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Ethical preparedness in health research and care: the role of behavioural approaches | BMC Medical Ethics

Public health scholars have long called for preparedness to better help negotiate ethical issues that emerge during public health emergencies [1,2,3,4,5,6]. Being ethically prepared for a public health emergency is viewed by some to be just as important as being prepared to acquire resources, such as personal protective equipment [7]. Scholars have argued that by applying various values and principles, such as openness, transparency, and accountability, ethical issues can be anticipated, identified, and addressed in public health emergency decision-making [1, 4]. Furthermore, by providing the moral language to describe and resolve situations in which values conflict during an emergency, this can provide ethical legitimacy to the policy decision-making processes [2, 8]. A lack of such preparedness has been perceived to lead to low levels of trust and morale in pandemic situations, as well as fear and misinformation [6]. It may also leave the public vulnerable to unequitable and ‘regrettable’ decision-making by governments and health providers [9], especially when rapidly changing situations make routinised decision-making difficult [10].

We argue that the concept of ethical preparedness has much to offer other areas of health research and medicine in addition to public health emergencies, particularly where rapid technological developments have the potential to transform practices. This is because health researchers and healthcare professionals need to be prepared, i.e., expectant and ready, to face new challenges born of the complexity, uncertainty and longevity of technologies and their implementation into health contexts, and it is vital that they do so in ethically appropriate ways.

In this paper we problematise the concept of ethical preparedness in the literature to date, which mainly constructs the concept as a need to develop frameworks and principles [2, 8, 11,12,13,14,15,16]—exceptions include Leach et al. [17] and Coggon et al. (2017), or refers to it as ‘legalistic’ [18], or ‘bureaucratic’ processes. Such processes are insufficient as a proxy for ethical preparedness and do not ensure the implementation of ethical decision-making in practice [11, 13, 14, 17, 19]. This is because ethics is also about the ethical questions that are faced by individuals in their day-to-day practices [18]. Ethics is situated and contextual: it might draw upon laws and guidance but will likely require knowledge of particular factors in a specific situation (situated knowledge) to be enacted, and which in turn can sometimes reveal the deficits of a framework or policy.

We experiment with the concept of ethical preparedness by shifting it away from one that involves the development of principles and frameworks. Rather, following Leach et al. [17], we view the process of ethical decision-making as something that is enacted by a person, group or organisation, i.e., a behaviour. Being ethically prepared therefore means establishing settings that make it more likely for a person, group, or organisation to adopt ethical decision-making behaviour. Importantly, ethical preparedness is not about the outcome—and says nothing about how such moral decisions can or should be made, nor on the basis of what values and/or principles—but rather it allows us to consider how we can promote factors which support the ethical decision-making process in a particular setting.

To do this, we turn to behaviour change and implementation models. Such models are designed to identify what attributes are required for the implementation of certain behaviours into practice. Behaviour change can be targeted at individuals, groups, organisations, and at a societal level, but it will always be individuals doing the behaviour, even when targeting an organisation. We use these models to understand what attributes affect the setting in which the behaviour of the ethical decision-making process is occurring, and then include these attributes in our conceptualisation of ethical preparedness. Specifically, we draw on the COM-B model because it has been systematically developed as an overarching framework (Theoretical Domains Framework (TDF)) combining 33 theories to conceptualise factors affecting implementation in practice. The COM-B model is widely accepted in the field of behaviour change [20].

Next, we apply the COM-B model to two illustrative case studies: if we view ethical preparedness as being a setting which promotes a person, group or organisation’s ethical decision-making behaviour, then to understand particular attributes within particular settings requires in-depth empirical analysis of contextualised cases. This can provide answers to the question ‘what could have been done better?’ in situations where ethical preparedness was lacking or limited in practice. It can also provide a forward-looking empirical model to study future cases and understand what would have been required to be ethically prepared in any specific context.

