Introduction
A recent study was done in Canada to identify what clinical ethicists felt were the top 10 clinical ethical challenges facing Canadians in healthcare. (Breslin et al., 2005; Table VII.1).
From Breslin et al., 2005.
What is clear from this list is that many of these ethical issues are core to challenges of healthcare more broadly today. While this study was conducted in Canada, it is likely these same challenges may be similar in other healthcare systems, at least in the developed world.
Clinical ethics is a comparatively recent endeavor in healthcare, but despite its relative newness it provides an ideal model for initiatives that can impact healthcare because of its inherent interdisciplinary make-up and its unique capacity to impact care across the healthcare spectrum from “boardroom to bedside.” While clinical ethics offers this unique perspective to address healthcare problems, it is often missing from the meetings where significant system-wide decisions are made. Many decision makers miss the key point that much of healthcare is grounded in values and many of the solutions may be found in the ethical field of inquiry. The most likely reason for this absence of clinical ethics at the decision tables in healthcare is related to the still developing nature of this work. What the chapters in this section show, however, is that perhaps clinical ethics is “coming of age” and is beginning to make serious arguments to the healthcare community about how its activities and frameworks can offer useful, real-world contributions to help to guide system decision makers, healthcare professionals, and the public.
In Ch. 40, the authors outline the importance of systems thinking in the practice of clinical ethics with the goal of impacting the overall professional and organization ethics culture and accountability of hospitals and other healthcare settings. The authors built their chapter around a challenge by Singer, Pelligrino and Siegler from their 2001 article “Clinical ethics revisited,” who stated that the two significant challenges in the field of clinical ethics for this decade are (i) for clinical ethics practice (consultation and committees) to integrate clinical ethics work into the culture of health care organizations and (ii) to improve organizational accountability for clinical ethics. The authors take this challenge and offer systems thinking as an important response to these problems by arguing that clinical ethics must focus more on the underlying systems factors that give rise to many of the ethical concerns in healthcare rather than focusing only on cases and acute situations. The three authors provide leadership to major clinical ethics programs in Canada, the USA, and the UK and have each independently evolved to this systemic approach to clinical ethics. In this chapter, they describe their reasons for and experience with this approach. At the end of the chapter, the authors highlight their own top 10 leading practices in applying systems thinking to clinical ethics.
Chapter 41 reviews four innovative strategies that may improve clinical ethics effectiveness in healthcare organizations: (i) the hub and spokes model for clinical ethics service delivery, (ii) leadership and management skills training for clinical ethicists, (iii) ethics strategic planning and (iv) evaluation of clinical ethics services based on process indicators. These innovations were developed in the “laboratory” of the University of Toronto Joint Centre for Bioethics, where 15 healthcare organizations and 25 bioethicists collaborate across a broad spectrum of health care organizations (from acute care, home care, specialty hospitals, and a genomic institute) to model, pilot, test, and share innovations in clinical ethics service and practice. This chapter reviews these innovations in the context of clinical ethics effectiveness. In so doing, they give a brief history and outline some of the complexities involved in evaluating clinical ethics effectiveness. They make a further point that the unique patient populations, variability of ethics capacity in any given institution, and the different missions and values of different organizations will demand that “some component of evaluating clinical ethics effectiveness will necessarily [be] context-dependent.” Nevertheless the authors challenge us to take this notion of effectiveness seriously, as ethics is increasingly recognized as an important component of high-quality clinical care and valued strongly by patients and their families.
In Ch. 42, the authors tackle the challenge of bioethics teaching in clinical practice and advocate for a clinician–teacher approach. The authors intend the chapter to encourage clinician–teachers to accept the important responsibility of teaching bioethics and to provide them with some practical advice. While the focus in this chapter is on medical students and medical residents, the authors acknowledge that a similar clinical approach applies to teaching other clinicians, such as nurses. The authors organize their chapter around five questions for the clinical teacher. (i) Why should I teach? (ii) What should I teach? (iii) How should I teach? (iv) How should I evaluate? (v) How should I learn? The authors review the importance of a bedside or case-based approach as a way to capture the interest of the clinical audience. The authors quite extensively review various evaluation strategies for clinical training, including in-training evaluation reports, chart audits, objective structured clinical examination using standardized patients, multiple choice examinations, and short answer or essay examinations. Finally, the authors encourage clinicians to seek continued and further education for themselves if they are to teach bioethics as a specialized skill. The authors provide an extensive list of bioethics teaching resources in an appendix at the end of the chapter.
This section is a limited examination of only a few innovations in clinical ethics that strive to make an impact on the healthcare system. There are others in the field working toward the same goal. Perhaps it is now time for those individuals interested in clinical ethics as a vehicle for quality improvement and influence in healthcare to collaborate and share lessons and strategies. There are considerable opportunities to further research and gather evidence to demonstrate how changing the ethical culture in healthcare can make a significant impact to the current problems we face in healthcare.