LAUSR

In their contribution, Kok et al raise a relevant, though often underestimated, issue: clinical ethics support services (CESS) are often assumed to lead to an improvement of quality of care at the organisational level, but evidence in support of this claim is weak, if not completely lacking. Therefore, the authors propose a complex theoretical model connecting a specific kind of CESS, moral case deliberation (MCD), with mechanisms for quality of care improvement at the individual and the organisational level. The proposal is original, and the topic discussed of great interest not only to practitioners and researchers dealing with CESS, but also to health policymakers and managers of healthcare system, for all of whom it is indeed crucial to understand whether and how ethics support can positively impact quality of care. However, despite its undoubtful merits, we feel that some claims and model’s underlying assumptions might require indepth scrutiny and more solid justification. i. First, the authors discuss two different approaches to understanding quality of care: the first approach, which they define as reductionist, interprets quality as an outcomeoriented, quantitative, and therefore, measurable function. The second approach defines quality as a pluralistic and dynamic process, variable according to the context and the perspectives of actors involved. It is not clear to us why the quantitative approach is being dismissed so quickly. If quality is no longer a ‘measurable property’, how then can we assess that MCD, and CESS in general, improve it? More to the point, we contend that measurable indicators can include both objective and subjective measures, and that being quantifiable/measurable does not per se exclude situational considerations. Notably, in a recent systematic review collecting available assessments of another form of CESS, clinical ethics committees (CECs), we found that the mostly recurrent evaluated outcomes are both subjective outcomes—for example, clinical ethics consultation effectiveness, its perceived helpfulness—and objective outcomes—for example, how often advice are followed, the duration of encounters, the waiting time from the request. Notwithstanding the fact that different forms of CESS may require different impact assessment tools—the number of requests presented to the ethics service may be a valid indicator for CECs while not necessarily for MDC, because of the different involvement of professionals in the two—some form of measurement is necessary and a mix of subjective and objective variables seem appropriate to catch the complexity of cases. Among the subjective indicators to be factored in the assessment, user’s satisfaction seems crucial; for, if MCD (and CESS in general) does not appear useful, even in the long run, to its final users, why maintaining such an expensive, complex, timeconsuming service? Moreover, although the reported satisfaction/dissatisfaction of a single user may not be considered as an adequate mirror of its impact on the quality of care, if intended recipients’ evaluations are not taken into account, MCD runs the risk of becoming a purely intellectual exercise. In addition, using quantifiable instruments does not exclude the inclusion of a personcentred or situational approach. In our experience, it is possible to design robust contextbased assessment measures, for example, using mixed methods, precisely to take into account the complexity and uniqueness of each case. ii. Another issue warranting additional explanation is individual learning. The authors seem to assume that participation in MCD implies per se a learning curve for individuals, but do not suggest how this alleged improvement may be assessed in practice. To address this issue, the authors should clarify what the content of individual learning is. At a first glance, it may appear that it corresponds to gaining the skills to analyse morally complex cases, recognising common patterns and differences among them, and determine the best course of action for each individual case. If this is the case, in our view, individual learning is a measurable outcome of MCD and could be assessed. However, the authors additionally relate individual learning with the acquisition of practical wisdom. As interpreted in a (neo) Aristotelian fashion, however, the latter can be hardly said to be objectifiable or quantifiable. Therefore, how would the authors propose to measure a potential improvement of individual learning qua acquired practical wisdom? iii. Finally, the authors seem to assume that MCD, leads to some improvement in quality of care by providing structure to moral reasoning. Since they do not mention at all the methodologies potentially in place, the question is whether the methodology through which MCD is conducted plays a role or impacts on the quality of the process itself? Or does any methodology, as long as it geared towards promoting moral reasoning as a rational process (as in the authors’ view), lead to the same outcome in any case? Our contention is that, in order to address the question raised by Kok et al—whether and how MCD, but more generally CESS, improves quality of care at the organisational level—transparency with respect to the methodology used and the ethical approaches of the professionals who lead or mediate the discussion of cases is crucial—as distinct methodologies may lead to different outcomes. As bioethicists and clinical ethicists, we hold the belief that CESS, in their different implementations, do have an impact on individual and organisational learning, thus improving quality of care. However, the complexity of, and the kind of efforts implied in, creating and maintaining CESS within an institution do require, we believe, the development of models able to measure—in pluralistic and contextsensitive manners—the impact of CESS in a clear, transparent and verifiable fashion. Department of Oncology and HematoOncology, University of Milan, Milano, Italy Istituto Nazionale Tumori IRCCS Fondazione Pascale, Napoli, Italy