‘I just love these sessions’. Should physician satisfaction matter in clinical ethics consultations?

Introduction

Clinical ethics committees aim to resolve conflict, facilitate communication and ease moral distress in health care. ¹ In the USA, clinical ethics services are an integral component of hospital accreditation. ² In Australia, the UK and Europe, clinical ethics committees are not mandated, but there is growing interest in their development. ^3–5 The interaction between people in clinical ethics consultations is complex and involves a balance between implicitly and explicitly expressed values of patients, families, professionals, institutions and cultures. ⁶ This process is difficult to evaluate and the outcomes on patients and other hospital functions are challenging to identify. ⁷ Broad benefits of clinical ethics committees include improved quality of care for patients; protection of their rights; reduction of unnecessary, unwanted or wasteful treatments, and at the institutional level, promotion of responsible institutional policies and practices and risk management. ^8–11 More specific evaluation of clinical ethics committee deliberations include measuring their impact on patient preferences and whether they improve consistency of informed-consent procedures or enhance patients’ rights. ^9,12,13

In this paper we refer to the work of one clinical ethics committee in a large paediatric hospital in Australia, the Royal Children's Hospital (RCH). We use a recurring comment, ‘I just love these sessions’, made by physicians after attending clinical ethics discussions, as a trigger to explore the role of physician or more generally participant satisfaction in clinical ethics consultations. As members of the RCH clinical ethics committee, we have found that the comment was often made by the physician who requested the clinical ethics consultation, and was made irrespective of the outcome of the discussion. We highlight the nature and method of clinical ethics discussions at this hospital in order to more broadly identify reasons for the expressed feeling of satisfaction, and to question whether and why this feeling matters as an outcome of ethics consultations. Our speculative hypothesis is that physician satisfaction is extremely important for successful and sustainable ethics committee work and that by discussing and analysing physician satisfaction, as one element of clinical ethics consultations, there is potential to identify important features of interactions within ethics consultations that are crucial to successful and sustainable practice.

We propose some explanatory ideas about the clinical ethicists’ role. These ideas focus on the type of communication, facilitation and interaction that is fostered within clinical ethics meetings as a potential explanation for why a physician might feel satisfied and why this feeling is or could be significant to outcomes of such consultations more generally. Two specific enquiries will be explored:

What is it about clinical ethics discussions that provokes and explains reactions of this type from the health professional?

Ethics consultations: RCH context

The clinical ethics committee at the RCH was established in 2005. ¹⁴ In Australia, hospital clinical ethics committees are not mandated and are developing on an ad hoc basis, which differs both within and between Australia's six states and two territories. The committee at the RCH is called the Clinical Ethics Response Group (CERG). It is a multidisciplinary committee made up of approximately 20 doctors, nurses, allied health, ethics and legal representatives recruited from within the hospital and the hospital clinical ethicist. Clinical case consultations are always done by a group, rather than by the clinical ethicist alone and the service can convene a group within 24 hours to respond to a case referral. Any hospital staff member can refer a case and after a case is referred, 6–8 members of the CERG meet with the referring clinician and treating team. The aim of the CERG consultation is to reach a consensus with the treating team about the range of ethically appropriate options in the situation. The CERG recommendations are advisory rather than binding or enforceable. The discussion and recommendation is documented, provided to the referring clinician and stored in CERG files. The service is an inhouse hospital resource, available to hospital staff only.

Since the CERG formally commenced in 2005, it has received 68 referrals for ethics case consultation. This figure is similar to international standards as reported in the 2010 Kesselheim study of 46 paediatric hospitals in the USA where 46% of hospitals had between six and 10 referrals per year and 16% per had more than 15 cases per year. ¹ The types of ethical issues which have been referred to the CERG include questions about the appropriateness of experimental treatments; whether parents can refuse treatment for their child; refusal of or resistance to treatment by children; parents wanting treatment to continue for children with life-limiting conditions, when clinical staff believe the treatment is not in the child's best interest; requests from adolescents for predictive genetic testing; and parental requests that the truth about diagnosis, prognosis, or other aspects of their hospital stay be withheld from their child.

