Ethics as a source of tension?

I’ve been thinking about a blog post on Spirituality for a while now; but I’ve also been getting absolutely swamped with work – so I thought I would just go for a briefer and likely less rambling post in the interim.

The last post I wrote was about a conference I attended on the possibility of particularism in medical practice. My conclusion to that post was that I was concerned that should we abandon a principlist position then how would we manage during times of anxiety and uncertainty?

This feels uncertain to me and at times unsafe to me [sic]. Perhaps this is because I fear attack and wish to reach a defensible position where I can explain my-self to others in a readily understandable post-hoc position and I realise that this is a weak argument. However – when I am struggling to keep my head above water in a flood what I look for is a solid grounding, a rock to which to cling. I believe that psychologically this analogy holds – we seek firm points on which to ground ourselves – our social identifies, religious faiths etc…

Apologies for the appalling grammar, I should read these more closely before posting…

Anyway I was struck by this thought again while reading a fascinating paper just published in the journal BMC Medical Ethics.

Molewijk, B., Hem, M. H., & Pedersen, R. (2015). Dealing with ethical challenges: a focus group study with professionals in mental health care. BMC Medical Ethics, 16(1), 4. doi:10.1186/1472-6939-16-4 [Open Access – hooray].

In this paper the authors report on the findings from a series of focus groups conducted with mental health professionals. As I said I want to keep this post relatively short, and as the article is free to access I would recommend reading it as well, so I will cut directly to the point I found most interesting.

Ethics as tension

Focus group participants were asked to discuss the idea of an ethical problem abstractly – no specific examples were given in order that they had to identify for themselves what they considered an ethical problem to be.

Much of the material discussed was unremarkable and well recognised – frequent ethical dilemmas and limited supervision / reflective space in which to discuss these experiences. However on finding in particular jumped out at me.

Ethical challenges emerged when health care professionals did not agree due to different viewpoints. Often disagreement involved a conflict between different values that are aimed for. (p9)

What appeared to be the most challenging point for professionals was when there was disagreement within the team. This is hardly surprising but there was evidence from the material presented that this type of disagreement had generated some fairly heated discussion between professionals – and there were incidences cited where individuals felt isolated on behalf of their behaviour in relation to people they were supposed to be supporting:

Chief physician: ‘It’s not always coincidental who starts to identify with patients, and finds this [the use of coercion, authors] to be impossible or difficult. It is not seldom connected to other things than only this specific situation. There can be many additional reasons [for nagging those who make the decisions, authors]. Sometimes it can be that they protest, and at other moments it can be that they have their own specific reasons.’

What struck me in this quote was the negative manner in which ‘identifying with’ was presented and how this was likely to lead to ‘nagging’ of ‘chief physicians’ [the authors abstract this from previous material]. There is more to this problem though – the idea that ethical dilemmas arise from disagreements between team members. This, to me, is troubling that when asked to discuss ‘Ethical problems’ participants turn to disagreements with colleagues – I would suggest this is representative of a considerable underlying tension. Participants in the study identified this conflict within teams as being a potential cause for burnout among professionals – particularly for ‘specialists’ who were described as having a very short life-span within these environments.


I recognise these tensions; I’m sure most people do as they are hardly unique to mental health or medicine; the clash of egos and belief systems within closed environments can result in some spectacular pyrotechnic displays.

So how do we work through this?

The authors cite theoretical and practical examples that demonstrate the power of clear reasoning, transparent discussion and subsequent communication to all involved in a process. These they state are known to lead to better decision making and less distress for those involved in the discussion.

So how does this relate to ideas of Particularism versus Principlism?

I think it could actually be a strong argument in favour of the particularist position. One of the commonest examples cited by participants in this study was, obviously, the idea of coercive treatment. If we believe that coercive treatment is justified in one situation then a principles based argument would say that we should be able to generalise from that conclusion to other ‘similar’ situations. Perhaps there is a danger in this conclusion however?

We have a strong cognitive bias towards rapid jumping to conclusions; particularly in relation to situations that we recognise, or believe we recognise. This type of ‘thinking fast’ can lead to errors of thought and reasoning.

So perhaps we need to slow things down, consider each situation through group discussion on its own merits and in so doing improve dialogue within teams. If we do not assume there to be universal truths that can be applied then we can not experience tension in relation to them during discussion?

In my original thoughts and post I was reflecting on my individual experiences and perhaps fearing being held to account in relation to personal choices. This is quite powerful stuff. Thinking back to that time I can see why I was perhaps so orientated in that way as there was a clinical case I was working on that was causing me particular anxiety. A particular theme in my discussions relating to this person was ideas of accountability, responsibility and guilt – how we process these feelings in ourselves as we reflect on our past experience. Since that time I have been able to speak with a number of different people about similar experiences and difficulties and this has lessened my anxiety and will, I hope, prove beneficial in this clinical situation.

So I think there is a lesson from this paper, and the conference again, for me: – These types of decisions are rarely actually individual processes, instead representing combinations of interactions between varied parties. Perhaps this type of decision making is simply too complex for a principled stand point and we should therefore adopt a particularist view?

There is power in groups! Just don’t succumb to group think…

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