1. Ethics and guidelines, ethics in guidelines? EiR-A project Noks Nauta, André Weel, Jim Faas, Inge den Besten, Kerst Zwart, Medard Hilhorst NVAB, NVVG, Welder, ErasmusMC Olomouc, Nov 2010 Grant from ZonMw, The Netherlands organization for health research and development

2. New dimension Medicine, 1975 Psychology, 1999 Ethics: new dimension Essential, could not work without it

3. One minute with neighbour Definition of ‘dilemma’?

4. Dilemma More perspectives More than one choice Each supports value(s) Each harms value(s)  Ethical sensitive situation

5. Eir-A project 2009-2010 Survey: interviews and questionnaire Focusgroup patients Working group Moral framework 2 working groups ethics chapters Start of implementation

6. Recommendations Awareness Recognition Explicit description in CPG Giving clues for dealing Moral case deliberation

7. One minute with neighbour Barriers to add ethics to guidelines? Your opinion and/or others’ opinions

8. Barriers Difficult, vague, subjective Other things more important EBM Autonomy of professionals How to do this?

9. One minute with neighbour Advantages of adding ethics to CPGs? Your opinion and/or others’ opinions

10. Arguments pro What is best for patient Professionality, reflection Multidisciplinarity Transparency of decisions Quality of care, improvements, innovations

11. CPGs and ‘other arguments’ Patients perspectives –Social –Cultural Society’s perspective –Economical –Political Legal aspects Collaboration, division of responsibilities

12. Work and health Functioning versus disease/ complaints Collaboration Professional roles Legal issues for insurance physicians Effects of therapy on capacity for work

13. Fundamental principles Doing well + causing no harm Respect for autonomy Justice Carefulness, attention Trust Honesty Collaboration

14. Moral case deliberation Facts Choices Values per alternative, from different perspectives Weighting of values Choice with argumentation  Making values explicit  Trained supervisor

15. Value-based chapters in guidelines For guidelines –Depression –Breast cancer Testing by professionals and patients

16. Ethics chapter Depression Content Introduction, questions, evidence Elements of sensitive situations –Vision of client/ patient –Interdisciplinary collaboration –Diagnostics –Treatment –Assessment of functioning –Professional’s self reflection –Context client/ patient Moral case deliberation recommended

17. Ethics chapter breastcancer Content (6 of the10 topics) Co-operation of medical professionals Patients’ participation in treatment and rehabilitation Fatigue: assessment and support Cases with bad or moderate prognosis Negative feelings about work Intercultural and SES aspects

18. Results EiR-A project Strengths and opportunities –Innovative and challenging –Many involved, many enthusiastic –Opportunities for innovating guidelines Weaknesses and threats –Guideline groups Depression and Breast cancer have not decided how to deal with the chapter –How to go on after this project?

19. Recommendations Awareness Recognition Explicit description in CPG Giving clues for dealing Moral case deliberation

20. Spin off Ethics chapters in other guidelines (NL) Training supervisors moral case deliberation (NL) Contact IQ health care (NL) Adding ethical criteria to AGREE (Licenik et al) (international) Working group ethics in GIN (international)

21. Thank you for your attention! Comments are welcome: Arnolda.nauta@gmail.com