A clear vision and message about being a reflective forum

If the CEC wishes to promote itself as a “forum in which health professionals can raise ethical problems, check their own judgements and intuitions, while benefiting from open discussion with other clinicians and appropriate outsiders” (Dare 2010 p7), they will need to ensure that the clinician and the organisation see their role in the same way. The term ‘committee’ could be misinterpreted by practitioners as a group who are going to solve the problem, leading to a different expectation of the CEC remit than the CEC has of itself. Traditionally other types of committees have been devised to review evidence or information and to reach a conclusion about the presented ‘facts’. The traditional notion of the committee is identified as an:

“individual or a group, appointed by an agency, authority, or larger assembly, to whom a matter is referred, or is committed for attention, investigation, analysis, or resolution” (Business Dictionary 2012).

The clinician may be looking to take the case or issue to the CEC for a quick answer to a difficult problem. It would not seem unreasonable that the clinician

should look for this. Within health service culture there is a precedent that difficult clinical problems are escalated by more junior staff to more senior for a ‘decision’. The demands of the clinical arena generate demand for quick, practical solutions from patient, client and clinicians. The healthcare culture also generally accepts the legitimacy of referral of difficult cases to ‘consultants’ who are expected to have developed greater expertise and may be able to direct the case more appropriately. The referrer will in turn expect an answer to be borne out of this consultant expertise.

In referring to the CEC, particularly with regard to contemporaneous cases, there may be an expectation by clinicians that ethical deliberation will be carried out by those sufficiently trained in ethical analysis and that the ‘right’ ethical answer will be offered. Here the expertise assumed to be embodied within the CEC is an expertise that somehow the CEC has the skills to make a ‘better’ decision. This assumption rests upon two premises. First there is the assumption that an interest in ethics, or theoretical knowledge of ethical theories, makes the CEC able to make a better decision in clinical practice than the clinician. Secondly there is the assumption that this decision carries with it a claim to greater moral authority than the clinician could claim and therefore the clinician can defer the responsibility for that decision to the CEC.

Before we explore these two premises it could be argued that whatever the skills of the CEC the clinician should always retain responsibility for their own actions and justifications of such actions. Siegler (1986) has argued that the notion of abdication of responsibility by the clinician may be in itself unethical, as the

physician is responsible morally and legally for decisions around patient care, and should not abrogate that responsibility to others. Blake (1992) questions whether

any single group of medical professionals can claim sole ethical authority.

Decision making in practice is a community endeavour and the notion of expert in ethics or morals with moral authority, whoever that may be, should be rejected, as the CEC can neither claim moral expertise which is greater than the clinician, nor the moral authority to have any recommendation made by them implemented over and above the wishes of the clinical team.

Example from practice

A recent case experienced in my clinical practice highlights the problems inherent in accepting the traditional referral to experts’ model in relation to moral issues. Certain details have been changed to protect patient confidentiality.

When lecturing at a large university I was approached for support by a group of distressed chemotherapy nurses as I was their mentor in practice. They had been caring for an elderly lady with dementia who had been recently diagnosed with lymphoma. She had fluctuating capacity, but in their opinion, did not have the capacity to consent to chemotherapy treatment or at least to understand how to comply with the aftercare required which would maintain her health during the treatment. The nurses were concerned that if she were administered the

chemotherapy she would be unable to comply with the instructions needed to help her avoid infection and that she may not tolerate supportive measures such as blood transfusions. The nurses were administering the chemotherapy (although the Doctors prescribed it) and they felt they would be administering something that would potentially hasten her death from an associated infection. The medical team did not agree and prescribed the medication, and the nurses felt obliged to

administer. Unfortunately the anticipated problem happened and the lady died of a septic neutropaenia one week after the chemotherapy, having not reported

symptoms that would have led to medical interventions that had a high chance of saving her life, due to her confusion. The nurses were frightened that this situation might happen again. They felt their concerns were unheard by the medical team, and they felt a tremendous guilt for having administered the chemotherapy injection. If a best interests meeting had taken place there would hopefully have been an opportunity to discuss the nurses concerns, and hopefully a compromise decision about care reached to the satisfaction of all team members and in the best interests of the patient. The medical team in this case, it could be argued, took a paternalistic and narrow minded approach to the situation, not considering the non-medical influences on the situation. Their objective view of the ability of the lady to consent was not wrong, but was rendered inappropriate due to other contextual issues. Neither the CEC nor any one clinician has the claim to authority to make the decision without consulting and considering the perspectives of others. The CEC may objectively have agreed with the judgement of the medics, if they had not been aware of the other issues influencing the situation. Rather than taking the medical issue out of context, a CEC structured to support team

discussion, from a non expert position, could facilitate all the perspectives to be considered and avoid the risk of supporting a clearly wrong judgement.

The CEC being seen to be ‘expert in ethics’ making decisions where those referring think the situation is too complex, could be seen to be akin to a narrow minded paternalistic medical team who believe they have the answers and the jurisdiction to pressurise others to behave in a manner that those being

pressurised did not agree with or understand. The resulting decision would

undermine team relationships and trust and may be catastrophically wrong for the patient. The CEC should approach decisions in a different way and ensure all,

from management to worker, to patient and carer, understand why this needs to be the case.