Volume 25, Issue 2, February 2025, Page 23-25.

The COVID-19 pandemic that struck New York City in the spring of 2020 was a natural experiment for the clinical ethics services of NewYork-Presbyterian (NYP). Two distinct teams at NYP’s flagship academic medical centers—at NYP/ Columbia University Medical Center (Columbia) and NYP/ Weill Cornell Medical Center (Weill Cornell)—were faced with the same pandemic and operated under the same institutional rules. Each campus used time as an heuristic to analyze our collective response. (...) The Columbia team compares consults during the pandemic with the same period during the year prior. The Weill Cornell service describes the phases of the pandemic to depict its temporal evolution and subsequent ethical challenges. Both sites report that the predominant ethical challenges centered around end-of-life decision making, setting goals of care, and medical futility, all complicated by resource allocation questions and the ambiguity of state law under crisis standards of care. The Columbia campus saw a statistically significant increase in ethics consultations provided to Hispanic patients, perhaps reflective of the disproportionate burden of COVID-19 suffered by this demographic. While Weill Cornell and Columbia saw a surge in clinical ethics consultations, the two services assumed a more expansive role than one normally played in institutional life. Serving as intermediaries between frontline clinicians and senior hospital administrators, consultants provided critical intelligence to hospital leadership about the evolution of the pandemic, disseminated information to clinicians, and attended to the moral distress of colleagues who were asked to provide care under truly extraordinary circumstances. The COVID-19 surge in New York City revealed latent capabilities in ethics consultation that may prove useful to the broader clinical ethics community as it responds to the current pandemic and reconceptualizes its potential for future service. (shrink)

Naloxone, which reverses the effects of opioids, was synthesized in 1960, though the hunt for opioid antagonists began a half-century earlier. The history of this quest reveals how cultural and medical attitudes toward opioids have been marked by a polarization of discourse that belies a keen ambivalence. From 1915 to 1960, researchers were stymied in seeking a “pure” antidote to opioids, discovering instead numerous opioid molecules of mixed or paradoxical properties. At the same time, the quest for a dominant (...) explanatory and therapeutic model for addiction was likewise unsettled. After naloxone’s discovery, new dichotomizing language arose in the “War on Drugs,” in increasingly divergent views between addiction medicine and palliative care, and in public debates about layperson naloxone access. Naloxone, one of the emblematic drugs of our time, highlights the ambivalence latent in public and biomedical discussions of opioids as agents of risk and relief. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 11.2 (2001) 165-168 [Access article in PDF] UPMC Presbyterian Policy and Procedure Manual Guidelines for Disclosure and Discussion of Conditions and Events with Patients, Families and Guardians* I. Introduction and Background In the course of hospital care, an extensive amount of clinical information is generated. It includes diagnostic findings, treatment options, responses to interventions, and professional opinions. The information can be positive (...) or negative. Clinical events may or may not be caused by clinicians and consequently may be iatrogenic (caused by medical treatment), nosocomial (occurring in the hospital) or natural events.In accordance with the informed consent policy (#4011), Patients' Bill of Rights (# 0154, Section II H), and the Guidelines on Forgoing Life Sustaining Treatment (#4007), patients have the right to information regarding their condition and care. Physicians and other caregivers are obligated to provide accurate information as expeditiously as possible. While it is usually easy to provide positive information, negative information is more difficult to disclose, especially when the cause is iatrogenic."Therapeutic privilege" has been invoked to explain why certain negative information might be withheld. By invoking therapeutic privilege, the physician refrains from full disclosure to protect the patient from the effects of receiving the information itself. The use of therapeutic privilege is increasingly being called into question because it decreases patient autonomy and reduces trust.The following recommendations are provided to clinicians to help guide delivery of sensitive information, positive and negative. Specific recommendations [End Page 165] are provided for situations where the information is about an unfavorable or adverse event, or where the information might best be characterized as "bad news." II. Definitions Unfavorable event or unfavorable condition. For the purposes of these guidelines, an unfavorable condition is an occurrence or diagnosis that results in or is likely to result in a significant negative outcome, and/or a significant alteration in the care plan.An unfavorable event in this context is not the same as a sentinel event, which in policy #4025 is defined as, "a serious, unexpected, adverse patient event which has resulted in, or if repeated would have a significant probability of resulting in, loss of life or serious physical or psychological injury, that is judged to be a warning of an underlying problem involving hospital facilities, policies, procedures, systems or personnel."Adverse Event. An unfavorable event for the purposes of these guidelines is also distinguished from the FDA definition of the term "adverse event", which is a reportable negative effect of a drug or device potentially resulting in death, hospitalization, or medical or surgical intervention. (See policy #4022 Safe Medical Device Act.)Examples of unfavorable events or conditions for the purpose of these guidelines include a new diagnosis of cancer, a perioperative myocardial infarction, or unintended delivery of an incorrect medication that results in clinical change.Examples of events not covered by these guidelines are intravenous saline infiltration and medication dosing errors that have no clinical impact on care.Iatrogenic. Event caused by the treatment of a healthcare provider. III. Guidelines and Principles It is appropriate that UPMC Presbyterian support basic principles for patient and family notification regarding all clinical events and conditions, including unfavorable ones. Physicians must be honest because that is a cornerstone of the patient-physician relationship, and because it fosters patient autonomy.UPMC Presbyterian supports the following AMA position regarding patient information: [End Page 166] It is a fundamental ethical requirement that a physician should at all times deal honestly and openly with patients. Patients have a right to know their past and present medical status and to be free of any mistaken beliefs concerning their conditions. Situations occasionally occur in which a patient suffers significant medical complications that may have resulted from the physician's mistake or judgement. In these situations, the physician is ethically required to inform the patient of all the facts necessary to ensure understanding of what has occurred. Only through full disclosure is a patient able to make informed decisions regarding future medical care. Ethical responsibility includes informing patients of changes in their diagnoses... (shrink)

Nonpharmaceutical interventions to minimize the transmission of the severe acute respiratory syndrome coronavirus 2 are necessary because we currently lack a vaccine or specific treatments. Healthcare facilities have adopted visitor restrictions and masking requirements. These interventions should be evaluated as public health measures, focusing on their efficacy, the availability of less-restrictive alternatives, and the minimization of the burdens and their balance with the benefits. These interventions, as well as exceptions, can be justified by the same analysis. For example, visitor restrictions (...) are sound, as are exceptions for women in labor, adults with disabilities, minor children, and individuals who are dying. In implementing these policies, specific rules are preferable to general principles because they are more efficient and reduce possible bias. There should, however, be appeal mechanisms and retrospective review processes. Evaluating requests for medical exemptions to masking requirements is particularly difficult, given the prevalence of nonmedical objections, false claims of medical exemptions, and a lack of objective medical criteria. Requiring written statements by licensed healthcare providers that undergo subsequent substantive review may therefore be justified. (shrink)

Medical care in the United States traditionally has focused on the treatment of disease rather than on its prevention. Heart disease, cancer, hypertension, diabetes, and other chronic diseases are the primary drivers of American health care costs; compared to other high-income countries, U.S. health indices are lowest and costs are highest.A “triple aim” — “improving the individual experience of care, improving the health of populations, and reducing the per capita costs of care for populations” — has gained traction, as (...) the social determinants of health are recognized as having significant effects on health outcomes. (shrink)

