Quantitative Unease

A column dedicated to demystifying psychotherapy research – love it, hate it, or both…at least try to know what it’s all about!

Navigating through Ethical Approval – A Journey through Winter Wonderland?

Christmas and scientific research share a faith that we can give birth to someone or something extraordinary by the power of an immaculate conception. Such belief demands obedience to this dogma of truth. I’ve downloaded the Ethics Pack and glance outside, where the blanket of snow is as white as the forms in front of me: “Study Description”, “Recruitment of Participants”, “Participant Information Sheet”, “Consent Form”. Praise the Lord that I can ski, so I know how to navigate through the unknown territory of consent, skilfully avoiding obstacles on the way.

Informed consent rests on the assumption that people are autonomous human beings, who have the freedom to make independent decisions. Does such wishful thinking reflect a desire for a quiet Christmas myth? As I start my journey through ethics, I feel like a storyteller of human mankind.

Ethics, the science of moral conduct, of what is right and wrong, the adherence to moral principles. Do I subscribe to Kant’s Ethics, an ethical rationalism, or to ethical relativism – whatever is good or bad is only so relative to a situation? Confucian Ethics or confusion?

‘Silent Night – Holy Night’, sings a voice on the radio. Christmas and Ethics are full of mystery. I’d like to run a depression group to show that group analytic treatment works. But the Code of Ethics doesn’t tell me much about ethical dilemmas in group settings. For example, “what happens when the group ends?” ‘Sleep in heavenly peace’, as the tenor suggests?

“No!” Classical religious tales don’t provide me with answers to this conundrum. Thankfully, Group Analysis does.  “I’ll offer individual sessions and attend to the after-effects of the group experience, if needed”, I write on the form. Despite the comforting familiarity with Group Analysis, dark clouds emerge on the horizon as I continue reading through the “Informed Consent” section.

I must inform my future participants of all “facts” that could influence their willingness to take part in my project. This includes information on procedures and purpose of my study, expected benefits, possible risks, alternative available treatments, my willingness to answer any questions and an instruction that they can withdraw consent and discontinue participation at any time. I must also orient my subjects to the group process and my techniques. They must understand my role as conductor and my expectations towards them. ‘Glories stream from heaven afar’, sings the tenor in the background, leaving behind any arising uncertainty and ambivalence.

The Ethics Committee has pointed out that no harm should come to my participants. Hence, I must put safeguards in place. That sounds straightforward until I ponder this. What will I do, if I assess a patient and find him unsuitable for my study? I couldn’t say “Thank you very much for having shared difficult experiences, but unfortunately I won’t offer you a place in my group, because your depression isn’t the main problem, you’ve an underlying personality disturbance.” Although true, this disheartening explanation could be harmful and, therefore, unethical. ‘Silent Night’ with its cultural norms doesn’t seem so idyllic anymore. Is it ethical to not offer this person treatment, knowing that he suffers? And what if my assessment will open old wounds? I avoid this abyss through diversion, by referring him to another group analyst.

‘All is calm …’ until one patient asks about the benefits of participating in my study. She wants a guarantee that she can forever wave farewell to her depression. The ethical landscape of my group isn’t as magical as Winter Wonderland and I’m not Mrs Miracle.

“I can’t make such promises”, I’ll admit to the patient. Disappointment washes over her worn-out face, because this truth goes together with disenchanted hopes for cure.

But Christmas is the time and story of love. So, I’ll say in cheerful optimism that the group could help. My tale of therapeutic success remains a bit vague and I only escape for one bitter-sweet moment. “It can’t make me worse, can it?” Her eyes express the fear we feel when we reminisce about a lost dream.

“It could, initially.” Aware of this possibility, I’ll have to explain to the Ethics Committee, too, that this wouldn’t be unusual. But they aren’t romantic relativists, will they understand that sometimes mental states get worse before they get better? The whole journey through ethical approval is starting to resemble a terrain that is about to be buried under an avalanche of doubt and uncertainty. Who will join my group? Will members get on or negatively affect each other? Even the Christmas Spirit couldn’t predict this at this moment in time. 

