Ethical deliberation in health: an integrative literature review

Working in the health field requires that professionals master means and tools for resolving the ethical dilemmas they face. We conducted an integrative review of the literature in health-related databases. We included original research articles, reports of experience, theoretical studies, case studies and editorials, in English, Spanish and Portuguese carried out with healthcare teams that included nurses. The review covered 28 studies, published between 1999 and 2013. The analysis yielded four categories: concept of deliberation; strategies of deliberation; contributions of deliberation, and facilitators of implemention of the deliberation process. We concluded that deliberation is a useful and relevant strategy for health teams in the analysis, assessment and indication of the best course of action in problem solving. It is also an instrument of continuing education for professionals through mutual exchange of experience and dialogue about values, beliefs and principles.


Resumen
Deliberación ética en salud: revisión integrativa de la literatura El trabajo en salud requiere que los profesionales dominen medios y herramientas para resolver los problemas éticos de la práctica. Este estúdio analisa el uso de la deliberación ética em la solución de los problemas éticos vividos por el equipo de salud. Hemos llevado a cabo una revisión integradora de la literatura en las bases de datos de salud. La revisión incluyo artículos originales de investigación, informes de experiencias, estudios teóricos, estudios de casos, editoriales, publicados en los idiomas inglés, español y portugués, realizados efocándo se em los casos de salud que contasen con enfermeros. La revisión incluyó 28 estudios publicados entre 1999 y 2013. Del análisis hemos extraído cuatro categorías: el concepto de la deliberación; estrategias de deliberación; contribuciones de deliberación y facilitadores de la implementación del proceso de deliberación. Se concluyó que la deliberación es una estrategia útil y relevante para los equipos de salud en el análisis, la evaluación y la indicación del mejor curso de acción para resolver los problemas éticos experimentados. También es una forma de educación continua para los profesionales a través del intercambio mutuo de experiencias y conversaciones acerca de los valores, creencias y principios en un ambiente ético de solidaridad y pertenencia. Palabras-clave: Deliberaciones. Ética. Bioética. Técnicas de apoyo para la decisión. Toma de decisiones. Revisión. The progress of biomedical science and of health practices has lead to increase and emergence of new ethical problems 1,2 . A conflict in the professional practice becomes an ethical problem when it compromises the conduct and reputation of the professional, when it compromises the interests and well being of the user and when the decision to be taken is nos clear, because several elements and interests are involved, being necessary to deliberate in order to reach the most adequate course of action 3 .
Ethical problems are challenges that count on several courses of action for their solution and management, requiring deliberation and consideration in order to find the best path to be followed, which, in turn, need to be continually reassessed 4 . Ethical problems cannot be resolved with ready-made recipes, requiring permanent creativity in a way to open new solution alternatives, considering the ethical excellence of the practice in health care.
The present study focus on the theme of ethical deliberation, which seeks to analyze ethical problems in context and in a systematized way, seeking concrete solutions among the prudent solutions. Prudence is expressed as the ability to value what is involved in ethical conflict, reaching reasonable decisions. This process entails a collective construction, which helps to reduce the uncertainty of professionals in ethical decision making 4 .
Ethical deliberation, as proposed in the model moral liberalism by Diego Gracia intends to find the best course of solution to each ethical case through the analysis of the problem in it whole complexity. This assumes the consideration of the situation and the comprehension of the conflicting values and the consequences involved, allowing for the possible courses of solution to be equated 5 . Consideration of the conflicting ethical values in the ethical problem aims to reduce uncertainty in order to reach a reasonable decision, that is, the most prudent, not only the most correct one 4 .
The present integrative review study intended to analyze the use of ethical deliberation in the solution of ethical problems experienced by the health team.

Methods
An integrative literature review -one of the broadest methods of methodological approach referring to reviews, which makes possible the comprehensive exploration of a certain subject, in order to identify the present state of the art and point out knowledge gaps 6 . This is a study with data collected from secondary sources through a bibliographic survey. In order to increase the rigor of the integrative review, the research followed six steps: elaboration of the guiding question, search in the literature, data collection, critical analysis of the studies included, discussion of the results and presentation of the integrative review 6 .
