Palliative care and euthanasia have become the subject of ethical and political debate in Poland. However, the voice of nurses is rarely heard. The aim of this study is to explore the perception of palliative care and euthanasia among recent university bachelor degree graduates and experienced nurses in Poland. Specific objectives include: self-assessment of the understanding of these terms, recognition of clinical cases, potential acceptability of euthanasia, and an evaluation of attitudes towards palliative care and euthanasia. This is an exploratory (...) study. A convenience sample of 206 recent graduates and 252 experienced nurse practitioners were interviewed. A structured questionnaire was used for collecting and interpreting data. Subjective perception of the terms `palliative care' and `euthanasia' was high and consistent with the recognition of clinical cases. The majority of the nurses excluded euthanasia from palliative care. They recognized personal philosophy of life as the most influential factor affecting attitudes towards euthanasia. The importance of the law was valued more highly by the experienced nurses. (shrink)

The medical assessments of criminal responsibility and competence to consent to treatment are performed, developed and debated in distinct domains. In this paper I try to connect these domains by exploring the similarities and differences between both assessments. In my view, in both assessments a decision-making process is evaluated in relation to the possible influence of a mental disorder on this process. I will argue that, in spite of the relevance of the differences, both practices could benefit from the recognition (...) of this similarity. For cooperative research could be developed directed at elucidating exactly how various mental disturbances can affect decision-making processes. (shrink)

Over the past decade, the ideal model of shared decision-making has been increasingly promoted as the preferred standard of doctor-patient communication in medical consultation. The model advocates a treatment decision-making process in which the doctor and his patient are considered coequal partners that carefully negotiate the treatment options available in order to ultimately reach a treatment decision that is mutually shared. Thereby, the model notably leaves room for—and stimulates—argumentative discussions to arise in the context of medical consultation. A paradigm example (...) of a discussion that often emerges between doctors and their patients concerns antibiotics as a method of treatment for what is presumed to be a viral infection. Whereas the doctor will generally not encourage treatment with antibiotics, patients oftentimes prefer the medicine to other methods of treatment. In this paper, two cases of such antibiotic-related discussions in consultation are studied using insights gained in the extended pragma-dialectical theory to argumentation. It is examined how patient and physician maneuver strategically in order to maintain a balance between dialectical reasonableness and rhetorical effectiveness, as well as an equilibrium between patient participation and evidence-based medication, while arguing a case for and against antibiotics respectively. (shrink)

Resource allocation decisions are often made on the basis of clinical and cost effectiveness at the expense of ethical inquiry into what is acceptable. This paper proposes that a more compassionate model of resource allocation would be achieved through integrating ethical awareness with clinical, financial and legal input. Where a publicly-funded healthcare system is involved, it is suggested that having an agency that focuses solely on cost-effectiveness leaving medical, legal and ethical considerations to others would help depoliticise rationing decisions and (...) command greater public acceptance. (shrink)

Moral decision procedures such as principlism or casuistry require intuition at certain junctures, as when a principle seems indeterminate, or principles conflict, or we wonder which paradigm case is most relevantly similar to the instant case. However, intuitions are widely thought to lack epistemic justification, and many ethicists urge that such decision procedures dispense with intuition in favor of forms of reasoning that provide discursive justification. I argue that discursive justification does not eliminate or minimize the need for intuition, or (...) constrain our intuitions. However, this is not a problem, for intuitions can be justified in easy or obvious cases, and decision procedures should be understood as heuristic devices for reaching judgments about harder cases that approximate the justified intuitions we would have about cases under ideal conditions, where hard cases become easy. Similarly, the forms of reasoning which provide discursive justification help decision procedures perform this heuristic function not by avoiding intuition, but by making such heuristics more accurate. Nonetheless, it is possible to demand too much justification; many clinical ethicists lack the time and philosophical training to reach the more elaborate levels of discursive justification. We should keep moral decision procedures simple and user-friendly so that they will provide what justification can be achieved under clinical conditions, rather than trying to maximize our epistemic justification out of an overstated concern about intuition. (shrink)

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe primary (...) objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

