Introduction

This unique book provides an open, sensitive and enriching insight into what peer review of clinical ethics support can look like and how peer review can reflect on the quality of a concrete clinical ethics consultation. It is based on a thick description of an ethics consultation, written by an ethics consultant. The book consists of several layers: within each layer, peer-review is organized in a different way and with a different focus. First, five colleagues review the case consultation itself, addressing its strong and weak points. Next, four ethicists reflect on the methods used within both the case consultation and the five initial reviews of the case. In this chapter, we comment on the conclusions of the five initial reviews and the four reflections of the methods used, adding another layer to the reflection process.

We will first go into the relevance of peer review for assessing the quality of clinical ethics consultation. We will argue that peer review in the narrative form as presented in this book provides an alternative to the formal clinical ethics consultation review procedures typically found in the clinical ethics literature. Subsequently, drawing on the four chapters on method, we will elaborate on peer review as a reflection on clinical ethics consultation practice (addressed by Agich and Bruce), the elements which a story should contain in order to provide a basis for peer review (discussed by Agich and Aulisio), and the differences between the assessments of the peer reviewers (highlighted by Bruce and Rasmussen). Next, we will argue that a narrative approach to assessing the quality of ethics consultation can be further developed by allowing all stakeholders who are involved in the clinical ethics practice to actively take part in the evaluation process, following a “responsive evaluation” approach. An example of this is creating a Community of Practice, the aim of which is to foster a joint learning process of all parties involved. At the end of this chapter, we draw some conclusions on peer review as a dialogical tool for evaluating quality of clinical ethics consultation.

The Relevance of Peer Review for Assessing the Quality of CES

Clinical ethics support services (CESS) has become broadly accepted in many countries over the past 30 years. Bringing together ethicists and health care professionals trained in ethics, its aim is to contribute to the quality of healthcare. Typically, this is accomplished by having clinical ethics consultants interact with physicians and other healthcare professionals, patients and families, and others directly involved in the care of patients in order to provide input – by fostering deliberation, by asking questions, or by giving case or policy recommendations – into what are often crucial decisions and processes. Although the comprehensive and sustained study of the effects of CES – and especially clinical ethics consultation – is still in its infancy, there is evidence from practice and research that clinical ethics consultation is often experienced as meaningful and relevant by the parties involved (Slowther et al. 2001; Fox et al. 2007; Førde et al. 2008; Molewijk et al. 2008a, b; Pedersen et al. 2009; Førde and Pedersen 2011; Lillemoen and Pedersen 2013; Janssens et al. 2015; Weidema et al. 2015; Svantesson et al. 2014). However, this evidence for the meaningfulness and relevance of clinical ethics consultation does not guarantee that the ethics consultation itself was of a good quality. Therefore, the question of how best to assess the quality of clinical ethics consultation deserves further attention. At issue are such matters as: How to determine, both empirically and theoretically, the quality of ethics consultation? What are characteristics of good ethics consultation? Which elements are necessary? How should the quality of ethics consultation be evaluated? Who should evaluate the quality of ethics consultation? Which methods or measures should be used? Such questions are important, especially because clinical ethics consultation presents itself as a reflective practice in relation to ethical issues in healthcare institutions. At the heart of ethics consultation is the focus on how to determine and define ‘quality’. Therefore, we agree with Agich that clinical ethics consultation should also reflect upon its own activities.

In response to questions concerning the quality of ethics consultation, professionals in the field have taken initiatives, for instance by describing the core competencies of ethics consultants (e.g., ASBH 2011), by developing educational programs (La Puma and Schiedermayer 1991; Spike 2012; Dorries et al. 2014; Stolper et al. 2015), and by developing guidelines and protocols (Reiter-Theil 2009; Pedersen et al. 2010; Tarzian et al. 2015; Molewijk et al. 2015; Pearlman et al. 2016). Emphasis has been placed on both procedural aspects (what steps to follow during the consultation, how to make a report, how to evaluate the consultation and take care of follow up, etc.), and on content (how to delineate the ethical issue at stake, which method of analysis is to be used, which aspects should be taken into account in the deliberation, etc.).

Despite their value, most of these initiatives remain abstract and procedural in describing (conditions for) quality of ethics consultation: they focus on the quality of CESS staff, CESS structures/groups and clinical ethics procedures. They often entail formal prescriptions of what should be done instead of a thick and narrative description on what is actually done in clinical ethics practice. Moreover, core competencies, guidelines and protocols for quality of ethics consultation tend to be used in a deductive way, applying a certain framework of definitions, criteria and norms. This does not allow for a more interactive, critical and reflective process for examining quality of ethics consultation in the context of actual clinical ethics consultation practice. Peer review, on the other hand, is such a process.

