What do we mean by conflict, and why does it matter?
Conflicts can unfortunately arise in healthcare, and can occur between (and within) a treating team, a patient, and those close to them. But what counts as a conflict is itself contested.
Some draw a distinction between a 'dispute' and a 'conflict'. Disputes tend to be short-term, negotiable, and amenable to resolution. Conflicts, however, tend to be longer-term, less negotiable, and may even be resistant to resolution.
The precise concept might be difficult to pin down, but it is evident that the presence of conflict can lead to sub-optimal or outright harmful consequences. Decision-making - and therefore the whole process of treatment and care - might stall, which could compromise the patient's welfare.
Others might also experience ill effects, besides the patient; conflict can leave a moral residue, with the result that clinicians (or, indeed, others) might experience burn-out and moral distress. So why might conflict arise and, when it does, how might it be addressed?
Why does conflict occur?
In our research, we have focused on intensive care, and specifically on treatment decisions made in the best interests of patients who lack the mental capacity or competence to make these decisions themselves.
In such cases, there may be various people and perspectives involved, including those from the multidisciplinary team, those close to the patient, and of course any views the patient might currently express or have previously expressed. Given the nature of the decisions to be made, including around providing or withdrawing life-sustaining treatment, the stakes can be high - and so too can the emotions of those involved.
Under such conditions, it is perhaps unsurprising that disagreements can sometimes arise. Looking to the wider literature on conflict, including studies of intensive care, it is apparent that the origins of conflict can vary.
Sometimes conflicts arise from a clash of personalities or from discrepant beliefs and values. On other occasions, the conflicting parties might have different expectations about the outcomes to aim for or how best to achieve them. And, sometimes, the conflict might arise from - or be exacerbated by - failures to communicate or work together effectively.
Returning to the intensive care unit, we appreciate that many teams and families will enjoy a harmonious relationship, despite the inevitable stresses of the situation. Yet, the law reports and international media confirm that conflicts arising from one or more of the above sources can sometimes lead the disputants to a courtroom. But is this always the right place to address conflicts?
How can we manage conflict when it occurs?
There are skills and competencies - such as communication skills - that can help to ensure that conflict is avoided. If, however, a conflict does arise, there exist various processes that can help to address and, ideally, resolve, the situation. Which processes are indicated, and when, is one of our research questions, and we hope in due course to make recommendations about the way(s) forward. For now, however, we will outline some of the existing options and note some of their respective pros and cons.
It is essential that the lines of communication are open between the team and the family. Meetings, such as 'best interests meetings', can help to identify and air any points of potential disagreement and, through discussion, prevent any escalation.
Studies suggest that consensus can often be reached, but such meetings are often physician led, with the outcome largely dependent on their communication skills. Unfortunately, some legal cases reveal how contentious (and even pejorative) terms are sometimes used in such meetings and notes.
For example, a clinician's reference to the 'futility' of treatment might generate hostility, because it risks conveying to the patient or their family that the team is giving up on the patient. Consider also the high-profile case of critically ill infant Charlie Gard, in which the judge remarked upon "an unfortunate email", in which a clinician stated, "parents are spanner in the works".
Labelling families as 'difficult' or 'problematic' may further jeopardise the therapeutic relationship, as this label may be carried forward by other members of the clinical team. A desire to avoid 'difficult' conversations may result in avoiding the family, or adopting a defensive approach during family meetings, which might in turn exacerbate the conflict.
Sometimes outside input will be indicated, such as recourse to second (or more) medical opinions. An independent view could help; as one judge has noted, this can serve the interests of patients and their families, by safeguarding "against errors in diagnosis and evaluation, premature decisions, and local variations in practice".
But the evidence suggests that external medical opinions do not always serve to resolve a conflict: the family might judge the external expert to be insufficiently independent of the treating team, or the team might be suspicious of the family's 'doctor-shopping' for a sympathetic ally.
Given the nature of the decisions to be made, including around providing or withdrawing life-sustaining treatment, the stakes can be high - and so too can the emotions of those involved.
If meetings and external opinions don't resolve matters, then mediation might offer a way forward. The courts have encouraged the use of mediation, including in high-profile cases like that of Charlie Gard, the critically ill infant whose parents sought treatment the clinicians were unwilling to provide.
Mediation has its advantages; the mediator is an independent third party, who may be viewed by each side as more impartial, and the mediation process is flexible, fairly inexpensive, confidential, and is designed to bring the parties together - rather than position them as adversaries.
However, mediation is not available everywhere. It also requires the parties to be willing not only to come together, but also potentially to shift their positions. There is, of course, no guarantee that even those who are willing to come together will change their minds.
Clinical ethics support services
An alternative to mediation is recourse to clinical ethics support services. These are familiar worldwide, and in the UK usually take the form of Clinical Ethics Committees (or Clinical Ethics Advisory Groups).
Like mediation, they are not strictly regulated as such, and are essentially informal advisory groups, comprising a variety of professional and lay perspectives. They have, notably, undertaken a great deal of valuable advisory work during the COVID-19 pandemic.
One obvious advantage is that these groups focus squarely on the ethical dimensions of the disputed matter - and experience suggests that they will often be approached to advise on the ethical complexities of working out where the best interests of a patient lie.
However, despite their promise, there are concerns about the remit, processes and composition of such groups, the competencies required of their members, and the evaluation of their activities, including in case consultation. Families might also consider such groups insufficiently independent or impartial, as they often work within hospital trusts.
Furthermore, they are also not available in every healthcare setting, and even where they are, their work is voluntary and unremunerated. As with mediation, there is also no guarantee that the group's advice will settle the conflict.
But there is one final forum that can decisively settle a conflict, because that is one of its key jobs - the law courts. The courts have rigorous, transparent processes, and will scrupulously examine all the evidence and opinions, as well as sometimes looking to the wider, ethical aspects of the contested matter.
But many query whether the courts are the right location for resolving such sensitive issues. The legal process can be adversarial, time-consuming, and both financially and emotionally costly. In summary, each of the options discussed above shows promise, but each also has its pitfalls.
Our research is ongoing, and we hope in time to provide signposts to different means of addressing, ameliorating, and ideally resolving conflicts in healthcare, whoever they are between and whatever their causes.
We would encourage further research in healthcare, beyond our focus on intensive care and best interests decisions, and we may also need to look again at prevailing cultures and attitudes. We are struck, for example, that clinicians reportedly view external mechanisms as a last resort - we have heard this comment applied to mediation, clinical ethics committees, and also the courts.
As we noted earlier, many clinical encounters have high stakes and can engender high emotions. Because of this, we should be prepared for conflict to occur, and equipped with the skills to anticipate and address it when it does.
The authors thank Louise Austin, whose prior work with Huxtable for the Nuffield Council on Bioethics informed this article. Huxtable and Johal are part-funded by the Wellcome Trust, and Huxtable's research is also funded by the NIHR and ESPCR.
The authors additionally serve on various local, regional and national ethics committees and related groups. The views expressed in this publication are those of the authors and not necessarily those of the funders, the Department of Health and Social Care, and/or the organisations with and for which the authors work.