The process followed within the discussion in this context is to invite the referring clinician to provide background information about the particular issue or case. All committee members are encouraged to ask questions which aim to draw out facts, circumstances and contexts related to the case. Ethical principles of autonomy, beneficence, justice and harm are usually integrated within descriptions of ‘the best interests’ of the child and/or family rather than singled out as specific principles to guide the discussion. The group is chaired by a physician. The clinical ethicist asks questions and models a process of enquiry about the facts of the case, possible harms and benefits that might arise as a result of proposed actions or decisions and clarifies the values and beliefs that are expressed by those around the table.

In this specific Australian hospital context, referral for an ethics consultation is entirely voluntary and at the request of clinicians. This differs from the USA and some other countries, where patients or their family can request an ethics consultation, thereby requiring a clinician to attend. Relying on clinical staff to recognize a need to use the clinical ethics service means their level of satisfaction with the processes is important. We argue, however, that physician satisfaction potentially represents an important measure of success intrinsic to the ethics consultation, and therefore warrants closer examination.

Ethics consultations: the nature of the interaction

Clinical ethics consultations have been described as complex forms of interaction involving a balance ‘between values and identity of patients, families, professionals, institutions and culture’ (p. 46). ⁶ The ethical issues raised are fundamentally dialogical, ¹⁵ that is, they concern and arise from communication and interactions between people. Within this consultation interaction, the role of a clinical ethicist may be referred to as a dichotomous one. ¹⁶ On the one hand, the ethicist is seen as a specialist who possesses expertise in moral theory and, like a physician, uses this specialist knowledge along with their experience and other techniques in order to solve complex moral problems. On the other hand, the role of the ethicist is to act as a ‘critical outsider’ who brings skills of critical reflection, mediation and hermeneutics. The role in this latter description is ‘to facilitate communication, clarify moral positions and arrange a safe moral space within which differences can be ‘aired, understood and resolved’ (p. 2). ¹⁶ A distinction in skill sets that arises from these two descriptions is that the clinical ethicist is either a problem solver so as to correspond to the first description, or an interpreter, communicator and consensus builder so as to fall within the second description. If a physician consistently walks away from this interaction including the complex roles and positions adopted by the clinical ethicist, with a feeling of satisfaction, this response warrants an examination of the elements of the interaction that might lead to such a response.

Educational philosophy sheds some light on the processes and possible impact of dialogue where values and differing moral perspectives are discussed. Burbules and Rice ¹⁷ use the term ‘dialogue across difference’. They suggest a key benefit of participating in dialogue across difference, for students and others in an education context, is the development of a particular type of epistemic knowledge which includes greater understanding of an issue, enhanced skills in problem-solving and deliberation and increased awareness of how and why one view may differ from another.

The meaning of ‘difference’, according to these authors, derives from the work of the philosopher Derrida, ¹⁸ who rejected static forms or categories of difference between people, including their identification with professional membership and social position. ‘Différance’ is a French word coined by Derrida to suggest that descriptions of events or objects or understandings are not static or one-dimensional and are usually made by deferring to how they differ from something else. Difference, from this perspective and in the context of an ethics committee, means that the range of people in the group will bring their own views and perspectives, but will also be developing understanding of how their perspective adds to or is different from others within the group. This is a dynamic process of defining individual values and beliefs while also identifying with group values.

Difference also implies, at the least, elements of sameness. Focusing on points of difference as a method of categorization is conceptually the same as identifying similarities as a reference for summarizing or categorizing views. As Burbules and Rice ¹⁷ highlight, distinguishing between or describing the differences between two people or two points of view is only meaningful or useful when there are at least some respects that are similar. In an ethics consultation, each person is motivated by the desire to achieve the best interests of the young person at the centre of the case. This common interest combined with a common background in health practice and acceptance of established biomedical ethical principles ¹⁹ help to distinguish points of difference in values about proposed treatments or management.

