Abstract
Introduction
This is the 13th in a series of cases for the Case Studies section of this journal, and involves a case discussed in Sweden according to a specific method of moral case deliberation (MCD) – the dilemma method 1 (see the Appendix). Within an MCD, participants reflect upon a specific moral question derived from a concrete experience, structured by a specific conversation method and facilitated by a trained facilitator (often an ethicist). The facilitator does not give direct advice on the case in hand but supports participants’ moral inquiry through a dialogue. All MCD participants gave their consent to publication. To safeguard confidentiality, some non-relevant facts of the original case have been changed and the case presenter referring the case is not identified. The first author (BM) facilitated the MCD and wrote this paper with revisions from the MCD group.
The MCD
Step 1: Introduction – goals and expectations
The MCD facilitator discusses the participants’ goals and expectations from the MCD meeting. The participants aim to have a moral inquiry together into the question at stake. Although the participants do not function as one team of health-care professionals and the case presenter ultimately needs to make concrete steps within his case, the primary goal in this MCD is to learn from various kinds of reasoning through collective reflection on the case and each others’ reasoning.
Step 2: Case presentation by a Swedish school doctor
I am a school doctor and was referred a young woman of 17 by worried teachers who thought she had changed. They reported she was often absent and was behind in her studies. I planned a 20-minute consultation with her which ended up taking 45 minutes. She was initially hard to talk to, very quiet with few words but gradually it became easier. She reported severe sleep disturbance, loss of appetite, inertia, low mood, sense of meaninglessness – all in all several of the cardinal symptoms of a major depression. I carefully approached the question of her will to live, and whether she had had any suicidal thoughts – either vague or concrete. Initially she avoided the question, but eventually admitted to thinking about suicide a lot as a means of escape. She had vague ideas of how she might enact these thoughts. At that moment I started to worry. She did not want me to contact her mother from whom she is somewhat estranged. She described a poor relationship with her mother. The young woman is not yet legally independent so the mother is her official guardian. In six months she will be legally independent. Her mother works abroad in Finland during the week but lives with her daughter during the weekends. Her father committed suicide 14 months ago; she said she thinks about this a lot. My preliminary impression was that the risk for a suicidal act was considerable.
It was difficult to have a good dialogue with her. I was glad that, after a while, she seemed to respond more openly to me. I cherished this fragile relationship with the young woman during the consultation. I realized how important this was in order to reach her and to motivate her to accept professional psychiatric help.
After a rather long talk with her, she said she was willing to go to the psychiatric clinic but not if her mother was contacted. This posed a problem because the clinic has a strict policy that an adult should be informed about a child's suicidal ideation, so that the adult can take care of the child. The clinic does not admit minors overnight.
There are several reasons why I am uncertain about informing the mother:
The young woman had told me she would only have psychiatric input if her mother was not informed;
I was uncomfortable about conveying this sort of information by phone to the mother and this was the only available course because she was in a different country;
The fact that the mother–daughter relationship is not very good; and
The fact that Swedish law does not guide me either way.
Step 3: Formulation of the moral dilemma according to the case presenter
The MCD facilitator asks the case presenter to present, in a short sentence and as concretely as possible, what in his view is the most central and urgent dilemma. The case presenter says: ‘During the consultation, I experienced the following dilemma as most urgent: Should I inform the mother or not?’
The MCD facilitator asks the case presenter to clarify what he means by ‘inform’: 2 ‘So what would you actually do if you “inform” the mother?’ The case presenter says: ‘I would call her today’. Therefore the MCD facilitator changed the formulation of the dilemma into: ‘Should I call the mother or not?’
The MCD facilitator asks: ‘Could and would you tell us what you felt during that encounter?’ The case presenter says: ‘I felt both a degree of emotional distress, because I was acting with incomplete information and with too little time, but I was also aware there was a degree of urgency. I felt compelled to gain appropriate help for this young woman. I felt a responsibility to get her adequate psychiatric support. My experience of similar situations is considerable, so I was not deeply disturbed’.
