Clinical ethics consultants (CECs) are not moral authorities. Standardization of CECs’ professional role does not confer upon them moral authority. Certification of particular CECs does not confer upon them moral authority (nor does it reflect such authority). Or, so we will argue. This article offers a distinctly Orthodox Christian response to those who claim that CECs—or any other academically trained bioethicist—retain moral authority (i.e., an authority to know and recommend the right course of action). This article proceeds in three parts. (...) First, we discuss recent movements toward the certification of CECs in the United States, focusing primarily on proposals and programs put forth by the American Society for Humanities and Bioethics (ASBH). Second, we outline two secular reasons to be concerned about the relevant trends toward certification. For one thing, certification is currently being advanced via political dominance, rather than gaining authority by reliance on rigorous philosophical argument or reason. For another, the trends operate on the assumption that there exists a secular, content-full, canonical, morality. There is no such morality. Next, we argue that Orthodox Christians should resist the current trends toward certification of CECs. Specifically, we unpack ways in which the ASBH’s certification program (and those like it) conflict with Orthodox claims about moral authority and the moral life more generally. We conclude that Orthodox Christians should resist the current certification trends. (shrink)

Timothy Murphy argues in his article “In Defense of Irreligious Bioethics” (2012) that the role of religion in normative bioethics should be limited and that a viable means for limiting its role (o...

David Denz; Bioethics and the Literature of Pluralism, Christian bioethics: Non-Ecumenical Studies in Medical Morality, Volume 7, Issue 3, 1 January 2001, Pages.

The nature of the doctor–patient relationship is central to the practice of medicine and thus to bioethics. The American Medical Association (in AMA principles of medical ethics, available at: https://www.ama-assn.org/delivering-care/ethics/patient-physician-relationships, 2016) states, “The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.” In this issue of Christian Bioethics, leading scholars consider what relevance (if any) Christianity (...) brings to the relationship between physician and patient: does Christianity make a difference? The contributors consider this question from several different perspectives: the proper model of medicine, the role that the Christian moral tradition can play in medicine in a secular pluralistic society, how a Christian understanding of virtue can inform practices such as perinatal hospice and physician-assisted suicide, and whether or not appeals to Christian values can (or should) ground a physician’s right to conscientious objection. (shrink)

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in (...) medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians. Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease. (shrink)

From time to time medical ethicists bemoan the loss of a religious perspective in medical ethics. The discipline had its origins in the thinking of explicitly religious thinkers such as Paul Ramsey and Joseph Fletcher. Furthermore, many of those who contributed to the early development of the discipline had training in theology. One thinks of Daniel Callahan, Richard McCormick, Albert Jonsen, Sam. Banks. As the discipline becomes more and more self-reflective, with attention being paid to methodological and conditional concerns, it (...) is only natural that the roots are due for a reexamination. The time has therefore come for some reassessment. The first steps here are taken in the form of a dialogue between the coauthors to clarify authentic contributions and weed out unauthentic ones. (shrink)

Let us look at autonomy in a new way. Autonomy has a richly deserved place of honor in bioethlcs. It has led the set of principles that formed the basis of the discipline since the beginning. It is the leading principle In what is now regularly called “the Georgetown Mantra,” a phrase suggested by one of the first philosophers ever to be hired In a medical school, K. Danner Clouser. The phrase applies to the principled approach of autonomy, beneficence, nonmaleficence, (...) and justice. This kind of bioethics was developed by scholars like Beauchamp and Childress, Veatch, and Engelhardt, during their association with Georgetown University. (shrink)

Evaluation scales are used in the care of elderly people. They are useful for estimating the workload, the necessary resources, the care cost, the patient’s dependency or autonomy in daily life, and/or the patient’s needs. The large number of grids already indicates their insufficiency.This article explores the stakes implied by the evaluations, which use concepts more or less clearly defined as autonomy, dependency, deficiency, incapacity. It also questions our understanding of interdependence, vulnerability, and responsibility, and their implications in the care (...) relations with elderly people. (shrink)

As climate change risks intensify, I welcome Ray and Cooper’s call for bioethicists to engage with environmental injustice, though I am pessimistic it is another false dawn for bioethics engagement...

