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Integrating justice and care in animal ethics.

In this paper I argue that the standoff between justice and care approaches to animal ethics presents us with a false dilemma. We should take justice's focus on reasoning from principles, and care's use of sympathetic awareness, as two integrated deliberative capacities necessary for the consideration of arguments for extending moral concern to animals. Such an integrated approach rests on a plausible account of the psychology of moral deliberation. I develop my argument as follows. Section I summarizes the nature of the debate between justice and care approaches to animal ethics, focusing on Brian Luke's arguments against justice approaches. Section II provides pro-justice rebuttals to Luke's objections. These rebuttals, while largely successful against Luke's objections, do not account for the intuition that sympathy does play a central epistemological role in animal ethics. Section III explains how sympathy cognitively simulates the perspective of the other, and thus can play an epistemological role in animal ethics. I argue that the abilities to simulate the perspective of the other and to reason from moral principles can complement each other. In section IV, I argue that though it may not be desirable to use both sympathy and reasoning from principles in all moral deliberation, it is a desirable aim when offering, and considering, moral arguments for what I will term the "extensionist project" of extending over moral concern to animals. I make this idea plausible by elucidating the claim that arguments for this project are best thought of as second-order deliberations about our first-order deliberative life.

Animal Rights↗

Nurse moral distress: a proposed theory and research agenda.

As professionals, nurses are engaged in a moral endeavour, and thus confront many challenges in making the right decision and taking the right action. When nurses cannot do what they think is right, they experience moral distress that leaves a moral residue. This article proposes a theory of moral distress and a research agenda to develop a better understanding of moral distress, how to prevent it, and, when it cannot be prevented, how to manage it.

Adaptation, Psychological↗

The sociomoral reflection measure: applicability to Swedish children and adolescents.

The Sociomoral Reflection Measure (SRM; Gibbs & Widaman, 1982) was developed as a group administerable instrument for measuring developmental stages of moral reasoning. The aim of this study was to examine its reliability and construct validity, employing a sample of 542 Swedish elementary and high school students (aged 8-17), from schools within metropolitan Stockholm. Interrater reliability varied between 0.83 and 0.92, and the internal consistency coefficient was 0.76. Factor analyses of the norms (on which the overall score is based) revealed one factor for the oldest age group (16-17 years), but two factors among the younger subjects (8-15 years), clearly separating the norms related to each of the two moral dilemmas. The Sociomoral Reflection Maturity Score was moderately, but significantly, related to both age and grade. The results suggests that, although used in a non-American context and with self-trained raters, the SRM seems highly applicable in Sweden, at least for research purposes.

Adolescent↗

Workplace diversity: a leadership challenge. Managing diversity is a social, financial, and moral imperative.

Fostering workplace diversity is about building an organizational culture that embraces personal differences and encourages heterogeneous persons to work together toward a common end. Setting in motion the transition to a more inclusive and productive workplace is an uncommon challenge and the primary responsibility of leaders, especially in Catholic healthcare. The origins of diversity can be found in creation itself. Not only are we united as a people of God and as members of the body of Christ, we are bound together through our shared humanity. Three values are especially relevant to promoting diversity in the workplace: respect for human dignity, the common good, and distributive justice as participation in the common good. Economic incentives strengthen the theological and moral motives for developing a diverse work force. Organizations' financial success will depend ultimately on how well diversity is integrated into the organizational culture. As a process, managing diversity enables healthcare leaders to discover new ways to develop the potential of all employees and at the same time improve performance and production. At the heart of managing diversity lies the reform of internal systems, structures, and processes. Managing diversity also requires the transformation of the organization's culture. Initiatives that are useful for setting a positive future course include conducting a cultural audit, establishing a cultural diversity task force, and putting in place a diversity "champion" who is accountable directly to the chief executive officer.

Catholicism↗

Framing the future: embryonic stem cells, ethics and the emerging era of developmental biology.

