Andrea Dorries, Alfred Simon, Gerald Neitzke, Jochen Vollmann. Implementing clinical ethics in German hospitals: content, didactics and evaluation of a nationwide postgraduate training programme. J Med Ethics. 2010;36: 721-6.

The concept of ethics in clinical practice is based on a need for treatment from the patient’s perspective. Most physicians have not been trained in the concepts and language of ethics, while most ethicists have minimal training in medicine. This limits the ability of both to tackle clinical ethical issues.

Who would fit the role of an ethics consultant?

Jonsen defined the role of the ethics consultant as one who not only "clarifies principles [but also] solves cases." (1)

La Puma and Toulmin have attempted to develop the concept of ethics consultants and ethics committees. They state that an ethics consultant needs to be a clinician who understands the technical and personal details of a particular patient’s care, can clarify clinical questions that have a bearing on ethics, and help in managing the patient by educating the healthcare team and offering advice to the attending physician.

An ethics committee as defined by them is one comprising people from different backgrounds such as law and philosophy, and therefore covering all facets of patient care. It may have a role in initiating and framing institutional policies and guidelines along with educating healthcare professionals (2).

The evolution of clinical ethics committees in some countries, like the Netherlands and Australia, seems to have been in combination with research ethics committees (3). These ethics committees which have been set up in various hospitals have been linked by networks, such as the European Clinical Ethics Network (thus working in a bottom-up manner). One of the purposes of these networks is to increase awareness among healthcare professionals. They have also introduced the idea of training them (4).

In contrast to this, in a top-down approach – in countries like the United States and Germany – the initiative has come from organisations for accreditation of hospitals. They have recommended the establishment of ethics consultancies in clinical institutions to formally facilitate ethical approaches to patient care.

Criticism has been directed towards currently functioning ethics committees, questioning their competency, pointing out that standards are yet to be put in place in most committees for the training of members (5). As a consequence, training programmes in clinical ethics have been established in the US and in a few European countries. However, the applicability of these programmes, the adequacy of training, and whether they meet the increasing needs for such committees do not appear to have been formally studied; the emphasis here has been on a discussion of how to teach ethics to those who need to apply it.

The article

In this context, the article by Dorries et al (6), chosen for selected summary, introduces a programme which attempts to train people in the application of ethics in a clinical framework, and discusses its achievements over the last seven years.

The programme is entitled the "Hannover qualifying programme ‘ethics consultation in hospitals’" and is conducted by a four-institution cooperative partnership. Parallel to the development of this programme, a curriculum on ethics consultation in hospitals, considered a national standard for training programmes in clinical ethics in Germany, has been developed.

According to the authors of this article, the need for training for clinical ethicists is burgeoning in Germany due to the requirement for accreditation. According to them, classical courses in ethics provide a theoretical and philosophical background of medical ethics, and are mostly university-based. They hypothesise that the need for practical applications of ethical principles in a medical setting requires training in clinical situations and needs to involve those who are already in the healthcare profession, as they are the primary decision makers. The authors foresee that such training must also include modules on how to set up and run an ethics committee.

This course caters to healthcare professionals interested in ethics consultation services. It has provided training and education for 367 healthcare professionals with 570 participations from 2003 to February 2010. A third of these are nursing staff, another third physicians (mainly from anaesthesiology and internal medicine), and the rest comprise hospital chaplains and people from other backgrounds. The teaching is by people trained in genetics, internal medicine, psychiatry, paediatrics, philosophy, organisation development and pastoral care.

The course involves two parts: a basic and an advanced module. The basic module, conducted within a three-month period, comprises two parts with a gap in between. Participants are expected to discuss their experiences and the use of their newly acquired skills in the second part. The curriculum covered includes knowledge and skills in clinical ethics, organisational ethics, and ethics deliberation. It enables participants to implement ethics consultation services at their own institutions.

The first part of the basic module deals with moral challenges and ethical dilemmas in the current practice of patient care. A variety of different services for ethics consultation is introduced and analysed in the context of the participants’ working fields. The tasks, structures and methods of such services in a ward and on an organisational level are discussed. In the second part, ethics case discussion techniques are explained. The relationship between individuals and the organisation; the individual participant’s concept of his/her ethics consultation service; and the strategy for implementation are brought up. Methods of evaluation and quality control are presented and participants’ experiences are discussed.

