A DEVIANT CASE

The predominant way the informants talked about making ethical decisions was as a group process designed to produce a consensus on the way forward. However, one informant, Dr Lovate did not give an account of consensus decision-making that conformed to this analysis and his account can be seen as a negative instance of the general hypothesis.

The use of negative instances or deviant cases has been argued to be an important tool for improving the interpretation of qualitative research accounts (Silverman, 1993; Becker, 1998; Seale, 1999).175 The methodology in this section draws on Seale‟s study „Living alone towards the end of life.‟ (1996) This study interviewed friends, relatives and others who knew people who had lived alone in the last year of their lives. Seale argues that the majority of his informants were concerned to

demonstrate their moral identities to the interviewer by justifying their behaviour and actions, but there were five informants who gave accounts that did not conform to this analysis. Seale argues that the consideration of these deviant cases could be instructive:

I felt these apparently deviant cases, where speakers appeared to locate

themselves outside the ideal of accompaniment, were satisfactorily explained as aberrations. The speakers in each instance successfully demonstrated their moral adequacy by alternative means. In doing this, they showed an orientation towards the event as deviant from normal behaviour, requiring explanation, so

strengthening the general case that accompaniment of dying people is perceived as a generally desirable norm. (1999:80)

Therefore, these deviant cases give additional support for his theory of moral adequacy (Seale, 1999:78).

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See Chapter Four for a detailed consideration of this method of aiding the validity of qualitative research.

Dr Lovate was the twelfth doctor interviewed and it was just over halfway in the data collection. The analysis of the data that I had conducted before this interview had not given the process of consensus in making ethical decisions any pre-eminence and it was the subsequent analysis of his transcript that prompted thinking in these terms. Dr Lovate did not see the process of consensual decision-making as a useful way of making ethical decisions and this highlighted that the other informants had used it in this way. By drawing attention to the problems he thought were created by his colleagues using a consensual decision-making processes, he threw the other

accounts into relief. His account suggested that consensual decision-making was the „dominant model‟ of ethical decision-making used in the infertility clinic.

Dr Lovate thought that decisions about how to treat and manage a patient should be taken by the individual doctor dealing with them. When asked about how he made ethical decisions Dr Lovate gave the following account:

I‟m interested in the patients. I‟m sorry, the patient is my patient and I…I‟m a damned good doctor, I know that I‟m a good doctor, I know that I give my patients more than what‟s called of me….So, I know that I have the patient‟s interest at heart, and just knowing that gives me strength to do what I want to do. But I‟m shackled, you know, I can‟t….And part of the reason I‟m pleased that I‟m in the twilight of my career is that I‟m so bound down and my practice is inhibited by the rules that I have to keep by. And the thing that really upsets me is that I don‟t believe it‟s in the interest of the patient. I think a lot of what‟s happening now is not in the interest of the patient, because it takes the initiative, you know, one‟s not allowed to have initiative any more because there are guidelines, you‟ve got to stick by the guidelines. And I think that the patient loses out, and that‟s really what upsets me. So, when you say moral and ethical issues, I always spend a lot of time discussing with the patient what I intend doing. I‟m one of the few doctors who on my private consent form in my private practice, when it comes to induction of ovulation I have these are the potential complications, and the sixth one is death. And I actually write on there that patients have died from this treatment, so I tell them everything….So I spend a lot of time explaining in great detail to the patient what I intend doing, what the potential complications are, and if the patient hears that, and then I get consent, you know, written consent, then I would like to treat the patient the way I think that that particular patient

His more individual approach to patient care was reflected in his unhappiness with the increasing amount of guidelines in infertility practice. „You see, I find that I would prefer to have no policy at all. I‟d rather we had no policy and that we raised all these issues and discussed it on a personal individual basis, because - but, of course, if you do that then you can be accused of favouritism or, you know, you like this couple so you‟re allowing them to have a third.‟ (12-25) Although he recognised that having no policies might lead to a clinician being accused of partiality, he thought that each case should be decided purely on its merits. Guidelines, for Dr Lovate, interfered with his preferred way of making ethical decisions which was, for him, a focus on the particular patient by an individual doctor without outside

interference. He thought decisions were best taken by the individual doctor not a unit meeting.

