Nurse Ethicists bring a unique perspective to clinical ethics consultation. This perspective provides an appreciation of ethical tensions that will exist beyond the consult question into the moral space of patient care. These tensions exist even when an ethically preferable plan of action is identified. Ethically appropriate courses of action can still lead to moral dilemmas for others. The nurse ethicist provides a lens well suited to identify and respond to these dilemmas. The nurse–patient relationship is the ethical foundation of (...) nursing practice and this relational ontology is well suited to addressing ethical dilemmas that exist prior to and beyond the initial consult question. This paper will describe one nurse ethicist’s phronetic and pragmatic approach to a clinical ethics consult elucidated through feminist ethics and systems thinking. This paper will describe the theoretical basis for this method, present a case, and describe how this consultation approach provides a rich analysis based around relationships and responsibilities that also highlights the important ethical tensions within the social structure that exists around the patient and continue after the consult question is answered. (shrink)

The moral expertise of clinical ethicists is not a question of mastering codelike theories and lawlike principles. Rather, ethicists are architects of moral space within the health care setting, as well as mediators in the conversations taking place within that space.

Business Ethics, the Environment &Responsibility, Volume 33, Issue 2, Page 157-169, April 2024.

Neuropsychiatric disorders introduce distinct challenges to clinical decision-making. Affected patients often experience impairments or absences in rationality, lucidity and cogni-emotional capacities, rendering it difficult for them to engage in the decision-making process. In turn, dynamics of the patient-physician relationship become strained, including when physicians employ bioethical principlism or moral case deliberation to arrive at ethically justified courses of action–both of which require sufficient communication and rationality that may be impaired or altogether absent in the presence of psychopathology. The complexity of (...) neuropsychiatric conditions therefore compels interrogation towards how ethics consultations are currently constructed and conducted when full communication or rational decision-making cannot be assumed. Delany et al, for example, present a robust, methodical framework for ethical deliberation.1 Such methodologies for facilitating ethical decision-making, although valuable in predominant contexts, assume full participant engagement and decision-making capacities (eg, independent moral agency). Neuropsychiatric disorders complicate this assumption, making it difficult for patients with limited decision-making capacity to engage meaningfully in proposed ethics consultations.2 This paper will explore how neuropsychiatric disorders complicate the assumptions of full participant engagement underlying ethical frameworks. It will argue that, by adapting ethics consultations to function as a ‘mental prosthesis’, clinicians can better navigate the ethical challenges posed by neuropsychiatric disorders, helping to ensure that patient autonomy is upheld even in cases of impaired cognitive …. (shrink)

Volume 23, Issue 3-4, November - December 2024, Page 219-244.

Sexually transmitted infections (STIs) are socially constructed as more ‘dirty’ than other gynaecological conditions. This article analyses women’s accounts of interactions with clinicians, subsequent to a diagnosis of genital herpes simplex virus or human papilloma virus. Women conceptualised consultations as a ‘moral event,’ different from other consultations. This moral component is highlighted drawing on Foucault’s notion of ‘the confessional.’ Additionally, Douglas’ anthropological construction of ‘dirt’ is used to consider why these consultations are ‘confessional’ experiences. Email interviews were conducted with 26 (...) women diagnosed with a viral STI and 12 sexual health clinicians. Data were analysed thematically using a feminist, poststructuralist approach. Findings indicated that discourses of morality shape sexual health consultations. Five themes were identified in relation to the moral ‘work’ in clinical consultations about a viral STI diagnosis: the particular ‘dirtiness’ of viral STIs, clinicians as moral agents, the ‘non‐judgmental’ clinician, women juggling truth‐telling and risk and clinicians prescribing moral work. Clinicians support and educate women more effectively if they recognise subjective, moral aspects of sexual health consultations rather than assuming that effective clinical teaching is rational, scientific and non‐judgmental. (shrink)

