Bioethics represents a dramatic revision of the centuries-old professional ethics that governed the behavior of physicians and their relationships with patients. This venerable ethics code was challenged in the years after World War II by the remarkable advances in the biomedical sciences and medicine that raised questions about the definition of death, the use of life-support systems, organ transplantation, and reproductive interventions. In response, philosophers and theologians, lawyers and social scientists joined together with physicians and scientists to rethink and revise (...) the old standards. Governments established commissions to recommend policies. Courts heard arguments and legislatures passed laws. This book is the first broad history of the growing field of bioethics. Covering the period 1947-1987, it examines the origin and evolution of the debates over human experimentation, genetic engineering, organ transplantation, termination of life-sustaining treatment, and new reproductive technologies. It assesses the contributions of philosophy, theology, law and the social sciences to the expanding discourse of bioethics. Written by one of the field's founders, The Birth of Bioethics is based on extensive archival research into sources that are difficult to obtain and on interviews with many of the leading figures in the moral debates in medicine. A very readable and comprehensive account of the evolution of bioethics, this book stresses the history of ideas but does not neglect the social and cultural context and the people involved. It will serve the information needs of philosophers, ethicists, social historians, and everyone interested in the origins of some of today's most hotly debated issues. (shrink)

OBJECTIVES: To study the ethical reasoning of nurses and physicians, and to assess whether or not modified focus groups are a valuable tool for this purpose. DESIGN: Discussion of cases in modified focus groups, each consisting of three physicians and three nurses. The discussion was taped and analysed by content analysis. SETTING: Five departments of internal medicine at Danish hospitals. SAMPLE: Seven discussion groups. MAIN MEASUREMENTS: Ethical content of statements, style of statements, time used by each participant. RESULTS: Danish physicians (...) and nurses do not differ in the kind of ethical reasoning they use, but physicians use more of the discussion time than nurses, they use a more assertive style of argumentation, and the solutions chosen are usually first put forward by physicians. CONCLUSION: The results and informal comparisons with similar data from long qualitative interviews indicate that groups of this kind are a useful tool for gathering data on ethical reasoning. (shrink)

Objectives—While clinical practice is complicated by many ethical dilemmas, clinicians do not often request ethics consultations. We therefore investigated what triggers clinicians' requests for ethics consultation. Design—Cross-sectional telephone survey.Setting—Internal medicine practices throughout the United States.Participants—Randomly selected physicians practising in internal medicine, oncology and critical care.Main measurements—Socio-demographic characteristics, training in medicine and ethics, and practice characteristics; types of ethical problems that prompt requests for consultation, and factors triggering consultation requests. Results—One hundred and ninety of 344 responding physicians (55%) reported requesting ethics (...) consultations. Physicians most commonly reported requesting ethics consultations for ethical dilemmas related to end-of-life decision making, patient autonomy issues, and conflict. The most common triggers that led to consultation requests were: 1) wanting help resolving a conflict; 2) wanting assistance interacting with a difficult family, patient, or surrogate; 3) wanting help making a decision or planning care, and 4) emotional triggers. Physicians who were ethnically in the minority, practised in communities under 500,000 population, or who were trained in the US were more likely to request consultations prompted by conflict. Conclusions—Conflicts and other emotionally charged concerns trigger consultation requests more commonly than other cognitively based concerns. Ethicists need to be prepared to mediate conflicts and handle sometimes difficult emotional situations when consulting. The data suggest that ethics consultants might serve clinicians well by consulting on a more proactive basis to avoid conflicts and by educating clinicians to develop mediation skills. (shrink)

Aim: To assess ethical issues in everyday clinical practice among physicians and nurses of the University Hospital Rijeka, Rijeka, Croatia.Subjects and methods: We surveyed the entire population of internal medicine, oncology and intensive care specialists and associated nurses employed at the University Hospital Rijeka, Rijeka, Croatia . An anonymous questionnaire was used to explore the type and frequency of ethical dilemmas, rank of their difficulty, access to and use of ethics support services, training in ethics and confidence about knowledge in (...) ethics. Physicians ranged in age from 27 to 61 years, and nurses , from 20 to 52.Results: The most frequent ethical dilemmas concerned uncertain or impaired decision-making capacity , limitation of treatment at the end of life and disagreements among family members . The most difficult dilemmas concerned euthanasia and physician-assisted suicide and limitation of treatment at the end of life . Only a minority reported ever using any kind of ethics support services or being very confident about knowledge in ethics .Conclusions: Similar ethical difficulties are present in the clinical practice of both physicians and nurses, with important differences in access and use of ethics support services. A need for systematic ethics educational activities was identified. Inclusion of individual ethics consultants in Croatian healthcare ethics support services is strongly advised. (shrink)