Throughout the 20(th) century, advances in biology were accomplished largely through the study of biochemical parts apart from their place within the whole organism. This reductive and analytic approach, which has culminated in the sequencing of the human genome, has now led us back to the study of living beings. When applied to human biology, this inquiry re-opens the most fundamental questions concerning the moral meaning of developing life. The current conflict over ES (embryonic stem) cell research is just the first in a series of difficult controversies that will require us to clearly and precisely define the boundaries of humanity that we seek to defend. Through a careful consideration of the social, political, and scientific foundations of our current debate, we may discern the terms of a possible resolution that can sustain social consensus while opening avenues for scientific advance. Four such proposals were discussed in a May 2005 publication by the President's Council on Bioethics, entitled "Alternative Sources of Pluripotent Stem Cells." One of these methods, altered nuclear transfer, proposes to use the technology of somatic cell nuclear transfer (SCNT), but with a pre-emptive genetic or epigenetic alteration that precludes the integrated and coordinated organization essential for natural embryogenesis. The moral and scientific dimensions of this proposal are discussed as a way forward for embryonic stem cell research as well as a frame for further studies in developmental biology.

Animals↗

Rational diagnosis and treatment.

Clinical decisionmaking includes reasoning from prescientific or scientific theories, reasoning from uncontrolled or controlled experience, and reasoning based on empathic understanding and moral beliefs. The development of contemporary clinical thinking is discussed, and it is found that successive generations of medical practitioners have had different views of the rationality and relative importance of these modes of reasoning: that which is considered rational by one generation of doctors is sometimes denounced by the next. The author's book, Rational Diagnosis and Treatment, which is an example of clinical thinking in the 1960s and early 70s, is used to illustrate one particular view of clinical decisionmaking.

Clinical Trials as Topic↗

Assessing moral distress in respiratory care practitioners.

OBJECTIVE: To test the reliability and validity of a modified moral distress tool, originally developed for the nursing profession, on respiratory care practitioners. To describe the relationship between moral distress, career dissatisfaction, and job turnover in respiratory care. DESIGN: A 28-question survey was developed. Three categories of survey questions were predefined: "individual responsibility," "not in the patient's best interest," and "deception." Additional questions measured career dissatisfaction, job turnover, and demographic information. SETTING: University Hospital at the University of Virginia Health System, a 552-bed tertiary care hospital. SUBJECTS: Fifty-seven of 115 (49.6%) of respiratory care practitioners responded to the survey. INTERVENTIONS: Exploratory factor analysis was used to investigate the underlying factor structure. After we extracted theoretically meaningful factors, reliability of each factor was estimated. Multiple regression analysis was conducted to test if the underlying factors predicted career dissatisfaction and job turnover. MEASUREMENTS AND MAIN RESULTS: The factor analysis yielded a five-factor structure. Several questions in the "not in patient's best interest" category scored the highest moral distress including disagreements with surrogate decision makers and providing futile care. Higher scores were also found with questions regarding the perception of unsafe staffing and passively or actively participating in deception. None of the demographic variables predicted career dissatisfaction or job turnover. However, the perception of unsafe staffing was found to be a significant factor in predicting career dissatisfaction and job turnover. CONCLUSIONS: In this one-center pilot study, respiratory care practitioners reported experiencing moral distress in many areas of their practice. Distress related to the perception of unsafe staffing may be related to career dissatisfaction and job turnover. Further exploration of the factors that contribute to respiratory care practitioners' moral distress is needed, as well as implementing ways to ameliorate it.

Adult↗

A team approach to musculo-skeletal disorders.

INTRODUCTION: The majority of patients with musculo-skeletal problems referred to hospitals in the UK have to wait for months, if not over a year, before finally seeing an orthopaedic surgeon. In Stobhill Hospital, Glasgow, the waiting time for an out-patient appointment was 182 days in 1995, with only 20% of the referrals requiring surgery. The aim of this paper was to reduce the out-patient waiting times based on a co-ordinated team approach. METHODS: An outpatient musculo-skeletal service was developed over a 7-year period at Stobhill Hospital. The traditional consultant-based model, in which the consultant and a trainee saw all new patients referred to the hospital, was gradually replaced with a team approach, based on continuous reconfiguration of the roles of the orthopaedic surgeon and rheumatologist and extending the roles of nurses, physiotherapists and podiatrists. This was achieved by: (i) protocol-based daily triage for all referrals to the most appropriate health professional in the team, by the senior out-patient nursing staff; (ii) allocation of appointments based on clinical priority, with a fast-track for urgent cases; and (iii) improvement of inter-disciplinary communication, facilitating the retraction as well as the extension of traditional roles. RESULTS: Despite the number of GP referrals to the orthopaedic out-patient department at Stobhill nearly doubling in a period of 5 years, the out-patient waiting time decreased by about 50% (90 days from 182 days). This reduction in waiting times improved patient and GP satisfaction levels. We also noticed an improved morale and personal development of the health professionals as they saw patients appropriate to their skills and expertise. CONCLUSION: The team's experience demonstrates the effectiveness of a team approach in tackling what is often seen as the insoluble problem of orthopaedic waiting times. This is based on excellent communication and collaboration, with a clear aim of improving patient care that is evidence based.

