The results of two observational studies of clinical directorates (CDs) are presented. The paper exposes fresh perspectives about the management of hospitals and CDs, and suggests that the most important axis on which hospital decision-making rests continues to be profession rather than the CD, even though CDs are designed at least in part to mitigate professional tribalism and bridge professional divides. In empiricising social structural and cultural theories it seems clear that changes to the prescribed organisational framework, which (...) CDs represent, have had negligible effects on behaviour. This being the case, the paper questions the benefits alleged to have accrued from establishing CDs and calls for more effective, micro-behavioural change strategies than merely altering the structure. (shrink)

Suppose that a patient is receiving treatment options from her doctor. In one case, the doctor says, “the surgery has a 90% survival rate.” Now, suppose the doctor instead said, “the procedure has a 10% mortality rate.” Predictably, the patient is more likely to consent on the first description and more likely to dissent on the second. This is an example of a framing effect. A framing effect occurs when “the description of [logically-equivalent] options in terms of gains (positive frame) (...) rather than losses (negative frame) elicits systematically different choices.” Framing effects are ubiquitous, but they are particularly troublesome in medicine. Many worry that there is tension between valuing informed consent and using framing effects in clinical settings. In this paper, I answer this question: if an individual is subject to a framing effect when she gives her consent, does this undermine the validity of her consent? I argue that framing effects do not undermine consent in general. (shrink)

In the American medical system, patients do not know the final price of treatment until long after the treatment is given, at which point it is too late to say “no.” I argue that without price disclosure many, perhaps all, tokens of consent in clinical medicine fall below the standard of valid, informed consent. This is a sweeping and broad thesis. The reason for this thesis is surprisingly simple: medical services rarely have prices attached to them that are known (...) to the patient prior to treatment. Yet, for many patients, knowledge of the price is relevant to whether they would give consent. If informed consent requires that patients know all information about their treatment that is relevant to their decision, then consent to a medical intervention in the absence of the price is not informed consent. (shrink)

While Immanuel Kant is recognized as one of history's most influential philosophers and ethicists, his thought and writings also contain significant clinical implications that deserve attention. His philosophy is briefly explained and shown to anticipate modern developments in understanding human consciousness and many principles for effective psychotherapy. Kant's "categorical imperative," in particular, implies and anticipates valuable clinical interventions. Kant's principles that are ethically "right" for clients turn out to be clinically "good" for them as well. 2012 APA, all (...) rights reserved). (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical Bioethics at NIH:History and A New VisionJohn C. Fletcher (bio)On July 3, 1995, Dr. John I. Gallin, Director of the Magnuson Clinical Center of the National Institutes of Health (NIH), convened a one-day "Conference on the Future of Clinical Bioethics at the National Institutes of Health Intramural Program." Conferees included NIH officials and a panel of consultants from bioethics programs around the nation.1 The subject (...) was the future of NIH's intramural bioethics program and specifically a vision of a new multi-component program, presented by Dr. Gallin, the first speaker. Dr. Harold Varmus, Director of NIH, was there to assure his support for Dr. Gallin's vision. This author, honored to be second speaker, was invited to sketch a brief history of bioethics at NIH. The present article reviews some of this history and then reports on Dr. Gallin's proposal, points of consensus among speakers and conferees, and the search for a Chief of the Clinical Bioethics Program.History of Bioethics at NIHIt is often said that NIH is a well-kept secret as the nation's leading biomedical research facility. Also, few people know that NIH has a long history in bioethics. Some key events in that history are shown in Figure 1, beginning with two that occurred prior to the birth of bioethics. NIH made an early policy response to protect human subjects of research and to find acceptable limits for scientific freedom. The Clinical Center (CC), a 550-bed research hospital, opened in 1953. A subcommittee of the Medical Board, the Clinical Research Committee (CRC), was formed for prior group review of all studies with normal volunteers. The traditional practice was for researchers themselves to decide when studies would begin, which subjects to recruit, and whether informed consent would be sought. The CRC intervention bit into this tradition. In addition, patient studies that posed significant risks or departed widely from medical practice were reviewed by referral from the Clinical Directors of the various Institutes. Was this CRC an early institutional review [End Page 355] board (IRB)? As a guest researcher, I was permitted to observe the CRCs meetings between 1966 and 1969. It functioned much like an IRB but had no community or non-scientist members. Other IRB-like review groups undoubtedly existed prior to the CRC. Robert Levine (personal communication, September 7, 1995) recalls that Beth Israel Hospital in Boston had one in 1938. Historical research is clearly needed on the earliest forms of research review.Table 1. Bioethics at NIHEventYearClinical Research Committee1953Surgeon-General's PPO #1291966NIGMS funds Hastings Genetics Group1973OPRR's Mission1974NLM's grant to KennedyInstitute for Bibliography of Bioethics1974Recombinant DNA Advisory Committee1974STEP Series Bioethics Speakers1975Pre-IRBs at the CC1975-76Assistant for Bioethics to Director, CC1977RAC-Human Gene Therapy Subcommittee1983Lipsett Proposal (ICD)1983Liaison Group, CC1983Bioethics Program, CC1985Durable Power of Attorney for Researchwith Incapacitated Subjects1985-86NLM funds National Reference Centerfor Bioethics Literature1985National Institute for Nursing Research1986Bioethics Post-Doctoral Fellows Program1989ELSI Program1989Bioethicists on CC-IRBs1989CC-Ethics Committee1990Office of Human Subjects Research1992 [End Page 356]Between 1963 and 1967, the media exposed instances of ethically troubling research, and Beecher (1966) and Pappworth (1967) published sharp criticisms of the weak state of research ethics. In 1966, Surgeon-General William Stewart and NIH Director James Shannon issued a policy requiring local group review of all research involving human subjects before making an application for NIH peer review (Surgeon General 1966). The policy was the first in any nation to mandate ethics committees for clinical research. However, it did not apply to the NIH intramural program until Congress passed the National Research Act in 1974 (Public Law 93-348; 202, 88 Stat. 342, 1974). This lag permitted NIH intramural investigators the luxury of feeling above the norms imposed on ordinary mortals and guaranteed more resistance to the inevitable change to come. Resistance to change marked the intramural program from the mid-1960s to the mid-1970s... (shrink)

This essay describes an example of how we—one professor of the elective course Art, Medicine, and Clinical Moral Perception at Creighton University School of Medicine, one Director of Adult Programs at the Joslyn Museum of Art in Omaha, Nebraska, and fourth year medical students—practice perception skills using art objects. This essay presents one example of the journal assignments to which students respond in written narratives about their own perception habits. We also share questions any health professions educator can use (...) to guide students’ study of their habits of perception using art objects. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Clinical Ethics Consult: Transforming Ambivalence to ActionEve MakoffAs palliative care practitioners, we’re good at diffusing explosive family dynamics and holding space for patients and families in emotional crises. We also help everyone involved with the care of seriously ill patients focus on what is best based on the values of the most important person in the room; the one in the hospital bed. So, when we call (...) for a bioethics consultation from a clinical ethicist, it’s because something has gotten stuck or, perhaps, we could benefit from a reframe—or a new set of eyes to ground the scenario or the emotional miasma that tends to linger and drift when on the cusp between life and death.In the 1990s, at least in my medical school and residency programs, medical ethicists in the hospital were not often a part of direct patient care. They were like philosophers, available to curbside and advise on ethically murky cases but at a distance from the trenches. These wise, generally older men with white beards parceled out all potential ethical sides of the case, leaving us to decide the best way forward. The Socratic Method1 was often employed, so we were left to grapple with the ambiguity that exists in most issues about what’s right or wrong. It sometimes felt frustrating but now I realize the importance of honing the skill of tolerating the feeling of not immediately knowing the best way to proceed in the practice of medicine. As it turned out, by the time I started practicing palliative care in 2013 and began to regularly collaborate with what was then our clinical ethics partners in care, our ethics director Dr. F was also a wise older man with a white beard. But he and the rest of his (non-male, un-bearded) team didn’t have that untouchable ivory tower kind of protection around them. They were accessible. They dug into the hard stuff right alongside us when they were asked to get involved.One time when I consulted ethics on a case, I’d been navigating a switch from practicing internal medicine to palliative care. At the time I was dealing with personal ambivalence—feeling mired in the heaviness that infused my workdays and unsure if I could take it. It turned out that a clinical consultation, and a family meeting with Dr. F, helped in more ways than one.That day, we gathered in the medical intensive care unit conference room. It doubled as a storage closet, so the team, including our patient’s family, dragged in chairs and stools and crowded around the oblong melamine table next to the whiteboard with half-erased arterial blood gas calculations. We hunched together to see where things stood and make some essential decisions.As we do in family meetings, we reconfirmed our roles on the team: ICU fellow, resident, and medical student. Nurses fluttered in and out as their patient care allowed. The patient’s daughter with silver-streaked hair was in attendance, as well as her son, who was slumped in his seat. Both looked sleepless and frazzled. And finally, Dr. F and myself—clinical ethicist and palliative care doctor—gathered. Dr. F then took the lead, announcing our intention to come together and discuss what was best for our patient—their mother. Dr. F then requested a medical update from the ICU team.“Mrs. Lyons is on a ventilator. She’s sedated and medicated for pain. But her organs aren’t doing well. She’s not getting better,” the resident read off of his white paper of scribbles. [End Page 12]Suspended between her life and her death, Mrs. Lyons lay unperturbed but unreachable, and her family was agonizing about what to do. For days our palliative team had discussed the options with the family—we could cut back on the medications and try to wake her up, knowing she’d likely have considerable pain, and to what end? We could reconsider that surgery for her infected bowels, but she’d likely not survive.Or we could let her go—discontinue the ventilator and likely let her die.They could not decide... (shrink)