People are using innovative internet of things technologies to gain individualised management of their type 1 diabetes. The #WeAreNotWaiting movement supports them to build their own hybrid closed loop systems and access their real time blood sugar data via any web connected device. A small number of parents in Australia use such DIY looping systems to manage their child’s type 1 diabetes, but these systems have not been approved by the Therapeutic Goods Administration in Australia, creating ethical dilemmas for clinicians (...) about how to respond to the use of medical devices that are not registered on the Australian Register of Therapeutic Goods. This article considers whether the use of DIY looping is in the best interests of the child and, if not, whether intervention in parental decision making is justified to prevent harm to the child. It addresses the ongoing duty of healthcare professionals to provide care to children who are ‘looping.’ Reference is made to findings from a study, Personalised Closed Loop Systems for Childhood Diabetes, to illustrate stakeholders’ perceptions of benefits and harms of DIY looping systems. I conclude that the decision of parents to use DIY looping technology could be considered to be in a child’s best interests, broadly defined, and falls within the Zone of Parental Discretion, however healthcare practitioners who support parents may have professional concerns in doing so. (shrink)

Over the past decades, great strides have been made to professionalize and increase access to transgender medicine. As the evidence base grows and conceptualizations regarding gender dysphoria/gender incongruence evolve, so too do ideas regarding what constitutes good treatment and decision-making in transgender healthcare. Against this background, differing care models arose, including the ‘Standards of Care’ and the so-called ‘Informed Consent Model’. In these care models, ethical notions and principles such as ‘decision-making’ and ‘autonomy’ are often referred to, but left unsubstantiated. (...) This not only transpires into the consultation room where stakeholders are confronted with many different ethical challenges in decision-making, but also hampers a more explicit discussion of what good decision-making in transgender medicine should be comprised of. The aim of this paper is to make explicit the conceptual and normative assumptions regarding decision-making and client autonomy underpinning the ‘Standards of Care’ and ‘Informed Consent Model’ currently used in transgender care. Furthermore, we illustrate how this elucidation aids in better understanding stakeholders’ ethical challenges related to decision-making. Our ethical analysis lays bare how distinct normative ambiguities in both care models influence decision-making in practice and how foregrounding one normative model for decision-making is no moral panacea. We suggest that the first steps towards good decision-making in gender-affirming medical care are the acknowledgement of its inherent normative and moral dimensions and a shared, dialogical approach towards the decision-making process. (shrink)

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics (...) consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed. Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units, and surgical patients were more likely to have a DNR in place. Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment, while non-surgical specialties were more likely to call about issues related to discharge planning. There appear to be morally relevant differences between consults classified as the “same” that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field. (shrink)

The clinical clerkships in medical school are the first formal opportunity for trainees to apply bioethics concepts to clinical encounters. These clerkships are also typically trainees’ first sustained exposure to the “reality” of working in clinical teams and the full force of the challenges and ethical tensions of clinical care. We have developed a specialized, embedded ethics curriculum for Vanderbilt University medical students during their second year to address the unique experience of trainees’ first exposure to clinical care. Our embedded (...) curriculum is centered around core “ethics competencies” specific to the clerkship: for Medicine, advanced planning and end-of-life discussions; for Surgery, informed consent; for Pediatrics, the patient-family-provider triad; for Obstetrics and Gynecology, women’s autonomy, unborn child’s interests, and partner’s rights; and for Neurology/Psychiatry, decision-making capacity. In this paper, we present the rationale for these competencies, how we integrated them into the clerkships, and how we assessed these competencies. We also review the additional ethical issues that have been identified by rotating students in each clerkship and discuss our strategies for continued evolution of our ethics curriculum. (shrink)

Innovation in ethics pedagogy has continued to evolve and incorporate other forms of storytelling aimed at improving student engagement and learning. The use of bioethics narratives in feature-length films, medical television shows, or short clips in the classroom has a well-established history. In parallel, screenplays present an opportunity for an active approach to ethical engagement. We argue that screenplays and screenwriting provide a rich supplement to current medical ethics teaching and serve as a strong form of reflective learning.

