There is a consensus that the effects of medical brain drain, especially in the Sub-Saharan African countries, ought to be perceived as more than a simple misfortune. Temporary restrictions on the emigration of health workers from the region is one of the already existing policy measures to tackle the issue—while such a restrictive measure brings about the need for quite a justificatory work. A recent normative contribution to the debate by Gillian Brock provides a fruitful starting point. In the first (...) step of her defence of emigration restrictions, Brock provides three reasons why skilled workers themselves would hold responsibilities to assist with respect to vital needs of their compatriots. These are fair reciprocity, duty to support vital institutions, and attending to the unintended harmful consequences of one’s actions. While the first two are explained and also largely discussed in the literature, the third requires an explication on how and on which basis skilled workers would have a responsibility as such. In this article, I offer a vulnerability approach with its dependency aspect that may account for why the health workers in underserved contexts would have a responsibility to attend to the unintended side effects of their actions that may lead to a vital risk of harm for the population. I discuss HIV/AIDS care in Zimbabwe as a case in point in order to show that local health workers may have responsibilities to assist the population who are vulnerable to their mobility. (shrink)

Journal of Social Philosophy, EarlyView.

How ethics in human services is a political activity, shaping social relationships, is explored through the examination of two opposing discourses, a principle-based and a situated/relational narrative. Factors such as neo-liberalism, managerialism, and the risk-aversive society give a context for the reasons that the principle-based discourse has been the predominant influence, and what interests are served by this trope taking center stage. A delineation and critique of both perspectives are provided, including an explanation of the epistemological underpinnings of these discourses. (...) The piece ends with what needs to be done to strengthen ethics. (shrink)

: International instruments now defend a "right to the truth " for victims of political repression and violence and include truth telling about human rights violations as a kind of reparation as well as a form of redress. While truth telling about violations is obviously a condition of redress or repair for violations, it may not be clear how truth telling itself is a kind of reparations. By showing that concerted truth telling can satisfy four features of suitable reparations vehicles, (...) I defend the idea that politically implemented modes of truth telling to, for, and by those who are victims of gross violation and injustice may with good reason be counted as a kind of reparations. Understanding the doubly symbolic character of reparations, however, makes clearer why truth telling is unlikely to be sufficient reparation for serious wrongs and is likely to be sensitive to the larger context of reparative activity and its social, political, and historical background. (shrink)

In recent decades, care has played an increasingly crucial role in the self-understanding of the human being in the West. Nevertheless, there is a great deal of confusion and uncertainty surrounding the notion of care. One of the focal points of critics is the normativity of care. To what extent does care have an obligatory character? Only when the objective normative basis of care is sufficiently clarified, care practices can be evaluated and optimised from an ethical perspective. In this contribution (...) we explain how the anthropology of personalism could bring us closer to the normative core of care. The paper starts with a general overview of the contribution of care ethics in healthcare and the problems in relation to the normativity of care. Thereafter, we set the viewpoints of the Louvain tradition of personalism apart en show that this view on the human person is in keeping with a few basic principles of care ethics. Next, we describe how a personalist approach to care ethics can indeed indicate in which direction action must be taken so that human action may be considered ethically sound. (shrink)

This introduction to the special issue on ‘Ricoeur and the ethics of care’ is not a standard editorial. It provides not only an explanation of the central questions and a first impression of the articles, but also a critical discussion of them by an expert in the field of care ethics, Joan Tronto. After explaining the reasons to bring Ricoeur into dialogue with the ethics of care, and analyzing how the four articles of this special issue shape this dialogue, the (...) authors give the floor to Tronto. She focuses on the central issue at stake: what may be the value of a more abstract, conceptual approach for the ethics of care as a radically practice-oriented way of thinking? She argues that the four contributions too easily frame this value in terms of Ricoeur’s relational anthropology. Instead she points out that if the ethics of care is a kind of practice, it makes sense to think of such practices as necessarily building upon one another, expanding constantly the context and relationships upon which practices are built. In the final section the authors respond to Tronto’s framing of ‘practices all the way up’ by arguing that this approach need not be at odds with one inspired by Ricoeur’s conceptual thinking. Rather the two can be seen as different movements—upwards and downwards—that both contribute constructively to the shaping of the important intermediary zone between the practices and the abstract ideals. (shrink)

