In recent years, there have been growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts. Initially proposed in the cultural context of the USA where nurse ethicists have long been recognised, the idea is being advocated in other judications outside of the USA such as the UK, Australia and elsewhere. Such calls are not without controversy, however. Underpinning this controversy are ongoing debates about the theoretical, methodological and political dimensions of (...) clinical ethics support services generally, and more recently where nurses might ‘fit’ within such a service. In considering whether nurse ethicists ought to have a place in clinical ethics support services, a number of questions arise such as: Is such a role warranted? If so, what credentials should nurses assuming the title of ‘nurse ethicist’ be required to have? What standards of practice ought nurse ethicists be required to uphold? What is the ultimate role and function of nurse ethicists in hospital contexts? And in what contexts might a nurse ethicist be most useful? In this essay, brief attention will be given to addressing these questions. It will be concluded that, as a minimum, nurses wishing to assume an advanced nursing practice role as a nurse ethicist must have substantive grounding in the foundational knowledge of the disciplines of both moral philosophy and nursing ethics. They must also not lose sight of the ultimate goal of nursing ethics, notably, to promote and advance ethical nursing practice and the provision of ‘good’ nursing care. (shrink)

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)

A project featuring scholars in nursing ethics was planned in 2005. The goal was to document the contributions of some 24 selected American nurse ethicists to bioethics, and to discuss and explore the future trajectory of that work through a two-day working seminar. This article outlines the beginnings of bioethics in the USA and the specific contribution of nurse scholars to the debate, the preparation for the seminar, the results of the project, and the possible application of such (...) a model for teaching and archiving in the future. Documentation of the work carried out at the seminar resulted in the publication of a book. Short biographies of the participants at the seminar are included in Appendix 1. (shrink)

Since the 1960s, it has been recognized that “medical ethics,” the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary (...) aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one’s prior profession’s nomenclature as a prefix to “ethicist,” under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good. (shrink)

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, nursing practice has much to contribute to the ethical practice of healthcare, and with the strong grounding in ethics and aspiration for social justice considerations in nursing, there is no wonder that the specific role of the nurse ethicist has emerged. (...) class='Hi'>Nurse ethicists, expert in nursing practice and the application of ethical theories and concepts, are well positioned to guide nurses through complex ethical challenges. However, there is limited discussion within the field regarding the specific job responsibilities that the nurse ethicist ought to have. The recent appearance of job postings with the title “nurse ethicist” suggest that some healthcare institutions have identified the value of a nurse in the practice of ethics and are actively recruiting. Discomfort about the possibility of others defining the role of the nurse ethicist inspired this paper (and special issue). If the nurse ethicist is to be seen as an integral part of addressing ethical dilemmas and ethical conflicts that arise in healthcare, then nurse ethicists ought to be at the forefront of defining this role. In this paper, we draw upon our own experiences as nurse ethicists in large academic healthcare systems to describe the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a clinical setting linked to academic programs. Drawing upon our experience and the literature, we describe how we perceive the nurse ethicist adds value to healthcare organizations and teams of professional ethicists. (shrink)

The unique role of the nurse ethicist in the clinical setting is one meant to enhance the ethical capacity of nurses, and front-line healthcare providers. As a nurse ethicist, it is also my goal to enhance the ethical climate of each individual work area, patient care unit, and the broader institution by encouraging ethical conversations, navigating ethical dilemmas, and seeking creative solutions to minimize moral distress and burnout. To provide preventive ethics support and education, I began (...) regularly visiting patient care areas for ethics rounds, which I affectionately named “E-walks” (for Ethics Walks). I will discuss and reflect upon the lessons that have emerged as three key components of “E-Walks”: Recognition, Solidarity and Dialogue. These themes will speak to the unique presence and availability of a nurse ethicist as a valuable resource to front-line healthcare providers who face ethical dilemmas and morally concerning cases. I will go on to argue and demonstrate that my role as the nurse ethicist lies at the intersection of bioethics and the theoretical framework of the “ethic of care,” which is focused on building, creating, and sustaining caring interprofessional relationships through the work of ethics, nursing, and education. (shrink)

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between ‘nurse ethicist’ and ‘clinical ethicist’ is largely irrelevant. The second (...) author describes the impact and value that a nurse in an ethics role plays, highlighting the ‘tacit knowledge’ and ‘lived experience’ they bring to clinical ethics consultation. However, the second author also warns that the ‘nurse ethicist’ must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as ‘nurse ethicist’ on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics. (shrink)

BackgroundMoral distress (MD) is an emotional and psychological response to morally challenging dilemmas. Moral distress is experienced frequently by nurses in the intensive care unit (ICU) and can result in emotional anguish, work dissatisfaction, poor patient outcomes, and high levels of nurse turnover. Opportunities to discuss ethically challenging situations may lessen MD and its associated sequela.ObjectiveThe purpose of this project was to develop, implement, and evaluate the impact of nursing ethics huddles on participants’ MD, clinical ethics knowledge, work satisfaction, (...) and patient care among ICU nurses.Sample and SettingThe sample, 32 nurses from three ICU settings in an 800-bed tertiary academic medical center, participated in six nursing ethics huddles over a two-month period.MethodsAlvita K. Nathaniel’s Theory of Moral Reckoning guided development of the nursing ethics huddle process.1 The Moral Distress Thermometer was administered at three data points: baseline level of MD, and pre- and post-huddle to determine changes in the subjects’ level of MD.2 Focused content analysis was used to analyze qualitative responses from questionnaires about the subjects’ perception of the effect of the huddles on work satisfaction and patient care. Knowledge attainment was evaluated via open-ended short-answer questions.ResultsOverall, use of nurse-ethicist-led nursing ethics huddles was associated with improved quality of work life, patient care, and clinical ethics knowledge. The change in pre- and post-nursing ethics huddles MD scores was statistically significant (p < 0.0001). (shrink)

