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43 4 The Stages of Bioethics Mediation This chapter introduces the stages of a typical bioethics mediation, mediator activity at each stage, and the ways mediator skills can be helpful in dealing with bioethics problems. Its purpose is to describe the mediation process and show what mediators do to make the process work. Overview of the Stages of Bioethics Mediation Mediative bioethics intervention is a fluid process. To provide structure for discussion and training we have divided the process somewhat artificially into eight stages. Be warned, however: in real life, events never proceed in a predictable and orderly manner. Stage 1: Assessment and preparation Stage 2: Beginning the mediation Stage 3: Introducing the patient Stage 4: Presenting and refining the medical facts Stage 5: Gathering information Stage 6: Problem solving Stage 7: Resolution Stage 8: Follow-up Our descriptions represent a meld of traditional ways of describing mediation as a process that takes place in stages (Moore 2003, 66–70) with an analysis of what happens in actual bioethics mediations. Although the activities included at each stage may appear to be distinct and sequential, most mediations are far from linear. They tend to move through phases in which each party may be at a different stage. For example, some participants may be ready to start problem solving while others are still intent on making certain their views of the situation have been heard. Moreover, participants often circle back to earlier stages of the process, especially as they near the time when they must make difficult decisions. Similarly, the mediator may take steps throughout the process that are described here as characteristic of a 44 Bioethics Mediation: A Guide to Shaping Shared Solutions particular stage. These stages describe what typically occurs during bioethics mediation when the mediator is an employee of the hospital. The entry activities required of an external mediator are not discussed in this book. This step-by-step guide for mediators includes suggestions about where they may want to make changes and enough theory to guide the variations. In any particular case, steps might occur in a different order and some steps might be eliminated entirely. Interventions that are critical in one case might be counterproductive in another. Paramount at this point, however, is understanding the goals of each stage and the techniques that can best be used to accomplish each goal. Throughout the process, mediators play multiple roles: convener, amplifier, coach, guide, process manager, information gatherer, referee, seeker of common interests, facilitator, reality tester, and empathizer. Bioethics mediators also take on the additional roles of norm enforcer and staff educator. During all stages of a bioethics mediation, the mediator has certain overriding obligations that arise from the intimidating nature of the medical setting and the tremendous imbalance of power and education that separates patients and families from staff. The mediator must manage the negotiation; prevent the staff from ganging up on the patient and the family; ensure that family members, increasingly supported by legal counsel who may be intimidating to the medical team, do not distort the medical realities and possibilities; and provide the neutral space that permits a principled resolution to emerge. Throughout the process, the mediator maintains an impartial stance by having no investment in any specific outcome, by facilitating discussion among all the parties, by identifying the sources of the conflict, and by maximizing the options for resolution. Although bioethics mediation works within a legal framework and the bioethics mediator does provide information about the governing legal rules (as we will see in Jennifer’s case), it is not useful for the bioethicist, when in the role of mediator rather than consultant, to offer complicated legal analysis. In the rare situations in which detailed legal analysis is required, a legal expert can be invited to participate or to counsel one of the parties outside the mediation or to make a presentation during a subsequent mediation session. Likewise, the bioethics mediator should not offer therapeutic counseling. Again, experts can be called on for this purpose, but it is important that the parties not confuse the role of the mediator with that of other experts. The following case illustrates some of the difficult issues typical of bioethics mediations. How the Process Works: Jennifer’s Case Jennifer was an eighteen-year-old patient who had been hospitalized many times for complications arising from Von Recklinghausen’s (elephant man) disease. This disease causes huge and unsightly tumors all over the body, internally and externally . Not only is the...

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