Within the research community, it is generally accepted that consent processes for research should be culturally appropriate and tailored to the context, yet researchers continue to grapple with what valid consent means within specific stakeholder groups. In this study, we explored the consent practices and attitudes regarding essential information required for the consent process within hospital-based trial communities from four referral hospitals in Vietnam. We collected surveys from and conducted semi-structured interviews with study physicians, study nurses, ethics committee members, (...) and study participants and family members regarding their experiences of participating in research, their perspectives toward research, and their views about various elements of the consent process. In our findings, we describe three interrelated themes related to the consent process: words and regulation; reimbursement, suspicions, and joining; and responsibilities. In general, stakeholders had highly varied perspectives of nghiên cứu and researchers used varying levels of detail regarding all aspects of the study in the consent process to build trust with and/or promote potential research participants’ choices about taking part in research. Findings additionally highlight how researchers felt that offering financial reimbursements in a hospital setting, where payment for services was routine, would be unfamiliar to participants and could raise suspicions about the research. Participants, however, focused their discussions on reimbursement or alternative reasons for joining the study, such as health related benefits or altruism. Finally, participants often relied on their physician to help them decide about joining a study or not. Further research is needed to understand how researchers and participants make sense of and practice consent, and how that impacts participants’ decision-making about research participation. To promote valid consent within this context, it is important to engage with hospital-based trial communities as a whole. The data from this study will inform future research on consent, guide the revisions of consent related policies within our research sites and point to several larger issues surrounding researcher-participant expectations, communication, and trust. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Organizational Ethics and Health Care: Expanding Bioethics to the Institutional Arena **Laura Jane Bishop (bio), M. Nichelle Cherry (bio), and Martina Darragh* (bio)In 1995, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) expanded its patient rights standards to include requirements for assuring that hospital business practices would be ethical. Renamed “Patient Rights and Organization Ethics,” these standards are based on the realization that a hospital’s (...) obligation to its patients is derived from two relationships: the patient-provider relationship governed by “clinical ethics,” and the customer-supplier relationship governed by “business ethics.” “[This] boundary between ‘clinical’ ethics and ‘business’ ethics is not clear and in many cases is nonexistent. While marketing and admission practices are seen as issues related to ‘business’ ethics, they can lead to unneeded admissions or demand for unneeded services, both of which can unnecessarily expose the patient to the risk of side effects or complications. Likewise, underutilization of needed services is likely to lead to less than optimal health outcomes” (I. Schyve 1996, p. 17). “These new standards arose out of well-publicized concerns about abuses in which patients were admitted to hospitals unnecessarily and were discharged or transferred only after their insurance expired” (I. Schyve 1996, pp. 15–16).These abuses also sparked eloquent protests against threats to patient well-being and to the nature of the patient-provider relationship in the bioethics literature. The fiduciary responsibility of the provider to inform and to protect the patient was fragmented by insurer business practices such as gag clauses and economic credentialing of providers (VII. Scope Note 31, 1996). The background role that the institution plays, though poorly articulated historically, has been brought sharply into focus by the explosive growth of the managed practice of medicine. The context of medical ethics is no longer limited to the resolution of individual cases, but instead encompasses the adoption of institutional structures to protect and promote patient welfare (IV. Emanuel 1995, p. 335). In this new configuration, the institution and the providers are co-fiduciaries for populations [End Page 189] of patients, and the medicine that is practiced is “appropriately economically disciplined.” The expression “My patient always comes first” is no longer “... intellectually serious or morally responsible.” But, “... to be sure, both conceptually and in practice, being an economically disciplined fiduciary professional or institution is ethically unstable.... The task is to identify the boundaries outside of which institutional policy and behavior will not count as an ethically defensible form of being... [a] fiduciary.” (IV. McCullough 1997, pp. 143–44). This process of delimiting and enforcing boundaries requires the development of “... a language for talking about the ethical values of the organization. If such a language does not exist, discussions about ethics become cumbersome and unlikely to occur” (IV. Cleveland Clinic Foundation 1998, p. 2).As with bioethics generally, the literature addressing organizational ethics is multidisciplinary. JCAHO’s compliance guide for its revised standards, Ethical Issues and Patient Rights, draws on a wealth of ideas from both clinical ethics and business ethics. This is often an awkward alliance. “Because the study of organizational ethics is in its infancy compared to other areas of healthcare ethics, discussions about it often seem like hot air with no palpable payoff” (I. Boyle 1998, p. 2). The fact that “... there is an ancient history that reflects widespread doubt about the moral probity of business” (II. Frederick 1995, p. 209) does not help. To begin, “Aristotle had rude things to say about business” (II. Jackson 1998, p. 401). A brief review of introductions to several of the business ethics textbooks cited in this bibliography reveals that a rebuttal of “business ethics as an oxymoron” is the standard opening paragraph. This stigma is unfounded, and “increased stability” has characterized the state of business ethics literature during the 1990s (II. Beauchamp and Bowie 1997, p. ix). Significant attention has been given to elaborating two often overlapping theories—stakeholder and social contractarian.Originating in the 1960s as a pun on “stockholder,” proponents of stakeholder theory claim that a corporation’s fiduciary responsibility extends beyond increasing its profitability to protecting the rights of individuals or groups affected by its actions. Popular as a strategic planning tool in the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Healing Power of an Ethics ConsultLaura J. HoeksemaOur interdisciplinary team was inhaling and exhaling conflict, frustration, anger, confusion, guilt, and feelings of helplessness as we cared for a 21-year-old woman who was dying. We had regular disagreements about how our team should best care for her. She was receiving hospice care and had complex medical, psychosocial, physical, and emotional needs. She was frequently transitioning between hospice care (...) at home, living with different family members at different times, and hospice care in the hospital due to uncontrolled symptoms. This led to her having an inpatient hospice team made up of me—her physician—and a nurse, social worker, and chaplain and also an outpatient hospice team with a different physician, nurse, social worker, and chaplain. All of us cared for her regularly in our respective settings. Members of the two care teams advocated passionately for what they thought was best for her. At times, team members were advocating strongly for conflicting interventions. Every member of both teams experienced moral distress related to some aspect of her care.How could we move forward in a unified way to provide her with the best care possible when there was uncertainty and disagreement within the teams about whether we were providing her with ethically appropriate care?Several questions arose about her care:• What is our responsibility in protecting a vulnerable patient when there is concern she’s being taken advantage of by others?• How do we address concerns about possible opioid diversion? Was a dying patient not receiving the pain medication she needed because someone else was using it?• How do we address household members smoking in the presence of someone on oxygen?• Do we honor a dying patient’s wish to live in an environment that we’re concerned is unsafe for her and our staff?• When team members receive contradictory information from a patient, how do we develop a common understanding of the situation?• Was it appropriate for our team to spend hours and hours caring for her each day which prevented us from caring for other patients who also needed our support?• What is our responsibility in relation to supporting her family with their financial and legal concerns?We placed an ethics consult to help us think through the answers to these questions and address the intense moral distress of team members. After listening to us share our experiences, the ethicists acknowledged the complexities of caring for her and affirmed that we were doing a good job. This acknowledgment from someone not directly involved in caring for the patient was meaningful. Having colleagues, who weren’t impacted by the emotional intensity of caring for her, empathize with us helped us gain some perspective in the swirling tornado of our emotions.Moral distress was running rampant. Some team members were distressed that we were giving the patient too much autonomy to make decisions they felt put her at risk. Others felt we should restrict her autonomy significantly to protect her. Some were distressed by family members smoking near her when she was on oxygen. Others were distressed that the investment of time in caring for her was so great that we couldn’t care for other patients in ways they deserved. Team members were very passionate about their beliefs about what was right and wrong as we cared for her. [End Page 21]The ethics consultants addressed the conflicting ethical values and helped us feel more comfortable with the plan of care we developed together. We were asked thoughtful questions to help draw out sources of moral distress. We were given new ways of thinking about conflicting ethical values, which helped us understand the underlying reasons for the conflict our team was experiencing. Highlighting the ethical values that were in conflict and helping each of us understand that the specific aspects of her care that we found distressing were related to our personal values, helped decrease the intensity of disagreements and frustration. The ethicist’s ability to share this knowledge with our team was powerful. Our team realized that we weren’t frustrated or upset with each other. We came to understand that because of the... (shrink)