The guiding questions were: "What is the concept of deliberation?"; "What strategies of deliberation are used the most?"; "What are the contributions and facilities in the implementation of the deliberation process?". In order to answer these, online bibliographical searches were performed in the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL); Scientific Electronic Library Online, Web of Science (SciELO); Latin American and Caribbean health Sciences Literature (Literatura Latino-Americana e do Caribe em Ciências da Saúde -Lilacs); Medical Literature Analysis and Retrieval System Online (MedLine).
Data collection and analysis were performed between January and February 2014, separately by two researchers. Results were compared and disagreements were resolved by consensus; that is, the researchers confronted the results of the searches performed independently on the databases, checking for the differences in the findings, aiming to include the largest possible number of studies. MeSH/descriptors and subject keywords were: "deliberation"; "moral deliberation"; "ethical deliberation"; "ethics"; "bioethics"; "ethical challenges"; "ethical dilemmas"; "nursing ethics"; "decision making"; "moral decision". The same descriptors were used in English, Portuguese and Spanish. In order to assemble several search strategies with the insertion and withdrawal of descriptors and keywords, Boolean operators (and, or, not) were utilized. A reverse search was performed from the selected articles, that is, the reference of the reference.
Inclusion criteria were: original research articles, theoretical studies, reports of experiences and editorials in English, Spanish and Portuguese, focusing health teams that included nurses. No time limit was established. Exclusion criteria were: users as research subjects; studies with research designs or objectives poorly defined or little explicit; news stories; conjunctural analysis and protocol assessment studies; studies with health teams without nurses. The process of selection of the publications included is represented in Figure 1.
Data analyses and interpretation were performed through the procedures of systematic review in the literature 6 , with data reduction, visu- alization, comparison, conclusion and verification. In the stage of data reduction, subgroups were defined (concept, strategies, contributions and facilitators) in order to facilitate analysis; in the stage of visualization, a structured instrument was designed, in which information in the studies was registered, considering the guiding question; in the compari-son of data similarities and differences were found between results; in the conclusion the synthesis of important elements was performed in an integrated sum of the subject.
The final sample included 28 studies that were integrated in the review.
The selected studies were distributed between 1999 and 2013, with over 53% of them published in the last five years of the period.
The authors of the studies analyzed are teachers and researchers in universities, being: 50% from The Netherlands 7-12, 14

Concept of deliberation
The most used concept of deliberation, referred to in nine studies 4,5,20,21,23,25,26,30,32 is the one proposed by Diego Gracia 5 . This author describes deliberation as a process of consideration of values and duties involved in a certain concrete situation, in order to find the optimal solution or, when this is not possible, the least detrimental one. That is, deliberation has the aim to analyze different courses of action, seeking the most adequate or the least detrimental one, for the resolution of the situations of moral conflict, in a reasonable and prudent way. Deliberation was described as a process of self education, almost self analysis, providing transformation in the professional practice and attitude changes, allowing for ethical problems to be identified, interpreted and approached 30 .
The study 21 that uses the definition by Beauchamp and Childress 33 described deliberation as a decision-making process in which individuals or groups deliberate in order to specify and consider beliefs and values in a certain case to reach a conclusion. The essence of deliberation is to identify the different ethical values and the process of balancing these values in each case 13 .
The study 17 that characterizes deliberation according to the definition by Bridges 34 mentions the effort of professionals to discuss ethical issues in the thorough way possible, offering arguments based on the best evidence available 17 . Deliberation is collaborative, analytical, reflective and meticulous discussion of the group, focused on the careful analysis of the alternatives, points of view and choices made. The study 20 that approaches deliberation base don the understanding of Aristotle exposed in "Nicomachean Ethics", defines it as a fundamental procedure of ethics, which is a deliberative practice.
One of the studies 21 presents the view of philosopher and sociologist Jürgen Habermas 35 , to whom the deliberation process must take place in argumentative form, through the exchange of information among the people involved. Being inclusive and public, deliberation requires liberty and absence of external coercion, for all have to be equally heard. Deliberation will help professionals in dealing with ethical problems and to define good care based on a dialogic process 19 .
