constraint was that most candidates participated on an individual basis (candidates were not really representatives of their teams or managers): they submitted only their own clinical moral cases during the train-the-facilitator program without harmonizing with their team members. The same thing happened with the analysis of the case during the moral case deliberation training: participants did not inform their team members about the lessons they had learned. Finally, interviews with the candidates revealed that they complained of becoming responsible for the public relations and implementation of the moral case deliberation project in general, while the primary task of learning to facilitate a moral case deliberation was already burdensome enough. Candidates felt they had too little support from their teams and managers concerning the importance and relevance of moral deliberation. Because of the responsive evaluation approach, we were able to deal with these constraints of the train-the-facilitator program immediately and to adjust the program to the new situation. Through the initiative of the board of directors, all managers were urged to plan moral case deliberations as a
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structural part of professionalization processes, team building processes, and processes of improving the quality of care and communication. The managers also planned to have two three-hourlong moral case deliberations every year in which the responsible psychiatrist of every division would be included. Within the train-the-facilitator program, more attention was paid to the questions ‘‘What do you need in order to exercise enough within your team?’’ and ‘‘How can we, as trainers or the hospital, help you and your team to implement moral deliberation?’’ Finally, we proposed that the moral cases that were brought into the training sessions should arise out of candidatesÕ own team meetings. In other words, although we trained an individual to become a facilitator, the ingredients of the train-the-training program were derived from a team, and the moral analysis of the case during the training was communicated with the team afterwards.
Discussion As a whole, the moral deliberation project was successful. Almost all of the participants reacted enthusiastically and asked for more attention for moral deliberation within regular work processes and team meetings. Many employees of the hospital have gained experience with moral case deliberation and, as a result, professionals are now paying more attention to ethical issues at different levels. They have developed skills to reflect on their work, and to create an atmosphere of dialogue instead of one of discussion and debate. They have become aware of the complexity of seemingly simple cases, and of the diversity of perspectives regarding a case. They have also learned to acknowledge the inherent moral dimension of care and the caring process even in situations that, at first hand, seemed to involve practical or communication issues. Two groups of moral case deliberation facilitators have been trained, and they can now slowly take over the moral case deliberations that initially have been facilitated by the ethicist from the university.14 Lastly, the content of the moral case deliberations, the role of the facilitator, and the train-the-facilitator program were evaluated positive to very positive. Despite these positive results, the process of implementation was fraught with some serious difficulties. Too often the moral case deliberation sessions were initiated at an ad-hoc basis without a regular organizational structure. Participants felt they had little support from their managers; it was as
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if they themselves were solely responsible for the implementation. Based on the research data, the board of directors and the moral deliberation project group made arrangements with the managers in order to secure the progress of the moral deliberation project. This not only created opportunities for employees to participate within moral case deliberation, it also created opportunities for the trained facilitators to further develop their skills as facilitators of moral case deliberations. Furthermore, it proved to be important to have a steering group that slowly took over the role of the project manager from the university. In the current phase, the steering group consists of both managers and caregivers in order to guarantee a balanced mix of top-down and bottom-up approaches to implementation. Three enthusiastic certified facilitators were made members of the new project group, since they actually experienced ‘‘from the inside’’ what it is like to facilitate moral case deliberations, and how essential a good organizational structure and commitment is for a successful implementation. Currently, the implementation process is in its last phase of transferring the responsibilities to the steering group, the project group, and the group of trained facilitators, thereby finishing the project status of the moral deliberation project. Based on our experiences with this moral deliberation project, we have the following suggestions. Enthusiasm and high-quality moral deliberation sessions are not enough; in order to guarantee a successful implementation, ethicists should focus more on various implementation strategies. Furthermore, moral case deliberations often take place in rooms outside the place where professionals actually work. It is important to develop simple activities for moral reflection that are not time-consuming and can take place during the actual work processes. Moreover, knowledge obtained from single moral case deliberations should be used to instruct managers and other health care professionals in an effort to stimulate collective learning processes and develop appropriate policy guidelines (e.g. the development of an anonymous data base on moral cases). Moral deliberation sessions sometimes run the risk that the sessions become the primary goal of the meeting. It should always be clear that a moral case deliberation is a means to another goal (e.g. improving the quality of care). Therefore, it is important to pay appropriate attention to the direct consequences of a moral case deliberation, and to demonstrate in which way things have improved. The same business-like approach applies to those who participate in a moral deliberation
ET AL.