The advanced modules of two days cover the methodology of facilitating moral deliberation and ethics case discussion on the ward. These are taught using role play scenarios with participants’ own cases, imparting communication skills in hospitals. Some others involve specific themes including decision making at the end of life (with the involvement of different professions, medical and legal frameworks, and methods to assist dying patients), living wills and decision making at the beginning of life (focusing on ethics consultation in the context of pregnancy, prenatal diagnosis and abortion, issues of raising handicapped children, etc.).

The authors have included results of feedback solicited from the course participants about the content, presentation and the diversity of backgrounds of the teaching staff. The questions raised by this article include some on how to assess the efficacy of clinical ethics training. While we found a randomised controlled trial that attempts to measure benefit to hospitals by implementing ethical principles in end-of-life decisions (6), in many cases the benefits of formal ethics consultation cannot be quantified except in terms of patient satisfaction.

The development and implementation of a clinical ethics training programme on such a wide scale and to different groups of health professionals is indeed a challenging and laudable effort. It enhances the awareness of ethical principles and dilemmas in patient care and also has the potential to help formulate hospital and institutional policies.

Applicability in the Indian situation

As a postgraduate trainee, I feel strongly that such a programme will be relevant and important in India. This is not just for purposes of accreditation but for good clinical practice as well. In fact, it might be useful to consider it as part of undergraduate teaching and make it more speciality-specific in post graduate studies.

As a doctor who has recently completed training, I have been taught to think in terms of patient benefit from a doctor’s point of view. Patient autonomy in most situations, especially in tricky cases where a patient’s decision might be in conflict with a clinician’s, is a principle that medical graduates in India are not trained to consider. Currently, when called upon to make such decisions, a clinician’s own feelings and past experience would be given primary consideration. The variability which is bound to occur due to this, and the lack of patient involvement in making such a decision, is something which most of us have experienced during our training.

The presence of an ethics consultant, even a single person in a hospital, will raise awareness about ethical decision making. If a team approach is brought in to solve such problems, it will result in more responsible decision making. In my opinion, communication skills when dealing with patients and with their families would also radically improve, as there will be more opportunities for them to air their views. Undergoing such training must sensitise healthcare professionals to issues which they may independently not have observed. A course which deals with the method of applying ethics consultations would be very useful in establishing such a system in a hospital, and in involving those professionals who make patient-related decisions every day.

In the case of the western world, the rise of patients’ rights organisations has brought about the evolution of the concept of clinical ethics from a patient’s perspective. In an Asian context, clinical ethical consultancy services are being initiated in countries like Japan (7).In our country; however, the lack of a clear vocal consumer group in the field of medical care has resulted in a void in the field of clinical ethics.

The expanding number of private hospitals and the advances in medical technologies in a developing country like India, have not been accompanied by appropriate laws and rules governing decisions regarding patient rights and medical care. The lack of clear guidelines has led to a situation where physicians and staff who desire to make enlightened decisions have no forum for debate or precedent on which to base them. There is no published (or internet) account regarding a clinical ethics committee in India.

The establishment of institution-based organisations to formalise the practical application of ethics is sure to be of benefit in patient care. Here the issue of lack of standards becomes an issue, along with the absence of initiatives for participation in training. A bottom-up approach to create an organisation for such a purpose would be applicable in an Indian context, as in the UK system (5).

The authors have mentioned that attendance in this particular programme was regularly high over the previous seven years probably due to the need for accreditation. The lack of such a requirement in the Indian setting, and poor awareness of their rights among patients, makes it all the more important to introduce the idea of ethics in decision making here. We have seen many private hospitals in which hospital policies and decisions like the establishment and continuation of certain departments and facilities are based solely on a profit perspective, as are hospital charges.

Resistance and poor participation in the programme is a potential roadblock unless it becomes a felt need both for physicians and the hospital administration. Resistance may be related to a "know it all" attitude among experienced physicians, the hierarchical nature of hospital systems where the seniors may not want to learn from juniors, or the existing absence of monitoring systems or clinical audits in most hospitals in India. However, once health professionals realise that it might actually be beneficial to have a clinical ethics committee that might share their responsibility in tight clinical situations, it might be welcomed.

There is, in conclusion, a need for a national movement among health professionals to make a demand for clinical ethics committees. There is also a need for trained persons to be part of these groups. The article summarised here has brought to the fore the need for clinical ethics training in India as part of a larger reform in healthcare and medical education. This is important to initiate discussion and expedite the process of an organised application of ethics in patient care.