Moral deliberation has been receiving more attention in nursing ethics. Several ethical conversation models have been developed. This article explores the feasibility of the so-called CARE (Considerations, Actions, Reasons, Experiences) model as a framework for moral deliberation in psychiatric nursing practice. This model was used in combination with narrative and dialogical approaches to foster discourse between various stakeholders about coercion in a closed admission clinic in a mental hospital in the Netherlands. The findings demonstrate that the CARE model provides a (...) substantial framework for structuring moral deliberations. Narratives and dialogue are useful tools for broadening issues in conversations, to engage various stakeholders (including patients), and to gain shared understandings. (shrink)

This written account of a clinical encounter - depicting fragments of a more extensive array of events - attempts to exemplify many facets and associated complexities of clinical ethics consultation. Within the general telling, I provide more detailed portrayals of several key events. In secion 1, I document briefly my initial interactions at the beginning of the consultation, focusing on the information gained - in the context of those interactions - as I read the medical chart of Mrs. Rose. Next (...) in section 2, I briefly describes my initial conversation with Mrs. Rose's three sons. Section 3 illustrates several questions raised in sections 1 and 2. Then section 4 presents my encounter with Paul, the youngest son, as he was carrying out his vigil at his mother's bedside in the hospital. Section 5 chronicles my interactions with several care providers involved in Mrs. Rose's situation, including two different meetings that occurred with Mrs. Rose's attending physician. I conclude in section 6 by telling about a conversation I had with Mrs. Rose's middle son, Russell, approximately one month after Mrs. Rose died. (shrink)

Clinical ethics consultants (CECs) work in complex environments ripe with multiple types of expectations. Significantly, some are due to the perspectives of professional colleagues and the patients and families with whom CECs consult and concern how CECs can, do, or should function, thus adding to the moral complexity faced by CECs in those particular circumstances. We outline six such common expectations: Ethics Police, Ethics Equalizer, Ethics Superhero, Ethics Expediter, Ethics Healer or Ameliorator, and, finally, Ethics Expert. Framed by examples of (...) requests for ethics consultation that illustrate each kind, along with brief descriptions, we argue that while these expectations ought to be resisted for clear and practical reasons, they also create opportunities for CECs to articulate, educate, and ultimately be responsible to the professional demands of clinical ethics work. Recognizing, acknowledging, and at times resisting those expectations thus become key activities and responsibilities in the performance of ethics consultation. (shrink)

This paper focuses on the _ethics of how_ to approach the introduction of MAiD as an organizational ethics challenge, a focus that diverges from the traditional focus in healthcare ethics on the _ethics of why_ MAiD is right or wrong. It describes a method co-designed and implemented by ethics and medical leadership at a tertiary hospital to develop a values-based, grassroots response to the decriminalization of assisted dying in Canada. This organizational ethics engagement method embodied core tenants that drew inspiration (...) from a variety of sources, including poetic ones. These tenants are: make the problem bigger; focus on values; cultivate open moral spaces; and trust emergence. The paper describes how these tenants were put into practice in order to create a rigorous and sustainable MAiD program that delivers high-quality care to patients and families while honoring the moral diversity of the hospital workforce. One of the goals in sharing this method is to provide a roadmap for healthcare organizations in Canada and other jurisdictions around the world that are facing the challenge of responding to patient requests for MAiD following the decriminalization of this care option. (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)

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...

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

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)

In an age of professionalization and specialization, the practice of clinical ethics is facing an identity crisis. Are clinical ethicists moral experts, ethics experts, or merely quasi-lawyers giving legal advice? Are they extensions of the hospital, always working to advance the hospital’s interests? Or is there another option? Since 1998, when the American Society for Bioethics and Humanities first issued its Core Competencies for Healthcare Ethics Consultation, there has been debate about the role of standardization and proceduralism in clinical ethics (...) consultation. Now, as ASBH continues to move forward with its credentialing program, proceduralism in clinical ethics must be critically examined. In this paper, I argue that the proceduralist approach to clinical ethics consultation, as espoused by the ASBH’s call for credentialing, creates a demeaning experience for all parties involved and precludes goods internal to the practice of clinical ethics consultation from being actualized. As a practice embedded in medicine and in institutions such as the hospital, clinical ethics consultation must define and examine its own goods in order to bring about more than a sterile, law-like solution to difficult moral quandaries, as these sterile solutions leave patients, families, and providers unsatisfied, abandoned, and disappointed. Thus, in an effort to push back against this proceduralism in clinical ethics consultation, I will offer a preliminary exploration of what these goods might be. (shrink)

In most children’s hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians (...) about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children’s hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are ethics committee meetings, Nursing Ethics Forum, ethics Brown Bag workshops, PICU ethics rounds, Grand Rounds, NICU Comprehensive Care Rounds, Palliative Care Team case conferences, multidisciplinary consults in Fetal Health Center, and ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of “core competencies” than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple “moral spaces” in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today. (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)

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)

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.

Communication and Conflict Management Training for Clinical Bioethics Committees Content Type Journal Article Pages 341-349 DOI 10.1007/s10730-009-9116-7 Authors Lauren M. Edelstein, Johns Hopkins Medicine’s Howard County General Hospital 5755 Cedar Lane Columbia MD 21044 USA Evan G. DeRenzo, Washington Hospital Center Center for Ethics 110 Irving St Washington, D.C. NW 20010 USA Elizabeth Waetzig, Change Matrix Inc. 485 Maylin St. Pasadena CA 91105 USA Craig Zelizer, Georgetown University Department of Government 3240 Prospect St. Washington, D.C. NW 20057 USA Nneka O. (...) Mokwunye, Washington Hospital Center Center for Ethics 110 Irving St Washington, D.C. NW 20010 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4. (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)

According to G. E. Moore, moral expertise requires abilities of several kinds: the ability to factor judgments of right and wrong into (a) judgments of good and bad and (b) judgments of cause and effect, (2) the ability to use intuition to make the requisite judgments of good and bad, and (3) the ability to use empirical investigation to make the requisite judgments of cause and effect. Moore’s conception of moral expertise is thus extremely demanding, but he supplements it with (...) some very simple practical guidance. (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)

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...