Reacting against the dominance of obligation-based moral theories in both general and nursing ethics, the author proposes a 'strong' (action-guiding) account of a virtue-based approach to moral decision-making within contemporary nursing practice. Merits and criticisms of obligation and virtue-based approaches to morality are identified and examined. One of the author's central premises is that the notions of moral goodness and badness carry more moral weight than the traditionally important notions of moral rightness and wrongness. Therefore, the author argues that in (...) order to deliver morally good care, it is vital to consider the kind of nurse one is and this means examining one's moral character. This book will be rewarding reading for a wide range of readers including clinical nurses, nurse educators and nurse ethicists; indeed, anyone interested in morality and ethics and the work of nurses will find this book stimulating reading. (shrink)

In this article I will argue that futile medical and nursing care is not only inefficacious but that it may be harmful to the patient and also to health professionals, who may be diminished both as clinicians and as persons if they are not able to give appropriate care to dying patients and their families. I discuss futile care in intensive care units because the opportunities and the temptation to provide futile care in these settings is higher than, for instance, (...) in internal medicine and nursing home care. I argue, following two nurse ethicists, Carol Taylor and Colleen Scanlon, that, even if nurses are not the initiators of futile care, they play an important role in its prevention because of their clinical expertise. They can do this by convening ‘patient care conferences’ when they recognize the need to bring together the various parties that have conflicting expectations. These conferences would then result in appropriate palliative care. The nurses providing this care would demonstrate their understanding of the process whereby living becomes the process of dying. (shrink)

The level of impairment shown by the 1.3 million residents of nursing homes in the United States varies significantly, and this raises considerable challenges for how to address the sexual and romantic interests and needs of these diverse individuals. Unfortunately, bright-line rules and a onesize- fits-all approach are often taken when addressing these challenges. This article proposes a novel taxonomy for classifying the potential sexual and romantic relationships of cognitively impaired nursing home residents that includes relationships between unmarried residents, relationships (...) between residents and their own spouses, and adulterous relationships. We explore the ethical and logistical challenges distinctive to each category of relationship. (shrink)

Now in its sixth edition, this highly popular text covers the range of ethical issues affecting nurses and other healthcare professionals. Authors Simon Robinson and Owen Doody take a holistic and practical approach, focused in the dialogue of ethical decision making and how this connects professional, leadership and governance ethics in the modern healthcare environment. This focuses on the responsibility of professionals and leaders, and the importance of shared responsibility in the practice of healthcare. With a foreword by the eminent (...) medical ethicist Alastair Campbell, the revised edition includes contemporary topics, such as the duty of candour, recent cases, such as the Mid Staffs scandal, and ethical perspectives on vulnerable groups, such as; persons with intellectual/learning disability, dementia and those with an enduring mental illness. It builds on professional identity and personal development as part of ongoing learning, individual and organizational, and provides interactive ways that helps the reader to develop reflective ethical practice. This text aims to enable ethical engagement with the ever changing healthcare environment, and is a must-have for anyone serious about ethics in healthcare. Holistic and practice relevant approach New perspectives on vulnerable groups, such as persons with intellectual/learning disability, dementia and those with an enduring mental illness Descriptive as well as normative ethical theory Promoting dialogue and engagement with practice, practitioners, patients and families Development of professional ethical skills Connecting professional ethics to leadership, governance and social ethics Highly accessible format Case studies/Scenarios presented within chapters and pause for thought exercises to promote dialogue and engagement? Suitable for pre/post registration nurses, students, health care professionals. (shrink)

The question of whether nursing ethics is a distinct entity within bioethics is an important and thought-provoking one. Though fundamental bioethical principles are appreciated and applied within the practice of nursing ethics, there exist distinct considerations which make nursing ethics a unique subfield of bioethics. In this article, we focus on the importance of relationships as a distinguishing feature of the foundation of nursing ethics, evidenced in its education, practice, and science. Next, we consider two objections to our claim of (...) distinctiveness: first, that nursing ethics is merely an application of bioethical principles; second, that many bioethical subfields emphasize relationships. We respond by highlighting that throughout nursing education and generally in every career path that follows, the creation and nurturing of relationships is emphasized. Compassion and respect for the dignity of every patient is the framework upon which these therapeutic relationships are built. Much of the focus of nursing science rests on creating meaningful interpersonal experiences and human connection. After responding to each objection, we turn to the implications of this distinctiveness on clinical ethics practice, arguing that the strengths of our approach outweigh the limitations. The deep emphasis on creating meaningful interpersonal experiences and human connection supports a greater integration of relationships and social contexts into the evaluation of whether an action is ethically permissible, which is an important benefit in addressing the challenging human situations that patients face. Moreover, this perspective allows nurse ethicists to account for diverse and complex social structures and their influence in making ethical determinations. These strengths outweigh the limitations of potential inconsistencies between nurse and non-nurse clinical ethicists on the same service, a result we attribute to nursing ethics—and, in turn, the practice of the nurse ethicist—being framed by relationships to a larger extent than other bioethical subfields. (shrink)