For our purposes here, by “peer review “we mean the evaluation of one’s work by qualified members of a profession within the relevant field (peers). Peer review is thus a form of self-regulation used to maintain quality standards, improve performance, and provide credibility. For a large part, the work presented in this book is concerned with this kind of self-regulatory quality assessment; utilizing “The Zadeh Scenario,” Finder’s narrative of the Zadeh case, the central question that is being explored is this: how and on which grounds do peers evaluate the quality of the work of a clinical ethicist?

In particular, Finder’s initiative and effort to describe a case consultation in detail and to ask for different kinds of review from peers of different clinical ethics backgrounds stimulates a series of in-depth reflections at several levels. One general conclusion that appears to be shared by all commentators is that peer review should go beyond checking whether clinical ethics staff is adequately educated, guidelines are known or protocols are present. Of crucial importance are the attention for details and the sensitivity for how facts in the case (e.g. behavior, words used, medical situation) are interpreted and valued by both the stakeholders within the specific clinical ethics consultation and for the individual clinical ethics consultant. This hermeneutic sensitivity relates both to the consultation process itself and to the way in which it is reviewed by peers. Another conclusion which is generally shared by the commentators is that peer review requires openness, vulnerability and willingness to learn. This goes beyond a formal attitude of accounting for ethics consultation procedures.

Peer Review as a Reflection on CES Practice

According to Agich, clinical ethics consultation is a practice with implicit standards and rules. Following Schön, Agich argues that clinical ethics professionals are and should be reflective practitioners, and that reflection is needed in order to prevent routinization. Peer review can foster this process of reflection by focusing on the rules which are inherent in the practice of clinical ethics consultation. This is not a theoretical matter of first identifying basic principles of quality of ethics consultation and then investigating whether a certain clinical ethics practice adheres to them, but a practical matter of discovering, or exploring the ways in which what might be called “implicit” standards and rules are enacted in clinical ethics practice. A narrative which presents the concrete experiences of an ethics consultant can therefore provide material for peer review and help the peer reviewer to understand the issues at stake in clinical ethics practice. This we see in the appreciation of “The Zadeh Scenario” by the other authors in this book. They are interested in what the narrative tells about the clinical ethicist’s practice and are keen to learn from the experiences which Finder shares with the reader. Despite the fact that a narrative is never complete, the narrative form itself evokes reflection and enables us to understand and reflect upon quality of ethics consultation.

Like Agich, Bruce also recognizes the interest of the peer reviewers in the intricacies of Finder’s story. She notices that the reviewers hardly refer to accepted methods of ethical analysis, like principlism and casuistry, to assess the quality of the ethical consultation presented in the story. Accordingly, Bruce regards both the story and the reviews as examples of a narrative and clinical pragmatist approach to clinical ethics consultation, and she applauds the fact that the peer reviews of the Zadeh case are practical and process-oriented rather than theory-driven: “their methods are interpersonal in nature, one involving an interpretative process or a deliberate uncovering of ethical meanings. A common feature that undergirds all of their assessments seems to be an implicit belief that engaging in patient care entails finding a clinically-feasible (but process-driven) solution” (Bruce 2018: 114). Hence, Bruce appreciates the pragmatist and intersubjective nature of this kind of peer review.

Both Agich and Bruce, therefore, are drawing explicit attention to the fact that the quality of ethics consultation as a practice can only be assessed by reflecting on the experiences and actions of the ethical consultant, and that a narrative form is of crucial importance.

A Focus on Dealing with Ethical Issues

Although both the peer reviewers in Part Two and the commentators in Part Three are positive about the use of narratives to provide insight into the practice of clinical ethics consultation, they also are critical of “The Zadeh Scenario” in particular, mainly because it does not tell much about Finder’s actions as an ethicist.

According to Agich, the story Finder presents does not provide information about the way in which the consultant addressed and analyzed relevant values and norms of participants. The story does show the process of consultation, especially the communication in the consultation team, the importance of consultation service records, and the dynamic character of the consultation. As such it provides useful information for peer review. Yet, it lacks reflection on the role of the consultant as ethicist and the analytical and reflective actions of the ethicist. According to Agich, the story is inadequate in this respect, and the commentaries of the peer reviewers make this clear.

Like Agich, Aulisio too highlights information that is missing in “The Zadeh Scenario” as pertinent to core elements of ethics consultation. From the missing information, he draws three lessons, stating what core elements of ethics consultation should entail. First, ethics consultation needs to identify and analyze value conflicts. Second, it should focus on fostering an adequate distribution of responsibilities, and establish who has authority over decision-making. And third, it should, while recognizing the needs of family, keep a focus on the patient. In drawing out these core elements of clinical ethics practice, Aulisio critically evaluates both the narrative Finder presents and the clinical ethics practice presented by that narrative. According to him, both reflect a lacking or absence of key elements necessary for what he considers to be “good” clinical ethics consultation practice.