Although advance directives are widely believed to be a key way to safeguard the autonomy of incompetent medical patients, significant questions exist about their moral authority. The main philosophical concern involves cases in which an incompetent patient no longer possesses the desires on which her advance directive was based. The question is, does that entail that prior expressions of medical choices are no longer morally binding? I believe that the answer is “yes.” I argue that a patient’s autonomy is not (...) respected by honoring the desires she used to have but no longer does. I also consider and reject the view that honoring an advance directive that reflects the patient’s previous values must be in that patient’s best interests. If that is correct, then advance directives in the kind of case at issue are not morally binding. (shrink)

This article describes a qualitative study of models of ethics consultation used by ethics consultants in Canada. We found four different models used by Canadian ethics consultants whom we interviewed, and one sub-variant. We describe the lone ethics consultant model, the hub-and-spokes sub-variant of this model; the ethics committee model; the capacity-building model; and the facilitated model. Previous empirical studies of ethics consultation describe only two or three of these models.

How do we respond to the patient who no longer needs inpatient care but refuses to leave the hospital? Complex hospital discharges commonly involve consideration of legal, financial, clinical, and practical issues. Yet, the ethical and contextual issues embedded in complex inpatient discharges are of concern and have not received adequate attention by medical ethicists. The aim of this work is to encourage clinicians and administrators to incorporate a justice rubric when approaching inpatient discharge dilemmas. This paper presents justice as (...) the ethical principle most neglected in situations involving complex discharges and suggests that a justice focused lens allows clinicians and administrators to move beyond notions of patient autonomy in crafting morally responsible hospital discharge decisions that reflect efficient stewardship of an appropriate share of medically indicated services. This issue deserves additional attention from medical ethicists in the future. (shrink)

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Informed consent is normally understood as something that a patient gives prior to a medical intervention that can render it morally permissible. Whether or not it must be given prior to the intervention is debated. Some have argued that subsequent consent—that is, consent given after a medical intervention—can also render an otherwise impermissible act permissible. If so, then a patient may give her consent to an intervention that has already been performed and thereby justify a physician’s act retroactively. The purpose (...) of this paper is to argue that even if subsequent consent can render an otherwise impermissible act permissible, doctors are still blameworthy if they rely on it when prior consent could be given, because they would be banking on the justification of their interventions. Since doctors can only guess if patients will consent after the fact, they would be placing their patients at unreasonable risk of being disrespected as persons. (shrink)

Evaluating clinical ethics support services has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS. In this paper, we argue that a first necessary step for progress is to better understand the intervention in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a first step, we (...) introduce principles of “complex intervention research” and show how CESS fulfil the criteria of “complex interventions”. In a second step, we develop a generic “conceptual framework” for “ethics consultation on request” as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of “bioethics mediation” to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: “proactive ethics consultation” and “moral case deliberation” and discuss implications for evaluating both types of CESS. To make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer “good” CESS. (shrink)

The dead donor rule (DDR) originally stated that organ donors must not be killed by and for organ donation. Scholars later added the requirement that vital organs should not be procured before death. Some now argue that the DDR is breached in donation after circulatory determination of death (DCDD) programs. DCDD programs do not breach the original version of the DDR because vital organs are procured only after circulation has ceased permanently as a consequence of withdrawal of life-sustaining therapy. We (...) hold that the original rendition of the DDR banning killing by and for organ donation is the fundamental norm that should be maintained in transplantation ethics. We propose separating the DDR from two other fundamental normative rules: the duties to prevent harm and to obtain informed consent. (shrink)

