Open Access Open Badges Research article

Outcomes of Moral Case Deliberation - the development of an evaluation instrument for clinical ethics support (the Euro-MCD)

Mia Svantesson12*, Jan Karlsson13, Pierre Boitte4, Jan Schildman5, Linda Dauwerse6, Guy Widdershoven6, Reidar Pedersen7, Martijn Huisman8 and Bert Molewijk67

Author Affiliations

1 Centre for Health Care Sciences, Örebro University hospital and School of Health and Medical Sciences, Örebro university, Örebro, Sweden

2 Karlskoga Hospital, Karlskoga, Sweden

3 Department of Medicine, Örebro University Hospital, Örebro, Sweden

4 Centre of Medical Ethics, Department of Ethics, Catholic University of Lille, Lille, France

5 Institute for Medical Ethics and History of Medicine, NRW Junior Research Group “Medical Ethics at the End of Life: Norm and Empiricism”, Ruhr-University Bochum, Bochum, Germany

6 Institute for Health and Care Research,VU University Medical Center and Department of Sociology, VU University, Amsterdam, Netherlands

7 Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway

8 Department of Epidemiology & Biostatistics and the EMGO, Dep. Medical Humanities, Vumc & Emgo, Amsterdam, Netherlands

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BMC Medical Ethics 2014, 15:30  doi:10.1186/1472-6939-15-30

Published: 8 April 2014



Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers’ experiences and perceived importance of outcomes of Moral Case Deliberation.


A multi-item instrument for assessing outcomes of Moral Case Deliberation (MCD) was constructed through an iterative process, founded on a literature review and modified through a multistep review by ethicists and health care providers. The instrument measures perceived importance of outcomes before and after MCD, as well as experienced outcomes during MCD and in daily work. A purposeful sample of 86 European participants contributed to a Delphi panel and content validity testing. The Delphi panel (n = 13), consisting of ethicists and ethics researchers, participated in three Delphi-rounds. Health care providers (n = 73) participated in the content validity testing through ‘think-aloud’ interviews and a method using Content Validity Index.


The development process resulted in the European Moral Case Deliberation Outcomes Instrument (Euro-MCD), which consists of two sections, one to be completed before a participant’s first MCD and the other after completing multiple MCDs. The instrument contains a few open-ended questions and 26 specific items with a corresponding rating/response scale representing various MCD outcomes. The items were categorised into the following six domains: Enhanced emotional support, Enhanced collaboration, Improved moral reflexivity, Improved moral attitude, Improvement on organizational level and Concrete results.


A tentative instrument has been developed that seems to cover main outcomes of Moral Case Deliberation. The next step will be to test the Euro-MCD in a field study.

Clinical ethics; Clinical ethics support; Ethics consultation; Moral case deliberation; Ethics rounds; Health care providers; Questionnaire; Instrument development; Evaluation