Experiences with remote ethics consultation: a qualitative study with ethics consultants in Germany

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Sakowsky, Robert Ranisch, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7261781/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Feb, 2026 Read the published version in BMC Medical Ethics → Version 1 posted 13 You are reading this latest preprint version Abstract Background The use of remote methods such as video conferencing has the potential to improve access to ethics consultations, particularly in outpatient and rural healthcare settings. Although their use has increased significantly since the COVID-19 pandemic, little is known about ethics consultants’ experiences with remote consultations so far. Methods We conducted three focus groups with 14 certified ethics consultants in Germany in October 2024 to investigate their experiences with and attitudes towards remote ethics consultations. The data was analysed using structuring qualitative content analysis according to Kuckartz. Results Participants reported experiences with a range of remote methods, including email, phone, and video-based ethics consultations. Video conferencing was primarily used when in-person meetings were not feasible. Attitudes towards video-based consultations varied, and consultants with more experience with this technology tended to view it more favourably. Reported advantages included improved accessibility, especially in rural areas, easier scheduling, and the ability to involve additional stakeholders. Disadvantages included technical challenges and concerns about privacy. Participants reported that video-based ethics consultations reduce non-verbal communication and emotional expression. According to some, this made video consultations more structured and egalitarian, while others found this disadvantageous. Participants emphasised the need for specific preparation for video-based ethics consultations, such as ensuring adequate technical set-up or assigning roles to monitor emotional dynamics. Possible challenges regarding the involvement of patients and relatives in remote consultations were noted. While some participants viewed remote formats as more suitable for less emotionally intense cases, others saw no inherent limitations regarding consultation topics. Conclusion Our findings indicate that ethics consultants regard video-based remote consultations as a viable alternative when in-person meetings are not feasible. The study identified specific communicative challenges that should be addressed in training for ethics consultants. Further research is needed to explore the perspectives of patients and relatives on remote ethics consultations. clinical ethics support ethics committees moral case deliberation digitization digital communication video conferencing Introduction Ethics consultations provide support in identifying, analysing, and resolving ethical issues in healthcare settings, with the aim of improving patient care ( 1 , 2 ). In hospitals, they are usually provided by clinical ethics committees, which offer consultations for specific cases upon request ( 3 ). Consultations are most commonly requested by healthcare professionals, but can also be initiated by patients, relatives, or legal representatives ( 4 , 5 ). They are moderated by individual ethics consultants or by several members of the clinical ethics committee and can involve members of the treatment team, patients, legal representatives, and/or relatives ( 6 ). A variety of methods for conducting ethics consultations have been developed ( 2 ). Common approaches include gathering relevant facts about the case, hearing the perspectives of all involved parties, identifying possible courses of action, and providing recommendations based on ethical reasoning ( 1 , 2 ). In Germany, clinical ethics committees have been established since the 1990s, and are now present in most hospitals ( 7 – 11 ). Next to ethics consultations, the tasks of clinical ethics committees include developing institutional ethical guidelines for hospitals, delivering ethics education for staff and advising hospital management on ethical questions at the organizational level ( 12 ). The German association for medical ethics, the Academy of Ethics in Medicine (AEM), sets national standards for ethics consultation and certifies consultants at three competency levels ( 5 ): “Ethics Consultant in Healthcare” (level 1), “Coordinator for Ethics Consultation in Healthcare” (level 2), and “Trainer for Ethics Consultation in Healthcare” (level 3). More recently, outpatient clinical ethics services have emerged in Germany, which offer ethics consultation outside hospitals - for example in nursing homes and for general practitioners ( 13 ). The significance of these services was highlighted by a recent statement of the Central Ethics Committee of the German Medical Association, which called for their increased implementation ( 14 ). Unlike clinical ethics committees, these services are independent entities that provide ethics consultations to various institutions within a region ( 8 ). Many outpatient ethics services have developed out of palliative care structures (13), and their numbers have steadily increased over the past decade ( 15 ). They primarily rely on the voluntary work of their members ( 8 ). Outpatient ethics consultations often involve coordinating participants from diverse groups and settings – such as relatives, general practitioners, nurses, and nursing home representatives. Given the time-sensitive nature of many ethical conflicts in healthcare, organising ethics consultations promptly is essential. This urgency compounds logistical challenges, especially in rural or large geographic areas with a low density of healthcare professionals and trained ethicists ( 13 ). Remote formats - via email, telephone, or videoconference - could offer a solution to help address these challenges. A recent survey highlights the demand for increased availability of ethics consultation via telephone among general practitioners ( 15 ). Next to the outpatient context, remote formats can also help provide ethics consultations to hospitals without their own clinical ethics committees, particularly in rural areas ( 16 ). Moreover, clinical ethics committees can also use remote formats to involve additional stakeholders or to comply with contact restrictions. Internationally, first experiences with remote ethics consultation have been reported ( 17 – 19 ). In Germany, both clinical ethics committees and outpatient clinical ethics services made initial experiences with video-based consultations during the COVID-19 pandemic, although remote formats have not yet been widely implemented. Generally, the COVID-19 pandemic increased the demand for remote consultations ( 20 ), especially video-based formats, across healthcare settings. Initial research has examined the effects of remote consultations in different settings ( 21 ), attitudes and acceptance ( 22 ) as well as changes in communication between in-person and remote interaction ( 23 , 24 ). However, no study to date has explored the perspectives of ethics consultants on the specific challenges of conducting ethics consultations online. Therefore, the goal of this qualitative study was to gather ethics consultants’ experiences with and attitudes towards remote ethics consultation formats in Germany. By identifying practical benefits and obstacles, our findings aim to inform best practices for remote ethics consultation, guide targeted curricula, and clarify when remote formats are most appropriate. Methods Study design We conducted a focus group study with clinical ethics consultants to explore their experiences with and attitudes towards remote ethics consultation. We chose a focus group format to facilitate an in-depth exploration of participants’ views regarding this underexplored topic, while allowing participants to build on each other’s ideas and express contrasting views. We followed the standards for reporting qualitative research proposed by O’Brien et al. ( 25 ). Researcher reflexivity Our research team combined expertise from medical ethics, medicine, philosophy, theology and health economics. Several team members were certified ethics consultants who had experience conducting ethics consultations remotely and were involved in establishing an outpatient clinical ethics consultation service for the German state of Brandenburg. The results of the study were also intended to inform the development of this service. Participant selection We sent invitations to participate in the study via email to relevant mailing lists and to representatives of organizations for outpatient clinical ethics consultation in Germany. Ethics consultants with an interest in or experience with remote clinical ethics consultations in the inpatient or outpatient context were eligible for participation. We used purposive sampling and aimed for diversity of participants with respect to gender, age, level of experience and certification. Participant characteristics A total of 14 ethics consultants participated in our study. All were certified ethics consultants according to the standards of the AEM, the professional society for ethics in healthcare in Germany, holding qualifications at level K1, K2, or K3 ( 5 , 26 ). Their experience with ethics consultations ranged from 1 to 27 years, and their ages ranged from 30 to 69 years. 7 participants identified as male and 7 as female. Data collection We conducted three focus groups with 4–6 participants each via videoconference (Zoom) in October 2024. The focus groups lasted between 79 and 94 minutes (mean: 88 minutes) and were moderated by EB, JH, and RS using a semi-structured discussion guide (an English translation is provided in the online supplement). While the discussion guide included questions on both outpatient clinical ethics services and remote ethics consultation, this manuscript focuses exclusively on the latter topic. We created audio recordings of the focus groups, which were initially transcribed with the software noScribe. A student assistant checked the initial transcription against the audio recording and corrected the transcripts, and EB pseudonymized the transcripts. Data analysis The data was analysed with the software MAXQDA 2024 using structuring qualitative content analysis according to Kuckartz (27). The coding system was developed both deductively, following the questions from the discussion guide, and inductively, based on the content of the focus groups. All transcripts were coded by EB and one other researcher (FF or JH) to ensure inter-rater reliability. Discrepancies were discussed in team meetings among all authors until consensus was reached. Ethical considerations All participants received information on the study in writing and verbally, and had the opportunity to ask questions. They gave verbal and written informed consent prior to participating in the focus groups. Ethical approval for the study was obtained from the Research Ethics Committee of the University of Potsdam (registration number 69/2024). Results Five themes emerged from our analysis: 1) experiences with different forms of remote ethics consultation, 2) attitudes towards remote ethics consultation, 3) advantages of remote ethics consultation, 4) disadvantages of remote ethics consultation, and 5) differences between in-person and video-based ethics consultations. In the following, we describe these themes and present representative quotes from the focus group discussions, which were translated from German to English by EB. Main advantages, disadvantages, and learnings regarding remote ethics consultations are summarised in Table 1 . Experiences with different forms of remote ethics consultation Participating ethics consultants reported on experiences with different forms of remote ethics consultation via email, telephone, and videoconferencing. Participants stated that they frequently conducted short consultations via telephone, which was described as the most common form of remote consultation. These often resolved the initial question, so that a full ethics consultation did not become necessary: And then the initial contact is made by telephone. And as I said, our experience is that approximately half of the requests are ultimately resolved with this initial contact, with the telephone call. It’s possible that you have an initial contact like this, discuss it in the phone call, and that then maybe a week later you get another response, but now a case consultation would be desirable or useful. But in many cases, it is