Few bioethicists are educated with a view into nursing. Thus, much of the conceptual and empirical research on ethical issues in nursing practice has been conducted by nurse ethicists themselves and, to a lesser degree, by individuals with a strong interest in nursing ethics. Although this work has internally shaped nursing practice, education, and policy, the broader field of bioethics has seldom examined and acknowledged the everyday ethical concerns of practicing nurses and their important contributions to bioethics discourse. In (...) this special report of the Hastings Center Report —the first to focus on nursing—Christine Grady, Ann Hamric, and I, along with consulting editor Nancy Berlinger, strive to give voice to the contributions of nurses in addressing some of our obstinate everyday ethics and health policy challenges. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical Ethicists: Can They Help Families in Their Times of Need?Tracy R. WilsonI am a doctorally-prepared nurse practitioner with over 20 years in healthcare, and I am currently pursuing my MS in Bioethics and Medical Humanities at Tulane University, with an anticipated graduation of May 2023. In the fall of 2022, I had the pleasure of taking a Clinical Ethics course. As part of that course, I shadowed (...) a Clinical Ethicist for a week. It was a valuable experience, and I gained some insights about a role I didn’t know about previously. The last two years have been difficult for my family and me. I lost my dad in November 2020 and then a “sister cousin” in May 2021. In both instances, we had the team involved in their care and helping with the decision-making process.The role of the Clinical Ethicist Consultant (CEC) service is to help families process medical decisions—most of those decisions deal with endof-life care. The CEC works as the mediator between the family and the medical team. This is how I saw the CEC role play out in my experience.During my shadowing experience, my preceptor was phenomenal at his role because 1) he listened to the patient and the family, and 2) he consulted with the appropriate team members. My shadowing experience was virtual due to the restrictions of the healthcare facility. However, I was able to attend ethical team meetings. I was able to listen to multiple family calls and consultations. During my experience, my clinical ethicist was very conscientious of taking inventory of the feelings of everyone involved. Before he provided an opinion on a case, he did a deep dive into the patient’s chart to gain the patient’s historical context. He always asked for my opinion while we discussed a case, which made me feel included even as a student. It made me feel like my opinion had some weight, and it did in one of the cases. When I returned the next day, the feelings I had about a patient and her family using her for financial gain turned out to be true. Elder abuse was taking place.My personal experiences were more complicated, in which we didn’t always have a medical team that always heard what we needed for our loved ones. In the case of my sister cousin, she entered the hospital and was diagnosed with COVID-19. Our family never thought she would die from it, so it was shocking to us when she was placed on a ventilator and never came off. When the critical care MD stated that “there was nothing else he could do for her,” I could not understand how that could be when lung transplants were being done all over the US and even less than 100 miles away.We needed a CEC team then. I was the medical expert for my family, and I felt the medical team was not listening to what we wanted. The medical team believed that to continue treatment would be futile and their belief about this exceeded their need to continue treating my sister cousin. However, having a CEC mediate by first understanding the clinical team’s perspective, explaining those considerations to us, and then helping our family relay back our [End Page 23] wants, needs, and values to the clinical team could have helped. Unfortunately, my cousin never got this option. There was a palliative care team implemented but never a Clinical Ethicist. Having faced both, from a student perspective and from a personal experience, I would say that having a CEC present allows a family to have an advocate in the room, someone who knows the medical language and can explain to you and will explain to the medical team your perspective, which can sometimes be lost in translation or not heard.When my father passed away, he did not have a Clinical Ethicist as a part of his medical team either. My dad was a Vietnam Vet and a very prideful man. So, when my dad became ill in 2018 with vascular dementia, it took a toll on me and my sisters. To... (shrink)

This article explores the social and ethical elements of cultural safety and combines them in a model of culturally safe practice that should be of interest and relevance for nurses, nurse educators and nurse ethicists in other cultures. To achieve this, the article briefly reviews and critiques the main underpinnings of the concept from its origins and development in New Zealand, describes its sociocultural and sociopolitical elements, and provides an in-depth exploration of the key socioethical elements. Finally, a (...) model is presented to illustrate the strong connection between the social and ethical components of cultural safety that combine to produce culturally safe practice through the activities of a ‘socioethical’ nurse. (shrink)

Nursing Law and Ethics explores a variety of key legal and ethical issues in nursing practice using a thought-provoking and holistic approach. It addresses both what the law requires and what is right, and explores whether these two are always the same. The book provides an overview of the legal, ethical and professional dimensions of nursing, followed by exploration of key issues in greater depth. This edition features updated legislation and new material on patient safety. Key topics are accompanied by (...) both a legal and an ethical perspective, covering both law and ethics Case examples throughout place concepts in a real-life context Written by experts in the field and includes contributions from leading nurses, lawyers and ethicists Accessible, relevant, and comprehensive, this title is ideal for pre- and post-registration nurses. (shrink)