(2005). Between Morality and Repentance: Recapturing “Sin” for Bioethics. Christian Bioethics: Vol. 11, No. 2, pp. 93-132.

McCarthy et al.’s proposal gains much of its plausibility by relying on a superficial treatment of justice, human dignity, sin, and the common good within the Christian tradition. Upon closer inspection of what these terms mean within the context of Christianity, it becomes clear that despite using the same phrases (e.g., a commitment to “protecting vulnerable populations,” the goal of “promoting justice,” etc.) contemporary secular bioethical goals are often deeply at odds with goals of Christian bioethics. So, while the authors (...) are right that there is room for dialogue (and even agreement) concerning general moral principles, the process of specification and application of these principles will often be heavily influenced by competing ethical traditions. Such divergent influences will often frustrate cooperative ventures between secular and religious bioethical projects. Thus, when put into action, McCarthy et al.’s proposal will—at best—produce a divided kingdom; one that cannot hope to stand. (shrink)

Jake Greenblum and Ryan K Hubbard argue that physicians, nurses, clinical ethicists and ethics committee members should not cite religious considerations when helping patients (or their proxies) make medical decisions. They provide two arguments for this position: The Public Reason Argument and the Fiduciary Argument. In this essay, I show that the Public Reason Argument fails. Greenblum and Hubbard may provide good reason to think that physicians should not invoke their own religious commitments as reasons for a particular medical decision. (...) But they fail to show that it is wrong for physicians to cite the patient’s own religious commitments as reasons for a particular decision. As such, if Greenblum and Hubbard’s thesis is to survive, the Fiduciary Argument (or some unmentioned argument) will have to do the bulk of the work. (shrink)

There are numerous ways in which “the particular”—particular individuals, particular ideologies, values, beliefs, and perspectives—are sometimes overlooked, ignored, or even driven out of the healthcare profession. In many such cases, this is bad for patients, practitioners, and the profession. Hence, we should seek to find a place for the particular in health care. Specific topics that I examine in this essay include distribution of health care based on the particular needs of patients, the importance of protecting physicians’ right to conscientious (...) objection, the value in tolerating a plurality of moral and medical perspectives within the field, and more. Ultimately, as the imagery in the essay’s title suggests, I argue that if one cares about the “well-being” of the medical profession, then one should seek to avoid destroying the many diverse and particular entities that constitute it. (shrink)

This article explores the limits of secular philosophy and philosophical reason. It argues that once one abandons God, philosophical reason is unable to establish any particular bioethics or understanding of morality as canonical; that is, as definitively true and binding. Philosophy simply cannot secure the truth of any particular account of the right, the good, the just, or the virtuous. Once one abandons God, all is approached as if it were without ultimate meaning. Throughout, the article explores H. Tristram Engelhardt (...) Jr’s arguments in After God: Morality and Bioethics in a Secular Age, which confronts this major intellectual and cultural crisis. As Engelhardt remind us, traditional Christianity is not a life-style choice, much less another meta-narrative that one chooses and writes for oneself. It is an encounter with God, Who changes everything. Christian bioethics must be appreciated in terms of an encounter with and an authentic experience of God, Whose commands will routinely conflict with the moral dictates of secular morality. (shrink)

Commentators routinely urge that it is morally permissible forcibly to treat psychiatric patients (1) to preserve the patient's best interests and (2) to restore the patient's autonomy. Such arguments specify duties of beneficence toward others, while appreciating personal autonomy as a positive value to be weighted against other factors. Varying by jurisdiction, legal statutes usually require, in addition, at least (3) that there exists the threat of harm to self or others. In this paper, I argue against embracing the first (...) two elements of this prevailing view. I also argue for a very restricted reading of the third element, based on the moral limits of permissible state action. (shrink)

The goal of my comments regarding the case study of Eve Hyde — presented in the introduction of this symposium — is not first and foremost to resolve the conflict between individual autonomy and medical paternalism regarding non-consensual psychiatric treatment. Instead, the goal is to step back far enough from what is generally accepted as the morally appropriate basis for non-consensual psychiatric treatment, including involuntary hospitalization and medication, and to ask very basic questions about when patients may permissibly be treated (...) without their consent. My goal, in short, is Socratic — to explore aspects of what we take for granted in order better to determine whether we ought to take them for granted. Commentators routinely urge that it is morally permissible forcibly to treat psychiatric patients, such as Eve Hyde, in order to preserve the patient’s best interests and restore the patient’s autonomy. Such arguments typically specify duties of beneficence toward others, while appreciating personal autonomy as a positive value to be weighed against other factors. (shrink)