already resolved with a telephone consultation. (S02, focus group 1) Video consultations were used by ethics consultants in hospitals as well as outpatient settings. Some participants gained initial experiences with video-based consultations during the COVID-19 pandemic, as these became necessary due to contact restrictions, while others first began to use such formats independently of the pandemic. Regarding technical requirements, study participants reported challenges with hybrid setups, especially when multiple participants used one device. In contrast, video consultation involving small groups, where each person joined from their own device, was generally perceived as more effective and technically reliable. The following themes focus on the study participants’ experiences with video-based remote consultations. Attitudes towards remote ethics consultation Participants expressed mixed attitudes towards remote ethics consultations. There was a tendency for participants who were more experienced with remote formats to have a more positive attitude, while less experienced participants were more sceptical and had doubts about whether conducting ethics consultations remotely was feasible, for example due to technical challenges. For instance, a participant who had not used video consultations before expressed a sceptical attitude: Now we lack experience here a bit, but what was mentioned earlier, so, to what extent can it be used, can it be operated, are the conditions in place, is there a stable internet connection, so, these are things that cannot be taken for granted and that require a lot of clarification. So I see that rather critically. (S06, focus group 2) On the other hand, a participant who had been using video consultations regularly stated: And so, it’s a tool that works well. If people are reasonably tech-savvy, it’s not a problem at all [...] so there’s no big difference compared to an in-person consultation. (S09, focus group 3) Overall, most participants in our study preferred in-person consultations and used video consultations as a substitute when face-to-face meetings were not possible. Some did not regard video consultations as an adequate replacement for an in-person meeting, instead viewing them as a useful option for preparation ahead of a complete ethics consultation. Table 1 Remote ethics consultation: main advantages, challenges and learnings Advantages Challenges Learnings • Bridging geographical distances • Including family members who live far away • Including professionals from other institutions • Less challenging to schedule • Allow adherence to infection prevention guidelines • Video-based consultations can be more structured • Technical prerequisites and skills are necessary • Concerns about privacy and data protection • Lack of physical proximity • Non-verbal communication is lost • Emotional dynamics are less noticeable • Involving relatives and patients can be challenging and requires preparation • Many initial requests can be resolved with telephone consultations • Remote formats are regarded as a feasible alternative when in-person meetings are not possible • Hybrid setups are often perceived as challenging, especially when multiple participants use one device • Specific preparation is necessary, for example by ensuring that technical requirements are met • Offering specific opportunities for debriefing and follow-up is necessary Advantages of remote ethics consultation Participants particularly valued the ability of remote formats to bridge geographical distances, making them especially suitable for rural settings. They allow including family members who live far away and would otherwise not be able to participate in ethics consultations, as well as professionals from other institutions. This was particularly important for members of outpatient ethics consultation services, allowing them to take on requests from individuals who lived further away. Participants also found ethics consultations via videoconference less challenging to schedule than in-person meetings, which allowed finding appointments faster, and reported that this was also valued by clinicians who request ethics consultations: In our case, online consultations are actually often requested. So it’s not the case that we only use it when somehow nothing else is possible. Because it’s quicker, because it’s more convenient for everyone. Because the doctors in their practices and the person in the care home and the care team can simply join in. And sometimes it’s just the time, so everyone would have to wait for it longer. That's why it’s just, everyone is happy that they can now, that they can quickly get a solution to their problem. (S03, focus group 1) Participants also found video consultations particularly valuable during the Covid-19 pandemic, as they allowed ethics consultants to adhere to infection prevention guidelines. Disadvantages of remote ethics consultation Some participants regarded the technical aspects of video-based ethics consultations as disadvantageous, partly because consultants themselves or participants in consultations lacked “technological aptitude”, which was also described as an age-related issue. Some regarded the technical prerequisites needed for video consultations as a disadvantage, particularly in rural areas in Germany, where internet connection is often unstable. This was described as particularly unfavourable given that remote consultations offer the greatest benefits in rural locations: [W]e have the greatest need in rural areas, but the fewest possibilities. Because that’s where the biggest problems are with the technology, with the connection, so the cat is chasing its own tail. (S06, focus group 2) Some participants expressed concerns about privacy and data protection, which led one ethics consultant to avoid using video-based consultations altogether. Another disadvantage was the lack of physical proximity and possibility for “touch”, which some participants regarded as particularly important for people who request ethics consultations: ​​We are professional groups [...] where everything is also about touch. That means you have to be touched and also touch the person that it’s about. And the relatives, too. That means either direct physical touch or allowing yourself to be touched in a kind of closeness that cannot be realised in the same way with remote techniques. (S08, focus group 2) Differences between in-person and video-based ethics consultations Participants described various changes and particularities that they had experienced as a result of conducting ethics consultation via videoconference compared to in-person consultations. These referred to various stages of planning and conducting an ethics consultation, i.e., preparation, communication during the consultation itself, follow-up and debriefing, whether including patients and relatives was regarded as appropriate, and which types of requests they considered appropriate for the format. In the following, we discuss these themes in more detail. Preparation Focus group participants noted that video consultations required changes in preparing for an ethics consultation compared to in-person consultations. First, it was necessary to make sure that technical requirements were met: for example, each participant had to access the meeting from their own device in a quiet environment. Some ethics consultants reported providing a phone number that participants could call in case of technical difficulties. Moreover, it was noted that changes in video-based communication required specific preparation, for example, by assigning moderators to have an eye on emotional dynamics in specific participants: As with online, a certain awareness of emotional changes in the people involved can possibly be lost, we have always agreed in advance who will keep an eye on which people in order to be aware of any changes in mood as far as possible, so that we can deal with them accordingly, recognise emotional overwhelm at an early stage and prevent it from occurring in the first place. So I think, this mentorship, which we are also familiar with from in-person consultations, where the ethics team thinks about who will keep half an eye on which person, is even better in the digital format. (S12, focus group 3) Communication during consultations Participants noted that non-verbal communication was largely lost in video consultations. For example, in-person consultations allowed them to register whether a participant was nervous or aggressive by observing how they entered a room, greeted someone, or sat in a chair, which was not possible during video consultations. They noted that emotional dynamics were less noticeable in video consultations: And also, when the mood somehow starts to change, I notice that much better in person than when I do it online. (S10, focus group 3) Some found that this made it more difficult to moderate video-based ethics consultations because it was easier to overlook certain aspects, such as a participant rolling their eyes. It was also noted that video consultations lowered the threshold for exiting a conversation, for example, by answering a phone call. Some participants, however, characterised the reduced ability to convey emotions in video consultations as a benefit. They noted that a lesser degree of emotionality allowed for more “structured” consultations, and could protect participants from hierarchical and aggressive behaviour, for example, by senior hospital staff. By limiting each participant in an ethics consultation to their own “video square”, online consultations were regarded as promoting egalitarian communication: Now that (S11) has also said it, that everyone is actually very limited by their [video] square and somehow, everyone is practically standing next to each other, too, this may even have a more empowering effect, at least for some relatives and patients, that you don’t sit next to each other in this digital setting, so to speak, but rather that everyone gets their own protected space, but then very decidedly gets their own time. (S14, focus group 3) Overall, ethics consultants found that they had to be more focused when moderating video-based consultations, for example, by checking that each participant had the ability to contribute to the conversation. However, this could also make ethics consultations more structured, particularly because the online format allowed moderators to have an eye on all individual participants: But I think it works very, very well online, too, because in this Zoom format with these squares and so on, you really have all the participants in your view. Sometimes even better than with in-person consultations. Because, we sometimes have consultations in some kind of meeting room in the hospital. There you’ve got very long, narrow tables. Then it’s often difficult to keep an eye on all participants. (S02, focus group 1) Follow-up and debriefing Ethics consultants noted that informal opportunities for debriefing and follow-up, such as brief conversations while saying goodbye to participants in the hallway after an in-person consultation, were lost in video-based consultations. They stated that this posed the risk of leaving participants to process the emotional impact of the ethics consultation on their own: Yes, the resonance is simply lacking. You don’t know what the people affected or the people who are present, how they will feel after the entire consultation. That is difficult to sense. Even if you have the feeling, oh dear, now we’re ending the entire session, and you have the feeling that you can’t really let them go home, but still, I don’t know. (S01, focus group 1) Having the opportunity to debrief was also described as psychologically important for ethics consultants themselves, particularly after difficult case consultations. The ethics consultants therefore noted that follow-up meetings with participants and among themselves were particularly important in online settings. This could be realised via telephone or video conferencing. Including patients and relatives While remote ethics consultations have the advantage of potentially including relatives who live further away, several participants found it challenging to involve patients or their relatives in video consultations. Some found the online format inappropriate for addressing complex, emotionally challenging questions that deeply affected patients and their relatives, who often were experiencing personal crises. They noted that the lack of informal follow-up after a remote ethics consultation particularly affected these groups: But if, for example, relatives