Internationally, the prevalence of clinical ethics support (CES) in health care has increased over the years. Previous research on CES focused primarily on ethics committees and ethics consultation, mostly within the context of hospital care. The purpose of this article is to investigate the prevalence of different kinds of CES in various Dutch health care domains, including hospital care, mental health care, elderly care and care for people with an intellectual disability. A mixed methods design was used including two (...) survey questionnaires, sent to all health care institutions, two focus groups and 17 interviews with managing directors or ethics support staff. The findings demonstrate that the presence of ethics committees is relatively high, especially in hospitals. Moral case deliberation (MCD) is available in about half of all Dutch health care institutions, and in two-thirds of the mental health care institutions. Ethics consultants are not very prominent. A distinction is made between explicit CES forms, in which the ethical dimension of care is structurally and professionally addressed and implicit CES forms, in which ethical issues are handled indirectly and in an organic way. Explicit CES forms often go together with implicit forms of CES. MCD might function as a bridge between the two. We conclude that explicit and implicit CES are both relevant for clinical ethics in health care. We recommend research regarding how to combine them in an appropriate way. (shrink)

Given the enduring debate over what constitutes quality, and therefore appropriate training, in clinical ethics consultation, it is unsurprising that there is variation in the structure and content of clinical ethics fellowship programs. However, this variation raises questions about the value of fellowship training when the ethicists that emerge from these programs might be quite different. The specifics of fellowship programs are largely internal. As such, the extent of variation and whether such variation is problematic remains unclear. In (...) this article, we summarize lessons learned from discussions between fellows, their mentors and program directors at the 2020 Clinical Ethics UnConference, and outline some possible ways to advance the conversation about variation in fellowship programs and training. We argue for the more open sharing of training specifics in order to help break down the siloed nature of fellowship programs. Greater transparency could, firstly, allow for more robust reflection on and refinement of training practices and, secondly, allow us to better balance professionally appropriate consistency with unavoidable or desirable variation based on local norms, culture and leadership. (shrink)

How can one be trained to enter the evolving field of clinical ethics consultation? The classroom is not the proper place to teach clinical ethics consultation; it is best done in a clinical setting. The author maps the elements that might be included in an apprenticeship, and sets out propositions for debate regarding the training needed for clinical ethics consultants and directors of clinical ethics consultation services.

This study examines the influence of women on the boards of directors of National Health Service Foundation Trusts in England. FTs provide a public service where social performance is the primary objective, although financial constraints must be met. Female presence is higher for executive directors than non-executives, reflecting the high number of women employed in the sector. We find that a high female presence among executive and non-executive directorships does not result in significant differences either in financial return or service (...) quality. When gender diversity on boards is consistently high, the benefits on performance of having more women on the board may not be discernible. However, female Chairs or Chief Executives result in significant reductions in negative social outcomes, such as lower clinical negligence costs, without harming financial management. The findings of this study, carried out in a context of high female presence and where a woman frequently occupies one of the two most influential board positions, Chair and Chief Executive, have implications for gender diversity and gender targets on the boards of directors in business and other sectors. (shrink)

The Director of Public Prosecutions has recently released the Policy for Prosecutors in Respect of Cases of Encouraging or Assisting Suicide. These guidelines provide information on the factors that shall be considered when contemplating whether to bring a prosecution in the public interest in cases concerning assisting and encouraging suicide. While intended to clarify the potential liability of those engaged in or considering such practices, the guidelines have also stumbled into controversial and murky areas of law. As such any potential (...) positive outcomes the guidelines may produce must be weighed against the potential confusion they may also cause. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it (...) often comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

An examination of the salient literature on hospital clinical directorates (CDs) is presented. A critique of the largely managerialist, instrumental, hortatory and normative extant literature about CDs is offered. In analysing the literature this way the earlier promotional and critical literature is eschewed in favour of an evaluative approach. CDs are then reconceptualised by locating them within two overarching accounts of social structure—formalised, prescribed frameworks, and enacted, patterned interactions—following the kinds of distinctions made by Giddens, Weick, social action (...) and institutional theorists. Social structure as it relates to culture is also considered, following Martin. Such an approach facilitates an understanding of the general weaknesses of health service perspectives and methods of analysis, and exposes the strengths of Giddens–Weick type paradigms. (shrink)

Fifty years ago, Henry Knowles Beecher published his essay on clinical research ethics in the New England Journal of Medicine. The culmination of more than a decade and a half’s rumination and reflection on the use of patients and “captive populations” in research, Beecher’s 1966 article understandably casts a large shadow in American bioethics. In 1976, the Institute of Society, Ethics and the Life Sciences established the Henry Knowles Beecher Award for Contributions to Ethics and the Life Sciences and (...) named the Harvard professor as the first recipient of the Award. “It is unusual for a researcher,” Daniel Callahan explained, on behalf of the Board of Directors of the... (shrink)

In accordance with standards published by the American Society for Bioethics and Humanities (ASBH), ethics consultants are expected to provide recommendations that align with scholarly literature, professional society statements, law, and policy. However, there are no studies to date that characterize the specific references that ethics consultants and educators use to inform their work. To address this gap, a convenience sample of clinical ethics consultants and educators was surveyed online through two major listservs for clinical ethics, the ASBH (...) Clinical Ethics Consultation Affinity Group (CECAG) and the Association of Bioethics Program Directors (ABPD). Ninety-five ethics consultants and/or educators with diverse educational background, credentials, and experience provided responses. In total, 451 references, 315 of which were unique, were reported. These references were broken into 6 categories after analysis: bioethics literature (divided into articles and books), professional society documents (divided into professional society statements and codes of ethics), federal/state/uniform/case law, hospital/health system policies, official religious teachings, and other. We found extensive variation and minimal overlap in the references respondents used for ethics consultation and education, even when referring to the same topics. Future research directions should include conducting more systematic efforts to characterize the references used by ethics consultants across the US; determining whether demographic characteristics of consultants influence the references used; and ascertaining whether the variation in references used reflects genuine disagreements in consultants’ and educators’ bioethical analysis or recommendations. (shrink)