This paper applies a relational and familial ethic to address concerns relating to nursing home deaths and advance care planning during Covid‐19 and beyond. The deaths of our elderly in nursing homes during this pandemic have been made more complicated by the restriction of visitors even at the end of life, a time when families would normally be present. While we must be vigilant about preventing unnecessary deaths caused by coronavirus outbreaks in nursing homes, some deaths of our elders are (...) inevitable. Thus, it is essential that advanced care planning occurs in a way that upholds the familial and relational aspects of elders’ lives that often matter to them the most. We invoke concepts from feminist ethicists like Hilde Lindemann and Eva Kittay and introduce Avery Weisman and Thomas Hackett’s concept of “appropriate death” to suggest better ways of planning for those deaths of our elderly that cannot be avoided. Our hope is to allow for deaths that are as meaningful as possible for both the elderly and the family members who survive them. (shrink)

Concepts and Cases in Nursing Ethics maps the ethical landscape of contemporary nursing. The book is the product of a collaboration between philosopher-ethicist Michael Yeo, nurse-ethicist Anne Moorhouse, and six representatives of various areas of professional nursing. It thus combines philosophical and ethical analysis with nursing knowledge and experience in a manner that is both understandable and relevant. The book is organized around six main concepts in nursing ethics: beneficence, autonomy, confidentiality, truth-telling, justice, and integrity. A chapter (...) is devoted to the elucidation of each of these concepts. In each chapter, historical background and conceptual analysis are supplemented by case studies that exemplify issues and show how the concept applies in nursing practice. In this new edition, the materials in each chapter have been updated to reflect recent developments in nursing and more generally in health care. In addition, a totally new chapter on ethical theory has been added. Complete with bibliographies and study questions for further analysis of cases, this book is ideally suited for textbook use. It will help both practitioners and students to deal better with the clinical problems and issues that are encountered in the field. However, it's simple prose and clear exposition of complex issues will make Concepts and Cases in Nursing Ethics attractive to anyone concerned about health care. (shrink)

Nurses and ethicists worry that the implementation of care at a distance or telecare will impoverish patient care by taking out ‘the heart’ of the clinical work. This means that telecare is feared to induce the neglect of patients, and to possibly hinder the development of a personal relation between nurse and patient. This study aims to analyse whether these worries are warranted by analysing Dutch care practices using telemonitoring in care for chronic patients in the Netherlands. How do (...) clinical practices of nursing change when telecare devices are introduced and what this means for notions and norms of good nursing? The paper concludes that at this point the practices studied do not warrant the fear of negligence and compromised relations. Quite the contrary; in the practices studied, telecare lead to more frequent and more specialised contacts between nurses and patients. The paper concludes by reflecting on the ethical implications of these changes. (shrink)

This article deals with the question of how ethicists respond to practical moral problems emerging in health care practices. Do they remain distanced, taking on the role of an expert, or do they become engaged with nurses and other participants in practice and jointly develop contextualized insights about good care? A basic assumption of dialogical ethics entails that the definition of good care and what it means to be a good nurse is a collaborative product of ongoing dialogues among (...) various stakeholders engaged in the practice. This article discusses the value of a dialogical approach to ethics by drawing on the work of various nursing scholars. We present a case example concerning the quality of freedom restrictions for intellectually disabled people. Issues for discussion include the role and required competences of the ethicist and dealing with asymmetrical relationships between stakeholders. (shrink)

Nursing ethics centres on how nurses ought to respond to the moral situations that arise in their professional contexts. Nursing ethicists invoke normative approaches from moral philosophy. Specifically, it is increasingly common for nursing ethicists to apply virtue ethics to moral problems encountered by nurses. The point of this article is to argue for scepticism about this approach. First, the research question is motivated by showing that requirements on nurses such as to be kind, do not suffice to establish virtue (...) ethics in nursing because normative rivals (such as utilitarians) can say as much; and the teleology distinctive of virtue ethics does not transpose to a professional context, such as nursing. Next, scepticism is argued for by responding to various attempts to secure a role for virtue ethics in nursing. The upshot is that virtue ethics is best left where it belongs – in personal moral life, not professional ethics – and nursing ethics is best done by taking other approaches. (shrink)