This was an in-depth qualitative study that looked at the reasons patients were referred to the Clinical Ethics Committee of an acute hospital in Singapore and explore how the CEC approached cases referred. Jonsen’s four topics approach was applied in the deliberative process for all cases. A comprehensive review of the case records of 28 patients referred consecutively to the CEC from 1 January 2012 to 31 December 2014 was conducted. Data and information was collated from the referral forms, patient (...) medical records, and emails communicated among CEC members. A deductive approach to thematic analysis based on Jonsen’s four topics approach was used to analyze the documents. Majority of the patients were male, Chinese, and above 65 years of age. Ethical dilemmas surfaced due to differences in opinion regarding withholding of aggressive management, withdrawing treatment, and ascertaining patient’s autonomy. In most cases, the patients’ preference on end-of-life care was unknown. The main reasons for referral to the CEC were conflicts in clinical management and uncertainty about the decision-making capacity of patients. The CEC members tended to emphasize on “patient preference” more than the other quadrants in the four topics approach as they worked through each case. The Jonsen’s four topics approach lays the groundwork to frame ethical dilemmas that can be easily applied in the clinical setting and is a useful tool for the CEC’s teaching and discussion. Nonetheless, the approach only organizes ethical dilemmas and requires clinicians to apply own judgment in weighing ethical principles. Further studies can look into adapting the four topics approach to suit the local practices and context. (shrink)

Healthcare ethics committees, physicians, surgeons, nurses, families, and patients themselves are constantly under pressure to make appropriate medically ethical decisions concerning patient care. Various models for healthcare ethics decisions have been proposed throughout the years, but by and large they are focused on making the initial ethical decision. What follows is a proposed model for healthcare ethics that considers the most appropriate decisions before, during, and after any intervention. The Just War Tradition is a model that is thorough in its (...) exploration of the ethics guiding a nation to either engage in or refuse to engage in combatant actions. In recent years, the Just War Tradition has expanded beyond the simple consideration of going to war or not to include how the war is conducted and what the post-war phase would look like ethically. This paper is an exploration of a healthcare ethics decision making model using the tenets of the Just War Tradition as a framework. It discusses the initial consult level of decision making prior to any medical intervention, then goes further in considering the ongoing ethical paradigm during medical intervention and post intervention. Thus, this proposal is a more holistic approach to healthcare ethics decision making that encourages healthcare ethics committees to consider alternate models and ways of processing so that ultimately what is best for patient, family, staff, and the environment is all taken into consideration. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

Cardiology is characterized by its state-of-the-art biomedical technology and the predominance of Evidence-Based Medicine. This predominance makes it difficult for healthcare professionals to deal with the ethical dilemmas that emerge in this subspecialty. This paper is a first endeavor to empirically investigate the axiological foundations of the healthcare professionals in a cardiology hospital. Our pilot study selected, as the target population, cardiology personnel not only because of their difficult ethical deliberations but also because of the stringent conditions in which they (...) have to make them. Therefore, there is an urgent need to reconsider clinical ethics and Value-Based Medicine. This study proposes a qualitative analysis of the values and the virtues of healthcare professionals in a cardiology hospital in order to establish how the former impact upon the medical and ethical decisions made by the latter. (shrink)

Efforts to professionalize the field of bioethics have led to the development of the Healthcare Ethics Consultant-Certified (HEC-C) Program intended to credential practicing healthcare ethics consultants (HCECs). Our team of professional ethicists participated in the inaugural process to support the professionalization efforts and inform our views on the value of this credential from the perspective of ethics consultants. In this paper, we explore the history that has led to this certification process, and evaluate the ability of the HEC-C Program to (...) meet the goals it has set forth for HCECs. We describe the benefits and weaknesses of the program and offer constructive feedback on how the process might be strengthened, as well as share our team’s experience in preparing for the exam. (shrink)

BackgroundRespect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice.MethodsBy means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we recruited students (...) enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology.ResultsFollowing 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient’s clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas, such as corridors, elevators, the cafeteria, stairs, and locker rooms.ConclusionsIn addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches, thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality. (shrink)

The concept of moral distress can be extended from clinical settings to larger environmental concerns affecting health care. Moral distress—a common experience in complex societies—arises when individuals have clear moral judgments about societal practices, but have difficulty in finding a venue in which to express concerns. Since health care is large in scale and climate change is proving to be a major environmental problem, scaling down health care is inevitably a necessary element for mitigating climate change. Because it is extremely (...) challenging to discuss these concerns in health care settings, those concerned about climate change and health care experience distress. This article outlines some philosophical concepts and perspectives that may be useful in mitigating this distress. (shrink)

