Understanding clinical ethics situations: a co-created repertoire of practices

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.