Nurse Ethicists bring a unique perspective to clinical ethics consultation. This perspective provides an appreciation of ethical tensions that will exist beyond the consult question into the moral space of patient care. These tensions exist even when an ethically preferable plan of action is identified. Ethically appropriate courses of action can still lead to moral dilemmas for others. The nurse ethicist provides a lens well suited to identify and respond to these dilemmas. The nurse–patient relationship is the ethical foundation of (...) nursing practice and this relational ontology is well suited to addressing ethical dilemmas that exist prior to and beyond the initial consult question. This paper will describe one nurse ethicist’s phronetic and pragmatic approach to a clinical ethics consult elucidated through feminist ethics and systems thinking. This paper will describe the theoretical basis for this method, present a case, and describe how this consultation approach provides a rich analysis based around relationships and responsibilities that also highlights the important ethical tensions within the social structure that exists around the patient and continue after the consult question is answered. (shrink)

Zusammenfassung Krankenhäuser müssen sich an der ethischen Qualität ihrer Versorgung messen lassen. Es geht dabei um einen Zustand, in dem allgemein anerkannte moralische Normen in der Patient:innenversorgung konsequent berücksichtigt werden. Damit sind zwei Ebenen angesprochen: die der ethisch-normativen Deutung und die der Gestaltung intra- und interpersonaler Prozesse. Die Klinische Ethik ist die Disziplin, die in der Verbindung beider ihre zentrale Aufgabe sieht. Um sie zu erfüllen, muss Ethikarbeit auf der Basis komplexer Kompetenzen erfolgen. Neben fundiertem Ethikwissen ist das Beherrschen von (...) geeigneten Methoden für die Steuerung solcher Prozesse eine unabdingbare Voraussetzung. Dazu aber ist die Studienlage vergleichsweise dünn. Die vorliegende Arbeit greift dieses Desiderat auf und geht dabei von der Hypothese aus, dass die Systemik einen wichtigen Beitrag zu einer im obigen Sinne effektiven Ethikarbeit leisten kann. Die Darstellung gibt einen Einblick in das systemische Denken und diskutiert die Möglichkeiten, die systemisches Handwerkszeug für die Herausforderungen der Klinischen Ethik bereithält. Die Ausführungen laden dazu ein, über den Einfluss systemischer Grundannahmen und Methoden auf die Gestaltung einer effektiven Ethikarbeit nachzudenken. Darüber hinaus ruft dieser Beitrag dazu auf, die Beratungsmethodik als solche mehr in den Fokus zu rücken. (shrink)

Definition of the problemQuality of care also includes a professional approach to ethical challenges. This involves the moral interpretation of an issue and the management of intra- and interpersonal reflection processes. Combining both is the central task of clinical ethics consultation (CEC). Despite its importance only a few studies have dealt with the appropriate methods for steering reflection processes.ArgumentsCEC requires a theory-based and methodological approach. The argumentation shows the effects that systems theory and systemic methods have on the effectiveness of (...) CEC. The main methods such as clarification of mandates and handling complexity are presented, and their impact on dealing with ethical challenges is shown through the discussion of two cases.ConclusionThe paper provides insight into systems thinking. It discusses the influence that systemic tools have on dealing with typical challenges within clinical ethics counselling. It also shows how specific counselling methods impact a normative level. (shrink)

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (...) (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses’ empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members. (shrink)

In a comment on my paper "Feminism, Ethics, and the Question of Theory", Keith Burgess-Jackson argues that I have misdiagnosed the problem with modern moral theory. Burgess-Jackson misunderstands both the illustrative-"theoretical-juridical"-model I constructed there and how my critique and alternative model answer to specifically feminist concerns. Ironically, his own view seems to reproduce the very conception of morality as an individually internalized action-guiding code of principles that my earlier essay argued is the conception central to modern moral theories.