Advocacy is an important concept in nursing practice; it is frequently used to describe th nurse-client relationship. The term advocacy, however, is subject to ambiguity of interpretation. Such ambiguity was evidenced recently in criticisms levelled at the nursing profession by hospital ethicist Ellen Bernal. She reproached nursing for using 'patient rights advocate' as a viable role for nurses. We maintain that, for nursing, patient advocacy may encompass, but is not limited to, patient rights advocacy. Patient advocacy is not (...) merely the defence of infringements of patient rights. Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice. La défense des malades joue un grand rôle dans la pratique des infirmiers/ères. Le terme est souvent utilisé pour définir les rapports entre malades et soignants. Le mot 'defénse' pourtant, peut être mal compris. Une ambiguïté était évidente récemment dans la critique de la profession infirmière faite par la philosophe éthique Ellen Bernal. Elle reproche à la profession d'utiliser le terme 'avocat des droits des malades' pour désigner le rôle primordial des infirmiers/ères. Nous croyons que pour les soignants, la défense des malades peut comprendre le rôle 'd'avocat des droits des malades' mais elle ne s'y borne pas. La défense n'est pas limitée à la défense des infractions des droits des malades. La défense dans la profession infirmière est basée sur une philosophie où la pratique infirmière est le soutien des malades dans leur quête de promouvoir leur propre bien-être. Die Fürsprache spielt eine wichtige Rolle in der Krankenpflege. Sie wird oft als kennzeichnend für die Beziehung zwischen Patient und Pflegepersonal beschrieben. Der Ausdruck 'Fürsprache' kann aber auch mehrdeutig interpretiert werden. Das wurde letzthin in der Kritik der Ethikerin Ellen Bernal an der Krankenpflege sichtbar. Sie machte den Pflegenden den Vorwurf, dass sie sich die Rolle des 'Rechts-Advokat des Patienten' aneignen. Wir sind der Meinung, dass es die Aufgabe des Pflegepersonals ist, auch die Rechte der Patienten zu vertreten, aber dass das nur ein Teil der Fürsprache ist. Sie ist nicht nur Verteidignung von verletzten Patientenrechten. Die Fürsprache in der Krankenpflege stammt von einer Philosophie, deren Ausübung die Unterstützung der Patienten für ihr Wohlergehen zum Ziel hat, so wie die Patienten selbst ihr Wohlergehen verstehen. Sie ist eine Ethik der Tat. (shrink)

Objectives—To assess whether UK and US health care professionals share the views of medical ethicists about medical futility, withdrawing/withholding treatment, ordinary/extraordinary interventions, and the doctrine of double effectDesign, subjects and setting–A 138-item attitudinal questionnaire completed by 469 UK nurses studying the Open University course on “Death and Dying” was compared with a similar questionnaire administered to 759 US nurses and 687 US doctors taking the Hastings Center course on “Decisions near the End of Life”.Results–Practitioners accept the relevance of concepts widely (...) disparaged by bioethicists: double effect, medical futility, and the distinctions between heroic/ordinary interventions and withholding/ withdrawing treatment. Within the UK nurses' group a “rationalist” axis of respondents who describe themselves as having “no religion” are closer to the bioethics consensus on withholding and withdrawing treatment.Conclusions—Professionals' beliefs differ substantially from the recommendations of their professional bodies and from majority opinion in bioethics. Bioethicists should be cautious about assuming that their opinions will be readily accepted by practitioners. (shrink)

Background The COVID-19 pandemic continues to disrupt every society as SARs-CoV-2 variants surge among the populations. Health care providers are exhausted, becoming ill themselves, and in some instances have died. Indeed, hospitals are struggling to find staff to care for critically ill patients most in need. Previous work has reported on the unending work-related conditions that hospital staff are laboring under and their subsequent mental and physical health strains. Health care providers need support, but it is not clear where that (...) support is to come from. While much research has reported on the COVID-19-related fears of nurses and physicians, fewer studies have focused on supportive features of the hospital work environment and how it may provide relief to front-line health care providers.Purpose This purpose of this study was to explore an often-overlooked resource within hospital systems across the United States—clinical ethicists—and examine their many roles during COVID-19 and the types of ethical issues they addressed with nurses, physicians, administrators, and others.Methods This was a primary analysis of semi-structured, qualitative interviews with 23 clinical ethicists across the United States. The interviews were conducted from November 2020–April 2021 and were audiotaped, transcribed verbatim, and de-identified; both inductive and deductive analyses were used to identify qualitative themes.Results Five major themes were identified: ethical issues that were increasingly more complex, moral distress that was “endemic,” shifting ethical paradigms from the focus on the individual to the population, fostering a supportive environment, and organizational ethics: variation in the value, roles, and policy input of clinical ethicists.Conclusions Our findings report on the integral and expanded role of clinical ethicists at an unprecedented time in our nation, and how they stepped forward to support front-line clinicians in hospitals across the country. (shrink)

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside.We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or (...) nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management. (shrink)

The purpose of this article is to clarify both the role of nurses in ethics meetings and the way in which ethics meetings can function as a catalyst for good nursing care. The thoughts presented are practice based; they arose from our practical experiences as nurses and ethicists with ethics meetings in health care organizations in Belgium. Our reflections are written from the perspective of the nurse in the field who is participating in (inter)professional ethical dialogue. First, the difficulties (...) that nurses experience while participating in ethics meetings are described. Then the possibilities for support of nurses in their ethical responsibility are explored. (shrink)

Objective: To evaluate one ethics rounds model by describing nurses’ and doctors’ experiences of the rounds. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. Findings: The goal of the rounds was (...) partly fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous. Conclusion: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented. (shrink)

