Abstract
Background
Over the years, Bulgarian bioethics has been mainly an academic enterprise and fallen short of providing health professionals with skills for ethical decision-making. Clinical ethics support (CES) was piloted by the author through two bottom-up models – METAP (Modular, Ethical, Treatment, Allocation of resources, Process) and MCD (Moral Case Deliberation).
Aims
This paper aims to present and analyse developments in the area of clinical ethics and the first experiences in CES in Bulgaria.
Methodology
The project reported here included a review of relevant literature on CES methods and evaluation and a documentary review of data from two CES pilot projects: METAP and MCD.
Results
Most of the 69 METAP ethics meetings reviewed were first time meetings (88,4%); the average duration was 36 min and the average number of participants was four (44,9%). The meetings were organized in response to cases of severely or critically ill patients. The ethical dilemmas included choice of treatment (31,9%) and conflicts with the patient or their relatives (23,2%). Consensus was achieved in 34,8% of the cases. The situation was clarified with the patient (27,5%) and within the team (15,9%). The rights and obligations of both sides were discussed in 7,2% of the cases. The experience of the members of the Bulgarian Association of Bioethics and Clinical Ethics (BABCE) with MCD was also presented to justify the inference about the applicability of the two CES models in a Bulgarian context.
Conclusion
Among Eastern European countries Bulgaria has made progress in CES. Both METAP and MCD have been found to be useful methods.
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Notes
The term is used to mean part of general ethics that deals with “those norms that govern the behaviour of the medical profession…. the obligations of the doctor to the patient, other doctors and health professionals and the society” (Francis 2007).
The term is used to mean „new discipline“ that “no longer identifies with traditional professional deontology” (Gracia 2001) but “applies ethical principles to the new and unsettling questions presented by scientific and technological advance” while looking “into the social aspects of health and health care” (Francis 2007).
These types of ethics committees do not differ in name, but only in their functions as defined in their rules of procedure.
In 2016 in Washington, DC Silviya Yankulovska was awarded the Hans Joachim Schwager Award for Clinical Ethics for the successful introduction of the METAP approach in the country.
The term „norm” is used in MCD to mean the action to be taken among the identified alternatives justified by a particular value.
To be understood as “integrity”.
Palliative care for patients’ relatives is among the specific characteristics of palliative care in line with the definition of WHO: “Palliative care is the active total care of patients whose disease is not responsive to curative treatment…. The goal of palliative care is achievement of the best possible quality of life for patients and their families… Palliative care offers a support system to help the family cope during the patient’s illness and in their own bereavement“ (WHO 1990).
Still bioethicist is required to provide basic ethics training, including training to use properly METAP instruments.
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Acknowledgements
I would like to express special gratitude to Prof. Stella Reiter-Theil who inspired the introduction of METAP methodology in the country, provided theoretical knowledge and materials of the original METAP project and advised on its application. I am also grateful to Victoria Atanasova who constantly supports clinical ethics development in the country.
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Appendix 1
Appendix 1
Feedback self-administered questionnaire for evaluation of ethics meetings.
Questions on meetings’ content.
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1.
Was the moral problem well defined at the meeting? Yes/No.
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2.
Were the values and preferences of the patient well clarified at the meeting? Yes/No.
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3.
Were the patient’s preferences respected at the meeting? Yes/No.
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4.
Was there an opportunity for each participant to share their views at the meeting? Yes/No.
Questions on the instruments.
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5.
Was the informational brochure useful in the meeting? Yes/No/I can’t judge.
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6.
Do you have any recommendations to the informational brochure? Yes/No/I can’t judge.
Questions on the organisation of the meetings.
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7.
How you judge the duration of the meeting? Too short/Sufficient/Too long.
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8.
Do you have any recommendations towards the organisation of the meeting?
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9.
Have you participated in an ethical meeting before? Yes/No.
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10.
Would you like to be involved in an ethics meeting again? Yes/No.
Questions on the outcome of the meeting.
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11.
Was the meeting useful in your opinion? Yes/No/I can’t judge.
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12.
Was the moral problem solved at the meeting? Yes, fully solved/ Yes, partially solved/No.
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13.
What benefits of the meeting would you point out?
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14.
Are you satisfied by the meeting? Yes/No.
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15.
Would you say that consecutive participation in ethical meetings contributes to your easier decision-making of moral problems? Yes/No.
Final questions on participant’s gender and role in the meeting.
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16.
What is your gender? Male/Female.
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17.
What was your role in the meeting? Treating physician/Nurse/Patient’s relative/Patient/ Other.
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Aleksandrova-Yankulovska, S. Bulgaria at the onset of clinical ethics consultation. Monash Bioeth. Rev. 40 (Suppl 1), 6–27 (2022). https://doi.org/10.1007/s40592-022-00158-4
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DOI: https://doi.org/10.1007/s40592-022-00158-4