Healthcare ethics consultation is therefore one of the most consequential, institutionally accepted, and widespread forms of public philosophy in the United States. In this chapter, the authors begin with an overview of the development of healthcare ethics and its emergence as a concrete practice embedded in healthcare settings. They then describe the core ethical principles that inform the everyday practice of ethics consultations and the generally accepted steps involved in conducting a consultation. The authors discuss the role of clinical ethicists (...) in medical education and policy development. Finally, they conclude with some remarks on the distinctive contributions made by those with philosophical training to these endeavors and the importance of continued engagement by philosophers in this important public work. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Womanist-Buddhist Consultation as a Reading CommunityCarolyn M. Jones MedineIn Breaking the Fall, the late Robert Detweiler (1932-2008) imagines what a reading community, "a contemporary version of the old storytelling cultures,"1 might look like. He suggests that in such a community, "The accent on community itself would offer a balance to our excessively privatizing tendencies; the communal interaction could counter our relentless drive to interpret... with attitudes of play (...) and Gelassenheit (abandonment, chance, and relaxation); the writing and reading community especially as a liminal entity, could nurture a respect for the incomprehensibility of form and a reverence for mystery."2 This description offers an entry to the work of the Womanist-Buddhist Consultations. To reach a provisional understanding of the meaning of that work, I shall reflect on first what we mean when we say that we want to read something. Second, I turn to a conversation with Robert Detweiler, who was one of my mentors, as a way to address the form of reading that we do and the form of community that we make in the Womanist-Buddhist Consultations. Third, I want to draw on the thought of the consultations themselves, using Emmanuel Levinas's work on reading and ethics, to examine the capacity the consultations have to hold tensions creatively and to allow multiple meanings to be part of them. Finally, I want to address the goals for the consultations. I am thinking specifically of Melanie Harris's desire to see the consultations as generating practices that promote peace, compassion, and justice, and Charlie Hallisey's desire to generate a more complex reading of Buddhist texts in and of themselves.The Womanist-Buddhist Consultations have met three times between 2009 and 2011. We met at Harvard Divinity School and at Texas Christian University for sessions of four days each, and for an evening at the University of Georgia between the two longer meetings. The Texas Christian meeting included some previous members from the Harvard meeting, and added new ones. The University of Georgia meeting consisted primarily of students who participated in the reading practice.In the meeting at the University of Georgia, Charles Hallisey looked askance at me when I said that Buddhism offers an entry into peace and compassion; yet Melanie Harris, when she constructed the later session at Texas Christian University, deployed the terms "peace" and "justice" as descriptors for the work of the group. Hallisey's ironic glance occurred right before we read, at the University of Georgia, a text that contained magic and murder. His glance and the content of that text have prompted [End Page 47] me to think through Harris's claims and to see how our group achieves both a reading of Buddhism and an ethical practice that generates peace and points to justice.The instructions that Hallisey gives for the reading process describe a practice of "being and reading together" as we encounter a variety of Buddhist texts.3 The group's guide is the bodhisattva Manjushri, who has overseen our work through an image gracing the wall at all our meetings. Manjushri has a sword to cut through obstacles, and holds a book, signifying wisdom. The practice of reading with friends, Hallisey told us, comes from Jewish tradition: we need a friend to help us overcome what we can and to begin to see what we cannot. The work involves three steps:1. To read passages individually.2. To read the same passages together in small groups.3. To gather again as a large group and discuss what we have discovered.The major goal of reading is to encounter levels of ourselves to which we ordinarily have no access, by examining a text that becomes "generous" to us. Reading together, Hallisey asserts, makes the generosity of the text visible to us.This process of reading, I would argue, is different from what we usually do when we read and different from what we mean when we tell students to read. Patricia O'Connell Killen, an AAR Teaching Award winner, has delineated some of what we mean when we say to our students: "Read chapter 2 of 'X' and come to class prepared."4... (shrink)

A businessperson acts,quabusinessperson, in two institutional contexts which in principle are completely distinct, and normally entail two different ways of relating to other people; on the one hand as an actor in the market, and on the other as the employees’ manager. We shall assume that different sets of norms govern how to relate to trading partners in the market and how to relate to subordinates in the company. The moral problems which arise in the two different institutions for conducting (...) human relations consequently also differ. The main problem relating to market operations originates in the fact that one achieves the most desirable consequences when the objective as such is difficult to justify on moral grounds. Profit is the target, if necessary at the expense of the person one is dealing with. In this context—i.e. in the market—altruistic considerations, or acting out of consideration for the other party, can produce socially undesirable results. The problems confronting the businessperson as manager are of a different nature. We shall not be considering all aspects of management or consultancy ethics, only what we regard as in principle the fundamental problem, one which in fact applies to all management in modern society. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Bioethics ConsultationPat Milmoe McCarrick (bio)(John La Puma, M.D., from the Department of Medicine at Lutheran General Hospital in Chicago, contacted the National Reference Center for Bioethics Literature and suggested bioethics consultation as a topic for the Scope Note Series. He provided an extensive list of citations about ethics consultations collected by him and by David Schiedermayer, M.D., for their new book Ethics Consultation: A Practical Guide.)In Ethics Consultation in (...) Health Care, editors John Fletcher, Norman Quist, and Albert R. Jonsen (I, 1989) define ethics consultation as "the provision of specialized help in identifying, analyzing, and resolving ethical problems that arise in clinical care. In medical ethics the area of consultation has grown rapidly since 1978 when Edmund D. Pellegrino (II, 1978) noted, "we cannot separate technical-moral decisions from the philosophic principles we use to justify them. Medicine and ethics must be engaged with each other at every level."In 1980 Albert Jonsen raised the question of whether an ethicist could be a consultant and said that the ethicist as consultant is a casuist, one whose moral reasoning is based on a system of reasoning that is applied to particular cases. He describes historical casuistry in Western culture, comparing it to modern moral philosophy, and suggests that a "new casuistry seems timely" for ethics consultation (II, Jonsen 1980). By 1984 ethicist Ruth Purtilo recorded her thoughts following an ethics consultation. She raised questions about the ethicist's place on a hospital staff and how to make that role appropriate and beneficial to all concerned, saying that "the ethicist retreats after the consultation; under no circumstances would the outcome of an ethics consultation be that the ethicist became the primary care giver or assumed ongoing responsibility for the clinical management of a case" (II, Purtilo 1984). Nevertheless, in 1992 two physician-ethicists who had been called as ethics consultants for a patient who had requested that he be removed from his ventilator reported that they became the persons who turned off the ventilator and administered the drugs that eased his dying (II, Edwards and Tolle 1992).In recognition of the growing number of persons identifying themselves as [End Page 433] consultants, the Society for Bioethics Consultation was founded in October 1985 as a professional society of persons engaged in bioethics consultation. It encourages and supports consultation, assists in establishing clinical education programs, and raises funds for consultation education. Although the Society has no permanent office, the president (currently, George Kanoti in the Cleveland Clinic Foundation's Bioethics Department) conducts its work and plans an annual meeting.The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) established new criteria concerning ethics in its 1992 Manual (III, JCAHO 1992) and in a special issue of QRB devoted to ethics consultation (I, Defining Quality 1992). These publications undoubtedly have contributed to the increased use of experts in medical ethics. The Manual notes that all organizations seeking accreditation should have some sort of "mechanism for the consideration of ethical issues arising in the care of patients and to provide education to care givers and patients on ethical issues in health care." A health care institution's eligibility for JCAHO accreditation, which is required for federal reimbursement, requires adherence to this specification (III, JCAHO 1992).The new International Directory of Bioethics Organizations provides an index of 129 different groups that indicated to the authors that they offer bioethics consultations. Of these, 83 are in the United States and 46 are in other countries. The ethics consultants included in the directory encompass a broad group of professionals who will assist patients, families, and primary care medical staff in finding solutions to ethical dilemmas resulting from use of new technologies or new treatments in health care. Consultants often come from the health fields: physicians, nurses, and other health personnel, but other professionals are also active as ethics consultants. Lawyers, pastoral counselors, philosophers, and social workers also offer bioethics consultation services (III, Nolen and Coutts 1993).Drs. Siegler, Pellegrino, and Singer wrote in 1990 that "Physician-ethicists and professional ethicists will continue to work side by side in the future. One is not likely to replace the other, nor is this desirable, because... (shrink)

