Unknown consequences of decision | Unable to determine or predict consequences of decision made, for example, predicting financial implications of decisions | Difficulty justifying decisions to public/patients/clinicians on the ground based on harms/costs versus benefits if unable to easily quantify these. Hard to make truly informed decisions |
Lack of evidence utilisation | Lack of evidence altogether or barriers to academic access Poor-quality evidence Lack of transparency surrounding evidence (for example, evidence not disclosed by other organisations) Limitations of biomedical evidence when applied to complex systems | Unable to make truly informed decisions |
Guidelines | Applicability of national guidelines to real life, for example, NICE recommends ‘best practice’ but in reality, often because of financial restrictions, only able to offer ‘restricted practice’ | Guidelines not applicable to current challenges and fail to address ethical issues Difficulty translating clinical guidelines into formal policy |
Lack of specific ethics tools | Lack of formal ethics guidelines or frameworks Available frameworks not applicable, too abstract, or involve too many complicating factors | Difficulty formalising decision-making process and identifying and addressing relevant ethical factors |
Inappropriate decision makers | Inappropriate, biased, or unrepresentative members steering committee decisions Incorrect or unrepresentative panel on CCG, for example, no clinicians, insufficient expertise | Not feeling able to justify position on board and therefore not able to justify their role and power in decision-making Implications for public accountability |
Inadequate time | Rushed decisions and ‘knee jerk reactions’, often worsened where this is lack of time for reflection and evaluation | Perceived uninformed and unethical decision-making and at times incorrect decisions being made Contributes to sense of moral unease as unable to reflect on decisions |
Lack of transparency | Non-transparent decision-making process Commercial factors and commissioning of ‘NHS’ services to private companies without involvement of public or clear explanation of role of private companies Information not provided to public Lack of general public and patient involvement Inappropriate patient and public involvement (for example, selective or unrepresentative) | Contributes to feeling of moral distress and unease |