The passage of the Servicemen’s Readjustment Act of 1944 — or GI Bill — opened up a dialogue about men’s physical and mental health, for it addressed very directly what ordinary men would need to recover from extraordinary violence. Political leaders identified veterans’ “welfare,” by which they meant general well-being, as a top priority of World War II’s recovery, and the GI Bill was the centerpiece of their agenda. The bill’s passage was an impressive legislative triumph, the collective product of (...) massive medical, legal, and social science research, bipartisan politicking, and veterans’ activism. It provided education, housing, and small business assistance, along with mental and physical rehabilitation in government-funded hospitals. All of these programs, whether they served mind, body, or wallet, amounted to welfare — a set of government-sponsored policies and services designed to aid a soldier’s transition from enlisted man to healthy, productive citizen. Thus we have to think about the broad reach of the GI Bill’s welfare provision as one of the health legacies of World War II. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Searching for Peace in DeathLaura WachsmuthDisclaimers. No funding was utilized for this manuscript. The author, Laura Wachsmuth, has worked at several hospitals. The opinions contained herein are her own. All names have been changed to protect the privacy of the patient and the patient's family.I first met Ellen when she was admitted to the Women and Infant unit on a late spring day in May. She was 27 (...) weeks pregnant and was experiencing intense abdominal pain.As a hospital chaplain, I support patients and their families emotionally and spiritually. Sometimes, this looks like praying with patients; other times, it looks like sitting in quiet because there are no adequate words. Over time, I have developed ways to help me cope with the intensity I witness daily. Still, cases come up that I must grieve. The case of Ellen is one such example.The first time I met Ellen, she was waiting to hear back about her scans and tests. A quick look at her chart and a conversation with the medical team revealed that she was in her mid-thirties. While she spoke English fluently, she had immigrated to the US, and English was her second language. She, along with her husband, Mark, and their young son, had come to the United States on a work visa.After knocking on the door and entering her dim hospital room, I noticed right away what a beautiful person Ellen was, inside and out. Lying in bed, her long dark hair piled up on her head, her slim figure was visibly pregnant underneath her hospital gown. She smiled and gently greeted me. Mark was at her side. Clearly, Ellen was in physical pain, and while she and Mark still hoped the doctors were wrong in thinking she may have cancer, the emotional strain of waiting lay heavy upon them.Ellen and Mark kindly welcomed me and were attentive as best they could as I introduced myself and explained my role as a chaplain. They told me [End Page 75] that they were spiritual, not religious, but welcomed chaplain visits. Both exuded a certain peace and kindness, which was striking considering all they were enduring.As Ellen and her family waited for the results to come back, I waited as well and frequently checked her medical chart, looking for updates. About a week after she was first admitted, the medical team broke the dreaded news: Ellen had stage IV gastric cancer; it was estimated she only had 11 months to live. At this point, the Palliative Care team became involved in Ellen's care, and the chaplain on this team supported Ellen through the shock of her diagnosis and the difficult treatment choices she faced.Originally, the plan was for Ellen to deliver her daughter at 29–30 weeks and then to receive 2–3 rounds of chemotherapy. After further deliberation, however, it was decided that it was riskier to deliver a baby at 29–30 weeks than it was to undergo chemotherapy while pregnant, so Ellen began chemotherapy while still carrying her baby. Her chemotherapy was not a curative treatment, but there was hope it might give her more time.While my role became more peripheral at this point, I continued visiting Ellen. She was often tired or in pain, so I was mindful to keep my visits short. Mark, who stayed with his wife day in and day out, was usually in the room when I came by, and I often inquired after his well-being. Since Ellen and Mark's families still lived abroad, Mark was Ellen's primary support, and needed care and support himself.After two rounds of chemotherapy, Ellen made the decision to stop treatments. She made this decision because she was concerned about the risks of chemotherapy on her baby. It was an agonizing decision, and even after she made it, Ellen turned it over in her mind. During one of our visits, she asked me if I thought she had made the right decision. I told her that I fully supported her, but as I left her room, I wondered if I had done the right thing in affirming her choice. Looking... (shrink)

Introduction: Medical ethics raises the question of the meaning of medical practices in light of the humanities. In France, the spaces for ethical discussion (SED) are multiple and heterogeneous. The objective of this study was to investigate the typology and functioning of SEDs in the health field. Methods: Twenty-one semi-structured interviews were conducted with members of eleven different SEDs in France. The data were analyzed according to the basic steps of qualitative research: coding, categorization, linking and presentation of (...) results. Results: The five categories of SEDs (National Consultative Ethics Committee, Regional Ethical Reflection Spaces, Ethics Commissions of Medical Learned Societies, Research Institute Ethics Committees, Hospital Ethics Committees) all differ in their links with institutions, their composition, their choice of themes discussed and the presentation of their work. However, they all agree on the following points: the importance of multi-disciplinarity, the frequency of working meetings, the sense of ethical commitment, the absence of professional recognition, the difficulty of valorizing work and the lack of recognition by peers. The respondents regret that there is insufficient coordination between the different SEDs, although their work may be complementary. Conclusion: Opening up the SEDs and encouraging their articulation, without distancing them from the practice of care, could promote the visibility of their ethical approach in the daily lives of caregivers. Finally, if ethical reflection is encouraged by the scientific community as a whole, greater recognition is desired by professionals who participate in applied ethics research. (shrink)

Background The first COVID-19 wave started in February 2020 in France. The influx of patients requiring emergency care and high-level technicity led healthcare professionals to fear saturation of available care. In that context, the multidisciplinary Ethics- Support Cell (EST) was created to help medical teams consider the decisions that could potentially be sources of ethical dilemmas. Objectives The primary objective was to prospectively collect information on requests for EST assistance from 23 March to 9 May 2020. The secondary aim (...) was to describe the Cell’s functions during that period. Research design This observational, real-time study of requests for Cell consultations concerned ethical dilemmas arising during a public health crisis. The EST created a grid to collect relevant information (clinical, patient’s/designated representative’s preferences and ethical principles strained by the situation), thereby assuring that each EST asked the same questions, in the same order. Participants and research context Only our university hospital’s clinicians could request EST intervention. Ethical considerations The hospital Research Ethics Committee approved this study (no. CER-2020-107). The patient, his/her family, or designated representative was informed of this ethics consultation and most met with EST members, which enabled them to express their preferences and/or opposition. Findings/results 33 requests (patients’ mean age: 80.8 years; 29 had COVID-19: 24 with dyspnea, 30 with comorbidities). 17 Emergency Department solicitations concerned ICU admission, without reference to resource constraints; others addressed therapeutic proportionality dilemmas. Discussion Intervention-request motives concerned limited resources and treatment intensity. Management revolved around three axes: the treatment option most appropriate for the patient, the feasibility of implementation, and dignified care for the patient. Conclusions COVID-19 crisis forced hospitals to envisage prioritization of ICU access. Established decision-making criteria and protocols do not enable healthcare professionals to escape ethical dilemmas. That acknowledgement highlights ethical risks, enhances the added-value of nursing and encourages all players to be vigilant to pursue collective deliberations to achieve clear and transparent decisions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Religious Perspectives on Bioethics, Part 2Laura Jane Bishop (bio) and Mary Carrington Coutts (bio)This is Part Two of a two part Scope Note on Religious Perspectives on Bioethics. Part One was published in the June 1994 issue of this Journal. This Scope Note has been arranged in alphabetical order by the name of the religious tradition.Contents for Parts 1 and 2Part 1I.GeneralVI.HinduismII.African Religious TraditionsVII.IslamIII.Bahá'í FaithVIII.JainismIV.Buddhism and ConfucianismIX.JudaismV.Eastern OrthodoxyPart 2I.Native (...) American ReligiousChristian Scientist TraditionsEpiscopal/AnglicanII.ProtestantismEvangelicalGeneralJehovah's WitnessAnabaptist (Church of theLutheranBrethren, Friends SocietyMethodist/Wesleyan(Quaker), and Mennonite/NazareneAmish/Hutterite)Presbyterian/ReformedAssemblies of GodSeventh-day AdventistBaptistUnitarian UniversalistChurch of Jesus Christ of theUnited Church of Christ Latter-day SaintsIII.Roman CatholicismChristian Church (Disciples of Christ)[End Page 357]IntroductionThe many religions of the world bring diverse, and occasionally divergent attitudes to bioethical issues. These beliefs may guide patients and health care professionals as they seek or provide health care. In an attempt to facilitate understanding of and access to information about these beliefs in our pluralistic and global society, this Scope Note identifies literature by the world's major religious groups on topics relating to bioethics.Topics covered by this Scope Note include general attitudes to health and health care, the physician-patient relationship, treatment refusal, abortion, contraception, sterilization, reproductive technologies, genetics, mental health, human experimentation, organ transplantation and donation, death, euthanasia, suicide, and prolongation of life. Material was not available on all of these topics for each religion.The literature gathered here represents only a small portion of the available writing on religion and medicine for these faith traditions in the United States, and is limited to that which comments explicitly on bioethical issues. Some faiths have a rich tradition of writing on bioethics, for others the literature is more limited. Variation in coverage is not intended to indicate the relative importance of a faith but reflects accessibility and space constraints. Individuals interested in obtaining additional information are encouraged to contact the National Reference Center for Bioethics Literature.It is important to remember that doctrinal and theological differences exist even within the same denomination and that views of individual patients, family members, and health care providers should be sought.Native North American ShamanismAvery, Charlene. Native American Medicine: Traditional Healing. Journal of the American Medical Association 265 (17): 2271, 2273, 1 May 1991. A brief description of the general principles of Southwestern Native American religions is provided. Most tribes believe that health and religious well-being are interconnected.Day, Thomas W. Cross-Cultural Medicine at Home. Minnesota Medicine 75 (3): 15-17, March 1992. The Ojibwe tribe's view of health incorporates spiritual health and emphasizes a holistic approach to health care that encompasses a harmonious balance between the individual, community, and nature, as well as between body, mind, and spirit.Hirschfelder, Arlene B., and Molin, Paulette. The Encyclopedia of Native American Religions. New York: Facts on File, 1992. 367 p. A survey of Native American religions is provided, including tribal histories, descriptions of religious ceremonies, and biographical sketches.Hultkrantz, Åke. Health, Religion, and Medicine in Native North American Traditions. In Healing [End Page 358] and Restoring: Health and Medicine in the World's Religious Traditions, ed. Lawrence Sullivan, pp. 327-58. New York: Macmillan, 1989. Hultkrantz summarizes the Native American attitude toward medicine and health care, explaining that belief in the supernatural and its powers is one of the most important tenets of life. Ailing persons are aided by those who have been trained to act as mediators between the sick individual and the supernatural powers. Attitudes toward health and disease, and the role of the medicine man are demonstrated through the use of examples taken from many tribes.Hultkrantz, Åke. Shamanic Healing and Ritual Drama: Health and Medicine in Native North American Religious Traditions. New York: Crossroad, 1992. 197 p. Hultkrantz surveys the varied traditions of Native North Americans and their outlook on medical care, health, and religion, and emphasizes that Native American medical beliefs... (shrink)