Research assistantships have long been viewed as an extension of the formal education process, a form of apprenticeship, and a pathway into the professional practice of research in institutional settings. However, there are other contexts in which researchers practice research. Our self-reflective analysis identified that RAship experiences during the masters and the PhD may serve developmentally foundational roles in the advancement of an RA’s knowledge, skills, and passion for research. Further, analysis of participants’ experiences revealed that RA supervisors play critical (...) roles in the development of RAs as researchers. We conclude with the understanding that RAships may be formative in contributing to the development of individuals who go on to specialise as professional research consultants as research consulting is a natural extension of the RA role. Students entering into RAships, current RAs, new faculty members, current RA supervisors, faculty members looking to improve their research productivity, and Chairs of departments will all benefit from reading this paper and its contribution to the current understanding of how RAships impact the development of researchers, and specifically how RAships contribute to the development of research consultants. (shrink)

RESUMEN: El presente trabajo propone un análisis de los Derechos Fundamentales de los pueblos indígenas a la luz de los principios internacionales de Libre Determinación y Consulta Previa, como fundantes y presupuestos de los demás Derechos Indígenas. En consecuencia, se analiza el Derecho a la Consulta, que debe ser previa, libre, informada, de buena fe, culturalmente adecuada y con el propósito de obtener el consentimiento; donde todas éstas características son el estándar mínimo a cumplir en cualquier proyecto de desarrollo o (...) extractivo que afecte a pueblos indígenas, por lo que debe explicarse también el extractivismo al interior de los estados-nación y su modus operandi, que ha provocado la existencia de zonas y regiones que algunos autores caracterizan como “estados de excepción” o estados de “de no-derecho”. El análisis propuesto contrasta las bases mencionadas con algunos casos llevados ante la jurisdicción del Sistema Interamericano de Derechos Humanos, cuya última fase descansa en las sentencias de la Corte IDH.ABSTRACT: The present paper proposes an analysis of the Fundamental Rights of the indigenous peoples in the light of the international principles of Free Determination and Prior Consultation, as foundations and budgets of the other Indigenous Rights. Consequently, the Right to Consultation is analyzed, which must be prior, free, informed, in good faith, culturally appropriate and with the purpose of obtaining consent; where all these characteristics are the minimum standard to be met in any development or extractive project that affects indigenous peoples, so the extractivism within the nation-states and its modus operandi, which has caused the existence of zones and regions that some authors characterize as "states of exception" or "non-right" states. The proposed analysis contrasts the mentioned basis with some cases brought before the jurisdiction of the Inter-American Human Rights System, whose last phase rests on the judgments of the Inter-American Court.PALABRAS CLAVE: Libre determinación y consulta, Derechos Fundamentales, pueblos indígenas. KEYWORDS: Free determination and consultation, Fundamental Rights, indigenous peoples. (shrink)

