The key to making ethical decisions is to be methodical, says CIHM’s National Inquiry into Organisational Ethical Decision-Making in the NHS.
The report is essential reading for NHS boards and senior managers. Government reforms to increase public access to information are set to raise the risk of challenges to trust decisions.
The inquiry, led by the Centre for Innovation in Health Management at the University of Leeds (CIHM), was based on one-to-one interviews with NHS managers.
One manager described ethics as “that real hard slog of thinking things through”. The inquiry aims to take the slog out of ethical decision-making, and provides a checklist for immediate implementation.
Recommendations include:
- Decisions affecting large groups should not receive less time than those affecting one patient
- Separate values from data. Managers are often more comfortable with data, believing that enough data will reveal the ‘right’ answer. In fact, there will always be a value base to apparently ‘right’ answers so bring those values to the surface
- Define the values you have identified – the inquiry helps with this in a section on key value concepts in healthcare
- Use these principles with real decisions and the process will get easier
- Ethical decisions are better for staff and patients.
The report adds: “Time is not always apportioned rationally. A couple’s request for a third round of IVF might be agonised over. Halving a budget which affects many people is less emotionally vivid but needs the same consideration.”
CIHM associate and co-author Martin Fischer said: “With open access to information, contestability is going to increase dramatically. If you follow the steps in the inquiry this is a way of reducing the amount time spent on challenges to your decision.”
He added: “Our ability to make decisions that deeply engage with ethics is fundamental to public services – this inquiry helps remind us to do it rigorously, to make it core business rather than a one-off. Almost all managers are working in the NHS because of a deep public sector ethos. This inquiry is way for them to re-ground themselves in those values.”
Values only become clear in action.
The inquiry recommends that trusts start using the principles immediately in real decisions, as values only become clear in action. Jim Baxter, a researcher at Leeds University’s Interdisciplinary Ethics Applied Centre for Excellence and co-author of the report, said: “You don’t have a choice about making ethical decisions – you’re doing it already. The inquiry is about knowing how to apply values in practice. There’s not very much point sitting around pontificating about what your value set is – it only becomes apparent during decisions. The decisions themselves are complex, but there are certain approaches you can take that help them become clearer.”
CIHM director and report author Becky Malby said: “Sometimes in trusts, straightforward decisions like car parking get amplified into complex decisions because it makes the board feel good – it’s something they can do. Whereas deeply complex decisions, like the line between what is social care and what the family should do, get simplified.
“But it’s not daunting – getting to grips with ethics and values can liberate decision-making and make it easier. People find it hard because they don’t have a shared understanding of how to deal with ethics. Without working through the ethics, decision-making becomes frustrating – people wonder why their view has not been recognized. The eventual decision and resulting policy isn’t congruous, it doesn’t add up for people who are using the service or for staff. Organisations which have worked really hard on ethical decision-making reap the benefits with decisions their staff can understand and can implement.
The reports can be downloaded here::
For more information about CIHM: http://www.cihm.leeds.ac.uk/new/