Two types of deliberation were shown in the studies: clinical and ethical 5 . Clinical deliberation is the one the health professional performs in the daily practice, in attending users. Ethical deliberation consists in the analysis of ethical problems every time the professional provides medical care to a user. The second is not so easy to perform because it requires that ethical problems be analyzed in all their complexity. Both may take place in the individual or in the collective scale 4,5,21 . In the collective scale, the professional deliberates with team members, users, or the user's family to make a decision; in the individual scale, the professional deliberates alone when he/she needs to make decisions based on his/ her own knowledge and experience 21 . However, the opinion of users and families must be taken into account in any deliberation process.
Ethical deliberation is the approach adequate to ethical problems in health care provided by multidisciplinary teams because it permits knowing the diverse experiences and perspectives of the people engaged in the process. Professionals use deliberation as a strategy in the search of the best course of action to answer ethical problems in daily practice 24 . Deliberation does not equal decision making 4,5 . For this reason, an individual or group of professionals different from the one that must make the ethical decision may deliberate on the case. An example of this are bioethical committees.
Collective deliberation may help the professional to recognize and perceive the possible courses of action; however, it is the professional who must face the case and, in practice, to make the decisions, since deliberation made by a group of professionals does not exempt the ones who experience the ethical problem from the responsibility of making decisions. Therefore, ethical decisions are considered nontransferable.
The concept of deliberation is similar in the studies analyzed: the professional recognizes a certain situation as an ethical problem and, collectively or individually, seeks the best way to solve the conflict; that is, the ethical problem only arises when the professional considers it so. Deliberation is the process of maturing decisions, aiming to reach a prudent course of action.

Strategies of deliberation
The deliberation strategies identified in the studies were: Diego Gracia's deliberation process; moral case deliberation; Nijmegen method; "CARE" model (considerations, actions, reasons, experiences); casuistry and principlism. The four strategies mentioned first have, as common aspects, the stages of case introduction, ethical problem identification, identification of the solution course and decision-making; casuistry and principlism are characterized by other aspects which will be explained later. There are several methods to structure the deliberative process 32 . The deliberation proposed by Gracia 5 , described in nine studies 4,5,20,21,23,25,26,30,32 , makes possible the resolution of many ethical problems, or, at least, their discussion or clarification. Diego Gracia's deliberative process include deliberation on the facts, values, duties and responsibilities 23  The tests for consistency of the decision correspond, respectively, to the questions: "Is this a legal decision?"; "Would you be prepared to defend the chosen course of action in public?"; "Would you get to the same conclusion a few hours or days later? " 5 . The decision considered the most prudent is the one that answers affirmatively to the three questions 23 .
It must be noted that the role of facilitator of the dialogue in this deliberation strategy may be assumed by a specialist in ethics or a health professional prepared to promote a sincere and constructive dialogue among participants. The function of the facilitator is to stimulate respect and understanding among professionals as well as articulate the several perspectives involved in the cases. The facilitator has to be able to cooperate in the inclusion of the different points of view and to stimulate the dialogic interaction among the professionals 20 .
In the moral case deliberation [7][8][9][10][11]15,16,19,31 a group of professionals meet to reflect systematically on a certain moral question om a concrete clinical case, coming from the practice 8,11,15,16,19 . Such strategy has the aim of allowing professional to reflect on the moral case; improve the quality of their service; discuss on the meaning of being a good professional and strengthen their moral competencies; reflect on institutional and organizational issues; improve the quality of their care 11,15,19 .
In this strategy, good deliberation combines content, process and perspectives 16 . Content relates to the formulation of the moral question. Process refers to the mutual listening of participants, with space for different opinions. Perspectives require the appreciation of the diversity of opinions of the participants, from the starting point of a concrete case, presented by any of the participants. Mediation of the deliberative process is done by the facilitator, who may be an ethics specialist or a professional trained for the task. Conversation is the basis of the method and, for this reason, the facilitator promotes constructive dialog among the participants, keeping focus on the moral dimension of the case and helping in the planning of actions, aiming at the improvement of the service provided 9,11,15,19 . It is similar, in the procedures, to the strategy proposed by Gracia.