are involved, for whom the situation has a completely different meaning, then I would always try to make use of an in-person meeting. I would also find it difficult, myself as a relative, if it was suggested to me that we’re negotiating, I’m going to put it a bit bluntly, we’re negotiating about the future of your mother or father today and we’ll do that here with these funny little colourful squares. And at some point the screen goes black and then I’m sitting there alone with this decision. I couldn’t take responsibility for that either, as a moderator, for example. (S06, focus group 2) Some participants, however, found involving patients and relatives in ethics consultations challenging in general, independently of whether a consultation took place remotely or in person. They noted that successfully including patients in ethics consultations may require additional support, particularly for patients with disabilities. Yet, it was stressed that involving patients and relatives in ethics consultations is often essential to understand their perspectives and to gain a more complete understanding of the respective ethical issue. Appropriate types of requests Some participants stated that remote formats were less appropriate for emotionally challenging consultations that have potentially serious consequences for patients or relatives, for example, in cases where patients had a wish for death, or when members of the treatment team were highly emotionally involved in the case. Some participants believed that concrete and urgent decisions should only be made in person because they are often emotionally charged. Some viewed remote ethics consultations as particularly appropriate for preventative ethics consultations, training settings, consultations with participants the moderators already knew, or “factual” discussions that involved a lesser degree of emotionality. Other participants, however, especially those who were more experienced with remote consultations, did not regard any topics as particularly suitable or unsuitable for video-based consultations. Discussion Attitudes and experiences In this study, we identified a range of experiences with and attitudes towards remote ethics consultations among ethics consultants in Germany. Participants reported using several remote technologies, including telephone and video conferencing. Telephone consultations were frequently used to quickly resolve an ethical question, so that full consultations did not become necessary. Participants reported using video consultations in clinical and outpatient settings, typically when in-person meetings were not feasible. Attitudes towards video consultations appeared to correlate with experience: those who had more experience using remote formats tended to evaluate them more positively. This could suggest that familiarisation to remote formats reduces initial scepticism. This is in line with research on remote consultations in other medical settings, which shows effects of familiarisation, increased acceptance and confidence through use ( 28 , 29 ). Yet, it is also possible that consultants who already have positive attitudes towards such formats use them more often, while those with negative attitudes avoid them. Future research should examine this bidirectional relationship more systematically to determine whether training and usage alone can shift attitudes or if deeper professional values and expectations drive preferences towards remote formats. Advantages and disadvantages Participants identified several benefits of video-based consultations, including greater geographical reach, increased accessibility – especially in underserved rural areas –, the ability to include relatives who live far away and professionals from different institutions, and easier scheduling. These advantages align with broader arguments for the utility of telehealth consultations ( 24 , 30 ). Disadvantages and points of scepticism included technical difficulties and challenges due to limited technological literacy. Notably, the areas most in need of remote formats - those with limited access to in-person ethics consultation - are often the very regions where internet infrastructure and technological competence are the weakest. This represents a structural challenge to equitable implementation. Involvement of patients and relatives A similar challenge emerged with respect to the involvement of patients and relatives in remote ethics consultations: while one important advantage of remote consultations is the possibility of including relatives more easily, participants in our study were sceptical regarding whether including relatives in video-based consultations was appropriate at all. In particular, they raised concerns regarding technical challenges and meeting relatives’ emotional needs via remote formats. Similar concerns were raised regarding the participation of patients in remote consultations, although some participants also found it difficult to involve patients in in-person consultations. Thus, those who would arguably benefit most from additional opportunities to take part in ethics consultations are also those whose involvement is met with the greatest barriers. These findings resonate with the broader debate on patient involvement in ethics consultations ( 31 , 32 ). While AEM guidelines recommend patient participation ( 5 ), research indicates that many ethics consultations in Germany do not involve patients ( 33 ). On the one hand, excluding patients from ethics consultations seems problematic, as their perspectives are often essential to fully understand ethical conflicts ( 34 , 35 ). However, it has also been argued that the routine involvement of patients in ethics consultations could cause harm, as this may lead to “needless fears, unjustified expectations or false hope” ( 6 ). Our findings highlight that ethics consultants often find including patients in ethics consultations difficult, and may find their involvement in remote formats even more challenging. However, simply assuming that patients or relatives cannot be included in consultations because of emotional or technical challenges appears to be based on paternalistic assumptions rather than on the attitudes of patients and relatives themselves. Hence, more research on the perspectives of these groups on ethics consultations in general ( 32 ), and digital formats in particular, is needed. The role of emotions in online communication Study participants highlighted the limited possibility of conveying non-verbal cues and expressing emotions in video-based consultations, which is in line with findings from other healthcare settings in which video consultations have been implemented ( 23 , 30 , 36 , 37 ). Participants had diverging attitudes on how this impacted ethics consultations. Some found the equalising and structuring effects of video conferencing beneficial. They understood the limited expression of emotions in video consultations as a benefit in itself, as this could prevent specific participants from dominating the discussion. Others instead found the reduced expression of emotions disadvantageous, stating that this makes it difficult to involve relatives and patients, and makes remote formats less appropriate for emotionally charged, sensitive topics. Generally, the sensitive topics discussed in ethics consultations often lead to intense emotions such as irritation, anger, sadness, and grief ( 38 ). Some ethics consultants regard emotions as distracting from the moral question and hindering ethical decision-making ( 39 ), which leads some ethics consultants to encourage participants to distance themselves from their emotions ( 38 ). Others, however, understand emotions as crucial for informing moral decision-making ( 40 ) and regard them as a potential source of new insights, which makes acknowledging them essential ( 38 ). Research also indicates that many healthcare professionals regard the opportunity to share difficult emotions and receive emotional support as one of the most important benefits of ethics consultations ( 41 ). How the role of emotions in ethics consultations is perceived - in general as well as in video-based consultations in particular -, might hinge on how ethics consultants understand their own role and the goals they believe ethics consultation should achieve. Haltaufderheide et al. ( 42 ) distinguish two possible roles of ethics consultants. As part of an “analytical role”, ethics consultants act as moral problem solvers that identify, analyse and resolve ethical issues ( 43 ) by applying their knowledge to a case, explaining and clarifying normative concepts. The associated goal is to improve participants’ ability to identify ethical issues and improve patient outcomes. As part of a “hermeneutic role”, on the other hand, ethics consultants act as observers and facilitators ( 44 ) that improve and enable effective communication between participants, help clarify individual moral perspectives, and communicate support and empathy to participants ( 45 ). As part of the latter role, ethicists can sometimes act as “conflict managers” that facilitate conversations between healthcare professionals, patients, and relatives. In this context, perceiving emotions and demonstrating empathy are central skills ( 39 ). Hence, it could be hypothesised that if ethics consultants primarily understand their role as an “analytical” one with the goal of coming to an ethically well-founded decision, they could be more likely to prefer digital formats that allow for structured discussions. In contrast, a more “hermeneutical” and empathetic role may be more difficult to realise in video-based consultations that do not allow for the full expression of non-verbal cues and emotions as well as physical touch, and lack opportunities for informal debriefing after sessions. This explains why some participants did not regard remote consultations as appropriate for certain emotionally charged topics. Strengths and limitations To our knowledge, this is the first qualitative study on ethics consultants’ experiences with and attitudes towards remote consultation formats – particularly video-based consultations. Nonetheless, several limitations should be acknowledged. Due to its qualitative nature and small sample size, the findings of our study do not aim to be representative of the attitudes of all ethics consultants in Germany. However, our study included the perspectives of ethics consultants working in a range of different contexts and geographical areas. The study results may be biased towards positive experiences with remote formats, given that participants with more positive attitudes may have been more likely to participate. Additionally, the study does not include the perspectives of patients and relatives on remote formats, whose views are critical to evaluating the acceptability of remote ethics consultation. Future research should therefore include these important perspectives and examine how remote formats affect outcomes, satisfaction, and ethical decision-making processes from the perspectives of different stakeholders. Conclusion This study provides important insights on ethics consultants’ attitudes towards and experiences with remote formats, particularly video-based consultations. Our findings indicate that ethics consultants regard video-based ethics consultations as a feasible alternative when in-person meetings are not possible. The results demonstrate that further research on the effective implementation of remote ethics consultation is necessary to realise their advantages while mitigating possible disadvantages. In particular, the question of to what extent, and how, patients and relatives can be involved in remote consultations needs to be addressed, which requires further research on the perspectives of these groups. Our findings highlight that ethics consultants have developed a range of strategies to effectively employ remote consultations, for example specific measures for preparation, follow-up, and managing emotional dynamics remotely. This knowledge could be integrated into future training courses on remote ethics consultations. Declarations Clinical trial number Not applicable. Ethics approval Ethical approval for the study was obtained from the Research Ethics Committee of the University of Potsdam (registration number 69/2024). The study was conducted in accordance with the Declaration of Helsinki. Consent to participate All focus group participants received information on the study in writing and via videoconference and gave verbal and written informed consent to participate in the study. Consent for publication Not applicable. Competing interests The authors have no competing interests to disclose. Data availability The data generated during the current study are not publicly available to protect the privacy of the participants but are available from the corresponding author on reasonable request. Funding This study was funded by the VolkswagenStiftung as part of the Digital Medical Ethics Network (grant number 9B233). Acknowledgements We are grateful to all participants for taking part in our study. We thank Clara Keusgen for her assistance with transcription, and Alexander Buschner for proofreading. We also thank the audience at the AEM Spring Conference 2025 for helpful comments. Author contribution statement The initial study design was planned by EB, and all authors contributed to working out the study design in further detail. EB, RS and JH conducted the focus groups. EB, FF and JH performed the data analysis, and all authors participated in team discussions on the data analysis. EB wrote the initial draft of the manuscript. All authors revised the various drafts for important intellectual content. All authors gave their approval for the final version to be published. RR is the principal investigator for the research projects from which this paper originated. References Tarzian AJ, Asbh Core Competencies Update Task F. Health care ethics consultation: an update on core competencies and emerging standards from the American Society For Bioethics and Humanities' core competencies update task force. Am J Bioeth. 