Background: Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today’s hospital cultures. Nursing is rooted in a holistic approach with an ethical obligation to maintain and respect the individual’s dignity and integrity. However, working within time limits and heavy workload leads to burnout and ethical insensitivity among nurses, and may challenge nurses’ options to act on the basis of ethical and (...) moral grounds in the individual care situation. Aim: The aim of this study is to describe and discuss ethical dilemmas described and experienced by nurses in clinical practice today. Method: The study was performed as a literature review following the matrix method allowing to synthesize literature across methodological approaches. A literature search was performed, including relevant studies published between 2011 and 2016. A total of 15 articles were included and analyzed focusing on their description of ethical dilemmas. Ethical consideration: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources. Results: The analysis revealed three themes, relating to important aspects of nursing practice, such as the nurse–patient relationship, organizational structures, and collaboration with colleagues. The findings are summarized in the following three themes: (1) balancing harm and care, (2) work overload affecting quality, and (3) navigating in disagreement. Ethically difficult situations are evident across settings and in very diverse environments from neonatal care to caring for the older people. Organizational structures and being caught in-between professional values, standardization, and busyness was evident, revealing the complexity of nursing practice and the diversity of ethical dilemmas, concerns, and distress experienced by clinical nurses. Conclusion: Nursing practice is challenged by organizational structures and the development of the health care system, inhibiting nurses’ professional decision-making and forcing them to compromise basic nursing values. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

This article contends that an ethics of care has a particular moral ontology that makes it suitable to argue for the normative significance of relational responsibilities within professional health care. This ontology is relational. It means that moral choices always have to account for the web of relationships, the relational networks and responsibilities that are an essential part of particular moral circumstances. Given this ontology, the article investigates the conditions for health care professionals to be partial and to act on (...) the basis of particular responsibilities to their patients. We will argue that priorities could be partial in three ways: first, because there may be exceptional circumstances that allow for giving priority to one patient over another; second, because the integrity of the patient and a health care worker may be connected in special ways; and, finally, even if impartiality is essential, the institutional basis of health care must always give ample space for an ethically qualified individual and personal care for patients. Even if difficult priorities may be necessary, the conditions of institutional health care should always seek to create the prerequisites for nurses and doctors to administer proper care. (shrink)

Although most theorists of healthcare rationing argue that rationing, including rationing that takes place in the physician–patient relationship (“bedside rationing”) is unavoidable, some health professionals strongly disagree. In a recent essay, Vegard Bruun Wyller argues that bedside rationing is immoral and thoroughly at odds with a sound view of the physician–patient relationship. We take Wyller to be an articulate exponent of the reluctance to participate in rationing found among some clinicians. Our essay attempts to refute the five crucial premises of (...) his argument yet build on his genuine insights. In our analysis, Wyller’s critique of bedside rationing is instructive both for harbouring some very common misconceptions that must be exposed and refuted, but also for offering important words of caution. In particular, bedside rationing must be performed in ways that do not harm the physician–patient relationship. Read irenically, Wyller’s critique is a reminder of what must not be lost in our painful endeavour to update the ethics of medicine to encompass the unavoidability of rationing. (shrink)

Patient-centered care is now recognized as a clinical method and ideal model for patient – health professional relationships, and many definitions have influenced its evolution. Overall the patient-centered care literature has provided relatively little to define patient-centered care at the level of the patient-professional relationship. Additionally, patient-centered care lacks grounding in ethical theory. This thesis asserts that theoretical concepts from the ethics of care can provide a stronger conceptual basis for patient-centered care.This thesis begins with a critical interpretive review of (...) the patient-centered care literature, yielding 12 articles that previously introduced new theoretical and definitional work on patient-centered care and patient-centered communication. Six common themes and ideas were discovered, and include Engaging the Patient as a Whole Person, Recognizing and Responding to Emotions, Fostering a Therapeutic Alliance, Promoting an Exchange of Information, Sharing Decision Making, and Enabling Self-Management and Patient Navigation. These elements were then compared to key elements of the ethics of care. This thesis argues that feminists have good reason to consider care as a type of moral duty, and it describes how this duty functions. This thesis also argues that a duty to care is triggered when caregivers are presented with particular substantive forms of vulnerability. Specifically, this thesis argues that vulnerable subjects whose constitutive needs are at risk require particular moral obligations. The links between the ethics of care and patient-centered care are discussed, including how an ethics of care response ought to function in the health care context. Finally, the cases of J.J. and Makayla Sault, two aboriginal girls who refused chemotherapy in favour of traditional aboriginal healing practices, are analyzed. This thesis offers a short scoping review of the bioethics discourse surrounding these cases. A review of this discourse revealed several common themes, which included the peripheral importance of culture and history, the equating of best interests with survival, the supremacy of science-based medicine, and the impartial application of ethical principles. This thesis recommends that health care professionals apply an ethics of care approach to similar ethical dilemmas in the future, which involves shifting one's ethical focus to the central relationships of the case, understanding the unique perspective of the patient's narrative, and promoting a care-based rather than a justice-based approach to problem-solving. (shrink)

