letter to editor
concerning submitted paper to BMC Medical Ethics: 1691029874134662
Title of the paper: “How do health care professionals in mental health care deal with ethical
challenges related to the use of coercion? A focus group study”
Oslo, the 27th of October, 2014
Dear editor,
We are grateful for the positive and constructive comments of the two reviewers.
We are grateful that reviewer one, prof.dr. Stella Reiter-Theil, writes that this is an ‘interesting
topic’ and ‘an article whose findings are important to those with closely related research
interests’.
We are happy that reviewer two, dr. Rouven Christian Porz, thinks that this is a ‘highly
interesting paper’, ‘innovative research’ and that he thinks that this paper ‘can (and should)
be published like that’. We are also happy that he thinks that the theme of our research
(defining what ethical challenges are and describe how health care professionals deal with
them) is often overlooked. Finally, we were honored that this reviewer thinks that this paper
is ‘of outstanding merit and interest in its field’
Below we will respond to the specific comments to the reviewers (in italics) and indicate how
we addressed the comments in the resubmitted paper. Changes in the resubmitted paper are
in yellow.
We think this paper has been further improved by taking into account the comments of the
two reviewers. We are looking forward to receive your response.
Yours sincerely,
On behalf of the co-authors Marit Helene Hem & Reidar Pedersen,
Bert Molewijk
(bert.molewijk@medisin.uio.no)
Center for Medical Ethics (HELSAM)
University of Oslo, Norway
Reviewer(s)' Comments to Authors:
Reviewer: Prof.dr. Stella Reiter-Theil (1825273621439235)
1. Please shorten redundant parts of text, esp. regarding quotes and descriptive
text referring to these quotes (without giving additional information).
We have reread the paper and have deleted some redundant parts of the texts
thereby using blue marks.
2. Please formulate clear and explicit categories of what participants called
"ethical challenges" - or understood by them. Otherwise, the empirical basis of
this central topic remains too vague, esp. as it is emphasized how diverse the
participants' answers were.
We think this is an important and useful comment. Therefore we wrote an
additional part in the seventh paragraph of the Discussion section (as from line
568) in order to formulate clear and explicit categories of what participants
called ‘ethical challenges’.
3. In the discussion about what researchers (other authors) have called "ethical
challenges, you should add references where triggers for requesting ethics
support (ethics consultation) are articulated. For example, in > 'The Freiburg
approach to ethics consultation: process, outcome and competencies' ReiterTheil 2001, Journal of Medical Ethics, you will find 4 basic categories that
seem to be helpful; see p. 199, last paragraph. (This is the first mention of the
categorization that has been developed / referred to in further papers.)
We did an additional check for references from other authors related to ‘ethical
challenges’ and inserted some extra references in the Discussion section
(DuVal et al 2001JME; 42 & Reiter-Theil 2001JME; 43).
4. Please edit the language of the text.
We edited the language of the text again, we clarified the present and past
tense (see Reviewer Porz, point 1) and we asked for an additional language
check for the whole paper by a native English speaker.
5. It is a merit to articulate weaknesses of a paper. However, the authors
neutralize their self-criticism by calling the same aspect (weakness) a strength.
The reviewer considers the decision of not offering a definition (understanding)
of "ethical challenge" to the participants beforehand, rather a weakness than a
strength; the study apparently did not work with the arising uncertainties or
discrepancies of understanding in the sense that participants were interviewed
towards further developing their concepts in order to increase clarity of
consistency ...
We recognize the reviewer’s consideration that not offering a definition
(understanding) of ‘ethical challenges’ to the participants can be understood
as a weakness, like we already wrote in the ‘limitations and strengths’ section.
Still, we think that it was worthwhile to first explore how participants thought
and talked about ethical challenges ‘naturally’, without a definition from our
side. This resulted in a rich and varied harvest. We think this lacked in the
literature so far, in particular related to the use of coercion in mental health
care.
We strongly agree with the reviewer that it is necessary and worthwhile to
further develop the participants’ concepts in order to increase clarity and
consistency. This was one of the aims of the larger study indeed. However,
within this first part of that larger study we tried to focus on what the
participants themselves presented (at the beginning of the implementation
project). Later on in that implementation project, both when we as researchers
gave our presentations on ethics and ethics reflection groups, and when we
trained health care professionals as facilitators, we developed these concepts
explicitly with these participants. We have clarified this point further in both the
Methods section and the ‘limitations and strengths’ section.
As the respondents were not very articulate about ethical content in the narrow
sense, it is desirable that the authors instead give some more insight on how
they reconstruct / reformulate the ETHICAL (in the strict sense) quality of the
challenges.
We agree with the reviewer that it is worthwhile and relevant to give more
insight in how we as authors reconstruct and reformulated the ethical quality of
the challenges. We therefore added our temporarily formulation of the
categories which the participants described as ethical challenges in the last
part of the Discussion section.
Reviewer: Dr. Rouven Christian Porz (1020542341395203)
1. As discretionary revision, the authors might consider an additional language
check. I sometimes got confused in the change of present/past tense, but
these are just minor language issues.
We edited the language of the text again, we clarified the present and past
tense (see Reviewer Reiter-Theil, point 4) and we asked for an additional
language check for the whole paper by a native English speaker.