Practitioners’ ethical orientation and responses vary between practice settings. Yet, currently, the ethics for midwifery practice that is explicit in the literature and which provides the ideals of socialization into practice, is that of bio(medical)ethics. Traditional bioethics, developed because of World War II atrocities and increased scientific research, is based on moral philosophy, normative theory, abstract universal principles and objective problem solving, all of which focus on right and wrong ‘action’ for resolving dilemmas. They exclude context and relationship. Personal narratives (...) of mothers and midwives contest the appropriateness of these accepted values and systems for childbirth because they induce conflict between work-place/service provider ethics and personal/professional midwifery ethics. In contrast to the disembedded and disembodied approach of biomedical ethics, an ethically adequate response in midwifery practice resonates more with the ethics of intimates, such as feminist virtue ethics. (shrink)

Discourses on Responsible Innovation and Responsible Research and Innovation, in short RI, have revolved around but not elaborated on the notion of critique. In this article, generative critique is introduced to RI as a practice that sits in-between adversarial armchair critique and co-opted, uncritical service. How to position oneself and be positioned on this spectrum has puzzled humanities scholars and social scientists who engage in interdisciplinary collaborations with scientists, engineers, and other professionals. Recently, generative critique has been presented as a (...) solution to the puzzle in interdisciplinary collaborations on neuroscientific experiments. Generative critique seeks to create connections across disciplines that help remake seemingly stable objects in moments when taken-for-granted ways of seeing and approaching objects are unsettled. In order to translate generative critique from the neurosciences to RI, socio-technical integration research is proposed as a practice of generative critique in interdisciplinary RI collaborations. These collaborations aim to account for societal aspects in research and technology development. For this purpose, a variety of approaches have been developed, including STIR and video-reflexive ethnography. STIR and VRE resemble each other but diverge on affective, collaborative, and temporal dimensions. Their juxtaposition serves to develop suggestions for how STIR could be modified on these dimensions to better enact generative critique in interdisciplinary RI collaborations. In this way, the article contributes to ongoing discussions in RI and in the engaged programme in science and technology studies more broadly on the dynamics of positioning in collaborative work. (shrink)

There are several important conceptual issues and questions about the practice of healthcare ethics that can, and should, inform the development of any practice standards. This paper provides a relatively short overview of seven of these issues, with the invitation for further critical reflection and examination of their relevance to and implications for practice standards. The seven issues described include: diversity (from the perspective of training and experience); moral expertise and authority/influence; being an insider or outsider; flexibility and adaptability (for (...) local contexts of practice); the relative weighting of procedural and normative aspects of ethics practice; making mistakes or errors; and conflicts of interest in practice. (shrink)

Volume 19, Issue 7, July 2019, Page 59-61.

Background: Living with a renal disease often reduces quality of life because of the stress it entails. No attention has been paid to the moral challenges of living with renal disease. Objectives: To explore the moral challenges of living with a renal disease. Research design: A case study based on qualitative research. We used Walker’s ethical framework combined with narrative ethics to analyse how negotiating care responsibilities lead to a new perspective on moral issues. Participants and research context: One case (...) was chosen from 20 qualitative interviews with renal patients in the Netherlands. Ethical considerations: Several actions have been taken to ensure the informed consent, privacy, anonymity and confidentiality of the patient in this article. More details are offered in this article. The study has been conducted in line with the recommendations of the Medical Ethical Committee of the VU Medical Center. Findings: A renal disease can force people to change their identity, relationships, values and responsibilities. The case study illustrates the moral challenges confronting renal patients. Discussion and conclusion:: Moral issues can be raised by the changes to identities, relationships, values and responsibilities caused by renal disease. Support services for renal patients and their relatives should pay more attention to these issues in order to promote self-management. (shrink)

Clinical ethics support services are experiencing a phase of flourishing and of growing recognition. At the same time, however, the expectations regarding the acceptance and the integration of traditional CES services into clinical processes are not met. Ethics rounds as an additional instrument or as an alternative to traditional clinical ethics support strategies might have the potential to address both deficits. By implementing ethics rounds, we were able to better address the needs of the clinical sections and to develop a (...) more comprehensive account of ethics quality in our hospital, which covers the level of decisions and actions, and also the level of systems and processes and aspects of ethical leadership. (shrink)