Dr Lovate gave an example to illustrate these points. The amount of super-ovulatory drugs to administer and then how many embryos to transfer back are currently contentious areas in infertility practice.176 Dr Lovate said, „I mean I am much more aggressive in my treatment of infertile patients in that I feel that it‟s important to get a pregnancy even at the expense of it being a multiple pregnancy.‟ (12-28)

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See HFEA (2007) consultation document on single embryo transfer and Ledger (2007) for a consideration of lower doses in IVF treatment.

His unit, Clinic 2, had a policy on the prescribing levels for drugs:

I mean for years I used to do battle. Vicky177 is our, a senior nurse who, because if patients need ovulation induction or super-ovulation, the nurses actually do it, it‟s a nurse-led clinic, and I for years have said, “Look, when it comes to my patients, I want them to have three ampoules or two ampoules”, but that went against the grain because what about the policy of the clinic, and how can Dr Lovate have a - so we used to have wild discussions in these meetings. But it was always settled amicably and I lost. But I thought it was important to give my views, and there was no blood or anything like that, so its….(12-29)

Thus, for Dr Lovate having to abide by clinic policies and protocols interfered with his ethical decision-making – this should be done on the basis of acting in the best interests of one‟s patient, without recourse to outside influences.

Dr Lovate‟s deviant account can be argued to strengthen the analysis of consensual ethical decision-making. Dr Lovate, by drawing attention to his battles with

colleagues over patient management and his views on general guidelines, positions himself as going against the grain of the prevailing ethos. In the end, he still had to abide by the clinics‟ policies and the decisions it made on the basis of a general consensus. So he still participated in the process of consensus decision-making, he just did not see it as a beneficial way of making such decision. Therefore, this account reinforces the analysis that making ethical decisions on the basis of consensus was, generally, seen as the most appropriate and useful way of approaching them in the infertility clinic.

177 _{This is a pseudonym.}

CONCLUSION

This chapter has examined how the informants made and approached ethical decision-making in their everyday practice. I have agued that they used group processes to try and reach a consensus over how to handle difficult cases. The cases that were discussed in clinic meetings and CEC were those that were part of a controversial morality, where there was no generally agreed opinion on how to proceed. In these cases the informants had to find a way of managing such cases in practice. For the informants consensus decision-making gave them a consistent, transparent and, generally, uniform process that was the key to making „good‟ and „acceptable‟ ethical decisions. It is this process that could be seen to legitimise the decision. The process and the product of decision-making were inextricably linked for the informants. It was the due process, the taking of the decision out of the hands of one clinician and making it a clinic or CEC decision that gave such decisions their legitimacy. Thus, having explained how the informants made ethical decisions, it was possible to develop a theory of consensus by both examining how the notion was used and formulated in practice and considering the philosophical literature on the subject.

By focussing on the way that ethical decisions are actually made in practice, it is held that the process of decision-making is of importance as well as the actual decision itself. One of Moreno‟s key claims in Deciding Together (1995) is that, led by his formulation of naturalism, it is imperative to study social process of consensus formulation to see if these specific manifestations of consensus are morally acceptable. Therefore, social science and psychological research are needed to establish how well an actual consensus process functions, it is not a matter that can

be settled by abstract argument alone. This chapter is an attempt to do this, by examining a particular setting where consensus is used to make ethical decisions. As the social production of decisions becomes more important for bioethics alongside a concern for the actual decision itself and if we are to be confident in our ethical decisions, we need to have some understanding of the procedures that were used to make them. This can open up new arenas of inquiry for bioethics: the social

production of decision-making.

The next chapter will look critically at consensus decision-making and consider whether it is a defensible way of making ethical decisions in the infertility clinic.