The standardization of clinical ethics consultation and technique’s “long encirclement” of humanity: a response to Brummett and Muaygil

In their recent article, Brummett and Muaygil reject Bishop et al.’s framing of the debate over standardization in clinical ethics consultation (CEC) “as one between pro-credentialing procedural and anti-credentialing phenomenological,” claiming that this framing “amounts to a false dichotomy between two extreme approaches to CEC.” Instead of accepting proceduralism and phenomenology as a binary, Brummett and Muaygil propose that these two views should be seen as the extreme ends of a spectrum upon which CEC should be done. However, as evidenced by several inconsistencies within their article, they have failed to fully appreciate the concern animating Bishop et al.’s proposal. Additionally, because of this failure, they do not seem to realize that credentialing ethicists for CEC will only create different problems in Saudi Arabia even as it possibly solves some of the current problems they identify. In this commentary, we highlight and clarify Brummet and Muaygil’s five misunderstandings of Bishop et al. This leads us to conclude that while they claim to be advocating a middle way between proceduralism and phenomenology, in fact they would like for us to standardize another proceduralism, albeit one that incorporates some of the “qualitative” values of American bioethics.

Quality Assessment of Clinical Ethics Consultation. Reflection on the Applicability of the Ethics Consultation Quality Assessment Tool

"Background. Clinical ethics consultation has been implemented in many health care institutions. Different methods exist for their evaluation. In this paper we present findings from an evaluation of 21 documentation conducted 2019-2020 by means of the Ethics Consultation Quality Assessment Tool (ECQAT). The applicability of the instrument was analyzed based on a) duration of use, b) ease of use, c) comprehensibility of the items. Results. On average, the analysis with the ECQAT takes 11 minutes per protocol. The greatest difficulties in applying the ECQAT arise a) in assessing the counselling-related information and b) in assessing the ethical analysis as well as the recommendations. Here, different demands on the level of detail of the information may lead to different assessments. Furthermore, the transitions of the ethical analysis and the recommendations, which are relevant for the assessment, could not be delimited exactly in parts of the protocols. Discussion. The assessment of documentation represents a limited part of the quality of ethics consultation. In particular, the quality dimensions of the EQAT do not map communicative elements of process quality, which are essential components (if not the core) of ethics consultations. Moreover, the assessment is strongly depending on the format of the protocols, which, depending on the institution, range from a brief overview of the results to a detailed account. Even in light of aforementioned limitations the ECQAT provides an incentive to improve the process quality of (documented) ethics consultation. "

Clinical Ethics Consultation in Neurology – a case series

Background The concept of clinical ethics consultation (CECs) was implemented to provide support in ethical controversies in clinical settings and are offered in at least every second hospital in Germany. Neurological disorders often require complex decision-making. The aims of this study were to determine which situations lead to CEC in neurology and to investigate the influence of the individual patient’s wishes on the recommendation. Methods Standardised CEC protocols in the years 2011 to 2017 at the University Hospitals of Goettingen and Jena were retrospectively surveyed. The contents were categorised along existing protocol templates of CEC scenarios and subsequently paraphrased and reduced to significant meanings. Results 27 CEC scenarios which were facilitated by various professional disciplines were reviewed. Stroke was the most frequent underlying condition. Nearly all patients were not able to consent. Mostly, the relatives acted as representatives or health advocates. In 67 % of cases, a sense of conflict triggered a CEC; in 33 % a sense of uncertainty was the reason for the CEC request. In 21 CEC scenarios, a recommendation was reached in consensus with all parties involved. In 59 % of cases, a decision was made to continue medical therapy. In seven cases, the patient’s wishes led to a limitation of therapy, while in just two cases this decision was made primarily relying on the patient’s best interest. In only 13 % of cases, a valid advance directive led to respective therapeutic consequences. Conclusions CEC is feasible for consensus-finding not only in conflicts, but also in situations of therapeutic uncertainty in neurology. There is a special importance of the patient’s wishes in decision-making in neurology. However, only in a few cases were advance directives precise and specific enough to have sufficient and decisive weight in therapeutic decision-making.