This issue of The Journal of Medicine and Philosophy assesses the deep and abiding tensions that exist among the competing epistemic perspectives that bear on medicine and morality. Concepts of health and disease, as well as the theoretical framing of medical ethics and health care policy, intersect with an overlapping set of culturally situated communities, striving to understand and manipulate the world in ways that each finds explanatory, appropriate, or otherwise befitting. The articles explore the complexities of framing public health (...) care policy to guide bioethical decision making in the face of the plurality of ethical viewpoints and moral rationalities—including health enhancing supplements, continuous sedation until death, medical futility, the protection of vulnerable populations, and competing professional obligations. (shrink)

This article raises three challenges to Richard McCormick's proportionalism. First, adequately to judge proportionate reason requires the specification of a particular background moral content and metaphysical context. Absent such specification, evaluation of proportionate reason is inherently and deeply ambiguous. Second, to resolve such ambiguity and yet remain Christian, proportionalism must adopt a forthrightly Christian moral content set within a straightforwardly Christian metaphysics. This move will, however, set Christian bioethics off as sectarian—a conclusion McCormick wishes to avoid. Third, even if proportionalism (...) were to adopt a Christian moral content and metaphysics to avoid such ambiguity, its methodology sets aside a key aspect of the Christian life: repentance. Proportionalism does not account for the core reality that repentance plays in one's personal encounter with and knowledge of God. As I will argue, the challenge in part is that moral action cannot be adequately conceptualized, nor can moral theology be properly understood, outside of the authentic practice of the religious life, and repentance is central to that Christian reality. (shrink)

Mark J. Cherry; Foundations of the Culture Wars: Compassion, Love, and Human Dignity, Christian bioethics: Non-Ecumenical Studies in Medical Morality, Volume 7.

How can we definitively determine which biomedical choices are morally correct and which engage in seriously wrongful acts? Depending on whom one asks, one is informed that choices such as abortion, euthanasia, and significant body modification involve real moral harm (either as forms of murder or as denying the goodness of the body that God has provided), or that disallowing such “medical care” violates the basic rights of persons (where abortion, active euthanasia, and body modification are appreciated as positive expressions (...) of personal autonomy). Secular bioethics appears no longer able to appreciate what could possibly be wrong with such activities, provided that the individuals involved consent in some fashion. Indeed, many actions that were once openly and easily recognized as sinful have become so commonplace, as well as politically desirable, as to appear as if they were obviously good. As the authors in this issue of Christian Bioethics explore, fully to appreciate the serious moral issues raised by modern medicine requires a foundational orientation to the Christian God. (shrink)

The day-to-day work of clinical ethics consultants and healthcare ethics committees can easily become overly routine. Too much routine, however, comes with a risk that morally important practices will be reduced to mere bureaucratic formalities, while practitioners become desensitized to ethically significant distinctions between cases. Clinical ethics consultation and organizational ethics must be set within the broader social and cultural context of the healthcare environment. This practice requires looking beyond mere legal compliance and the routinely false assumption that there are (...) unambiguous ethical norms that easily govern clinical ethics and hospital policy formation. Together the essays in this issue of HEC Forum challenge readers to rethink taken-for-granted assumptions regarding patient care, physician obligation, clinical ethics consultation, and organizational ethics. (shrink)

Power tends to corrupt and absolute power corrupts absolutely. To be clear, I do not think that blood transfusions necessarily...