Hospital administrators may lack familiarity with what clinical ethicists do (and do not do), and many clinical ethicists report receiving inadequate financial support for their clinical ethics consultation services (CECSs). Ethics consultation is distinct in that it is not reimbursable by third parties, and its financial benefit to the hospital may not be quantifiable. These peculiarities make it difficult for clinical ethicists to resort to tried-and-true outcome-centered evaluative strategies, like cost reduction or shortened length of stay (...) for patients, to show a “need” for ethics consultation. Likewise, it can be difficult for clinical ethicists to “speak the same language” as healthcare administrators and managers, which, in turn, means that CECSs run the risk of being unable to demonstrate value to those who pay for the service. The purpose of this descriptive article is to provide practical guidance to clinical ethicists and program directors on how to cultivate administrative support for a CECS. Specifically, we discuss two elements that clinical ethics leaders must critically appraise and successfully argue to meet the expectations of administrators— the value of a CECS and its fit in clinical workflow. (shrink)

Purpose: to characterize ethics course content, structure, resources, pedagogic methods, and opinions among academic administrators and course directors at U.S. medical schools. Method: An online questionnaire addressed to academic deans and ethics course directors identified by medical school websites was emailed to 157 Association of American Medical Colleges member medical schools in two successive waves in early 2022. Descriptive statistics were utilized to summarize responses. Results: Representatives from 61 (39%) schools responded. Thirty-two (52%) respondents were course directors; 26 (43%) were (...) deans of academic affairs, medical education, or curriculum; and 3 with other roles also completed the survey (5%). All 61 schools reported some form of formal ethics education during the first year of medical school, with most (n = 54, 89%) reporting a formal mandatory introductory course during preclinical education. Schools primarily utilized lecture and small-group teaching methods. Knowledge-based examinations, attendance, and participation were most commonly used for assessment. A large majority regarded ethics as equally or more important than other foundational courses, but fewer (n = 37, 60%) provided faculty training for teaching ethics. Conclusions: Despite a response rate of 39 percent, the authors conclude that medical schools include ethics in their curricula in small-group and lecture formats with heterogeneity regarding content taught. Preclinical curricular redesigns must innovate and implement best practices for ensuring sound delivery of ethics content in future curricula. Additional large-scale research is necessary to determine said best practices. (shrink)

Selective reproductive technologies, such as preimplantation genetic diagnosis, enable enhanced clinical success rates, create reproductive choices, and produce new commercial opportunities. Drawing upon empirical material acquired during a ten-month period in 2016, this study uses a total of twenty-two in-depth interviews with doctors, CEOs, clinical directors, marketing directors, patient counselors, and embryologists to discuss how traveling for the SRT of gender selection for nonmedical reasons is mediated by fertility clinics and clinicians in Dubai. Multimodal analysis was used to (...) analyze the clinical websites’ key rhetorical and visual features. Meanwhile, interviews and observational studies highlighted the context within which gender selection takes place. Findings revealed that gender selection is promoted as a form of “enhancement” and “family balance,” which, when combined with the ways that Dubai is assembled as a sensory tourist destination, routinize SRTs and lead to an understanding of gender selection as not merely an individualized reproductive journey but an optimization of the family unit. (shrink)

As several studies, along with a book and movie depicting the true story of a former clinic director, have recently brought to the public’s attention, fetal ultrasound images dramatically impact some viewers’ normative judgments: a small but non-negligible proportion of viewers attribute increased moral status to fetal humans and even form the belief that abortion is impermissible. I consider three types of psychological explanation for a viewer’s shift in beliefs: increased bonding or empathy, various forms of cognitive bias, and type (...) of cognitive processing involved. I consider the normative implications of each explanation, arguing that in each case the viewer’s judgment is presumptively rational. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Incorporating Religion into Psychiatry:Evidenced–Based Practice, Not a Bioethical DilemmaMary D. MollerFor over sixteen years I was the owner and clinical director of an advanced practice nurse–managed outpatient rural psychiatric clinic staffed by APNs, a social worker, a licensed counselor and several graduate students. Many of our patients were victims of severe and often brutal trauma and abuse suffered at the hands of family, friends, and various professionals including (...) spiritual leaders. We also uncovered sources of abuse suffered from those involved in occult practices ranging from seemingly innocent white witchcraft (Wicca, Paganism, New Age) that includes such activities as astral projection and remote viewing to the darkest possible black witchcraft (perpetrating evil, incanting evil spirits, casting spells and hexes, creating dissociative identities) such as occurs in ritual abuse and satanic rites. Both types of witchcraft also typically involved family, friends, various professionals, and spiritual leaders. Recognizing the controversy surrounding the reality of witchcraft I am sharing a story that I hope will help break down the barriers that prevent many patients from receiving the treatment that would provide the most benefit to recovery.Seeking services for these patients led me on an intense personal and professional journey that included a profound Christian born–again experience at almost 50 years of age. My professional career grew in nearly indescribable terms as a result of the incorporation of prayer and deliverance ministry as part of the services we selectively provided. Today I always include assessment of spiritual experiences a patient has as well as spiritual supports that are available with every new patient intake. For patients who indicate that prayer is one of their supports, I ask if they would like prayer at the conclusion of the session. The gratitude that is expressed by individuals who appreciate being able to pray with a psychiatric provider is often profound.In the field of psychiatry there has been a long–standing and distinct taboo regarding incorporating religious and spiritual aspects of life experience into treatment unless it is to frame most of these discussions within the context of psychosis. This stems from the advent of psychoanalysis in which religion was deemed a neurosis and atheism became the goal. Some still hold to that belief and there certainly remains controversy regarding the incorporation of prayer into routine outpatient or inpatient care. The essential starting point is the determination of accurate differential diagnosis, which can often be a lengthy process. The clinician must be careful about distinguishing between religious experiences and religious delusions, and often this takes time to sort out. The determination of the etiology of hearing the voice of God or the devil or demons must be carefully parsed and framed within the context of the situation and culture the patient describes. If the clinician denies the existence of God or the devil or demons or the practice of witchcraft, the patient’s descriptions of such experiences will be quickly [End Page 206] labeled psychotic. The patient may then experience a lengthy hospitalization and treatment with psychotropic medications that can have an extremely negative effect on the possibility of recovery. Once I witnessed the level of healing that occurs with carefully administered spiritual interventions that are related to specific spiritual experiences that are based on the patient’s belief system, there was no going back to using only allopathic medication and non–spiritual psychosocial interventions, even in spite of the criticisms from others. The key is to understand and respect the patient’s belief system, if this is not congruent with the practitioner’s belief system, then practitioner must refer out.In the United States, an increasing persecution of Christianity and a devaluing of the Judeo–Christian heritage of our Constitution are creating a climate of intolerance to the expression of religious values resulting in an expectation that Christians should compromise their beliefs for the sake of political correctness. As a doctorally prepared psychiatric–mental health advanced practice nurse I experienced a profound born–again Christian experience that ultimately led to study of the Hebrew roots of Christianity and I now worship in a Messianic Jewish synagogue. It is impossible for me to not include the concept of spirituality into... (shrink)

The "Director" controls Ms. B’s life. He flatters her, beguiles her, derides her. His instructions pervade each aspect of her life, including her analytic sessions, during which he suggests promiscuous and dangerous things for Ms. B to say and do, when he suspects that her isolated state is being changed by the therapy. The "Director" is a diabolical foreign body installed in the mind who purports to protect but who keeps Ms. B feeling profoundly ill and alone. The story of (...) Ms. B’s analysis is one of many vivid illustrations presented in this collection of papers by Paul Williams, who shares his lifetime of experience working with severely disturbed patients. As the title suggests, the unifying thread of these papers is the investigation of serious mental disturbance, often characterized by the presence of intrusive and invasive thoughts and fantasies that originate in a traumatic past but which can colonize and destroy the rational mind. The diverse papers are grouped into two related sections. Part one is comprised of papers with a clinical orientation, including a summary of the analysis of Ms. B as well as a speculative paper on the psychosis and recovery of John Nash. In part two, applied psychoanalytic thinking is integrated with Williams’ other professional passion, anthropology, in a paper that exemplifies generative thought through art, poetry, and tribal masks. Other papers in this section include a short essay that takes Freud-bashers to task, a reappraisal of the Rat Man, and a lively discussion of André Green’s "central phobic position" in borderline thinking. Whether engaging in the coconstructed therapeutic relationship or the implications for "madness in society" at large, Williams’ diverse influences – psychoanalytic and otherwise – repeatedly come to the fore in an intellectually stimulating and clinically enriching way. It goes without saying that work with patients whose thinking is psychotic is a challenge, as these papers clearly demonstrate, but Williams reminds us that it is a challenge that psychoanalysis can not only engage but also treat with enduring and impressive therapeutic results. (shrink)

In this essay, the directors of an NEH Institute on “Medicine, Literature, and Culture” consider the lessons they learned by bringing humanities scholars to a teaching hospital for a month-long institute that mingled seminar discussions, outside speakers and clinical observations. In an exchange of letters, they discuss the productive tensions inherent in approaching medicine from multiple perspectives, and they argue the case for a broader conception of medical humanities that incorporates the methodologies of cultural studies.

