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PubMed2000

British community pharmacists' views of physician-assisted suicide (PAS).

OBJECTIVES: To explore British community pharmacists' views on PAS, including professional responsibility, personal beliefs, changes in law and ethical guidance. DESIGN: Postal questionnaire. SETTING: Great Britain. SUBJECTS: A random sample of 320 registered full-time community pharmacists. RESULTS: The survey yielded a response rate of 56%. The results showed that 70% of pharmacists agreed that it was a patient's right to choose to die, with 57% and 45% agreeing that it was the patient's right to involve his/her doctor in the process and to use prescription medicines, respectively. Forty-nine per cent said that they would knowingly dispense a prescription for use in PAS were it to be legalized and 54% believed it correct to refuse to dispense such a prescription. Although 53% believed it to be their right to know when they were being involved in PAS, 28% did not. Most pharmacists (90%) said that they would wish to see the inclusion of a practice protocol for PAS in the code of ethics of the Royal Pharmaceutical Society of Great Britain (CE-RPSGB) in the event of a change in the law on PAS. In addition, 89% would wish to see PAS included in the Conscience Clause of the CE-RPSGB. Males were found to be significantly less likely to favour PAS than females (p < 0.05), as were those declaring an ethnic/religious background of consideration when dealing with ethical issues in practice compared with their counterparts (p < 0.00005). CONCLUSION: Pharmacists view their professional responsibility in PAS to be more obligatory than a physician's, in having to provide the means for PAS. It is worrying that a proportion of the respondents prefer to remain in ignorance of the true purpose of a prescription for PAS; a finding at odds with current developments within the pharmaceutical profession. A practice protocol for PAS and an extension of the conscience clause should be considered in the event of PAS becoming legal. Such measures would allow the efficient provision of the pharmaceutical service whilst at the same respecting the personal beliefs of those who object to cooperating in the ending of a life.

Age Factors↗
PubMedDate not supplied

Ethics in psychiatry and psychoanalysis.

Ethics plays a dual role in psychiatry. The extrinsic role is in defining the rules of ethical conduct for the psychiatrist as a professional dealing with patients, peers and society at large. The intrinsic role is in defining ethical or moral conflict as a determining component in the construction of symptoms of mental disorder. Ethical considerations play a role in the truthful description of the disorder, diagnosis, dynamic formulation and the doctor-patient relationship in treatment. In treatment, there is a need to acknowledge 2 dimensions of psychological conflict: (1) an appraisal of the actual realistic moral conflicts due to symptomatic unethical conduct that goes against one's normative conscience, and (2) resolution of past conflicts arising from unconscious or repressed aspects of the neurotic conscience or superego, i.e. a holdover of unreflected obedience to parental authority. The resolution of past and ongoing conflicts promotes growth toward autonomy of moral judgment, free choice and moral responsibility.

Ethics, Medical↗
PubMed2004

Striving for purity: shared understandings in retired Swedish care providers' narratives on nursing care around 1950.

Caring for the sick has been important throughout all times. Nursing care has been illuminated from various perspectives. The aim of this study was to illuminate nursing care as narrated by 27 retired care providers in northern Sweden. The themes of cleanliness, order, and clear conscience stood out as important in the text. The results are interpreted as pointing to purity. Purity is a complex phenomenon within the cultural context. Some literature states that in the past, physical cleanliness, moral purity, and order were closely interrelated. Nurses were expected to be religious, morally pure persons in clean and perfect uniforms, always prepared to serve and do their duty. Purity is not always readily apparent. It is often revealed through its absence or opposite. Purity and conscience are seldom addressed in contemporary nursing research. More research is needed to further reflect on purity and its significance for nursing care today.

Aged↗
PubMed2006

Health worker motivation in Africa: the role of non-financial incentives and human resource management tools.