In After God: Morality & Bioethics in a Secular Age, Professor H. Tristram Engelhardt, Jr. argues that the now dominant intellectual culture of the West actively shuns any transcendent point of orientation, such as an appeal to God or to a God’s eye perspective on reality. Instead, it seeks to frame its understanding of reality and morality, and thus its bioethics, without reference to any foundation outside of particular human concerns. This article explores the implications of living in a secular (...) culture that eschews any appeal to a fully objective perspective on reality. Drawing on Engelhardt’s analysis, it argues that absent access to a binding moral standpoint that is not already conditioned by a particular society, culture, or place in history, all moral and bioethical commitments are merely contingent, subject to particular human interests, aesthetic inclinations, personal intuitions, idiosyncratic choices, and political objectives. (shrink)

Bioethicists often remind health care professionals to pay close attention to issues of diversity and inclusion. Approaches to ethics consultation, where the perspective of the bioethicist is taken to be more morally correct or necessarily authoritative, have been critiqued as inappropriately authoritarian. Despite such apparent recognition of the importance of respecting moral diversity and the inclusion of different viewpoints, authoritarianism is all too often the approach adopted, especially as bioethics has shifted evermore into concerns for public policy. Yet, secular values (...) and philosophical principles are not morally neutral; nor are the private moral convictions of bioethicists. Such analysis is always grounded in particular understandings of the right and the good, the virtuous and the just. Critical examination of common treatments and new alternatives is essential for the careful scientific practice of medicine. The same is true with regard to bioethics. Stagnating in customary or accepted claims of a common secular morality or a standard set of bioethical principles out of an unwillingness to explore the real diversity of moral thought, including traditional religious and cultural worldviews, fails to tap the human capacity to find innovative solutions to the complex challenges facing medicine. (shrink)

A comprehensive analysis of the evolving conditions that provided for the emergence and autonomization of the field of bioethical inquiry, as well as the social, cultural and political background against which its birth can be set, should enlighten us about the problematic nature that characterises it from its very onset. Those conditions are: abuses in experimentation on human subjects, availability of new biomedical technologies, the challenging of prevalent medical paradigms and the ultimate meaning and purpose of medical care, new scientific (...) and social fields of concern dealing with ecology and environmental health, genetic engineering and biotechnologies, demographics, behavioural manipulation, reproductive medicine, etc., the upsurge of social movements raising issues of medical importance, and the need for an ethics for the technological age. The scope and meaning of bioethics is best defined by the overriding questions that open up the field of both theoretical and practical bioethical inquiry rather than by the individual responses given to such questions by the most prominent spokesmen in bioethics. (shrink)

Moral pluralism poses a foundational problem for secular clinical ethics: How can ethical dilemmas be resolved in a context where there is disagreement not only on particular cases, but further, on...

Robert Card has proposed a reasonability view of conscientious objection that asks providers to state the reasons for their objection for evaluation and approval by a review board. Jason Marsh has challenged Card to provide explicit criteria for what makes a conscientious objection reasonable, which he claims will be too difficult a task given that such objections often involve contentious metaphysical or religious claims. Card has responded by outlining standards by which a conscientious objection could be judged reasonable. In this (...) paper, I extend Marsh’s critique to key concepts in the standards outlined by Card such as abortifacient, harm, emergency, and discrimination, showing they can be given radically different interpretations given different metaphysical or religious presumptions. To resolve these conflicting interpretations, a reasonability view of conscientious objection will need more than the criteria outlined by Card, it will need the resources to evaluate the reasonability of metaphysical or religious claims. (shrink)

One of the most significant and persistent debates in secular clinical ethics is the question of ethics expertise, which asks whether ethicists can make justified moral recommendations in active patient cases. A critical point of contention in the ethics expertise debate is whether there is, in fact, a bioethical consensus upon which secular ethicists can ground their recommendations and whether there is, in principle, a way of justifying such a consensus in a morally pluralistic context. In a series of recent (...) articles in this journal, Janet Malek defends a positive view of ethics expertise, claiming that secular ethicists should comport their recommendations with bioethical consensus. In response, Nick Colgrove and Kelly Kate Evans deny the existence of a secular bioethical consensus; question why, even if it did exist, consensus should be considered a reliable way of resolving bioethical questions; and recommend a friendlier approach to clinical ethics based on the thought of H. Tristram Engelhardt Jr. In this article, I respond to Colgrove and Evans on all three points. In part one, I show there is a secular bioethical consensus but note it could be better consolidated and created through a more systematic and inclusive process. In part two, I argue that bioethical consensus is morally justified but note that this justification cannot be plausibly based upon claims that it only invokes moral principles available to or shared by all. In part three, I argue Engelhardt’s approach cannot be described as “friendlier” to clinical ethics because it is incompatible with many current healthcare laws and policies. (shrink)