This article describes and rejects three standard views of reason in secular clinical ethics. The first, instrumental reason view, affirms that reason may be used to draw conceptual distinctions, map moral geography, and identify invalid forms of argumentation, but prohibits recommendations because reason cannot justify any content-full moral or metaphysical commitments. The second, public reason view, affirms instrumental reason, and claims ethicists may make recommendations grounded in the moral and metaphysical commitments of bioethical consensus. The third, comprehensive reason view, also (...) affirms instrumental reason, but encourages ethicists to make recommendations grounded in the moral and metaphysical commitments of their private worldviews. A compatibilist view of public reason is then defended, which holds that each standard view captures an important role for reason in different aspects of secular clinical ethics. The article ends by identifying three implications for enduring theoretical debates in clinical ethics. (shrink)

The article is dedicated to the application questions of a case study method known as casuistry. In its long tradition, it focuses on an influential variant of the early modern period and reconstructs its functionality. In the course of reading recent receptions, it is noted that some studies speak of a “casuistic revival” in moral case deliberation in health care. As a result of this revival, casuistry has been modified in such a way that it guides case discussions in practice (...) with the help of a tripartite methodology. However, as it turns out, casuistry, a case comparison method of ethical judgement based on reasoning logic, is less suitable for moral case deliberations in direct patient care. This stems from the fact that casuistry is a detailed procedure of ethical learning beneficial to institutionalized ethics committees or similar forms of ethics consultation in health care. (shrink)

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: double-effect sedation, parsimonious direct sedation, and sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices (...) are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected. (shrink)

Abstract“Clinical ethics consultants” have been practicing in the United States for about 50 years. Most of the earliest consultants—the “pioneers”—were “outsiders” when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became “insiders” very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient “critical distance” for appropriate reflection about the complex medical ethics dilemmas of the day (...) if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field. (shrink)

Moral conflicts occur in theories that involve more than one principle. I examine basic ways of dealing with moral dilemmas in medical ethics and in ethics generally, and propose a different approach based on a principle I call the "mutuality principle". It is offered as an addition to Tom Beauchamp and James Childress' principlism. The principle calls for the mutual enhancement of basic moral values. After explaining the principle and its strengths, I test it by way of an examination of (...) three responses—in the recent Festschrift for Dr Raanon Gillon—to a case involving parental refusal of a blood transfusion. The strongest response is the one that comes closest to the requirements of the mutuality principle but yet falls short. I argue that the mutuality principle provides an explicit future orientation in principlism and gives it greater moral coherence. (shrink)

Institutional ethics consultation services for biomedical scientists have begun to proliferate, especially for clinical researchers. We discuss several models of ethics consultation and describe a team-based approach used at Stanford University in the context of these models. As research ethics consultation services expand, there are many unresolved questions that need to be addressed, including what the scope, composition, and purpose of such services should be, whether core competencies for consultants can and should be defined, and how conflicts of interest should (...) be mitigated. We make preliminary recommendations for the structure and process of research ethics consultation, based on our initial experiences in a pilot program. (shrink)

Wojtasiewicz (2006) raises an intriguing and concerning possibility: that end-of-life conflict resolution processes—“futility” policies—may compound discrimination against African Americans, who ha...

The patient we call Danny was a mildly mentally retarded male in his mid-thirties who adamantly refused kidney dialysis when it was offered as the only therapeutic option for his progressive kidney failure. It was uncertain how fully Danny understood the implications of his refusal. To complicate the case still further, several “advocates” emerged to speak on Danny's behalf — each with a somewhat different interpretation of the situation and different sets of value presuppositions and ethical principles to apply to (...) the choice. We chronicle the development of this situation through a series of scenes; and in each scene we also attempt to clarify the ethical and medico-legal issues involved at that point. Danny was finally permitted to make this decision for himself — though more by default than by an agreement by all parties to honor his autonomy. Our hope is that this presentation will lead to further discussion and clarification of these important issues. (shrink)

Objectives—While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. Design—Cross-sectional telephone survey.Setting—Internal medicine practices throughout the United States.Participants—Randomly selected physicians practising in internal medicine, oncology and critical care.Main measurements—Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. Results—One hundred and ninety of 344 responding physicians (55%) reported requesting ethics (...) consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. Conclusions—Conflicts and other emotionally charged concerns trigger consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills. (shrink)