BACKGROUND: There is a serious human resource crisis in the health sector in developing countries, particularly in Africa. One of the challenges is the low motivation of health workers. Experience and the evidence suggest that any comprehensive strategy to maximize health worker motivation in a developing country context has to involve a mix of financial and non-financial incentives. This study assesses the role of non-financial incentives for motivation in two cases, in Benin and Kenya. METHODS: The study design entailed semi-structured qualitative interviews with doctors and nurses from public, private and NGO facilities in rural areas. The selection of health professionals was the result of a layered sampling process. In Benin 62 interviews with health professionals were carried out; in Kenya 37 were obtained. Results from individual interviews were backed up with information from focus group discussions. For further contextual information, interviews with civil servants in the Ministry of Health and at the district level were carried out. The interview material was coded and quantitative data was analysed with SPSS software. RESULTS AND DISCUSSION: The study shows that health workers overall are strongly guided by their professional conscience and similar aspects related to professional ethos. In fact, many health workers are demotivated and frustrated precisely because they are unable to satisfy their professional conscience and impeded in pursuing their vocation due to lack of means and supplies and due to inadequate or inappropriately applied human resources management (HRM) tools. The paper also indicates that even some HRM tools that are applied may adversely affect the motivation of health workers. CONCLUSION: The findings confirm the starting hypothesis that non-financial incentives and HRM tools play an important role with respect to increasing motivation of health professionals. Adequate HRM tools can uphold and strengthen the professional ethos of doctors and nurses. This entails acknowledging their professionalism and addressing professional goals such as recognition, career development and further qualification. It must be the aim of human resources management/quality management (HRM/QM) to develop the work environment so that health workers are enabled to meet their personal and the organizational goals.

Journal Article↗
PubMed1979

The Mosher Guilt Scales: a construct validity extension.

The three subscales of the Mosher Guilt Scales (sex guilt, hostility guilt, and morality conscience guilt) and several personality and attitude measures were ad ministered to college subjects in an effort to examine the construct validity of the Mosher Guilt Scales. The variables that were compared with the guilt subscales were hostility, anxiety, religious orthodoxy, self-esteem, and the importance of religious and economic values in one's life. The results indicated that both the construct validity of the Mosher Guilt Scales and the need for the continued use of its three subscales were supported. Among the most crucial findings of the study were that both of the religiosity measures were positively correlated with all three guilt subscales, and that economic values were negatively correlated with both sex guilt and morality-conscience guilt.

Journal Article↗
PubMed1986

The superego: a revised developmental model.

The superego is not, as psychoanalytic theory asserts, primarily heir to the oedipus complex. Freud proposed two theories of identification and superego formation, only one of which is widely known and accepted. The first, which he abandoned, argues for the genesis of conscience as compensation for lost narcissism. The second explains superego formation as a response to object loss and fear of castration. The latter view faces a number of anomalies, including the occurrence of preoedipal and postoedipal identifications unrelated to the castration complex, and the difficulty in providing a cause for female superego development. An alternative theory is proposed that returns to Freud's first theory of identification, arguing that gender-specific explanations are inappropriate for a phenomenon such as conscience, which occurs in both sexes. Prototypical male and female cases are presented alongside a general model of the development of ego processes and object relations. Case material is briefly examined, and the argument is made for conceptualizing psychosexual development as a developmental line rather than as the core of character formation.

Adult↗
PubMed2005

New and lingering controversies in pediatric end-of-life care.