Clinical Protocols↗

Joining together to combat poverty.

The International Poverty and Health Network (IPHN) was created in December 1997 following a series of conferences organized by the World Health Organization, with the aim of integrating health into plans to eradicate poverty. Around 1.3 billion people live on less than US$1 per day. Of the 4.4 billion people in developing countries nearly 60% lack access to sanitation, 30% do not have clean water, 20% have no health care, and 20% do not have enough dietary energy and protein. Even among rich nations there are gross socioeconomic inequalities. Many children are robbed of their physical and mental potential through poverty. Expressed in constant 1963 US dollars, an average Croatian family needed the annual income of US$894 to meet the poverty line in 1960 and US$9,027 in 1995. Accordingly, 9-25% of Croatian households were below the poverty line between 1960 and 1995. The increase in the poverty rate after 1991 was compounded by the war that destroyed almost a third of industrial capacity and infrastructure. Dissipation of the communist economy and inadequate privatization have contributed to the increase in unemployment rate, corruption, and other social ills. IPHN invited Croatian Medical Journal to publish this editorial to help push the issue of poverty up political and medical agendas on a global level. We argue that a factor contributing to the failure of most large-scale programs against poverty to date is the excessive emphasis on material and infrastructure assistance at the expense of spiritual, moral, and intellectual development.

Croatia↗

Decision-making in palliative care practice and the need for moral deliberation: a qualitative study.

The development of palliative care is increasing the interest in the moral problems that arise in the practice of palliative care. It is not clear how caregivers deal with these moral problems. In this article, we focus on the decision whether to continue treatment or to withhold it, and discuss the way caregivers deal with this question amongst themselves and in communication or consultation with the patient. We look at moral deliberation, the process of identifying the crucial arguments for this decision in palliative care.

Adaptation, Psychological↗

Development of the school organisational health questionnaire: a measure for assessing teacher morale and school organisational climate.

BACKGROUND: A growing body of empirical evidence suggests that organisational factors are more important than classroom specific issues in determining teacher morale. Accordingly, it is necessary to have available measures that accurately assess morale, as well as the organisational factors that are likely to underpin the experience of morale. AIM: Three studies were conducted with the aim of developing a psychometrically sound questionnaire that could be used to assess teacher morale and various dimensions of school organisational climate. SAMPLE: A total of 1,520 teachers from 18 primary and 26 secondary schools in the Australian state of Victoria agreed to participate in three separate studies (N = 615, 342 and 563 in Studies 1, 2 and 3, respectively) that were used to develop the questionnaire. The demographic profile of the teachers was similar to that found in the Department as a whole. METHOD: All teaching staff in the participating schools were asked to complete a self-report questionnaire as part of the evaluation of an organisational development programme. RESULTS: A series of exploratory and confirmatory factor analyses were used to establish the questionnaire's factor structure, and correlation analyses were used to examine the questionnaire's convergent and discriminant validity. CONCLUSIONS: The three studies resulted in the 54-item School Organisational Health Questionnaire that measures teacher morale and 11 separate dimensions of school organisational climate: appraisal and recognition, curriculum coordination, effective discipline policy, excessive work demands, goal congruence, participative decision-making, professional growth, professional interaction, role clarity, student orientation, and supportive leadership.

Adolescent↗

The virtues in the moral education of nurses: Florence Nightingale revisited.

The virtues have been a neglected aspect of morality; only recently has reference been made to their place in professional ethics. Unfashionable as Florence Nightingale is, it is nonetheless worth noting that she was instrumental in continuing the Aristotelian tradition of being concerned with the moral character of persons. Nurses who came under Nightingale's sphere of influence were expected to develop certain exemplary habits of behaviour. A corollary can be drawn with the current UK professional body: nurses are expected to behave in certain ways and to display particular kinds of disposition. The difference lies in the fact that, while Nightingale was clear about the need for moral education, current emphasis is placed on ethical theory and ethical decision-making.

Education, Nursing↗

On lying and the lie of a toddler.