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 10.2 (2000) 171-174 [Access article in PDF] Bioethics Inside the Beltway The Oversight of Human Gene Transfer Research LeRoy Walters Jesse Gelsinger's death last September in a gene transfer study being conducted at the University of Pennsylvania has helped to spark a national debate. In part, this debate parallels the broader discussion of how human subjects research should be reviewed and regulated in the (...) United States. However, human gene transfer research is one of a handful of biomedical technologies that seem to deserve special attention, at least in the early years of their development.The major participants in the national debate on human gene transfer include the National Institutes of Health (NIH), the Food and Drug Administration (FDA), the National Bioethics Advisory Commission, members of Congress, biotechnology and pharmaceutical companies, disease-oriented advocacy groups, reporters, and academics. At the December 1999 meeting of the NIH Recombinant DNA Advisory Committee (RAC), the protocol that involved Jesse Gelsinger was a central focus of discussion, but other topics emerged as well. One ad hoc panel reviewed adverse events that had occurred in other research protocols using adenovirus vectors, while a second proposed changes in the general system for reporting adverse events to NIH and the RAC.During the first several months of the year 2000, the United States Congress also became involved in the human gene transfer debate. In February, Senator Bill Frist (R-TN) convened a hearing to which Jesse Gelsinger's father, representatives of NIH and FDA, and several other witnesses were invited. At approximately the same time, the House Commerce Committee and its Subcommittee on Oversight and Investigations initiated their own inquiries, asking the Office of Inspector General at the Department of Health and Human Services to review the oversight roles of NIH and FDA. In March and April, the House committee also wrote directly to the NIH Director, the FDA Commissioner, and the President of the University of Pennsylvania, requesting extensive documentation on gene transfer, in general, and the trial in which Jesse Gelsinger was involved, in particular. Congressman Henry Waxman (D-CA) and Senator Edward Kennedy (D-MA) have also raised questions and proposed solutions in multiple letters to the NIH Director and the Secretary of Health and Human Services. [End Page 171]The major general questions that have emerged from this discussion are the following:(1) What kinds of information about adverse events should be reported by researchers or sponsors during the course of human gene transfer trials?(2) To what group or groups should adverse-event information be reported? How often and in what ways should the information be analyzed?(3) Should the information about adverse events remain confidential, or should it be discussed publicly?(4) How can the disclosure and consent process in gene transfer trials be improved?(5) Which federal agency should have primary responsibility for overseeing human gene transfer research, and how can it best fulfill its oversight role?How these questions are answered will have immediate relevance to the field of human gene transfer research as it enters into its next phase. At the same time, the models that are created for this important cutting-edge field also may be useful in other complex or controversial arenas of biomedical research, for example, xenotransplantation or human embryonic stem-cell research. In addition, the lessons learned from this one important area of human subjects research may suggest ways to improve protections for all the volunteers who make clinical research--and medical progress--possible.In the remainder of this article, I will turn from reporting, in as objective a way as possible, on the status of the public policy debate about human gene transfer research to suggesting measures for improving the current oversight system for such research. My initial general recommendation is that we should not expect a single regulatory agency to be solely responsible for a field as large and dynamic as human gene transfer research. Rather, there should be some helpful redundancy or, to change the metaphor, checks and balances in the public oversight of this field. Thus, an... (shrink)

The new National Institutes of Health (NIH) Policy on the Use of a Single Institutional Review Board (sIRB) for Multi-Site Research was adopted primarily to simplify and speed the review of complex multisite clinical trials. However, speeding review requires overcoming a number of obstacles. Perhaps the most substantial obstacle is the time and effort needed to develop reliance agreements among the participating sites. We conducted 102 semistructured interviews with sIRB personnel, including directors, chairs, reviewers, and staff, from 20 IRBs (...) that acted as sIRBs for multisite research, including 6 commercial/independent sIRBs, and 10 university-based academic and 4 federal sIRBs. Almost without exception, the interviewees agreed that reliance agreements were complex, difficult to develop, and time-consuming. A major problem for relying sites was that different agreements specified different responsibilities for the relying sites. Attitudes differed about whether these problems will be resolved as IRB staff and managers become more experienced with sIRBs. However it is clear that the process of developing reliance agreements must be simplified. Federal assistance in standardizing at least some sections of reliance agreements might reduce the difficulties involved. (shrink)

Our encounters with the physical world are filled with miraculous puzzles-wind appears from somewhere, heavy objects float on oceans, yet smaller objects go to the bottom of our water-filled buckets. As adults, instead of confronting a whole world, we are reduced to driving from one parking garage to another. The Child's Conception of Physical Causality, part of the very beginning of the ground-breaking work of the Swiss naturalist Jean Piaget, is filled with creative experimental ideas for probing the most sophisticated (...) ways of thinking in children. The strength of Piaget's research is evident in this collection of empirical data, systematically organized by tasks that illuminate how things work. Piaget's data are remarkably rich. In his new introduction, Jaan Valsiner observes that Piaget had no grand theoretical aims, yet the book's simple power cannot be ignored. Piaget's great contribution to developmental psychology was his "clinical method"-a tactic that integrated relevant aspects of naturalistic experiment, interview, and observation. Through this systematic inquiry, we gain insight into children's thinking. Reading Piaget will encourage the contemporary reader to think about the unity of psychological phenomena and their theoretical underpinnings. His wealth of creative experimental ideas probes into the most sophisticated ways of thinking in children. Technologies change, yet the creative curiosity of children remains basically unhindered by the consumer society. Piaget's data preserve the reality of the original phenomena. As such, this work will provide a wealth of information for developmental psychologists and those involved in the field of experimental science. Jean Piaget is known for investigations of thought processes. He was professor at Geneva University and director of the International Center for Epistemology. He is the author of The Language and Thought of the Child, Judgment and Reasoning in the Child, The Origin of Intelligence in Children, and The Early Growth of Logic in the Child. Jaan Valsiner is professor of psychology at Clark University, and a recognized authority on the life and work of Piaget. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:"Call me Dr. XXX!"Yilu MaDisclaimers. Names have been changed to protect the privacy of those mentioned.Scheduled to interpret for a Mandarin-speaking woman, I entered the examination room and introduced myself to the neurologist and the patient, who was accompanied by her husband, brimming with smiles and sitting on the edge of the chair."How are you, Katie?" the husband greeted the doctor, using his accented English."Call me Doctor XXX!", the (...) physician returned, her eyebrows knotted with gravity. Immediately, the friendly and light-hearted air in the room froze.This occurred many years ago at a small clinic where I usually went to interpret as a per-diem interpreter. It happened so quickly that I was totally unprepared, and honestly, shocked at the way the physician reacted to the husband. I felt bad for the patient who sat next to her husband without saying anything, being quiet throughout the interactions. She suffered from dementia and was so dependent on her husband. I also felt slightly angry at the doctor's insensitive response to a mere friendly gesture, though seemingly improper, given the conventional power dynamics between the patient and the physician and the way doctors are esteemed in the American medical culture. But the doctor could have reacted to this perceived slight and disrespect with a mere laugh or simply pretended not to have heard it.Even more distinct was the fact the doctor showed her irritation in front of a third party—me, the medical interpreter. I felt she almost directed that to me and right in my face, and yet I felt powerless, helpless, and even embarrassed. I wondered if the doctor would do the same in front of her other colleagues—physicians and nurses. She might have been more diplomatic. Was her rebuke an impulsive reaction or a deliberate projection of her power, putting the husband back into his place? Should I intervene to ameliorate the impact and explain it? What if the doctor became angry with me if I ventured, and would it worsen things despite my good intentions? All these questions were stirring around in my head. Eventually, I decided to mind my own business and stayed in my role. But this episode of her open reprimand and implicit power projection stuck in my mind then and many years after.Over the years, I moved up from a medical interpreter to the Director of the Interpreter Services Department of a major teaching hospital in Boston and worked deliberately to elevate the status of [End Page 151] medical interpreters by educating clinicians about who we are, what we do, what qualifications and trainings we have and the unique roles we play in cross-cultural communication and care delivery. We demythologized medical interpreters' traditionally reductive role of mouthpiece and advocated their full-fledged member role on the care team. Through our regular conversations and dialogues (instead of top-down teaching sessions by clinicians), medical interpreters partner and team up with physicians, nurses, social workers, chaplains, ethicists, residents, and fellows. We learn from one another to foster a culture of collaboration and mutual respect, gradually bringing about a transformation of power dynamics; medical interpreters are valued for their unique roles of language conduit, clarifier, cultural broker and patient advocate. Interpreters now are empowered to ask questions, seek clarification, and advise on care approaches before, during, and after medical encounters with confidence and teamwork spirit.One of the tangible changes that we collectively implemented is that for each patient appointment, we will allocate time for a short meeting between the interpreter and the provider in what we call a "pre-huddle"; the purpose of the quick meeting is for the provider to brief the interpreter about the patient's medical condition and the goal of treatment. The provider will use the opportunity to solicit any input from the interpreter around language and cultural challenges.The interpreter, possibly having worked with the patient before, will provide some background and context if proper and necessary. This simple process change has boosted the interpreter's morale and engagement. Both parties feel comfortable and familiar with each other's roles and moves. By working in such an environment of... (shrink)