This paper discusses the relation between medical ethics and general moral theory, the argument being that medical ethics is best seen as independent from general moral theory. According to this independence thesis, here explicated in terms of what is called a disunitarian stance, the very idea of applied ethics, which is often seen as underlying medical ethics, is misguided. We should instead think of medical ethics as a domain-specific ethical inquiry among other domain-specific ethical inquiries. On this alternative kind of (...) picture, such ethical inquiries should start with looking at the particularities of the domain under consideration and then proceed from there. Some possible consequences of this idea for medical ethics are then identified and discussed. (shrink)

In writing The Way of Medicine: Ethics and the Healing Profession, Farr Curlin and Christopher Tollefsen have provided a helpful, accessible resource for clinicians seeking to conscientiously practice medicine in pursuit of health. These authors identify a major threat to such a practice, which they call the provider of services model (PSM), and compare it to a historic way of practicing that they seek to recover, called the Way of Medicine. Throughout the book, they contrast the PSM and the Way (...) in ways that are helpful. However, the process of continual contrasts and the reliance on controversial cases presents several counter-productive drawbacks that weaken their project. (shrink)

ZusammenfassungIn der Medizinethik sind der Respekt vor der Patientenselbstbestimmung, das Nichtschadensgebot, das Handeln zum Wohl des Kranken und das Gerechtigkeitsgebot praxisrelevante Prinzipien. Anhand des Beispiels der Frühintervention und Akutbehandlung schizophrener Störungen wird aufgezeigt, dass es in der psychiatrischen Praxis zu einer Kollision dieser Prinzipien kommen kann. Der frühe Krankheitsbeginn und der häufig chronische Verlauf schizophrener Störungen führen zu großem Leid der Betroffenen und ihrer Angehörigen sowie zur ökonomischen Belastung der Solidargemeinschaft. Die negativen Folgen einer verzögerten Intervention stehen den Risiken der (...) Stigmatisierung sowie den möglichen Nebenwirkungen durch die psychotherapeutische oder psychopharmakologische Behandlung gegenüber. Es wird für eine an der konkreten Situation orientierte, lebensnahe und dynamische Ethik plädiert, die vom konkreten Fall aus diskutiert und verschiedene Perspektiven berücksichtigt – mit dem Ziel von einer Arztethik und Patientenethik zu einer Verantwortungspartnerschaft zu gelangen. (shrink)

I served as a medical student and resident in the 1960s. Science as a belief system had reached a pinnacle. Yet Not infrequently in those days, I found myself caring, with little available backup, for a hospital ward filled with sick and dying people. It was a lonely and often frightening responsibility. I began to encounter situations that were at odds with our collective certainty that science would provide the answers. Some of these memories I repressed for almost a decade. (...) I was unable to process them until I had personally experienced a more humanistic side of medicine. (shrink)

OBJECTIVES: This study was designed to identify and compare the attitudes of patients and health care professionals towards advance directives. Advance directives promote recognition of the patient's autonomy, letting the individual exercise a certain measure of control over life-sustaining care and treatment in the eventuality of becoming incompetent. DESIGN: Attitudes to advance directives were evaluated using a 44-item self-reported questionnaire. It yields an overall score as well as five factor scores: autonomy, beneficence, justice, external norms, and the affective dimension. SETTING: (...) Health care institutions in the province of Québec, Canada. Survey sample: The sampling consisted of 921 subjects: 123 patients, 167 physicians, 340 nurses and 291 administrators of health care institutions. RESULTS: Although the general attitude of each population was favourable to the expression of autonomy, multivariate analysis of variance (MANOVA) indicated that physicians attached less importance to this subscale than did other populations (p < .001). Above all, they favoured legal external norms and beneficence. Physicians and administrators also attached less importance to the affective dimension than did patients and nurses. Specifically, physicians' attitudes towards advance directives were shown to be less positive than patients' attitudes. CONCLUSION: More attention should be given to the importance of adequately informing patients about advance directives because they may not represent an adequate means for patients to assert their autonomy. (shrink)