OBJECTIVES: Professional societies, ethics institutes, and the courts have recommended principles to guide the care of children with life-threatening conditions; however, little is known about the degree to which pediatric care providers are aware of or in agreement with these guidelines. The study's objectives were to determine the extent to which physicians and nurses in critical care, hematology/oncology, and other subspecialties are in agreement with one another and with widely published ethical recommendations regarding the withholding and withdrawing of life support, the provision of adequate analgesia, and the role of parents in end-of-life decision-making. METHODS: Three children's hospitals and 4 general hospitals with PICUs in eastern, southwestern, and southern parts of the United States were surveyed. This population-based sample was composed of attending physicians, house officers, and nurses who cared for children (age: 1 month to 18 years) with life-threatening conditions in PICUs or in medical, surgical, or hematology/oncology units, floors, or departments. Main outcome measures included concerns of conscience, knowledge and beliefs, awareness of published guidelines, and agreement or disagreement with guidelines. RESULTS: A total of 781 clinicians were sampled, including 209 attending physicians, 116 house officers, and 456 nurses. The overall response rate was 64%. Fifty-four percent of house officers and substantial proportions of attending physicians and nurses reported, "At times, I have acted against my conscience in providing treatment to children in my care." For example, 38% of critical care attending physicians and 25% of hematology/oncology attending physicians expressed these concerns, whereas 48% of critical care nurses and 38% of hematology/oncology nurses did so. Across specialties, approximately 20 times as many nurses, 15 times as many house officers, and 10 times as many attending physicians agreed with the statement, "Sometimes I feel we are saving children who should not be saved," as agreed with the statement, "Sometimes I feel we give up on children too soon." However, hematology/oncology attending physicians (31%) were less likely than critical care (56%) and other subspecialty (66%) attending physicians to report, "Sometimes I feel the treatments I offer children are overly burdensome." Many respondents held views that diverged widely from published recommendations. Despite a lack of awareness of key guidelines, across subspecialties the vast majority of attending physicians (range: 92-98%, depending on specialty) and nurses (range: 83-85%) rated themselves as somewhat to very knowledgeable regarding ethical issues. CONCLUSIONS: There is a need for more hospital-based ethics education and more interdisciplinary and cross-subspecialty discussion of inherently complex and stressful pediatric end-of-life cases. Education should focus on establishing appropriate goals of care, as well as on pain management, medically supplied nutrition and hydration, and the appropriate use of paralytic agents. More research is needed on clinicians' regard for the dead-donor rule.

Analgesics, Opioid↗
PubMed1998

Eight 'Cs' of caring: a holistic framework for nursing terminally ill patients.

This introductory paper describes how nurses can incorporate eight caring elements into nursing care for terminally ill patients. These caring elements can be described as: Compassion, Competence, Confidence, Conscience, Commitment, Courage, Culture and Communication. The Eight Cs of caring are comprised of Simone Roach's five Cs plus three further Cs. According to Roach (1993), who developed the Five Cs (Compassion, Competence, Confidence, Conscience and Commitment), knowledge, skills and experience make caring unique. Here, I extend Roach's work by proposing three further Cs (Courage, Culture and Communication). The paper takes as its framework the concept of holistic care, which encompasses physical, psychological, emotional, spiritual and cultural aspects. Examples are provided as to how the Eight Cs may be applied. Literature from various nursing scholars is included to support the discussion throughout.

Aged↗
PubMed1993

Futile care. Physicians should not be allowed to refuse to treat. Point.

Eighteen years after the era of Karen Ann Quinlan, the debate over futile care has shifted. Now some patients are asking for treatment that care givers believe to be useless. In virtually all cases of so-called futile care, the real disagreement is not over whether a treatment will produce an effect; it is over whether some agreed-on potential effect is of any value. An obvious reason to resist providing care believed to be futile is that is appears to consume scarce resources and therefore burden others. However, for care that affects the dying trajectory but appears to most of us to offer no benefit, the proper course is for society--not clinicians--to cut patients off. Under certain circumstances patients should have the right to receive life-prolonging care from their clinicians, provided it is equitable funded, even it the clinicians believe the care is futile and even if it violates their conscience to provide it. Society is not in a position to override a competent patient who prefers to live even if life prolongation is burdensome. For incompetent patients, if a clinician believes a treatment is actually hurting a patient significantly, he or she may appeal to a court to have it stopped. A society that forces people to die against their will produces more offense than one that forces healthcare providers to provide services that violate their conscience. And medical professionals have a social contract with society to control the use of medical, life-prolonging technologies.(ABSTRACT TRUNCATED AT 250 WORDS)

Ethics, Medical↗
PubMed1988

Collaboration needed in discussion of ethical issues.

