Medicine, Health Care and Philosophy

, Volume 11, Issue 1, pp 43–56 | Cite as

Implementing moral case deliberation in a psychiatric hospital: process and outcome

  • Bert Molewijk
  • Maarten Verkerk
  • Henk Milius
  • Guy Widdershoven
Scientific Contribution



Clinical moral case deliberation consists of the systematic reflection on a concrete moral case␣by health care professionals. This paper presents the study of a 4-year moral deliberation project.


The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of␣the evaluation of the moral case deliberation sessions, and (d) present the implementation process.


The implementation process is both monitored and supported by an interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).


Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects.


clinical moral case deliberation implementation moral competency responsive evaluation design train-the-facilitator program 


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  1. Abma T.A.: 2005, Patient Participation in Health Research. Research with and for People with Spinal Cord Injuries. Qualitative Health Research, 15(10), 1–19CrossRefGoogle Scholar
  2. Abma T.A., G.A.M. Widdershoven.: 2005, Sharing Stories: Narrative and Dialogue in Responsive Nursing Evaluation. Evaluation and the Health Professions, 28(1), 90–109CrossRefGoogle Scholar
  3. Abma T.A., G.A.M. Widdershoven.: 2006, Moral Deliberation in Clinical Psychiatric Nursing Practice. Nursing Ethics, 13(5), 1–12CrossRefGoogle Scholar
  4. Argyris C.: 1983, Action Science and Intervention. Journal of Applied Behavioural Science, 19(2), 115–140CrossRefGoogle Scholar
  5. ASBH Task Force on Standards for Bioethics Consultation: 1998, Core Competencies for Health Ethics Consultation. The Report of the American Society for Bioethics and Humanities. ASBHGoogle Scholar
  6. Aulisio M.P., R.M. Arnold, S.J. Youngner (eds.).: 2003, Ethics Consultation: From Theory to Practice. Baltimore & London: The John Hopkins University PressGoogle Scholar
  7. CEG.: 2005, ‹Signalering ethiek en gezondheid’ [‹Agenda ethics and health care’], in CEG, Ethiek in de zorgopleidingen en zorginstellingen [Ethics in the Care Education and the Health Care Institutions] (ch. 6). Zoetermeer: Centrum voor Ethiek en Gezondheid [Center for Ethics and Health]Google Scholar
  8. Dartel H. van: 1998, Van ethische commissie naar stuurgroep ethiek. Over de implementatie van moreel beraad in het kwaliteitsbeleid van instellingen voor gezondheidszorg [From Ethics Committee to Steering Committee. On the Implementation of Moral Deliberation Within the Quality Policy of Health Care Institutions]. Utrecht: CELAZ/Nederlandse ZorgfederatieGoogle Scholar
  9. Fox E.: 1996, Concepts in Evaluation Applied to Ethics Consultation Research. The Journal of Clinical Ethics, 7(2), 116–121PubMedGoogle Scholar
  10. Fox E., R.M. Arnold.: 1996, Evaluating Outcomes in Ethics Consultation Research. The Journal of Clinical Ethics, 7(2), 127–138PubMedGoogle Scholar
  11. Fox E., J.A. Tulsky.: 1996, Evaluation Research and the Future of Ethics Consultation. The Journal of Clinical Ethics, 7(2), 146–149PubMedGoogle Scholar
  12. Fox E., K.A. Berkowitz, B.L. Chanko, T. Powell.: 2004, Integrated Ethics. Improving Ethics Quality in Health Care. Ethics Consultation, Responding to Ethics Concerns in Health Care. Washington, D.C.: National Center for Ethics in Health Care, Veterans Health AdministrationGoogle Scholar
  13. Gabriel, Y.: 2000, Storytelling in Organizations. Facts, Fictions, and Fantasies. Oxford: Oxford University PressGoogle Scholar
  14. Gadamer, H.G.: 1960, Wahrheit und Methode. Tübingen: J.C.B. MohrGoogle Scholar
  15. Geertz, C.: 1973, The Interpretation of Cultures. New York: Basic BooksGoogle Scholar
  16. Gracia, D.: 2003, Ethical Case Deliberation and Decision-Making. Medicine Health Care and Philosophy, 6(3), 227–233CrossRefGoogle Scholar
  17. Greene, J.C.: 1988, Stakeholder Participation and Utilization Program Evaluation. Evaluation Review, 12(2), 91–116CrossRefGoogle Scholar
  18. Guba, E.G., Y.S. Lincoln.: 1989, Fourth Generation Evaluation. Beverly Hills: SageGoogle Scholar
  19. Hammersley M., P.M. Atkinson.: 1995, Ethnography: Principles in Practice (2nd ed.). New York: RoutledgeGoogle Scholar
  20. Hull S.C., H.A. Taylor, N.E Kass.: 2001, Qualitative Methods. in J. Sugarman, & D.P. Sulmasy (Eds.), Methods in Medical Ethics (pp. 146–168). Washington, D.C.: Georgetown University PressGoogle Scholar
  21. Koch, T.: 2000, ‹Having a Say:’ Negotiation in Fourth Generation Evaluation. Journal of Advanced Nursing, 31(1): 117–125PubMedCrossRefGoogle Scholar
  22. Lave J., E. Wenger.: 1991, Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University PressGoogle Scholar
  23. Leder, D.: 1994, Toward a Hermeneutical Bioethics. in E. Dubose, R. Hamel, L. O’Connell. (Eds.), A Matter of Principles? (pp. 240–259). Valley Forge: Trinity Press InternationalGoogle Scholar
