Introducing clinical ethics consultation service in Malaysia: A SWOT analysis

Introduction

There are challenges when clinical ethics consultation service (CES) is initiated in any country. Doctors may have negative perceptions of CES and see them as an intrusion on the doctors’ professional domain. CES may be perceived as undermining clinician’s autonomy and violating patient confidentially. When such services were introduced in UK, they were rarely used. ¹ In 1997, Larcher et al.² expressed the view that such services should not erode clinical freedom. In Australia, CES was initially perceived in a similarly hostile way.³ Attempts to implement CES in Asia have also had its challenges. ⁴

Once such services are accepted, their effect is very different. CES contributes to better patient outcomes and improved quality assurance and governance. They help broaden discussions in end-of-life care; confidentiality and its limits; pandemic planning; termination of pregnancy; refusal of treatment by minors and even resource allocation. ⁵ The service can benefit patients, families and carers, and healthcare providers (HCPs) through facilitation of the development of ethical guidelines in contentious areas of clinical practice and educational services and through provision of regular opportunities for reflection. CES helps to strengthen the ethical climate of institutions, preserves a consciously developed moral community, and, in some cases, may also reduce litigation against hospitals and HCPs by helping to prevent conflict escalation. ⁶

CES may prove difficult to translate to the Malaysian healthcare context. Malaysia has a two-tier system that consists of a state-funded universal healthcare system and a co-existing private healthcare network. The country is a multicultural and multilingual society with diverse religions and value systems and even a separate state and religious law. Introducing variations in interpretation and ethical perceptions may complicate clinical decision-making. Plus, some hospitals are religiously affiliated and such religious affiliations are known to contribute to overall patient satisfaction. ⁷

Currently, there are no formal institution-based clinical ethics services in Malaysia. However, with the launch of a National Declaration ‘Engaging Healthcare Professionals in Paediatric Bioethics’, ⁸ on March 2017 in Kuala Lumpur, Malaysians started to explore the roles of clinicians in ethical guidance for a multireligious society. Because physician satisfaction is a valid measure of an effective ethics consultation, ⁹ a workshop was designed with the aim of identifying clinician’s expectations of a CES and to analyse factors that could prevent or delay the introduction of formal CES. It was hoped that the results can inform the practical strategic directions for the introduction of CES in the country.

Methods

This study was part of a workshop during the 13th Asian Congress of Paediatric Nephrology in conjunction with the 39th Malaysian Paediatric Association Annual Congress held on 4–7 October 2017 in Kuala Lumpur, Malaysia. A 2-h workshop entitled Introduction of Clinical Ethics and Ethics Consultation in Malaysia was divided into three segments: (i) plenary, (ii) Strengths, Weaknesses, Opportunities and Threats (SWOT) questionnaire and (iii) focus group discussion (a qualitative research method in which the moderator asks specific questions about a topic to provide added dimension of the interactions among participants). ¹⁰

We promoted the workshop to paediatricians participating in the Congress. Three groups were targeted: (i) individuals representing key paediatric societies in the country who were committee members of Malaysian Paediatric Association or head of departments in their individual institutions, (ii) individuals representing both public and private academic and healthcare institutions and (iii) paediatric trainees who were particularly interested in clinical ethics. We recruited these groups of informants to maximise variation in representation and to stimulate dialogue. The SWOT questionnaire (Appendix 1) was first piloted using six faculties from the International Medical University and College of Paediatrics Academy of Medicine Malaysia for validity, readability and clarity. Two of the faculty were certified paediatric bioethicists. The questionnaire and structure of discussion were revised to address goals of the workshop.

The initial part of the workshop comprised a plenary session where the purpose and types of a CES as well as examples of challenges faced by other countries were presented to the participants. Subjects then completed the SWOT questionnaire. This was followed by a focus group discussion moderated by two co-authors.

During the discussion, the informants were asked if these services should be available in the country, and if so what were their expectations of such a service. They were then asked to define Strengths, Weaknesses, Opportunities and Threats to the introduction of CES in Malaysia. ‘Strengths’ were defined as factors favouring the introduction of the CES; ‘weaknesses’ were defined as factors that might hinder its success; ‘opportunities’ were defined as factors that could enhance the success of the clinical ethics service; and ‘threats’ were defined as any factors that could act as a barrier to the initiation of the service. Informants presented their findings during the final hour, and a Delphi-like analysis was conducted. ¹¹ Throughout the discussion, informants are encouraged to communicate with one another as well as to exchange ideas and comments on each other’s experiences or points of view. At the end of the workshop, the discussions were summarised and presented to participants for validation.

Data were collected primarily by the means of SWOT questionnaire and focus groups. Responses were analysed by two member of the writing committee, both experts in the evaluation of qualitative interviews using qualitative research criteria and content thematic analysis. ¹² We also descriptively examined the frequencies of response for all items of the survey.

Direct quotes have not been used in this report to maintain key informants’ confidentiality and because of the possibility of them playing important roles later in the implementation of clinical ethics service.

Results

There were 16 participants. Age, gender, institutional affiliation, working patterns and expectations regarding CES are shown in Tables 1 and 2.

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Table 1.

Demographics of informants (N = 16).

Demographics
Age in years, median (range)	53 (33–66)
Respondent gender, n
Male	12
Female	4
Respondent’s institution, n
Private university	3
Private hospital	4
Public university	3
Public hospital	6
Allocation of professional working time, mean %
Patient care	56
Formal teaching	20
Administrative duties	12
Research	11
Ethics (research/clinical)	1

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Table 2.