Care ethics emphasizes responsibility as a key element for caring practices. Responsibilities to care are taken by certain groups of people, making caring practices into moral and political practices in which responsibilities are assigned, assumed, or implicitly expected, as well as deflected. Despite this attention for social practices of distribution and its unequal result, making certain groups of people the recipient of more caring responsibilities than others, the passive aspect of a caring responsibility has been underexposed by care ethics. By (...) drawing upon the work of the French phenomenologist Jean-Luc Marion, a care ethical conceptualization of responsibility can by enriched, by scrutinizing how responsibility is literally a response to something else. This paper starts with a vignette of an everyday situation of professional care. After that the current body of care ethical literature on responsibility is presented, followed by Marion’s phenomenology of givenness, using his analysis of Caravaggio’s painting The Calling of St. Matthew and resulting in his redefinition of responsibility. In the next section we present a table in which we juxtapose four distinct paradigms of responsibility, which we will describe briefly. The final section consists of an exploration of the paradigms by an analysis of the vignette and results in a conclusion concerning what Marion’s view has to offer to care ethics with regard to responsibility. (shrink)

Notwithstanding the fact that care ethics has received increased attention, it has also faced much criticism. One of the focal points of critics is the normativity of care. Only when the objective normative basis of care is sufficiently clarified can care practices be evaluated and optimized from an ethical point of view. We emphasize that two levels of normativity can be identified: the context level and the foundational anthropology level. The personalist approach to care ethics is normatively stronger, at least (...) on one level, namely the foundational anthropology level. This personalist approach to care ethics indicates in which direction action must be taken so that human action may be considered ethically sound. (shrink)

Making better choices about future technologies that are being researched or developed is an important motivator behind lay ethics interventions. However, in practice, they do not always succeed to serve that goal. Especially authors who have noted that lay ethicists sometimes take recourse to well-known themes which stem from old, even ‘archetypical’ stories, have been criticized for making too little room for agency and decision-making in their approach. This paper aims to contribute to a reflection on how lay ethics can (...) acquire more practical relevance. It will use resources in narrative ethics to suggest that in order to be relevant for action, facilitators of lay ethics interventions need to invite participants to engage in a narrative quest. As part of a quest, lay ethicists should be asked to reflect on a specific question or choice, use diverse input which is informative about the heterogeneity of viewpoints that are defended in society and argue for their standpoints. (shrink)

Background:The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.Research objective:To explore what the nurse’s advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).Research design:An exploratory critical qualitative study was conducted from (...) October 2015 to March 2016. Thematic analysis was used to analyse the data.Participants:Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).Ethical considerations:Approval was obtained from the Basque Country Clinical Research Ethics Committee.Findings:Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.Discussion:The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses’ advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.Conclusion:This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians. (shrink)

Are social movements responsible for their unfinished agendas? Feminist successes in opening the professions to women paved the way for the emergence of the upper middle-class two-career household. These households sometimes hire domestic servants to accomplish their child care work. If, as I shall argue, this practice is unjust and furthers social inequality, then it poses a moral problem for any feminist commitment to social justice.

Are social movements responsible for their unfinished agendas? Feminist successes in opening the professions to women paved the way for the emergence of the upper middle-class two-career household. These households sometimes hire domestic servants to accomplish their child care work. If, as I shall argue, this practice is unjust and furthers social inequality, then it poses a moral problem for any feminist commitment to social justice.

: Are social movements responsible for their unfinished agendas? Feminist successes in opening the professions to women paved the way for the emergence of the upper middle-class two-career household. These households sometimes hire domestic servants to accomplish their child care work. If, as I shall argue, this practice is unjust and furthers social inequality, then it poses a moral problem for any feminist commitment to social justice.

Ten nurses at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The main theme in the narratives was being close to and moved by the suffering of patients and relatives. The nurses' responsibility for patients and relatives was expressed as a commitment to act, and they needed to ask themselves (...) whether their responsibility had been fulfilled, that nothing had been left undone, overlooked or neglected, before they could leave the unit. When there was confirmation by the patients, relatives, colleagues and themselves that the needs of patients and relatives had been attended to in a morally and professionally satisfying manner, this increased the nurses' confidence and satisfaction in their work, and their strength to live with the burden of being in ethically difficult situations. (shrink)

: Drawing from work in feminist moral philosophy, Tobin argues that the most common methodology used in practical ethics is a questionable methodology for addressing practical problems across diverse cultural contexts because the kind of impartiality it requires is neither feasible nor desirable. She then defends an alternative methodology for practical ethics in a global context and uses her proposed methodology to evaluate a problem that confronts many Sunni Muslim women around the world.