Ask any clinical ethics consultant, and they can tell you about their transformative cases. Some stick with us because all roads led nowhere. Cassandra Lee had a history of pulling out lines and tubes and a distaste of warming blankets. Her admission marked her thirtieth over the past year. Many of the challenges facing the hospital caring for her were not unique: significant psychiatric issues, prolonged nonadherence to medical advice, and end‐of‐life decision‐making combined to create an ethically dense (...) and vexing situation. Ms. Lee, like so many patients, was suffering because of system failures. (shrink)

In their article “Agent-Regret in Healthcare,” Enck and Condley provide a nuanced and sensitive lens to better examine a phenomenon related to, but distinct from, moral distress: that of agent-regr...

BackgroundAs a number of commentators have noted, SARS exposed the vulnerabilities of our health care systems and governance structures. Health care professionals (HCPs) and hospital systems that bore the brunt of the SARS outbreak continue to struggle with the aftermath of the crisis. Indeed, HCPs – both in clinical care and in public health – were severely tested by SARS. Unprecedented demands were placed on their skills and expertise, and their personal commitment to their profession was severely tried. Many (...) were exposed to serious risk of morbidity and mortality, as evidenced by the World Health Organization figures showing that approximately 30% of reported cases were among HCPs, some of whom died from the infection. Despite this challenge, professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk.DiscussionIn the aftermath of SARS and with the spectre of a pandemic avian influenza, it is imperative that we (re)consider the obligations of HCPs for patients with severe infectious diseases, particularly diseases that pose risks to those providing care. It is of pressing importance that organizations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. In this paper, we address the issue of special obligations of HCPs during an infectious disease outbreak. We argue that there is a pressing need to clarify the rights and responsibilities of HCPs in the current context of pandemic flu preparedness, and that these rights and responsibilities ought to be codified in professional codes of ethics. Finally, we present a brief historical accounting of the treatment of the duty to care in professional health care codes of ethics.SummaryAn honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue. (shrink)

Background: Despite the reported harms and ethical concerns about physical restraint use in the critical care settings, nurses’ intention to apply them is unequal across countries. According to the theory of planned behaviour, eliciting nurses’ beliefs regarding the use of physical restraints would provide additional social information about nurses’ intention to perform this practice. Aim: To explore the salient behavioural, normative and control beliefs underlying the intention of critical care nurses to use physical restraints from the theory of planned behaviour. (...) Research design: A belief elicitation study was conducted. Participants and research context: Twenty-six critical care nurses were purposively sampled across gender, work-shift patterns and professional experience in five intensive care units of three hospitals in Spain. Data were obtained from a nine-item open-ended questionnaire and a focus group. Deductive content analysis was performed. Ethical considerations: Ethical approval was obtained from the hospital ethics committee. Participants were assured their participation was voluntary. Findings: Nurses framed the use of restraints as a way of prioritising patients’ physical safety. They referred to contextual factors as the main reasons to justify their application. Nurses perceived that their decision is approved by other colleagues and the patients’ relatives. Some nurses started advocating against their use, but felt powerless to change this unsafe practice within an unfavourable climate. Control beliefs were linked to patients’ medical condition, availability of alternative solutions, analgo-sedation policies and work organisation. Discussion: Safety arguments based on the surrounding work environment were discussed. Conclusion: Nurses’ behavioural and control beliefs were related. Nurses should be trained in alternatives to physical restraint use. The impact of analgo-sedation protocols, relatives’ involvement, leadership support and intensive care unit restraint policies on physical restraint practices need to be revised. Further research is required to explore why nurses do not act with moral courage to change this harmful practice. (shrink)

ABSTRACT In Mexico informed consent is a legal requirement that ensures that patients who are invited to participate in clinical trials are provided with all the information needed to decide whether to participate, or not, in a research protocol. To improve our understanding of the problems physicians in developing countries encounter, when obtaining informed consent (IC), we examined their opinion on the importance of IC in clinical research, the quantity and quality of the information provided to the participant, and the (...) conditions in which the IC is obtained. Investigators considered that IC was useful to the patients, providing information that helped the patient to make a decision about his/her participation. Nevertheless, they felt that for some aspects of the research, like drug development in general, the use of placebos, and the randomization process, many of the patients were not capable of fully understanding the information provided, referring to the complexity of the information and illiteracy as the main reasons. Many investigators were not acquainted with some of the guidelines established in the Mexican General Law of Health,1 36% of them admitting to not having completed their IC letters. Most investigators gave only minutes to the patient to make a decision and 20% of ICs were obtained while the patient was hospitalized. Except for one investigator, all of them considered that specific training in medical ethics would be useful for the daily clinical work. (shrink)