A related idea is that difference is a relative term and depends on one's frame of reference. For example, the surgeon who insists that surgery is necessary immediately is using a therapeutic outcome frame of thinking, whereas a social worker who believes a family needs more time to contact relatives perceives the needs of the child and family from a more experiential and relational frame of thinking. Parents’ religious and cultural beliefs are also highly significant when they conflict with values and perspectives of different clinical judgements. Each person is concerned with their version of the best interests of the child and yet, despite this shared over-riding goal, differences often emerge over interpretations of what constitutes quality-of-life for a child; who can withdraw treatment – God's will or treating doctors; whether a child has the right to know the truth about his terminal condition, or old enough/competent enough to make a decision to cease treatment; whether a mother has a right to refuse morphine and pain relief for her child because in her culture there is a belief that morphine is associated with death. All of these beliefs and values depend on an area or zone of discretionary decision-making. ²⁰ Progress in the form of overall consensus in ethics consultations requires understanding of such differences.

Translating these types of interactions to possible impacts for a participating clinician highlights an important outcome – to enable them to construct a more flexible identity through exposure to others’ frames of reference leading to a concomitant understanding of themselves. Dialogue that enables differing views and perspectives to be shared creates opportunities for deeper self-understanding, and reflection of common sense assumptions that typically frame daily decisions and practices about what constitutes the best (clinical and non-clinical) interests of their patients. Pursuing and maintaining dialogue across difference is also likely to foster dispositions and practices of communication that are relational in character, and that enhance relationships between people within the clinical ethics consultation and, importantly, beyond that sphere into the clinical context, for the benefit of children and their family.

According to Burbules and Rice, ¹⁷ achieving such dispositional and epistemic outcomes requires an ability to foster sensitivity to the world view of others; to generate an over-riding commitment to establishing shared or common meanings; and to demonstrate a level of comfort and acceptance of partial understanding of an issue or a person's perspective.

The requirement to engender sensitivity to the world view of others is achieved by eliciting and respecting the way others identify themselves and their role. This requires a preparedness to learn from what another has to say and to be committed to building a type of communicative trust where participants feel safe to contribute their views. Importantly, this type of trust does not preclude questioning other's beliefs or views but it does include being open to learning something from their views and beliefs.

Being committed to establishing shared or common meanings among participants, and across different (clinical) languages and perspectives is demonstrated when the ethicist attempts to overcome misunderstandings or conflicting views by summing up the common beliefs, views or values around the table, or highlighting where there is a general agreement. The subtle goal of facilitating common meanings is to aim, not for conformity with a particular clinical management plan, but to foster a level of understanding, tolerance and respect about different clinical and ethical views. ²¹

Acceptance of the possibility of dialogue creating partial understandings, which are neither complete understanding nor total incomprehension, means being able to provide a foundation of common meanings from which differences can be discussed. Burbules and Rice ¹⁷ argue that the process of ‘misunderstanding’ others is what helps to move towards ‘new understandings’ and growth in knowledge.

If clinical ethics consultations are accepted as examples of ‘dialogue across difference’, and the ethicist is successful in facilitating these epistemic outcomes, irrespective of decisions reached, it is very likely that the physician will walk away from the dialogue feeling satisfied. They will have gained new perspectives and understandings about a clinical ethical dilemma, which can be applied in their clinical practice.

