4.1 Introduction
Clinical ethics (and clinical ethics support) can be approached from a number of disciplinary perspectives – philosophy, medical, epidemiological, social sciences and humanities, psychology. This study approaches clinical ethics support services (the ‘capacity’ to be built) firstly as a health service intervention and secondly as a sociological development. In this report our primary interest is practical.
In its most abstract form clinical ethics support is a complex intervention intended to be, as evaluation researchers such as Ray Pawson would put it, a ‘fresh input’ into the system introduced in the hope that it will bring change or restore balance et al (2004, 4).
We consider what is known about ethic support services as an intervention and draw on our research with clinicians to describe how ethics currently features in daily clinical routine and what kind of support they might prefer. The sociological analysis is not fully developed in this report but will be presented in reports prepared for academic audiences/peer-review journals.
To recapitulate; the original research proposal stated: this 2 year project will use qualitative and quantitative methods to determine:
The kinds of ethical and issues that arise in the context of patient care in NSW;
How much ethical discussion happens now in clinical practice, of what kind, and between whom;
Potential entry points for normalising or ‘routinising’ clinical ethics discussion in daily practice;
Situations where prospective ethics review might be warranted;
The degree to which clinical ethics resources are desired and needed by health professionals and health systems; and
The range of clinical ethics resources that could/should usefully be made available within the NSW health system.
In the remainder Section 5 we briefly outline the theoretical framework guiding the qualitative and quantitative research methods used.
4.2 Theoretical Framework
The epistemological framework for this study is ‘realism’ – drawing on both the ‘subtle realism’ of Hammersley (Hammersley 1992, Hammersley and Atkinson 2007) and ‘critical realism’ advocated by Sayer (2002) and Danermark et al (2003). The ‘realism’ refers to treating the objects of study as real independent, knowable phenomena. The ‘subtle’ or ‘critical’ acknowledges that our observations are concept dependent – our cultural, professional, scientific assumptions colour what we see. This important to note given that much of this report is taken up with an interpretation of what clinicians’ told us about clinical ethics i.e. how they interpret things.
In the realist approach – people’s perceptions are real in their consequences; we act on what we believe the situation to be. Methodologically we need to understand how clinicians understand the situations they find themselves in. The situations that clinicians encounter may involve any number of social structures, arrangements and relationships. Talking to people and listening to their descriptions and explanations can show ‘real’ social arrangements - defensive medicine because of fear of litigation, for example. The belief that you could be sued (well noted in the literature and observable in our data) regardless that statistics suggest the likelihood is actually low is related to some established social ‘facts’ such as the increasing interaction of health and law and associated areas like insurance.
Our study uses standard social science methods. We draw on the empirical work (e.g. surveys, RCTs) of earlier investigators to establish some of the basic descriptive features of ethics support services such as prevalence, types, functions and to determine what is known about their performance. Our own empirical work includes ethnography, interviews and a survey used to establish the views, experiences, attitudes and practices of clinicians regarding ethics support. More detail on these methods is given below.
The approach taken can be categorised as empirical or descriptive ethics. We empirically explore but do not normatively appraise the clinical practices and decisions that we have observed. Our approach roughly follows the position described in the quote below by ten Have and Lelie – our task is to describe not evaluate:
“Descriptive ethics is geography; it maps the moral domain; it can explain how clinicians and their patients behave in moral situations. But it does not tell us how actors ought to behave or what kinds of decisions are morally justified.” Ten Have and Lelie (1998)
Qualitative Data
Our data is primarily clinicians’ accounts of how they manage the ethical issues they encounter. Accounts are people’s descriptions, explanations and justifications of events, ranging from the mundane to the dramatic (Orbuch 1997). In their accounts events and experiences will be described, typically in the form of (more or less coherent and complete) narratives. Narratives of events and experiences are where meanings are observed. We can see in their accounts how people interpret and make sense of the world and their experience of it. In their accounts, people demonstrate their knowledge of ‘ideal’ behaviours and talk about themselves as legitimate actors with reference to the socially constructed moral order. In sum, accounts show us people’s beliefs about how the world is and how it should be and their reasons for acting in it.
Our qualitative analysis involves categorising what clinicians said about what is and ought to be, identifying the degree of convergence and divergence on what is and ought and extracting ‘themes’. The intention, not at this point fully realised (see note below) is to develop a sociological explanation for our observations. Accounts should give us a plausible description of the situation and we can largely take it as how that individual understands a situation. They could be wrong, they could be lying but they must give a plausible account which can be compared with other accounts.
“Separating the question of the truth or falsity of people’s accounts from the analysis of those accounts as social phenomena allows us to treat participants’ knowledge as both resource and topic, and to do so in a principled way” (Hammersley &Atkinson 2007, 99)
You put together a story from all the stories people have put together for you. You do not end up with a value free collection of facts but you do get a glimpse of the ideas, values and interests at play in a given situation.
Quantitative data
The survey data is primarily clinicians responses to fixed-choice questions about the type of issues faced, how these are managed, how often and openly ethics is discussed and preferences for different types of ethics support. Descriptive statistics are used. In addition to putting numbers against specific features of everyday ethics (e.g. type of ethical issues) the survey data are used to explore some of the findings that emerged from our qualitative research.