Bioethics in Finland and abroad

The ways and measures in which bioethics practices—such as ethics consultation or ethics committees—have been absorbed by the social,

institutional and governmental agendas in different countries around the globe vary greatly. Having first originated as a field of inquiry in the United States and reflecting a primarily Anglo-American cultural ethos, bioethics has later increasingly spread to many countries around the globe, from the developed West all the way to Eastern countries such as China and India (for global bioethics, see Myser 2011).

I will shortly introduce in this chapter some of the ways in which bioethics has been applied to practices in clinical contexts, or more informally, “at the bedside.” Still a fairly uncommon practice in European hospitals, in North America—United States and Canada—clinical ethicists are routinely hired or designated to assist staff and patients to deal with the ethical issues emerging in healthcare (see, for example, Coughlin & Watts 1993; Greenberg et al.

2013; Fox 2007). However, the term ethics consultation, also known as ethics support, can refer to a wide scale of different practices, from the work of an individual or a group of consulting ethicists to the deliberations of a large, multidisciplinary clinical ethics committee (see Fox et al. 2015, 3–5 about the different models for ethics consultation).

Ethics consultations have many goals for the North American hospitals where they are practiced. The overall aim of their practice can be defined as “to improve the quality of health care through the identification, analysis, and resolution of ethical questions or concerns” (Fox et al. 2015, vi). Effective ethics consultations are seen to 1) promote practices consistent with high ethical standards, 2) foster consensus and resolve conflicts in a respectful atmosphere, 3) honor participant’s authority and values in the decision-making process, and 4) educate participants to handle present and future ethical concerns (ibid.). European countries have also slowly become interested in ethics consultation: For example, Fournier et al. (2009) recorded over ten years ago that consultation services were being implemented in certain hospitals in France, Norway, Germany, the United Kingdom, and Italy. Eleven years later, it is likely that clinical ethics practices have become even more common outside of North America. Time will tell whether the coronavirus crisis—manifesting at the time of writing this in the spring of 2020—will have the potential to change clinical ethics practices in healthcare institutions around the globe in unprecedented ways.

Next, to provide context, I briefly examine some of the practices that are carried out in the European context as well as the current situation in Finland in relation to this topic. Bioethics has spread to many different spheres and contexts among the Western developed and democratic societies, yet Finland is a curious exception, because there are no established, influential structures existing for practical applications of bioethics in clinical settings.

Bioethics has become slightly more common in Finland as an academic topic, with people from different backgrounds and disciplines working on bioethical themes (see, for example, Häyry 2010; Launis & Räikkä 2008). However, the marginality of the field is reflected by the fact that there is no academic degree (or study program) available in Finnish universities that would lead to the specific skillset of a ‘bioethicist.’

Despite the fact that some academic discussions on bioethics endure in Finland, the clinical domain is strangely silent: neither clinical tradition nor legislative mandate for having interdisciplinary ethical discussions in clinical environments exists.³ Most hospital districts, however, have ethics committees that discuss ethics at the level of principle (Louhiala et al. 2012, 83). These hospital committees rarely, if ever, pick topics with reference to the uncertainties purporting in the grassroots levels of clinical care. Additionally, a nation-wide ethics committee under the Ministry of Social Affairs and Health discusses “general principles in ethical issues in the field of social welfare and healthcare and concerning the status of patients and clients as well as to publish recommendations on them” (online resource, see ETENE).