Much has been written about the importance of narrative in teaching ethics and humanities to medical students and residents, as well as the value of narratives in clinical care. Relatively little has been said about the essential role of narrative in bioethics consultations. For most consults, the interpretation of narratives is the central moral feature, and the ethics consultant is inevitably one of the narrators. In a recent consult in which I participated, at least three narratives were in play. (...) The medical record itself was a narrative, or really, a variety of narratives. A second distinct narrative was the story of why this case had come to be categorized as an ethical concern for the medical team. A third narrative was the tentative sketch running through my mind as a consultant‐partly factual, partly anticipatory and conjectural, inevitably personal‐about what was going on here. (shrink)

In the clinical setting, questions of medical ethics raise a host of perplexing problems, often complicated by conflicting perspectives and the need to make immediate decisions. In this volume, bioethicists and physicians provide a nuanced, in-depth approach to the difficult issues involved in bioethics consultation. Addressing the needs of researchers, clinicians, and other health professionals on the front lines of bioethics practice, the contributors focus primarily on practical concerns -- whether ethics consultation is best done by individuals, teams, or committees (...) how an ethics consult service should be structured the need for institutional support and techniques and programs for educating and training staff -- without neglecting more theoretical considerations, such as the importance of character or the viability of organizational ethics. (shrink)

The year 2013 may someday be seen as the year a new profession was born. Clinical ethics consultation has been practiced in different ways for roughly 30 years, originally initiated by a group of h...

Ongoing evaluation of a clinical ethics consultation service (ECS) allows for continuous quality improvement, a process-based, data-driven approach for improving the quality of a service. Evaluations by stakeholders involved in a consultation can provide realtime feedback about what is working well and what might need to be improved. Although numerous authors have previously presented data from research studies on the effectiveness of clinical ethics consultation, few ECSs routinely send evaluations as an ongoing component of their everyday clinical activities. The primary (...) purpose of this article is to equip and encourage others to engage in ongoing evaluation of their own ECS. Toward that end, the following resources are shared: (1) the survey tool used to gather the evaluation data, (2) the procedure used to elicit and collate responses, and (3) how the resulting data are used to support continuous quality improvement and justify the continued financial support of the ECS to hospital administration. (shrink)

Despite the increasing interest in clinical ethics, ethics consultation as a professional service is still rare in Europe. In this paper I refer to examples in the United States. In Germany, university hospitals and medical faculties are still hesitant about establishing yet another “committee”. One of the reasons for this hesitation lies in the ignorance that exists here about how to provide medical ethics services; another reason is that medical ethics itself is not yet institutionalised at many German universities. The (...) most important obstacle, however, may be that medical ethics has not yet demonstrated its relevance to the needs of those caring for patients. The Centre for Ethics and Law, Freiburg, has therefore taken a different approach from that offered elsewhere: clinical ethics consultation is offered on demand, the consultation being available to clinician(s) in different forms. This paper describes our experiences with this approach; practical issues are illustrated by a case study. (shrink)

This qualitative social scientific interview study delves into the ways in which professional vision is constructed in clinical ethics consultation (CEC). The data consist of 11 semi-structured interviews that were conducted with clinical ethics consultants currently working in hospitals in one major urban area in the U.S. The interviews were analyzed with the qualitative research method of critical discourse analysis, with a focus on identifying the cultural structures of knowledge that shape CEC as a professional practice. The discourses were first (...) identified as belonging to two higher discourse categories, order and agency. Order was divided into three lower categories, emotional, managerial, and rational order, and discourses of agency into the lower categories of exploration, technique, deliberation, and distancing. An additional discourse of neutral interaction was identified as a bridging discourse, activated to level tensions emerging out of conflicting goals and agencies embedded in CEC practice. This analysis brings out as its main observation that clinical ethics consultants draw on and shift between potentially ideologically conflicting social positions that can create built-in tensions within the professional domain. The study calls attention to these tensions and suggests for the professional group to discuss the possibility of defining priorities between different kinds of order, identified in this study, that shape the CEC domain. (shrink)

Over the past few decades, Indigenous communities have successfully campaigned for greater inclusion in decision-making processes that directly affect their lands and livelihoods. As a result, two important participatory rights for Indigenous peoples have now been widely recognized: the right to consultation and the right to free, prior and informed consent (FPIC). Although these participatory rights are meant to empower the speech of these communities—to give them a proper say in the decisions that most affect them—we argue that the way (...) these rights have been implemented and interpreted sometimes has the opposite effect, of denying them a say or ‘silencing’ them. In support of this conclusion we draw on feminist speech act theory to identify practices of locutionary, illocutionary, and perlocutionary group silencing that arise in the context of consultation with Indigenous communities. (shrink)

The author argues that bioethics ought properly to be regarded "both" as a consulting profession that counsels health practitioners in dealing with the individual problems they face "and" as an academic discipline that defines problem areas on its own and includes attention to the institutional and social aspects of health care. The argument is conducted by means of a brief history of bioethics and comparison of its development with that of history of medicine and sociology of medicine. Several examples of (...) the social issues in bioethics are examined. (shrink)

