To Örebro University

Healthcare is infused with values concerning what is important to patients and healthcare professionals and, thereby, ethics might seem to be inherent and self-evident. However, in clinical practice, ethics is elusive and difficult to articulate, and a gap persists between theory and practice. Thus, the overall aim of this thesis was to generate understandings about ethics close to practice by exploring doctors’ moral reasoning when caring for the patient.

The research design was qualitative and explorative. The phenomenon of‘moral reasoning’ was explored in 22 audio recorded ethical reflection groups (Moral case deliberation) (I), 27 interviews with UK consultants about their experiences of the complex decision-making process of initiating intensive care (II), 19 Swedish vascular surgeons in the outpatient setting (III), and observation and audio recording of 7 team conferences accompanied by 23 follow-up interviews with vascular surgeons (VI). The data were analysed by using content analysis, employing a phenomenological-hermeneutical method, and systematic text condensation.

A composite result of the four studies revealed moral reasoning as a proces sof balancing between promoting the patient’s best interests and the patients’ preferences, deliberating one’s moral responsibility in the patient’s care, and expanding understandings of complex situations through multiple perspectives. Moral reasoning is embedded in the clinical language, and the patient encounter emerges as the hub for these reasonings. As such, the patient encounter signifies carefully exploring the clinical details of the case to weigh conflicting values, to expand one’s understanding of the patient’s health and life beyond the diseases, and to explore the patient’s wishes for care. Meetings between doctors to discuss the patient’s care entailed learning by broadening their understanding of complex situations as well as balancing different perceptions to reach reasonable decisions. The doctors’ own security instanding in complex decision-making and critical situations can be facilitated through discussions with colleagues as well as meetings by expanding perspectives and generating new understanding of what is important in a clinical situation. The clinical implications of this knowledge are that ethics is a tangible part of doctors’ care of patients that needs continuous exploration and verbalizing as a means of maintaining quality of care, which is a moral obligation in itself.