Next SectionBackground: Physicians face ethical difficulties daily, yet they seek ethics consultation infrequently. To date, no systematic data have been collected on the strategies they use to resolve such difficulties when they do so without the help of ethics consultation. Thus, our understanding of ethical decision making in day to day medical practice is poor. We report findings from the qualitative analysis of 310 ethically difficult situations described to us by physicians who encountered them in their practice. When facing such (...) situations, the physicians sought to avoid conflict, obtain assistance, and protect the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These goals could conflict with each other, or with ethical goals, in problematic ways. Being aware of these potentially conflicting goals may help physicians to resolve ethical difficulties more effectively. This awareness should also contribute to informing the practice of ethics consultation. Objective: To identify strategies used by physicians in dealing with ethical difficulties in their practice. Design, setting, and participants: National survey of internists, oncologists, and intensive care specialists by computer assisted telephone interviews (n = 344, response rate = 64%). As part of this survey, we asked physicians to tell us about a recent ethical dilemma they had encountered in their medical practice. Transcripts of their open-ended responses were analysed using coding and analytical elements of the grounded theory approach. Main measurements: Strategies and approaches reported by respondents as part of their account of a recent ethical difficulty they had encountered in their practice. Results: When faced with ethical difficulties, the physicians avoided conflict and looked for assistance, which contributed to protecting, or attempting to protect, the integrity of their conscience and reputation, as well as the integrity of the group of people who participated in the decisions. These efforts sometimes reinforced ethical goals, such as following patients’ wishes or their best interests, but they sometimes competed with them. The goals of avoiding conflict, obtaining assistance, and protecting the respondent’s integrity and that of the group of decision makers could also compete with each other. Conclusion: In resolving ethical difficulties in medical practice, internists entertained competing goals that they did not always successfully achieve. Additionally, the means employed were not always the most likely to achieve those aims. Understanding these aspects of ethical decision making in medical practice is important both for physicians themselves as they struggle with ethical difficulties and for the ethics consultants who wish to help them in this process. (shrink)

Background: Ethics support services are growing in Europe to help doctors in dealing with ethical difficulties. Currently, insufficient attention has been focused on the experiences of doctors who have faced ethical difficulties in these countries to provide an evidence base for the development of these services.Methods: A survey instrument was adapted to explore the types of ethical dilemma faced by European doctors, how they ranked the difficulty of these dilemmas, their satisfaction with the resolution of a recent ethically difficult case (...) and the types of help they would consider useful. The questionnaire was translated and given to general internists in Norway, Switzerland, Italy and the UK.Results: Survey respondents ranged in age from 28 to 82 years, and averaged 25 years in practice. Only a minority reported having access to ethics consultation in individual cases. The ethical difficulties most often reported as being encountered were uncertain or impaired decision-making capacity , disagreement among caregivers and limitation of treatment at the end of life . The frequency of most ethical difficulties varied among countries, as did the type of issue considered most difficult. The types of help most often identified as potentially useful were professional reassurance about the decision being correct , someone capable of providing specific advice , help in weighing outcomes and clarification of the issues . Few of the types of help expected to be useful varied among countries.Conclusion: Cultural differences may indeed influence how doctors perceive ethical difficulties. The type of help needed, however, did not vary markedly. The general structure of ethics support services would not have to be radically altered to suit cultural variations among the surveyed countries. (shrink)

In Croatia, the subject of medical ethics, or bioethics, was introduced into the curriculum in the early 1990s at the medical schools of the University of Rijeka and the University of Zagreb. Today, bioethics education has become a basic part of undergraduate medical education not only in Rijeka and Zagreb but also in Osijek.