Step 4: Clarification round
This step gives the participants the opportunity to prepare their personal answer to the formulated dilemma. The facilitator asks the other MCD participants: ‘What factual information do you need in order to imagine yourself in that situation and to answer the dilemma question for yourselves?’
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The following are some of the questions posed, together with responses from the case presenter.
Why was the young woman thinking about suicide?
I had limited time to figure that out. I spent 45 minutes instead of the scheduled 20 minutes with this young woman. So the following patients had a delay of 25 minutes. I had limited background information about her suicidal thoughts. My main concern was to earn the trust of this young woman and at the same time try to motivate her to attend the psychiatric unit. I first needed to gain her confidence; I find this particularly important with patients who are depressed and think about suicide.
Was it possible to judge whether this was a 17-year-old who was mature for her age and hence, in practice if not legally, competent to decide about her life?
The impression I got was that this changed from day to day. In fact I had too little information about this, but I felt I had to do something.
Was there a time pressure to make a decision or could it be postponed until after she had attended the psychiatric clinic?
I felt the young woman needed adult support before she got to the clinic in order to support her before and after her contact with the clinic. I also knew that, in the end, the clinic would want to inform the parents or an adult anyway.
Is there another adult in the situation that can take care of the young woman?
You have hit the nail on the head with this question. I found out that she had a good relationship with her uncle, her father's brother. She trusted him. I could read it in her face. Also, the clinic would accept a relative. Therefore, with her consent, I called her uncle directly when she left and he was willing to take care of her and to go to the clinic with her. I then phoned the clinic.
What does the law say about your duty to inform the parent? Is there a legal obligation?
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Swedish law is undecided in these cases. Precedents from Supreme Court decisions tell us to respect the will of teenagers close to adulthood as far as possible. But there are situations where this does not apply, like abuse or risk to life.
What fears did the young woman have about disclosure of her suicidal thoughts to her mother?
She said she did not want disclosure because their contact was ‘lousy’ and because she thought that the mother only complained and shouted at her.
What benefits might the young woman gain from you calling her mother?
Despite their difficult relationship, it might give the young woman support as well as supervision that might prevent suicidal actions. Furthermore, if the mother understood the seriousness of the situation, this might lead to an opening up of their relationship and allow it to improve.
What was most important to you?
I was urgently looking for a solution and my main concern was that this young woman needed a psychiatrist very soon due to the real risk of suicide.
Did you promise her that you would say nothing to her mother?
No.
The first round of questioning for clarification ends and the MCD facilitator asks whether the participants have enough information in order to answer the dilemma question for themselves (as if they were in that situation themselves). Most participants report they have enough information for the time being.
Then the facilitator asks whether the original dilemma with the original consituents is still there.
One MCD participant now doubts both the urgency and ultimately the existence of the dilemma at this phase of the MCD: ‘I think the dilemma as formulated is now not really that important any more since we now know that the uncle can take care of the young woman’. In other words, it seems the initial moral dilemma had disappeared since there was no longer any urgency to call the mother. The MCD facilitator asks whether the moral dilemma still exists for the case presenter. The case presenter confirms it does: ‘My original dilemma was caused by my concern for the young woman, but the dilemma remains for me since I feel a professional responsibility to inform the mother. Psychologically and morally, parents should know about such a crisis, even if the young woman is taken care of at the moment and will now attend the clinic. In the end, I think parents have the right to know if their child's life is in danger. The fact remains that the mother does not know and I bypassed her as the primary caregiver in favour of a relative’.
Another MCD participant adds: ‘I want to stress that this situation is very special since this mother lost her husband through suicide. Imagine what it would be like if you, as a parent in that situation, know that your daughter is thinking about suicide, or imagine if you as a mother were to find out later that the school doctor knew but did not tell you?’