Several years ago, we built a new hospital from the ground up in Dublin, Ohio, for the OhioHealth system, and we found ourselves presented with an opportunity to try to put the Fable hospital concept into practice. This planned ninety-four-bed community hospital was intended to serve the growing northwest quadrant of Franklin County, along with areas to the west and northwest. With tertiary facilities already a part of the OhioHealth system, Dublin Methodist was intended to provide (...) primary and secondary care. Our goal was to be as innovative as we could afford to be, to challenge the status quo at every turn. Our stated purpose was to "redefine the way patient care is provided" through the development of a .. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Parenting Children With Autism Spectrum Disorders Through the Transition to AdulthoodAnonymous One, Anonymous Two, Lorri Centineo, Anonymous Three, Virginia Clapp, Catherine Cornell, Nancy Coughlin, David McDonald, Mark Osteen, Laura Shumaker, Julie Van der Poel, Anonymous FourMy Son's Life with Autistic Spectrum DisorderAnonymous OneThis is the story of how my son, David, has tried to become independent. David is now 25–years–old. His immediate family is his dad, a (...) brother (age 22) and myself (his mother). He was diagnosed with an autism spectrum disorder (ASD) when he was 13. We looked up all the information and decided not to make a big deal of it. Looking back, he displayed all the classic signs of a high functioning autistic disorder. Would he have been diagnosed with the new DSM 5 guidelines? He probably would have. His life would be much, much different if he had been diagnosed at an early age.I'll start with David at age 13 when he was able to harness his big interest in computer science into a career for himself. He was expelled from middle school for threatening some kid that had been picking on him all year. He had a meltdown and wasn't able to communicate his side of the story and that was it.During the summer of that year he took classes in computer engineering (Microsoft) and became an engineer when he was 13. At that time it was quite an accomplishment because he was the youngest person in the United States to do so at such a young age. (By the way, the administration of the school that expelled him sent him a congratulatory card when he was written up in the paper).His father and uncle are in business running a computer company so David had a ready–made job waiting for him when he graduated from high school and was able to keep it during difficult times. David finished high school (mainstreamed special education as emotionally disturbed) and he also received another engineering certification (Cisco).I have to mention here that I truly did not understand what it was like for my son until one day when he was in high school, as I was lecturing him again for some stupid reason, he said, "You don't know how hard it is for me to not sit in a corner and rock every day." Think about that. ASD individuals get up and keep going every day when they know they are going to be misunderstood and picked on. They all deserve a medal for bravery.David became really upset that he had never had a date and that girls were not even interested in talking to him. He started cutting himself and shaving his head. That got him some attention from the stoner group. He had someone to sit with at lunch anyhow. Parents, I think it's better to have no friends than the wrong friends. They introduced him to drugs.We did not mention any trouble David was having to any relatives. We had lived 800 miles from our families in a very unspoiled part of northern America. In hindsight this was not good either. [End Page 151]Another thing, and I think every parent will agree with this—teachers, school staff, health care industry staff, doctors and every one that comes into contact with an ASD individual—take the time to get to know them. It may be difficult and some may appear non–caring and rude. You must overlook this and look to the person underneath. They are great people. They have been through stuff and it means so much to them. Like I said—parents, you know this. Please remember it when times get tough.During David's senior year he started work release so he could start earning money to buy a car and move out as soon as he turned 18. Things were made easy for David since the company was owned by his father and his uncle and I worked there also. David enjoyed the work but had the occasional meltdown and had difficulties fitting in with other employees. He wasn't able to communicate... (shrink)

von Goethe was a daring and wide-ranging biologist as well as a great playwright. His work was a whole: for him, theory and theatre were both based on keen observation of life. Even ‘Faustian’ striving, the blind upward urge of life, can be found in significant details of organisms and their evolution, according to Goethe. Such observations cannot be dismissed as sheer poetry. On the contrary, his teleology provides a broad empirical background for the organismic approach in bio-medical science, (...) while exposing inconsistencies in strict reductionist doctrines. Keywords: anastomosis, anatomical type, dialectic, Faustian, Platonic idealism, serial homology, sociobiology, teleology CiteULike Connotea Del.icio.us What's this? (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Personal Narratives: Parenting Children With Autism Spectrum Disorders Through the Transition to AdulthoodCatherine Cornell, Julie Herren, Susan Osborne, and Kelly WeissTransition years: From Learning, Living and Loving to Maintenance and MediocrityCatherine CornellWhat does every parent of an autistic child worry about the most? For those of us with severely affected children, the answer to that question is: “Who will care for my child and keep her safe when (...) I am gone?”I drove my daughter back to her “group home” for a scheduled drop off on Saturday. There was only one car in the driveway and the house van was gone. Lily was not happy about returning “home.” Agitated, she opened the door to the car, almost before it was stopped, ran to the back of the house, and up the fire escape stairs to the door of her third floor bathroom, as if she was avoiding going through the main living rooms of the house. I called up to her that there was no one at home and she came back down and pushed through the unlocked door. Racing ahead of me, she was already shed of her clothes and in the shower: her self–calming method that she used whenever returning to the house. Thirty minutes later, after three attempts to leave the shower and throwing up in the shower, she dressed and ran back out to our car. I played her favorite music, attempting to calm her anxiety. This transition, from home to “group home,” was increasingly difficult due to recent changes in staff and housemates. Having no one there to greet her was ratcheting up the anxiety level for both of us.When the on–call manager came, Lily was so distraught that I asked for her medications and took her back home with me. Two days later she was calm enough and I was reassured enough to return her to the house. Somehow the house manager made the incident my fault. Perhaps I did react strongly, but on reflection, what triggered the strong reaction in me was the insecurity I felt at finding no one home. It seemed like a breach of trust. Like we were left, abandoned, our plans shattered and at the mercy of fate. Strong emotions for a little mix–up in communications (if that is what it was) but, nevertheless, there it is—how I felt and more to the point how my daughter felt.I relate this story because it illustrates what has changed the most about our lives since Lily left her school and entered the world of adult services: missing is the feeling of trust and security that responsible caring people would keep Lily safe when my husband and I cannot.My 25–year–old daughter Lily has severe autism. She was the most beautiful and easy baby imaginable and appeared to develop normally until she began to lose speech and have night terrors at 15 months of age. She was diagnosed initially with atypical autism, then pervasive developmental disorder not otherwise specified, and finally with autism at age four.From age four to twenty–two, she attended a specialized school for autism where she received age level academics, therapies for speech, and training in self–care and independent living. She did not do well in academics nor did she regain her lost speech. She did learn to care for herself with assistance and, as important, she gained social and behavioral skills and learned to live with others in a social way. She [End Page E1] also learned recreational and vocational skills that would be transferrable to the community, such as bicycle riding, rollerblading, swimming and jogging. The philosophy of her school was to build self–esteem and confidence by teaching music, art and physical skills—in small steps, ensuring success, and then building on those skills.In her last year at school, Lily was a happy and well–adjusted member of her small group of five young women living in a town house with support from trained school staff. She participated in job programs, earning money by recycling and working for Meals–On–Wheels. She went out into the community with her group... (shrink)

Looking Beneath the Surface explores Arab-Islamic and Western perspectives on medical ethical issues: genetic research and treatment, abortion, organ donation, and palliative sedation and euthanasia. The contributions in this volume discuss the state of the art, the role of laws, counseling, and spiritual counseling in the decision-making process. The different approaches to the ethical issues, ways of moral reasoning, become clear in these contributions, especially the role of tradition for Islam and the importance of autonomy for the West. Beneath (...) the differences, however, the reader will also discover common values, such as the role of dignity and the value of life, and similar practices. Some of the main differences are sociocultural in nature, rather than religious as such. Well-known experts in the fields of medicine and ethics have contributed to this volume from different religious and secular backgrounds. The book offers a carefully written introduction and final chapter on intercultural comparisons. Looking Beneath the Surface is more than a collection of writings on issues in medical ethics: it helps the reader to compare different paradigms of accountability and moral reasoning. (shrink)