Official directives, public tension between moral theologians and the Vatican, and practical decisions about such issues as sterilization and life preservation raise confusion about the role of the Church authority in teaching about healthcare ethics. To alleviate this confusion, it is necessary to clarify the fundamental issues of Church authority, infallibility, and conscience. Many people mistakenly view infallibility as a characteristic of the pope alone in all he says and does. In fact, the heart of infallibility is that the presence of God makes the Church invulnerable to self-destruction, and the characteristic is vested in those who have supreme authority over the whole Church--the college of bishops and the pope as the head of the college. On the other hand, noninfallible but authoritative teachings, such as the documents of the Second Vatican Council and papal encyclicals, are presumed to be true and play an important role in the formation of conscience, acting as privileged sources of guidance and not programs for uniformity. The possibility of error is part of the distinction between infallible and noninfallible teachings. This possibility underlines the necessity for the magisterium to learn from as many sources as possible in preparing noninfallible teachings.

Catholicism↗
PubMed2001

End-of-life issues in intensive care units: a national random survey of nurses' knowledge and beliefs.

OBJECTIVE: To investigate the knowledge, beliefs, and ethical concerns of nurses caring for patients dying in intensive care units. METHODS: A survey was mailed to 3000 members of the American Association of Critical-Care Nurses. The survey contained various scenarios depicting end-of-life actions for patients: pain management, withholding or withdrawing life support, assisted suicide, and voluntary and nonvoluntary euthanasia. RESULTS: Most of the respondents (N = 906) correctly identified the distinctions among the end-of-life actions depicted in the scenarios. Almost all (99%-100%) agreed with the actions of pain management and withholding or withdrawing life support. A total of 83% disagreed with assisted suicide, 95% disagreed with voluntary euthanasia, and 89% to 98% disagreed with nonvoluntary euthanasia. Most (78%) thought that dying patients frequently (31%) or sometimes (47%) received inadequate pain medicine, and almost all agreed with the double-effect principle. Communication between nurses and physicians was generally effective, but unit-level conferences that focused on grief counseling and debriefing staff rarely (38%) or never (49%) occurred. Among the respondents, 37% had been asked to assist in hastening a patient's death. Although 59% reported that they seldom acted against their consciences in caring for dying patients, 34% indicated that they sometimes had acted against their conscience, and 6% had done so to a great extent. CONCLUSIONS: Intensive care unit nurses strongly support good pain management for dying patients and withholding or withdrawing life-sustaining therapies to allow unavoidable death. The vast majority oppose assisted suicide and euthanasia. Wider professional and public dialogue on end-of-life care in intensive care units is warranted.

Adult↗
PubMed2002

[Botulism in Casablanca. (11 cases)].

Botulism is a rare but severe disease. Whereas until 1980, only one case of botulism had been reported in our department, in 1999, a real botulism epidemic took place in Morocco. To our knowledge, it's the first outbreak of that kind in Morocco. We report here an epidemiologic and descriptive study of 11 patients suffering from botulism, admitted at the Infectious Diseases department and in the Medical Intensive Care Unit of Ibn Rochd University Hospital, from August, the 10th to October, the 1st, 1999. Clinical diagnosis of botulism was made, at the admission, on ocular signs (diplopia, ptosis), swallowing troubles and/or muscle weakness. There was no fever, no trouble of conscience and normal reflexes, at the early stage of the disease. The average age of patients was of 23.9 years +/- 12.07. Three patients were first admitted in the Medical Intensive Care Unit. The period before symptom appearance varied between 7 and 96 hours. Dysphagia sore throat, dry mouth and dysphonia were always found in all patients, with normal conscience. The fever was noted in 3 cases, polypnea in 3 cases leading to respiratory assistance in 2 cases. Neurologic findings were dominated by ptosis and hypotonia. The search of botulism toxin B in blood was positive in 6 cases. The electromyography showed clear signs of botulism. The evolution was favourable in 10 cases. Respiratory complications were found in 2 cases and infectious complications in 4 cases. One patient died. The period of hospitalization varied between 10 to 24 days with an average stay of 15.8 days. Eating "mortadella" has been noticed in 7 patients) and investigations permitted to identify the factory of "mortadella" as well as the toxin's type B responsible for these poisoning. It appears clearly that it is important to reinforce hygiene controls. Physicians and specialists in public health must be aware of the severity of this illness, knowing that the recovery is shortened when the treatment is administered on an early stage of the disease.