Clinical ethics, like the broader field of bioethics from which it emerged, is at a critical crossroads in its development, with conflicting paths ahead. It can either claim its distinctive place in the clinical arena, insisting unapologetically on certain minimal standards of professional training, practice and competence, addressing head on debates about various models of and methodological approaches to consultation, and establishing a shared vision of the purpose and meaning of the enterprise of clinical ethics itself. Or, it can devolve (...) into a hobby that untrained, albeit interested, and generally well intentioned individuals can dabble in for fun or even profit, as they see fit, and without regard to the deep history and rich disciplinary roots of the field, the serious debates in the academic literature of bioethics, the foundational case histories and legal theories, or even any sense of professional accountability. (shrink)

Clinical ethics, like the broader field of bioethics from which it emerged, is at a critical crossroads in its development, with conflicting paths ahead. It can either claim its distinctive place in the clinical arena, insisting unapologetically on certain minimal standards of professional training, practice and competence, addressing head on debates about various models of and methodological approaches to consultation, and establishing a shared vision of the purpose and meaning of the enterprise of clinical ethics itself. Or, it can devolve (...) into a hobby that untrained, albeit interested, and generally well intentioned individuals can dabble in for fun or even profit, as they see fit, and without regard to the deep history and rich disciplinary roots of the field, the serious debates in the academic literature of bioethics, the foundational case histories and legal theories, or even any sense of professional accountability. (shrink)

It has been argued that bioethicists too often tend to represent the interests of scientists and not of the broader polity. Indeed, bioethicists seem predisposed to discard the voices and viewpoints of all but the cognoscenti . Focusing particularly on human pluripotent stem cell research, this commentary explores a variety of characterizations of bioethics and bioethicists in relation to forbidding science. Rather than proselytizing or prohibiting, bioethicists should work in partnership with scientists and publics to craft scientifically well-informed and morally (...) sophisticated debates about forbidding science. (shrink)

As we reread Mary Shelley's Frankenstein at two hundred years, it is evident that Victor Frankenstein is both a mad scientist (fevered, obsessive) and a bad scientist (secretive, hubristic, irresponsible). He's also not a very nice person. He's a narcissist, a liar, and a bad “parent.” But he is not genuinely evil. And yet when we reimagine him as evil—as an evil scientist and as an evil person—we can learn some important lessons about science and technology, our contemporary society, and (...) ourselves. (shrink)

Moral or ethical questions are vital because they affect our daily lives: what is the best choice we can make, the best action to take in a given situation, and ultimately, the best way to live our lives? Health ethics has contributed to moving ethics toward a more experience-based and user-oriented theoretical and methodological stance but remains in our practice an incomplete lever for human development and flourishing. This context led us to envision and develop the stance of a “living (...) ethics”, described in this inaugural collective and programmatic paper as an effort to consolidate creative collaboration between a wide array of stakeholders. We engaged in a participatory discussion and collective writing process known as instrumentalist concept analysis. This process included initial local consultations, an exploratory literature review, the constitution of a working group of 21 co-authors, and 8 workshops supporting a collaborative thinking and writing process. First, a living ethics designates a stance attentive to human experience and the role played by morality in human existence. Second, a living ethics represents an ongoing effort to interrogate and scrutinize our moral experiences to facilitate adaptation of people and contexts. It promotes the active and inclusive engagement of both individuals and communities in envisioning and enacting scenarios which correspond to their flourishing as authentic ethical agents. Living ethics encourages meaningful participation of stakeholders because moral questions touch deeply upon who we are and who we want to be. We explain various aspects of a living ethics stance, including its theoretical, methodological, and practical implications as well as some barriers to its enactment based on the reflections resulting from the collaborative thinking and writing process. (shrink)