Background: Ethically difficult situations are frequently encountered by healthcare professionals. Moral case deliberation is one form of clinical ethics support, which has the goal to support staff to manage ethical difficulties. However, little is known which difficult situations healthcare teams need to discuss. Aim: To explore which kinds of ethically difficult situations interprofessional healthcare teams raise during moral case deliberation. Research design: A series of 70 moral case deliberation sessions were audio-recorded in 10 Swedish workplaces. A descriptive, qualitative approach was (...) applied, using thematic content analysis. Ethical considerations: An advisory statement specifying no objections to the study was provided from an Ethical Review Board, and consent to be recorded was assumed by virtue of participation in the moral case deliberation. Findings: Three themes emerged: powerlessness over managing difficult interactions with patients and next-of-kin, unease over unsafe and unequal care, and uncertainty over who should have power over care decisions. The powerlessness comprised feelings of insufficiency, difficulties to respond or manage patient’s/next-of-kin’s emotional needs or emotional outbursts and discouragement over motivating patients not taking responsibility for themselves. They could be uncertain over the patient’s autonomy, who should have power over life and death, disclosing the truth or how much power next-of-kin should have. Discussion: The findings suggest that the nature of the ethically difficult situations brought to moral case deliberations contained more relational-oriented ethics than principle-based ethics, were permeated by emotions and the uncertainties were pervaded by power aspects between stakeholders. Conclusion: MCD can be useful in understanding the connection between ethical issues and emotions from a team perspective. (shrink)

The paper argues that a particular version of moral realism constitutes an important basis for ethics in medicine and health care. Moral realism is the position that moral value is a part of the fabric of relational and interpersonal reality. But even though moral values are subject to human interpretations, they are not themselves the sole product of these interpretations. Moral values are not invented but discovered by the subject. Moral realism argues that values are open to perception and experience (...) and that moral subjectivity must be portrayed in how moral values are discovered and perceived by the human subject. Moral values may exist independent of the particular subject’s interpretative evaluations as a part of reality. This epistemological point about normativity is particularly significant in medical care and in health care. The clinician perceives moral value in the clinical encounter in a way that is important for competent clinical understanding. Clinical understanding in medical care and health care bears on the encounter with moral values in the direct and embodied relations to patients, with their experiences of illness and their vulnerabilities. Good clinical care is then partly conditioned upon adequate understanding of such moral realities. (shrink)

The vision of global health with justice which Larry Gostin articulates in his book Global Health Law envisages a switch to ‘upstream’ priority-setting for expenditure on health, with a focus upon social determinants and a goal of redressing health inequalities. This article explores what is meant by this proposal and offers a critical evaluation of it. It is argued that difficulties arise in respect of the ethical and evidential bases for such an approach to the setting of priorities, while significant (...) challenges may also arise in the necessary modification of structures of governance. (shrink)

Background: More and more adults in their fifties and sixties are confronted with the need to support their ageing parents. Although many aspects of filial caregiving have been researched, a well-documented and comprehensive overview of the caregiving experience is lacking. Aim: This study aims for a better understanding of the caregiving experience of adult children by generating an overview of main themes in international research. Method: A literature review of qualitative studies, focusing on the experiences of adult children caring for (...) their ageing parents, was performed. The electronic EBSCO databases Academic Search Premier, CINAHL and PsycINFO, and Google Scholar were searched to identify relevant qualitative studies published between 2000 and 2017. The ‘SPIDER’ eligibility criteria directed the approach. The quality of studies included was screened with the assessment sheet designed by Hawker and colleagues. The experiences reported were analysed and themes were synthesized. Ethical consideration: Ethical requirements were respected in every phase of the research process. Findings: Nineteen qualitative studies met the inclusion criteria. The quality of the relationship with the parent appears to be an important determinant of the children’s caregiving experience. Within this context, three themes were found: caregiving as an emotional rollercoaster, a normatively demanding experience and an opportunity for personal development. Discussion: Children caring for their ageing parents have to deal with a wide range of contradicting and conflicting norms and values. Implications for healthcare professionals and future research have been discussed. Conclusion: Caring for ageing parents is a continuous quest for giving the best possible care and living up to one’s personal values, within the context of the parent’s declining health. Professionals who support filial caregivers should address not only practical responsibilities but also the normative questions and moral considerations caregivers are dealing with. (shrink)

The aim of this study was to explore neonatal nurses’and mothers of preterm infants’experiences of daily challenges. Interviews took place asking for good, bad and challenging experiences. Data were analysed using qualitative content analysis and findings were clustered in two categories: good and challenging experiences, each containing three themes. The good experiences were: managing with success as a nurse, small things matter for mothers, and a good day anyhow for mothers and nurses. The challenging experiences were: mothering in public, being (...) pulled between responsibilities, and adverse things stick under the nurses’skin. The study shows that small daily clinical matters become big issues and could lead to moral distress, and that nurses integrate ethics of justice and ethics of care while mothers are concerned about health and well-being of their specific infant only. The challenge for nursing to integrate fairness and sensitive care in family-oriented neonatal care is discussed. (shrink)