In recent years, research in robotics and artificial intelligence (AI) has made rapid progress. It is expected that robots and AI will play a part in the field of nursing and their role might broaden in the future. However, there are areas of nursing practice that cannot or should not be entrusted to robots and AI, because nursing is a highly humane practice, and therefore, there would, perhaps, be some practices that should not be replicated by robots or AI. Therefore, (...) this paper focuses on several ethical concepts (advocacy, accountability, cooperation, and caring) that are considered important in nursing practice, and examines whether it is possible to implement these ethical concepts in robots and AI by analyzing the concepts and the current state of robotics and AI technology. Advocacy: Among the components of advocacy, safeguarding and apprising can be more easily implemented, while elements that require emotional communication with patients, such as valuing and mediating, are difficult to implement. Accountability: Robotic nurses with explainable AI have a certain level of accountability. However, the concept of explanation has problems of infinite regression and attribution of responsibility. Cooperation: If robot nurses are recognized as members of a community, they require the same cooperation as human nurses. Caring: More difficulties are expected in care-receiving than in caregiving. However, the concept of caring itself is ambiguous and should be explored further. Accordingly, our analysis suggests that, although some difficulties can be expected in each of these concepts, it cannot be said that it is impossible to implement them in robots and AI. However, even if it were possible to implement these functions in the future, further study is needed to determine whether such robots or AI should be used for nursing care. In such discussions, it will be necessary to involve not only ethicists and nurses but also an array of society members. (shrink)

Clinical ethics consultants are inevitably called to participate in and bear witness to emotionally challenging cases. With the move toward the professionalization of ethics consultants, the responsibility to respond to and address difficult ethical dilemmas is likely to fall to a small set of people or a single clinical ethicist. Combined with time constraints, the urgent nature of these cases, and the moral distress of clinicians and staff encountered during consultation, like other healthcare professionals such as physicians and nurses, (...) clinical ethics consultants could risk burnout. If it is true that clinical ethicists are at risk for burnout, an important strategy to avoid burnout is to develop sound self-care practices. This article reviews the goals and skills of ethics consultation and the role-specific reasons that clinical ethicists may be at risk for burnout, and argues that clinical ethicists may need to engage in self-care practices. Strategies to address burnout are reviewed and opportunities for future research are identified. (shrink)

Several times each month, usually on a Thursday morning, I join one or more of my physician colleagues on teaching rounds. Most weeks these are traditional rounds, where an attending physician leads a group of medical students, residents, and clinical fellows from bed to bed reviewing charts, examining patients, and planning daily procedures. As a medical ethicist, my role is to discuss some of the ethical issues that are embedded in these decisions about medical care and help students to (...) hone the skills required to manage these issues successfully in the context of ongoing care.Although the clinical setting varies, questions of patient management are always at the center of teaching rounds. Since my training is in philosophy, and not in medicine or nursing, there have been occasions when this focus on patient care has prompted me to reflect upon my role as a medical ethicist in these contexts. Lacking even the most basic medical training, and having been remarkably fortunate in having had limited personal experiences as a patient, what can I possibly contribute to the training of physicians?I suspect that at some time or another most teachers, but perhaps especially those trained in the humanities, have moments when they question the usefulness of their teaching. In my case, by introducing perspectives from the humanities on teaching rounds, my hope is to add some balance to the often narrow focus on the ordering of diagnostic tests, scheduling of procedures, obtaining of patient consent, and other practical matters. I often stress, for example, how the patients with whom students and residents interact are not mere patients, but persons with lives outside the hospital that can be made profoundly better or worse as a result of the brief time they are seen in the hospital. I draw attention to the …. (shrink)

Lachman, Grace and Gaylord have argued that for bioethics education for undergraduate nursing students, a preferred combination of instruction involves a clinically-based nurse with ethics training and a philosophically-based ethicist with clinical training. At the University of Pennsylvania School of Nursing, undergraduate nursing ethics instruction takes this form. The course director is a philosopher with extensive clinical experience in ethics. The course utilises four distinct forms of nursing clinical inputs to educate undergraduate nursing students using a unique combination (...) of didactic and experiential learning exercises to simulate real ethics cases. This paper describes how the course was developed and refined over the past several years and suggests several ideas for improvements in nursing ethics education at an undergraduate level. (shrink)

Increasing pharmaceutical industry presence in health care research and practice has evoked critical social, political, economic, and ethical questions and concern among health care providers, ethicists, economists, and the general citizenry. The case example presented of the ‘marketization’ of nursing practice not only reveals the magnitude of the purview of the pharmaceutical industry, it demonstrates how that industry imparts effect upon the organization of nursing work, an area of health care professional practice where the ethical polemic of pharmaceutical industry involvement (...) and influence has been largely ignored, and the profession of nursing conspicuously silent. Drawing on a Foucauldian dispositive analysis that troubled the complex apparatus responsible for the production of knowledge and action in the neurology subspecialty of multiple sclerosis (MS), the case discloses how the pharmaceutical industry has created compliance and adherence as clinical imperatives in the practice of MS nursing. The case makes explicit the conscious transformative self‐action undertaken by MS nurses as a result of their subjectivation (marketization) and demonstrates how MS nurses have become pawns in pharmaceutical industry strategic games of power, truth, identity, and wealth creation by turning their clinical practice settings into heterodiscursive spaces of surveillance and persuasion. MS nurses have become instruments of the pharmaceutical industry, and their clinical practices ordered, organized, limited, constrained, and marketized as a result. (shrink)