Services of ethics consultants are nowadays commonly used in such various spheres of life as engineering, public administration, business, law, health care, journalism, and scientific research. It has however been maintained that use of ethics consultants is incompatible with personal autonomy; in moral matters individuals should be allowed to make their own decisions. The problem this criticism refers to can be conceived of as a conflict between the professional autonomy of ethics experts and the autonomy of the persons they serve. (...) This paper addresses this conflict and maintains that when the nature of both ethics consultation and individual autonomy is properly understood, the professional autonomy of ethics experts is compatible with the autonomy of the persons they assist. (shrink)

The figure of the cordial host of the Academy, who invited the most gifted mathematicians and cultivated pure research, whose keen intellect was able if not to solve the particular problem then at least to show the method for its solution: this figure is quite familiar to students of Greek science. But was the Academy as such a center of scientific research, and did Plato really set for mathematicians and astronomers the problems they should study and methods they should use? (...) Our sources tell about Plato's friendship or at least acquaintance with many brilliant mathematicians of his day (Theodorus, Archytas, Theaetetus), but they were never his pupils, rather vice versa -- he learned much from them and actively used this knowledge in developing his philosophy. There is no reliable evidence that Eudoxus, Menaechmus, Dinostratus, Theudius, and others, whom many scholars unite into the group of so-called "Academic mathematicians," ever were his pupils or close associates. Our analysis of the relevant passages (Eratosthenes' Platonicus, Sosigenes ap. Simplicius, Proclus' "Catalogue of geometers", and Philodemus' "History of the Academy", etc.) shows that the very tendency of portraying Plato as the architect of science goes back to the early Academy and is born out of interpretations of his dialogues. (shrink)

Although ethics consultation is offered as a clinical service in most hospitals in the United States, few valid and practical tools are available to evaluate, ensure, and improve ethics consultation quality. The quality of ethics consultation is important because poor quality ethics consultation can result in ethically inappropriate outcomes for patients, other stakeholders, or the health care system. To promote accountability for the quality of ethics consultation, we developed the Ethics Consultation Quality Assessment Tool. ECQAT enables raters to assess the (...) quality of ethics consultations based on the written record. Through rigorous development and preliminary testing, we identified key elements of a quality ethics consultation, established scoring criteria, developed training guidelines, and designed a holistic assessment process. This article describes the development of the ECQAT,.. (shrink)

Background The American Society for Bioethics and Humanities (ASBH), a professional organization that certifies ethics consultants who pass the qualifying examination, published standards for the conduct of ethics consultations (EC). A national survey of adult hospital ethics consultants identified adherence to these standards, but no assessment of pediatric hospitals’ adherence has been done.Methods In this cross-sectional study, a national questionnaire was distributed electronically in 2022 to pediatric ethics consultants at children’s hospitals, collecting information about adherence to the ASBH standards. Hospital (...) characteristics were extracted from the Children’s Hospital Association Annual Benchmark Report. Quantitative analysis included descriptive statistics to assess adherence and analyses of variance to investigate associations between hospital characteristics and the time taken to respond to consultations.Results Of the 181 eligible pediatric hospitals, we received 104 completed surveys (57%) from 45 states. Pediatric EC have similar adherence rates to ASBH standards as adult hospitals. High-adherence (>75%) areas included having an expert available for EC and permitting any staff member to request EC. Low-adherence areas included having comprehensive policies covering all aspects of EC activities, having a response plan for egregious violations, and the elicitation of formal feedback after EC. There is an increased average response time for ethics consultation services in smaller pediatric hospitals and church-operated hospitals.Conclusions Pediatric hospitals overall have moderate adherence to the ASBH EC standards, with the highest rates occurring for standards that are shared by the American Academy of Pediatrics. Additional research into the barriers to standard adherence and the effectiveness of standards is warranted with emphasis on the impact of adherence on consultation quality. (shrink)

There is no doubt that emotions have an important effect on practices of moral reasoning such as clinical ethics consultation. Empathy is not only a basic human emotion but also an important and learnable skill for health care professionals. A basic amount of empathy is essential both in patient care and in clinical ethics consultation. This article debates the “adequate dose” of empathy in ethics consultations in clinical settings and tries to identify possible situations within the process of consultation in (...) which this crucial feeling is at risk. (shrink)

Similar to its old history, Japan has a rich traditional and ethical Architecture. Based on these tenets and ethics, different concepts and spaces are formed through the time, as now Japan's ethical and traditional design ideas has its standard principles. Linking the present and the past has always been a momentous criterion in the countries with an old rich Architecture. This fact is indeed important in Japan due to the blend of ethics and religions with peoples` life. Through this idea, (...) three Japanese Architects, Kenzo Tange, Fumihiko Maki and Tadao Ando-who are the only Japanese pritzker prize winners-have well, noticed the need for linking the country's traditional and ethical Architecture criteria with the contemporary Architecture. So, analyzing such projects of these architects prepares a good basis to find out the quality of how traditional and ethical design ideas crystallize in the works of contemporary Japanese architects. The research method for this article is a comparative analysis between the architects` particular projects and Japan's ethical and traditional design ideas, formed through the history of architecture in this country. The contents of this article rely heavily on three bases: 1) study of the historical documents concerning the ethical and traditional design concepts in Japan. 2) The consultancy of leading experts on Asian traditional constructions and ethical architecture specialists from Azad Universities in Tehran. 3) Comparative analysis between the ethical concepts applied in different contemporary works. The results show that the contemporary architects have had good bases for presenting the traditional design concepts as standard principles are all formed in the architecture of Japan today. Meanwhile, it seems that Maki and Ando are more likely to have a conceptual look at Japan's traditions while Tange has a more formal viewpoint. Chronological analysis of the architects` projects shows that despite, all the three architects were impressed by the works of le Corbusier, they were successful to keep contacts with Japan's traditional design concepts. (shrink)