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

This article critically examines, and ultimately rejects, the best interest standard as the predominant, go-to ethical and legal standard of decision making for children. After an introduction to the presumption of parental authority, it characterizes and distinguishes six versions of the best interest standard according to two key dimensions related to the types of interests emphasized. Then the article brings three main criticisms against the best interest standard: (1) that it is ill-defined and inconsistently appealed to and applied, (2) that (...) it is unreasonably demanding and narrow, and (3) that it fails to respect the family. Finally, it argues that despite the best interest standard’s potent rhetorical power, it is irreparably encumbered by too much inconsistency and confusion and should be rejected. (shrink)

Emerging data indicates the prevalence and increased use of pharmaceutical enhancements by young medical professionals. As pharmaceutical enhancements advance and become more readily available, it is imperative to consider their impact on medical professionals. If pharmaceutical enhancements augment a person’s neurological capacities to higher functioning levels, and in some situations having higher functioning levels of focus and concentration could improve patient care, then might medical professionals have a responsibility to enhance? In this paper, I suggest medical professionals may have a (...) responsibility to use pharmaceutical enhancements. In some situations, having higher functioning levels of focus and concentration is conducive to providing the best possible care to a patient. In these circumstances medical professionals should use pharmaceutical cognitive enhancements. I conclude by examining the limitations and implications of this responsibility in the practice of medicine and areas for future research. (shrink)

Health policy frameworks usually construe environmental protection and human health as harmonious values. Policies that protect the environment, such as pollution control and pesticide regulation, also benefit human health. In recent years, however, it has become apparent that promoting human health sometimes undermines environmental protection. Some actions, policies, or technologies that reduce human morbidity, mortality, and disease can have detrimental effects on the environment. Since human health and environmental protection are sometimes at odds, political leaders, citizens, and government officials need (...) a way to mediate and resolve conflicts between these values. Unfortunately, few approaches to applied bioethics have the conceptual tools to do accomplish this task. Theories of health care ethics have little to say about the environment, and theories of environmental ethics don’t say much about human health. In this essay, I defend an approach to ethical decision-making that gives policy-makers some tools for balancing promotion of human health and protection of the environment. (shrink)

In Japan, where a prominent gap exists in what is considered a patient’s best interest between the medical and patient sides, appropriate decision-making can be difficult to achieve. In Japanese clinical settings, decision-making is considered an act of choice-making from multiple potential options. With many ethical dilemmas still remaining, establishing an appropriate decision-making process is an urgent task in modern Japanese healthcare. This paper examines ethical issues related to shared decision-making (SDM) in clinical settings in modern Japan from the psychocultural-social (...) perspective and discusses the ideal decision-making process in present Japan. Specifically, we discuss how five psychocultural-social tendencies – “surmise (Sontaku),” “self-restraint (Jishuku),” “air (atmosphere or mood, Kuuki),” “peer pressure (or tuning pressure, Docho-Atsuryoku),” and “community (Seken)”—which have often been referred to as characteristics of present-day Japanese people, may affect the ideal practice of SDM in Japanese clinical settings. We conclude that health care professionals must be aware of the possible adverse effects of the above Japanese psychocultural-social tendencies on the implementation of SDM and attempt to promote autonomous decision-making, thereby allowing patients to make treatment choices that sufficiently reflect their individual and personal views of life, experiences, goals, preferences, and values. (shrink)