Drawing from work in feminist moral philosophy, Tobin argues that the most common methodology used in practical ethics is a questionable methodology for addressing practical problems across diverse cultural contexts because the kind of impartiality it requires is neither feasible nor desirable. She then defends an alternative methodology for practical ethics in a global context and uses her proposed methodology to evaluate a problem that confronts many Sunni Muslim women around the world.

Drawing from work in feminist moral philosophy, Tobin argues that the most common methodology used in practical ethics is a questionable methodology for addressing practical problems across diverse cultural contexts because the kind of impartiality it requires is neither feasible nor desirable. She then defends an alternative methodology for practical ethics in a global context and uses her proposed methodology to evaluate a problem that confronts many Sunni Muslim women around the world.

An authoethnography explores the lived experiences of patients being in control and self-managing their chronic illness among their families and friends. Findings show that the current health discourse narrows down people to mere patients and gives rise to tensions. This article indicates that people with one or several chronic illnesses or disabilities are first of all full citizens with needs, values, and drives seeking a meaningful life. Fair possibilities ought to exist to satisfy their needs to belong, to care for (...) and to matter to others since these constitute an essential aspect of being human. (shrink)

I briefly introduce Moral Failure as a book that brings together philosophical and empirical work in moral psychology to examine moral requirements that are non-negotiable and that contravene the principle that “ought implies can.” I respond to Rivera by arguing that the process of construction that imbues normative requirements with authority need not systematize or eliminate conflicts between normative requirements. My response to Schwartzman clarifies what is problematic about nonideal theorizing that limits itself to offering action-guidance. In response to Kittay, (...) I defend my rejection of “ought implies can,” and consider the implications of the concept of unfair moral requirements. (shrink)

This paper draws on Claudia Card’s discussions of moral luck to consider the complicated moral life of people—described as pessimists—who accept the heavy knowledge of the predictability of the bad moral luck of oppression. The potential threat to ethics posed by this knowledge can be overcome by the pessimist whose resistance to oppression, even in the absence of hope, expresses a sense of still having a ‘‘claim’’ on flourishing despite its unattainability under oppression.

John Dewey developed a pragmatic theory of inquiry to provide intelligent methods for social progress. He believed that the logic and attitude of successful scientific inquiries, properly conceived, could be fruitfully applied to morals and politics. Unfortunately, his project has been poorly understood and his logic of inquiry neglected as a resource. Contemporary pragmatists, like Richard Rorty, for example, dismiss his emphasis on method and avoid judgments of moral progress that are in any way independent of the biases of particular (...) cultures. In this article, I argue that Dewey’s theory of inquiry indeed provides intelligent methods and intellectual criteria for engaging moral and political matters. Inquiry, as Dewey conceives it, issues in judgments that are increasingly objective, reliable and refined in application. These judgments are rooted in particular times and places, in actual ‘situations’, but are not entirely hostage to specific cultures. I then apply Dewey’s theory to two standard moral problems to demonstrate how it works. The conclusion is that Dewey’s theory of inquiry gets it just right: it provides solid ground for criticism and moral progress while remaining acutely sensitive to cultural differences and changing circumstances. (shrink)

The theory and practise of care is defined and enacted differently in different national as well as cultural contexts, illuminating how differently constructed the personal and societal structures in Europe are. A common trait is however that care work paid or non-paid, private or public is identified with women. To navigate in the landscape of care and ethics requires taking into account the constitutive relation between one’s identity, embodiment and position. The author suggests conceiving care as an existential condition of (...) life demanded from all human beings. This will free care from the identification with women and pave a way towards a more gender equal and just society with less gender segregation in the labour market and at the arena of education. (shrink)

People who are involuntarily childless need to use assisted reproductive technologies if they want to have a genetically related child. Yet, from an ethical point of view it is unclear to what extent assistance to satisfy this specific desire should be warranted. We first show that the subjectively felt harm due to the inability to satisfy this reproductive desire does not in itself entail the normative conclusion that it has to be met. In response, we evaluate the alternative view according (...) to which the satisfaction of this desire is regarded as a way to meet one’s presumed intermediate need for parenthood. This view presupposes that parenthood is one of those general categories of experiences and activities that contribute an irreplaceable value to people’s lives, but the central difficulty is to find those characteristics that mark out parenthood as an irreplaceable constituent of a valuable life. We go on to argue, however, that even if one assumes that parenthood is such an irreplaceable constituent that makes life more valuable, this does not necessarily entail a moral duty to satisfy the desire for genetic parenthood. We conclude that there is a pro tanto obligation to help people conceive a genetically related child (if this is what they prefer), but that this can be outweighed by other moral considerations, such as safety and justice concerns. (shrink)

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)

Moral madness is a symptom of the moral violence experienced by teachers who are expected to exercise responsibility for their students and their work, but whose moral voice is misrecognized as self-interest and whose moral agency is suppressed. I conduct a feminist ethical analysis of the figure of Cassandra to examine the ways in which teachers may be driven to moral madness.