One indication of the need for an ethics consultation service in the Finnish clinical setting is the establishment of a web-based physician’s ethics forum (Louhiala et al. 2012). However, the forum is composed solely of professionals from medical subspecialties and is available for use only by physicians. Based on the intradisciplinary formation of the forum and the fact that the forum responds to cases within the duration of a whole month, the observation

3 It should be disclosed here that during the years of making the substudies for this thesis, it has been my personal professional aspiration to introduce bioethics in Finland for the clinical audience. However, while clinicians have often found the topic fascinating, the practical undertakings for establishing bioethics practices have so far not succeeded.

can be made that the physician’s forum is not actually an active service in comparison to the clinical bioethics services elsewhere. Conversations about a need to support the ethical competence of nurses exist in Finland in addition to the physicians’ forum (for example, Poikkeus 2019; Poikkeus et al. 2013). Both of these examples sustain a strong profession-based ethos of ethics in which nurses and physicians are separated from being exposed to each other’s influence, even though in the nursing research the difficulty of reaching multiprofessional dialogue is recognized as a barrier to enhancing nurses’ ethical competence (Poikkeus et al. 2013, 13).

Formal structures are yet to be established, but a new interest is emerging in Finnish healthcare regarding the practice of moral case deliberation (MCD) and other similar, structured and facilitated group discussion models (see Nikunen 2018; Peltoniemi et al. 2018). Moral case deliberation is a Dutch step-by-step method for guiding reflective, interdisciplinary and proactive case discussions on ethically complex cases with professionals, facilitated by a trained MCD-facilitator (for an introduction to the method, see Molewijk et al. 2008). However, MCD has not become an established practice so far in Finland’s clinical scene, because it is operated without a formal hospital structure and budget, being organized on a case-by-case basis by a handful of clinicians enthusiastic about the method. Regardless of the promising, newly developing interest in MCD, it still seems reasonable to make the claim that the Finnish healthcare system is a tough nut to crack for the influence of what could be called the “bioethics ethos”: that is, an orientation toward value pluralism, interdisciplinarity, transparent structures of documentation of clinical ethical decision making, case-by-case consultation and dialogue, and the pursuit of having an institutionally organized space for open-ended moral discussions.

Unlike Finland, other Nordic countries appear to express a genuine interest in clinical bioethics. Clinical ethics committees dealing with prospective and genuine clinical cases (hence, not solely on the level of principle) have existed in Norway since 1996, and most of the hospital trusts had a clinical ethics committee already by 2008. The Section for Medical Ethics at the University of Oslo is funded by the Ministry of Health and Care Services to support the ongoing clinical applications in terms of coordination and competence

building. (Førde et al. 2008, 17.) The Norwegian model of clinical ethics operates mostly through the committee model to which the Ministry mandates the hospitals to provide. Additionally, pilots have been initiated to experiment with ethics consultation (see, for example, Pedersen et al. 2009, 461).

Academic bioethics is flourishing in Sweden at the University of Uppsala’s Center for Research Ethics and Bioethics, as well as in smaller units in other universities. However, clinical ethics is not as formally structured in Swedish hospitals as it is in Norway, because there is no parallel authoritative mandate for organizing clinical ethics committees. However, some clinical ethics applications inviting multidisciplinary discussions of ethics are implemented in everyday healthcare practices, because there are research studies of ethics rounds with clinical professionals (Silén et al. 2016) and of the practice of moral case deliberation in Swedish hospitals (Rasoal 2016).

Clinical ethics committees in Denmark dealing with patient care have only lately been established for both psychiatric and somatic healthcare. However, even though clinical ethics structures are in use, no national requirement demanding hospital trusts to secure clinicians’ access to ethical consultant services exists (Bruun et al. 2018). After the establishment of the first ethics committee in 2010, ethics reflection groups (ERGs) were additionally implemented to include the moral support for the reflection of moral quandaries in everyday clinical practice (Bruun et al. 2019).

This short outline of the bioethics practices in Nordic countries indicates a continuously strengthening interest in implementing bioethics in hospital clinics, from organizing formal institutional forums all the way to case reflection groups supporting healthcare professionals and patients in their clinical-ethical decision making. Toward the end of the thesis, I will make the case for why I believe Finland would gain from the implementation of bioethics practices as well, embracing the example of the neighboring countries.

However, before moving on to the social scientific theory and methodology of the studies, it is important to note that bioethics builds on moral philosophy as its backbone. Therefore, I will next address some basic ethics concepts and theories to provide further theoretical context for the thesis.