Moral expertise in the clinic : lessons learned from medicine and science

Philosophers and others have questioned whether or not expertise in morality is possible. This debate is not only theoretical, but also affects the perceived legitimacy of clinical ethicists. One argument against moral expertise is that in a pluralistic society with competing moral theories no one can claim expertise regarding what another ought morally to do. There are simply too many reasonable moral values and intuitions that affect theory choice and its application; expertise is epistemically uniform. In this article, we discuss how similar concerns have recently threatened to undermine expertise in medicine and science. In contrast, we argue that the application of values is needed to exercise medical, scientific, and moral expertise. As long as these values are made explicit, worries about a pretense to authority in the context of a liberal democracy are ill-conceived. In conclusion, we argue for an expertise that is epistemically diverse

Measurement and meaning in health-related quality of life research.

In this thesis I take up the topic of our understanding of questions in a detailed case study of non-utility measures of health-related quality of life. I argue that efforts to standardize these measures lead to limitations in our ability to understand and measure quality of life. In the first half of this thesis I describe two types of bias that affect quality of life measures despite efforts to validate them. On the one hand, quality of life measures can perpetuate ethnocentric understandings of quality of life. On the other hand, respondents often understand the questions in these measures very differently than researchers imagined. I argue that the residual bias found in quality of life measures is the result of two assumptions built into the use of construct validity: 1) when a measure's outcomes confirm our hypotheses, we are warranted in having greater confidence in the accuracy of our theory 2) respondents understand the questions and answers in our measures in the same way as researchers imagined they would. In the second half of this thesis I argue that the limitations of construct validity stem from the logic of asking questions, a logic which precludes standardization. I propose that quality of life measures ought to be understood differently-they are not independent instruments capable of unambiguous claims, but rather one element in a dialogic framework whose questions and outcomes serve as the starting point for further inquiry. Finally, I examine what might have motivated the misguided use of construct validity. I suggest that the motivation lies in an erroneous picture of the human subject. I argue for an alternative picture that allows me to introduce an ethical dimension to our questions about quality of life

Development of Clinical Ethics Services in the UK: A National Survey

Background In 2001 a report on the provision of clinical ethics support in UK healthcare institutions identified 20 clinical ethics committees. Since then there has been no systematic evaluation or documentation of their work at a national level. Recent national surveys of clinical ethics services in other countries have identified wide variation in practice and scope of activities. Objective To describe the current provision of ethics support in the UK and its development since 2001. Method A postal/electronic questionnaire survey administered to the chairs of all 82 clinical ethics services registered with the UK Clinical Ethics Network in July 2010. Results Response rate was 62% with the majority of responding services situated in acute trusts. All services included a clinical ethics committee with one service also having a clinical ethicist. Lay members were present in 72% of responding committees. Individual case consultation has increased since 2001 with 29% of chairs spending more than 50% of their time on this. Access to and involvement in the process of case consultation is less for patients and families than for clinical staff. There is wide variation in committee processes and levels of institutional support. Over half of the responding committees undertook some form of evaluation. Conclusion Clinical ethics services in the UK are increasing as is their involvement in case consultation. However, the significant variation in committee processes suggests that further qualitative research is needed to understand how these committees function and the role they play in their institution

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis

Background: In this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians’ awareness of patients’ problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes. Results: PROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit. Conclusions: This paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making

The problem of purpose in quality of life research

In this paper I investigate one aspect of the validity of a certain type of subjective assessment of health and illness or as they are sometimes called Health-Related Quality of Life (HRQoL) measures. These assessments are typically a series of questions directed to individual patients in the form of a questionnaire and their aim is to discover the subjective experience of a cohort of people at different times, for instance before and after a surgical intervention. These measurements can be, and often are used in conjunction with clinical assessments to gain information on health outcomes for policy implementation or revision. For example, to determine which hospitals or surgeons are doing well and which ones are doing poorly or to determine which interventions are most effective

Can UK clinical ethics committees improve quality of care?

Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the many ethical elements that are highlighted in the Commission’s Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK