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PubMed2007

Ethical difficulties in clinical practice: experiences of European doctors.

BACKGROUND: Ethics support services are growing in Europe to help doctors in dealing with ethical difficulties. Currently, insufficient attention has been focused on the experiences of doctors who have faced ethical difficulties in these countries to provide an evidence base for the development of these services. METHODS: A survey instrument was adapted to explore the types of ethical dilemma faced by European doctors, how they ranked the difficulty of these dilemmas, their satisfaction with the resolution of a recent ethically difficult case and the types of help they would consider useful. The questionnaire was translated and given to general internists in Norway, Switzerland, Italy and the UK. RESULTS: Survey respondents (n=656, response rate 43%) ranged in age from 28 to 82 years, and averaged 25 years in practice. Only a minority (17.6%) reported having access to ethics consultation in individual cases. The ethical difficulties most often reported as being encountered were uncertain or impaired decision-making capacity (94.8%), disagreement among caregivers (81.2%) and limitation of treatment at the end of life (79.3%). The frequency of most ethical difficulties varied among countries, as did the type of issue considered most difficult. The types of help most often identified as potentially useful were professional reassurance about the decision being correct (47.5%), someone capable of providing specific advice (41.1%), help in weighing outcomes (36%) and clarification of the issues (35.9%). Few of the types of help expected to be useful varied among countries. CONCLUSION: Cultural differences may indeed influence how doctors perceive ethical difficulties. The type of help needed, however, did not vary markedly. The general structure of ethics support services would not have to be radically altered to suit cultural variations among the surveyed countries.

Adult↗
PubMed2001

A national study of ethics committees.

Conceived as a solution to clinical dilemmas, and now required by organizations for hospital accreditation, ethics committees have been subject only to small-scale studies. The wide use of ethics committees and the diverse roles they have played compel study. In 1999 the University of Pennsylvania Ethics Committee Research Group (ECRG) completed the first national survey of the presence, composition, and activities of U.S. healthcare ethics committees (HECs). Ethics committees are relatively young, on average seven years in operation. Eighty-six percent of ethics committees report that they played a role in ongoing clinical decision making through clinical ethics consultation. All are engaged in developing institutional clinical policy. Although 4.5% of HECs write policy on managed care, 50% of HEC chairs feel inadequately prepared to address managed care. The power and activity of ethics committees parallels the composition of those committees and the relationship of members to their institutions. The role of ethics committees across the nation in making policies about clinical care is greater than was known, and ethics committees will likely continue to play an important role in the debate and resolution of clinical cases and clinical policies.

Data Collection↗
PubMedDate not supplied

Medical students' understanding of ethical issues in the ambulatory setting.

BACKGROUND: The education of medical students concerning ethical issues focuses mainly on critically ill hospitalized patients. However, in the outpatient setting physicians encounter many problems that require ethical decision making. The present study is an assessment of medical students' awareness and understanding of ethical issues commonly encountered in the ambulatory setting. METHODS: A questionnaire was designed to evaluate general knowledge of medical ethics using 12 clinical vignettes. These vignettes depict situations in the ambulatory setting which involve ethical problems. The questionnaire was distributed to medical students who were asked to state whether an ethical issue was present, its significance, and what the specific issue was. RESULTS: Students' abilities to identify that an ethical issue was involved in each vignette ranged from 34.2% to 96.4%. A majority of students identified the presence of an ethical dilemma in seven out of 12 vignettes. The significance rating varied from 2.8 to 4.4 on a scale of 1 to 5. The results indicate that traditional education in medical ethics does not necessarily prepare students to recognize these problems in the clinical setting. CONCLUSIONS: The medical students surveyed for this study seem to be variably prepared to recognize obvious ethical dilemmas in the ambulatory setting. Medical education must prepare students to recognize and appropriately manage these commonly encountered situations.

Beneficence↗
PubMed1994

The status of ethics education in obstetrics and gynecology.

