A traditional approach to teaching medical ethics aims to provide knowledge about ethics. This is in line with an epistemological view on ethics in which moral expertise is assumed to be located in theoretical knowledge and not in the moral experience of healthcare professionals. The aim of this paper is to present an alternative, contextual approach to teaching ethics, which is grounded in a pragmatic-hermeneutical and dialogical ethics. This approach is called moral case deliberation. Within moral case deliberation, healthcare professionals (...) bring in their actual moral questions during a structured dialogue. The ethicist facilitates the learning process by using various conversation methods in order to find answers to the case and to develop moral competencies. The case deliberations are not unique events, but are a structural part of the professional training on the work floor within healthcare institutions. This article presents the underlying theory on ethics and illustrates this approach with an example of a moral case deliberation project in a Dutch psychiatric hospital. The project was evaluated using the method of responsive evaluation. This method provided us with rich information about the implementation process and effects the research process itself also lent support to the process of implementation. (shrink)

Since its origin bioethics has been a specialized, academic discipline, focussing on moral issues, using a vast set of globalized principles and rational techniques to evaluate and guide healthcare practices. With the emergence of a plural society, the loss of faith in experts and authorities and the decline of overarching grand narratives and shared moralities, a new approach to bioethics is needed. This approach implies a shift from an external critique of practices towards embedded ethics and interactive practice improvement, and (...) from a legal defence of rights towards fostering interdependent practices of responsibility. This article describes these transitions within bioethics in relation to the broader societal and cultural dynamics within Western societies, and traces the implications for the methodologies and changing roles of the bioethicist. The bioethicist we foresee is not just a clever expert but also a relationally sensitive person who engages stakeholders in reciprocal dialogues about their practice of responsibility and helps to integrate various sorts of knowledge (embodied, experiential, visual, and cognitive-scientific). In order to illustrate this new approach, we present a case study. It concerns a project focusing on an innovation in elderly care, based on the participation of various stakeholders, especially older people themselves. (shrink)

Knud Ejler Løgstrup’s _The Ethical Demand_ is the most original influential Danish contribution to moral philosophy in this century. This is the first time that the complete text has been available in English translation. Originally published in 1956, it has again become the subject of widespread interest in Europe, now read in the context of the whole of Løgstrup’s work. _The Ethical Demand_ marks a break not only with utilitarianism and with Kantianism but also with Kierkegaard’s Christian existentialism and with (...) all forms of subjectivism. Yet Løgstrup’s project is not destructive. Rather, it is a presentation of an alternative understanding of interpersonal life. The ethical demand presupposes that all interaction between human beings involves a basic trust. Its content cannot be derived from any rule. For Løgstrup, there is not Christian morality and secular morality. There is only human morality. _The Ethical Demand _is of the highest relevance to contemporary debate, especially around those issues raised by Levinas. It will exert a steadily increasing influence both in theology and philosophy. (shrink)

A sequel to Levinas' Totality and Infinity.

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support inspired by Habermas’ theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this (...) study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved. (shrink)

Background Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated. This article presents a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and some general observations on these ethical challenges. Results The ethical challenges are divided into four main thematic categories: formal coercion, informal coercion, uncertainty related to the Norwegian legislation on coercion (...) and professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law. Conclusion Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion. (shrink)

The procedures for structuring clinical ethics case reflections in a childhood cancer care setting are presented, including an eight-step model. Four notable characteristics of the procedures are: members of the inter-professional health care team, not external experts, taking a leading role in the reflections; patients or relatives not being directly involved; the model explicitly addressing values and moral principles instead of focussing exclusively on the interests of involved parties; using a case-based rather than principle-based method. By discusing the advantages and (...) disadvantages of the proposed procedures, our paper aims to contribute to the literature on models and procedures for ethical analysis that can be used in clinical settings. It is suggested that our proposed procedures have some advantageous features when it comes to promoting health care staff’s learning to structure their thinking about ethical issues. (shrink)

Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The (...) aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers’ experiences and perceived importance of outcomes of Moral Case Deliberation. (shrink)

