Clinical ethical decision-making and the deliberative process: The ‘Ethox approach’ revamped
Michael Dunn1, National University Of Singapore Singapore2, Oxford Oxfordshire 1National University Of Singapore, Singapore, Singapore, Singapore2University of Oxford, Oxford, Oxfordshire, United Kingdom
Abstract
What approach should Clinical Ethics Committees (CECs) adopt to best fulfil their supportive function? Internationally, CECs typically use structured approaches to consider clinical cases and to issue advice to the referring clinical team (or, in some places, to make decisions on behalf of that team). These approaches, presented as ‘ethical frameworks’, guide how the CEC operates to support the team’s reasoning through ethically complex clinical scenarios.
Current frameworks endorse one of two strategies, which we refer to as substantive or procedural approaches. Substantive approaches, which include the ‘Four Quadrants/Boxes’ and the ‘Four Principles’ frameworks, rely on pre-specified ethical values to direct the ethical analysis. However, such frameworks offer little guidance when the identified values come into conflict in the analysis of any given case. Procedural approaches, which include the original ‘Ethox Approach’ and the ‘Moral Case Deliberation’ framework, impose a structure on ethical analysis by emphasising specific deliberative requirements. However, these approaches typically underspecify the demands of ethical reasoning, focused more on how committee members should engage with each other rather than crafting the product of their engagement.
In light of these concerns, we propose a revamped version of the ‘Ethox Approach’, originally developed in the UK in the mid-2000s. Our revamp provides a distinctive, analytic approach to clinical ethics case review, and we seek to refine a deliberative process such that it is focused primarily on the construction of ethical arguments. This revised framework emphasises the importance of carefully positioning facts, values and the incorporation of clear and rigorous conceptual and normative reasoning requirements.
Biography
Michael Dunn is an Associate Professor and the Co-Director of Education at the Centre for Biomedical Ethics, National University of Singapore.
He works across bioethics, health care ethics, medical law, socio-legal studies, and health/social care services research, but his core research interests focus currently on the ethical aspects of home-based, community-based, and long-term care practice, policy and law – in Singapore, the UK and internationally. One of his current research projects is exploring appropriate models for clinical ethics case deliberation and for ethics support services in social and community care settings.
Michael has written more than 100 peer-reviewed academic journal articles and book chapters, and co-authored or co-edited 6 books. He is currently a Trustee of the UK’s Clinical Ethics Network, and has over 15 years of experience of serving and training clinical ethics committees.