2013;13(2):3–13. Milliken A, Monteverde S, Grace P. Models of Ethics Deliberation and Consultation. In: Grace P, Milliken A, editors. 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Hessisches Ärzteblatt. 2018;79(4):238–40. (ZEKO) ZEbdBr. Ethikberatung in der klinischen Medizin. Dtsch Ärztebl. 2006;103(24):A1703–7. C S. Entwicklung der ambulanten Ethikberatung in Deutschland – Verstärkte telefonische Beratung und bessere Finanzierung gefordert. Hessisches Ärzteblatt. 2020;81(3):174–6. Kon AA, Garcia M. Telemedicine as a tool to bring clinical ethics expertise to remote locations. HEC Forum. 2015;27(2):189–99. Bramstedt KA. International Access to Clinical Ethics Consultation via Telemedicine. AMA J Ethics. 2016;18(5):521–7. Kon AA, Walter RJ. Health Care Ethics Consultation via Telemedicine: Linking Expert Clinical Ethicists and Local Consultants. AMA J Ethics. 2016;18(5):514–20. Kon AA, Rich B, Sadorra C, Marcin JP. Complex bioethics consultation in rural hospitals: using telemedicine to bring academic bioethicists into outlying communities. J Telemed Telecare. 2009;15(5):264–7. Petrick N, Kreuzenbeck CCJ. [Effects of the Covid-19 Pandemic on Online Use of Video Consultation by General Practitioners in Germany - a Secondary Data Analysis of German Health Insurance Data]. Gesundheitswesen. 2023;85(3):188–92. Elsner P. Teledermatologie in den Zeiten von COVID-19 - ein systematisches Review. J Dtsch Dermatol Ges. 2020;18(8):841–7. Gerbutavicius R, Brandlhuber U, Gluck S, Kortum GF, Kortum I, Navarrete Orozco R, et al. [Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]. Ophthalmologe. 2020;117(7):659–67. Ford J, Reuber M. Comparisons of Communication in Medical Face-To-Face and Teleconsultations: A Systematic Review and Narrative Synthesis. Health Commun. 2024;39(5):1012–26. Walthall H, Schutz S, Snowball J, Vagner R, Fernandez N, Bartram E. Patients' and clinicians' experiences of remote consultation? A narrative synthesis. J Adv Nurs. 2022;78(7):1954–67. O'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245–51. Akademie für Ethik in der Medizin. Curriculum Ethikberatung im Gesundheitswesen. Available: https://www.aem-online.de/fileadmin/user_ upload/Ethikberatung/Curriculum_Ethikberatung_im__Gesundheitswesen_2019-06-24__geaendert_am_ 12.22_.pdf. 2022. Kuckartz U. Qualitative text analysis: a guide to methods, practice & using software. London: SAGE; 2014. Connolly SL, Miller CJ, Lindsay JA, Bauer MS. A systematic review of providers' attitudes toward telemental health via videoconferencing. Clin Psychol (New York). 2020;27(2). Alhajri N, Simsekler MCE, Alfalasi B, Alhashmi M, AlGhatrif M, Balalaa N, et al. Physicians' Attitudes Toward Telemedicine Consultations During the COVID-19 Pandemic: Cross-sectional Study. JMIR Med Inf. 2021;9(6):e29251. Nguyen AD, White SJ, Tse T, Cartmill JA, Roger P, Hatem S, et al. Communication during telemedicine consultations in general practice: perspectives from general practitioners and their patients. BMC Prim Care. 2024;25(1):324. Murdoch K. Hindering or Helping: Discussing Patient Participation in Clinical Ethics Support Service Deliberation. J Clin Ethics. 2025;36(1):9–15. Eijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations-a national survey. BMC Med Ethics. 2022;23(1):62. Löbbing T, Carvalho Fernando S, Driessen M, Schulz M, Behrens J, Kobert KKB. Clinical ethics consultations in psychiatric compared to non-psychiatric medical settings: characteristics and outcomes. Heliyon. 2019;5(1):e01192. Ho A, Unger D. Power hierarchy and epistemic injustice in clinical ethics consultation. Am J Bioeth. 2015;15(1):40–2. Faissner M, Brunig L, Gaillard AS, Jieman AT, Gather J, Hempeler C. Intersectionality as a tool for clinical ethics consultation in mental healthcare. Philos Ethics Humanit Med. 2024;19(1):6. Duffy CMC, Benotsch EG. Nonverbal behavior in telehealth visits: A narrative review. Patient Educ Couns. 2025;132:108600. Frittgen EM, Haltaufderheide J. Can you hear me?': communication, relationship and ethics in video-based telepsychiatric consultations. J Med Ethics. 2022;48(1):22–30. Spronk B, Widdershoven G, Alma H. The role of emotions in Moral Case Deliberation: Visions and experiences of facilitators. Clin Ethics. 2021;17(2). Bruns F, Frewer A. Ethics consultation and empathy. HEC Forum. 2011;23(4):247–55. Molewijk B, Kleinlugtenbelt D, Widdershoven G. The role of emotions in moral case deliberation: theory, practice, and methodology. Bioethics. 2011;25(7):383–93. Svantesson M, de Snoo-Trimp JC, Ursin G, de Vet HC, Brinchmann BS, Molewijk B. Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities. J Med Ethics. 2019;45(9):608–16. Haltaufderheide J, Nadolny S, Vollmann J, Schildmann J. Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants. J Med Ethics. 2022;48(6):401–6. Fletcher JC, Siegler M. What Are the Goals of Ethics Consultation? A Consensus Statement. J Clin Ethics. 1996;7(2):122–6. Steinkamp NL, Gordijn B, ten Have HA. Debating ethical expertise. Kennedy Inst Ethics J. 2008;18(2):173–92. Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med. 2000;133(1):59–69. Additional Declarations No competing interests reported. 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Sakowsky","email":"","orcid":"","institution":"University of Potsdam","correspondingAuthor":false,"prefix":"","firstName":"Ruben","middleName":"A.","lastName":"Sakowsky","suffix":""},{"id":501755666,"identity":"c9011013-7d99-4220-b4c8-da24a4fd51cb","order_by":3,"name":"Robert Ranisch","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIie3QPQrCMBiA4ZSutq4OUq/wSQfHXqWZujTi6NAhIOgVLHiIeIOGgA5GugZ0cHKqg5uiiCmo6NDS0SEvGRLIQ34QMpn+tEwPDyGLfpao1YD4LwLNSKnw64gGZDDbcn5J9hHbTag9Gt8Dd70JUTGuJl05DEVrdSRsz6k9l4BTSZi1kNWkg2IQFhWEKTy7OVMIISPMdqY1pF0Av1IRgcJU74QA8pMmjxrSiSFzqAjfxGKqPIXWkQL0W0Q/Lclc+jhVJ8YXq7qLxf75koieq6KD/jEvcHOyPBRJNfnJfk+yhuCLmEwmk+m7J7OFXHqiA25hAAAAAElFTkSuQmCC","orcid":"","institution":"University of Potsdam","correspondingAuthor":true,"prefix":"","firstName":"Robert","middleName":"","lastName":"Ranisch","suffix":""},{"id":501755668,"identity":"26f267f9-4ea3-4a1b-a079-2dd3363c39ac","order_by":4,"name":"Joschka Haltaufderheide","email":"","orcid":"","institution":"University of Potsdam","correspondingAuthor":false,"prefix":"","firstName":"Joschka","middleName":"","lastName":"Haltaufderheide","suffix":""}],"badges":[],"createdAt":"2025-07-31 11:38:29","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7261781/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7261781/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-026-01401-x","type":"published","date":"2026-02-10T15:58:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102785785,"identity":"93ee9964-63fe-45b1-ab92-638349a5b2bd","added_by":"auto","created_at":"2026-02-16 16:10:06","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":827314,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7261781/v1/2f1be63b-2c2a-447b-8aad-69fa1c748bfd.pdf"},{"id":89665607,"identity":"a096e91a-bdf7-4cb6-b686-aa9a2d7d7360","added_by":"auto","created_at":"2025-08-22 12:04:23","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17640,"visible":true,"origin":"","legend":"","description":"","filename":"RemoteEthicsConsultationDiscussionguide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7261781/v1/3156d0610cc8e005b3ef3799.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Experiences with remote ethics consultation: a qualitative study with ethics consultants in Germany","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEthics consultations provide support in identifying, analysing, and resolving ethical issues in healthcare settings, with the aim of improving patient care (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In hospitals, they are usually provided by clinical ethics committees, which offer consultations for specific cases upon request (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Consultations are most commonly requested by healthcare professionals, but can also be initiated by patients, relatives, or legal representatives (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). They are moderated by individual ethics consultants or by several members of the clinical ethics committee and can involve members of the treatment team, patients, legal representatives, and/or relatives (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A variety of methods for conducting ethics consultations have been developed (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Common approaches include gathering relevant facts about the case, hearing the perspectives of all involved parties, identifying possible courses of action, and providing recommendations based on ethical reasoning (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Germany, clinical ethics committees have been established since the 1990s, and are now present in most hospitals (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Next to ethics consultations, the tasks of clinical ethics committees include developing institutional ethical guidelines for hospitals, delivering ethics education for staff and advising hospital management on ethical questions at the organizational level (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The German association for medical ethics, the Academy of Ethics in Medicine (AEM), sets national standards for ethics consultation and certifies consultants at three competency levels (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e): \u0026ldquo;Ethics Consultant in Healthcare\u0026rdquo; (level 1), \u0026ldquo;Coordinator for Ethics Consultation in Healthcare\u0026rdquo; (level 2), and \u0026ldquo;Trainer for Ethics Consultation in Healthcare\u0026rdquo; (level 3).\u003c/p\u003e\u003cp\u003eMore recently, outpatient clinical ethics services have emerged in Germany, which offer ethics consultation outside hospitals - for example in nursing homes and for general practitioners (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). The significance of these services was highlighted by a recent statement of the Central Ethics Committee of the German Medical Association, which called for their increased implementation (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Unlike clinical ethics committees, these services are independent entities that provide ethics consultations to various institutions within a region (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Many outpatient ethics services have developed out of palliative care structures (13), and their numbers have steadily increased over the past decade (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). They primarily rely on the voluntary work of their members (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOutpatient ethics consultations often involve coordinating participants from diverse groups and settings \u0026ndash; such as relatives, general practitioners, nurses, and nursing home representatives. Given the time-sensitive nature of many ethical conflicts in healthcare, organising ethics consultations promptly is essential. This urgency compounds logistical challenges, especially in rural or large geographic areas with a low density of healthcare professionals and trained ethicists (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRemote formats - via email, telephone, or videoconference - could offer a solution to help address these challenges. A recent survey highlights the demand for increased availability of ethics consultation via telephone among general practitioners (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Next to the outpatient context, remote formats can also help provide ethics consultations to hospitals without their own clinical ethics committees, particularly in rural areas (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Moreover, clinical ethics committees can also use remote formats to involve additional stakeholders or to comply with contact restrictions. Internationally, first experiences with remote ethics consultation have been reported (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In Germany, both clinical ethics committees and outpatient clinical ethics services made initial experiences with video-based consultations during the COVID-19 pandemic, although remote formats have not yet been widely implemented.