Although clinical ethics consultation has existed for more than 40 years in the USA and Europe, it was not available in Bulgaria until recently. In introducing clinical ethics consultation into our country, the Modular, Ethical, Treatment, Allocation of resources, Process (METAP) methodology has been preferred because of its potential to be used in resource-poor settings and its strong educational function. This paper presents the results of a METAP evaluation in a hospital palliative care ward in the town of Vratsa. The evaluation was based on Beauchamp and Childress’ four principles of biomedical ethics and involves implementation of specific instruments for clinical ethics decision-making. Research tasks emphasised analyses of ethics meetings in the ward. Data were processed by SPSS v.24 using descriptive statistical analysis. Altogether, 32 ethics meetings of an average duration 20.63 min were conducted on cases involving critically ill patients. Most of the participants (86.0%) expressed satisfaction with the ethics process. The principlist approach supported resolution of conflicts between autonomous patients and their relatives, clarified definitions of “medical benefit” and “social good,” and enabled assessments of the risk of unequal treatment. Even as the specific research tasks were achieved, further participant follow-up is necessary to identify any improvement in healthcare personnel’s ethical competence. METAP worked well in end-of-life care settings. Participants experienced several benefits, including improved team communication, better understanding of patient preferences, and confidence in the correctness of decisions. Despite the significant educational potential of METAP, the need for additional and ongoing ethics training of health professionals should not be underestimated.
AgichGJ.What kind of doing is clinical ethics?Theoret Med2005;
26: 7–24.
2.
ASBH Core Competencies Task Force. Core Competencies for Health Care Ethics Consultation: The Report of the American Society for Bioethics and Humanities. 2nd ed.Glenview, IL:
American Society for Bioethics and Humanities, 2011.
3.
GeppertCMASheltonWN.A comparison of general medical and clinical ethics consultations: what can we learn from each other?Mayo Clin Proc2012;
87: 381–389.
4.
BishopJPFanningJBBlitonMJ.Of goals and goods and floundering about: a dissensus report on clinical ethics consultation. HEC Forum2009;
21: 275–291.
5.
AgichGJ.Joining the team: ethics consultation at the Cleveland clinic. HEC Forum2003;
15: 310–322.
6.
KovacsL.Implementation of clinical ethics consultation in conflict with professional conscience? Suggestions for reconciliation. In: SchildmannJGordonJSVollmannJ (eds) Clinical Ethics Consultation: Theories & Methods – Implementation – Evaluation.
England:
Ashgate, 2010, pp.65–77.
7.
AgichGJ.Authority in ethics consultation. J Law Med Ethics1995;
23: 273–283.
8.
La PumaJSchiedermayerDL.Ethics consultation: skills, roles, and training. Ann Intern Med1991;
114: 155–160.
9.
Reiter-TheilS.Ethics consultation on demand: concepts, practical experiences and case studies. J Med Ethics2000;
26: 198–203.
10.
DublerNNWebberMPSwiderskiDM.Charting the future. Credentialing, privileging, quality and evaluation in clinical ethics consultation. Hastings Cent Rep2009;
39: 23–33.
SwiderskiDMEttingerKMWebberM, et al.
The clinical ethics credentialing project: preliminary notes from a pilot project to establish quality measures for ethics consultation. HEC Forum2010;
22: 65–72.
13.
TarzianAJ.Credentials for clinical ethics consultation – are we there yet?HEC Forum2009;
21: 241–248.
14.
YarmolinskyR.Ethics for ethicists? The professionalization of clinical ethics consultation. AMA J Ethics2016;
18: 506–513.
SchochowMSchnellDStegerF.Implementation of clinical ethics consultation in German hospitals. Sci Eng Ethics2019;
25: 985–991.
17.
FrolicAJenningsBSeidlitzW, et al.
From reactive to proactive: developing a valid clinical ethics needs assessment survey to support ethics program strategic planning (part 1 of 2). HEC Forum2013;
25: 47–60.
18.
FrolicAAndreychukSSeidlitzW, et al.
Implementing a clinical ethics needs assessment survey: results of a pilot study (part 2 of 2). HEC Forum2013;
25: 61–78.
19.
FiesterA.A Dubious export: the moral perils of American-style ethics consultation. Bioethics2013;
27: ii–iii.
20.
HurstSFørdeRReiter-TheilS, et al.
Physicians’ views on resource availability and equity in four European health care systems. BMC Health Services Research2007;
7: 137.
21.
WeidemaFCAbmaTAWiddershovenGAM, et al.
Client participation in moral case deliberation: a precarious relational balance. HEC Forum2011;
23: 207–224.
22.
MolewijkBVerkerkMMiliusH, et al.
Implementing moral case deliberation in a psychiatric hospital: process and outcome. Med Health Care Philos2008;
11: 43–56.
23.
MeyerDReiter-TheilS.Context-adjusted clinical ethics support in psychiatry: accompanying a team through a sensitive period. Clin Ethics2016;
11: 70–80.