A further explanation that links satisfaction with clinical ethics discussions arises from the idea that applying philosophical knowledge and analysis to ethical problems assists in a similar way to how medical treatment helps people who are unwell. Nussbaum ²² suggests that philosophy and the reasoning accompanying philosophical explanations may act as a form of healing for those who call for an ethics consultation. This author refers to philosophical reasoning as a way to explain emotions and to thereby cast out the ‘suffering of the soul’. ²²

In our experience, a common, although anecdotal, response to discussions about ethical issues is for people to say how ‘they feel much better’ after the discussion, they look less puzzled and they suggest they feel in some way lighter. Reactions of relief or feelings of satisfaction following involvement in ethics discussions suggest that clarification of values and being involved in developing ethical rationales about beliefs and clinical decisions can be as ‘healing’ as having a therapeutic treatment. Nussbaum ²² suggests that the emotions that accompany ethical dilemmas, including frustration, anger or concern, can be ‘treated’ through identification and clarification of underlying reasons that explain such emotions. Importantly, the healing process is an empowering one and should encourage change and growth in philosophical understanding.

A final explanation for physician satisfaction is the important role of respect within members of the group and in particular the respect that is needed through the competence and empowering but not domineering authority of the clinical ethicist. Agich ²³ refers to the importance of the clinical ethicist being able to generate necessary authority, based on the ability to reason and by extension fostering others to think and reason. He uses the term ‘epistemic authority’ as authority in a field of knowledge requiring three main criteria or conditions to be met. The first is a requirement that the ethicist has relevant knowledge (which could be philosophical, ethical or medically based). The second is that they are able to use the relevant knowledge within consultations in ways that are pertinent to the needs of those who rely on such knowledge. Third, the knowledge used by the ethicist must be relevant to the issue at hand.

These criteria taken together highlight a need for a type of ‘competence authority’ (p. 281). ²³ The ethicist must be able to show that they are practically able to perform the task and that they have the necessary knowledge and skills. Authority in this context is ‘constituted both by the practical actions and intentions’ (p. 117) ²³ of the ethics consultant. They derive from the actual practice of doing an ethics consultation, and therefore include processes of talking, listening and noticing. They rely on the nature of the relationships between the ethics consultant and the people engaged (either directly or indirectly) in the consultation. In particular, they suggest a need for a level of respect for the involvement of the ethics consultant.

This means an ‘authoritative’ ethics consultant is a person who can be trusted, achieves respect and is taken seriously, or is able to provide some satisfaction and empowerment to those involved in the discussion. This is different from a type of authority derived from possession of a particular philosophical or medical qualification and knowledge base. ²⁴ Instead, as Agich ²³ points out, the authority of an ethics consultant emerges from their ability to construct a basis for cooperation and engagement in dialogue between individuals who have diverse values, beliefs and moral understanding; from their ability to identify shared values among this group of people, and their ability to contribute to a rational discussion of the case. This concept of authority also applies where ethics consultants act in a mediation role. ²¹ These concepts of authority are important in generating goodwill and maintaining and sustaining respect among those who call for an ethics consultation.

Burbules and Rice ¹⁷ suggest that in order to achieve beneficial outcomes of goodwill, and ongoing preparedness to engage in dialogue across difference, the facilitator (in this case, the clinical ethicist) requires particular virtues of character. These include tolerance, patience, respect for difference; a willingness to listen; the inclination to admit that they may be mistaken; the ability to reinterpret or translate ethical concerns in a way that make them comprehensible to others; the imposition of self-restraint to allow others to have a turn to speak; and the disposition to speak honestly and sincerely.

Other authors frame the necessary attributes for facilitation of a clinical ethics committee as specific skills. ^23,25 These include:

Exercising one's judgement by ascertaining what is at issue in a particular case; and how to best frame the discussion about the case. This also means exercising judgement that is grounded in relevant principles, paradigm cases, rules and regulations and an awareness of the basic value commitments of the relevant parties involved, the details and nuances of the particular clinical case and the political, psychological and social circumstances actually structuring the case;