\u003c/p\u003e\u003cp\u003eGenerally, the COVID-19 pandemic increased the demand for remote consultations (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), especially video-based formats, across healthcare settings. Initial research has examined the effects of remote consultations in different settings (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), attitudes and acceptance (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) as well as changes in communication between in-person and remote interaction (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, no study to date has explored the perspectives of ethics consultants on the specific challenges of conducting ethics consultations online.\u003c/p\u003e\u003cp\u003e Therefore, the goal of this qualitative study was to gather ethics consultants\u0026rsquo; experiences with and attitudes towards remote ethics consultation formats in Germany. By identifying practical benefits and obstacles, our findings aim to inform best practices for remote ethics consultation, guide targeted curricula, and clarify when remote formats are most appropriate.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy design\u003c/h2\u003e\u003cp\u003e We conducted a focus group study with clinical ethics consultants to explore their experiences with and attitudes towards remote ethics consultation. We chose a focus group format to facilitate an in-depth exploration of participants\u0026rsquo; views regarding this underexplored topic, while allowing participants to build on each other\u0026rsquo;s ideas and express contrasting views. We followed the standards for reporting qualitative research proposed by O\u0026rsquo;Brien et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eResearcher reflexivity\u003c/h3\u003e\n\u003cp\u003e Our research team combined expertise from medical ethics, medicine, philosophy, theology and health economics. Several team members were certified ethics consultants who had experience conducting ethics consultations remotely and were involved in establishing an outpatient clinical ethics consultation service for the German state of Brandenburg. The results of the study were also intended to inform the development of this service.\u003c/p\u003e\n\u003ch3\u003eParticipant selection\u003c/h3\u003e\n\u003cp\u003eWe sent invitations to participate in the study via email to relevant mailing lists and to representatives of organizations for outpatient clinical ethics consultation in Germany. Ethics consultants with an interest in or experience with remote clinical ethics consultations in the inpatient or outpatient context were eligible for participation. We used purposive sampling and aimed for diversity of participants with respect to gender, age, level of experience and certification.\u003c/p\u003e\n\u003ch3\u003eParticipant characteristics\u003c/h3\u003e\n\u003cp\u003e A total of 14 ethics consultants participated in our study. All were certified ethics consultants according to the standards of the AEM, the professional society for ethics in healthcare in Germany, holding qualifications at level K1, K2, or K3 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Their experience with ethics consultations ranged from 1 to 27 years, and their ages ranged from 30 to 69 years. 7 participants identified as male and 7 as female.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eWe conducted three focus groups with 4\u0026ndash;6 participants each via videoconference (Zoom) in October 2024. The focus groups lasted between 79 and 94 minutes (mean: 88 minutes) and were moderated by EB, JH, and RS using a semi-structured discussion guide (an English translation is provided in the online supplement). While the discussion guide included questions on both outpatient clinical ethics services and remote ethics consultation, this manuscript focuses exclusively on the latter topic. We created audio recordings of the focus groups, which were initially transcribed with the software noScribe. A student assistant checked the initial transcription against the audio recording and corrected the transcripts, and EB pseudonymized the transcripts.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eThe data was analysed with the software MAXQDA 2024 using structuring qualitative content analysis according to Kuckartz (27). The coding system was developed both deductively, following the questions from the discussion guide, and inductively, based on the content of the focus groups. All transcripts were coded by EB and one other researcher (FF or JH) to ensure inter-rater reliability. Discrepancies were discussed in team meetings among all authors until consensus was reached.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eEthical considerations\u003c/h3\u003e\n\u003cp\u003e All participants received information on the study in writing and verbally, and had the opportunity to ask questions. They gave verbal and written informed consent prior to participating in the focus groups. Ethical approval for the study was obtained from the Research Ethics Committee of the University of Potsdam (registration number 69/2024).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFive themes emerged from our analysis: 1) experiences with different forms of remote ethics consultation, 2) attitudes towards remote ethics consultation, 3) advantages of remote ethics consultation, 4) disadvantages of remote ethics consultation, and 5) differences between in-person and video-based ethics consultations. In the following, we describe these themes and present representative quotes from the focus group discussions, which were translated from German to English by EB. Main advantages, disadvantages, and learnings regarding remote ethics consultations are summarised in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eExperiences with different forms of remote ethics consultation\u003c/h2\u003e\u003cp\u003eParticipating ethics consultants reported on experiences with different forms of remote ethics consultation via email, telephone, and videoconferencing. Participants stated that they frequently conducted short consultations via telephone, which was described as the most common form of remote consultation. These often resolved the initial question, so that a full ethics consultation did not become necessary:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAnd then the initial contact is made by telephone. And as I said, our experience is that approximately half of the requests are ultimately resolved with this initial contact, with the telephone call. It\u0026rsquo;s possible that you have an initial contact like this, discuss it in the phone call, and that then maybe a week later you get another response, but now a case consultation would be desirable or useful. But in many cases, it is already resolved with a telephone consultation. (S02, focus group 1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eVideo consultations were used by ethics consultants in hospitals as well as outpatient settings. Some participants gained initial experiences with video-based consultations during the COVID-19 pandemic, as these became necessary due to contact restrictions, while others first began to use such formats independently of the pandemic.\u003c/p\u003e\u003cp\u003eRegarding technical requirements, study participants reported challenges with hybrid setups, especially when multiple participants used one device. In contrast, video consultation involving small groups, where each person joined from their own device, was generally perceived as more effective and technically reliable. The following themes focus on the study participants\u0026rsquo; experiences with video-based remote consultations.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eAttitudes towards remote ethics consultation\u003c/h2\u003e\u003cp\u003eParticipants expressed mixed attitudes towards remote ethics consultations. There was a tendency for participants who were more experienced with remote formats to have a more positive attitude, while less experienced participants were more sceptical and had doubts about whether conducting ethics consultations remotely was feasible, for example due to technical challenges. For instance, a participant who had not used video consultations before expressed a sceptical attitude:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eNow we lack experience here a bit, but what was mentioned earlier, so, to what extent can it be used, can it be operated, are the conditions in place, is there a stable internet connection, so, these are things that cannot be taken for granted and that require a lot of clarification. So I see that rather critically. (S06, focus group 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOn the other hand, a participant who had been using video consultations regularly stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAnd so, it\u0026rsquo;s a tool that works well. If people are reasonably tech-savvy, it\u0026rsquo;s not a problem at all [...] so there\u0026rsquo;s no big difference compared to an in-person consultation. (S09, focus group 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Overall, most participants in our study preferred in-person consultations and used video consultations as a substitute when face-to-face meetings were not possible. Some did not regard video consultations as an adequate replacement for an in-person meeting, instead viewing them as a useful option for preparation ahead of a complete ethics consultation.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRemote ethics consultation: main advantages, challenges and learnings\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdvantages\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChallenges\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLearnings\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Bridging geographical distances\u003c/p\u003e\u003cp\u003e\u0026bull; Including family members who live far away\u003c/p\u003e\u003cp\u003e\u0026bull; Including professionals from other institutions\u003c/p\u003e\u003cp\u003e\u0026bull; Less challenging to schedule\u003c/p\u003e\u003cp\u003e\u0026bull; Allow adherence to infection prevention guidelines\u003c/p\u003e\u003cp\u003e\u0026bull; Video-based consultations can be more structured\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Technical prerequisites and skills are necessary\u003c/p\u003e\u003cp\u003e\u0026bull; Concerns about privacy and data protection\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of physical proximity\u003c/p\u003e\u003cp\u003e\u0026bull; Non-verbal communication is lost\u003c/p\u003e\u003cp\u003e\u0026bull; Emotional dynamics are less noticeable\u003c/p\u003e\u003cp\u003e\u0026bull; Involving relatives and patients can be challenging and requires preparation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Many initial requests can be resolved with telephone consultations\u003c/p\u003e\u003cp\u003e\u0026bull; Remote formats are regarded as a feasible alternative when in-person meetings are not possible\u003c/p\u003e\u003cp\u003e\u0026bull; Hybrid setups are often perceived as challenging, especially when multiple participants use one device\u003c/p\u003e\u003cp\u003e\u0026bull; Specific preparation is necessary, for example by ensuring that technical requirements are met\u003c/p\u003e\u003cp\u003e\u0026bull; Offering specific opportunities for debriefing and follow-up is necessary\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eAdvantages of remote ethics consultation\u003c/h2\u003e\u003cp\u003eParticipants particularly valued the ability of remote formats to bridge geographical distances, making them especially suitable for rural settings. They allow including family members who live far away and would otherwise not be able to participate in ethics consultations, as well as professionals from other institutions. This was particularly important for members of outpatient ethics consultation services, allowing them to take on requests from individuals who lived further away. Participants also found ethics consultations via videoconference less challenging to schedule than in-person meetings, which allowed finding appointments faster, and reported that this was also valued by clinicians who request ethics consultations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIn our case, online consultations are actually often requested. So it\u0026rsquo;s not the case that we only use it when somehow nothing else is possible. Because it\u0026rsquo;s quicker, because it\u0026rsquo;s more convenient for everyone. Because the doctors in their practices and the person in the care home and the care team can simply join in. And sometimes it\u0026rsquo;s just the time, so everyone would have to wait for it longer. That's why it\u0026rsquo;s just, everyone is happy that they can now, that they can quickly get a solution to their problem. (S03, focus group 1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Participants also found video consultations particularly valuable during the Covid-19 pandemic, as they allowed ethics consultants to adhere to infection prevention guidelines.