Adolescent↗
PubMed2000

[Intraoperative awakening: report of a case in pediatric surgery].

Intraoperatory awakening or awareness can be defined as recovering of conscience during general anesthesia. We report such a case happened in a 11 year-old boy during a hypospadias repair. After anesthetic education he related intraoperatory conscience without pain, anxiety, displeasing symptoms or long-term psychoconductal distress. We remark fisiopathology, diagnostic and preventive aspects of this rare event in pediatric surgery.

Anesthesia, General↗
PubMed2002

[Are psychological concepts of Japanese origin relevant?].

This paper was originally given as a lecture in English at the XII World Congress of Psychiatry held in Yokohama, August 2002. Its primary aim was to introduce Morita therapy and the amae psychology to participants from abroad, not as something exotic, but as something intrinsically relevant to them. In my opinion, Morita therapy is based upon Morita's discovery that certain neurotics, whom he eventually named as shinkeishitsu, can recover spontaneously from severe anxiety when placed in isolation and forced to rest in bed without any diversion under the doctor's strict supervision. In other words, only those patients who follow the doctor's advice faithfully through initial isolation and subsequent work-stages can benefit from Morita therapy. It is further argued that it does not do justice to Morita to speculate that he developed his theory and therapy under the influence of Zen. Apropos of the amae psychology what is most noteworthy about it is that its genuine feeling can be conveyed only nonverbally unlike love which one can express verbally when one says "I love you". It is understood that ambivalence refers to the co-existence of love and hate. This love, however, had better be called amae since it is usually nonverbal and not even acknowledged. Narcissism also entails amae, in fact amae turned upon itself, because narcissism consists in denying one's virtual dependence. Interestingly, the word amae alone may suggest a narcissistic state when it is used in the sense of self-indulgence, the usage which is now becoming quite common. Apart from elucidating two psychiatric terms, the concept of amae turns out to be quite handy in describing what transpires in the psychotherapeutic situation including that of Morita therapy. The concluding remark is to emphasize the importance of psychological concepts against the prevailing view of evidence-based psychiatry. It is argued that the objectivity of scientific findings is in the final analysis a postulate guaranteed by the conscience of individual scientists. If so, the same kind of objectivity may be attributed to the observations made by the doctor when he maintains the psychotherapeutic relationship against all odds and also without any compromise of his conscience.

Cross-Cultural Comparison↗
PubMed2002

[Legal status of human dead body in the context of corporal phenomenology].

It is pointed out that phenomenological settlements are convergent with human dead body status change which has been made on the basis of Polish law. In the 1969 Criminal Code, in chapter "Crime Against the Liberty of Conscience And Religion", there was an entry concerning the protection of human dead body. The reason was that a dead body used to be placed in a sphere of sacrum. In the new Criminal Code, published in 1997, analogical entries were put in chapter "Crime Against Law And Order". In chapter "Crime Against the Liberty of Conscience And Religion" there is an entry concerning sanctions for disturbing funeral service. It means that in legal consciousness a dead body does not belong to a sacral sphere. A ceremony belongs to that sphere but not the subject of that ceremony--a dead body is just a thing. Perhaps in future a dead body will be legally acknowledged as a subject of legal turn, and it will be marked off and specially protected.

