Dealing with situations where parents’ views about treatment for their child are strongly opposed to doctors’ views is one major area of ethical challenge in paediatric health care. The traditional approach focuses on the child’s best interests, but this is problematic for a number of reasons. The Harm Principle test is regarded by many ethicists as more appropriate than the best interests test. Despite this, use of the best interests test for intervening in parental decisions is still very common in (...) clinical settings and can lead to confusion. In this paper, I propose the Zone of Parental Discretion as a means of putting into practice the key ideas of the Harm Principle, in a clear, step-by-step process. The Zone of Parental Discretion provides a tool for ethical deliberation by clinicians and ethicists about all situations in which parents and doctors disagree about treatment of a child, whether parents are refusing medically recommended treatment, or requesting non-recommended treatment. (shrink)

Simon May has argued that the notion of a principled compromise is incoherent. Reasons to compromise are always in his view strategic: though we think that the position we defend is still the right one, we compromise on this view in order to avoid the undesirable consequences that might flow from not compromising. I argue against May that there are indeed often principled reasons to compromise, and that these reasons are in fact multiple. First, compromises evince respect for persons that (...) we have reason to think of as our epistemic peers, and acknowledgement of our own finitudes as moral reasoners. Second, compromises are often made morally necessary by the shortfalls that unavoidably separate democratic institutions from democratic ideals. Third, compromises express a desirable form of democratic community. And fourth, compromises are often justified from a consequentialist point of view, in that they allow for the realization of values that would not be realized as well by the failure to compromise. (shrink)

Doing Right: A Practical Guide to Ethics for Medical Trainees and Physicians is a concise and practical guide to ethical decision-making in medicine. The text is aimed at second- and third-year one-semester ethics courses offered in medical schools, health sciences departments, and nursing programs. By taking an applied approach rather than a theoretical approach, this text serves the needs of medical and nursing students, residents, and practicing physicians by sorting through questions of moral principles relevant to the diverse and growing (...) number of healthcare professionals. The many topics covered include truth telling, refusal of treatment, assisted suicide, managing error, and reproductive choice. (shrink)

In this study, Canadian healthcare ethics consultants describe their use of ethics decision-making frameworks. Our research finds that ethics consultants in Canada use multi-purpose ethics decision-making frameworks, as well as targeted frameworks that focus on reaching an ethical resolution to a particular healthcare issue, such as adverse event reporting, or difficult triage scenarios. Several interviewees mention the influence that the accreditation process in Canadian healthcare organizations has on the adoption and use of such frameworks. Some of the ethics consultants we (...) interviewed also report on their reluctance to use these tools. Limited empirical work has been done previously on the use of ethics decision-making frameworks. This study begins to fill this gap in our understanding of the work of healthcare ethics consultants. (shrink)

First Published in 2002. Routledge is an imprint of Taylor & Francis, an informa company.

Clinical ethics committees (CECs) in the United Kingdom (UK) have developed significantly over the past 15 years. The issue of access to and participation in clinical ethics consultation by patients and family members has, however, gone largely unrecognized. There are various dimensions to this kind of contact, including patient notification, consent and participation. This study reports the first specific investigation of patient contact with UK CECs. A questionnaire study was carried out with representatives from UK CECs. Results suggest that patient (...) participation in clinical ethics consultation is low and unlikely to change significantly in the near future. Attitudes towards patients having a role in clinical ethics consultation are mixed, with a variety of reasons put forward both for and against patient participation. These results are discussed in the light of common themes in the literature and the practical and political context of clinical ethics support in the UK. (shrink)

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

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

Why mediation? -- What makes bioethics mediation unique? -- Before you begin a bioethics mediation program -- The stages of bioethics mediation -- Techniques for mediating bioethics disputes -- How to write a bioethics mediation chart note -- Mediation with a competent patient : Mr. Samuels's case -- Mediation with a dysfunctional family : Mrs. Bates's case -- A complex mediation with a large and involved family : Mrs. Leonari's case -- Discharge planning for a dying patient : a role-play (...) -- An at-risk pregnancy : a role-play -- HIV and postsurgical complications in the ICU : a role-play -- Treating the dying adolescent : a role-play -- She didn't mean it : a role-play -- Don't tell mama : a role-play -- An at-risk pregnancy : a role-play transcript -- HIV and postsurgical complications in the ICU : a role-play transcript -- She didn't mean it: a role-play transcript -- Don't tell mama : a role-play transcript. (shrink)

Autumn Fiester identifies an important element in clinical ethics consultation (CEC) that she labels, from the Greek, aporia, “state of perplexity,” evidenced in CEC as ethical ambiguity. Fiester argues that the inherent difficulties of cases so characterized render them inappropriate for voting and more amenable to mediation and the search for consensus. This commentary supports Fiester’s analysis and adds additional reasons for rejecting voting as a process for resolving disputes in CEC including: it distorts the analysis by empowering individual voters (...) preferences and biases rather than focusing on the interests and wishes of the patient and family; it offers an insufficiently sensitive model for resolving the awesome, nuanced, conflicted, and ethically complex issues surrounding life and death; it marginalizes minority opinions that may have moral validity. (shrink)

Many clinical ethics support services do not involve patients. This is surprising because of the broad commitment to provide patient-centered healthcare. Clinical ethics support services are a component of the healthcare system and have an influence on patient care, and should therefore align with the regulatory and ethical requirements of patient-centered care, just process and cultural competence. First, in order to achieve good patient care, it is essential to involve patients in making their own healthcare decisions. Second, just ethical deliberation (...) requires that the deliberating parties have access to complete, accurate and unbiased information – this is best achieved through direct patient input. These arguments are especially compelling in the case of non-dominant cultural and ethnic groups. Here, we argue that when a clinician refers a case to a clinical ethics support services for consideration, and that case involves a conflict between the views or values of the clinician and the patient, the patient is entitled to, at a minimum: (a) be informed of the referral; (b) have the opportunity to speak directly to the clinical ethics support services prior to deliberation; (c) be provided with any opinion directly from the clinical ethics support services; and (d) have the opportunity to speak to a clinical ethics support services member after the deliberation. We use New Zealand as a case study to support and extrapolate the ethical principles and the minimum patient involvement requirements. We draw on our empirical research with senior doctors at a tertiary New Zealand hospital. Clinicians in our study indicated that they would feel bound by clinical ethics support service advice and that the clinical ethics support service has a significant impact on patient care in the case it reviews. (shrink)

In this commentary on a clinical ethics case pertaining to a same-sex couple that does not have explicit surrogate decision-making or hospital-visitation rights (in the face of objections from the family-of-origin of one of the queer partners), the authors invoke contemporary legal and policy standards on LGBTQ health care in the United States and abroad. Given this historical moment in which some clinical rights are guaranteed for LGBTQ families whilst others are in transition, the authors advocate for the implementation of (...) clinical ethics mediation as the soundest and most humane form of resolution in matters where there is a dispute between family members about an incapacitated loved one. They argue that clinical ethics mediation is an ideal alternative solution because it works toward consensus about outcome, even where consensus about values is not achievable. (shrink)

Clinical ethics consultations are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of adverse, lingering (...) sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”. (shrink)

In their systematic review of the work of the ASBH Core Competencies Update Task Force, Anita Tarzian and ASBH Core Competencies Update Task Force (2013) write, “The ethics facilitation approach do...