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eDisadvantages of remote ethics consultation\u003c/h2\u003e\u003cp\u003eSome participants regarded the technical aspects of video-based ethics consultations as disadvantageous, partly because consultants themselves or participants in consultations lacked \u0026ldquo;technological aptitude\u0026rdquo;, which was also described as an age-related issue. Some regarded the technical prerequisites needed for video consultations as a disadvantage, particularly in rural areas in Germany, where internet connection is often unstable. This was described as particularly unfavourable given that remote consultations offer the greatest benefits in rural locations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e[W]e have the greatest need in rural areas, but the fewest possibilities. Because that\u0026rsquo;s where the biggest problems are with the technology, with the connection, so the cat is chasing its own tail. (S06, focus group 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome participants expressed concerns about privacy and data protection, which led one ethics consultant to avoid using video-based consultations altogether. Another disadvantage was the lack of physical proximity and possibility for \u0026ldquo;touch\u0026rdquo;, which some participants regarded as particularly important for people who request ethics consultations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e​​We are professional groups [...] where everything is also about touch. That means you have to be touched and also touch the person that it\u0026rsquo;s about. And the relatives, too. That means either direct physical touch or allowing yourself to be touched in a kind of closeness that cannot be realised in the same way with remote techniques. (S08, focus group 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eDifferences between in-person and video-based ethics consultations\u003c/h2\u003e\u003cp\u003eParticipants described various changes and particularities that they had experienced as a result of conducting ethics consultation via videoconference compared to in-person consultations. These referred to various stages of planning and conducting an ethics consultation, i.e., preparation, communication during the consultation itself, follow-up and debriefing, whether including patients and relatives was regarded as appropriate, and which types of requests they considered appropriate for the format. In the following, we discuss these themes in more detail.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003ePreparation\u003c/h2\u003e\u003cp\u003eFocus group participants noted that video consultations required changes in preparing for an ethics consultation compared to in-person consultations. First, it was necessary to make sure that technical requirements were met: for example, each participant had to access the meeting from their own device in a quiet environment. Some ethics consultants reported providing a phone number that participants could call in case of technical difficulties.\u003c/p\u003e\u003cp\u003eMoreover, it was noted that changes in video-based communication required specific preparation, for example, by assigning moderators to have an eye on emotional dynamics in specific participants:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAs with online, a certain awareness of emotional changes in the people involved can possibly be lost, we have always agreed in advance who will keep an eye on which people in order to be aware of any changes in mood as far as possible, so that we can deal with them accordingly, recognise emotional overwhelm at an early stage and prevent it from occurring in the first place. So I think, this mentorship, which we are also familiar with from in-person consultations, where the ethics team thinks about who will keep half an eye on which person, is even better in the digital format. (S12, focus group 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eCommunication during consultations\u003c/h2\u003e\u003cp\u003e Participants noted that non-verbal communication was largely lost in video consultations. For example, in-person consultations allowed them to register whether a participant was nervous or aggressive by observing how they entered a room, greeted someone, or sat in a chair, which was not possible during video consultations. They noted that emotional dynamics were less noticeable in video consultations:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eAnd also, when the mood somehow starts to change, I notice that much better in person than when I do it online. (S10, focus group 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eSome found that this made it more difficult to moderate video-based ethics consultations because it was easier to overlook certain aspects, such as a participant rolling their eyes. It was also noted that video consultations lowered the threshold for exiting a conversation, for example, by answering a phone call.\u003c/p\u003e\u003cp\u003e Some participants, however, characterised the reduced ability to convey emotions in video consultations as a benefit. They noted that a lesser degree of emotionality allowed for more \u0026ldquo;structured\u0026rdquo; consultations, and could protect participants from hierarchical and aggressive behaviour, for example, by senior hospital staff.\u003c/p\u003e\u003cp\u003eBy limiting each participant in an ethics consultation to their own \u0026ldquo;video square\u0026rdquo;, online consultations were regarded as promoting egalitarian communication:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eNow that (S11) has also said it, that everyone is actually very limited by their [video] square and somehow, everyone is practically standing next to each other, too, this may even have a more empowering effect, at least for some relatives and patients, that you don\u0026rsquo;t sit next to each other in this digital setting, so to speak, but rather that everyone gets their own protected space, but then very decidedly gets their own time. (S14, focus group 3)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Overall, ethics consultants found that they had to be more focused when moderating video-based consultations, for example, by checking that each participant had the ability to contribute to the conversation. However, this could also make ethics consultations more structured, particularly because the online format allowed moderators to have an eye on all individual participants:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eBut I think it works very, very well online, too, because in this Zoom format with these squares and so on, you really have all the participants in your view. Sometimes even better than with in-person consultations. Because, we sometimes have consultations in some kind of meeting room in the hospital. There you\u0026rsquo;ve got very long, narrow tables. Then it\u0026rsquo;s often difficult to keep an eye on all participants. (S02, focus group 1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up and debriefing\u003c/h2\u003e\u003cp\u003e Ethics consultants noted that informal opportunities for debriefing and follow-up, such as brief conversations while saying goodbye to participants in the hallway after an in-person consultation, were lost in video-based consultations. They stated that this posed the risk of leaving participants to process the emotional impact of the ethics consultation on their own:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eYes, the resonance is simply lacking. You don\u0026rsquo;t know what the people affected or the people who are present, how they will feel after the entire consultation. That is difficult to sense. Even if you have the feeling, oh dear, now we\u0026rsquo;re ending the entire session, and you have the feeling that you can\u0026rsquo;t really let them go home, but still, I don\u0026rsquo;t know. (S01, focus group 1)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Having the opportunity to debrief was also described as psychologically important for ethics consultants themselves, particularly after difficult case consultations. The ethics consultants therefore noted that follow-up meetings with participants and among themselves were particularly important in online settings. This could be realised via telephone or video conferencing.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eIncluding patients and relatives\u003c/h2\u003e\u003cp\u003eWhile remote ethics consultations have the advantage of potentially including relatives who live further away, several participants found it challenging to involve patients or their relatives in video consultations. Some found the online format inappropriate for addressing complex, emotionally challenging questions that deeply affected patients and their relatives, who often were experiencing personal crises. They noted that the lack of informal follow-up after a remote ethics consultation particularly affected these groups:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eBut if, for example, relatives are involved, for whom the situation has a completely different meaning, then I would always try to make use of an in-person meeting. I would also find it difficult, myself as a relative, if it was suggested to me that we\u0026rsquo;re negotiating, I\u0026rsquo;m going to put it a bit bluntly, we\u0026rsquo;re negotiating about the future of your mother or father today and we\u0026rsquo;ll do that here with these funny little colourful squares. And at some point the screen goes black and then I\u0026rsquo;m sitting there alone with this decision. I couldn\u0026rsquo;t take responsibility for that either, as a moderator, for example. (S06, focus group 2)\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e Some participants, however, found involving patients and relatives in ethics consultations challenging in general, independently of whether a consultation took place remotely or in person. They noted that successfully including patients in ethics consultations may require additional support, particularly for patients with disabilities. Yet, it was stressed that involving patients and relatives in ethics consultations is often essential to understand their perspectives and to gain a more complete understanding of the respective ethical issue.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAppropriate types of requests\u003c/h2\u003e\u003cp\u003eSome participants stated that remote formats were less appropriate for emotionally challenging consultations that have potentially serious consequences for patients or relatives, for example, in cases where patients had a wish for death, or when members of the treatment team were highly emotionally involved in the case. Some participants believed that concrete and urgent decisions should only be made in person because they are often emotionally charged.