What we can learn from Agich and Aulisio is that a narrative may only serve as a vehicle for peer review if what it shows is how the ethics consultant addressed ethical issues. The narrative, thus, should focus on the identification of ethical elements of a clinical situation, the analysis of values and norms of the stakeholders involved in that clinical situation, and the way in which value conflicts are made explicit and turned into an issue for deliberation.

Differences Between Assessments

A pertinent feature of this book is not only that it presents a series of peer reviews but that there is real difference between the assessments of the peer reviewers. In referring to these differences, Bruce highlights the relevance of a procedural approach when assessing not merely Finder’s consultation but the quality of ethics consultation more generally. This is in line with the traditional focus on competencies, protocols and guidelines when assessing and warranting quality of clinical ethics services; similar focus can be found in current approaches to quality management in healthcare as a whole. Rasmussen too clearly argues for standards. She sees in the lack of congruence between the peer reviewers a need for a more standardized approach, both for clinical ethics consultation and for peer review. As a consequence, Rasmussen writes that the story should contain certain core elements in order to serve as a source for review.

A common presumption in these reflections is that differences between assessments are undesirable. We disagree; indeed, we question the validity of this presupposition. In short, if clinical ethics consultation is regarded as a practice which can be understood by interpreting narratives, differences between interpretations are not in themselves problematic. A narrative approach to evaluation is based on the idea that there are no absolute standards for assessing a practice. Various stories about a practice are necessarily divergent, because they highlight various elements in that practice. The interpretations of these stories will also be different, because they departs from specific views on (the quality of) ethics consultation. This is, in fact, seen clearly in the different reviews of quality as reflected in each of the five initial peer reviews of “The Zadeh Scenario” in Part Two and the subsequent meta-reflections in Part Three. Each author, from his or her perspective, emphasizes specific elements in “The Zadeh Scenario.” Stories and their interpretations can enrich our understanding of a practice exactly because they present various views on this practice and put the practice in a new light. Introducing a standardized approach would remove the richness of the story and its interpretations. A standardized approach is itself only one perspective, which is, like all perspectives, limited and in need of other perspectives which may complement it. Allowing for a variety of assessments may stimulate learning through a process of comparing them, and investigating where they may meet. Thus, it is the dialogue between interpretations that holds out the promise for actual growth in understanding what the quality of clinical ethics practice entails.

Towards a Dialogical Approach of Clinical Ethics Assessment

Several contributions to this book emphasize the need for a variety of perspectives when assessing a specific clinical ethics practice. From Frolic & Rubin, for example, we see that peer review efforts are limited and perhaps even flawed if they focus on isolated snapshots of clinical ethics practice. They write that efforts should be made to get a fuller picture through presentation of a range of narratives from the same consultant or consultation service in order to represent the spectrum of one’s diverse consultations. Armstrong also argues that “an account of the clinical engagement of a consultant is ultimately not enough to provide a holistic account of the consultant’s practice, or to discern the core moral considerations that emerge among the divergent standpoints” (Armstrong 2018: 73).

A variety of stories and interpretations can contribute to our understanding of a clinical ethics practice and its quality (Widdershoven and Molewijk 2010). This, however, requires an exchange between stories and interpretations. Putting stories and interpretations next to one another is in itself not helpful. A diversity of stories and interpretations actually calls for comparison and integration of perspectives. Various stories and interpretations can add to one another, and bring to light the limitations involved in each of them. Thus, the reviewers noticed a limitation in the Zadeh story in that the perspective of the patient is mostly absent. This implies the need for a different story, namely that of the patient. Rosell & Johnson refer to Richard Zaner in arguing for the importance of attentive interest in the patient and his/her narrative.

The value of this book is that it shows the relevance of stories and interpretations for assessing quality. In order to determine the quality of clinical ethics consultation, one should have in-depth insight into the actual practice of clinical ethics, which requires a multitude of stories and interpretations. Moreover, these stories and interpretations provide perspectives which are in need of exchange. A story presents a meaningful perspective on a practice, but also raises questions in the interpreter, which may require new stories in response. What is needed is a dialogue between stories and interpretations, resulting in new and richer views on the specific clinical ethics practice. Having read “The Zadeh Scenario” and the reviewers’ comments, one immediately is interested in the possible answer of Finder to the reviews, and in the reviewers’ reactions towards each other. Thus, stories and their interpretations call for a dialogue between the storyteller and the interpreters. As the critique of some reviewers on the absence of the patient’s story shows, this dialogue should not only include the ethicist and his or her colleagues, but also other parties involved.