Objective:The purpose of this study was to describe the current situation of moral distress and to explore its influencing factors among Chinese nurses.Methods:This is an exploratory, descriptive design study. A total of 465 clinical nurses from different departments in three Grade-III, Level-A hospitals in Jinan, Shandong Province, completed the questionnaires, including demographics questionnaire, Chinese version of Moral Distress Scale–Revised, and Job Diagnostic Survey.Ethical considerations:The study was approved by the university ethics board and the local health service director.Results:The total score (...) of Moral Distress Scale–Revised was 36.01 ± 24.02 points. The mean frequency and intensity scores of moral distress were 1.13 ± 0.49 and 1.09 ± 0.58, respectively. The level of moral distress among Chinese clinical nurses was low, and the frequency and intensity of moral distress were on low to moderate level. The level of moral distress experienced by clinical nurses is associated with demographics features and job characteristics, including age, education degree, department, task significance, autonomy, and dealing with others.Conclusion:Our conclusion suggests that hospital and organizational administrations should attach much importance to the moral distress experienced by clinical nurses in China. Further studies should focus on interventions about how to reduce the levels of the frequency and intensity of moral distress among clinical nurses. (shrink)

By employing the theoretical template provided by agency theory, this article contributes a detailed clinical analysis of a large multinational Canada-headquartered telecommunications company, Nortel. Our analysis reveals a twenty-first century norm of usual suspects: a CEO whose compensation is well above those of his peers, a dysfunctional board of directors, acts of income smoothing to preserve the confidence of volatile investors, and revelations of financial irregularities followed by a downfall. In many ways, the spectacular rise and – sudden – (...) fall of Nortel illustrates excesses of actors within, and contradictions of the system of corporate governance implied by the agency model. Furthermore, this case illustrates limitations of the agency framework in complex situations with short-term oriented investors. (shrink)

By employing the theoretical template provided by agency theory, this article contributes a detailed clinical analysis of a large multinational Canada-headquartered telecommunications company, Nortel. Our analysis reveals a twenty-first century norm of usual suspects: a CEO whose compensation is well above those of his peers, a dysfunctional board of directors, acts of income smoothing to preserve the confidence of volatile investors, and revelations of financial irregularities followed by a downfall. In many ways, the spectacular rise and – sudden – (...) fall of Nortel illustrates excesses of actors within, and contradictions of the system of corporate governance implied by the agency model. Furthermore, this case illustrates limitations of the agency framework in complex situations with short-term oriented investors. (shrink)

Shutter Island is a much-criticized and highly debated film. Scorsese, in fact, has been accused of distorting the facts and altering his historical sources. The depictions we see of the Holocaust are false, not based on visual documents, a mix of incompatible evidences and iconographies, an amalgam of irreconcilable informations and representations. The director has created a visual style and a sound design that vacillate between thriller and horror, drama and fantasy, while betraying the medial transparency of the reconstruction and (...) the ethical responsibility of interpretation. The viewer sees and believes in the images of the concentration camp of Dachau which are, in reality, dialectical imaginings of another scene: in these images, constructed according to the clinical and critical vision of Scorsese as cinephile, the past and the repressed return in the present. In our present too. On the one hand, in fact, the viewer participates empathically in the mental images relived and suffered by the protagonist in his post-traumatic hallucinations; on the other hand, the viewer is prompted to recall the pictures quoted or paraphrased from the archives of the imagery of cinema and of the photojournalism of war–in which Pontecorvo, Resnais, Fuller, George Stevens and John Huston live side by side with the RKO horror films of Jacques Tourneur and Mark Robson. For Scorsese, the images of the violence of war and of the horror of extermination cannot be linked to an origin or past that have definitively been concluded. They are more than recorded pictures or concrete evidences: they are clues and symptoms. They come from a conflictual and endless descent of which cinema is the living and ambiguous memory; they are the open wounds of an original struggle between human and inhuman and of man–they still survive, here and now. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Reaching the Age of Majority:The Life Trajectory of the CIHR Institute of AgingYves Joanette, Anne Martin-Matthews, Réjean Hebert, and Joanne GoldbergThe Canadian Institutes of Health Research (CIHR) was created in 2001 under the Canadian Institutes of Health Research Act S.C. 2000, c. 6 (Government of Canada, 2000). The creation of CIHR was in follow-up to the Canadian Medical Research Council (MRC) as well as to the National Health Research (...) and Development Program of Health Canada that, up until that point in time, had supported the breadth of health research in Canada. Two important characteristics of CIHR were crucial for the development of research on aging. The first was that CIHR, unlike MRC, was entrusted with the challenge of supporting the whole spectrum of health research, from the basic biomedical perspective to clinical research, research on health services and policies as well as social aspects of health research, not to mention research on ethics and other perspectives (including the science of research). The second characteristic of the nascent CIHR that impacted the community of research on aging was the decision that a small part of the overall CIHR budget would be used to address priority-driven questions or topics (strategic competitions), while the majority of the budget would be invested in grants and awards programs that would be investigator-initiated, as in the time of the MRC (open competition). Since its inception, CIHR has included 13 institutes that are central to the priority-driven actions. Institutes not only play an important convener role within their communities and among their stakeholders, but they are also expected to listen to the needs, gaps and opportunities in their area and to introduce initiatives---most of the time involving more than one Institute---in order to tackle these needs and gaps and to seize upon the opportunities.The Institute of Aging was introduced at the same time as the other 12 Institutes and it is clear that many challenges were awaiting the new Institute since, at that time, research on aging was still in its early years. This article is about the trajectory of the CIHR Institute of Aging in its first 18 years of existence. Having now reached an age that is either the age of majority or quite close to it, it is important to be able to provide a reflection on the evolution of the priorities over this period, while also taking a peek at some of the priorities that will surely come in the near future.The Early Years (2001-2004)The founding Scientific Director of the Institute of Aging was Dr. Réjean Hébert. A well-known and prolific [End Page 1] geriatrician and researcher, Dr. Hébert was the perfect person to launch the Institute. One of his first actions was, in fact, to harmonize the French and English names of the Institute. In French, the name of the Institute focused on Aging (Institut du vieillissement) while, in English, the name of the Institute focused on Healthy Aging. The CIHR Institute of Healthy Aging thus became the CIHR Institute of Aging in all versions of its documentation. But above and beyond this important name change, the real work of Dr. Hebert, accompanied by the first Institute Advisory Board1, chaired by Prof. Dorothy Pringle, was to identify the gaps, the needs and the opportunities. After a rigorous process came the first Strategic Plan of the CIHR Institute of Aging, which was clearly influenced by Dr. Réjean Hébert's vision of the aging population as an opportunity, instead of a catastrophe, for our society that comes, of course, with its own challenges. Dr. Hébert left CIHR during his first mandate as he was called upon to become the Dean of his Faculty, and then went on to become the first CIHR Scientific Director to sit as a Minister of Health and Social Services in the Québec Government. The main outcomes of Dr. Hebert's years (2001-2004) can be summarized as follows2.• Organizing many workshops and meetings to ensure that the Institute of Aging would become the premier national convener for research on aging, bridging between disciplines... (shrink)