\u003c/p\u003e\u003cp\u003eSome viewed remote ethics consultations as particularly appropriate for preventative ethics consultations, training settings, consultations with participants the moderators already knew, or \u0026ldquo;factual\u0026rdquo; discussions that involved a lesser degree of emotionality.\u003c/p\u003e\u003cp\u003eOther participants, however, especially those who were more experienced with remote consultations, did not regard any topics as particularly suitable or unsuitable for video-based consultations.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eAttitudes and experiences\u003c/h2\u003e\u003cp\u003e In this study, we identified a range of experiences with and attitudes towards remote ethics consultations among ethics consultants in Germany. Participants reported using several remote technologies, including telephone and video conferencing. Telephone consultations were frequently used to quickly resolve an ethical question, so that full consultations did not become necessary. Participants reported using video consultations in clinical and outpatient settings, typically when in-person meetings were not feasible. Attitudes towards video consultations appeared to correlate with experience: those who had more experience using remote formats tended to evaluate them more positively. This could suggest that familiarisation to remote formats reduces initial scepticism. This is in line with research on remote consultations in other medical settings, which shows effects of familiarisation, increased acceptance and confidence through use (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eYet, it is also possible that consultants who already have positive attitudes towards such formats use them more often, while those with negative attitudes avoid them. Future research should examine this bidirectional relationship more systematically to determine whether training and usage alone can shift attitudes or if deeper professional values and expectations drive preferences towards remote formats.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eAdvantages and disadvantages\u003c/h2\u003e\u003cp\u003eParticipants identified several benefits of video-based consultations, including greater geographical reach, increased accessibility \u0026ndash; especially in underserved rural areas \u0026ndash;, the ability to include relatives who live far away and professionals from different institutions, and easier scheduling. These advantages align with broader arguments for the utility of telehealth consultations (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDisadvantages and points of scepticism included technical difficulties and challenges due to limited technological literacy. Notably, the areas most in need of remote formats - those with limited access to in-person ethics consultation - are often the very regions where internet infrastructure and technological competence are the weakest. This represents a structural challenge to equitable implementation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eInvolvement of patients and relatives\u003c/h2\u003e\u003cp\u003eA similar challenge emerged with respect to the involvement of patients and relatives in remote ethics consultations: while one important advantage of remote consultations is the possibility of including relatives more easily, participants in our study were sceptical regarding whether including relatives in video-based consultations was appropriate at all. In particular, they raised concerns regarding technical challenges and meeting relatives\u0026rsquo; emotional needs via remote formats. Similar concerns were raised regarding the participation of patients in remote consultations, although some participants also found it difficult to involve patients in in-person consultations. Thus, those who would arguably benefit most from additional opportunities to take part in ethics consultations are also those whose involvement is met with the greatest barriers.\u003c/p\u003e\u003cp\u003eThese findings resonate with the broader debate on patient involvement in ethics consultations (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e). While AEM guidelines recommend patient participation (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), research indicates that many ethics consultations in Germany do not involve patients (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e). On the one hand, excluding patients from ethics consultations seems problematic, as their perspectives are often essential to fully understand ethical conflicts (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e). However, it has also been argued that the routine involvement of patients in ethics consultations could cause harm, as this may lead to \u0026ldquo;needless fears, unjustified expectations or false hope\u0026rdquo; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Our findings highlight that ethics consultants often find including patients in ethics consultations difficult, and may find their involvement in remote formats even more challenging. However, simply assuming that patients or relatives cannot be included in consultations because of emotional or technical challenges appears to be based on paternalistic assumptions rather than on the attitudes of patients and relatives themselves. Hence, more research on the perspectives of these groups on ethics consultations in general (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e), and digital formats in particular, is needed.\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eThe role of emotions in online communication\u003c/h2\u003e\u003cp\u003eStudy participants highlighted the limited possibility of conveying non-verbal cues and expressing emotions in video-based consultations, which is in line with findings from other healthcare settings in which video consultations have been implemented (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Participants had diverging attitudes on how this impacted ethics consultations. Some found the equalising and structuring effects of video conferencing beneficial. They understood the limited expression of emotions in video consultations as a benefit in itself, as this could prevent specific participants from dominating the discussion. Others instead found the reduced expression of emotions disadvantageous, stating that this makes it difficult to involve relatives and patients, and makes remote formats less appropriate for emotionally charged, sensitive topics.\u003c/p\u003e\u003cp\u003eGenerally, the sensitive topics discussed in ethics consultations often lead to intense emotions such as irritation, anger, sadness, and grief (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Some ethics consultants regard emotions as distracting from the moral question and hindering ethical decision-making (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e), which leads some ethics consultants to encourage participants to distance themselves from their emotions (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Others, however, understand emotions as crucial for informing moral decision-making (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and regard them as a potential source of new insights, which makes acknowledging them essential (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Research also indicates that many healthcare professionals regard the opportunity to share difficult emotions and receive emotional support as one of the most important benefits of ethics consultations (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHow the role of emotions in ethics consultations is perceived - in general as well as in video-based consultations in particular -, might hinge on how ethics consultants understand their own role and the goals they believe ethics consultation should achieve. Haltaufderheide et al. (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e) distinguish two possible roles of ethics consultants. As part of an \u0026ldquo;analytical role\u0026rdquo;, ethics consultants act as moral problem solvers that identify, analyse and resolve ethical issues (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e43\u003c/span\u003e) by applying their knowledge to a case, explaining and clarifying normative concepts. The associated goal is to improve participants\u0026rsquo; ability to identify ethical issues and improve patient outcomes. As part of a \u0026ldquo;hermeneutic role\u0026rdquo;, on the other hand, ethics consultants act as observers and facilitators (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e44\u003c/span\u003e) that improve and enable effective communication between participants, help clarify individual moral perspectives, and communicate support and empathy to participants (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e45\u003c/span\u003e). As part of the latter role, ethicists can sometimes act as \u0026ldquo;conflict managers\u0026rdquo; that facilitate conversations between healthcare professionals, patients, and relatives. In this context, perceiving emotions and demonstrating empathy are central skills (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHence, it could be hypothesised that if ethics consultants primarily understand their role as an \u0026ldquo;analytical\u0026rdquo; one with the goal of coming to an ethically well-founded decision, they could be more likely to prefer digital formats that allow for structured discussions. In contrast, a more \u0026ldquo;hermeneutical\u0026rdquo; and empathetic role may be more difficult to realise in video-based consultations that do not allow for the full expression of non-verbal cues and emotions as well as physical touch, and lack opportunities for informal debriefing after sessions. This explains why some participants did not regard remote consultations as appropriate for certain emotionally charged topics.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003e To our knowledge, this is the first qualitative study on ethics consultants\u0026rsquo; experiences with and attitudes towards remote consultation formats \u0026ndash; particularly video-based consultations. Nonetheless, several limitations should be acknowledged. Due to its qualitative nature and small sample size, the findings of our study do not aim to be representative of the attitudes of all ethics consultants in Germany. However, our study included the perspectives of ethics consultants working in a range of different contexts and geographical areas.\u003c/p\u003e\u003cp\u003eThe study results may be biased towards positive experiences with remote formats, given that participants with more positive attitudes may have been more likely to participate. Additionally, the study does not include the perspectives of patients and relatives on remote formats, whose views are critical to evaluating the acceptability of remote ethics consultation. Future research should therefore include these important perspectives and examine how remote formats affect outcomes, satisfaction, and ethical decision-making processes from the perspectives of different stakeholders.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study provides important insights on ethics consultants\u0026rsquo; attitudes towards and experiences with remote formats, particularly video-based consultations. Our findings indicate that ethics consultants regard video-based ethics consultations as a feasible alternative when in-person meetings are not possible. The results demonstrate that further research on the effective implementation of remote ethics consultation is necessary to realise their advantages while mitigating possible disadvantages. In particular, the question of to what extent, and how, patients and relatives can be involved in remote consultations needs to be addressed, which requires further research on the perspectives of these groups. Our findings highlight that ethics consultants have developed a range of strategies to effectively employ remote consultations, for example specific measures for preparation, follow-up, and managing emotional dynamics remotely. This knowledge could be integrated into future training courses on remote ethics consultations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Research Ethics Committee of the University of Potsdam (registration number 69/2024). The study was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll focus group participants received information on the study in writing and via videoconference and gave verbal and written informed consent to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated during the current study are not publicly available to protect the privacy of the participants but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the VolkswagenStiftung as part of the Digital Medical Ethics Network (grant number 9B233).