One study 18 presented the Nijmegen method of ethical deliberation, which has the objective of structuring meetings of interdisciplinary teams in the process of decision-making. A specialist or trained professional acts as facilitator of the deliberation, which comprises four stages: 1) determination of the moral problem; 2) presentation of the facts; 3) identification of the values and norms involved; 4) decision-making. The Nijmegen method can be easily adapted to the different types of heath services 18 .
The CARE deliberation strategy -Considerations, Actions, Reasons, Experiences -proposes four questions to promote dialogue: 1) "What are the fundamental beliefs of the professional and how does he/she relate to the situation presented?"; 2) "How did the professional act when confronted with similar situations in the past?"; 3) "What is the opinion of the others about similar situations?"; 4) "What was the experience of others when confronted with similar situations?". In this model, the facilitator acts as educator, explaining the points of view of the parts involved through the ethical theories 12 .
Casuistry is a deliberative strategy 22,23,29 that analyzes the problems through ethical equation based on paradigms, analogies and opinions of specialists 23,29 . Its process is characterized by the organization of ethical cases by paradigms and analogies, appeal to maxims, analysis of circumstances, characterization of opinions, gathering of arguments and conclusion, in which the solution of ethical problem takes place. Casuistry involves the perception of cases and the application of ethical principles 22 , considering the scopes: 1) medical indications; 2) patient preferences; 3) quality of life; 4) context aspects. The method is also known as the four box method 22 .
The exploration of the four scopes allows for the understanding of the relevant ethical facts. For this, the analysis of the case starts by the preferences of the patient and by the quality of life, assessed according to the expectation of the patient returning to his/her habitual life. Context aspects regard Pinciplism refers to the process of decision-making in the field of health based on the respect to the principles of non-maleficence, beneficence, autonomy, justice 29 -principles considered prima facie. Principlists defend that decisions must contemplate such principles without ranking them. This method pays little attention to the singularity of the case and insufficient attention to the concrete circumstances having the principle, conceived in its abstract universality, applied to the particular case. When principles conflict, one cannot apply them mechanically; it is necessary to perform a survey of the particular elements that specify the direction and the reach of the principle to the singularity of the case in focus.

Contributions of the deliberation process
The deliberative procedure helped professionals to make consistent and argued decisions form the ethical point of view 30 . Benefits from the deliberation process reach the personal and professional spheres considering, in the latter, the whole multidisciplinary team (Table 1). Mutual Understanding and cooperation among professionals 7,10,12,28 Awareness of ethical questions 15,16 Strengthening of the dialogue among participants 7,15 Confidence to question and deal with ethical problems 11,30 Strengthening of the dialogue among participants 7,15 Recognition and discernment of ethical issues 10 Possibility of the educational process 21,28 Critical reflexion on ethical problems 7,11 Learning from other professionals 17,15 Relief from moral suffering 15,16 Establishing an ethical environment of reciprocity, solidarity and empathy 15 Decrease in frustration and anguish 15 A space to share experiences on a certain ethical problem 11 Aid in the recognition of solutions or answers to ethical problems 10 Useful and relevant for the daily practice 11 Development of moral competence 15 Motivation at work 10 Feeling of belonging to the team 8 The study with nurses in the psychiatric hospital showed that participants evaluated the practice as "positive" or "very positive" 10 . In the study with professionals of primary health care, participants felt safe to deal with situations of moral conflict and recognized that the ethical dimension is inherent to the clinical practice, encompassing the cases and values involved in the context.