Background As a number of commentators have noted, SARS exposed the vulnerabilities of our health care systems and governance structures. Health care professionals (HCPs) and hospital systems that bore the brunt of the SARS outbreak continue to struggle with the aftermath of the crisis. Indeed, HCPs – both in clinical care and in public health – were severely tested by SARS. Unprecedented demands were placed on their skills and expertise, and their personal commitment to their profession was severely tried. (...) Many were exposed to serious risk of morbidity and mortality, as evidenced by the World Health Organization figures showing that approximately 30% of reported cases were among HCPs, some of whom died from the infection. Despite this challenge, professional codes of ethics are silent on the issue of duty to care during communicable disease outbreaks, thus providing no guidance on what is expected of HCPs or how they ought to approach their duty to care in the face of risk. Discussion In the aftermath of SARS and with the spectre of a pandemic avian influenza, it is imperative that we (re)consider the obligations of HCPs for patients with severe infectious diseases, particularly diseases that pose risks to those providing care. It is of pressing importance that organizations representing HCPs give clear indication of what standard of care is expected of their members in the event of a pandemic. In this paper, we address the issue of special obligations of HCPs during an infectious disease outbreak. We argue that there is a pressing need to clarify the rights and responsibilities of HCPs in the current context of pandemic flu preparedness, and that these rights and responsibilities ought to be codified in professional codes of ethics. Finally, we present a brief historical accounting of the treatment of the duty to care in professional health care codes of ethics. Summary An honest and critical examination of the role of HCPs during communicable disease outbreaks is needed in order to provide guidelines regarding professional rights and responsibilities, as well as ethical duties and obligations. With this paper, we hope to open the social dialogue and advance the public debate on this increasingly urgent issue. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Journal of Speculative Philosophy 17.1 (2003) 73-75 [Access article in PDF] Retrieving Experience: Subjectivity and Recognition in Feminist Politics. Sonia Kruks. Ithaca and London: Cornell University Press, 2001. Pp. xii + 200. $35.00 h.c. 0-8014-3387-8; $16.95 pbk. 0-8014-8417-0. Sonia Kruks' latest book, Retrieving Experience, is a valuable contribution to ongoing debates about the relevance of feminist philosophy in a period of relative political quietism. It also offers (...) timely reminders of historical continuities between phenomenological and postmodern conceptions of subjectivity and political engagement. Drawing on Merleau-Ponty, Beauvoir, Fanon, and the later Sartre, Kruks proposes to "explore women's embodied experiences" and to "ask whether they might not offer some means to help build affective bonds among women who are in many ways radically different from one another" (6). The book approaches this task by means of two secondary issues. First, should feminist thought be oriented by phenomenological or postmodernist theoretical strategies? Second, can women's embodied experience be the conceptual basis for political and epistemological practices that avoid the pitfalls of "identity politics" or an "epistemology of provenance"? The answer to both questions comes through the notion of praxis developed in Sartre's Critique of Dialectical Reason. By thinking of embodiment as praxis or work, a strategy implicit in Beauvoir's idea that "one is not born, but rather becomes, a woman." Kruks seeks to resolve the ethical affront of finding one's individuality reduced to the "generality" of a collective—the ethical affront to which feminists of various generations and theoretical persuasions must respond.Retrieving Experience explores the significance of recognition as a political norm. Identifying Sartre's Anti-Semite and Jew as a pivotal work in the history of identitarian theorizing, she situates recent appeals for race- and gender-based political mobilization in the United States with respect to the dialectical relationship between the Look, shame, and recognition existentialists observed in situations of anti-Semitic and colonial domination during and immediately after the Second World War. Legitimating knowledge gained under oppressive conditions formed an important element of African, Southeast Asian, and ultimately African-American and feminist resistance to cultural imperialism. However, Kruks warns, discourses of "recognition" risk placing the blame for group domination on individuals' face-to-face interactions while concealing the role of state and economic institutions in enabling social disdain to systematically damage a group's quality of life. Moreover, they suggest that the experience of subjugation alone justifies knowledge claims or counts, without further elaboration, as an act of political engagement. Kruks argues that knowers and actors need to identify conceptual and practical mediations enabling individual interactions, experiences, and strategies to prompt the recognition and transformation of [End Page 73] group situations. Sartre's notion of praxis, she suggests, explains how an individual can participate in a collectivity while acting autonomously or acquiescing to subjection.The most important passages in Retrieving Experience examine the affective aspects of the decision to take up a political identity or engage in political action. Going beyond Sartre's account of mediations, Kruks suggests that the sensory and emotional qualities of embodiment are themselves mediators, the products of praxis as well as its vehicles. Since any act of social knowledge involves the emotions, affect plays an important role in the process whereby individuals from different cultural, economic, and bodily situations learn about and shape one another's' environment through the act of knowledge. Individuals, then, may have a moral responsibility to learn about others in a way that gives them "sympathetic bodies." Drawing on Maria Lugones' social epistemology, Kruks argues that "world-traveling" or existing simultaneously in several communities or sets of power relations is a bodily act, but also a fully cultural, ethical act rather than a natural way of being. One is not born, but becomes, an embodied knower. Understanding female embodiment as a kind of work or "world-traveling" praxis enables feminist solidarity—"respectful recognition" to replace a historically implausible "sisterhood" or a distinct epistemological perspective as a regulative ideal for feminist politics.But how far can the... (shrink)

The fields of medical ethics, bioethics, and women's studies have experienced unprecedented growth in the last forty years. Along with the rapid pace of development in medicine and biology, and changes in social expectations, moral quandaries about the body and social practices involving it have multiplied. Philosophers are uniquely situated to attempt to clarify and resolves these questions. Yet the subdiscipline of bioethics still in large part reflects mainstream scholars' lack of interest in gender as a category of analysis. (...) This volume aims to show how a feminist perspective advances bioethics. The author uncover inconsistencies in traditional arguments and argue for the importance of hitherto ignored factors in decision-making. The essays include theory and very specific examples that demonstrate the glaring inadequacy of mainstream bioethics, where gender bias is still often to be found, along with general lack of attention to women's concerns. (shrink)

Naked Science is about contested domains and includes different science cultures: physics, molecular biology, primatology, immunology, ecology, medical environmental, mathematical and navigational domains. While the volume rests on the assumption that science is not autonomous, the book is distinguished by its global perspective. Examining knowledge systems within a planetary frame forces thinking about boundaries that silence or affect knowledge-building. Consideration of ethnoscience and technoscience research within a common framework is overdue for raising questions about deeply held beliefs and assumptions (...) we all carry about scientific knowledge. We need a perspective on how to regard different science traditions because public controversies should not be about a glorified science or a despicable science. Contributors are: Ward Goodenough, Eloisa and Brent Berlin, Colin Scott, Jean Lave, Emily Martin, Troy Duster, Hugh Gusterson, Charles Schwartz, Joan Fujimura, Sharon Traweek, Estellie Smith, Ellen Bielawaski, David Jacobon, Charles Ziegler, Pamela Asquith. (shrink)

The network approach to psychopathology is becoming increasingly popular. The motivation for this approach is to provide a replacement for the problematic common cause perspective and the associated latent variable model, where symptoms are taken to be mere effects of a common cause (the disorder itself). The idea is that the latent variable model is plausible for medical diseases, but unrealistic for mental disorders, which should rather be conceptualized as networks of directly interacting symptoms. We argue that this rationale (...) for the network approach is misguided. Latent variable (or common cause) models are not inherently problematic, and there is not even a clear boundary where network models end and latent variable (or common cause) models begin. We also argue that focusing on this contrast has led to an unrealistic view of testing and finding support for the network approach, as well as an oversimplified picture of the relationship between medical diseases and mental disorders. As an alternative, we point out more essential contrasts, such as the contrast between dynamic and static modeling approaches, that can provide a better framework for conceptualizing mental disorders. Finally, we discuss several topics and open problems that need to be addressed in order to make the network approach more concrete and to move the field of psychological network research forward. (shrink)

Current challenges in medical practice, research, and administration demand physicians who are familiar with bioethics, health law, and health economics. Curriculum directors at American Association of Medical Colleges-affiliated medical schools were sent confidential surveys requesting the number of required hours of the above subjects and the years in which they were taught, as well as instructor names. The number of relevant publications since 1990 for each named instructor was assessed by a PubMed search.In sum, teaching in all (...) three subjects combined comprises less than two percent of the total hours in the American medical curriculum, and most instructors have not recently published articles in the fields they teach. This suggests that medical schools should reevaluate their curricula and instructors in bioethics, health law, and health economics. (shrink)