Shipwreck with Spectator traces the evolution of the complex of metaphors related to the sea, to shipwreck, and to the role of the spectator in human culture from ancient Greece to modern times. This elegant essay exemplifies Blumenberg's ideas about the ability of the historical study of metaphor to illuminate essential aspects of being human. Originally published in the same year as his monumental Work on Myth, Shipwreck with Spectator traces the evolution of the complex of metaphors related to the (...) sea, to shipwreck, and to the role of the spectator in human culture from ancient Greece to modern times. The sea is one of humanity's oldest metaphors for life, and a sea journey, Blumenberg observes, has often stood for our journey through life. We all know the role that shipwrecks can play in this journey, and at some level we have all played witness to others' wrecks, standing in safety and knowing that there is nothing we can do to help, yet fixed comfortably or uncomfortably in our ambiguous role as spectator. Through Blumenberg's seemingly inexhaustible knowledge of letters, from ancient texts through nineteenth-century reminiscences and modern speeches, we see layer upon layer revealed in the meaning humans have given to these metaphors; and in this way we begin to understand what metaphors can do that more straightforward modes of expression cannot. This edition of Shipwreck with Spectator also includes "Prospect for a Theory of Nonconceptuality," an essay that recounts the evolution of Blumenberg's ideas about metaphorology in the years following his early manifesto "Paradigms for a Metaphorology.". (shrink)

The American Society for Bioethics and Humanities is to be congratulated on its updating of competency standards for ethics consultations (Tarzian and ASBH Core Competencies Update Task Force 2013)...

In moral case deliberation (MCD), healthcare professionals meet to reflect upon their moral questions supported by a structured conversation method and non-directive conversation facilitator. An increasing number of Dutch healthcare institutions work with MCD to (1) deal with moral questions, (2) improve reflection skills, interdisciplinary cooperation and decision-making, and (3) develop policy. Despite positive evaluations of MCD, organization and implementation of MCD appears difficult, depending on individuals or external experts. Studies on MCD implementation processes have not yet been published. The (...) aim of this study is to describe MCD implementation processes from the perspective of nurses who co-organize MCD meetings, so called ‘ local coordinators ’. Various qualitative methods were used within the framework of a responsive evaluation research design. The results demonstrate that local coordinators work hard on the pragmatic implementation of MCD. They do not emphasize the ethical and normative underpinnings of MCD, but create organizational conditions to foster a learning process, engagement and continuity. Local coordinators indicate MCD needs firm back-up from management regulations. These pragmatic action-oriented implementation strategies are as important as ideological reasons for MCD implementation. Advocates of clinical ethics support should pro-actively facilitate these strategies for both practical and ethical reasons. (shrink)

Objective: To evaluate one ethics rounds model by describing nurses’ and doctors’ experiences of the rounds. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. Findings: The goal of the rounds was partly (...) fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous. Conclusion: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented. (shrink)

The empirical basis for this article is threeyears of experience with ethical rounds atUppsala University Hospital. Three standardapproaches of ethical reasoning are examined aspotential explanations of what actually occursduring the ethical rounds. For reasons given,these are not found to be satisfyingexplanations. An approach called ``imaginativeethics'', is suggested as a more satisfactoryaccount of this kind of ethical reasoning. Theparticipants in the ethical rounds seem to drawon a kind of moral competence based on personallife experience and professional competence andexperience. By listening to (...) other perspectivesand other experiences related to one particularpatient story, the participants imaginealternative horizons of moral experience andexplore a multitude of values related toclinical practice that might be at stake. Inhis systematic treatment of aesthetics in theCritique of Judgement, Kant made use ofan operation of thought that, if applied toethics, will enable us to be more sensitive tothe particulars of each moral situation. Basedon this reading of Kant, an account ofimaginative ethics is developed in order tobring the ethical praxis of doctors and nursesinto sharper relief. The Hebraic and theHellenic traditions of imagination are used inorder to illuminate some of the experiences ofethical rounds. In conclusion, it is arguedthat imaginative ethics and principle-basedethics should be seen as complementary in orderto endow a moral discourse with ethicalauthority. Kantian ethics will do the job if itis remembered that Kant suggested only amodest, negative role of principle-baseddeliberation. (shrink)