Coercion in mental health care gives rise to many ethical challenges. Many countries have recently implemented state policy programs or development projects aiming to reduce coercive practices and improve their quality. Few studies have explored the possible role of ethics in such initiatives. This study adds to this subject by exploring health professionals’ descriptions of their ethical challenges and strategies in everyday life to ensure morally justified coercion and best practices. Seven semi-structured telephone interviews were carried out in 2012 with (...) key informants in charge of central development projects and quality-assurance work in mental health services in Norway. No facilities used formal clinical ethics support. However, the informants described five areas in which ethics was of importance: moral concerns as implicit parts of local quality improvement initiatives; moral uneasiness and idealism as a motivational source of change; creating a normative basis for development work; value-based leadership; and increased staff reflexivity on coercive practices. The study shows that coercion entails both individual and institutional ethical aspects. Thus, various kinds of moral deliberation and ethics support could contribute to addressing coercion challenges by offering more systematic ways of dealing with moral concerns. However, more strategic use of implicit and institutional ethics is also needed. (shrink)

I introduce the notion of the counterstory: a story that contributes to the moral self-definition of its teller by undermining a dominant story, undoing it and retelling it in such a way as to invite new interpretations and conclusions. Counterstories can be told anywhere, but particularly when told within chosen communities, they permit their tellers to reenter, as full citizens, the communities of place whose goods have been only imperfectly available to its marginalized members.

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, nursing practice has much to contribute to the ethical practice of healthcare, and with the strong grounding in ethics and aspiration for social justice considerations in nursing, there is no wonder that the specific role of the nurse ethicist has emerged. Nurse ethicists, expert (...) in nursing practice and the application of ethical theories and concepts, are well positioned to guide nurses through complex ethical challenges. However, there is limited discussion within the field regarding the specific job responsibilities that the nurse ethicist ought to have. The recent appearance of job postings with the title “nurse ethicist” suggest that some healthcare institutions have identified the value of a nurse in the practice of ethics and are actively recruiting. Discomfort about the possibility of others defining the role of the nurse ethicist inspired this paper (and special issue). If the nurse ethicist is to be seen as an integral part of addressing ethical dilemmas and ethical conflicts that arise in healthcare, then nurse ethicists ought to be at the forefront of defining this role. In this paper, we draw upon our own experiences as nurse ethicists in large academic healthcare systems to describe the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a clinical setting linked to academic programs. Drawing upon our experience and the literature, we describe how we perceive the nurse ethicist adds value to healthcare organizations and teams of professional ethicists. (shrink)

Moral distress is a pervasive phenomenon in healthcare for which there is no straightforward “solution.” Rhetoric surrounding moral distress has shifted over time, with some scholars arguing that moral distress needs to be remedied, resolved, and eradicated, while others recognize that moral distress can have some positive value. The authors of this paper recognize that moral distress has value in its function as a warning sign, signaling the presence of an ethical issue related to patient care that requires deeper exploration, (...) rather than evidencing identification of the “right” course of action. Once the experience of moral distress is identified, steps ought to be taken to clarify the moral issue, and, if possible and reasonable, the patient’s values ought to be prioritized. This paper offers concrete actions steps, drawn from theory, which can be used in clinical practice to provide peer support or to facilitate self-reflection for morally distressed individuals. This approach empowers morally distressed individuals to explore ethical issues, identify concrete steps that can be taken, and mitigate feelings of powerlessness that are often associated with moral-constraint distress. The questions guide individuals and peers to reflect first on the micro-space and then more broadly on the institutional culture, facilitating meso- and macro-reflection and action. (shrink)

Ethical awareness enables nurses to recognize the ethical implications of all practice actions, and is an important component of safe and high quality nursing care (Milliken 2016; Milliken and Grac...