This paper examines whether realists can explain co-reference without appealing to subjects’ ideal convergence in judgment. This question is particularly pressing in the normative domain, since deep disagreement about the applicability of normative predicates suggests that different speakers may not pick out the same property when they use normative terms. Normative realists, we believe, have not been sufficiently aware of the difficulties involved in providing a theory of reference-determination. Our aim in this paper is to clarify the nature of this (...) reference-fixing task and the challenges that arise for a non-convergentist normative realist. Our focal point will be Richard Boyd’s externalist account, which has been a model for non-convergentist theories of reference in metaethics. A close examination of Boyd’s account of reference and the ways it could be developed or supplemented, we’ll argue, suggests that explaining co-reference without convergence in the normative domain is a more challenging problem than many realists have supposed. (shrink)

We have previously found that attention to internal somatic sensations during a heart beat perception task increases the misperception of external touch on a somatic signal detection task , during which healthy participants erroneously report feeling near-threshold vibrations presented to their fingertip in the absence of a stimulus. However, it has been suggested that mindful interoceptive attention should result in more accurate somatic perception, due to its non-evaluative and controlled nature. To investigate this possibility, 62 participants completed the SSDT before (...) and after a period of brief body-scan mindfulness meditation training, or a control intervention . The meditation intervention reduced tactile misperception and increased sensitivity during the SSDT. This finding suggests that the perceptual effects of interoceptive attention depend on its particular nature, and raises the possibility that body-scan meditation could reduce the misperception of physical symptoms in individuals with medically unexplained symptoms. (shrink)

Background: There is growing awareness that patient care suffers when nurses are not respected. Therefore, to improve outcomes for patients, it is crucial that nurses operate in a moral work environment that involves both recognition respect, a form of respect that ought to be accorded to every single person, and appraisal respect, a recognition of the relative and contingent value of respect modulated by the relationships of the healthcare professionals in a determined context. Research question/aim: The purpose of this study (...) was to develop better understandings of perceptions of nursing’s professional respect in community and hospital settings in England. Research design: The research design was qualitative. Focus groups were chosen as the most appropriate method for eliciting discussion about nursing’s professional respect. Participants and research context: A total of 62 nurses who had been qualified for at least a year and were working in two localities in England participated in this study. Methods: Data were collected using 11 focus group sessions. The data were analysed by means of an inductive content analysis, extracting meaning units from the information retrieved and classifying the arising phenomena into conceptually meaningful categories and themes. Ethical considerations: To conduct the research, permission was obtained from the selected universities. Results: Recognition respect of human beings was perceived as ingrained in the innermost part of nurses. Regarding appraisal respect, a great importance was placed on: the interactions among healthcare professionals, the time to build trust in these relationships, the influences of the workplace characteristics and nurses’ professional autonomy and decision-making. Conclusion: Recognition respect of persons was embedded in the inmost part of nurses as individuals. Concerning appraisal respect, it was thought to be deeply enshrined in the inter- and intra-healthcare professional interactions. The forging of trusting relationships over time was deemed to be strongly associated with good quality interactions with other healthcare professionals. (shrink)

This paper argues that the concept of paternalism is currently overextended to include a variety of actions that, while resembling paternalistic actions, are importantly different. I use the example of Japanese physicians’ non-disclosures of cancer diagnoses directly to patients, arguing that the concept of maternalism better captures these actions. To act paternalistically is to substitute one's own judgement for that of another person and decide in place of that person for his/her best interest. By contrast, to act maternalistically is to (...) decide for another person based on a reasonable understanding of that person's own preferences. The concept of maternalism allows for a more thorough assessment of the moral justification of these types of actions. I conclude that it is possible, at least in principle, to justify Japanese physicians’ non-disclosures, and that this justification must be based on an understanding of these actions as maternalistic. (shrink)

Clinical ethics support for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria at Amsterdam University Medical Center. We specifically aimed to integrate CES into (...) daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice. (shrink)

Background Studies have shown that medical students and residents believe that their ethics preparation has been inadequate for handling ethical conflicts. The objective of this study was to determine the self-perceived comfort level of medical students and residents in confronting clinical ethics issues. Methods Clinical medical students and residents at the University of Maryland School of Medicine completed a web-based survey between September 2009 and February 2010. The survey consisted of a demographic section, questions regarding the respondents’ (...) sense of comfort in handling a variety of clinical ethics issues, and a set of knowledge-type questions in ethics. Results Survey respondents included 129 medical students (response rate of 40.7%) and 207 residents (response rate of 52.7%). There were only a few clinical ethics issues with which more than 70% of the respondents felt comfortable in addressing. Only a slight majority (60.8%) felt prepared, in general, to handle clinical situations involving ethics issues, and only 44.1% and 53.2% agreed that medical school and residency training, respectively, helped prepare them to handle such issues. Prior ethics training was not associated with these responses, but there was an association between the level of training (medical students vs residents) and the comfort level with many of the clinical ethics issues. Conclusions Medical educators should include ethics educational methods within the context of real-time exposure to medical ethics dilemmas experienced by physicians-in-training. (shrink)

In their recent article in this journal, Giubilini, Gur-Arie, and Jamrozik argue that there is more to expertise than individual healthcare professionals’ knowledge of their fields. To be an expert is to be recognized as a credible authority, they explain, and being a credible authority necessitates trust. Among the core ethical principles they identify for trustworthy experts in medicine and healthcare are honesty, humility, and transparency. Here I aim to affirm these authors’ linkage of expertise and trust by decoupling both (...) from a presumptive norm of transparency. My suggestion is not that medical or healthcare experts should lie or deceive, but that articulating their credible authority in terms of transparency mischaracterizes things. We see this in several ways: through the negative epistemic effects of a general norm of expert transparency, the importance of discretion in healthy trust relations, and the need for relationally responsive interpretation in how medical and health experts communicate with different patients and publics across social-epistemic difference. (shrink)

In this paper we address a frontier topic in the humanities, namely how the cultural and natural construction that we call landscape affects well-being and health. Following an updated review of evidence-based literature in the fields of medicine, psychology, and architecture, we propose a new theoretical framework called “processual landscape,” which is able to explain both the health-landscape and the medical agency-structure binomial pairs. We provide a twofold analysis of landscape, from both the cultural and naturalist points of view: (...) in order to take into account its relationship with health, the definition of landscape as a cultural product needs to be broadened through naturalization, grounding it in the scientific domain. Landscape cannot be distinguished from the ecological environment. For this reason, we naturalize the idea of landscape through the notion of affordance and Gibson’s ecological psychology. In doing so, we stress the role of agency in the theory of perception and the health-landscape relationship. Since it is the result of continuous and co-creational interaction between the cultural agent, the biological agent and the affordances offered to the landscape perceiver, the processual landscape is, in our opinion, the most comprehensive framework for explaining the health-landscape relationship. The consequences of our framework are not only theoretical, but ethical also: insofar as health is greatly affected by landscape, this construction represents something more than just part of our heritage or a place to be preserved for the aesthetic pleasure it provides. Rather, we can talk about the right to landscape as something intrinsically linked to the well-being of present and future generations. (shrink)

Background: The concept of dignity can be divided into two main attributes: absolute dignity that calls for recognition of an inner worth of persons and social dignity that can be changeable and can be lost as a result of different social factors and moral behaviours. In this light, the nursing profession has a professional dignity that is to be continually constructed and re-constructed and involves both main attributes of dignity. Objectives: The purpose of this study was to determine how nurses (...) described nursing’s professional dignity in internal medicine and surgery departments in hospital settings. Research design: The research design was qualitative. Ethical considerations: This study was approved by the ethics committees of the healthcare organizations involved. All the participants were provided with information about the purpose and the nature of the study. Participants: A total of 124 nurses participated in this study. Method: The data were collected using 20 focus group sessions in different parts of Italy. The data were analysed by means of a conventional inductive content analysis starting from the information retrieved in order to extract meaning units and sorting the arising phenomena into conceptually meaningful categories and themes. Results: Nursing’s professional dignity was deeply embedded in the innermost part of individuals. Regarding the social part of dignity, a great importance was put on the values that compose nursing’s professional identity, the socio-historical background and the evolution of nursing in the area considered. The social part of dignity was also linked to collaboration with physicians and with healthcare assistants who were thought to have a central role in easing work strain. Equally important, though, was the relationship with peers and senior nurses. Conclusion: The organizational environments under scrutiny with their low staffing levels, overload of work and hierarchical interactions did not promote respect for the dignity of nurses. To understand these professional values, it is pivotal to comprehend the role of different health professions in their cultural milieu and the evolution of the nursing profession in diverse countries. (shrink)