Responsive Evaluation as a Method for Assessing Quality of Clinical Ethics Consultation

This book contains a fine example of a narrative approach to the assessment of clinical ethics consultation quality, starting with a rich story of the ethicist about a case in consultation practice, and presenting a wide range of peer reviews and reflections. As such, it contains the basis for a dialogue between ethicists on the quality of ethics consultation, elaborating on experiences and learning from other perspectives. A next step would be to actually foster a dialogue, by organizing an exchange of stories and perspectives. This dialogue may point out the need for other stories and perspectives than those of the ethicist(s). As mentioned before, some of the reviewers suggest that the story of the patient should also be heard. Without the patient’s perspective, the story about the consultation is incomplete. This is not only true for the content of the consultation (no advice can be finalized, and no valid conclusions may be definitively drawn, without taking into account the patient’s wishes and concerns), but also for the assessment of the quality of the consultation. The patient’s perspective is of crucial importance if it comes to determining the value of the process of ethics support. The same goes for the perspective of the family members, who were actively involved in this case.

An example of a method for assessing the quality of a practice through inclusion of perspectives and by establishing a dialogue is “responsive evaluation.” Responsive evaluation actively involves stakeholders such as, in the case of moral dilemmas in clinical practice, professionals, patients and family members in evaluation to actually contribute to the improvement of concrete practices (Abma et al. 2009). It focuses on dialogical learning processes of and between stakeholders (Stake 2004; Guba and Lincoln 1989; Abma 2001; Abma and Widdershoven 2011). Responsive evaluation seeks to be inclusive and participatory: together, stakeholders determine what is good in a democratic and dialogical way (Visse et al. 2012, 2015).

Within cases like “The Zadeh Scenario,” responsive evaluation can be organised in several ways. One can, for example, after the case consultation has been closed, ask the patient and the family members whether they want to reflect upon the quality of the ethics support as such. Several methods at several moments can be used. One can start with individual open interviews. Then, after having analysed the transcripts of those interviews, one can present different and similar viewpoints on what quality in clinical ethics consultation entails in a focus group interview with the stakeholders involved in the case. In the same focus group interview, or in a separate focus group, one can invite other relevant people, for instance colleague ethicists or patient and family representatives, to deliberate about the case and reflect on the quality of ethics consultation.

One way to put responsive evaluation on the quality of clinical ethics in practice is by creating a Community of Practice (CoP) (Molewijk et al. 2015; Bindels et al. 2014). Such a community is a mixed group of stakeholders (for instance, patients or their representatives, family caregivers, professionals, and ethicists) who share a common interest: the provision of good care in situations that are experienced as morally troublesome. In such a CoP, an active and explicit process of formative evaluation can take shape. By sharing analyses, experiences, and information, a CoP not only evaluates, but also improves and develops the quality of clinical ethics consultation.

Conclusion

We agree with the overall appreciation of the contributors to this book concerning the value of a narrative approach to clinical ethics consultation, both for clinical ethics consultation itself and its evaluation, as narratives present the concrete contexts in which ethics consultation takes place and the concrete individuals that are involved, and stress the subjective and action-oriented nature of clinical ethics consultation and its outcomes in clinical practice. Ethics consultation evaluation cannot be based on rules and principles that are defined beforehand, detached from concrete contexts: ‘the right thing to do’ is always context-bound and based on a joint reflection on lived experiences. In this sense, evaluation of ethics consultation is in line with clinical ethics practice, which also includes reflection on concrete experiences in specific contexts.

From a narrative perspective, peer review based on the ethicist’s narrative account provides valuable tools to evaluate the quality of clinical ethics consultation. In addition to studying guidelines and protocols which serve as the background of a specific clinical ethics consultation service, peer review can make explicit crucial elements in consultation practice. This requires insight in what actually happens during consultation. A thick description of a consultation, such as the one provided by Finder, is of major importance for starting a dialogue on the quality of clinical ethics consultation.

This book shows that peer reviewers interpret a case narrative about consultation practice differently. This can be regarded as a sign of a lack of a common framework as a basis for evaluation, as some of the commentators do. Yet, one may also see it as an indication that evaluating a practice requires a process of interpretation in which a variety of perspectives is needed, as each perspective can add to a better understanding of what is at stake. Again, this resembles the practice of clinical ethics consultation itself, which aims at making explicit various perspectives in order to reach a better understanding of the situation at hand. Peer review is not a judgment on a practice by applying given standards, but a process of deliberation on strong and weak points of the process of consultation which is presented in the case story.

As assessment of quality is essentially a matter of interpretation and deliberation, interaction between various perspectives is crucial. The peer reviews presented in this volume call for comparison and learning to see the case better by sharing commonalities and differences. A dialogue between various perspectives will contribute to the process of evaluation, as it enables a broader view on the case under consideration. Such a dialogue should also involve the people whose practice is reviewed. All stakeholders should be enabled to bring in their perspective on the value of ethics support. Assessing the quality of clinical ethics consultation requires that the participants learn from the experiences of others, and come to joint conclusions about what is good and what can be improved.