In applying a behavioural model approach, we do not aim to provide a reductive list of influential factors. We recognise that behaviour is the result of a complex interrelationship between a self and others, affected by various social, cultural, resource, political (and other) factors that interact at the micro, meso and macro level (see, for example, the ‘ethics of care’ literature). Though we emphasise that COM-B aims to encapsulate these factors (see below and Table 1) and allows us to group them with an understanding that the categories are interrelated and overlapping; and that sometimes some factors will be more prominent and important than others. These groupings make for more manageable understandings, which allows us to articulate and discuss across disciplines, and in a way that permits for a clearer understanding of ethical preparedness.

Table 1 Definitions of behaviour and each element of the COM-B model [22]

Below, we first describe the COM-B model and how we have drawn on the model to conceptualise our definition of ethical preparedness, we then present our case studies.

The COM-B Model

Central to the COM-B model is that for a behaviour to happen, a person, group or organisation must have the capability and opportunity to perform a behaviour, as well as sufficient motivation to perform it above the motivation to perform other behaviours (Capability, Opportunity, Motivation = Behaviour model; Fig. 1) [21]. Figure 1 shows the elements of COM-B and the six sub-elements: physical capability, psychological capability, reflective motivation, automatic motivation, physical opportunity, and social opportunity.

Fig. 1
figure 1

The Behaviour Change Wheel—at which COM-B is at the centre (see Fig. 2)—was developed by Michie, van Stralen and West in 2011. Each element of the COM-B model can be subdivided into theoretical domains (TDF), a more fine-grained version of the COM-B model (see Fig. 3 [23]). Specifically, capability encapsulates the domains of skills, knowledge, memory and behavioural regulation; opportunity includes social influences and environmental context, such as the wide range of social, religious, cultural, political, policy, and/or professional factors that were described above; and motivation includes emotion regulation, identity, beliefs in capability, goals, and beliefs about consequences (see Table 1). Together, these three domains cover a range of individualistic, social, and political factors functioning at the micro, meso, and macro levels. As Fig. 1 shows, both capability and opportunity can influence motivation, and motivation can influence capability. This means that the influences on a behaviour from the social domain can govern which competing motivations drive the performance of a behaviour (or not). The COM-B/TDF model has been used to explore issues similar to the cases we discuss below, such as the barriers and facilitators to mainstreaming genetics and genomics [24] and implementing crisis standards of care during the COVID-19 pandemic in acute care hospitals [25].

Fig. 2
figure 2

The Behaviour Change Wheel [22]

Fig. 3
figure 3

Theoretical domains framework (yellow circle) linked to COM-B (green circle) [26]

The COM-B model facilitates the understanding of a behaviour in context, which then allows for intervention. COM-B is at the centre of the wheel in green, with intervention functions in red and policy categories in grey. Each layer links to the next, for example, psychological capability can be achieved through education, training, and enablement interventions. Policy categories and intervention functions also link, meaning education can be achieved through policies regarding communication/marketing, guidelines, regulation, legislation, and service provision.

Ethical preparedness

Applying COM-B/TDF to our articulation of ethical preparedness, an individual—including individuals who are part of groups, or organisations by way of an organisational culture—needs to have the capability, opportunity and motivation to be ethically prepared. We define ethical preparedness as having the capability (ability), opportunity, and motivation (willingness) to anticipate and identify ethical issues and to be able to implement ethical decision-making in practice. Capability refers to how individuals can be ethically prepared in health research or healthcare. This could be in the form of guidelines but also refers to the skills to be ethically aware, sensitive, and reflective. This might be realised through training courses, multidisciplinary meetings, or through spontaneous ethical thinking for which individuals have capability. Opportunity refers to the social, political, cultural, and organisational factors within health research and/or care settings that allow ethical preparedness in practice. Finally, even with ability and opportunity, ethical preparedness could be absent if there is a lack of motivation. For example, a healthcare professional or researcher may choose not to follow-up a potential ethical issue that arises during practice, rationalising that it falls outside of their responsibility and that to do so would require [too much] time and effort on their part.

In the following, we apply our conceptualisation of ethical preparedness to two case studies from our own empirical research.


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