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)

Most arguments about conscientious objections in medicine fail to capture the full scope and complexity of the concept before drawing conclusions about their permissibility in practice. Arguments favoring and disfavoring the accommodation of conscientious objections in practice tend to focus too narrowly on prima facie morally contentious treatments and religious claims of conscience, while further failing to address the possibility of moral perspectives changing over time. In this paper, I argue that standard reasons against permitting conscientious objections in practice—that their (...) permission may result in harm to patients, the idea that medical providers willingly enter into the medical field, and that conscientious objections stand contrary to medical professionalism—do not apply in all cases and that the medical field and health systems in which many physicians now practice should continue to tolerate conscientious objections in practice. (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)

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)

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)

This paper offers an exposition of what the question of method in ethics consultation involves under two conditions: when ethics consultation is regarded as a practice and when the question of method is treated systematically. It discusses the concept of the practice and the importance of rules in constituting the actions, cognition, and perceptions of practitioners. The main body of the paper focuses on three elements of the question of method: canon, discipline, and history, which are treated heuristically to outline (...) what the question of method in ethics consultation fully involves. (shrink)

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)

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)

Evaluation of clinical ethical case consultations has been discussed as an important research task in recent decades. A rigid framework of evaluation is essential to improve quality of consultations and, thus, quality of patient care. Different approaches to evaluate those services appropriately and to determine adequate empirical endpoints have been proposed. A key challenge is to provide an answer to the question as to which empirical endpoints—and for what reasons—should be considered when evaluating the quality of a service. In this (...) paper, we argue for an approach that adopts the role of ethics consultants as its point of departure. In a first step, we describe empirical and ethical characteristics of evaluating clinical ethical case. We show that the mode of action and the explicit normative character of the interventions constitute two characteristics which pose challenges to the selection of appropriate quality criteria and require special attention. In a second step, we outline the way in which an analysis of the role of ethics consultants in the context of a clinical ethical case consultation services can account for the existing challenges by linking empirically measurable endpoints with normative theory. Finally, we discuss practical implications of our model for evaluation research. (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)

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)

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)

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)

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective (...) ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called “moral spaces,” reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings. (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)

Morally contoured empathy is a form of reasonable partiality essential to the healthy care of dependents. It is critical as an epistemic aid in determining proper moral responsiveness; it is also, within certain richly normative roles and relationships, itself a crucial constitutive mode of moral connection. Yet the achievement of empathy is no easy feat. Patterns of incuriosity imperil connection, impeding empathic engagement; inappropriate empathic engagement, on the other hand, can result in self-effacement. Impartial moral principles and constraints offer at (...) best meager protection against these perils, and hence serve poorly in securing morally contoured empathy. More nuanced and practical guidance should be sought in normatively substantive conceptions of our roles and relationships and their defining moral stakes. These, joined with more abstract moral tools, can facilitate rich, narratively textured interpretations of moralitys demands. While the content of our normative conceptions must be continually debated, engaging in this debate is vital to the achievement of proper empathy, and thus to effective, respectful, morally healthy care of dependents. (shrink)

BackgroundReports suggest that some health care personnel fear retaliation from seeking ethics consultation. We therefore examined the prevalence and determinants of fear of retaliation and determined whether this fear is associated with diminished likelihood of consulting an ethics committee.MethodsWe surveyed registered nurses (RNs) and social workers (SWs) in four US states to identify ethical problems they encounter. We developed a retaliation index (1–7 point range) with higher scores indicating a higher perceived likelihood of retaliation. Linear regression analysis was performed to (...) identify socio-demographic and job characteristics associated with fear of retaliation. Logistic regression analysis was performed to determine whether fear of retaliation was associated with less likelihood of seeking consultation. Results Our sample (N = 1215) was primarily female (85%) and Caucasian (83%) with a mean age of 46 years and 17 years of practice. Among the sample, 293 (48.7%) RNs and 309 (51.3%) SWs reported access to an ethics consultation service. Amongst those with access, 2.8% (n = 17) personally experienced retaliation, 9.1% (n = 55) observed colleagues experience retaliation, 30.2% (n = 182) reported no experience with retaliation but considered it a realistic fear, and 50.8% (n = 305) did not perceive retaliation to be a problem. In logistic regression modeling, fear of retaliation was not associated with the likelihood (OR = 0.64; 95% CI = 0.22–1.89) or frequency of requesting ethics consultation (OR = 0.81; 95% CI = 0.27–2.38). Conclusion Fear of retaliation from seeking ethics consultation is common among nurses and social workers, nonetheless this fear is not associated with reduced requests for ethics consultation. (shrink)

This paper provides a description of the role of the clinical ethicist as it is generally experienced in Canada. It examines the activities of Canadian ethicists working in healthcare institutions and the way in which their work incorporates more than ethics case consultation. The Canadian Bioethics Society established a “Taskforce on Working Conditions for Bioethics” (hereafter referred to as the Taskforce), to make recommendations on a number of issues affecting ethicists and to develop a model role description. This essay carefully (...) assesses this model role description. (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)

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)

Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their concern is that (...) any guidance offered by the ethics consultant will privilege and empower one party’s viewpoint over—and to the exclusion of—other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new spaces for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for clinical ethics conflict coaching can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes. (shrink)