24.
SchürmannJMeyer-ZehnderBMertzM, et al. (Chapter 18) Fairness and transparency in bedside micro-allocation: improving the ethical competence of clinical staff. In: DanisMHurstSSlowtherA, et al. (eds) Toward Fair Rationing at the Bedside.
Oxford: Oxford University Press, 2014, pp.301–351.
25.
Reiter-TheilSMertzMSchurmannJ, et al.
Evidence – competence – discourse: the theoretical framework of the multi-centre clinical ethics support project METAP. Bioethics2011;
25: 403–412.
26.
SchlegerAHMertzMMeyer-ZehnderB, et al. Klinische ethik – METAP. In: Leitlinie für Entscheidungen am Krankenbett (Clinical Ethics METAP – Guideline for Decisions at the Bedside).
Heidelberg, Berlin, New York:
Springer, 2012, pp.227–248.
27.
Aleksandrova-YankulovskaS.Development of bioethics and clinical ethics in Bulgaria. Folia Medica2017;
59: 98–105.
28.
AleksandrovaS.Survey on the experience in ethical decision-making and attitude of Pleven University Hospital physicians towards ethics consultation. Med Health Care Philos2008;
11: 35–42.
29.
AleksandrovaS.Experience in ethical decision-making and attitude of Regional hospital physicians towards ethics consultation. In: SchildmannJGordonJSVollmannJ (eds) Clinical Ethics Consultation: Theories & Methods – Implementation – Evaluation.
England:
Ashgate, 2010, pp.175–187.
30.
PfafflinMKobertKReiter-TheilS.evaluating clinical ethics consultation: a European perspective. Cambridge Q Healthc Ethics2009;
18: 406–419.
31.
ShumanAGMontasSMBarnoskyAR, et al.
Clinical ethics consultation in oncology. J Oncol Pract2013;
9: 240–245.
32.
SacchiniDCorsanoBRefoloP, et al. Clinical ethics consultation as “shared document”. Emerging ethical and medico-legal issues: the experience of IBioMedH-UCSC CEC Service (2005–2016). In: 4th open forum day of European clinical ethics network, Barcelona, Spain, 6 September 2017 (Unpublished conference paper, 2017).
33.
BecaJP. Roles, results and challenges of a 9-year experience on clinical ethics consultation in Chile. In: 4th open forum day of European clinical ethics network, Barcelona, Spain, 6 September 2017 (Unpublished Conference Paper, 2017).
HurstSReiter-TheilSHolzle-BaumannR, et al.
The growth of clinical ethics in a multilingual country: challenges and opportunities. Bioethica Forum2008;
1: 15–24.
36.
FørdeRHansenT.Do organisational and clinical ethics in a hospital setting need different venues?HEC Forum2014;
26: 147–158.
37.
NeitzkeG.Patient involvement in clinical ethics services: from access to participation and membership. Clin Ethics2009;
4: 146–151.
38.
NewsonAJ.The role of patients in clinical ethics support: a snapshot of practices and attitudes in the United Kingdom. Clin Ethics2009;
4: 139–145.
39.
RariEFournierV.Strengths and limitations of considering patients as ethics ‘actors’ equal to doctors: reflections on the patients’ position in a French clinical ethics consultation setting. Clin Ethics2009;
4: 152–155.
40.
PedersenRHurstSASchildmannJ, et al.
The development of descriptive evaluation tool for clinical ethics case consultations. Clin Ethics2010;
5: 136–141.
41.
The World Medical Association Declaration on the Rights of the Patient. Adopted by the 34th World Medical Assembly, Lisbon, Portugal, September/October 1981, and amended by the 47th WMA General Assembly, Bali, Indonesia, September 1995, and editorially revised at the 171st Council Session, Santiago, Chile, October 2005 and reaffirmed by the 200th WMA Council Session, Oslo, Norway, April 2015.
42.
Aleksandrova-YankulovskaSGrancharovaGVekovT. Advance directives in palliative care units in Bulgaria. In: 4th European Public Health Conference, 10–12 November, 2011, Copenhagen, Denmark. Eur J Public Health2011; 20(Supplement 1): 106.
43.
MolewijkBLucassenA.Clinical ethics committee case 4: how should we transfer a euthanasia request between general practice and a hospital setting?Clin Ethics2011;
6: 58–63.
44.
DuValGClarridgeBGenslerG, et al.
A national survey of US internists’ experiences with ethical dilemmas and ethics consultation. J Gen Intern Med2004;
19: 251–258.
45.
Reiter-TheilS.The Freiburg approach to ethics consultation: process, outcome and competencies. J Med Ethics2001;
27: 21i–123.
46.
SchneidermanLJGilmerTTeetzelHD, et al.
Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting. JAMA2003;
290: 1166–1172.
47.
McClimansLSlowtherAParkerM.Can UK clinical ethics committees improve quality of care?HEC Forum2012;
24: 139–147.