Facilitators of the implementation of the deliberation process
Deliberation is an arduous task 21 , reason for which we searched, in the studies, elements that facilitated the implementation of this process in the practice of health professionals and institutions (Table 2).  Table 2. Facilitators of the implementation of the deliberation process Professionals Institutions Availability of participants to influence and be influenced by different arguments 21 Support of the management and engagement of the organization at all levels 8,9,16 Good will 21 Provision of time and space 9,16 Wish to understand, cooperate and collaborate 21 Absence of external constraints 21 Ability for ethical reasoning 21 Guarantee of good organizational conditions 11 Engagement of participants 15 Reflection, deliberation of issues 15 Commitment of the ones engaged in the process 21 Active listening by professionals 21 Respect to different opinions 21 Suspension of judgments during deliberation 19 The study 13 with nurses from Holland demonstrated the need for larger knowledge and communication abilities among professionals. It also showed the need to approximate the teaching of ethics to student practice during initial training. That is because the training conditions the ability of nurses to deal with ethical problems 13 .

Discussion
Despite the considerable increase in the numbers of publications on the theme in the last five years of the period considered, the integrative review showed that studies are limited to the areas of psychiatry, geriatrics and primary health care indicating, thus, the existence of gaps in the production of knowledge on the subject.
The quality of decisions making needs to be evaluated in terms of its conclusion, as well as its deliberation process 36 . Deliberation strategies are tools that make rational, systematized and objective analysis of ethical problems experienced in health services possible. With this, they facilitate the process of decision-making by professionals.
It is a challenge for health professionals to establish an effective process of reflection, discussion and consideration in order to find the best course of action for each problem. Such process involves subjective elements, beliefs, values, principles as well as technical knowledge 37 . Deliberation, as this review shows, is the tool proposed by bioethics for decision-making, as it contributes for professionals to act with prudence and responsibility in a context of uncertainty 38 .
In decision-making, the deliberation process allows professionals to show the gaps in understanding a certain ethical problem, perceive the differences in values among participants and, thus to enrich their view of the world with new perspectives. The more perspectives the professionals integrate, the higher the probability of the decision being prudent and reasonable 39 . The results indicate that the facilitator has the role to coordinate the conversation in a way to permit the dialogue among different points of view of the participants.
The prudent decision does not require unanimity of the team. For this, to get to the most prudent course of action among several possible, the deliberation process is not performed based on quantitative reasoning, but through argumentation. The adoption of a systematized strategy for deliberation may improve the quality of decisions because, as found in the review, professionals feel more confident to deal with ethical problems when they resort to the more comprehensive and deeper approach to the situation, which allows the recognition and discernment of ethical questions involved in practice. A decision process with ethical criteria that considers the values and du- ties involved, not just intuition is established 36 . Making prudent decisions involves questioning the uncertainty, recognizing the special circumstances of the case and predicting the possible consequences.
It is common for professionals to assume that their decisions are the best to implement deliberation. That is the reason why they need to be open and willing to change their standpoints based on arguments and in the respect to different opinions. This way, deliberation becomes an educational process, a space to share experiences, beliefs and values in an atmosphere of reciprocity, solidarity and empathy. It is practical, relevant and motivating for the health work.
Results show deliberation as a space destined to keep permanent educational processes in ethics, aiming at the development of practical abilities, ethical competence and sensitivity to conduct process of reflection, discussion and prudent and resolution of ethical problems. Continued education promotes transformations in professional practices and is based on critical reflection on the work process. In this sense, initiatives for continued education of nurses need to be capable of calling professionals to reflect on their work process and on the moral questions related to it, looking at the broadening of their ethical horizons.
The strategies found in this review show similarities in the stages of their procedures. However, they differ in the ethical process for the definition of the best course of action. The deliberation criterion is prudence, after the analysis of facts, values and duties. Principlism is the strategy with the highest weight after consideration and specification of the principles case by case. Casuistry will follow the accumulated experience of previous similar cases balancing the opinion of specialists and conjunctural and life quality aspects, to contemplate the best medical indication and the preferences of the patient.
Meta-analysis 36 performed in 2012 on ethical decision-making models also got to five steps in the process: 1) collection of previous information, including the perception of an ethical problem; 2) collection of information; 3) post collection of information, including the identification of the ethical problem; 4) identification and analysis of alternatives of action; 5) selection of an alternative, with justification and decision. It was also perceived in the meta-analysis that, more than the method and its stages, what matters is the availability of the people engaged and the institutional conditions that ensure the availability of time, space and an organizational atmosphere that encourage dialogue, mutual cooperation and understanding, for people to join the deliberation.