Background and Objectives: Patient autonomy is a recognized principle in modern medical ethics, and truth-telling to the patient; thus, it holds special importance for its contribution to this principle. In practice, however, several challenges emerge that can lead to different responses. This difference is more marked in studies conducted in the Eastern and Muslim countries due to variations in cultural and religious beliefs. Truth-telling is a challenging concept respecting placebos, medical errors, and delivering bad news on diagnosis and treatment to (...) patients. Methods: This study employed an unsystematic review of library and online sources, as well as databases, including Google Scholar, Springer, PubMed, Ovid, and relevant Persian papers in an attempt to provide an overview of this concept and study the Islamic view, particularly the Shi’ite perspective, and the predominant approaches employed in Muslim countries. Results: Islamic scripture and hadith strongly advocate honesty and truth-telling. However, maleficence to patients and exposing them to serious harm is unallowed, and withholding the whole or a part of the truth; even lying is justified in extreme cases. Conclusion: Essentially, the philosophy of medicine is based on helping patients and reducing their pains. Considering the unique condition of each patient, a perfect solution cannot be prescribed for all of them and the same strategy to manage all cases. The emphasis on truth-telling in the Islamic view is no less than other schools of thought. However, if disclosing the truth may expose the patient to certain, serious biopsychological risks, denying the whole or a part of the truth might be advisable; even in frequent cases, lying can be justified to protect the patient. (shrink)

This paper offers a narrative approach to understanding the process of clinical reasoning in complex cases involving medical uncertainty, moral ambiguity, and futility. We describe a clinical encounter in which the pediatric health care team experienced a great deal of conflict and distrust as a result of an ineffective process of interpretation and communication. We propose a systematic method for analyzing the technical, ethical, behavioral, and existential dimensions of the clinical reasoning process, and introduce the Clinical Reasoning Discussion Tool—a dialogical (...) and interpretive device aimed at improving communication, understanding, empathy, and moral deliberation in the clinical setting. (shrink)

BackgroundAs hospitals have grown more complex, the ethical concerns they confront have grown correspondingly complicated. Many hospitals have consequently developed health care ethics programs (HCEPs) that include far more than ethics consultation services alone. Yet systematic research on these programs is lacking.MethodsBased on a national, cross-sectional survey of a stratified sample of 600 US hospitals, we report on the prevalence, scope, activities, staffing, workload, financial compensation, and greatest challenges facing HCEPs.ResultsAmong 372 hospitals whose informants responded to an online survey, 97% (...) of hospitals have HCEPs. Their scope includes clinical ethics functions in virtually all hospitals, but includes other functions in far fewer hospitals: ethical leadership (35.7%), regulatory compliance (29.0%), business ethics (26.2%), and research ethics (12.6%). HCEPs are responsible for providing ongoing ethics education to various target audiences including all staff (77.0%), nurses (59.9%), staff physicians (49.0%), hospital leadership (44.2%), medical residents (20.3%) and the community/general public (18.4%). HCEPs staff are most commonly involved in policy work through review of existing policies but are less often involved in development of new policies. HCEPs have an ethics representative in executive leadership in 80.5% of hospitals, have representation on other hospital committees in 40.7%, are actively engaged in community outreach in 22.6%, and lead large-scale ethics quality improvement initiatives in 17.7%. In general, major teaching hospitals and urban hospitals have the most highly integrated ethics programs with the broadest scope and greatest number of activities. Larger hospitals, academically affiliated hospitals, and urban hospitals have significantly more individuals performing HCEP work and significantly more individuals receiving financial compensation specifically for that work. Overall, the most common greatest challenge facing HCEPs is resource shortages, whereas underutilization is the most common greatest challenge for hospitals with fewer than 100 beds. Respondents’ strategies for managing challenges include staff training and additional funds.ConclusionsWhile this study must be cautiously interpreted due to its limitations, the findings may be useful for understanding the characteristics of HCEPs in US hospitals and the factors associated with these characteristics. This information may contribute to exploring ways to strengthen HCEPs. (shrink)

Although current literature about the “cure versus care” issue tends to promote a patient-centered approach, the disease-centered approach remains the prevailing model in practice. The perceived dichotomy between the two approaches has created a barrier that could make it difficult for medical students and physicians to integrate psychosocial aspects of patient care into the prevailing disease-based model. This article examines the influence of the formal and hidden curricula on the perception of these two approaches and finds that the hidden curriculum (...) perpetuates the notion that “cure” and “care” based approaches are dichotomous despite significant changes in formal curricula that promote a more integrated approach. The authors argue that it is detrimental for clinicians to view the two approaches as oppositional rather than complementary and attempt to give recommendations on how the influence of the hidden curriculum can be reduced to get a both-cure-and-care-approach, rather than an either-cure-or-care-approach. (shrink)