Marika Dawn Warren

Clinical ethics is largely about understanding concrete moral situations and supporting meaningful discussion on these to identify appropriate resolutions. However, concepts and methods to describe cases (e.g., dilemmas, situations, stories) vary between authors and case analysis methods. We undertook a non-exhaustive literature review — inspired by McDougall’s critical interpretive review method — to identify a range of influential ideas on how to describe clinical ethics cases and the methods recommended to understand these cases. We identified nine families of case analysis methods, which vary considerably with respect to the basic description of cases, the strategies recommended to understand cases, and additional features that should be considered (e.g., contexts, social and power dynamics, emotions). As a collective of clinical ethicists and academics, we identify five main limitations of these methods and underline the importance of developing methods based on the practical knowledge of clinical ethics consultants.

L’éthique clinique consiste en grande partie à comprendre des situations morales concrètes et à favoriser des discussions constructives à leur sujet afin d’identifier des solutions appropriées. Cependant, les concepts et les méthodes utilisés pour décrire les cas (ex. : les dilemmes, les situations, les récits) varient selon les auteurs et les méthodes d’analyse des cas. Nous avons entrepris une revue non exhaustive de la littérature — inspirée de la méthode d’analyse critique interprétative de McDougall — afin d’identifier une série d’idées influentes sur la manière de décrire les cas d’éthique clinique et les méthodes recommandées pour les comprendre. Nous avons identifié neuf familles de méthodes d’analyse de cas, qui varient considérablement en ce qui concerne la description de base des cas, les stratégies recommandées pour les comprendre et les caractéristiques supplémentaires à prendre en compte (ex. : les contextes, les dynamiques sociales et de pouvoir, les émotions). En tant que collectif d’éthicien(ne)s cliniques et d’universitaires, nous identifions cinq limites principales de ces méthodes et soulignons l’importance de développer des méthodes basées sur les connaissances pratiques des consultant(e)s en éthique clinique.

Understanding moral problems in clinical settings is central to clinical ethics consultation practice. Although this process may seem straightforward, it is in fact complex, multifaceted, and ongoing throughout consultations. Oftentimes the moral aspects of a situation will be articulated vaguely by those involved based on feelings of uneasiness and discomfort. Thus, clinical ethicists play a key role in helping to characterize these tensions in more formal and explicit terms using references to values and principles. The clinical ethics consultation literature points to the importance of this task and to some recommended practices in this process, such as those referenced in ASBH’s Core Competencies. However, there is a sizable gap between these practice guidelines and the actual methods, skills, and creativity deployed by clinical ethicists to accomplish this task. In this paper, we report a co-creative effort to lay out practices for understanding moral problems and structure them into a repertoire of practices. We followed a co-creative process involving semi-structured interviews with 20 practicing clinical ethicists as well as an iterative process involving drafting the repertoire and revising it during meetings and in manuscript form. The final repertoire structure and content includes: (1) elements considered to discern the moral nature of the problem; (2) actions and approaches taken to discern the moral nature of the problem; (3) elements considered in preparation for addressing the problem; (4) actions and approaches taken in preparation for addressing the problem; (5) modulating factors, and challenges and limits. We hope this work helps further ground the value of co-creative work in clinical ethics while also offering practical resources to support ongoing improvement of understanding moral problems in clinical ethics.

Integrating large language models (LLMs) like GPT-4 into medical ethics is a novel concept, and understanding the effectiveness of these models in aiding ethicists with decision-making can have significant implications for the healthcare sector. Thus, the objective of this study was to evaluate the performance of GPT-4 in responding to complex medical ethical vignettes and to gauge its utility and limitations for aiding medical ethicists. Using a mixed-methods, cross-sectional survey approach, a panel of six ethicists assessed LLM-generated responses to eight ethical vignettes. The main outcomes measured were relevance, reasoning, depth, technical and non-technical clarity, as well as acceptability of GPT-4’s responses. The readability of the responses was also assessed. Of the six metrics evaluating the effectiveness of GPT-4’s responses, the overall mean score was 4.1/5. GPT-4 was rated highest in providing technical (4.7/5) and non-technical clarity (4.4/5), whereas the lowest rated metrics were depth (3.8/5) and acceptability (3.8/5). There was poor-to-moderate inter-rater reliability characterised by an intraclass coefficient of 0.54 (95% CI: 0.30 to 0.71). Based on panellist feedback, GPT-4 was able to identify and articulate key ethical issues but struggled to appreciate the nuanced aspects of ethical dilemmas and misapplied certain moral principles. This study reveals limitations in the ability of GPT-4 to appreciate the depth and nuanced acceptability of real-world ethical dilemmas, particularly those that require a thorough understanding of relational complexities and context-specific values. Ongoing evaluation of LLM capabilities within medical ethics remains paramount, and further refinement is needed before it can be used effectively in clinical settings.

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un- Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article, we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.