This article surveys recent feminist contributions to moral philosophy with an emphasis on those works which engage with debates within mainstream ethics. The article begins by examining a tension said to arise from the two criteria a theory must meet if it is to count as feminist moral theory: the women's experience requirement and the feminist conclusion requirement. Subsequent sections deal with feminist relational theories of rights, feminist work on responsibility and feminist contractarian approaches to ethics. A final section looks (...) at the application of some feminist moral theories to the problem of abortion. (shrink)

Not all those who write philosophy are recognized as philosophers. In this paper I argue that Dutch writer Isabelle de Charrière, usually known as a novelist, is actually engaged in doing moral philosophy. In the second half of the eighteenth century, Charrière wrote novels about characters who endorsed moral theories and commitments. Her novels track the dilemmas that these characters face in trying to live according their moral theories and commitments. I consider the case for treating fiction as philosophically valuable, (...) and argue that Charrière's novels fall into the category of philosophically valuable fiction. (shrink)

Concern for human vulnerability seems to be at the heart of bioethical inquiry, but the concept of vulnerability is under-theorized in the bioethical literature. The aim of this article is to show why bioethics needs an adequately theorized and nuanced conception of vulnerability. We first review approaches to vulnerability in research ethics and public health ethics, and show that the bioethical literature associates vulnerability with risk of harm and exploitation, and limited capacity for autonomy. We identify some of the challenges (...) emerging from this literature: in particular, how to reconcile universal human vulnerability with a context-sensitive analysis of specific kinds and sources of vulnerability; and how to reconcile obligations to protect vulnerable persons with obligations to respect autonomy. We then briefly survey some of the theoretical resources available within the philosophical literature to address these challenges, and to assist in understanding the conceptual connections between vulnerability and related concepts such as harm, exploitation, needs, and autonomy. We also sketch out a taxonomy of sources and kinds of vulnerability. Finally, we consider the implications for policy evaluation of making vulnerability an explicit and central focus of bioethics. Our investigation is in the form of a broad survey motivating a research agenda rather than a detailed analysis. (shrink)

It is not uncommon for patients with advanced disease to express a wish to hasten death. Qualitative studies of the WTHD have found that such a wish may have different meanings, none of which can be understood outside of the patient’s personal and sociocultural background, or which necessarily imply taking concrete steps to ending one’s life. The starting point for the present study was a previous systematic review of qualitative studies of the WTHD in advanced patients. Here we analyse in (...) greater detail the statements made by patients included in that review in order to examine their moral understandings and representations of illness, the dying process and death. We identify and discuss four classes of assumptions: assumptions related to patients’ moral understandings in terms of dignity, autonomy and authenticity; assumptions related to social interactions; assumptions related to the value of life; and assumptions related to medicalisation as an overarching context within which the WTHD is expressed. Our analysis shows how a philosophical perspective can add to an understanding of the WTHD by taking into account cultural and anthropological aspects of the phenomenon. We conclude that the knowledge gained through exploring patients’ experience and moral understandings in the end-of-life context may serve as the basis for care plans and interventions that can help them experience their final days as a meaningful period of life, restoring some sense of personal dignity in those patients who feel this has been lost. (shrink)

This paper argues that human rights-based approaches to human security overlook the importance of caring values, relations of care, and care work in the achievement and long-term maintenance of human security. It outlines an alternative approach to the ethics of human security which combines a feminist ontological and normative position on the centrality of caring values and practices in sustaining life with a feminist account of the gendered political economy of contemporary globalisation. Moreover, it argues that a critical, feminist ethics (...) of care can provide a comprehensive ontological and normative framework for integrating economic exclusion with violence, and thus for understanding and conceptualising human security in a way that is sensitive to the role played by gender identities and other types of power relations. This, I argue, can be achieved through an interrogation of the relationship between neoliberal globalisation and hegemonic forms masculinity in the context of contemporary global governance. (shrink)