Science and religion pervade the 1973 horror The Exorcist (1973), and the film exists, as the movie’s tagline suggests, ‘somewhere between science and superstition’. Archival materials show the depth of research conducted by writer/director William Friedkin in his commitment to presenting and exploring emerging scientific procedures and accurate Catholic ritual. Where clinical and barbaric science fails, faith and ritual save the possessed child Reagan MacNeil (Linda Blair) from her demons. The Exorcist created media frenzy in 1973, with increased reports (...) in the popular press of demon possessions, audience members convulsing and vomiting at screenings, and apparent religious and specifically Catholic moral outrage. However, the official Catholic response to The Exorcist was not as reactionary as the press claimed. The United States Conference of Catholic Bishops’ Office of Film and Broadcasting (USCCB-OFB) officially and publicly condemned the film as being unsuitable for a wide audience, but reviews produced for the office by priests and lay Catholics and correspondence between the Vatican and the USCCB-OFB show that the church at least notionally interpreted it as a positive response to the power of faith. Warner Bros. Studios, however, were keen to promote stories of religious outrage to boost sales and news coverage – a marketing strategy that actively contradicted Friedkin’s respectful and collaborative approach to working with both religious communities and medical professionals. Reports of Catholic outrage were a means of promoting The Exorcist rather than an accurate reflection of the Catholic Church’s nuanced response to the film and its scientific and religious content. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Narrative Formulation RevisitedOn Seeing the Person in Mental Health RecoveryAnna Bergqvist (bio)The use of narrative in mental health contexts models consciousness as something necessarily embodied, as already part of the world, in an inherently value-laden and perspectival way. As such narrative presents a powerful tool for critical reassessment and reevaluation of preconceived ideas in relating to difficult concepts in clinical interactions.Narrative structures can reveal psychological differences between persons (...) in a way that matters for the provision of effective treatment and management. As emphasized by Solomon (2015), narrative reasoning is also motivated by distinctly first-personal concerns that are operative in the practitioner–client relationship. I maintain that the dynamics of that interpersonal relationship are part and parcel of what it means to address the patient's needs to be seen as a person in humanistic empathetic care—without thereby reducing truth to an individual person's perspective to encourage positive transformation.1The notion of empowering narratives to encourage positive change is a core concept behind the emphasis on the critical role of empathy in explaining human development and psychoanalytic change within the self-psychology tradition but is also key to recovery-based models of the significance of person-centered quality of life in medicine more generally. This is defined in mental health as recovering a good quality of life as determined by the values of (by what matters or is important to) the individual concerned (Allott, Loganathan, & Fulford, 2002; Fulford, 1989, 2004; Fulford, Peile, & Carroll, 2012). The importance of strengths in this regard was reflected for example in the UK government program on values-based mental health assessment. The 3 Keys program, as it was called (National Institute for Mental Health in England, NIMHE, and the Care Services Improvement Partnership, 20082) identified three shared 'keys' to good practice in mental health assessment: three things that were identified in a wide-ranging consultation as being important alike by health professionals of all kinds and by 'service users' thus understood as patients and carers (Fulford, Duhig, Hankin, Hicks, & Keeble, 2015a; Fulford, Dewey, & King, 2015b). The third of these keys was defined in [End Page 7] the subsequently published Good Practice Guidance, as "a person-centred focus that builds on the strengths, resiliencies and aspirations of the individual service user as well as identifying his or her needs and challenges" (NIMHE, 2008: 6); and the guidance included a number of real-life case examples of best recovery practice reflecting this aspect of mental health care (Slade et al., 2014).What my (Bergqvist, 2018, 2020, 2022, forthcoming) account adds to this claim is that while such choices are revelatory or expressive of a distinctly first-personal stance, they do not constitute or determine selfhood and self-interpretation in a fixed way. Moreover, the reason is that one can also adopt a second-personal stance on one's own experience and address oneself, where the relationship between the first- and the second-personal narrative perspective on experience and self-understanding is itself a dynamic and open-ended evaluative process.Anna Bergqvist Anna Bergqvist is Reader in Philosophy at Manchester Metropolitan University since 2021, and has been Postgraduate Research Coordinator and AHRC North West Doctoral Pathway Consortium Lead for Philosophy since 2020. I was elected to a Visiting Fellowship at St Catherine's College University of Oxford for Michaelmas Term 2021. Her service to the profession out with the University includes acting as Secretary of the World Psychiatric Association (WPA) Section for Philosophy & Humanities in Psychiatry (October 2020 – present), Executive Committee Member of the Royal College of Psychiatry (RCPsych) SIG in Philosophy (February 2020 – present) and External Examiner, University of Liverpool (November 2019 – present, 4-year tenure). She is also Director of the Values-based Theory Network at St Catherine's Collaborating Centre for Values-based Practice at the University of Oxford, and Member of its Whiteness and Race Equality Network. Her approach to philosophy bridges the disciplines of moral philosophy, moral psychology and philosophy of psychiatry to improve lives through her reputable expertise in moral perception and co-production as a mechanism for change.Notes1. Here I side with Goldie (2012) and Solomon (2015), who... (shrink)

