The nature of ethical conflicts and the meaning of moral community in oncology practice.

PURPOSE/OBJECTIVES To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH Ethnography. SETTING Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.