Ethics: 7 Steps of Facilitation

Rehabilitation providers experience ethical conflicts every day, whether they realize it or not. Just today, I was cruising through social media on my lunch break and saw a post (edited for autonomy) that posed an ethical concern, potentially without its author even knowing. We’ll refer back to this post throughout the blog so please read:

“We have a patient at my clinic whose partner called and scheduled the appointment for the patient. My colleague did the evaluation this morning and said the partner answered all questions for the patient. The partner was inquiring about decreasing posterior pelvic floor tension for anal sex. The therapist found it strange that the partner was answering all the questions for the patient. At this time, I'm really wondering if the partner is forcing the patient to come to pelvic floor therapy and participate. How would you all handle this situation?”

You know this stopped my scroll immediately. Yes, it is a patient care question. However, this situation also brings up so many other intricacies that we encounter as pelvic health providers. I gave my reply and then read others, and this experience made me glad that Herman and Wallace offered three ethics classes talking about ethics for pelvic floor therapists to attend and be able to collaborate on issues just like the one above.

There are many ways that people like to work through ethical situations and scenarios and the ethics series with H&W usually uses the RIPS model, but just to add some new perspective, today we are going to look at the above scenario through the lens of The Critical Dialogue Method.

Delaney et al. (2024) state “Clinical ethicists bring moral reasoning to bear on concrete and complex clinical ethical problems by undertaking ethical deliberation in collaboration with others.” Their article dives into 7 steps of facilitation of such discussions among clinicians. This model is intended to help clinicians identify issues, clarify, and guide them as needed. It also acknowledges that not all ethical problem-solving is linear, chronological, or top-down.

Step One is “setting the scene.”
This is known as an opening statement. This alerts a provider’s peers about the details of the inquiry and allows those participating to be fully present to give their input. As therapists like to do, we should be working to create a safe space for the provider with the questions. In the scenario above, that post was step one as it set the scene for what the therapist had concerns about.

Step two is “listening actively and without interruption.”
This is where therapists get to put all of their experience in being active listeners with patients to the test. Keep in mind these steps don’t need to be linear so listening and replying with questions that show a person was actively listening is important. In our example, we’ve all joined a social media location to collaborate and share clinical questions, thus tacitly agreeing to be active listeners.

Step three is “gathering information and perspectives.”
This is when those active listening skills come in. When it's a social media post, this might be the comments section or even DMs! In our scenario above, therapists were great at sympathizing, empathizing, clarifying, and giving their perspective. They said things like “I’m seeing the red flags you are” and “I’ve had that happen to me and here is what happened…” Someone even kindly took the partner’s side asking if maybe they were a medical provider and that was an explanation for the potentially problematic controlling behavior. Here are some examples of statements or questions that showed a therapist was actively listening.

• What I heard you say is….
• The way you described it, what seems to have happened is…
• I’m hearing that there is some (insert emotion here - confusion, uncertainty, apprehension)....
• Can you tell us more about….
• Can you explain what you meant when you said…

(Adapted from Delaney et al., 2024)

Step four entails "closing in on the ethical question(s).”
This helps move the situation from what has been ethically feeling problematic to what can be done to resolve the issue. In this scenario, I think we can think of a few ethical questions. Some that come to mind are below:

• Is a partner allowed to make their spouse attend a therapy session potentially against their will?
• Is a spouse entitled to privacy with only their therapist if they would like this?
• Is a therapist able to intervene if they suspect abuse is occurring?
• If abuse is suspected, what next steps should be taken?

Step five is about “identifying ways of responding.”
This allows the conversation to move from “What is wrong” to “How do we resolve this?” The first part of this is exploring all of the “possible and available courses of action (Delany et al., 2024).” In this case, we’re thinking about what options are on the table, and what is reasonable while also considering the “what ifs” and things that have already been tried. In our scenario, a variety of solutions were provided to the questioning clinicians.

• Separate the couple in order to let the patient speak about their needs without pressure from the spouse.
• Provide privacy with a closed door and noise machine.
• Address the patient’s goals, reviewing them privately with the patient’s permission, to ensure they align with what their partner may have said previously.
• Check in with the patient’s referring provider to see if they have any concerns about abuse.

Step six involves “identifying and weighing the ethical pros and cons of each possible response.”
In our above scenario, we have a variety of potential pros and cons. We could offend, embarrass, or potentially lose a client by making a false allegation. We could deny a shy, anxious, or scared patient their emotional support human. We could be robbing a partner who feels guilt or worry over possibly causing their partner pain the ability to help correct it. We could also be helping a patient leave an abusive relationship or avoid having to perform an activity they don’t want to. We could be preventing domestic violence or any type of abuse. There is a spectrum, and we can create many scenarios along the way.

Step seven, the last step, is “ethically justified outcomes.”
This means that all of the previous steps have been completed (not necessarily sequentially or singularly) and then an ethically appropriate action is selected. As the RIPS model teaches us, there are many different situations and so some ethical scenarios will be very simple with just one answer, while others may be a dilemma being two potentially right answers, while others may be a whole lot of “it depends” and “I’m not sure!” In our case above, the consensus was that we definitely needed more information in order to make an informed decision on the next course of action!

If you were intrigued by taking a clinical question like this and trying to come up with a “good” solution, you may enjoy taking Ethical Concerns for Pelvic Health Professionals to sharpen, or just use, your ethical and clinical decision-making skills! The next course event is scheduled for January 19th, 2025.

Reference:

• Delany C, Feldman S, Kameniar B, et al. Critical dialogue method of ethics consultation: making clinical ethics facilitation visible and accessible. Journal of Medical Ethics. Published Online First: 08 July 2024. doi: 10.1136/jme-2024-109927 https://jme.bmj.com/content/early/2024/10/24/jme-2024-109927