Another MCD participant adds: ‘I want to turn the question around: Why did you want to inform the mother at all?’ The case presenter says: ‘First because the legal situation is so open. Second, because I still feel a moral duty to inform the mother. Third, because I wanted to work on improving the relationship between mother and daughter. I think this is important for both (but especially for the health of the young woman) even though I accept it may not improve immediately. So, I struggled with the question of whether the mother had a right to know that her daughter has suicidal thoughts’.
After this clarification, all MCD participants say that they understand the new basis for the same dilemma as experienced by the case presenter: they see the reason for continuing with the MCD. However, not everybody experiences the new dilemma in the same way as the case presenter. Some MCD participants still perceive that ‘the’ dilemma has been solved due to the involvement of the uncle.
Step 5: Scheme with perspectives, values and norms
Should I contact the mother (A) or not (B)?
The MCD facilitator asks the case presenter which values or norms are the most important in how he experiences the dilemma. The case presenter says that he now feels the strongest tension between value 2 (‘respect autonomy of the young woman’) on the one hand, and value 3 (‘mother's right to know’) on the other. Earlier in the MCD, the case presenter felt more tension between value 1 (‘protect life’) and value 2 (‘respect autonomy of the young woman’), but since the uncle had agreed to take care of her, this basis of the dilemma had disappeared. Participant 1 says that she experiences the dilemma as a clash between trusting relationships.
The overview of values and norms within this scheme makes it easier for MCD participants to state that they experience the same dilemma but for different reasons, another dilemma, or no dilemma at all. Also, the scheme gives the MCD participants insight into why they experience it differently. For example, participants 2, 3 and 4 present just one value for a course of action, which indicates that they would not experience a dilemma at all if they were in that specific situation.
Step 6: Brainstorm of alternative actions
The MCD facilitator invites the participants to think beyond the formulated dilemma without discussing the feasibility of these alternatives. What can or would you do in such a situation? Participants mentioned:
‘Just call the mother to inform her’;
‘Inform the psychiatric unit about the problem and leave it to them; it is not your primary responsibility since you are not treating the young woman’;
‘Ask the uncle to inform the mother at a later stage’;
‘Ask the uncle to persuade the young woman to inform her mother’;
‘Book a new appointment with the young woman later to check if she has changed her mind about informing the mother’.
Step 7: Orientation of possible answers to the dilemma
MCD participants give their personal moral judgement about the formulated dilemma and say what they will do and why. Due to time restraints, not all participants give their answer.
Participant: ‘I think it is morally right not to call the mother at this time. It is right to contact the uncle because she trusts her uncle and you need her consent for any disclosure of information. It is also nice that he is the brother of her dead father’.
Another participant: ‘I agree that the young woman has a right to privacy and that her wishes should therefore be respected. I also think that she needs the support of an adult but it sounds like she will now get this from her uncle. I do think that it is a genuine dilemma since I think that the mother has the right to know, not legally perhaps but in order to be able to help her daughter. Therefore, at some later stage, I think I should use several routes to explore this with the young woman. For example, I could ask the uncle to talk with the young woman about contacting her mother. I also will inform the psychiatric unit about the relational problem and work with them. Finally, I will book a follow-up appointment at a later stage with the young woman’.
A third participant: ‘I think the right thing to do is not to call the mother; the uncle will be there for the young woman. In order to cope with the moral burden of not informing the mother I would work on the improvement of that relationship later because the mother should be a part of her daughter's life. The virtue I need here is to be able to cope with respect to all stakeholders and despite the different wishes do the right thing, that is to focus on what is best for your patient who is the young woman’.
Finally, the MCD facilitator asks the case presenter what he in the end sees as the morally right answer to the dilemma. ‘The dilemma is still there, but for now, I have made a choice not to call the mother . I will follow up to see what happens, and to be sure that the young woman receives appropriate care. But I think that my responsibility ends there. I trust that the uncle will be contacted by the clinic and they will find a way to resolve the issue between mother and daughter. I will also try to contact the uncle again’.