Working with elders around the world has taught me that those living in grass huts in Africa with children at their feet are often happier than people in assisted‐living homes with a chandelier over their heads. My work in design consultancy and in fifteen years of running a nonprofit, Ibasho, that aims to co‐create socially integrated and sustainable communities that value their elders has allowed me to learn much about how architects and designers can contribute to helping people live a (...) good life in late life. People often need supportive services or other adaptations as they age, but do they really need—or want—the luxury environment few are accustomed to? The challenge for architects and designers is not to create a built environment whose carefully curated facades hide lives of quiet desperation. It is to help elders access the support they need without upending their lives or severing virtually all ties to their communities. (shrink)

Green design tools are emerging as a new response to the dilemmas that architects and designers face in preventing the toxic impacts of building construction. Environmental health advocates, scientists, and consulting firms are stepping in to provide designers with new tools—including science-based assessment methods, standards, databases, and software—intended to help structure and inform decision-making in sustainable design. We argue that green design tools play an important but largely uninvestigated role in giving designers new forms of influence while mediating how designers’ (...) values are translated into actual design choices. Tool makers embed their own values and politics into the construction of the tools, which function as “black boxes”—their internal operations are understood as less important than their outputs for informing sustainable design. Using the green building movement as a case study, we consider three tools for selecting environmentally benign materials: the GreenScreen for Safer Chemicals, Pharos, and the Health Product Declaration. Examining controversies about the scientific validity of green design tools, we suggest that they are rooted in value conflicts and tensions in the politics of chemical knowledge. Transparent engagement with values and politics among tool developers and users could strengthen the legitimacy and credibility of green design tools. (shrink)

Ethics consultation has become an integral part of the fabric of U.S. health care delivery. This article summarizes the second edition of the Core Competencies for Health Care Ethics Consultation report of the American Society for Bioethics and Humanities. The core knowledge and skills competencies identified in the first edition of Core Competencies have been adopted by various ethics consultation services and education programs, providing evidence of their endorsement as health care ethics consultation (HCEC) standards. This revised report was prompted (...) by thinking in the field that has evolved since the original report. Patients, family members, and health care providers who encounter ethical questions or concerns that ethics consultants could help address deserve access to efficient, effective, and accountable HCEC services. All individuals providing such services should be held to the standards of competence and quality described in the revised report. (shrink)

Libertarian paternalism is a concept derived from cognitive psychology and behavioural science. It is behind policies that frame information in such a way as to encourage individuals to make choices which are in their best interests, while maintaining their freedom of choice. Clinicians may view their clinical consultations as far removed from the realms of cognitive psychology but on closer examination there are a number of striking similarities.

In order to build on the information that was obtained in the course of the first study, a follow-up survey was conducted first by phone and subsequently in a written form between August and October 2014. We contacted 1.858 hospitals in all of Germany for the follow-up survey by phone. In cases where a hospital had not participated in the first study, the willingness to participate in the follow-up survey was established in advance. The survey’s dispatch was ensured in the (...) case of acceptance. The same structured survey was used as a research tool. The data of the first study and the follow-up survey were merged and evaluated. 654 surveys could be evaluated altogether. Our survey by phone revealed that 912 hospitals in all of Germany have at least one form of clinical ethics consultation available. The health care ethics committee is the most frequently implemented structure of clinical ethics consultation. The implementation of clinical ethics consultation is dependent on sponsorship and hospital size. Recommendations to deliver structures of clinical ethics consultations have a smaller influence on the implementation compared to the certification by KTQ respectively proCum Cert. The rate of implementation in regard to the structures of clinical ethics consultation has steadily increased for years. The establishment of clinical ethics consultation in German hospitals should be further promoted. It would be desirable further to develop suitable juridical regulations in order to implement clinical ethics consultation as well as structural parameters. (shrink)

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

In its roughly 25 years of existence, the trial consulting profession has grown dramatically in membership, recognition, and breadth of practice. What began as a small activist group of social scientists volunteering their expertise to assist in the defense of Vietnam War protestors has evolved into a diverse set of professionals from a range of educational and professional backgrounds. In spite of such enormous growth, the work of trial consultants has gone largely unexamined. Trial Consulting takes an in-depth look at (...) the primary activities of trial consultants, including witness preparation, focus groups and mock trials, jury selection, change of venue surveys, and attorney presentation style. It also examines the profession's struggle to define itself, resisting certification and licensure requirements and settling instead for a set of practice standards. The authors draw upon empirical and other scholarly work in the social sciences, recommended "best practices" from trial lawyers, and the written and spoken recommendations and reflections of the trial consultants themselves. Addressing a broad spectrum of topics ranging from handwriting analysis to medical malpractice cases, they also suggest reforms for improving the profession and the efficacy of the trial consultant in the courtroom. The result is a critical analysis of what trial consulting truly adds to, and detracts from, the administration of justice. This book is an indispensable guide for practicing and aspiring trial consultants as well as the judges, attorneys, and psychologists who work with them. Trial Consulting provides a thought-provoking statement on the state of the profession, and students and professionals alike will benefit from the challenges it offers. (shrink)

