Tabla de contingencia o tabla cruzada

In addition to the benefits gained from the group not being ascribed expert status in ethics, but seeking competence in their advisory function, and excellence in their supportive function, there could be another advantage to combining skills of the non-expert CEC group members, with theoretically expert clinical ethicists (something CECs often seek). Communication between ethicists and non-ethicists within such groups will help to inform clinical ethicists, about the culture in which they are working, and the views that may be prevalent among non-ethicist clinicians and CEC members. Then, when clinical ethicists are asked to provide advice outside committees, their advice may more effectively bridge the theory- practice gap, as a result of their having gained a better understanding of the clinical context through being part of the deliberations within the CEC. As a group representative of the diversity of the healthcare team, the CEC should comprise morally competent members who “focus on the internalised faculty of judgement,

based on the expertise of healthcare providers in their professional field, and with the profession’s internal morality” (Steinkamp 2008 p187). That is they are all speaking the same language of the healthcare organisation and have a shared understanding of the culture in which they work.

As long as CECs consider their role to be supportive and non-advisory, they are in an excellent position to facilitate moral development of the clinical teams. The best compromise, as already stated, would be for everyone to learn from each other by reflection on case or guideline, be that performative or epistemological learning, in order to reach a balance that provides the growth and development of all involved, in the process of review.

Knowing the difficulty of knowing what is the ‘truth ’and supporting the healthcare team with that difficulty

The unique contribution of the CEC is to explore with the clinician, and patient as appropriate, the difficult situation they face. The range of perspectives within the group, whilst not seeking to be reflective of all, can challenge the clinician’s perception of the ‘truth’ and increase awareness as to its subjective nature, and that making judgement about morality in a complex situation is not adequately guided by one moral framework, for all of those involved. As Richardson (2011 p2) asks “Are there any true general principles of morality, and if so what are they? At this level utilitarianism competes with Kantianism, for instance, and both compete with anti-theorists of various stripes, who recognise only particular truths about morality.” Within healthcare as within life, we are constantly called upon to

consider one action against another, using moral reasoning. The benefit that can be offered by the CEC health care user is to offer the opportunity for those with

concerns to consider what appears reasonable against a range of subjective views on a difficult situation.

All of the members of the CEC, and those involved in the clinical case itself, will have different realities, influenced by a myriad of issues, including education, race, culture, ethnicity and experience. This diversity enables pertinent questions to be asked, which can improve clarity and result in the choice of an appropriate course of action. As Widdershoven (2007 p49) states “People interpret their situation from a specific perspective or background of practical expectations. This horizon of meaning structures understanding. It is normally taken for granted. Yet one’s perspective can be put into question, if it is being confronted by other

perspectives”. This process of “hermeneutic understanding” (Widdershoven 2007 p49), results in a dialogue between perspectives and consideration of a “fusion of horizons” (Widdershoven 2007 p49).

The ability to weigh up different insights, and decide which is most suitable in practice, appears to be a necessary skill/habit that should be encouraged for all clinicians. By practicing it through review, in a safe forum such as a CEC, which is set up as a supportive reflective practice group, clinicians are encouraged to develop this skill of judgement confidently and appropriately. Clinicians can be offered appropriate support to consider ethical issues from a range of

perspectives, acknowledging that consensus agreement by all, on right action, is not always achievable, due to the pluralistic nature of healthcare and wider society. As Powers (2005 p305) reflects, we are obliged to appreciate “the wide range of reasonable disagreement that will remain past the point of extended reflection and discussion”.

CEC members can practice and refine the previously mentioned skills themselves through post hoc review. The first role of the CEC is to reinforce to the clinician that his struggle with a complex situation, is representative of how it should be, (because he is wrestling with competing obligations). The clinician’s concern indicates ethical awareness and a desire to find the right path. This demonstrates that he is aware of competing obligations and is in a position that demands a judgement to be made on these competing issues, which is extremely difficult, and the CEC exists to offer some guidance on how to undertake this assessment even if it is not to recommend an action.

The forum can benefit the clinician by challenging and highlighting inconsistencies within the scenario being considered. CECs should approach the review, using a model that takes into account the particulars of a situation, but also acknowledges that in healthcare, clinicians’ work within the confines of legal and professional rules and principles, which shape their perceptions of an ethical dilemma. This approach acknowledges the pluralistic (diversity of values) nature of healthcare. Pellegrino (2005), whilst identifying the growing movement towards pluralistic approaches to applied ethics, and the growth of thinking in healthcare that

“absolutes are now judged to be out of date” (p471) nevertheless Pellegrino (2005) outlines some principles enshrined in our cultural norms, that can still be seen as guides to our personal and professional moral conduct. He describes the premise that all healthcare workers and CECs ascribe to, namely aiming to do good and not evil. He states that the:

“‘patient’, by definition is a person who is suffering in some degree and in some way. He is in an altered existential state – anxious, dependent,

formally when he decides he needs professional help. In that state the physician asks how he can help. The patient understands this as a promise of the possession of skill and knowledge and a promise that they will be used in the patient’s best interests” (p74).

Within the professional practice of the clinician should be embodied absolutes such as ‘do not kill’ and ‘act for the good of the patient’. The professional also has responsibilities to maximise choice, keep promises, and preserve dignity. Although these obligations can be explored by the CEC in relation a case, it has no more expertise to make judgements and recommend on these issues, than the clinician themselves. The CEC members may, however, be obliged to challenge actions that may not appear to be in the best interests of the patient in a given situation, and to support an exploration of why this may be the case.

The CEC, rather than promoting themselves as experts in ethics, a role they do not need to fulfil, should promote themselves as catalysts and facilitators for ethical review, a task in which they could achieve performative expertise if

supported by the organisation and trained appropriately to do so. This CEC activity is directly aimed at supporting the clinician to cope with the difficult situation, and its emotional and practical repercussions. Steinkamp et al (2008 p185) argues that “the main goal of clinical ethics is to improve the quality of patient care by

identifying, analysing and attempting to resolve the ethical problems that arise in practice”. They add “Referring to Dreyfus and Dreyfus, it could be shown that moral competence, prior to ethical reflection, plays a significant role when moral problems are to be approached.” But ethical competence within the CEC should represent the level of knowledge that may be sought by any clinician, in clinical practice.

The model promoted by Dreyfus and Dreyfus (1980) explores the concept of coping with skill acquisition, and this appears to be what clinicians are aspiring to do in the clinical environment, when wrestling with ethical issues. They are

attempting to cope with the stresses of balancing interests, and reaching a solution to a problem, in an often restricted period of time. As Dreyfus and Dreyfus (1980 p8) state “Competence comes only after considerable experience actually coping with real situations” which are seen as “no longer context free”.

Appropriate promotion of the role of CEC, to reflect that CECs were established to support clinicians in coping with difficult decisions, will remove any incorrect assumption on the part of the clinician, that the group can prescribe an action that must be adhered to, because of its ‘expert’ status. Then, CEC will be able to focus on supporting practitioners, to enable clinicians to make sense of complex clinical situations, and so reach their own decisions. According to Weinstein’s (1993) idea of expertise, this could be seen as performative expertise, which is described as the ability to perform a task well.