Learning Practical Wisdom from Moral Case Deliberation Through Morisprudence

"Moral case deliberation is regularly used as a teaching method at our medical school. Besides we facilitate moral case deliberation on the ward in our hospital. In both instances, our assumption is that practicing moral case deliberation will assist our (future) healthcare professionals to cultivate the virtue of practical wisdom. But, is this assumption, right? The answer to this question requires both empirical research and conceptual analysis. This paper focuses on the latter. The claim defended is that we can elucidate the relation between moral case deliberation and practical wisdom through an analysis of so called morisprudence. We start with discussing two divergent but related interpretations of morisprudence: one introduced by Toulmin and Jonsen, related to casuistry, and one related to a Dutch interpretation with a strong relation to moral case deliberation. The combination of the both interpretations shed new light on the conceptual connections between cultivating prudence (practical wisdom) and moral case deliberation, but it also provides new insights into the individual and collective dimensions of practical wisdom, of character formation within organizational contexts. Finally, it may have consequences for how moral case deliberation should actually be employed to teach practical wisdom. "

How to Train and Assess the Quality of Facilitators for Moral Case Deliberation? Experiences with and Evaluation of Self-Reflection and Observation Forms for Facilitators of Moral Case Deliberation

"In Europe, Moral Case Deliberation (MCD) has been well-known and established as a form of Clinical Ethics Support (CES) and implemented in many international (health care) institutions. Since 2007 Amsterdam UMC organizes training for professionals to become a facilitator of MCD. To support and asses the development of those future facilitators MCD, an instrument has been developed which can be used by both trainees and trainers. The instrument consists of a self-reflection form and an observation form. Both forms are almost identical and contain a part of open questions reflecting upon the personal learning goals of the trainee and a part of 56 closed questions. The part of closed questions contains concrete descriptions of preferred skills and attitude of the MCD facilitator trainee, related to MCD in general and the specific steps of the Dilemma method and the Socratic Dialogue in particular. Special attention is being paid to concrete actions for fostering a dialogue and deepening the moral inquiry. The instrument can also be used by trained and more experienced facilitators of MCD to reflect upon their acquired skills and attitude, and indirectly on the quality of CES they provide. In this presentation we will present the instrument and share our experiences in using the two forms in order to train and assess (the quality of) facilitators of MCD. Furthermore, we will present preliminary results of the analysis of more than 1200 forms collected in the past decade from trainings on national and international level. "

Moral Competence, Moral Teamwork, Moral Action – Outcomes of Moral Case Deliberation in the Euro-MCD 2.0 For Evaluating Clinical Ethics Support

"Background: For Moral Case Deliberation (MCD), like any form of Clinical ethics support (CES), it is important to know whether it reaches its presumed goal of supporting healthcare professionals in their ethical challenges. Evaluation is needed to gain insight in the value of MCD. Therefore, the Euro-MCD instrument was developed to assess outcomes of MCD, and has now been revised. The aim of this presentation is to present the revised Instrument: the Euro-MCD 2.0. Methods: The revision process was an iterative dialogue in which field study findings were integrated with theoretical reflections and expert-input. Results: The Euro-MCD 2.0 has three domains: 1) Moral Competence, 2) Moral Teamwork and 3) Moral Action. Moral Competence includes items on moral sensitivity, analytical skills and a virtuous attitude, like ‘I speak up in ethically difficult situations’. Moral Teamwork refers to open dialogue and supportive relationships, for example ‘We feel secure to share emotions in ethically difficult situations’. Moral Action includes items about moral decision-making and responsible care, like ‘We are able to explain and justify our care towards patients and their families’. Discussion: The Euro-MCD 2.0 is shorter and more strongly substantiated by empirical data and theoretical reflections. At the conference, we will reflect on the revision process and the underlying foundations of the domains. The revised instrument helps to get insight in the MCD related outcomes for healthcare professionals in their daily practice. Our research can further improve implementation of MCD and contribute to the research field of evaluation of CES in general. "

Moral Challenges of Ethics Support Staff. Developing a Moral Compass for Facilitators of Moral Case Deliberation

"Ethics support staff often help others to deal with moral challenges. However, they themselves can also experience moral challenges when practicing ethics support. Facilitators of Moral Case Deliberation (MCD) sometimes for example experience ethical questions when it comes to (breaking) confidentiality. Facilitators might find themselves compelled to intervene or act upon things they hear or see whilst facilitating a MCD. For example, a MCD facilitator finds out that a participant does something illegal. Or, what to do if a MCD facilitator is asked to inform the Inspectorate about details of a MCD? When is a facilitator allowed or obligated to break confidentiality and share information with others? How to make such a decision? And, if allowed to break confidentiality, how to do this in a morally sound way? Currently there are no moral guidelines on how to act upon these questions. We conducted empirical research that explores moral challenges of MCD facilitators related to confidentiality and develops a moral compass which provides directions to approach these challenges. Data collection consists of three complementary methods: * analyses of 3 a 4 audiotaped and transcribed MCD sessions about how and when to break confidentiality; * in-depth interviews about the topic; * focus group to validate the findings and co-create a moral compass. In our presentation, we will reflect upon both the theoretical and normative considerations concerning confidentiality in ethics support and the empirical results of this study. Furthermore, we will present a preliminary version of a moral compass in order to strengthen the moral competency of MCD facilitators. "

