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)

Increased work complexity and financial strain in the health care sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is, moral distress. One way to support professionals in handling ethical dilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects on moral distress. The results show that the participants were positive about the training (...) program. Moral distress did not change significantly. This could be interpreted as competence development, with no effects on moral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy. (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)

Objectives: To summarise the types of case brought to the Clinical Ethics Committee of the National Hospital of Norway from 1996 to 2002 and to describe and discuss to what extent issues of information/communication have been involved in the ethical problems. Design: Systematic review of case reports. Findings: Of the 31 case discussions, (20 prospective, 11 retrospective), 19 cases concerned treatment of children. Twenty cases concerned ethical problems related to withholding/withdrawing of treatment. In 25 cases aspects of information/communication were involved (...) in the ethical problem, either explicitly (n = 3) or implicitly (n = 22). Conclusion: Problems related to information/communication may underlie a classic ethical problem. Identification of these “hidden” problems may be important for the analysis, and hence, the solution to the ethical dilemma. (shrink)

Unlike research ethics committees, which were created in 1988, the number of functioning hospital based ethical organisations in France, such as clinical ethics committees, is unknown. The objectives of such structures are diverse. A recent law created regional ethical forums, the objectives of which are education, debate, and research in relation to healthcare ethics. This paper discusses the current situation in France and the possible evolution and conflicts induced by this law. The creation of official healthcare ethics structures raises several (...) issues. (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)

Medical ethics, principles, persons, and perspectives is discussed under three headings: History, Theory, and Practice. Under Theory, the author will say something about some different approaches to the study and discussion of ethical issues in medicine—especially those based on principles, persons, or perspectives. Under Practice, the author will discuss how one perspectives based approach, hermeneutics, might help in relation first to everyday ethical issues and then to public controversies. In that context some possible advantages of moving from controversy to conversation (...) will be explored; and that will then be illustrated with reference to a current controversy about the use of human embryos in stem cell therapy research. The paper begins with history, and it begins in the author’s home city of Edinburgh. (shrink)

Increased work complexity and financial strain in the health care sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is, moral distress. One way to support professionals in handling ethical dilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects on moral distress. The results show that the participants were positive about the training (...) program. Moral distress did not change significantly. This could be interpreted as competence development, with no effects on moral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy. (shrink)

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by (...) nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses’ perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment. (shrink)

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)

During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but (...) also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics. (shrink)