ObjectivesTo explore the objectives and outcomes most appropriate for evaluating clinical ethics support services (CESs) in the USA.MethodsA three-round e-Delphi was sent to two professional medical ethics listservs (Medical College of Wisconsin-Bioethics and American Society for Bioethics and Humanities) as well as 19 individual experts. The survey originally contained 15 objectives and 9 outcomes. In round 1, participants were asked to validate the content of these lists. In round 2, we had 17 objectives and 10 outcomes, and participants were asked (...) to rank them for appropriateness in a top 10 list of objectives and a top 5 list of outcomes.ResultsParticipants came to a high(at least 70%) level of agreement on seven objectives: mediate, educate, develop policy, improve the moral quality of a decision or action, counsel, create a moral space and manage moral distress. Participants came to a moderate (at least 51%) level of agreement on three objectives: empower, awareness of ethics and preventative ethics. Participants also came to a moderate (at least 51%) level of agreement on five outcomes: ethical justification, transformation of institution, improvement of quality of life, principled consensus and satisfaction with the expertise of a CES.ConclusionThis e-Delphi identified 10 objectives and 5 outcomes that are a good starting point for developing outcome measures to evaluate CESs in the USA, while reminding us of the diversity of perspectives still evident in the field. (shrink)

In April 2004 the Irish Government commissioned Judge Maureen Harding Clark to compile a report to ascertain the rate of caesarean hysterectomies at Our Lady of Lourdes Hospital in Drogheda, Republic of Ireland. The report came about as a result of complaints by midwives into questionable practices that were mainly (but not solely) attributed to one particular obstetrician. In this article we examine the findings of this Report through a feminist lens in order to explore what a feminist reading of (...) the Report and the events that led to the inquiry will bring to light. We consider how sex and gender feature in the Lourdes case, draw attention to the deeply gendered asymmetries of power and privilege that existed between the men and women at the centre of this inquiry, and explore the impact such asymmetries had on this particular situation. (shrink)

When clinical ethics committee members discuss a complex ethical dilemma, what use do they have for normative ethical theories? Members without training in ethical theory may still contribute to a pointed and nuanced analysis. Nonetheless, the knowledge and use of ethical theories can play four important roles: aiding in the initial awareness and identification of the moral challenges, assisting in the analysis and argumentation, contributing to a sound process and dialogue, and inspiring an attitude of reflexivity. These four roles of (...) ethical theory in clinical ethics consultation are described and their significance highlighted, while an example case is used as an illustration throughout. (shrink)

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, (...) existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals. (shrink)

It may be the case that the most challenging moral problem of the twenty‐first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do (...) the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency. (shrink)

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like TIC) is systematically sensitive (...) to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

As given, the case presents at least two questions for the ethics consultant to explore: to what extent should Declan’s parent, Karesha, be involved in his health care decisions, and why is...

Throughout its fifty-year history, the role of the medical humanist and even the name “medical humanities” has remained raw, dynamic and contested. What do we mean when we call ourselves “humanists” and our practice “medical humanities?” To address these questions, we turn to the concept of origin narratives. After explaining the value of these stories, we focus on one particularly rich origin narrative of the medical humanities by telling the story of how a group of educators, ethicists, and scholars struggling (...) to define their relatively new field rediscovered the studia humanitatis, a Renaissance curriculum for learning and teaching. Our origin narrative is composed of two intertwined stories—the history of the studia humanitatis itself and the story of the scholars who rediscovered it. We argue that as an origin narrative the studia humanitatis grounds the medical humanities as both an engaged moral practice and pedagogical project. In the latter part of the paper, we use this origin narrative to show how medical humanists working in translational science can use their understanding of their historical roots to do meaningful work in the world. (shrink)

Clinical ethics consultants occasionally encounter unethical and/or unprofessional behavior as part of their normal job functions. In this article, we explore whether resigning (i.e., threatening resignation or resigning) and whistleblowing are acceptable methods ethics consultants can use to address these situations. Per our analysis, whether one considers ethics consultants private or public employees, loyal to their employer or to patients, families, and the public, resigning and whistleblowing are all acceptable, if not obligatory, actions of ethics consultants in certain circumstances. In (...) this article, we analyze salient characteristics of ethics consultation as a profession as they pertain to resignation and whistleblowing in the context of ethics consultation. We also present tentative criteria for when ethics consultants are justified, if not obligated, to resign or blow the whistle. (shrink)

Volume 20, Issue 8, August 2020, Page 114-116.