A surprising ending of the case (and the MCD meeting)
The case presenter says that he called the uncle this morning just before the MCD meeting, in order to ask about the current health status of the young woman and also about the young woman's refusal to inform her mother. The uncle did not answer the phone and the case presenter left a message on the uncle's voicemail. Then, at the very end of this MCD meeting, the case presenter receives a call and leaves the MCD meeting room. When he returns, he says: ‘The uncle just called me. He was in the psychiatric unit with his niece and together with the psychiatric team they just agreed to contact the young woman's mother and propose a meeting of all three together’.
All participants react with surprise, because now the latest basis for the dilemma has also disappeared: the mother will be informed. The participants conclude that the dilemma has been resolved. Therefore, they omit the next steps (8: ‘Reflect upon possible group consensus or decision’; and 9: ‘Make practical appointments and plan date and place to evaluate those appointments’). The facilitator performs a brief evaluation round and asks the participants what they thought about the MCD.
Participants say they learned a lot through the facilitating of the dialogue, both about the content of the case and about their own thinking processes. They learned how, at first sight, one seemingly straightforward moral dilemma became less straightforward once they considered it in detail. One dilemma can consist of different conflicting values and/or norms, and different MCD participants may interpret and value these values and norms differently. Furthermore, participants learned how different participants perceived the dilemma. At an individual level they learned that the ingredients of a moral dilemma, and the importance of each ingredient, may change during and due to the MCD process. Regarding the dilemma method as a structure for an MCD, they reported that it made them focus and think in a structured and analytical way. They noted the strengths of the scheme of values and norms: it clarified the understanding of different perspectives about the same moral dilemma. At the same time, participants mentioned it was not always easy to ignore initial judgements, to ask true questions instead of trying to convince others and to postpone thinking about practical solutions for the dilemma.
The case presenter himself ended the MCD meeting by saying: ‘Today's development of the case during our moral case deliberation only partially solved the dilemma. It was my decision to side-step the mother, in order to win the confidence of the young woman. Although I think this was the right decision, there is also a loss here, despite the apparent resolution of the problem. It was an ‘unclean’ decision situation, tragic because neither option was entirely satisfactory. Having said that, I can see there is no right or wrong answer so I am not reproaching myself. Maybe I am too old in the game for that?’
Members of the MCD
The case presenter (school doctor), anonymous; Rolf Ahlzén MD PhD, Senior Lecturer, Department for Public Health, Karlstad University, Sweden; Mia Svantesson RN PhD, Research Supervisor, Anaesthesia & Intensive Care Department and Centre for Health Care Sciences, Örebro University Hospital, Örebro, Sweden; Anna Söderberg RNT PhD, Lecturer, Department of Nursing, Umeå University, Sweden; Håkan Thorsén PhD, Philosopher and Senior Lecturer, School of Health and Medical Sciences, Örebro University, Örebro, Sweden; Daniel Brattgård PhD, pastoral care, Sahlgrenska University Hospital & National Medical Ethics Council, Stockholm, Sweden; Vera Dahlqvist PhD, Lecturer, Umeå University and First Sköndals Highschool, Stockholm, Sweden; Veikko Pelto-Piri PhD, Psychiatric Research Centre, Örebro, Sweden; Pernilla Pergert RN PhD, Senior Nurse & Researcher, Childhood Cancer Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital/Solna, Stockholm, Sweden; Pontus Hoglund, PhD student, Forensic Psychiatry, Lund University, Lund, Sweden; Åsa C Persson RN, Helsingborg Community Hospital, Malmö, Sweden.
Footnotes
Acknowledgement
The authors want to thank the school doctor for presenting this case and giving consent for publication; and also the MCD participants for their consent and suggestions for revision. Finally, the authors are grateful for invaluable editorial input and advice from Professor Anneke Lucassen.