UK CECS should not seek to replicate the American model as using a principlist approach to seek recommendation out of context has the potential to cause harm as previously discussed. Therefore UK CECs need to find a model of practice that fits with our own unique healthcare system and answers the criticisms about abrogation of responsibility to the CEC and not the fact that recommendation does not support moral development of the clinician in practice.
If the CEC in the UK focuses on being a peer support group for ethical review, respecting their important function as a reflective practice forum to maintain dialogue with organisational management and the clinician the CEC is in the best position to offer meaningful support.
CECs in the UK can work best as reflective bodies by basing their reviews within the moderate Particularist philosophy and utilising the benefits of casuistry.
Particularist approaches offer the CEC a framework to support the clinician in their exploration of the detail of the situation. Through this exploration issues can be clarified. The clinician can then set goals to tackle the issues and can explore possible solutions to the problem in order to choose the most appropriate in the context. Kaebenick (2000 p310) notes the benefit of approaching an ethical issue in this way saying:
“Dancy (1993)...argues that deliberation over a moral case is analogous to grasping ‘the shape of the circumstances’ and Nussbaum (1986 p305) holds that ‘[p]ractical insight is like perceiving, in the sense that it is non- inferential, non-deductive; it is, centrally, the ability to recognize,
acknowledge, respond to, pick out certain salient features of this complex situation”.
Review of the situation and exploration around possible solutions to the dilemma through dialogue can increase practitioners’ awareness of possible options and the skills they already have to tackle the issue that is causing disquiet. The
clinician can explore motivations, moral and non moral influences on the situation, precedent cases and the use of the virtues he possesses. The clinician can consider the virtues required such as courage, honesty, truthfulness and kindness and can consider how the skills he has in these areas can be used to assist him with the case in hand. Recognition of the use of such skills builds confidence for the future that he has the ability to tackle situation and has done so in previous situations. The situation may be new but the skills needed to address the
can help develop habits within the worker that assist him to approach problems in the future in a manner that takes into account differing perspectives involved. The analysis of the case, using this approach, will be rooted in the situation not in the abstract. The complexity and the influence of the environment on the situation are recognised.
In the UK many committees have already identified the importance of their
supportive role. Larcher et al (2008) responded to an article criticising anonymous decision making by committee rather than by clinicians and patients as follows:
“As members of the clinical ethics service at Great Ormond Street Hospital for Children, we must challenge the picture painted in the article ‘Doing the right thing’ (24 April). You imply that complex ethical decisions are
increasingly taken by ‘anonymous committees’ rather than clinicians and parents. Clinical ethics committees provide advice, support and
consultation, but our role is clearly defined as advisory. To remove the power to make decisions from the clinical team helping a child and their family would be wrong.”
This thesis will discuss over the next chapters the evidence to support that CECs in the UK have a useful role to support clinicians and the organisation. It will then develop the argument to explore why CECs need to be clear about the scope of their influence to enable the clinician and organisation to view the CEC in the most appropriate manner. The next chapter will explore why the appropriate role for the CEC should be as a non expert facilitator to support dialogue about ethical issues. Skills to facilitate dialogue about ethics and to assist with clarification and solution focused resolution will assist teams to manage value conflict. The thesis will
further discuss that value, role and processes conflict are often reasons for a CEC referral.
After discussing these major points the thesis will present a model I have developed which answers the criticisms already levelled at CECs about
undermining of clinician autonomy and not stimulating or supporting moral growth. This model is titled the Ask, Seek, Clarify Solutions model of CEC case review. This is a clinician centred model which keeps the clinician, patient and their family at the heart of the dialogue. Using a particularist philosophy the CEC asks the clinician to tell their story and perception of events. Once differing perspectives have been sought in the seek part of the model the clinician is facilitated, by the use of solution focused questioning, to consider changes that can improve the situation and may lead to solutions and resolution of the dilemma. This does not require any particular ethical stance to be used. The problem talk is kept to a minimum and compromise solutions are actively sought. The CEC, if required, can assist the clinician’s considerations by providing information with regard to
precedent cases, or what other reasonable clinicians may have done in similar circumstances, using casuistry in the clarification quadrant of the model. The clinician having considered possible solutions will then be enabled to try some of the changes in practice discussed, knowing that the group is available for support. The support is not offered in a directive manner but in a supportive manner to assist the clinician to plan solutions to tackle the problem. As all the four stages of the model are distinct the skills used by the CEC to provide support is evaluable. Such evidence and can be used to support claims by CECs that they are a useful form of ethical support to the clinical team and can assist with identification of
areas for development. Chapter 5 and 6 will discuss the model in great detail and will offer a case example of the use of the model in practice.
In the next chapter I will discuss the perceptions and evidence available to support the argument that CECs are beneficial for the organisation and the clinical team. The influential position of the CEC within the healthcare culture obliges the CEC to use a clear and evaluable model such as the ASCS model to ensure that it can evidence it is offering the most effective service in the most appropriate way. By choosing a model for reflection that is simple, evaluable and clear the CEC can evidence benefit. The greater the evidence available to support the argument that CECs support the moral development of the practitioner rather than diminish it the greater chance clinicians and organisations will feel confident to use such an important service. Greater integration into the healthcare culture can enable the CEC to become firmly embedded as a useful service to assist in case and ethical issue debate, guideline review and formation, education and influencing a culture of dignity, respect and openness.
Chapter 2 The Benefits of the existence of Clinical Ethics Committees within