The role of emotions in Moral Case Deliberation: Visions and experiences of facilitators

Moral Case Deliberation is intended to assist healthcare professionals faced with difficult dilemmas in their work. These are situations that involve emotions. During Moral Case Deliberation, participants are invited to reflect on moral views and deliberate on them. Emotions are not explicitly addressed. This article aims to elucidate the role of emotions in Moral Case Deliberation, by analysing experiences of Moral Case Deliberation facilitators. Our research shows the role of emotions varies according to the phase of the Moral Case Deliberation process. One negative aspect of emotions is that they can obstruct the Moral Case Deliberation discussion or distract from the moral question. A positive aspect is that they bring the dilemma into sharper focus. Devoting attention to emotions can help to ensure that responsible decisions are made, while also increasing the moral resilience of participants.

Dealing with Ethical Issues in Countering Violent Extremism (CVE): An Exploration of Concepts and Tools to Support CVE Programs and Practitioners

Countering violent extremism (CVE) implies many pressing ethical issues. For policymakers and professionals, it is essential to identify concrete ethical dilemmas and to understand the underlying more abstract ethical issues. The proposed typology of ethical issues consists of four different levels: the structural, the political, the professional, and the personal levels. Ethical issues on the structural level are rooted in the conditions of the world risk society, such as the morality of CVE and counterterrorism in general or its fundamental inconsistencies. On the political level, the phenomenon of the state of emergency, the politicization of CVE and counterterrorism, the legitimacy of state interventions, and the tension between secrecy and transparency all play a role. Professional values can conflict with organizational interests on the professional level. Finally, on the personal level, integrity can come under pressure due to conflicting values. An exploration of the benefits for counterterrorism practitioners of the consequentialist, deontological, and virtue-ethical approaches concludes that none of them offers a sound approach to the practice of counterterrorism in a liquid world risk society. This provides an opportunity to highlight the potential of the philosophical concept of “compromise” (Benjamin) in reconciling opposing principles and underlying values of the key ethical approaches. A major source of guidance and inspiration for compromise is phronesis, or practical wisdom. Another powerful concept is the ethics triangle (Svara). This ethics triangle implies that public administrators should strive towards a balance of virtue, principle, and good consequences, all seen from the perspective of the duty of the public interest. There are several ethics tools available that can inform the design of CVE programs and support dealing with the various types of ethical issues once a CVE program is started. First, it is useful to engage in a closer analysis and value clarification of the ethical issues at stake. Second, the already established tool of privacy impact assessment represents an inspirational point of departure for a broader ethics impact assessment. Third, the institutionalization of ethics support in the field of CVE can be realized by the establishment of ethics committees, the appointment of ethics advisors or ethics rapporteurs, or the installation of reflection groups. Fourth, the implementation of tools of ethics support like moral case deliberation can empower CVE professionals to deal with ethical issues. It can also improve their decision making, support collective learning, and contribute to the development of policies and guidelines in the field of CVE and counterterrorism. Last, but not least, evaluating CVE programs can benefit from taking ethical issues into account. Moving beyond mandatory rituals of ethics checks can lead to an in-depth engagement with professionals and stakeholders within CVE programs and a re-adjustment and fine-tuning of programs if necessary. In the long run, the integration of ethics into the design, implementation, and evaluation of CVE programs can strengthen the legitimacy of these programs among targeted communities, professionals, and societies at large.

The Role of Worldview in Moral Case Deliberation: Visions and Experiences of Group Facilitators

This study investigates the role of worldview in moral case deliberation (MCD). MCD is a form of clinical ethics support which aims to assist caregivers in reflection on moral dilemmas, experienced in daily practice. Bioethicists acknowledge that existential and religious aspects must be taken into account in the analysis of ethical questions, but it remains unclear how these elements are addressed in clinical ethics support. We investigated how facilitators of MCD address worldview in MCD. MCD facilitation is often done by spiritual caregivers, but not in their role as spiritual caregiver. Discussing worldview is no standard part of the procedure in MCD. This study was qualitative, focusing on the views and experiences of the facilitators of MCD. Semi-structured interviews (N = 12) were conducted with facilitators of MCD. Grounded theory was used for analysis. The results show that worldview plays both an explicit and an implicit role in the MCD process. The explicit role concerns the religious beliefs of patients and professionals. This calls for avoiding stereotyping and devoting attention to different visions. The implicit role comes to the fore in addressing core values and spiritual fulfillment. In order to clarify the fundamental nature of values, more explicit attention for worldview might be useful during MCD. However, this should be done with caution as the term ‘worldview’ might be interpreted by participants in terms of religious and personal beliefs, rather than as an invitation to reflect on one’s view of the good life as a whole.

Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care

BACKGROUND: In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that HCPs in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden.METHODS: This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content-validated European Moral Case Deliberation Outcomes Instrument, before participating in regular MCDs. The main open-ended question included in the questionnaire was analysed according to systematic text condensation. RESULTS: Data was collected from 161 responses from the healthcare professionals who were invited to participate. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care on a care level. CONCLUSIONS: Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then tailor the conditions.