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Concluding Reflections Kenneth R. Melchin The changing face of health care has made the task of patient care much more complex than in past decades. This is especially the case in the field of chronic care. Professionals who care for patients, particular young children, face a bewildering array of challenges for which they often feel ill-prepared. These challenges come from the rapid pace of technological change, the diversity of religions and cultures in our society, the collaborative character of decision making, the restructuringof health care funding, the complexities of our diverse institutions of care and the diversity of citizens' valuesregarding the end of life. For a period of time in the history of health care in Canada, professionals viewed themselves as mandated and empowered to focus attention exclusively on the physiology of care with ever-improving tools for "getting thejob done." But recent decades have seen the meaning of "care" expand well beyond physiology to include wide ranges of social, cultural, philosophical, economic, political and religious considerations. The result, in many instances, is an alarming ambiguity about what the "job" is and what tools might be required for "getting it done." Health care, particularly chronic care, now involves a diverse range of professionals who meet patients in diverse institutional and community contexts and who encounterpatients in multipleaspects of their lives. In one way of another, care has come to mean something quite complex and it has become the concern of teams of professionals who understand their roles and responsibilities toward patients differently. Yet programs of care need to be coordinated and organized so that the diverse parts fit together within a common vision.This means that the professionals must talk together to arrive at some agreement on this vision. Most of the challenges that have made the lives of health care professionals complex and confusing in recent years are ethical in character. Tobe sure, not all are ethical in the most obvious sense of the term. Wedo not usually think of the procedures of hospital bureaucracies as ethical issues. Nor do we usually think of the professional obligations of social 215 ETHICAL DELIBERATION IN MULTIPROFESSIONAL HEALTH CARE TEAMS workers as ethical issues. Yetthis is precisely what they are. Ethics is not restricted to the "big issues." It includes the full range of goals, obligations , tasks, skills and virtues necessary for ensuring the patterns of human cooperation that meet the widest ranges of human needs over the longest spans of time. The "big issues" may command most of our explicit attention. But they are only the tip of the iceberg. It is the whole iceberg that is implicated in the cooperative social structures that ensure the competence, fairness and humanityof programs of care. This study has moved forward with the assumption that the ethical issues involved in health care will not be handled once and for all by professional ethicists. There will certainly remain "big issues" that will require the work of professionals: issues associated with the end of life and the withdrawal of treatment, issues associated with the equity of resource distribution and issues associated with patients' rights.However, even when such issues are resolved through legislation orinstitutional policies, they onlyserve to establish boundaryconditionsfor cases. Within the regions of normal practice carved out by these boundaries, there remain hosts of ethical complexities that are left to the decisions of the professionals in the case. Indeed, even when policy or legislation pronounces on "big issues," practitioners often find themselves wrestling with cases that do not seem to be envisioned by the spirit of the laws. We suggest that in the normal course of practice, particularly the practice of chronic care, the lion's share of the ethical issues in health care will be dealt within the day-to-day decisions of professionals.Given the diversity of professions and the diversity of types or styles that have emerged within each profession, this means that professionals needways of identifying and talking through the issues. The aim of this project has thus been to study the ethical deliberation of multiprofessional health care teams and to develop tools to help them in this task. The chapters of this study present the results of this work. We began by situating the project in its historical context within the field of bioethics. We then conducted a documentary analysis of published literature related to the implicit ethics of health care professionals. The goal, here, was to establish a typology of the implicit ethics of the principal professions...

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