session: participants are representatives of teams, and are responsible for sharing their experiences with others. Finally, one thing to avoid is a situation where professionals start to reflect on moral issues only in view of a moral deliberation project; moral issues are pervasive, and a good professional should have the competencies to deal with moral issues in an appropriate way. With respect to the methodologies of responsive evaluation, the combination of qualitative and quantitative approached was very useful for monitoring both the content of the moral deliberation activities and the (difficulties of) the implementation process. Quantitative data proved to be useful as a quick scan for the evaluation of the moral case deliberations and the train-the-facilitator programs. This provided a continuous feedback loop to the management team and the board of directors of the hospital. Qualitative data informed us about issues in practice and the reasons behind implementation difficulties. Qualitative data also helped us to understand the culture of the hospital, the moral cases of the managers and caregivers, the strengths and weaknesses of the first train-the-facilitator program, and the way in which participants described how their moral competencies improved, and how that influenced their actual work. The use of various research methods at the same time, and the various roles of the ethicist, the junior researcher, the three Master students, and the stakeholders of the hospital ensured continuous critical reflection on the way the research process was being executed. The dual role of the ethicist as facilitator/ trainer and researcher (within the responsive evaluation design) worked very well. In the first case, the ethicist played a crucial role in the moral case deliberation meetings and during the trainthe-facilitator program. In the second case, he collected data, which he used (pro-)actively for the implementation strategy of the project. In both roles, the ethicist did not act as an expert with respect to the concrete content of the case, but focused on making explicit the perspectives of the participants. His expertise was applied to stimulating reflection (both on ethical issues and on difficulties in the implementation of the project), creating and consolidating dialogue, using the right methods for moral deliberation, and directing the project and the involved stakeholders differently during different phases. The consistency in the activities of the ethicist helped him to gain the participantsÕ trust in the method of moral case deliberation and in the management of the project. This can be seen as an indication for the relevance of the theoretical background of hermeneutic
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ethics, which served as a foundation for both the process of facilitating moral deliberation and the responsive evaluation research design. Although most respondents were highly satisfied with the moral deliberation activities, we should take into account that satisfaction in general is not a demonstration of quality. Perhaps some health care professionals were merely satisfied because they had the opportunity to speak about their concerns. Therefore, future empirical research on moral case deliberation should focus on the quality of the moral case deliberation itself. Among others, the following questions should be put on the research agenda: ‘‘What do we consider a good process result and a good outcome result, and to which degree are they complementary?’’ ‘‘Which method is appropriate, and when?’’ ‘‘What kind of role should the facilitator fulfil with respect to his/her knowledge of ethics?’’ ‘‘How normative should the facilitator be?’’ ‘‘How should we understand the concept of moral competency, and what research instrument can be used to measure moral competency?’’ ‘‘What is the theoretical and empirical relationship between improved moral case deliberation, moral competencies, and improved quality of care?’’ Too often this relationship is taken for granted, without serious empirical and theoretical research. Finally, ‘‘Which conditions do we need in order to plan moral case deliberation between patients and professionals?’’ Future integration of theoretical and empirical research is important, not only to improve the quality of moral case deliberation and its structural implementation, but also to improve the (moral) quality of health care.
2.
3.
4.
5.
6.
7.
Acknowledgements This research has partly been possible thanks to a grant from Vijverdal Maastricht, a Dutch mental health care institution in Maastricht. We wish to thank all participants within this moral case deliberation project for our instructive and ongoing collaboration. We also wish to thank the members of the Moral Deliberation Project Group of Vijverdal. Finally, we wish to thank Sandra van der Dam, Saskia Ranson and Margreet Stolper of the Moral Deliberation Group of the University of Maastricht for their comments and indispensable research activities.
Notes 1. We intentionally leave out of consideration the literature on (evaluation of) ethics consultation in the United States (Fox, 1996; Fox and Arnold, 1996; Fox
8.
9.
10.
