Although clinical ethics support services are becoming increasingly prevalent in Europe and North America, they remain an uncommon feature of the Irish healthcare system and Irish health professionals lack formal support when faced with ethically challenging cases. We have developed a variant on existing clinical ethics decision-making tools which is designed to build capacity and confidence amongst Irish practitioners and enable them to confront challenging situations in the absence of any dedicated support structure. The tool provided below follows a transparent stepwise procedure which avoids an overcomplicated analysis while remaining sensitive to the complexity of the issues addressed. The novelty of the tool lies in the explicit association it makes between each step in the process and one or more responsibilities based on established norms of ethical decision-making in the public domain.
We use the term ‘clinical ethics support services’ to refer to all forms of clinical ethics support, not just to clinical ethics committees. The term ‘clinical ethics committee’ will be used to refer specifically to the service provided by a committee, as opposed to an individual ethicist working within a healthcare organisation.
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Such ‘unsettled’ cases often require ethics support because the allowable options are not clearly discernible (Aulisio 2011, 346).
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In 1986, Jonson, Siegler and Winslade proposed the so-called ‘four-box’ or ‘four quandant’ method for analysing clinical cases in which values collide (Jonson, Siegler and Winslade, 2006).
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American Society for Bioethics and Humanities. Core Competencies for Healthcare Ethics Education. 2nd ed. Glenview, IL, 2011.
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The American Society for Bioethics and Humanities describe the task of clinical ethics support services as helping patients, clinicians, family members or other involved parties to resolve “uncertainty or conflict regarding value-laden concerns that emerge in health care” (ASBH 2011, 2).
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National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research. The Belmont report: ethical principles and guidelines for the protection of human subjects of research,www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html (accessed 22 July 2017).
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Peppard J. A review of clinical ethics committees in acute hospitals in Ireland. 2012 MSc Thesis, Dublin City University, Dublin, Republic of Ireland.
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A notable phenomenon in several Irish hospitals is the review of clinical ethics issues by members of research ethics committees.
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We do not wish to be prescriptive in putting forward a single set of ethical principles. The four principles originally proposed by Beauchamp and Childress in 1979 were conceived as “general norms of the common morality” or guidelines for the formation of ‘more specific rules’ to inform empirical decision-making (2009, 12). As such, they are not supported by a robust philosophical foundation. For the same reason, they cannot be regarded as exhaustive. Depending on the decision-making context, other principles play equally important roles, such as the principle of solidarity put forward by the Nuffield Council in their 2009 report, Dementia: ethical issues.
24.
This case study is adapted from a case recounted to us by Mr. Richard Parker, Chair of the Jehovah’s Witness Ireland South Hospital Liaison Committee (personal communication, 10 October 2014).
25.
Irish Medical Council. Guide to Professional Conduct and Ethics for Registered Medical Practitioners. Author, 2016.