Attitude to Death↗
PubMed2003

[The meaning of Aristoteles' epikeia for medical treatment].

Epikeia was originally employed for the interpretation of legal conceptions in the ancient Greek polis. Based on rational-guided clemency, epikeia was extended to human justice in individual cases, and culminated in an independent virtue of natural law beyond mere jurisdiction. Thus, the virtue of epikeia is built on the principles of human rights and dignity of man. As a "principle of equity", the virtue of epikeia allows doctors medical, ethical and individual decisions with respect to the personality and dignity of patients especially in those cases, which have ben proved to be impersonal due to the extremes of medical over- and underdoing so far. Epikeia is adjusted to the individual conscience, which is based on knowledge and certainty, and which expects responsibility and forbearance by the doctor. Epikeia is motivated by the pursuit of well-being of the patient in his inviolable personality and dignity. The sense of epikeia derives from teh affirmation of man as the only purpose of man and from the bliss of medical profession. The virtue of epikeia assembles different numbers of other virtues, and is therefore called on fo the cardinal virtues of medicine. Epikeia is te proof of moral strength and conscience of doctors.

Ethics, Medical↗
PubMed2006

[Partial occipital seizures as main symptom of posterior encephalopathy secondary to immunosuppresants].

INTRODUCTION: Reversible posterior leukoencephalopathy syndrome (RPLS) affects patients who are following immunosupressive treatment. It can affect children too, it can be irreversible and occipital seizures can be the main manifestation. We describe the EEG of five children who presented occipital seizures due to posterior leukoencephalopathy syndrome secondary to treatment with immunosupressives. They had different clinico- electrical evolutions. CASES REPORTS: Five children aged from 18 months to 11 years who had been treated with bone marrow, liver or kidney transplantation and one or two immunosupressive drugs: cyclosporine, tacrolimus. 4-50 days after the transplantation they presented arterial hypertension and low conscience. Occipital seizures or status were registered in EEG. Neuroimaging showed edema lesions in posterior regions. They were treated with antihipertensives, antiepileptics and substitution or reduction of immunosupressive drugs doses. Two patients presented further episodes and three of them had persistent abnormal EEG. Two patients had more than one status even though Cys A had been replaced by Tacrolimus or because the drug dose had not been modified. The Immunosupressive drugs are necessary for the transplantation's good outcome and they cannot be easily stopped. CONCLUSIONS: Low conscience level and oculoclonic movements may form part of the subtle clinic of the occipital seizures, that may be the main manifestation of PLS in children who are following immunosupressor treatment. The realization of an EEG is indispensable for a quick diagnose and in order to achieve the reversibility of the syndrome. If we cannot get it, EEG will be useful for the evolution follow-up too.

Child↗
PubMed1991

[Cerebral contusions. Study of 182 cases].

Clinical cases were selected in which cerebral contusions were the only visible lesions in CT scan on admission over the period from January 1983 and December 1985. The following characteristics were evaluated: Age, sex, conscience level (Glasgow) at admission, early post-traumatic epilepsy, focal signs, lesion mechanism, cranial fracture, as well as CT scan in which specific signs of bad prognosis were analyzed. According to the evolution of conscience level 3 groups of patients were established: Group 1 "no coma", group 2 "coma with lucid interval", group 3 "coma without lucid interval" and were correlated with the previously mentioned characteristics. The highest mean age (59.2 years) appeared in group 2. In 75% of patients in group 3 a traffic accident was the lesion mechanism. Admission CT scan showed that the severity is related to bad prognosis signs (displacement of middle line, lack of 3rd ventricle, and basal cisterns and multiple lesions). Mortality was approximately 70, 80 and 90% whether they had one, two, or three bad prognosis signs at admission CT scan.

Adult↗