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and Tulsky, 1996; ASBH, 1998; Aulisio et al., 2003) since culture, context, methods and goals in ethics consultation differ significantly from moral deliberation projects. See also section methods of moral case deliberation. Only recently, since the foundation of the European Clinical Ethics Network (ECEN) by the Moral Deliberation Group of the University of Maastricht and the Clinical Ethics Centre at the Hospital Cochin in Paris, has clinical and scientific attention to moral case deliberation and clinical ethics consultation within Europe developed. Within the ECEN, 2–4 representatives of 14 countries have started to bring together clinical experiences and scientific research on moral deliberation and clinical ethics consultation (Molewijk and Widdershoven, 2007). In practice, there are many different goals for moral case deliberation (of which some are even opposite), many different methodologies, as well as many different roles for the participating ethicist. The statement about the distinction between moral case deliberation and clinical ethics consultation is based on a review of the international literature, clinical experiences in both Europe and the United States, and collaborative meetings as, for example, ASBH conferences and meetings in Cleveland. This distinction is not meant to be an essential or theoretical distinction. Hence, this also applies to, for example, the board of directors, the management teams, staff and housekeeping employees. Our model for the implementation of a 4-year moral deliberation project has similarities with the Integrated Ethics Program of the National Center for Ethics in Health Care of the Veterans Health Administration, except for our focus on moral competencies of health care professionals and health care managers (Fox et al., 2004). Responsive evaluation resembles (participatory) action research, in which learning is the first and overarching objective for the researcher, the clients, and the system in which they are embedded (Argyris, 1983). See also: Whyte (1991) and Rapoport (1970). Gabriel (2000) makes a distinction between a research report that presents facts as information, and a research report that presents a story with facts as experiences. He calls stories ‘‘factories of meaning.’’ See also: Weick (1995). In order to elicit more open and critical feedback we made the questionnaire anonymous. As a consequence, we were not able to monitor individual trends in the evaluation (which also means that we do not know how many participants filled in the questionnaire more than once). The moral deliberation group of the University of Maastricht developed this evaluation questionnaire. The evaluation data from moral deliberation projects, or separate moral case deliberations, are imported in a national database in which the associated moral cases, moral questions, and written reports of the moral case deliberation are also imported.
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11. During the analysis of the answers we made a distinction between lessons learned with respect to the content of the case, and lessons learned with respect to moral deliberation in general. Since the former is difficult to explain within the limited scope of this paper, and without getting into too much detail, we focus on the latter. 12. In the explorative analysis we concentrated on these two issues, despite the fact that many other things were discussed. 13. The director of the hospital had suggested the active involvement of managers in the first training group. In his view, this was an essential step in the implementation strategy since he wanted the managers to become a role model in moral deliberation. Furthermore, managers would improve their skills in understanding and supporting their employees when they became facilitators. 14. For both fundamental and pragmatic reasons, one can challenge the statement that only academic experts in clinical ethics should perform these activities, rather than staff members of the clinical teams themselves. Fundamental reasons are associated with questions of moral expertise, ownership of moral problems, and quality criteria of both the consultation process and consultation outcomes. Pragmatic reasons are associated with the financial costs of those ethics experts on health care institutions, and the limited availability of ethics experts in general, and in ad hoc situations in particular.
Appendix A Maastricht Moral Case Deliberation Evaluation Questionnaire
Evaluation questionnaire Moral Case Deliberation (MCD)
[Confidential]
Bert Molewijk & Guy Widdershoven Moral Deliberation Group
Date: Registration number:
Health Ethics and Philosophy P.O. Box 616, 6200 MD Maastricht, NL Information:
[email protected]
General questions
Date & duration of MCD Health care institution Department within health care institution Name of facilitator What is your educational background?
ET AL.
What is your age? What is your sex? What is your actual professional occupation? Did you participate in a MCD before? h h h h
No (please go to question 11) Yes, 1 to 3 times Yes, 4 to 9 times Yes, 10 times or more
Evaluate your past experiences with MCD by giving a mark between 1 and 10 Indicate how important MCD for you is by giving a mark between 1 and 10 Would you like to participate in future MCD? h No h Yes Specific questions regarding this MCD
Evaluate this MCD by giving a mark between 1 and 10 What was the theme of this MCD? Which method was used during this MCD? h h h h h h
Dilemma method Utrecht method Hermeneutic method Socratic Dialogue other, namely ……………………… no idea
Please indicate how you evaluated the facilitator on the following items (between 1 and 10) Introduction & explanation … Ordering session … Listening & understanding … Critical reflection … Encouraging … Expertise … What did you learn during this MCD? In which way does this MCD influence your work? What did you miss during this MCD? Below you will find some possible goals of a MCD. Some people find some goals (very) important while other goals (absolutely) not. Please indicate in the first column the importance of each goal in general by giving a mark between 1 and 10. In the second column, you can indicate to what extent the goal has been reached during this MCD (by giving a mark between 1 and 10).
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To what extent Possible goals of a MCD
Importance of this
has this goal been
goal
reached during this MCD?
To get knowledge of and insight in moral issues To influence my attitude with respect to the case To influence my behavior with respect to the case To improve my skills in dealing with moral issues To deliver an answer or solution to the moral problem To reach consensus within the group To pay attention to reasons and arguments To pay attention to feelings To improve mutual understanding To improve mutual cooperation To activate my job motivation To frees my mind To make myself a better professional To improve quality of (organization of) care indirectly To better ground decisions and reflect more on them
Suggestions, questions ………………………… ……………………………………………………… End of the questionnaire. Thanks for your contribution!
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