Hence, I know that I’m cheating, because I can’t really give my participants all the “facts”, when I’ll recruit them. Actually, I’ll never be able to do so. The Age of Ethics is making me more uneasy than the (quantitative) analysis. A tale of forbidden ethical practice, too difficult to comprehend. Anyway, I’ll return to this sublime part of my story at a later point to make it more palatable.

Unlike Group Analysis, Research Ethics isn’t a Christmas Carol I’m familiar with. It’s accompanied by ruthless scrutiny of my account of possible problems: difficult patients, drop-outs, anti-group phenomena, deterioration due to the return of the repressed and symptom displacement. I smile wryly whilst writing another paragraph of “ethical facts” on the “Participant Information Sheet”, maintaining a tone of lyrical truth.

It’s not unlike a Christmas story, where the course of the characters’ lives is determined by their chosen purpose. I choose my participants to show that group analytic treatment works and place their destiny in the group-as-a-whole. Hence, ethical principles remain mythical. Respect for autonomy, beneficence, non-maleficence, fidelity to promises made and justice. ‘Hallelujah’, I can hear the angels sing.

Ethical reasoning evokes a strange curiosity in me. Trying to understand the ethics of Ethics, I return to Moral Philosophy and Christmas Enlightenment.  What happens when ethical values become dis-ease? People aren’t autonomous in my analytic conceptualisations. This means that I can’t marry my personal and professional values.

Unable to see through the rose-tinted Christmas glasses, I’m wondering what to do. I could adopt a positive ethics philosophy that aims for the ideal. But I’m not an idealist, so I dismiss this option. Instead, I try to identify ways to integrate my values with professional standards.

What will I do if I’ll have more than eight suitable participants? How will I choose and what will happen to the rejected ones? “Research Ethics is complex”, I mumble and seek solace in the ‘radiant beams from the holy face’. There’re so many considerations. I regret that I’m not part of a multi-centre research group, which wouldn’t just make this thorny obstacle easier.

Another interested patient is profoundly deaf. According to the principle of justice, I shouldn’t discriminate and offer the group to all patients. Yet, I can see how isolated this person might feel and, therefore, try to think ethically about exclusion criteria. Suddenly, I find myself in the realm of utilitarianism, a theory that defines morality in terms of the benefits an action has for society. I can’t jeopardise the success of my group, because the study is beneficial for our society. That’s my mystical justification for excluding deaf patients. Somehow my story sounds less and less like a heart-warming Christmas tale. Nevertheless, the matrix of Research Ethics is gradually taking shape, although it looks like a treacherous slope.

“Will what I share in the group remain confidential?” ‘Heavenly hosts sing Hallelujah’. I’m neither the Messiah nor the Goddess of Justice and can’t force group members to adhere to confidentiality. Nevertheless, I’ll add a clause to the consent form that they must do, in the hope that it will create a safe atmosphere in the group.

Groups – the land of unlimited possibilities. Have I envisaged all imaginable obstacles? I’m trying to write a cheerful Ethics Novel until it meets suicidality. “I’ll follow procedure”, I state and explain what this means. Now my narrative reads more like a medication leaflet that all possible side-effects. Are these warning signs that my Ethics Story may not be able to deliver its Christmas wishes – that my group will be a success and the Panel will take my word for it?

Perhaps I should submit my ethics application on Christmas Eve. The Christmas magic may evoke the goodwill of the Committee. Like the Wise Men, they will decide that my Christmas Ethics Story is true, because I’d like to offer the reader an ending that says: ‘The stars are brightly shining. A thrill of hope the weary world rejoices.’ Am I an idealist after all? Be this as it may, right now navigating through ethical approval feels more like a journey through Winter Wonderland where one never knows what to expect.

Merry Christmas & Seasonal Greetings.

Dr Susanne Vosmer
s.vosmer@gmail.com