Results of the present review show that the dialogue is the base for discussions and reflections on ethical problems. In a dialogue, people argue, show their comprehension of ethical situations and listen to different interpretations of the situation, enriching themselves 40 . Dialogue is the learning process in which participants develop a more complete and comprehensive understanding of their practice. This way, the deliberation process contributes to the improvement of the performance of the professionals involved. Deliberation is a process of self education to the extent that education is acquired spontaneously, as well as a process of self analysis in allowing professionals to know themselves, to perceive their beliefs and values and, to a certain extent, deliberation also acts as a space of reflection, as found in this review 22 .
Besides the conditions to deliberate well, it is important that these extend to the implementation of the actions, putting in practice what was deliberated as an optimal course of action. In reducing frustration and anguish, and in strengthening the feeling of belonging to the team, deliberation may contribute to minimize the negative effects of ethical problems, such as moral suffering and stress. With this, inter-professional relationships are improved.
Moral suffering is a serious problem that, as it affects health professionals in different contexts, may generate feelings of dissatisfaction, physical and emotional symptoms, fatigue, professional turnover in the service and even abandonment of the profession, negatively impacting the quality of health care 41 . On the other hand, deliberation promotes a positive ethical atmosphere as it allows professionals to engage in a reflection process that helps them deal better with ethical issues, bringing positive results for themselves in the prevention or reduction of moral suffering, and for the patients, with an improvement in the quality of health care, and for the institution in terms of efficacy and results.

Final considerations
Deliberation is an adequate method for professional use in different types of health service for it allows ethical decisions to be taken in a systematized way, through a deep comprehensive approach of ethical aspects involved in the situation to be resolved. It may be used in different health scenarios, to the extent that it starts from the presentation of a concrete health case including the context in which it happens. For being an adequate approach to Ethical deliberation in health: an integrative literature review http://dx.doi.org/10.1590/1983-80422015231052 the complexity of ethically complex situations and for considering specific circumstances of each case, deliberation decreases the uncertainty of professionals in ethical decision-making and increases the accountability of multi-professional teams in this aspect. Deliberation involves the collective construction of a certain course of action through a joint shared process of dialogue and reflexion, discussion and consideration of facts, beliefs, values and principles involved in ethical questions.
However, as pointed out by the literary review, for the effective implementation of deliberation as part of the work process of professionals and teams, management support is necessary, providing time, place and conditions for the meetings of the teams to discuss the cases. Management also has to be participatory in order to engage professionals in the construction of dialogic and interactive processes that permit identifying the way to make possible the insertion of deliberation in the daily routine of health services. The deliberative process requires professionals and management to guide their actions by the desire to understand, cooperate and collaborate in decision-making with good will, argumentation and openness to change or enhance views and opinions.
The diverse strategies for deliberation identified have stages in common: introduction of the case, identification of the ethical problem, indication of the most adequate solution to the case and decision-making. The latter is always the responsibility of the professionals, not of the bioethics committees, whose role is simply to assist the multidisciplinary teams in the analysis of cases and definition of the optimal procedures to solve the ethical problem.
Deliberation is characterized by the integration between the practice and training of the individual and the team. This is essential, since ethics is not dissociated from the work; it is in the routine of health services that professional experience and have to solve ethical problems. If you can attach ongoing training to the routine, the deliberation will further benefit both professionals and the institution. The review pointed out that this is possible, in that the professionals recognize that the deliberation promotes mutual learning among them, for creating, in the work, a space to share experiences, anxieties, frustrations, besides increasing the motivation and the sense of belonging.
Thus, deliberation proves to be both means and instrument for the systematic management of ethical problems, working as a means of continuing education that assists in the development of competence, ethical sensitivity and critical and dialogic skills necessary to lead to reflection, discussion and prudent and ethically-responsible resolution of ethically problematic situations.