Doctors and nurses at the neonatal intensive-care unit at The University Hospital, Rigshospitalet, in Copenhagen, Denmark regularly find themselves in ethically challenging and potentially distressing situations concerning the life of ill newborn babies. In collaboration with the neonatal intensive-care unit, my project was to develop a method that could stimulate systematically dialogical moral inquiry within everyday clinical practice. My four months of ethnographic fieldwork at the neonatal intensive-care unit generated four fundamental themes that make up the scaffold of the developed model for ethical deliberation and decision making. The model is a reflective tool to be used by health care professionals in situ. It provides a structured and a systematic framework for dialogue that can clarify the obscurities of a case and give argumentative support for ethical decisions. This article explains how the 4C model was developed and whereof it consists.
Orzalesi M and Cuttini M. Ethical issues in neonatal intensive care. Annali dell'Istituto Superiore di Sanità 2011; 47: 273–277; Barnum B. Benevolent injustice. Adv Neonatal Care 2009; 9: 132–136; Meadow W and Lantos J. Moral reflections on neonatal intensive care. Pediatrics 2009; 123: 595–597; Carter BS. Ethical issues in neonatal care. eMedicine: http://emedicine. medscape.com/article/978997 (2006, accessed 9 November 2009).
2.
Corley MC. Moral distress of critical care nurses. Am J Crit Care 1995; 4: 280–285; Elpern EH, Covert B and Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005; 14: 523–530; Hamric AB, Davis WS and Childress MD. Moral distress in health care professionals: what is it and what can we do about it? Pharos Alpha Omega Alpha Honor Med Soc Winter 2006 (winter); 69(1): 16–23.
3.
Flow Chart for Ethox Approach developed at The Ethox Centre, University of Oxford, England, the SME-model developed at Senter for medisinsk etikk, University of Oslo, Norway, Aktörmodellen developed by E. Bischofberger i Barnet i vården, Liber AB, 2005 and modified by Marie Chenik to be used at Karolinska Universitetsjukhuset, Sweden and The Four Quadrants Approach developed by the Americans Jonsen A, Siegler M and Winslade W. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. 5th ed. New York: McGraw-Hill, 2002.
Before I started my fieldwork, the idea was to come up with a reflective tool that would only target decisions concerning life and death since the whole question of how far treatment should go is a recurring theme in the clinic. Even though approximately one child dies every week in the NICU in Copenhagen, only a fraction of these babies’ treatment process raise grave ethical questions. As the project began to take shape it made more sense to accommodate the many other ethical issues, and thus develop model that had a larger range than just questions pertaining to life and death decisions.
6.
The staff was informed that they could withdraw from the project at any moment and that participation was voluntary.
7.
At the NICU in Copenhagen there are three teams, each one focusing on a unique field within neonatology: Team 1 specializes in children with neurological diseases; team 2 specializes in children in need of surgery; and team 3x specializes in children with heart diseases.
8.
See: The report Critical Care. Decisions in Fetal and Neonatal Medicine: Ethical Issues. London: Nuffield Council of Bioethics, 2006; Miller, G (ed). Extreme Prematurity: Practice, Bioethics, and the Law. Cambridge: Cambridge University Press, 2007; Lantos J and Meadow W (eds). Neonatal Bioethics: The Moral Challenges of Medical Innovation. Baltimore: The Johns Hopkins University Press, 2006; Frankel L, Goldworth A, Rorty M, et al. (eds) Ethical Dilemmas in Pediatrics: Cases and Commentaries. Cambridge: Cambridge University Press, 2005; Diekema D, Mercurio M and Adam M (eds) Clinical Ethics in Pediatrics: A Case-based Textbook. Cambridge: Cambridge University Press, 2011.
9.
BenthamJ. Introduction to the Principles of Morals and Legislation (1789), Mineola (NY): Dover Philosophical Classics, 2007.
10.
KantI. Groundwork of the Metaphysics of Morals (1785), 2nd ed. Cambridge: Cambridge University Press, 2012.
11.
JonsenASieglerMWinsladeW. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, 5th ed. New York: McGraw-Hill, 2002.
12.
Beauchamp T and Childress J (eds). Principles of Biomedical Ethics. 6th ed. Oxford: Oxford University Press, 2009.
13.
RendtorffJKempP. Basic Principles in European Bioethics and Biolaw2000; Vol. I.Copenhagen: Centre for Ethics and Law.
14.
Due to a lack of funds the project managers have not been able to complete research on the implementation and use of the model in the clinic.
15.
Webster and Baylis defines moral residue as “That which each of us carries with us from those times in our lives when in the face of moral distress we have seriously compromised ourselves or allowed ourselves to be compromised.” Webster GC and Baylis FE. Moral residue. In: Rubin SB and Zoloth L (eds) Margins of Error: The Ethics of Mistakes in the Practice of Medicine. Hagerstown: University Publishing Group, 2000: p.21.
16.
CallahanDBioethics. In: ReichWarrenT (eds). Encyclopedia of Bioethics, Toronto: Macmillan Publishing Company, 1995, pp. 246–256.