Research in moral psychology has recently raised questions about the impact of context and the environment on the way the human mind works. In a 2012 call to action, Paley wrote: “If some of the conclusions arrived at by moral psychologists are true, they are directly relevant to the way nurses think about moral problems, and present serious challenges to favoured concepts in nursing ethics, such as the ethics of care, virtue, and the unity of the person” (p. 80). He (...) urges nurse ethicists and scholars to evaluate the impact these findings may have for moral theory.In this paper, I review some of Paley's (Nursing Philosophy, 13, 2012, 80) critique, focusing on the argument that theories of nursing ethics have failed to account for the role of context; both in terms of its impact on the way nurses make moral judgements and in terms of the environment's influence on the way the mind works. I then examine nursing literature on moral agency, and focus on the role of the environment and context play within existing theory. I argue that theories of moral agency have often accounted for the role of context on the way nurses make decisions; however, less attention has been paid to its impact on the mind. With this background, I use insights from the fields of moral philosophy and moral psychology to refine the conceptualization of nurse moral agency in a way that is reflective of current cognitive, philosophical and nursing practice‐based science. (shrink)

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as (...) such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience. (shrink)

Treatment of sick children of Jehovah's Witness and Christian Scientist families at times presents significant dilemmas to American medicine and ethics, for modern healthcare professionals rely heavily on active treatment, and withholding of some treatments is a central religious tenet for Witnesses and Scientists. In important instances, physicians, nurses, ethicists, and courts may wish to set aside traditional religious beliefs and values when medical values support treatment to which adherents of these sects at times object.

Clinical ethicists tend to see themselves as moral experts to be called in when clinicians encounter a particularly difficult moral problem. Drawing on a naturalized moral epistemology, we argue that clinicians already have the moral knowledge they need—the norms and values that guide clinical practice are built right into the various health care professions. To reflect on their practice, clinicians need to (a) be aware of their own professional norms and values; (b) be able to express them to their colleagues, (...) their patients, and the patients' families; and (c) work together with these other actors to provide ethically responsible care. The ethicist's job is to use her own training in three kinds of philosophical reflection as the basis for teaching clinicians how to think about what they do. (shrink)

Medical researchers must continue to develop and test non-blood oxygen-transport products. Resources provided by the Jehovah's Witness Hospital Assistance Line must be consulted. Sickle cell researchers must continue to test non-blood treatment. Information about non-blood treatments must be disbursed. Ways to enhance parental comport as the laws further and further support children's best interest must be provided. Information regarding cultural diversity must be disseminated. Hospitals and healthcare agencies that have not done so must institute the use of ethics consulting or (...) ethics committees. Nurse ethicists must continue development of the role of educating staff; mediation, arbitration and negotiation; problem solving; obtaining legal opinion; providing patient, family, or staff advocacy; and helping to reduce suffering on the part of the providers. Difficult ethical decisions should continue to be debated.Were the staff at X Med Center correct in overriding parental wishes and breaking tenets of their faith? In the doctor's, nurse's lawyer's, and judge's view they were. The child, now eight years old, is alive and well. The stroke resolved, and imminent death averted. The parents' and child's views are not presently available. Whether the family is suffering from the child's loss of his relationship with God, or are secretly relieved in their hearts that they are not, like Rita Swan, mourning their dead son, is unknown. What is known, is that this was a difficult case for all involved, and that such cases will continue to present themselves in the future. (shrink)

Public lecture series do not always, unfortunately, result in a published volume of interdisciplinary, informed and well argued papers. Medical Ethics and the Future of Health Care has succeeded, however, in doing just this. A public lecture series was organised by the Adelaide Hospital Society, Dublin, Ireland in 1999 to facilitate better public understanding of complex issues in health care confronting citizens and carers. The book assumes correctly that the Republic of Ireland is now indisputably a pluralist society, discomforting to (...) some readers who might look to the book for absolute answers and certainties. They would be disappointed because the essays show rather that it will be public debate and reasoned, imaginative approaches to decision making in health care that will replace the comforts of traditional certainties. Coming from the internationally recognised philosopher of principlism, James Childress, the nurse ethicist, Verena Tschudin and representatives from …. (shrink)

Background: Nursing Ethics has featured several discussions on what good care comprises and how to achieve good care practices. We should “nurse” ethics by continuously reflecting on the way we “do” ethics, which is what care ethicists have been doing over the past few decades and continue to do so. Ethics is not limited to nursing but extends to all caring professions. In 2011, Elin Martinsen argued in this journal that care should be included as a core concept in (...) medical ethical terminology because of “the harm to which patients may be exposed owing to a lack of care in the clinical encounter,” specifically between doctors and patients. However, Martinsen leaves the didactical challenges arising from such a venture open for further enquiry. Objectives: In this article, we explore the challenges arising from implementing care-ethical insights into medical education. Research design: Medical education in the Netherlands is investigated through a “care-ethical lens”. This means exploring the possibility of enriching medical education with care-ethical insights, while at the same time discovering possible challenges emerging from such an undertaking. Participants and research context: This paper has been written from the academic context of a master in care ethics and policy. Ethical considerations We have tried to be fair and respectful to the authors discussed and take a neutral stance towards the findings portrayed. Findings: Several challenges are identified, which we narrow down to two types: didactical and non-didactical. Discussion and conclusion: In order to overcome these challenges, we must not underestimate the possible resistance to a paradigm shift. Our efforts should mainly target the learning that takes place in the clinical phases of medical training and should be accompanied by the creation of awareness in healthcare practice. (shrink)