A critical examination of contemporary nursing theory suggests that two distinct discourses coexist within this field. On the one hand, proponents of the ‘knowledge discourse’ argue that nurses should drop the ‘virtue script’ and focus on the scientific and technical aspects of their work. On the other hand, proponents of the ‘caring discourse’ promote a view of nursing that embodies humanistic qualities such as compassion, empathy and mutuality. In view of this, we suggest a way to reconcile both discourses despite (...) the fact that they appear to be at odds theoretically and practically. To that end, we argue that nursing theory must give a prominent role to the Aristotelian conception of virtue, and we offer an account that includes both character and intellectual virtues. This account allows for a focus on moral competence but also accommodates the demands for discipline‐specific knowledge. Our account incorporates the caring discourse by suggesting a way for individuals to cultivate the conditions within themselves that make ‘caring in nursing’ possible, while the knowledge discourse is accommodated via the acquisition of the intellectual virtues. The process for achieving both these ends is the same: an intention to consistently develop, hone and exercise certain character traits over time. (shrink)

The case of Charlie Gard, an infant with a genetic illness whose parents sought experimental treatment in the USA, brought important debates about the moral status of parents and children to the public eye. After setting out the facts of the case, this article considers some of these debates through the lens of parental rights. Parental rights are most commonly based on the promotion of a child’s welfare; however, in Charlie’s case, promotion of Charlie’s welfare cannot explain every fact of (...) the case. Indeed, some seem most logically to extend from intrinsic parental rights, that is, parental rights that exist independent of welfare promotion. I observe that a strong claim for intrinsic parental rights can be built on arguments for genetic propriety and children’s limited personhood. Critique of these arguments suggests the scope of parental rights remains limited: property rights entail proper use; non-personhood includes only a small cohort of very young or seriously intellectually disabled children and the uniqueness of parental genetic connection is limited. Moreover, there are cogent arguments about parents’ competence to make judgements, and public interest arguments against allowing access to experimental treatment. Nevertheless, while arguments based on propriety may raise concerns about the attitude involved in envisioning children as property, I conclude that these arguments do appear to offer a prima facie case for a parental right to seek experimental treatment in certain limited circumstances. (shrink)

The literature on conscientious objection in medicine presents two key problems that remain unresolved: Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections? How does one respect both medical practitioners’ claims of conscience and patients’ interests, without leaving practitioners complicit in perceived or actual wrongdoing? My aim in this paper is to offer a new framework for conscientious objections in medicine, which, by bringing (...) medical professionals’ conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: an “Uber Conscientious Objection in Medicine Committee” —which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population—should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; medical practitioners should advertise their conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners. (shrink)

Background Older patients are often vulnerable and highly dependent on healthcare professionals’ assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. Aim To describe ambulance clinicians’ understanding of older patients’ self-determination when the patient’s decision-making ability is impaired. Research design A qualitative (...) design with an inductive approach, guided by descriptive phenomenology. Participants In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. Ethical considerations The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. Findings The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient’s best interests. The clinicians’ interpretations are based on an understanding of the patient’s situation using substitute decision-making in emergency situations and conversations that reveal the patient’s explicit wishes. Sometimes the clinicians collaborate to validate the patient’s implicit will, while they at other times subordinate themselves to others’ opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient’s self-determination. Conclusion The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient’s unique needs based on a holistic perspective and their ability to be autonomous. (shrink)

The debate continues about whether people have a duty to pass on the positive results of their genetic tests to relatives who are at risk from the same disease, and, should they refuse, whether physicians and genetic counselors then have the duty to do so. To date, the role and views of nurses in this debate have not been investigated. In our study, a sample of Israeli nurses, untrained in genetics, were asked for their theoretical opinions and what practical steps (...) they would take in the case of patients' refusal to disclose. The nurses were very sure that patients should inform their families but were equally sure that nurses must respect their decision to disclose or not. Few said they would take practical steps to disclose information if the patient objected. The authors believe that the most useful and appropriate role for nurses in this field is in working to bring about co-operation between patients and family members. (shrink)

Professor Jecker (2008) argues that a broader conception of justice in allocating health care resources would focus moral attention on how the determinants of socioeconomic marginalization unfairly...