Only recently have ethicists been invited into the clinical setting to offer recommendations about patient care decisions. This paper discusses this new role for ethicists from the perspective of content and process issues. Among content issues are the usual ethical dilemmas such as the aggressiveness of treatment, questions about consent, and alternative treatment options. Among process issues are those that relate to communication with the patient. The formal ethics consult is discussed, the steps taken in such a consult, and whether (...) there should be a fee charged. We conclude with an examination of the risks and benefits of formal ethics consults. (shrink)

The present book makes a particularly engaging case for a whole range of policy implications of behavioural economics. The rhetoric is highly compelling, and their approach is already having a significant impact. However, while the wider audience for whom the book is written may not be interested in the justification of the underlying principles, it is precisely the cracks in the foundations that pose the greatest threat to the project. For example, if Thaler and Sunstein are to have any chance (...) of their 'libertarian paternalism' meriting ‘libertarian’ credentials, it is essential that the re-engineering of choice architecture not be guided by any particular political or moral agenda. Their claim here is that what makes a nudge beneficial is not that it steers people in the direction of behaviour that is objectively ‘good’ but rather in the direction of behaviour that they won’t regret. That said, there are a number of points where it is hard to shake the suspicion that Thaler and Sunstein help themselves rather conveniently to the idea that, if a person’s choices are largely a function of various framing effects, say, then overriding those choices violates no autonomy, since there was no autonomy there to be violated. -/- In this review, I raise four concerns not adequately addressed in the book. -/- (1) Thaler and Sunstein are misleading in their use of the term ‘paternalism’, which is standardly defined as a matter of interfering with a competent person’s choices out of a motivation to improve that person’s welfare. As Thaler and Sunstein use the term, however, it becomes equivalent to beneficence: when the government acts to improve people’s welfare by influencing choices in any way, according to them, it is engaging in paternalism. -/- (2) Their appeal to the resistibility of nudges is a centrepiece of the account and particularly of its claim to be ‘libertarian’, but given what they themselves write about how effective nudges are and how poor we are at even noticing the influences to which we are subject, it is entirely unclear why we should expect nudges to be easily resisted. -/- (3) Thaler and Sunstein generally align themselves with the perspective of planners who half-pose the presumptuously rhetorical question, ‘Who would really mind?’ But the question is not just whether people would object, if they were consulted. People also care about whether they are consulted and whether they understand the influences to which they are subject. Thaler and Sunstein advise choice architects against being secretive about nudges, but this espousal of principle, in a late chapter responding to objections, is not borne out by the discussion in the rest of the book, which focuses almost exclusively and rather effusively on the possibilities for channelling individuals’ choice-behaviour toward better outcomes. -/- (4) Thaler and Sunstein tend to downplay alternative approaches to improving decision making that are perfectly compatible with the behavioural economics and social psychology discussed by Thaler and Sunstein, but less paternalistic. For example, there is a growing body of research on how to construct contexts of interpersonal deliberation to generate stable solutions to collective action problems, by improving people’s collective decision-making capacities, rather than subjecting them to nudges. More generally, one comes up with very different recommendations if one thinks of the problems to which nudges are supposed to be a solution not as a matter of human failings per se, but rather as a socially and historically contingent misfit between the decision-making capacities that particular policies and institutions require of individuals and the capacities that people actually have. Conceived in the latter way – in terms of what I have elsewhere dubbed ‘autonomy gaps’, it becomes an open question whether what is called for is a choice architecture that makes it easier to avoid regrettable decisions or, rather, various measures to improve individuals’ decision-making capacities, say, through education, ‘buddy’ arrangements, decision-making heuristics, etc. (shrink)

Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their (...) concern is that any guidance offered by the ethics consultant will privilege and empower one party’s viewpoint over—and to the exclusion of—other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new spaces for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for clinical ethics conflict coaching can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes. (shrink)

The COVID-19 pandemic swept through New York City swiftly and with devastating effect. The crisis put enormous pressure on all hospital services, including the clinical ethics consultation team. This report describes the recent experience of the ethics consultants and Columbia University Irving Medical Center during the COVID-19 surge and compares the case load and characteristics to the corresponding period in 2019. By reporting this experience, we hope to supplement the growing body of COVID-19 scientific literature and provide details of the (...) human toll the virus took on our hospitals and communities. We also aim to highlight the role of the clinical ethics consultant as well as areas of policy and law that may need to be addressed in order to be better prepared for a future public health crisis. (shrink)