BackgroundThe U.S. Food and Drug Administration traditionally has kept confidential significant amounts of information relevant to the approval or non-approval of specific drugs, devices, and biologics and about the regulatory status of such medical products in FDA’s pipeline.ObjectiveTo develop practical recommendations for FDA to improve its transparency to the public that FDA could implement by rulemaking or other regulatory processes without further congressional authorization. These recommendations would build on the work of FDA’s Transparency Task Force in 2010.MethodsIn 2016-2017, we (...) convened a team of academic faculty from Harvard Medical School, Brigham and Women’s Hospital, Yale Medical School, Yale Law School, and Johns Hopkins Bloomberg School of Public Health to develop recommendations through an iterative process of reviewing FDA’s practices, considering the legal and policy constraints on FDA in expanding transparency, and obtaining insights from independent observers of FDA.ResultsThe team developed 18 specific recommendations for improving FDA’s transparency to the public. FDA could adopt all these recommendations without further congressional action.FundingThe development of the Blueprint for Transparency at the U.S. Food and Drug Administration was funded by the Laura and John Arnold Foundation. (shrink)

Background and aimsFew Polish hospitals have Hospital Ethics Committee (HECs) and the services are not always adequate. In this situation, the role of HECs, in providing, among others, ethical advice on the discontinuation of persistent therapies, may be taken over by other entities. The aim of our research was to investigate, how often and on what issues hospital chaplains are asked for ethical advice in reaching difficult medical decisions.MethodsA survey of 100 Roman Catholic chaplains was conducted, that (...) is, at least 10% of all chaplains currently working in Polish hospitals.ResultsOf the participants, 29% confirmed receiving requests for advice in making a morally difficult medical decision. Receiving this type of request was not conditional on the place of their service, duration of their pastoral mission or HEC membership. The largest group of chaplains (21%) encounter questions concerning the ethical dilemmas associated with discontinuing persistent therapy. Patients and their families most often raise issues related to the methods of birth control, and the medical staff raise the issue of termination of pregnancy—as reported by 9% and 15% of chaplains, respectively. Most of the chaplains asked for help (79%) experience a deficit of specialist knowledge in the area of medicine or ethics.ConclusionsIn order to improve the quality of ethical consultations in Polish hospitals, in addition to further development of HECs, it is postulated to develop a system for bioethical education of chaplains. (shrink)

In the past ten years, there has been growing interest in and concern about protecting the privacy of personal medical information. Insofar as medical records increasingly are stored electronically, and electronic information can be shared easily and widely, there have been legislative efforts as well as scholarly analyses calling for greater privacy protections to ensure that patients can feel safe disclosing personal information to their health-care providers. At the same time, the volume of biomedical research conducted in this (...) country continues to grow. The budget of the National Institutes of Health, for example, was $20,298 million in 2001, having more than doubled from a budget of $9,218 million 10 years before. This growing body of research includes increased efforts to use stored medical records as a source of data for health services, epidemiologic, and clinical studies. (shrink)

In recent years, discussion around memory modification interventions has gained attention. However, discussion around the use of memory interventions in the criminal justice system has been mostly absent. In this paper we start by highlighting the importance memory has for human well-being and personal identity, as well as its role within the criminal forensic setting; in particular, for claiming and accepting legal responsibility, for moral learning, and for retribution. We provide examples of memory interventions that are currently available for (...) class='Hi'>medical purposes, but that in the future could be used in the forensic setting to modify criminal offenders’ memories. In this section we contrast the cases of dampening and enhancing memories of criminal offenders. We then present from a pragmatic approach some pressing ethical issues associated with these types of memory interventions. The paper ends up highlighting how these pragmatic considerations can help establish ethically justified criteria regarding the possibility of interventions aimed at modifying criminal offenders’ memories. (shrink)

From the earliest application of modern randomized controlled trials in medical research, scientists and observers have deliberated the ethics of randomly allocating study participants to trial control arms. Adaptive RCT designs have been promoted as ethically advantageous over conventional RCTs because they reduce the allocation of subjects to what appear to be inferior treatments. Critical assessment of this claim is important, as adaptive designs are changing medical research, with the potential to significantly shift how clinical trials are conducted. (...) Policy-makers are swiftly moving to encourage greater use of adaptive designs. In 2016, the newly enacted 21st Century Cures Act instructed the Food and Drug Administration to help product sponsors incorporate adaptive methods into proposed clinical trial protocols and applications for investigational drugs and also biological products. In this article, we review the ethical justifications commonly offered for adaptive designs, explore these arguments in the context of actual trials, and contend that clinical equipoise is a useful standard for adaptive-trial ethics. We distinguish between theoretical and clinical equipoise and explain why ethical arguments related to adaptive trials tend to focus on the former. Yet we contend that theoretical equipoise can be an unreliable standard for adaptive ethics. While we contend that clinical equipoise is the most critical principle for the primary ethical concerns posed by adaptive trials, we suggest ethical approaches to deal with some additional concerns unique to adaptive designs. (shrink)

Late in life, Foucault identified with “the critical tradition of Kant,” encouraging us to read both thinkers in new ways. Kant’s “Copernican” strategy of grounding knowledge in the limits of human reason proved to stabilize political, social-scientific, and medical expertise as well as philosophical discourse. These inevitable limits were made concrete in historical structures such as the asylum, the prison, and the sexual or racial human body. Such institutions built upon and shaped the aesthetic judgment of those considered “normal.” (...) Following Kant through all of Foucault’s major works, this book shows how bodies functioned as “problematic objects” in which the limits of post-Enlightenment European power and discourse were imaginatively figured and unified. It suggests ways that readers in a neoliberal political order can detach from the imaginative schemes vested in their bodies and experiment normatively with their own security needs. (shrink)

Problem: Medical student mistreatment, as well as patient and staff mistreatment by all levels of medical trainees and faculty, is still prevalent in U.S. clinical training. Largely missing in interventions to reduce mistreatment is acknowledgement of the abuse of power produced by the hierarchical structure in which medicine is practiced. Approach: Beginning in 2001, Yale School of Medicine has held annual “Power Day” workshops for third year medical students and advanced practice nursing students, to define and analyse (...) power dynamics within the medical hierarchy and hidden curriculum using literature, guest speakers, and small groups. During rotations, medical students write narratives about the use of power witnessed in the wards. In response to student and small group leader feedback, workshop organizers have developed additional activities related to examining and changing the use of power in clinical teams. Outcome: Emerging narrative themes included the potential impact of small acts and students feeling “mute” and “complicit” in morally distressing situations. Small groups provided safe spaces for advice, support, and professional identity formation. By 2005, students recognized residents that used power positively with Power Day awards and alumni served as keynote speakers on the use of power in medicine. By 2010, departments including OB/GYN, surgery, psychiatry, and paediatrics, had added weekly team Power Hour discussions. Next Steps: The authors highlight barriers, benefits, and lessons learned. Barriers include the notion of clinical irrelevance and resistance to the word “power” due to perceived accusation of abuse. Benefits include promoting open dialogue about power, fostering inter-professional collaboration, rewarding positive role modelling by residents and faculty, and creating a network of trainee empowerment and leadership. Furthermore, faculty have started to ask that issues of power be addressed in a more transparent way at their level of the hierarchy as well. (shrink)