Casarett et al. ¹⁶ use the term ‘moral argumentation’ and suggest more concrete and practical skills are necessary, including gathering data, enhancing communication, identifying areas of ethical discomfort and clarifying the goals of participants. They suggest a similar role to that of promoting dialogue across difference, where the clinical ethicist is ‘hermeneutic, conciliatory and directed toward the establishment of a dialogue that can lead to consensus’ (p. 7). ¹⁶ In this conception of the clinical ethicist's skills, the place of ethical principles are at the beginning of the discussion – that is as a beginning framework that represents relevant principles. Alongside this framework of knowledge, what is required is a broader understanding of the variety of moral positions that might be relevant and ‘a rough idea of where the consensus of the moral community might lie’ (p. 7). ¹⁶ To achieve this, the ethicist needs to be able to find common ground among conflicting views by posing questions, suggesting strategies for thinking and framing problems and helping participants to see their own positions relative to others.

If the clinical ethicist lacked these skills and virtues of character it is unlikely that a physician would have the reactions of satisfaction from and respect in the process. Critically, one would also not expect the physician whose views were not respected or acknowledged to return to their patient with changed views or new understandings about the ethical dimensions of their work.

Clinical ethics consultation: does a clinician's satisfaction matter?

In this paper, we have highlighted how conceptions of success or effectiveness in complex interactions such as clinical ethics consultations are both fragile and multidimensional and the process of the communication is crucial to achieving its goals. ^26,27 Casarett et al. ¹⁶ point out how such consensus can easily be disrupted if one or more participants hold tenaciously to a principle or value. It is easy to imagine that if one view predominated, even if it was the physician's, the feeling of satisfaction in this context would be a more short-lived victory rather than a longer-lasting satisfaction derived from growing in understanding and gaining new knowledge.

The interactions within clinical ethics consultations identified in this paper all point to a valid link between physician satisfaction and the clinical ethics consultation process. We have interpreted satisfaction to incorporate a sense of empowerment, enhanced understanding about an issue and a preparedness to engage again in such discussions. Success in the form of a sense of satisfaction, according to the ideas proposed in this paper, comprises first, epistemic progress through greater understanding and increased insight about oneself and others following participation in dialogue across difference; secondly, feeling satisfied or ‘better’ from having emotional conflict or uncertainty about values ‘treated’ through ethical reasoning; third, through respect for the authority (both practical and philosophical) of the clinical ethicist, a willingness to use the knowledge and insight gained within the discussion in ongoing interactions. In simple terms, the ‘satisfied’ physician represents a participant who has been listened to and respected by a range of other clinicians, and has perhaps developed greater understanding of and insights into their own work or values, and those of others. This outcome is particularly significant if the fragility of this interactive process is acknowledged, and how easy it is to ‘get it wrong’ and to lose the goodwill of people around the consultation table.

When situated within the goals of clinical ethics consultations to resolve conflict, facilitate communication and ease moral distress, these explanations provide compelling although non-empirical rationales for why physicians may feel satisfied and why this feeling is an important and significant outcome of clinical ethics discussions. In this paper, our discussion draws from observations of one clinical ethics committee and is clearly not generalizable. However, the theoretical accounts of the importance of participant satisfaction in clinical ethics discussions point to a clear need for further research that is able to further explore and evaluate the impact of interactive processes of ethics consultations, with targeted research questions and methods. ¹¹

Conclusion

In this paper we have proposed that the physician who suggests she ‘just loves these sessions’ after participating in clinical ethics consultations, means that she has had an opportunity to discuss significant ethical issues in a collaborative discussion. In addition, we have proposed that her professional autonomy in assisting and working with families and children to sort through complex ethical decisions of health and wellbeing has been augmented. We have suggested that such a sentiment means her sense of reality has been clarified or affirmed by others around the committee table; or she has been given some language or conceptual tools by the clinical ethicist and the broader discussion facilitated by the ethicist, to describe the moral dimensions of the clinical work in which she is engaged. These explanatory concepts about satisfaction, if further investigated empirically, have the potential to develop a much richer notion of what clinical ethics consultations can achieve for physicians and by extension for their patients.