Background Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable? Research question In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether (...) to provide lifesaving treatment when their child is born at the limit of viability? Research design We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014–2018. Ethical considerations All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study. Findings We identified six main themes in parents’ responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief. Conclusion The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for ‘everything to be done’. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child. (shrink)

Background In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. Setting A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. Methods Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: all professionals (...) who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. Results Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. Conclusion Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement. (shrink)

This text provides a comprehensive and timely examination of the most pertinent factors affecting institutional ethics committees, for ethicists, trustees, administrators, physicians, clergy, nurses, social workers, attorneys and others with an interest in ethics committees.

Incivility among physicians, between physicians and learners, and between physicians and nurses or other healthcare professionals has become commonplace. If allowed to continue unchecked by academic leaders and medical educators, incivility can cause personal psychological injury and seriously damage organisational culture. As such, incivility is a potent threat to professionalism. This paper uniquely draws on the history of professional ethics in medicine to provide a historically based, philosophical account of the professional virtue of civility. We use a two-step method of (...) ethical reasoning, namely ethical analysis informed by pertinent prior work, followed by identifying the implications of clearly articulated ethical concepts, to meet these goals. The professional virtue of civility and the related concept of professional etiquette was first described by the English physician-ethicist Thomas Percival (1740–1804). Based on a historically informed philosophical account, we propose that the professional virtue of civility has cognitive, affective, behavioural and social components based on a commitment to excellence in scientific and clinical reasoning. Its practice prevents a dysfunctional organisational culture of incivility and sustains a civility-based organisational culture of professionalism. Medical educators and academic leaders are in a pivotal and powerful position to role model, promote and inculcate the professional virtue of civility as essential to an organisational culture of professionalism. Academic leaders should hold medical educators accountable for discharge of this indispensable professional responsibility. (shrink)

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective (...) ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called “moral spaces,” reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Who Tells the StoryCindy BitterThirty years later, I do not remember her name, but I definitely remember her face, and this is how I remember her story.She came into the office for her flu shot. She was in her 70s and had a mild case of COPD attributed [End Page 87] to years of exposure to pesticides on the family farm. She said she was trying to stay healthy, (...) as the grandkids were due for a visit, and everyone had gotten a cold after Thanksgiving the year before. I was a sub-intern doing a required rural medicine rotation and diligently did an exam, finding asymptomatic new-onset atrial fibrillation of uncertain duration. We admitted her to the hospital and started anticoagulation. My attending also ordered a calcium channel blocker to slow her pulse, which was running 90–100 while she was at rest. The attending insisted that it would convert her back to sinus rhythm. The nurses were not experienced with the medication and were uncomfortable giving it. I was pretty sure the calcium channel blocker was not indicated, and a quick check of my pocket manual confirmed the drug would lower her heart rate and maybe her blood pressure but that it would not fix the abnormal rhythm. I refused to administer it. The attending came in, pushed the medication, and returned home. A few minutes later, the patient was struggling to speak. Her pulse fell to in the 30s, and her blood pressure had dropped dangerously low. I asked for the crash cart and calcium, and my attending, then started CPR when she lost her pulse. Half an hour later, my attending called her time of death.Hers was not the first death I'd witnessed, but it was the first time I felt like my patient would have been better off without our interventions. As a medical student hundreds of miles from the main hospital campus, I felt powerless to contradict the attending, and did not know where to turn for support in the moment. I rationalized it by saying that I had not actively contributed to her death by pushing the medication, but I held myself morally culpable for doing the exam and finding an asymptomatic abnormality that started her down that path. I felt I should have known the pathophysiology and medication side effects better, or been more assertive, or called for help.One could argue whether I was suffering from a grief reaction or falling into depression, but I questioned my calling to medicine and seriously considered leaving the field. But I was quite certain that I did not want another patient to be put at risk, or a student to feel cornered into taking actions against their better judgment. After returning to the main hospital, I met with the clerkship director and helped develop a pathway for students to raise safety concerns in real-time. Now I recognize the feeling I experienced as moral injury, but we weren't using that term at the time, or talking about Six Sigma safety, or stopping the line.Ultimately, I continued through medical school and trained as an emergency physician. My prior reverence for my attendings moderated to a healthier respect that had to be earned. I read voraciously, trying to prepare myself for unexpected situations. I became an advocate for patient safety and was an early adopter of shared decision-making. I strive to be a physician who welcomes questions and respects the concerns of all team members. Many of the principles that ground my career in medicine grew out of my exposure to this patient.It was always my least favorite of the tropes common to television medical dramas—the circumstances of the patient-of-the-week illuminated some aspect of our main characters' lives, providing a very important life lesson. I felt it positioned patients to be in service of the physician's aims, using patients as a means to our ends, when we should be using our knowledge and experience to further the patient's goals. Very un-Kantian, in addition to transgressing against multiple other philosophers and medical ethicists. As medicine learns more about the power of... (shrink)