By Joschka Haltaufderheide, Stephan Nadolny, Jochen Vollmann, and Jan Schildmann.
Clinical ethical case consultations have been widely implemented in clinical practice. It has been hailed as important tool to support clinical decision making. At the same time, it is a matter of debate what ethical case consultations actually do contribute to clinical practice and what it should actually contribute.
Against this background evaluation of ethical case interventions is an important research task. Evaluation research means the application of reasonable expectations of what ought to be achieved by an intervention. It, then, defines empirically measurable outcomes and gathers respective data to be able to assess whether and to what extent these expectations have been met. Evaluation research is important to ensure quality of existing interventions as well as to inform the development of new approaches. However, only very few methodological frameworks for the evaluation of clinical ethics consultation exist.
In the last years, we have researched this topic from different perspectives. We think that every approach striving to master this challenge has to consider at least three important questions.
Do we understand the intervention?
This is the conceptual question. One has to take note of the considerable differences in existing approaches to ethics consultations. This is not only due to different ideas of ethics and ethics consultation itself but often depends on differing organizational and structural factors, evolvement of the interventions over time. Knowing what the intervention is about is, however, crucial.
In light of this question, the first is challenge is, to develop an understanding of interventions and their structural elements. Given their plurality and structure, it seems to be a good starting point to understand ethics consultations as complex interventions. Tools of complex intervention research seem to provide adequate means to develop frameworks necessary to understand structural elements of an intervention and their connection to basic empirical endpoints or can be adapted to the needs of evaluation research and the case of clinical ethics consultation.
What outcomes are measurable and how can they be measured?
This is the empirical question. Evaluation requires adequate empirical outcomes to be selected. “Adequate” implies that these endpoints are clearly definable and measurable. As indicated by our own as well as other research groups’ work, the challenge here lies in the sheer multitude of available options to consider. For example, the last years have witnessed a variety of different methodological approaches to measure outcomes of clinical ethics consultation. These range from randomized controlled trials over survey research and in-depth qualitative social science approaches. The measured outcomes range from “length-of-stay in hospital”, consultation costs or patient mortality as well as subjective experiences and perceptions like perceived satisfaction of stakeholders or helpfulness in the decision making process. In addition to this multitude, robustness of outcomes and methods is very important.
What is a reasonable expectation towards ethics consultation?
Besides necessary improvements in methodology and quality of studies, there is a second meaning of “adequate outcome”, that points to the normative question: evaluation requires reasonable expectations, and hence, to justify the selection of endpoints by argument.
However, forming reasonable expectations towards ethics consultation has to reflect on the specific goals and character of these interventions. For the first and in contrast to most other medical intervention, clinical ethical case consultation does not target the treatment process itself but the decision making process. Second and more important, ethical interventions inherit a strong value perspective which determines the intervention. This perspective differs from other medical interventions as it is not concerned with reaching what is primarily good from a medical, functional or economic perspective but is concerned with what is good after weighing all interests. Forming reasonable expectations what ought to be achieved by ethics consultation, hence, must adapt to this perspective to align with the goals of the intervention.
The challenge here is, by no doubt, the considerable disagreement what this value perspective, that is, ethics, is about. Since a variety of different ideas of ethics are utilized as the normative basis of clinical ethics consultation, no exterior value perspective can be presupposed as a common standard. Rather the perspective of the intervention in question has to be reconstructed and explicated first to align with.
One way to do so, as we have argued in our recent JME paper, may be to focus on the role of ethics consultants. As we understand it, ethics consultants are a structural element of almost all ethical case consultations. At the same time their actual competencies, tasks and responsibilities are mostly determined by the underlying idea of ethics. Understanding the consultants’ role in an intervention and focusing on the outcomes within his/her range will therefore help to form reasonable expectations about what a specific ethics consultation service may achieve.
Author: Joschka Haltaufderheide , Stephan Nadolny [2,3], Jochen Vollmann , Jan Schildmann 
 Institute for Medical Ethics and History of Medicine, Ruhr-University Bochum, Germany
 Institute for History and Ethics of Medicine, Interdisciplinary Center for Health Sciences, Martin Luther University Halle-Wittenberg, Germany
 Nursing Science Staff Unit, Franziskus-Hospital Harderberg, Niels-Stensen-Kliniken, Germany
Competing interests: None declared
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