Clinician’s expectations of a CES.

Expectations
Should a clinical ethics service be introduced and be implemented in the country, n (%)	16 (100)
Preference on access to clinical ethics service, n
Specifically for use by my institution	4
Prefer a part of a larger service	1
Open to both choices above	11
How quickly should the service respond to a referral?, n
Within 1 hour	1
Within 24 hours	8
Within 48 hours	3
Within 48 hours to 1 week	3
Within 1-2 weeks	1
More than 2 weeks	0
How often should ethics committee meet per year?, n
2	3
4	6
6	3
12	1
Where necessary	3
The service should, n (%)
Notify the patient (and/or family) of the consult	15 (94)
Meet with the patient (and/or family)	15 (94)
Include the patient (and/or family) in the meeting	14 (88)
Enter and provide a written report	13 (81)
Provide a written report to patient (and/or family)	12 (75)

Discussion

This study illustrates the importance of involving stakeholders when introducing a new clinical service in a multicultural country such as Malaysia. While resistance is the normal human reaction in times of change, good change management can mitigate much of this resistance. The principle of CES is to assist conversations between different stakeholders in conflicts and is primarily about mediation and communication. ¹³

One of the striking but worrying themes in the SWOT analysis is the theme of deference to authority and superiority where ‘a doctor knows best’. Interestingly, the paternalistic attitude of HCPs was seen as both strength and weakness, and even a ‘danger’ in the analysis. As most literature on doctor–patient communication in Western societies emphasises the partnership model, ¹⁴ their findings may not be easily transferable to Malaysia because of cultural dissimilarities (patients’ passivity, patient’s lack of trust in physicians, differing values and acculturation) as well as lack of resources (infrastructure or time constraints) which are more substantial compared to the West.^15–17

The responses from our informants are not too different from other exploratory studies when it comes to partnership model such as HCP’s paternalistic attitude^15,18,19 and limited resources.^19–21 An Indonesian study on the communication styles of doctors found that the main barrier preventing Asian doctors from adopting a partnership style relates to the social gap between doctor and patient, with the doctor typically belonging to a higher social group. ²² Doctors state that they did not deliberately chose a paternalistic approach but believed that the situation arose as a result of inadequate communication skills, lack of time due to high patient load and the doctors’ belief that patients were not prepared for a more participatory style.

Studies have shown that Malaysian patients preferred an autonomous role in decision-making and the tendency where doctors underestimate patients’ preference to play this role is real. ²³ The concept of partnership model needs to be promoted and one way to increase patient involvement in decision-making is to simply increase HCP’s knowledge about this concept. ²⁴ Yet, there is little training of partnership model in medical education curricula along with lack of accurate and accessible health information for patients, peer support groups and ‘expert patient’ programmes in Malaysia. Although professional fraternities endorsed patient involvement in decision-making, there was no definitive implementation plan in the country. ¹⁷ We feel that introducing CES will be a good start to change HCP’s paternalistic attitude and to promote patient empowerment.

Implementing a uniform CES in Malaysia is furthermore challenging because of the multitude of cultural values (such as language differences, strong family involvement, religious beliefs and complementary medicine) that influence medical decision-making.^25,26 As such, patients’ autonomy may decisively be reduced due to an overarching and more important religious consideration. While Western medicine is secular and there is a clear separation of care and religion, it is also a fact that religion is a way of life in this region. ²⁷ A query beyond the physiological aspect of clinical care is seen as an intrusion, belonging to the realm of theology. Unfortunately, the medical field lacks cross-cultural studies that test this assumption. As a result, HCPs may be guided by cultural biases rather than doing ‘what’s best for patients’. Alden et al. ²⁶ suggest that it is important for HCPs to avoid East–West cultural stereotypes during medical decision-making when providing effective patient-centred care.

Our study has limitations that mandate caution in the interpretation and premature transference of its results. First, the SWOT analysis was conducted only on one fraternity, paediatricians. It had left out important stakeholders representing Ministry of Health, other fraternity and their professional societies as well as key bioethicists in the country. The lack of clarity on certain negative viewpoints such as ‘resource allocation’, ‘differing opinions’ and ‘lack of qualification’ could have been addressed with input of these stakeholders. We tried to ensure that all representative paediatricians be consulted in this discussion before moving on to a national level involvement. Second, the analysis does not address the models, structures and functions of proposed CES. If the focus group discussion had been moderated to answer these matters, certain threats such as litigation or fear of intrusion into the realm of religion may be seen as less critical if the CES carries a facilitative rather than a more authoritative role. These could then prompt further discussion on the training and skills needed for CES providers. Therefore, our SWOT analysis was more reflective of taking the first ‘baby step’ to introduce a formal CES in Malaysia. This analysis with paediatricians as stakeholders allowed us to identify preliminary roadblocks and important building blocks for improvement in the healthcare systems’ orientation towards patient’s rights and autonomy.

When introducing CES, it is crucial to consider the culture and system, particularly in Malaysia where concepts such as shared decision-making is still at its infancy. ²⁶ Clearly, discussion, debates and further studies are required in the setting of CES in Malaysia, in view of the cultural values, laws and religious beliefs. Stakeholders’ consultation can help identify strengths, weaknesses, opportunities and threats when introducing such ethical service. Recognition of critical issues is the initiation in developing solutions and clarifications on the roles of CES.

We hope that future discussion at a national level with diverse stakeholders will clarify how the findings of this analysis can assist implementation of the actual and preferred role of CES. The methodology used in this study is transferrable to other developing countries with multicultural society wishing to take up the challenge of introducing CES.