For most of its history, the psychoanalytic literature on lying dealt exclusively with the dynamic, genetic meanings of lying: the problems for treatment presented by a patient who lies, and the technique used in dealing analytically with lies. In recent decades, issues relating to the moral and general development of children in relation to lying have been considered. In this paper, a lie told by a 21-month-old child is used to raise and explore questions about lying and its relation to intrapsychic structure and development. It is suggested that cognitive abilities and the psychic apparatus have to develop to the point that self can be distinguished from object, and a superego prototype must be present, before the means and motivations for lying are in place. This would date the beginning of the capacity to lie to sixteen to twenty-four months of age.

Age Factors↗

[Environment. Preventive health action in the creation of the environment].

The present quantitative importance of prevention is in Switzerland extremely low in comparison to the health budget of the national community. It has taken in recent years increasing place however in speeches and talks as well as in medical thinking. Prevention presently tends to be seen as a medical specialty among others and perhaps prefigures a new form of medicine, the object of which would be the societal body more than the body of the sick individual. In this perspective (would that be good?), a new type of physician-informatician-statistician might be trained, with the mission to manage and supervise the health status of the population. Preventive health action through the environment at large could fulfill an important role in the foreseeable developments. New health "morals" are currently emerging, which are bringing together numerous adepts. This might mean that the time of a "health society" (or health-determined society) is not far.

Attitude to Health↗

Effects of motor and sensory stimulation in stroke patients with long-lasting dysphagia.

Dysphagia is a common poststroke symptom with negative effects on recovery and rehabilitation. However, the orofacial regulation therapy, developed by Castillo Morales, comprising body regulation and orofacial regulation in combination with a palatal plate application has shown promising results in stroke patients. This therapy is based not only on muscle exercises but also on an improvement of the entire sensory-motor reflex arc involved in normal deglutition, and on the knowledge that the function of face and oropharynx at deglutition is closely interrelated with the entire body posture as well as with appropriate breathing. The treatment concept is relatively unknown to caregivers, partly due to lack of scientific evaluation of treatment results. The present investigation aimed to assess the effect of motor and sensory stimulation in stroke patients with dysphagia persisting for more than six months. Seven patients were evaluated with respect to orofacial and pharyngeal motility and sensory function before and two weeks after a five-week treatment period. The evaluation comprised a swallowing capacity test, a meal observation test, clinical examination of oral motor and sensory function, a velopharyngeal closure test, and videofluoroscopy. In addition, the symptoms were scored by the patients. An overall single-blind estimation showed objective and self-assessed swallowing improvement in all seven patients. Kappa coefficients are calculated on all reliability data, both inter- and intrarater reliabilities. Sensory and motor stimulation seems to be a promising therapy in stroke patients with long-lasting and persistent oropharyngeal dysphagia.

Aged↗

A developmental approach to child assent for nontherapeutic research.

The question of when and how to obtain child assent for nontherapeutic research has received increasing attention in recent years. Although child assent and parent permission are grounded in the principle of respect for persons, assent is often understood from the more narrow principle of respect for autonomy. When viewed in this way, "assent" is frequently conflated with "consent," and children are held to a higher standard than what might be sufficient for meaningful involvement in decision-making about research participation. When nested within the requirement for parental permission, child assent functions as a way to promote children's moral growth and developing autonomy, rather than as an autonomous decision. A developmental approach to child assent is necessary to understand how children can be meaningfully involved in decision-making about research participation across development. This approach suggests that the content and process of child assent should be allowed to vary across development. In addition, a developmental approach requires that future research employ longitudinal designs, examine the developmental mechanisms underlying age variations in child assent, and attend to both cognitive and noncognitive variables that may influence the assent process as children mature.

Child↗

The medical ethics of bone marrow transplantation in childhood.

Bone marrow transplantation has been utilized for the treatment of severe aplastic anemia in a program at The Children's Hospital Medical Center. A protocol has been developed to help ensure that the interests and rightful claims of all involved parties will be taken into account. Three cases are presented. In one case all involved parties concurred with the plan for bone marrow transplantation. In a second case the prospective donor was deemed mentally incompetent to give truly informed consent for the procedure. In a third case the parents were unwilling to have their child undergo transplantation. The ethical issues raised in these cases suggest the need for further development of a moral technology to enhance decision-making competence and to aid in the recognition and application of the rights of children without impeding the advancement of pediatric medicine.

Adolescent↗