Welcome to the Dalhousie University Department of Bioethics’ ethics consultation simulation, which seeks to build both (a) understanding of the ethics consultation process and (b) capacity and confidence in approaching ethics consultation as a consultant.
This project was born out of our work in the Department providing ethics support to health care organizations in Nova Scotia as well as in working with health professions learners at various points in their training. The goal is to model the thinking, analysis, and decision making that goes on in the consultation process such that others who are not practicing healthcare ethicists are able to both appreciate the skill involved and envision engaging in the process themselves.
Some of the basic assumptions about ethics underlying the approach in these cases are (1) that questions of ethics are fundamentally about how we treat each other, whether directly or indirectly, (2) these questions can only be answered with reference to values, and (3) that deliberation regarding ethics is about arriving at an appropriate balancing of all the values that are relevant in a situation, such that even if a particular value or principle is not the primary driver of decision or action it is nonetheless taken into account in developing a recommendation.
In many case discussions in the literature, a case is presented with a linear narrative describing how the case unfolded and how a conclusion was reached. Alternative scenarios might be implied in the discussion, but there is not the opportunity to explore them in detail. In an ethics consultation it is rarely a straightforward journey from request through to evaluation, and this resource aims to capture that experience more accurately through the use of a Choose Your Own Adventure(™)-style branching framework.
One piece of learning in the process of developing this resource has been how many decisions are made in the course of a single consult, and thus the choices presented in these cases reflect only a small subset of the possible outcomes but nonetheless help to demonstrate why there are a range of answers in any given case to the question of “what should we do?”
The model of the consultation process underlying the approach in these cases breaks a consult down into three interrelated aspects, with various steps associated with each aspect.
The first aspect is setting the stage, which encompasses primarily preparatory tasks such as determining how a requester can access consultation, determining the issue at stake, eliciting facts, investigating relevant literature, policies, processes, and other forms of guidance, and preparing participants for the consultation.
The second aspect is facilitating the consult itself, which involves providing guidance through active listening, attentiveness to the effects of power dynamics, eliciting of perspectives, conflict management, and building consensus. Effective facilitation aims to maximize the range of pertinent values that are brought to bear in the discussion and that the discussion is focused on the specifically ethical question that has prompted the consult. The skills themselves are not unique to ethics consultation, but are essential to the consultation in ensuring that it will be effective in achieving its goals.
The third aspect is analyzing the specifically ethical issues relevant to the case or situation and bringing this analysis to bear on the consult. This begins in the preparatory process with surveying literature and other materials and reflecting on why this issue has resulted in a consultation. The initial analysis provides a starting point for the ethical discussion in the consult, but the expectation is that it will likely shift given the information obtained during the consult about the situation itself and the nature of the concern. Within the consult, it also involves helping participants to articulate the values and principles that underlie their positions and to draw out the relationship between values and principles and various possible courses of action.
We understand a successful consult to be one in which everyone involved feels that they have been heard and understood and that their perspective has been validated, even if the recommendation at the end is not what they were advocating for.
We hope that working through these cases helps to illustrate why the answer to ethics questions is often “it depends” as well as some of the factors that determine what those answers depend on.
Statement of Disclosure
All of the cases presented on this resource are either completely fictionalized or composite cases that are grounded in and reflective of the reality of ethics support work. The cases were contributed by ethicists and healthcare providers across Canada for your professional development.