This paper aims at addressing some questions considering the conflicting normative claims of partiality, i.e. to provide for the caring needs of the particular patient, and impartial claims of treating all patients with a relevant need equally. This ethical conflict between different conceptions of moral responsibilities within professional ethics relates to debates between an ethics of care and an ethics of justice. An ethics of care is a particularistic position that endorses some form of partiality, i.e. favouring persons to whom (...) one stands in particular relationships. This paper argues that also a professional ethics must endorse some kind of partiality at the clinical level of health care. In fact, consideration of care for particular patients is a prerequisite for giving proper and attentive care towards the individual patient. This paper will discuss how partial concerns might be balanced against claims of distributive justice within the frame of the formal principle of justice. It is concluded that there is an urgent need for the recognition of the consequences of macro-level decisions for the possibility of the discharge of moral responsibility on a clinical level of health care. This would mean that health care institutions should adapt for the possibility of a basic standard of proper care and attention for the individual patient. (shrink)

Background: Decisions regarding whether or not to institute mechanical ventilation during the later stages of chronic obstructive pulmonary disease is challenging both ethically, emotionally and medically. Caring for these patients is a multifaceted process where nurses play a crucial role. Research question and design: We have investigated how nurses experienced their own role in decision-making processes regarding mechanical ventilation in later stages of chronic obstructive pulmonary disease and how they consider the patients’ role in these processes. We applied a qualitative (...) approach, with six focus-group interviews of nurses (n = 26). Ethical considerations: The Regional Committees for Medical and Health Research Ethics approved the study. Voluntary informed consent was obtained. Findings: The nurses found themselves operating within a cure-directed treatment culture wherein they were unable to stand up for the caring values. They perceived their roles and responsibilities in decision-making processes regarding mechanical ventilation to patients as unclear and unsatisfactory. They also experienced inadequate interdisciplinary cooperation. Discussion: Lack of communication skills, the traditional hierarchical hospital culture together with operating in a medical-orientated treatment culture where caring values is rated as less important might explain the nurses’ absence in participation in the decision about mechanical ventilation. Conclusion: To be able to advocate for the patients’ and their own right to be included in decision-making processes, nurses need an awareness of their own responsibilities. This requires personal courage, leadership who are capable of organising common interpersonal meetings and willingness on the part of the physicians to include and value the nurses’ participation in decision-making processes. (shrink)

Nurse researchers engaged in qualitative interviews with patients and spouses in healthcare may often experience being in unforeseen ethical dilemmas. Researchers are guided by the bioethical principles of justice, beneficence, non-maleficence, respect for human rights and respect for autonomy through the entire research process. However, these principles are not sufficient to prepare researchers for unanticipated ethical dilemmas related to qualitative research interviews. We describe and discuss ethically challenging and difficult moments embedded in two cases from our own phenomenological interview studies. (...) We argue that qualitative interviews involve navigation between being guided by bioethics as a researcher, being a therapist/nurse and being a fellow human being or even a friend. The researchers’ premises to react to unexpected situations and act in a sound ethical manner must be enhanced, and there is a need for an increased focus on the researchers’ ethical preparation and to continually address and discuss cases from their own interviews. (shrink)

Background: Due to the major changes occurring in the demographic composition of the world’s population, the number of older individuals is increasing, which puts pressure on the healthcare systems in many different countries. The involvement of volunteers and family members may become necessary to fulfil a patient’s needs for follow-up treatments and long-term care in their homes. Aim: This study aimed to explore how nurses and physicians experienced and addressed ethical challenges when they dealt with relatives in what have traditionally (...) been one-on-one consultations at two Norwegian hospital outpatient clinics. Research Design and Methods: A total of eight nurses and two physicians from two different hospitals participated in individual in-depth interviews. The transcribed interviews were analysed using an eclectic approach called ‘bricolage’ inspired by Kvale and Brinkmann. We combined cross-case thematic and theoretical normative analyses. Ethical considerations: The principles of voluntariness, confidentiality, withdrawal and anonymity were respected throughout the research process. In addition, the Norwegian Social Science Data Services approved this study. Findings: The findings showed that respect for a patient’s autonomy was used as an argument for delimiting the relatives’ access to the patient’s consultations. We found that there were insufficient routines in place for inviting and involving relatives in the patient consultations in the outpatient clinics. Discussion: The traditional Western attitudes towards the principles of patient autonomy will likely be challenged due to the growing need for family involvement in the care of a patient in the future. Conclusion: This study’s description of the nurses and physicians’ interpretations of ‘patient autonomy’ as a phenomenon uncover the need for systematic ethical deliberation in the clinical setting. On an organisational level, there is a strong indication of the need to discuss the routines that are in place to invite the next of kin to participate in such patient’s healthcare consultations. (shrink)