AbstractEthics consultation has traditionally focused on the provision of expert guidance to health care professionals when challenging quandaries arise in clinical cases. Its role, however, is expanding as demands on health care organizations are negatively impacting their moral habitability. A sign of this impact can be seen in the moral distress experienced by staff and administrators, such that some leave their positions and their organizations. Ethics consultation, more broadly conceived, can be a major asset in ensuring that ethical practice is meaningfully supported, that moral distress is mitigated, and that the organizational environment is morally habitable.
Moral distress is an inherent risk in contemporary health care practice with its complexity, rapid innovation, and unprecedented ethical quandaries. The provision of competent and compassionate care can be compromised by rising costs of health care and the organizational strategies enacted to address it, such as service rationing, streamlining strategies, and demands for “efficiency” . Health care is thus a challenging environment for those striving to fulfill their moral obligations to patients, families, and the community at large. When real or perceived constraints inhibit health care professionals from acting on their moral responsibility in the way that they believe that they should, they can experience a deep sense of anguish and failure that, unless it is resolved, can remain to trouble them for years. Unresolved episodes of such “moral distress” can build to a crescendo and prompt professionals to resign their positions or even leave their fields entirely . Health care leaders experiencing moral distress can feel inhibited in voicing their concerns about their decisions due to fears of being viewed as less than a team player . However, research on health care leaders’ moral distress is scarce . The reality is that, if the weighty responsibilities of competent, compassionate care and treatment are to be borne without staff being overburdened by their responsibilities, health care organizations must be morally habitable so that space (literal and symbolic) exists for ethical reflection [5, 6]. What role might ethics consultation play in creating organizational conditions in which the inclusion, power, and trust necessary for authentic dialogue about ethical issues are fostered [6-8]? This question is explored here.
The Moral Habitability of Health Care Organizations
Moral distress has been attributed to lack of resources, human and material, manifested as unsafe staffing (i.e., inadequate number of health care staff or inappropriate skill mix of staff to provide safe, competent care) , equipment deficiencies, and lack of access to necessary treatments [10, 11]. Conflicts, whether between the patient or patient’s family and the team or among the team members, are another cause . For nurses, American  and Canadian  research shows that moral distress (its frequency and intensity) is correlated with poor quality of care, especially within an intractable, bureaucratic organizational system. It is morally distressing when organizational values are incongruent with those of one’s discipline  or when there is a disconnect between the espoused values, beliefs, and attitudes of an organization and its actual customs and practices . An example of both is when efficiency (defined in economic terms as maximizing value rather than as fulfilling the intended purpose) predominates over compassion within an institution, despite the latter appearing prominently in the mission statement.
There can be relational consequences to raising ethical issues in some organizations [13, 14]. One such consequence is to be “cut adrift.” This evocative term was used by a participant in a moral distress study; this participant explained that it was fear of becoming a castaway that kept her silent . She feared that her colleagues would regard her questioning of the ethics of a patient care situation as an indication that she was not a team player, “not one of us,” and thus that she would lose valued collegial support. If avoidance or blaming is a cultural norm, staff might remain silent rather than risk being seen as deviant or as a troublemaker by asking, “Is what we are doing truly ethical?” When such cultural norms are in place, ethical questions tend not to get raised until a crisis occurs; unfortunately, when the crisis is resolved, change in the moral life of the organization might not happen and silencing can remain the norm .
Although health care leaders are obligated to establish structures and supports such that decision making and action are ethically grounded at the levels of clinical practice and crisis response, there may be insufficient attention given to making ethics integral to the everyday life of the organization [17, 18]. Developing and sustaining a morally habitable organization is an ongoing challenge, but it is one that must be met. As ethical consultation is the primary mechanism of doing so, its form and substance deserve a closer look.
Ethics committees are the main approach to addressing ethical issues in hospitals in the US , although ethics consultation can take many forms. First, the individual ethics consultant, with or without support of health care professionals with ethics training (a “hub and spokes” approach), provides guidance with regard to particular cases upon request . Second, the capacity-building consultant focuses on training health care staff in ethics decision making, often using a particular framework . Third, in a facilitation or team approach an ethics consultant (responsible for ethics analysis and framing), a facilitator (responsible for the process and ensuring procedures are followed), and, with luck, a recorder join other resource people and stakeholders to address an ethics issue . Ethicists and ethics committees can and do play a role developing, implementing, and reviewing organizational policy . They could, for example, initiate policy in the area of end-of-life care or prescribe prospective reviews of ongoing cases so that a 30-day intensive care stay would require an ethics review. An alternate response could be, as exists in some hospitals—particularly in intensive care units—to have weekly unit-based ethics rounds to reduce both patients’ length of stay and clinicians’ moral distress . The best setup is likely for an organization to have several consultation options.
Regardless of the form ethics consultation takes, it seems profoundly important that its role goes beyond the provision of expertise for challenging cases. Ethics consulting needs to be an integral component in shaping and sustaining the moral life of a health care organization. It can, in all its forms, support staff and leadership in using the language of ethics and in cultivating their moral imagination, so necessary for understanding others’ perceptions, beliefs, and worries . The “moral sore spots” of the organization —those problems and practices that are dysfunctional but so omnipresent that they have become accepted and unquestioned (e.g., a tendency across the organization to delay discussions with patients and families about personal directives; the low bar held by some physicians for informed consent)—will reveal themselves to an engaged ethicist who can help staff to move past resignation toward solutions [8, 25].
There is a role to be played in fostering interprofessional collaboration. Moral distress can occur when key decisions are made in a patient’s treatment and care plan without input or discussion from the nursing or allied care staff assigned to carry it out . Ethical issues offer opportunities for encounters in which staff can come to mutual understanding or rapprochement  through inclusive sharing of information, feelings, and outlooks. Such encounters need to occur between health care staff and organizational leadership as well. Experiences of moral distress can be mitigated if staff members comprehend the reasons why particular organizational decisions are made and have opportunities to share their concerns about the reasons offered with decision makers, such as those in administration. Ethics consultants could serve as facilitators of such opportunities. While ethical challenges will always be part of life in a health care organization, ethics consultation can thoughtfully address and resolve such challenges. The organization can be a liveable, ethical space.
Nearly a quarter of a century ago, the philosopher Margaret Urban Walker described health care ethics consulting in architectural terms: there is genuine technical expertise involved but, as with the creation of functional structures, also social and psychological knowledge and “aesthetic sensibility” . Walker envisioned ethics consultants as having a sense of moral space, along with a sense of how and where it needs to be opened and structured within an institution. Ethics consultation can help create and sustain morally habitable health care organizations.
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