road institutional structures have built up around CECs. They are supported by training, capacity development, and professional networking opportunities led by the Clinical Ethics Network + Research Ethics Support (CENTRES) project based in NUS. CECs also pursue their own educational and development work in their local clinical settings. In contrast to other countries, the creation of CECs in Singapore was mandated by primary legislation: the Private Hospitals and Medical Clinics Act. This has led to highly formalised terms of reference for CECs, in terms of the composition of the committee, and in its management and reporting structure.

In 2021, the regulatory landscape for CECs evolved further. New licensing terms and conditions were issued by the Ministry of Health in advance of the implementation of the Healthcare Services Act. Amongst other developments, these revised terms and conditions extend the remit of ethics review to non-hospital licensees—including nursing homes. Health and care settings outside of hospitals may establish their own CECs if they can meet the requirements or, alternatively, they can refer their cases to an external CEC, if an agreement is put in place.

As CECs continue to develop so does Singapore’s overarching strategy for health and care provision. In an ageing society, there is increasing recognition of the central role that integrated, community-based health and social care delivery models will play. As these models are implemented, difficult and entirely new questions arise for the delivery of ethical care. These questions include ethical concerns that arise in home-based care, such as the appropriate use of assistive technologies, monitoring devices, the boundaries between private and public space, and the meaning of person- and family-centred care in the home environment. Ethical uncertainty will likely also arise because of professional and ethical responsibilities being dispersed across a much-wider network of caregiving roles and activities. This important feature of community-based care is discussed further below.

In the face of new ethical challenges and new strategies for delivering healthcare and support within our communities, we must also ask: Does the CEC model remain fit for purpose? In my view, there are good reasons to pursue a new paradigm of ethics support.

Why is this the case? I turn to the features of institutional settings in the community context first. Whilst the new licensing terms and conditions ensure that non-hospital-based care institutions like nursing homes can access ethics committee review of difficult cases, community-based care services differ from acute services in important ways. It is fair to say that a nursing home does not feel very much like a hospital, and such differences are not solely explained by reference to the different services provided.

In contrast to a hospital, it is less common for external professionals to enter nursing homes to provide guidance or advice. There tends to be more scepticism towards ‘outsiders’ amongst nursing home staff, given the close-knit nature of many professionals working in a single institutional setting. Fear and doubt can also be fostered amongst nursing home staff when there is limited public awareness about their jobs beyond occasional media reports highlighting scandals in care quality.

Encouraging discussions to focus on the good and bad of decision-making is only likely to heighten staff members’ concerns that their performance is being subject to external (negative) judgement. The word ‘ethics’ itself is likely to give rise to confusion and uncertainty. Formalising discussions about ethical issues could also further foster concerns amongst staff members that the ethicist is looking to unearth problems in the nursing home that could have implications for their employment status, or the home’s reputation more generally.

Turning next to the broader landscape of health and care delivered in the community, other differences in the approach to providing care in this context draw our attention to further worries about relying solely on CECs.

Integrated community services are diffused, decentralised, and involved a wide range of health and care professionals. Care interventions delivered in the community—within housing blocks and within people’s own homes—also increasingly involve paraprofessional caregivers, such as befrienders and foreign domestic workers, and unpaid carers, such as family members and neighbours. A committee model to shape care practice and caregiving is likely to be unfamiliar to these individuals, especially if that committee is based within a hospital and those issuing advice are hospital practitioners with limited awareness of the realities of community-based practice.

Additionally, a larger contingent of migrant caregivers is likely to be present in community settings, but the lower skill-base associated with the social care professions means that it is possible that these individuals will have a poorer grasp of shared languages, and therefore find it more difficult to participate in ethical discussions. Just as importantly, current research being undertaken by one of my doctoral students, Kumeri Bandara, is revealing that migrant social care workers in the UK rely frequently on informal networks of support to address the day-to-day challenges that arise in their jobs. This includes friends and family outside of the workplace, in addition to close/trusted colleagues at work.

For all these reasons, seeking advice from a CEC may be looked upon suspiciously, or will simply not be fit for purpose in community-based care settings. If this is the case, opportunities for ethics support will likely be poorly utilised, even though frontline caregivers may be encountering distinctive ethical challenges they struggle to resolve.

Where do we go from here? As I have argued elsewhere, the ideal approach is to foster the development of “a model of ethics support that can be implemented straightforwardly in the different settings in which care is provided, and that can incorporate skill development and training components within a self-reflective and formative approach to addressing ethical issues.” (Hope and Dunn, 2014).¹

In my view, alternative approaches of this kind will need to be configured, in a bottom-up fashion, as part of the grassroots design of new care delivery models. They will need to be responsive to the perceived ethical needs of caregivers (professional or not) and be largely informal in design—at least to begin with. Informal processes are more likely to be integrated more seamlessly into professionals’ working lives in the community, helping to ensure that ethics advice is welcomed as an adjunct to, rather than a distraction from, the fulfilment of daily routines.

It is also likely that any approach to ethics support of this kind will need to be embedded within existing community institutions, as opposed to being formally attached to, located in and managed by a hospital or other healthcare institution. As the full integration of care services in the community evolves further, informal structures for providing ethics support might even be best configured and organised at the level of the housing block, or within local neighbourhoods.

Any such model will also need to be inclusive, recognising that much of the care and support work in this context is provided by non-professionals. Family, volunteers, domestic workers and neighbours should increasingly be seen as part of a broad team of care providers who may benefit from ongoing access to ethics support and advice.

Looking at the particulars of this new paradigm of ethics support, a case can be made for the development of networks of community practitioners in ethics, and the use of open, relaxed, and deliberative meetings. Ethics support encounters that enable people with wide-ranging experiences and different responsibilities to adopt a self-reflective but critical stance on the difficult decisions they face, will be important. In this way, ethics support initiatives are likely to have an equally important educational function for caregivers who lack the formal training in ethics received in, for example, medical schools and nursing schools. Ultimately, the appropriateness of any contextual approach to ethics support will depend on how the institutional environment is configured, and the unique dynamics of the community setting within which ethics support activities will be situated.

In conclusion, careful thought needs to be given to a new paradigm of ethics support that is fit for purpose as Singapore increasingly pivots towards integrated and community-based health and care services. Attention will also need to be paid to the resources and steps needed to realise this ‘call to arms’. CECs will undoubtedly remain an important component of any new strategy for ethics support, continuing to provide a formalised mechanism to advise on high-profile dilemmas particularly in the medical setting. But, whilst necessary, they will not be sufficient.

1. Hope, T. and Dunn, M. (2014). ‘The ethics of long-term care practice: A global call to arms’, in A. Akabayashi (ed.) The Future of Bioethics: International dialogues. Oxford: Oxford University Press, pp. 628-643.