Background: Moral distress has been experienced by about 67% of critical care nurses which causes many complications such as job dissatisfaction, loss of capacity for caring, and turnover for nurses and poor quality of care for patients as well as health system. Objective: The purpose of this research was to provide a moral empowerment program to nursing directors, school of nursing, and the heads of hospitals to reduce moral distress in nurses and improve the quality of care. Methods: This research (...) was a randomized clinical trial conducted in two groups and three stages before, after 2 weeks, and 1 month after the intervention in order to evaluate the changes in moral distress of 60 nurses working in adults’ intensive care unit wards of Al-Zahra teaching hospital of Isfahan University of Medical Sciences. Data were collected using the standard Hamric’s Moral Distress Scale (2012) and analyzed using SPSS software version 22. Ethical considerations: This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran. Results: Results showed that in the three stages, there was no significant difference between the mean score of moral distress before (4.12 ± 2.70), 2 weeks after (4.23 ± 2.70), and 1 month after the intervention (4.04 ± 2.54) in the control group (p > 0.05), while in the experimental group, there was a significant difference between the three stages (p 0.05). However, this score significantly decreased 1 month after the intervention (2.64 ± 2.23; p < 0.05). Conclusion: In this research, it was observed that moral empowerment program has been effective in reducing the mean score of moral distress. Therefore, it is recommended that nursing managers and hospital directors implement empowerment program, in order to reduce the moral distress of nurses and improve the quality of care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:IntroductionRobert M. Veatch (bio)The Kennedy Institute of Ethics regularly sponsors intensive bioethics courses for physicians, nurses, and other health care professionals. While the basic course, held in June of each year, provides a general introduction to bioethics, advanced courses, which are often held in March, focus on more specific topics such as death and dying, justice and the allocation of resources, or theories and methods in bioethics. This year (...) the advanced course addressed one of the most sensitive and complex bioethical issues of our day: managed care. This issue of the Kennedy Institute of Ethics Journal includes revised versions of many of the papers from that meeting.As defined by one of the papers in this issue, managed care involves a system of health care delivery that manages resources, quality, and access associated with the delivery of health care. The key element of managed care is that, for the first time, managers—often from outside the health care professions—are intentionally controlling resources, and therefore controlling health care professional decisions that use those resources. The objective is not merely to eliminate utterly useless interventions—no one could plausibly object to that. Rather the target is also the elimination of inefficient and wasteful resource consumption. Increasingly, we recognize that many diagnostic tests and treatments offer, at best, a very marginal chance of doing the patient good. Some of these come at considerable cost. From the point of view of the rational organization of resources, no rational person would insist on receiving every last procedure that offers only a tiny chance to do a small amount of good at great cost. Managed care is designed to bring to consciousness and rationalize the decisions about which of these marginal, expensive benefits are worth pursuing.The problem is that any effort to eliminate any of the these expensive marginal services flies directly in the face of the Hippocratic ethic. Physicians and other clinicians traditionally are trained to believe that it is their moral duty to do what is best for the patient. Only now are we realizing that, taken literally, no rational person would want literally the best possible care, assuming that such care would include thousands of long-shot, expensive efforts to get the most modest of benefits at great cost. In a world of finite resources, rational people would certainly want very good medical care; they would want reasonable care. But they would also want some criteria of efficiency and fairness applied. The Hippocratic tradition has never addressed the problem of the difference between the best care and care that is of very high quality, but is chosen with an awareness that the best in medicine will necessarily come at the price of potentially serious [End Page vii] deprivation in other spheres of life. The ethics of managed care is fundamentally an exploration of how health care professionals can reconcile their traditional, if short-sighted and naive, commitment to doing what is best for their patients with increasing realism about the absurdity of pursuing every last possible increment of benefit.To the clinical health care professional, the issue raised most poignantly by managed care is whether the various health professions can still be practiced with integrity in a setting in which outsiders are charged with the rationalization and systematization of limits placed on excessive use of marginally beneficial resources. Edmund D. Pellegrino, a clinician and former Director of the Kennedy Institute, sets the tone for the course and for this issue of the Journal by making an appeal for the retention of the highest ethical standards of integrity for clinicians practicing in a managed care setting. He is unwilling to let standards be lowered in the process of systematizing the rational use of health care resources. The remaining papers in this issue respond to those pressures to change the nature of the clinical lay-professional relationship. Some of these presentations originated as panels designed to bring out varying points of view. The published form of the presentations, like the original oral remarks, are of different lengths. All have been edited by the presenters, some taking on the form of more finished papers, others still reflecting the less formal conversation of... (shrink)

Ethical training in graduate programs is an important part of the professional development process. Such training has taken a position of prominence in both counseling and clinical psychology but seems to be lagging behind in the field of sport psychology. A debate exists about whether such training is necessary and, if so, how it should be provided. An important step in better understanding these issues is to identify how such training is currently taking place. This study surveyed the program (...) directors of sport psychology programs listed in the Directory of Graduate Programs in Applied Sport Psychology about the ethical training that takes place in their programs and their perceptions of the preparedness of the students in their programs. Of those contacted, 54% responded to the e-mail based survey. The results from these respondents indicated that 64.4% of programs require training in ethics and that the training was most commonly integrated into other nonethics courses. Overall, respondents did not feel as if students were completely prepared for either the ethical or legal issues that they will face in their professional careers. The importance of ethical training and suggestions for improving ethical training are discussed. (shrink)

In the United States, the National Institute of Mental Health is seeking to encourage researchers to move away from diagnostic tools like the Diagnostic and Statistical Manual of Mental Disorders. A key mechanism for this is the “Research Domain Criteria” initiative, closely associated with former NIMH Director Thomas Insel. This article examines how key figures in US psychiatry construct the purpose, nature, and implications of the ambiguous RDoC project; that is, how its novelty is constituted through discourse. In this paper, (...) I explore and analyze these actors’ accounts of what is new, important, or desirable about RDoC, demonstrating how they are constituted through institutional context and personal affects. In my interviews with mental health opinion leaders, RDoC is presented as overly reliant on neurobiological epistemologies, distant from clinical imaginaries and imperatives, and introduced in a top-down manner inconsistent with the professional norms of scientific research. Ultimately, the article aims to add empirical depth to current understandings about the epistemological and ontological politics of contemporary psychiatry and to contribute to science and technology studies debates about “the new” in technoscience. Accordingly, I use discussions about RDoC as a case study in the sociology of novelty. (shrink)

Advocates for the professionalization of clinical bioethics argue that bioethics professionals play an important role in contemporary medicine and patient care, especially when addressing complex ethical questions that arise in the delivery of reproductive medicine. For bioethics consultants to serve effectively, they need adequate training in the medical and ethical issues that patients and clinicians will face, and they need skills to facilitate effective dialog among all parties. Because clinical ethics consultation is a “high‐stakes endeavor” that can acutely (...) affect patient care, efforts are under way to ensure that bioethics consultants have the competence to provide such guidance. Yet to date, no studies have examined whether the training of bioethics consultants meets the needs of health care professionals who are on the front lines of such issues. In fact, limited information is available on the reproductive health issues that bioethics training programs address or the degree to which these programs meet the needs of patients confronting reproductive health decisions and their clinicians. It is therefore important to answer this key question: What are the primary ethical issues encountered in reproductive medicine that currently affect patient care? Equally important, are bioethics training programs prepared to address those issues?To begin to answer these questions, we conducted parallel surveys of directors of graduate bioethics training programs and obstetrician‐gynecologists. The goal of this project is to lay the groundwork to establish a working partnership between bioethics educators and reproductive medicine practitioners to address the often troubling and frequently complex ethical issues in reproductive medicine. (shrink)

In May 1968, Gilles Deleuze was an established philosopher teaching at the innovative Vincennes University, just outside of Paris. Félix Guattari was a political militant and the director of an unusual psychiatric clinic at La Borde. Their meeting was quite unlikely, yet the two were introduced in an arranged encounter of epic consequence. From that moment on, Deleuze and Guattari engaged in a surprising, productive partnership, collaborating on several groundbreaking works, including _Anti-Oedipus_, _What Is Philosophy?_ and _A Thousand Plateaus_. François (...) Dosse, a prominent French intellectual known for his work on the Annales School, structuralism, and biographies of the pivotal intellectuals Paul Ricoeur, Pierre Chaunu, and Michel de Certeau, examines the prolific if improbable relationship between two men of distinct and differing sensibilities. Drawing on unpublished archives and hundreds of personal interviews, Dosse elucidates a collaboration that lasted more than two decades, underscoring the role that family and history—particularly the turbulent time of May 1968—play in their monumental work. He also takes the measure of Deleuze and Guattari's posthumous fortunes and the impact of their thought on intellectual, academic, and professional circles. (shrink)

BackgroundDespite consensus about the importance of implementing shared decision-making (SDM) in clinical practice, this ideal is inconsistently enacted today. Evidence shows that SDM practices differ in the degree of involvement of patients or family members, or in the amount of medical information disclosed to patients in order to “share” meaningfully in treatment decisions. Little is known on which representations and moral justifications physicians hold when realizing SDM. This study explored physicians’ experiences of SDM in the management of paediatric patients (...) with prolonged disorders of consciousness (PDOC). Specifically, we focused on physicians’ SDM approaches, representations, and ethical justifications for engaging in SDM.MethodsWe used a qualitative approach to explore the SDM experiences of 13 ICU physicians, paediatricians, and neurologists based in Switzerland who have been or were involved in the care of paediatric patients living with PDOC. A semi-structured interview format was used and interviews were audio-recorded and transcribed. Data were analysed through thematic analysis.ResultsWe found that participants followed three main decision-making approaches: the “brakes” approach, characterized by maximized family’s decisional freedom, though conditional to physician’s judgment regarding the medical appropriateness of a treatment; the “orchestra director” approach, characterized by a multi-step decision-making process led by the main physician aimed at eliciting the voices of the care team members and of the family; and the “sunbeams” approach, characterized by a process oriented to reach consensus with family members through dialogue, where the virtues of the physician are key to guide the process. We also found that participants differed in the moral justifications sustaining each approach, citing the duty to respect parental autonomy, to invest in an ethics of care, and to employ physicians’ virtues to guide the decision-making process.ConclusionOur results show that physicians come to perform SDM in different ways, with several representations, and distinct ethical justifications. SDM training among health care providers should clarify the ductility of SDM and the several ethical motivations underpinning it, rather than insisting on the principle of respect for patient’s autonomy as its only moral foundation. (shrink)