Declan and Karesha’s case reflects one of the most challenging narratives resulting from the COVID-19 pandemic: the experience of isolation, frustration, and disconnection for patients and their fa...

Bioethics promises a considered, unprejudicial approach to areas of medical decision-making. It does this, in theory, from the perspective of moral philosophy. But the promise of fairly considered, insightful commentary fails when word choices used in ethical arguments are prejudicial, foreclosing rather than opening an area of moral discourse. The problem is illustrated through an analysis of the language of The Royal Society Expert Panel Report: End of Life Decision Making advocating medical termination.

Early on in the development of Practicing Healthcare Ethicists Exploring Professionalization (PHEEP), the founding members recognized the need to address and meet two important goals: (1) the creation of a dynamic, rigorous process to support the exploratory work, and (2) the establishment of the means—deliberative engagement—to generate and justify the substantive content of professionalization-related products, such as practice standards and position statements. Drawing from social justice and deliberative democracy conceptions and insights (among others), the authors identify and describe the core (...) elements of the “process scaffolding” and “deliberative means” that inform PHEEP’s deliberative engagement methodology. The paper demonstrates how these process and substantive features have been meaningfully instantiated in the decision making framework established by PHEEP for its use in the development of professionalization-related products by Canadian practicing healthcare ethicists. (shrink)

It is often challenging for mental health‐care providers and health organizations to perform their various roles and to meet their varied obligations. In complex mental health‐care circumstances the concurrent application of relevant ethical principles and values often leads to the emergence of completing obligations that need to be carefully weighed and balanced in the making of care‐related decisions. Although some clinical circumstances, such as those potentially triggering the duty to warn, are adequately guided by existing rules based on legal precedents, (...) there is a gap in decision‐making support in other mental health‐care domains. This article proposes that a set of targeted, decision‐making approaches be developed to assist in the handling of specific, challenging circumstances. By way of illustration, two novel approaches are introduced; that is, choosing to work within a moral relational space of optimal therapeutic engagement (at the micro level of clinical practice), and the use of a health policy development approach that instantiates deliberative engagement (at the meso and macro levels of health organization). (shrink)

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between ‘nurse ethicist’ and ‘clinical ethicist’ is largely irrelevant. The second author describes the impact and value that (...) a nurse in an ethics role plays, highlighting the ‘tacit knowledge’ and ‘lived experience’ they bring to clinical ethics consultation. However, the second author also warns that the ‘nurse ethicist’ must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as ‘nurse ethicist’ on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics. (shrink)

It is time for the noon conference. Your job is to impart a career-changing experience in ethics to a group of students and interns gathered from four different schools with varying curriculums in ethics. They have just finished 1½ h of didactic sessions and lunch. One third of them were on call last night. Your first job is to keep them awake. The authors argue that this “tragic case” approach to ethics education is of limited value because it limits understanding (...) of moral problems to dilemmas; negates the moral agency of the student; encourages solutions that are merely intellectual; and suggests that ethical encounters are a matter for experts. The authors propose an alternative that focuses on three issues: the provider-patient relationship, the relationships between providers in the everyday world of health work and, the social position of healthcare providers in society. In this approach, teachers are not experts but more like guides on a journey who help students to learn that much of ethical practice comprises living through difficult situations of caring for vulnerable others and who help students to navigate some of these difficulties. (shrink)

Professionals within the mental health services face many ethical dilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Most participants report (...) positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. This focus group study indicates the potential of ethics reflection groups to create a moral space in the workplace that promotes critical, reflective and collaborative moral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improving health care practices. (shrink)