Barbara Russell
My last column talked about how health care workers deal with situations that are morally distressing or worrisome; how to respond to the situation they face "right now" and how to prevent it from happening again. When someone asks me for ethics-related analysis or advice (I'm starting my ninth year in this kind of work), it's either in the guise of what I call "rescue ethics" or "preventive ethics." Similar to other aspects of health care, prevention is always better: a person or team typically has more options to consider, less adrenalin is released, less sleep is lost, and fewer hasty words are spoken. But daily practice is busy; people change their minds; unexpected events occur, so the urgent or "right now" situations still happen.
Whether the issue or situation is urgent or not, there's an approach I use that reflects what I learned in the early years of being on the "front line" with hospital staff. After witnessing ethically good decisions and responses to a situation, I - being philosophically trained - spent time figuring out what the clinician or team did to produce such commendable outcomes. And with each formal consultation I did, I came to see that ethics does not stand alone in health care settings: it would have been naive to just say, "Choose the most ethical option."
CLEOS is the acronym for the approach I use, recommend and teach to clinicians and supervisors. (During the early years working at an acute care teaching, academic hospital in Edmonton, it was CLEO. Working in a mental health and addictions setting, it became CLEOS.)
The acronym reflects the complexity of everyday health care, namely paying attention to and working with the clinical, legal, ethical, organizational and systemic aspects of such care. Certainly the different areas or components are part and parcel of daily treatment and care. Separating them out, however, helps ensure that no area is missed. What are the different areas or components?
By clinical, I mean relevant treatment and therapeutic considerations such as counselling, medications, procedures and so on, what might be considered the "tech-y" side of health care.
Legal considerations include, for instance, applicable legislation and regulations such as provincial health care consent and substitute decision making acts, mental health acts, court rulings, privacy legislation and occupational health and safety regulations.
Ethical considerations include the person in a holistic and individualistic sense - their values, life story and commitments - as well as the mutual relationship between the patient/client and health care workers, and values such as preserving trust, being loyal and fair, protecting privacy (we'd worry about privacy even if there was no provincial legislation), keeping promises, respecting differences and rights, fulfilling professional duties and so on.
Organizational factors relate to the context or setting of providing quality services, programs and supports. Examples are a hospital's or program's existing policies and procedures (e.g., a bill of client rights), team dynamics, resource availability (e.g., available beds, program "spots" or counsellors) possible wait lists, risk management issues and institution-wide operations (e.g., strategic plans and guiding values).
The importance of systemic factors became very apparent as I listened to clients, families, and teams when I first arrived at CAMH. Included under the "S" of CLEOS are stigma/discrimination, the social determinants of health and the health system itself. Stigma and the social determinants have immense impact on people's recovery and living with a mental health or addiction concern. So it makes sense to take them into account when figuring out what is contributing to or compromising someone's quality of life, achievements, relationships and aspirations.
CLEOS is meant to be integrative, realistic and useful. As an approach to everyday work, it acknowledges the inescapable complexity of daily life, the diversity of experiences and meaning of health problems and the variability in treatment and care options. When a clinician or team feels "stuck" or has very different opinions about next steps ethically and asks for my assistance, I use CLEOS so we can first identify relevant factors to the situation or question at hand. In other words, the details matter. The next step is identifying reasonably viable responses or options and then figuring out which one or ones is the strongest clinically, legally, ethically, organizationally and systemically.
During this discussion, it often becomes clear that some options can be combined to produce an even stronger response. Moreover, if the desired outcomes don't actually materialize, then the next strongest option is likely the next one to try. Time spent initially on a thorough analysis can save time later (one of the practical benefits). Clinicians have told me they like this approach because it also helps them gain more clarity about "what's worrying me about this issue or situation" and it helps them get "unstuck" and move forward.
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Barbara Russell, bioethicist at the Centre for Addiction and Mental Health in Toronto, answers ethics questions that arise in the mental health and addiction fields. She is connected with the University of Toronto's Joint Centre for Bioethics and heads the neuroethics interest group of the Canadian Bioethics Society. She is also a contributing editor to the Journal of Ethics in Mental Health.
Submit your ethics questions to be considered for this column to CrossCurrents editor Hema Zbogar at hema_zbogar@camh.net. Please omit personally identifiable health-related information in order to respect people's privacy and follow privacy legislation.
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