Ethical training in graduate programs is an important part of the professional development process. Such training has taken a position of prominence in both counseling and clinical psychology but seems to be lagging behind in the field of sport psychology. A debate exists about whether such training is necessary and, if so, how it should be provided. An important step in better understanding these issues is to identify how such training is currently taking place. This study surveyed the program (...) directors of sport psychology programs listed in the Directory of Graduate Programs in Applied Sport Psychology (Burke, Sachs, & Schrader, 2002) about the ethical training that takes place in their programs and their perceptions of the preparedness of the students in their programs. Of those contacted, 54% (n = 47) responded to the e-mail based survey. The results from these respondents indicated that 64.4% of programs require training in ethics and that the training was most commonly integrated into other nonethics courses. Overall, respondents did not feel as if students were completely prepared for either the ethical or legal issues that they will face in their professional careers. The importance of ethical training and suggestions for improving ethical training are discussed. (shrink)

_What place do Anna Freud’s ideas have in the history of psychoanalysis? What can her writings teach us today about how to work therapeutically with children? Are her psychoanalytic ideas still relevant to those entrusted with the welfare of infants and young people? _ _Reading Anna Freud_ provides an accessible introduction to the writings of one of the most significant figures in the history of psychoanalysis. Each chapter introduces a number of her key papers, with clear summaries of the main (...) ideas, historical background, a discussion of the influence and contemporary relevance of her thinking, and recommendations for further reading. Areas covered include Anna Freud’s writings on: • The theory and practice of child analysis and 'developmental therapy' • The application of psychoanalytic thinking to education, paediatrics and the law • The assessment and diagnosis of childhood disorders • Psychoanalytic research and developmental psychopathology Nick Midgley draws on his extensive experience as a child psychotherapist and a teacher to bring Anna Freud's ideas to life. He illustrates the remarkable originality of her thinking, and shows how analytic ideas can be used not only in child psychotherapy, but also to inform the care of children in families, hospitals, classrooms, residential care and the court-room. __Reading Anna Freud__ will be of interest to child therapists, child analysts and psychoanalysts, as well as others working in the field of child and adolescent mental health, such as clinical psychologists, child psychiatrists and educational psychologists. It also has much to offer to those entrusted with the care of children in a wide range of settings - including teachers, nurses and social workers - for whom Anna Freud was always keen to demonstrate the value of a psychoanalytic approach. _Nick Midgley_ trained as a child and adolescent psychotherapist at the Anna Freud Centre, where he now works as a clinician and as Programme Director for the MSc in Developmental Psychology and Clinical Practice. Nick has written articles on a wide range of topics and is joint editor of _Minding the Child: Mentalization-based Interventions with Children, Young People and their Families_ and _Child Psychotherapy and Research: New Directions, Emerging Findings_. (shrink)

This textbook offers a unique and accessible approach to ethical decision-making for practicing pharmacists and student pharmacists. Unlike other texts, it gives clear guidance based on the fundamental principles of moral philosophy, explaining them in simple language and illustrating them with abundant clinical examples and case studies. The strength of this text is in its emphasis on normative ethics and critical thinking, and that there is truly a best answer in the vast majority of cases, no matter how complex. (...) The authors place high trust in a pharmacist’s moral judgment. This teaches the reader how to think, based on ethical principles, not necessarily what to think. This means navigating between the two extremes of overly theoretical and excessively prescriptive. The cogent framework given in this text uses the language of competing duties, identifying the moral principles at stake that create duties for the pharmacist. This is the balancing act of normative ethics, and of deciding which duties should prevail in a given clinical situation. This work presents a clear-cut pathway for resolving ethical dilemmas encountered by pharmacists, based on foundational principles and critical thinking. Presents a clear-cut pathway for resolving the ethical dilemmas encountered by pharmacists, based on foundational principles and critical thinking. Jon E. Sprague, RPh, PhD, Director of Science and Research for the Ohio Attorney General. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Oldest and Most Respected Uniform in the World1Zelig R. Weinstein“And all the peoples of the earth shall see that the name of the LORD is called upon thee; and they shall be afraid of thee.”(Deuteronomy 28:10)Rabbi Eliezer the Great says that this verse alludes to the Tefillin Shel Rosh, the small leather box containing Biblical verses that are worn by Jewish men on their head. During Talmudic times (...) and for centuries after, devout Jewish men would wear Tefillin the entire day. This practice is now only rarely seen. Since the 1960s, there has been a resurgence of public display of one’s adherence to traditional Jewish practices. It is increasingly common to see Jewish men wearing a yarmulke at work and in public spheres. There are perhaps thousands of Jewish doctors who don’t hesitate to wear their yarmulke in their places of practice–hospital, clinic, private practice.In the 1980s I joined the staff of the Department of Radiology at the Bethesda Naval Hospital as the Director of Neuroradiology and Interventional Radiology. As the hospital’s Neuroradiologist I presented the radiological findings for the cases presented at the bimonthly “brain cutting” sessions. These sessions were well attended by staff, residents and medical students from the Departments of Neurosurgery, Neurology, Neuropathology and Radiology. I was the only traditional Orthodox Jew at the hospital, clearly recognizable as such by the yarmulke I always wore (very unusual in the early 1980s). My yarmulke would provoke occasional good–natured kidding particularly from the neurosurgery staff and residents. [End Page 212]During one of these sessions, kidding about my yarmulke from a small group of residents was reaching a crescendo. The kidding came to a sudden halt when the Chief Resident of Neuro-surgery, a born and bred Louisianan, demanded everyone’s attention. When it quieted down he very sternly ordered everyone to carefully look at their uniforms. Everyone seemed perplexed but all followed suit. Almost a half–minute passed before the Chief Resident, with his thick Southern drawl, spoke. “Our [naval] uniforms are, at most, a couple of hundred years old.” He then pointed toward my yarmulke and said: “Dr. Weinstein’s uniform is thousands of years old and a lot more respected than our uniforms.”This was my initiation into the alluring, usually positive and unexpected fascination and respect that my obvious religiosity had on my patients, their families and my many colleagues during the almost seven years I spent at Bethesda.The story I will tell is very poignant. It involved the family of one of the most senior Chief Petty Officers of the United States Navy.Late one Sunday evening, I received a call from the Chief Resident, Dr. Steve Henning, informing me that the family matriarch had been admitted to Bethesda with relatively acute onset of significant neurological findings. The emergent workup confirmed the presence of a large mass, a meningioma, of the frontal lobe region with significant surrounding edema and mass effect. Neurosurgery requested embolization of the feeding vessels prior to surgery. The interventional procedure and possible serious complications were fully explained to the patient, her husband and her two daughters. Consent was signed and early Monday morning the patient was brought to Special Procedures to have the tumor embolized.Prior to the procedure I introduced myself to the patient’s family and spoke to them about the procedure. The patient’s husband and two daughters, one of whom was an active duty Navy nurse the other a minister of a fundamentalist church in the South, were very attentive and expressed concern about the procedure and its outcome. I tried to reassure them and told them I would speak to them during and after the procedure.All went well. Medically, the patient did well during and after the procedure. She was discharged from our care to neurosurgery. The patient and her family thanked us.After the patient left the Special Procedures area the Chief Technologist, Al, approached me and very cryptically asked if I was aware of what happened when the Chief Resident, Dr. Henning, spoke with the patient and family the night before. I was puzzled and replied, no. He... (shrink)