Ethical Deliberation in Multiprofessional Health Care Teams

Introduction

Introduction Hubert Doucet, Jean-Marc Larouche and Kenneth R. Melchin Technological changes have had a dramatic impact uponthe financing, organization and delivery of health care services in Canada. Professionals and health care decision makers now wrestle with increasinglycomplex sets of challenges that must involve various types of professionals in programs of care. The result is that administrators, nurses, physicians, social workers and other professionals have had diverse roles to play in programs of care and, consequently, have insisted that their voices be heard in the decision-making process alongside the voices of patients and their families. Needless to say, the ensuing discussions have become difficult because the diverse professional perspectives have given rise to conflicts over the goals, strategies and institutional supports for patient care. This study examines ethical deliberation in multiprofessional health care teams. While ethics typically focusses on the issues involved in patient care, we have placed the accent on the dynamics of the deliberation process itself. And while ethics frequently centres on issues explicitly identified as such, we have targeted values and aspects of professional ethos that implicitly guide the deliberation process. To help understand ethical deliberation among diverse health care professionals, we have drawn upon resources from the analysis of health care professions, from ethical theory and from the field of conflict resolution . These resources have been synthesized into a set of tools for understanding and guiding ethical deliberation in health care teams. To illustrate the relevance of these tools for health care teams, we have carried out a case-study observation of two teams of professionals working in the field of pediatric chronic illness. Two sets of hypotheses inform this work. First, despite the work of hospital ethics committees, most ethical decisions on patientcare are made 9 ETHICAL DELIBERATION IN MULTIPROFESSIONAL HEALTH CARE TEAMS outside of this structure, often in the health care units themselves. Furthermore, when professionals in these units gather to make decisions involving ethical issues, discourse and decision making are often influenced by the hierarchical or institutionalized relationships among the variousprofessions. Finally,the self-understandingof each professional often carries a set of implicit values that shapes the deliberation process without being articulated openly and evaluated critically in the discussions of the team. Second, when conflictsarise among professionals in healthcare teams, team members often turn to ethicists for their expertise in resolving issues . To offer such expertise, ethicists need tools for analyzing the dynamics of the deliberation process as well as tools for analyzing the issues . Furthermore, the ethical issues are often so closely bound up with the professional and technical aspects of the case that ethicists make their best contributionby developing tools for use by the professionals themselves . Guided by these hypotheses, this study examines the ethical deliberation process and proposes tools to help teams of professionals in their own effort to wrestle with the issues. The overall goals are: (1) to investigate how professionals experience value conflicts and make decisions on ethical issues in cases where their diverse forms of involvement bring diverse ethical perspectives into the team discussions; and (2) to develop tools for ethical deliberation that could help professionals in the team discussion and decision making. To meet these goals, the study is divided into three parts. Part 1is a documentary analysis of literature related to professionals involved in health care teams. We have focussed, in particular, on professionals typically involved in pediatric chronic care. However, the issues arising in the analyses are sufficiently general that the insights developed here are relevant to a variety of health care contexts. The goal in this part is to establish a typology of the implicit ethics of the principal professions involved in the team deliberations: nurses, physicians and social workers.1 A studyof each profession reveals a numberof diverse professional types, each with its own cluster of implicit values. Insights into these implicit values allow researchers and practitioners to anticipate forms of ethical conflicts that can arise from the interaction among diverse types. Part 2 deals with the process of ethical deliberation, and here we review published literature from the fields of conflict studies and ethical theory. The goal throughout this section is to draw on resources from conflict studies and theoretical ethics to develop analytic tools for studying 1. The choice of these professions is explained in the Introduction to Part 1. 10 INTRODUCTION ethical deliberation in health care teams. The overall theoretical framework for the analysis comes from...