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to all participants for taking part in our study. We thank Clara Keusgen for her assistance with transcription, and Alexander Buschner for proofreading. We also thank the audience at the AEM Spring Conference 2025 for helpful comments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial study design was planned by EB, and all authors contributed to working out the study design in further detail. EB, RS and JH conducted the focus groups. EB, FF and JH performed the data analysis, and all authors participated in team discussions on the data analysis. EB wrote the initial draft of the manuscript. All authors revised the various drafts for important intellectual content. All authors gave their approval for the final version to be published. RR is the principal investigator for the research projects from which this paper originated.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTarzian AJ, Asbh Core Competencies Update Task F. Health care ethics consultation: an update on core competencies and emerging standards from the American Society For Bioethics and Humanities' core competencies update task force. Am J Bioeth. 2013;13(2):3\u0026ndash;13.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMilliken A, Monteverde S, Grace P. Models of Ethics Deliberation and Consultation. In: Grace P, Milliken A, editors. Clinical Ethics Handbook for Nurses. The International Library of Bioethics. Dordrecht: Springer; 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHajibabaee F, Joolaee S, Cheraghi MA, Salari P, Rodney P. Hospital/clinical ethics committees' notion: an overview. 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J Telemed Telecare. 2009;15(5):264\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePetrick N, Kreuzenbeck CCJ. [Effects of the Covid-19 Pandemic on Online Use of Video Consultation by General Practitioners in Germany - a Secondary Data Analysis of German Health Insurance Data]. Gesundheitswesen. 2023;85(3):188\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElsner P. Teledermatologie in den Zeiten von COVID-19 - ein systematisches Review. J Dtsch Dermatol Ges. 2020;18(8):841\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerbutavicius R, Brandlhuber U, Gluck S, Kortum GF, Kortum I, Navarrete Orozco R, et al. [Evaluation of patient satisfaction with an ophthalmology video consultation during the COVID-19 pandemic]. Ophthalmologe. 2020;117(7):659\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFord J, Reuber M. Comparisons of Communication in Medical Face-To-Face and Teleconsultations: A Systematic Review and Narrative Synthesis. Health Commun. 2024;39(5):1012\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalthall H, Schutz S, Snowball J, Vagner R, Fernandez N, Bartram E. Patients' and clinicians' experiences of remote consultation? A narrative synthesis. J Adv Nurs. 2022;78(7):1954\u0026ndash;67.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO'Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAkademie f\u0026uuml;r Ethik in der Medizin. Curriculum Ethikberatung im Gesundheitswesen. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.aem-online.de/fileadmin/user_ upload/Ethikberatung/Curriculum_Ethikberatung_im__Gesundheitswesen_2019-06-24__geaendert_am_\u003c/span\u003e\u003cspan address=\"https://www.aem-online.de/fileadmin/user_ upload/Ethikberatung/Curriculum_Ethikberatung_im__Gesundheitswesen_2019-06-24__geaendert_am_\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e \u003cspan\u003e12.22_.pdf. 2022.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuckartz U. Qualitative text analysis: a guide to methods, practice \u0026amp; using software. London: SAGE; 2014.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConnolly SL, Miller CJ, Lindsay JA, Bauer MS. A systematic review of providers' attitudes toward telemental health via videoconferencing. Clin Psychol (New York). 2020;27(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAlhajri N, Simsekler MCE, Alfalasi B, Alhashmi M, AlGhatrif M, Balalaa N, et al. Physicians' Attitudes Toward Telemedicine Consultations During the COVID-19 Pandemic: Cross-sectional Study. JMIR Med Inf. 2021;9(6):e29251.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNguyen AD, White SJ, Tse T, Cartmill JA, Roger P, Hatem S, et al. Communication during telemedicine consultations in general practice: perspectives from general practitioners and their patients. BMC Prim Care. 2024;25(1):324.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurdoch K. Hindering or Helping: Discussing Patient Participation in Clinical Ethics Support Service Deliberation. J Clin Ethics. 2025;36(1):9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations-a national survey. BMC Med Ethics. 2022;23(1):62.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eL\u0026ouml;bbing T, Carvalho Fernando S, Driessen M, Schulz M, Behrens J, Kobert KKB. Clinical ethics consultations in psychiatric compared to non-psychiatric medical settings: characteristics and outcomes. Heliyon. 2019;5(1):e01192.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHo A, Unger D. Power hierarchy and epistemic injustice in clinical ethics consultation. Am J Bioeth. 2015;15(1):40\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaissner M, Brunig L, Gaillard AS, Jieman AT, Gather J, Hempeler C. Intersectionality as a tool for clinical ethics consultation in mental healthcare. Philos Ethics Humanit Med. 2024;19(1):6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDuffy CMC, Benotsch EG. Nonverbal behavior in telehealth visits: A narrative review. Patient Educ Couns. 2025;132:108600.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFrittgen EM, Haltaufderheide J. Can you hear me?': communication, relationship and ethics in video-based telepsychiatric consultations. J Med Ethics. 2022;48(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpronk B, Widdershoven G, Alma H. The role of emotions in Moral Case Deliberation: Visions and experiences of facilitators. Clin Ethics. 2021;17(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBruns F, Frewer A. Ethics consultation and empathy. HEC Forum. 2011;23(4):247\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMolewijk B, Kleinlugtenbelt D, Widdershoven G. The role of emotions in moral case deliberation: theory, practice, and methodology. Bioethics. 2011;25(7):383\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSvantesson M, de Snoo-Trimp JC, Ursin G, de Vet HC, Brinchmann BS, Molewijk B. Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities. J Med Ethics. 2019;45(9):608\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaltaufderheide J, Nadolny S, Vollmann J, Schildmann J. Framework for evaluation research on clinical ethical case interventions: the role of ethics consultants. J Med Ethics. 2022;48(6):401\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFletcher JC, Siegler M. What Are the Goals of Ethics Consultation? A Consensus Statement. J Clin Ethics. 1996;7(2):122\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSteinkamp NL, Gordijn B, ten Have HA. Debating ethical expertise. Kennedy Inst Ethics J. 2008;18(2):173\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: nature, goals, and competencies. A position paper from the Society for Health and Human Values-Society for Bioethics Consultation Task Force on Standards for Bioethics Consultation. Ann Intern Med. 2000;133(1):59\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"clinical ethics support, ethics committees, moral case deliberation, digitization, digital communication, video conferencing","lastPublishedDoi":"10.21203/rs.3.rs-7261781/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7261781/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe use of remote methods such as video conferencing has the potential to improve access to ethics consultations, particularly in outpatient and rural healthcare settings. Although their use has increased significantly since the COVID-19 pandemic, little is known about ethics consultants\u0026rsquo; experiences with remote consultations so far.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e We conducted three focus groups with 14 certified ethics consultants in Germany in October 2024 to investigate their experiences with and attitudes towards remote ethics consultations. The data was analysed using structuring qualitative content analysis according to Kuckartz.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003e Participants reported experiences with a range of remote methods, including email, phone, and video-based ethics consultations. Video conferencing was primarily used when in-person meetings were not feasible. Attitudes towards video-based consultations varied, and consultants with more experience with this technology tended to view it more favourably. Reported advantages included improved accessibility, especially in rural areas, easier scheduling, and the ability to involve additional stakeholders. Disadvantages included technical challenges and concerns about privacy. Participants reported that video-based ethics consultations reduce non-verbal communication and emotional expression. According to some, this made video consultations more structured and egalitarian, while others found this disadvantageous. Participants emphasised the need for specific preparation for video-based ethics consultations, such as ensuring adequate technical set-up or assigning roles to monitor emotional dynamics. Possible challenges regarding the involvement of patients and relatives in remote consultations were noted. While some participants viewed remote formats as more suitable for less emotionally intense cases, others saw no inherent limitations regarding consultation topics.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur findings indicate that ethics consultants regard video-based remote consultations as a viable alternative when in-person meetings are not feasible. The study identified specific communicative challenges that should be addressed in training for ethics consultants. Further research is needed to explore the perspectives of patients and relatives on remote ethics consultations.\u003c/p\u003e","manuscriptTitle":"Experiences with remote ethics consultation: a qualitative study with ethics consultants in Germany","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-22 12:04:18","doi":"10.21203/rs.3.rs-7261781/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-27T04:01:18+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-13T12:58:35+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-12T11:57:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134662338204820623164965930106960298828","date":"2025-09-24T03:41:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189807627598485493246694200882689700306","date":"2025-09-22T07:21:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-03T14:10:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40883352514653913274517051513831833085","date":"2025-08-18T07:13:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291842998099230775056458674332807860448","date":"2025-08-14T10:16:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-14T09:25:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-14T09:13:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T07:53:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-12T12:59:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2025-08-12T12:56:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4e815523-079f-44c9-9a16-12bfa359447b","owner":[],"postedDate":"August 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:07:04+00:00","versionOfRecord":{"articleIdentity":"rs-7261781","link":"https://doi.org/10.1186/s12910-026-01401-x","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2026-02-10 15:58:20","publishedOnDateReadable":"February 10th, 2026"},"versionCreatedAt":"2025-08-22 12:04:18","video":"","vorDoi":"10.1186/s12910-026-01401-x","vorDoiUrl":"https://doi.org/10.1186/s12910-026-01401-x","workflowStages":[]},"version":"v1","identity":"rs-7261781","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7261781","identity":"rs-7261781","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}