In spite of an intensive discussion of ethical subjects, psychiatric departments rarely request clinical ethics support. However, during regular psychological supervisions subjects with an underlying ethical conflict are increasingly encountered. Based on the case study of a 39-year-old female patient suffering from personality disorder and her newborn child, the role of ethical consultation in psychiatric treatment and the decision making regarding health and welfare of child and mother will be presented. While discussing opportunities and limitations of psychological supervision as a (...) possible vehicle for clinical ethics support, it becomes obvious that during psychological supervision, ethical conflicts can also be reflected and treatment alternatives be evaluated. Psychological supervision finds its limits because of its more intuitive processes when the conflict escalates, when the patient cannot be involved and when institutional interests dominate. In these cases, the more structured and formalised process of clinical ethics consultation clearly offers advantages. (shrink)

Introduction: Consultation methods differ between medical practitioners depending on the individual setting. However, the central tenet to the doctor–patient relationship is the issue of confidentiality. This prospective survey highlights patient attitudes towards consultation methods in the setting of an ophthalmic outpatient department. Method: Questionnaires were completed by 100 consecutive patients, who had been seen by an ophthalmologist in a single room, which had a joint doctor–patient consultation occurring simultaneously. Results: Each question of all 100 questionnaires was completed. 58% of patients (...) were not concerned about sharing a consultation room with another patient or doctor. However, this did not equate to the 49% of patients who were indifferent to discussing issues in the joint consultation room. The most common factor was the general issue of confidentiality. Discussion: Ensuring total patient confidentiality may be deemed more necessary for certain medical specialties than for others, as seen in the practice of separate medical records in genitourinary medicine, for instance. However, with regard to patient consultations, the same level of confidentiality should be afforded across all specialties, and such factors should be borne in mind when planning outpatient clinics. (shrink)

This chapter focuses on ethical governance, which speaks to the infrastructure, processes, and practices that decrease the probability of performing ethically wrong actions and ethically bad outcomes resulting from relatively innocent actions. The ethics consultant can help spot gaps or other insufficiencies in ethical infrastructure, process, and practice. Ethics consulting consists in engaging in a due diligence process for ethical risk. The goal is to identify possible sources of ethical risk both in terms of features of the product and (...) the ways it may or may not be used, and to recommend feature changes and best practices for ethical deployment and use of the product. Ethics consulting more generally can be seen as aimed at either doing a bunch of good or avoiding a bunch of bad. Ethical challenges often arise in business because of competing assumptions and commitments that create seemingly irresolvable tensions or obscure the potentially bad consequences of particular decisions. (shrink)

BackgroundTo help inform the development of more accessible, acceptable, and effective ethics consultation (EC) training programs, we conducted an EC training needs assessment, exploring ethics practitioners’ opinions on: the relative importance of various EC practitioner competencies; the potential market for EC training (that is, how many individuals would benefit and how much individuals and hospitals would be willing to pay); and the preferred content, format, and characteristics of EC training.MethodsAs part of a multipart study, we surveyed “best informants” who self-identified (...) as the person most actively involved in EC or healthcare ethics in a random sample of 600 U.S. general hospitals, stratified for bed size.ResultsThe competency that was ranked most important for a lead or solo ethics consultant was knowledge of ethics, while common sense was ranked least important. The median estimated number of individuals at each hospital who would benefit from EC training was six at the basic level, three at the advanced level, and two for EC management training. In 19.1 percent of hospitals, respondents thought their hospital would not be willing to pay anything for EC training within the next two years. Respondents thought potential trainees would be likely to participate in EC training on multiple different topics. Opinions varied widely on preferred formats. Most respondents thought it very important to be able to interact with instructors and with other trainees, practice EC skills, receive a certificate for completing EC training, and complete EC training during work hours.ConclusionsThese findings provide U.S. population data that may be useful to healthcare educators and bioethics leaders in their efforts to develop EC training programs and products that match trainees’ preferences and needs. (shrink)

Bioethics increasingly recognizes the impact of discriminatory practices based on social categories such as race, gender, sexual orientation or ability on clinical practice. Accordingly, major bioethics associations have stressed that identifying and countering structural discrimination in clinical ethics consultations is a professional obligation of clinical ethics consultants. Yet, it is still unclear how clinical ethics consultants can fulfill this obligation. More specifically, clinical ethics needs both theoretical tools to analyze and practical strategies to address structural discrimination within clinical ethics consultations. (...) Intersectionality, a concept developed in Black feminist scholarship, is increasingly considered in bioethical theory. It stresses how social structures and practices determine social positions of privilege and disadvantage in multiple, mutually co-constitutive systems of oppression. This article aims to investigate how intersectionality can contribute to addressing structural discrimination in clinical ethics consultations with a particular focus on mental healthcare. To this end, we critically review existing approaches for clinical ethics consultants to address structural racism in clinical ethics consultations and extend them by intersectional considerations. We argue that intersectionality is a suitable tool to address structural discrimination within clinical ethics consultations and show that it can be practically implemented in two complementary ways: 1) as an analytic approach and 2) as a critical practice. (shrink)