This article develops an approach to ethical globalization based on a feminist, political ethic of care; this is achieved, in part, through a comparison with, and critique of, Thomas Pogge's World Poverty and Human Rights. In his book, Pogge makes the valid and important argument that the global economic order is currently organized such that developed countries have a huge advantage in terms of power and expertise, and that decisions are reached purely and exclusively through self-interest. Pogge uses an institutional (...) rights framework to argue that direct responsibility for global poverty and inequality lies with the citizens of developed countries, since suffering and death are caused by global economic arrangements designed and imposed by our governments. While this argument is certainly compelling, I have argued that it tells us little about the actual effects of globalization on the real people of the South - including women, children and the elderly. As a result, it can offer little in the way of real alternatives or policy prescriptions. As a moral orientation, a care ethic relies on a relational moral ontology, and leads us to consider different values in terms of human flourishing. Moreover, it pushes us to consider the normative implications of aspects of the global political economy which are usually not 'seen' at all, including the global distribution of care work and the corresponding patterns of gender and racial inequality, the underprovision of care and resources for caring work in both the developed and developing world, and the ways in which unpaid or low-paid caring work helps to sustain a cycle of exploitation and inequality on a global scale. (shrink)

Health care professionals’ and trainees’ conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians’ changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least (...) two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others’ needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here. (shrink)

Traditional considerations of justice for those who require caregiving have centered on what is due to the dependent person. However, considerations of justice also bear strongly on what is due to the caregiver. I focus on unpaid dependency work, too long treated as a private matter rather than a public concern. More is owed to those who render care: the division of labor is unjust, the nature of dependency work creates vulnerabilities for caregivers, and unpaid caregivers are disadvantaged in the (...) world of paid work. Obligations to mitigate these facts are ultimately based on the truth that all members of society at some point in their lives benefit from caregiving and that noncaregivers benefit unfairly from the heavy distribution of dependency work to a small number of certain kinds of individuals. It is necessary to ask which agents of justice are responsible for remedying this state of affairs, and how. I propose a distributed scheme of obligation in which members of society and the state, as arbiter of social responsibility, share responsibility for the remedy. It is incumbent upon us as a society to refrain from making vulnerable the most essential among us, to reap benefits without sowing unjust burdens. (shrink)

ABSTRACTGiven the existing inequities in climate change, any proposed climate engineering strategy to solve the climate problem must meet a high threshold for justice. In contrast to an overly thin paradigm for justice that demands only a science-based assessment of potential temperature-related benefits and harms, we argue for the importance of attention to recognitional justice. Recognitional justice, we go on to claim, calls for a different type of assessment tool. Such an assessment would pay attention to neglected considerations such as (...) relationships, context, power, vulnerability, narrative, and affect. Here we develop a care-ethics related tool for assessing the justice of climate engineering with stratospheric aerosols, and suggest that qualitative social science methods may be required for its effective application. We illustrate the use of this tool with a case study involving interviews about stratospheric aerosol injection conducted in Kenya, the Solomon Islands... (shrink)

A decision was made at the UNFCCC, COP-18 meeting in Doha in 2012 to create a work programme on loss and damage. Part of this programme was to include the production of a technical paper to enhance the general understanding of non-economic losses from climate change. The following article looks carefully at that paper in order to discover whether it provides an adequate conceptual understanding of non-economic losses. Several shortcomings of the paper’s conceptualization of these losses are identified. An alternative (...) ethical framework with methods better suited for capturing a fuller range of non-economic losses is considered. This framework is likely to be most useful if used prospectively for the purpose of devising better adaptation policies to head off potential future losses rather than if used retrospectively for quantifying losses that have already occurred for the purposes of providing compensation. (shrink)

On realist terms, politics is about power, security, and order, and the question of whether politics can practice compassion is irrelevant. The author argues that a politics of compassion is possible and necessary in order to address human security needs. She extend debates on care ethics to develop a politics of compassion, using the example of asylum seekers to demonstrate that politics can practice compassion with attentiveness to the needs of vulnerable people who are suffering, an active listening to the (...) voices of the vulnerable, and open, compassionate, and appropriate responses to particular needs. (shrink)