  24. Manschot H. and H. van Dartel (eds.).: 2003. In gesprek over goede zorg. Overlegmethoden voor ethiek in de praktijk [Being engaged in conversations on good care. Conversations methods for ethics in practice]. Amsterdam: BoomGoogle Scholar
  25. MacIntryre, A.: 1981, After Virtue. London: DuckworthGoogle Scholar
  26. Marshall P.L., B.A. Koenig.: 2001, Ethnographic Methods. in J. Sugarman, D.P. Sulmasy (Eds.), Methods in Medical Ethics (pp. 169–191). Washington, D.C.: Georgetown University PressGoogle Scholar
  27. Merleau-Ponty, M.: 1945, Phénoménologie de la perception. Paris: GallimardGoogle Scholar
  28. Min. VWS.: 2005, Agenda ethiek en gezondheid 2006 [Agenda Ethics and Health Care 2006]. The Hague: Ministry of Health Care, Welfare and SportGoogle Scholar
  29. Molewijk, B.: 2004, Tussen evaluatie Moreel Beraad project Vijverdal-Riagg Maastricht [Interim Research Report of the Moral Deliberation Project Vijverdal-Riagg Maastricht]. MaastrichtGoogle Scholar
  30. Molewijk B., G. Widdershoven: 2006, Moreel beraad en goede zorg voor ouderen veronderstellen en versterken elkaar [Moral deliberation both presupposes and strengthen good care for the elderly] Tijdschrift voor Geneeskunde [Journal of Medicine (Belgium)], 62(23), 1693–1701CrossRefGoogle Scholar
  31. Molewijk, B. and G. Widdershoven: 2007, ‹Report of the Maastricht meeting of the European Clinical Ethics Network’, Clinical Ethics 2(1), 42–45Google Scholar
  32. Molewijk, B., T. Abma, M. Stolper and G. Widdershoven: 2007, ‹Teaching Ethics in the Clinic. The Theory and Practice of Moral Case Deliberation’, Journal of Medical Ethics, in pressGoogle Scholar
  33. Ranson, S., B. Molewijk and G. Widdershoven: 2006, ‹Deliberating on Deliberation. An Evaluation on Empirical Evaluation Studies on Ethics Consultation and Moral Deliberation’, paper presented at the EACME conference in Leuven, BelgiumGoogle Scholar
  34. Rapoport, R.: 1970, Three Dilemmas in Action Research. Human Relations, 23(6), 499–513CrossRefGoogle Scholar
  35. Ricoeur, P.: 1983, Temps et récit, I. Paris: Editions du SeuilGoogle Scholar
  36. Rosen, M.: 1991, Coming to Terms with the Field: Understanding and Doing Organisational Ethnography Journal of Management Studies, 28(1), 1–24CrossRefGoogle Scholar
  37. Schwandt, T.A.: 2001, A Postscript on Thinking About Dialogue Evaluation, 7(2), 264–276CrossRefGoogle Scholar
  38. Shulha L.M., J.B. Cousins.: 1997, Evaluation Use: Theory, Research, and Practice Since 1986. Evaluation Practice 18(3) 195–208CrossRefGoogle Scholar
  39. Stake, R.E.: 1975, To Evaluate an Arts Program in R.E. Stake (ed) Evaluating the Arts in Education: A Responsive Approach (pp. 13–31). Colombus, Ohio: MerrillGoogle Scholar
  40. Stake R., D. Trumbell.: 1982, Naturalistic Generalizations Review Journal of Philosophy and Social Science, 1, 1–12Google Scholar
  41. Steinkamp N., B. Gordijn.: 2003, Ethical Case Deliberation on the Ward. A Comparison of Four Methods Medicine Health Care and Philosophy, 6(3), 235–246CrossRefGoogle Scholar
  42. Steinkamp N., B. Gordijn.: 2004, Ethik in der Klinik. Ein Arbeitsbuch [Ethics in the Clinic. A workbook]. Köln-München: Springer-VerlagGoogle Scholar
  43. Verkerk, M.J.: 2004, Trust and Power on the Shop Floor. An Ethnographical, Ethical, and Philosophical Study on Responsible Behaviour in Industrial Organisations. Delft: EburonGoogle Scholar
  44. Verkerk M.J., J. de Leede, A.H.J. Nijhof.: 2001, From Responsible Management to Responsible Organisations: The Democratic Principle for Managing Organizational Ethics Business and Society Review, 106(4), 353–378CrossRefGoogle Scholar
  45. Walker, M.U.: 1998, Moral Understanding: A Feminist Study in Ethics. NY: RoutledgeGoogle Scholar
  46. Weick, K.E.: 1995, Sense Making in Organisations. London: SageGoogle Scholar
  47. Whyte, W.F. (ed.).: 1991, Participatory Action Research. Newbury Park: SageGoogle Scholar
  48. Widdershoven, G.A.M.: 2001, Dialogue in Evaluation: A Hermeneutic Perspective. Evaluation, 7(2), 253–263CrossRefGoogle Scholar
  49. Widdershoven, G.A.M.: 2005, Interpretation and Dialogue in Hermeneutic Ethics. in R. Ashcroft, A. Lucassen, M. Parker, M. Verkerk, G. Widdershoven (Eds.), Case Analysis in Clinical Ethics (pp. 57–75). Cambridge: Cambridge UPGoogle Scholar

Copyright information

© Springer Science+Business Media B.V. 2007

Authors and Affiliations

  • Bert Molewijk
    • 1
    • 2
  • Maarten Verkerk
    • 3
  • Henk Milius
    • 3
  • Guy Widdershoven
    • 1
  1. 1.Department of Health, Ethics and Society/metamedica Faculty of HealthMedicine and Life Sciences, School of Public Health and Primary care (Caphri)MaastrichtThe Netherlands
  2. 2.GGnetMental Health Care InstitutionZutphenThe Netherlands
  3. 3.Vijverdal MaastrichtPsychiatric HospitalMaastrichtThe Netherlands

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