OBJECTIVES: To study the ethical reasoning of nurses and physicians, and to assess whether or not modified focus groups are a valuable tool for this purpose. DESIGN: Discussion of cases in modified focus groups, each consisting of three physicians and three nurses. The discussion was taped and analysed by content analysis. SETTING: Five departments of internal medicine at Danish hospitals. SAMPLE: Seven discussion groups. MAIN MEASUREMENTS: Ethical content of statements, style of statements, time used by each participant. RESULTS: Danish physicians (...) and nurses do not differ in the kind of ethical reasoning they use, but physicians use more of the discussion time than nurses, they use a more assertive style of argumentation, and the solutions chosen are usually first put forward by physicians. CONCLUSION: The results and informal comparisons with similar data from long qualitative interviews indicate that groups of this kind are a useful tool for gathering data on ethical reasoning. (shrink)

Physicians, registered nurses and enrolled nurses engaged in geriatric and surgical care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs gave 78, the RNs 55 and the physicians 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were female; there were no differences in gender in the form and content of the moral reasoning disclosed in either morally difficult care episodes (...) or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

The debate and implementation of Clinical Ethics Consultation is still in its beginnings in Europe and the issue of the patient's perspective has been neglected so far, especially at the theoretical and methodological level. At the practical level, recommendations about the involvement of the patient or his/her relatives are missing, reflecting the general lack of quality and practice standards in CEC. Balance of perspectives is a challenge in any interpersonal consultation, which has led to great efforts to develop “technical”approaches, e.g., (...) in psychological counseling or psychotherapeutic treatment. In ethics, unbalance or partiality is a matter of justice and has provoked significant theoretical work, also relevant for practical medical ethics. A lack of balance seems to be particularly serious in those situations, where ethical conflict is triggering a consultation and where the “parties” involved may try to persuade the consultant that their particular opinion is the most convincing; but to our knowledge the connection between patient/relatives involvement and balance has not yet been discussed in the context of CEC. Central questions of access and involvement of the patient and his/her relatives will be analysed and discussed regarding the challenge of balance and the adequate role or attitude of a Clinical Ethics Consultant. It is argued that the Clinical Ethics Consultant should have a methodological awareness regarding the concepts of “neutrality” versus “advocacy” in his/her role and try to achieve a balanced procedure that allows for an optimum of change of perspectives. The argumentation is developed along the narrative of a real case study. Recommendations concerning the involvement of the patient or the relatives are formulated for the practice of CEC. (shrink)

Physicians, registered nurses (RNs) and enrolled nurses (ENs) engaged in geriatric (n = 49) and surgical (n = 59) care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs (n = 40) gave 78, the RNs (n = 38) 55 and the physicians (n = 30) 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were female; there were no differences in (...) gender in the form and content of the moral reasoning disclosed in either morally difficult care episodes or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

This paper provides a philosophical critique of professional stereotypes in medicine. In the course of this critique, we also offer a detailed analysis of the concept of care in health care. The paper first considers possible explanations for the traditional stereotype that caring is a province of nurses and women, while curing is an arena suited for physicians and men. It then dispels this stereotype and fine tunes the concept of care. A distinction between ‘caring for’ and ‘caring about’ is (...) made, and concomitant notions of parentalism are elaborated. Finally, the paper illustrates, through the use of cases, diverse models of caring. Our discussion reveals the complexity of care and the alternative modes of caring in health care. (shrink)

A medical centre is an institution established for a specific purpose: to facilitate the health and health-related welfare of the medical centre's patients. Within this institution, there are a variety of professionals who act and interact to serve this purpose. Of particular interest is the interaction between physician and nurse. Generally, the nurse is thought to be under a certain obligation to implement a physician's orders unless there is good reason not to do so. This qualifier places a conflicting obligation (...) upon the nurse not to implement some physician orders. How should a judgement about which orders there is 'good reason' not to implement be made? I propose to approach this question through an analysis of the obligation the nurse has to implement the order of a physician, and the conditions under which the order does not pose such obligations. This analysis will consist of an examination of the obligation in terms of the purposive authority of the physician. For example, in the context of the medical centre, the physician's medical training qualifies her as best able to make determinations of what treatment would promote the patient's health. However, this purpose not only serves as the basis of the physician's authority, but also serves as a limitation upon the physician's authority (for example, an order which would harm the patient would not reflect the purpose for which the physician has been given authority). Thus, a philosophical investigation into the nature of the obligation to implement a physician's orders can help to clarify those occasions when a nurse should not implement an order. (shrink)