This paper describes the approach of empirical ethics, a form of ethics that integrates non-positivist ethnographic empirical research and philosophy. Empirical ethics as it is discussed here builds on the ‘empirical turn’ in epistemology. It radicalizes the relational approach that care ethics introduced to think about care between people by drawing in relations between people and technologies as things people relate to. Empirical ethics studies care practices by analysing their intra-normativity, or the ways of living together the actors within these (...) practices strive for or bring about as good practices. Different from care ethics, what care is and if it is good is not defined beforehand. A care practice may be contested by comparing it to alternative practices with different notions of good care. By contrasting practices as different ways of living together that are normatively oriented, suggestions for the best possible care may be argued for. Whether these suggestions will actually be put to practice is, however, again a relational question; new actors need to re-localize suggestions, to make them work in new practices and fit them in with local intra-normativities with their particular routines, material infrastructures, know-how and strivings. (shrink)

Technology is pervasive and overwhelming in the intensive care setting. It has the power to inform and direct the nursing care of critically ill patients. Technology changes the moral and social dynamics within nurse—patient encounters. Nurses use technology as the main reference point to interpret and evaluate clinical patient outcomes. This shapes nurses’ understanding and the kind of care provided. Technology inserts itself between patients and nurses, thus distancing nurses from patients. This situates nurses into positions of power, granting them (...) epistemic authority, which constrains them as moral agents. Technology serves to categorize and marginalize patients’ illness experience. In this article, moral agency is examined within the technologically-mediated context of the intensive care unit. Uncritical use of technology has a negative impact on patient care and nurses’ view of patients, thus limiting moral agency. Through examination of technology as it frames cardiac patients, it is demonstrated how technology changes the way nurses understand and conceptualize moral agency. This article offers a new perspective on the ethical discussion of technology and its impact on nurses’ moral agency. Employing reflective analysis using the technique of embodied reflection may help to ensure that patients remain at the centre of nurses’ moral practice. Embodied reflection invites nurses critically to examine how technology has reshaped conceptualization, understanding, and the underlying motivation governing nurses’ moral agency. (shrink)

Health-care professionals in end-of-life care are frequently confronted with patients who seem to be ‘ambivalent’ about treatment decisions, especially if they express a wish to die. This article investigates this phenomenon by analysing two case stories based on narrative interviews with two patients and their caregivers. First, we argue that a respectful approach to patients requires acknowledging that coexistence of opposing wishes can be part of authentic, multi-layered experiences and moral understandings at the end of life. Second, caregivers need to (...) understand when contradictory statements point to tensions in a patient’s moral experience that require support. Third, caregivers should be careful not to negatively label or even pathologize seemingly contradictory patient statements. (shrink)

In Dutch healthcare policy patients are seen as informed, autonomous experts and active decision makers with control over their illness and care. Healthcare professionals are expected to operate as providers of information. The purpose of this article is to argue that the consumerist approach of the patient–professional relationship is not a productive way to envision the patient–professional relationship. We argue that an interpretive/deliberative model is a more productive way to envision this relationship, especially in the care for people with a (...) chronic illness. This is illustrated with a case study. It concerns a study of the experiences of a Multiple Sclerosis (MS) patient and healthcare professionals involved in her care. The presented stories show that the participants did not act in line with the roles and responsibilities embodied in the consumerism rhetoric in Dutch healthcare policy. Expectations of patients and healthcare professionals are better met when care is redefined as mutual endeavour in which the caring abilities of healthcare professionals and the vulnerability of chronically ill patients are taken into account. (shrink)

Background Clinical moral case deliberation consists of the systematic reflection on a concrete moral case␣by health care professionals. This paper presents the study of a 4-year moral deliberation project.Objectives The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of␣the evaluation of the moral case deliberation sessions, and (d) present the implementation process.Methods The implementation process is both monitored and supported by an (...) interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).Results Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects. (shrink)

In this paper, we argue that ‘good care’ in residential nursing homes is enacted through different care practices that are either inspired by a ‘professional logic of care’ that aims for justice and non-maleficence in the professional treatment of residents, or by a ‘relational logic of care’, which attends to the relational quality and the meaning of interpersonal connectedness in people’s lives. Rather than favoring one care logic over the other, this paper indicates how important aspects of care are constantly (...) negotiated between different care practices. Based on the intricate everyday negotiations observed during an ethnographic field study at an elderly nursing home in Germany, the paper puts forth the argument that care is always a matter of tinkering with different, sometimes competing ‘goods’. This tinkering process, which unfolds through ‘intuitive deliberation’, ‘situated assessment’ and ‘affective juggling’ is then theorized along the conceptualization of a ‘practical ethics of care’: an ethics which makes no a priori judgments of what may be considered as good or bad care, but instead calls for momentary judgments that are pliable across changing situations. (shrink)