To establish the present status of ethics education in obstetrics and gynecology, 256 questionnaires were sent to residency (graduate) and student (undergraduate) education programs. One hundred ninety-eight questionnaires were returned. Fifteen programs offered no ethics education; 167 offered resident level courses; 123 offered undergraduate (student) level courses; and 84 offered postgraduate education. The median number of hours offered was 2 undergraduate, 4 graduate, and 2 postgraduate. The courses offered relied primarily on formal lecture presentation, even though this was not considered most effective by the respondents. Most institutions (85%) used more than one format to present ethics material. General ethics principles were covered in 78% of the reporting institutions. Where ethics case histories were used, they were rated higher in efficacy by the respondents. Only 15% of the reporting institutions had any means of measuring outcomes. The issues cited most frequently as critical in a curriculum were abortion, maternal-fetal conflicts, issues surrounding care decisions at the end of life, and informed consent. The few hours dedicated to ethics were small relative to a long list of issues. Obstetric-gynecologic faculty with any training in medical ethics were uncommon (29%). The form of teaching, except in rare circumstances, seemed to lack structure or design and used few of the available reading materials. Recommendations from this survey include the development of a uniform national curriculum for undergraduate and graduate medical ethics, development of evaluation alternatives for ethics education, and encouragement and support for faculty development in medical ethics.

Bioethical Issues↗
PubMed1994

The hyperreality of clinical ethics: a unitary theory and hermeneutics.

Medical ethics nowadays is dominated by a conception of ethics as the application of moral theories and principles. This conception is criticized for its depreciation of the internal morality of medical practice and its narrow view of external morality. This view reflects both a lack of interest in the empirical realities of medicine and a neglect of the socio-cultural value-contexts of medical ethical issues, including the creative development of a broader philosophical framework for a practicable medical ethics. Several alternative approaches and conceptions have been proposed. The unified clinical ethics theory, developed by Graber and Thomasma, is an interesting attempt to synthesize these alternative approaches. It correctly identifies as the crucial problem the present disconnectedness of medical ethics from theoretical philosophy as well as the practice of medicine. In this paper, however, it is argued that the unitary theory should take more serious attention to the hermeneutic character of medicine as well as ethics. This implies that the unitary theory must in fact transform itself into an interpretive clinical ethics theory. The theoretical characteristics and practical consequences of an interpretive theory of medical ethics are discussed in the present paper.

Attitude↗
PubMed1998

Medical ethics research between theory and practice.

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illness of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.

Anthropology, Cultural↗
PubMed2003

Sacrifice: an ethical dimension of caring that makes suffering meaningful.

This article is intended to raise the question of whether sacrifice can be regarded stituting a deep ethical structure in the relationship between patient and carer. The significance of sacrifice in a patient-carer relationship cannot, however, be fully understood from the standpoint of the consistently utilitarian ethic that characterizes today's ethical discourse. Deontological ethics, with its universal principles, also does not provide a suitable point of departure. Ethical recommendations and codices are important and serve as general sources of knowledge when making decisions, but they should be supplemented by an ethic that takes into consideration contextual and situational factors that make every encounter between patient and carer unique. Caring science research literature presents, on the whole, general agreement on the importance of responsibility and devotian with regard to sense of duty, warmth and genuine engagement in caring. That sacrifice may also constitute an important ethical element in the patient-carer relationship is, however, a contradictory and little considered theme. Caring literature that deals with sacrifice/self-sacrifice indicates contradictory import. It is nevertheless interesting to notice that both the negative and the positive aspects bring out importance of the concept for the professional character of caring. The tradition of ideas in medieval Christian mysticism with reference to Lévinas' ethic of responsibility offers a deeper perspective in which the meaningfulness of sacrifice in the caring relationship can be sought. The theme of sacrifice is not of interest merely as a carer's ethical outlook, but sacrifice can also be understood as a potential process of transformation health. The instinctive or conscious experience of sacrifice on the part of the individual patient can, on a symbolic level, be regarded as analogous to the cultic or religious sacrifice aiming at atonement. Sacrifice appears to the patient as an act of transformation to achieve atonement and healing. Atonement then implies finding meaningfulness in one's suffering. The concept of sacrifice, understood in a novel way, opens up a deeper dimension in the understanding of suffering and makes caring in 'the patient's world' possible.

Altruism↗
PubMed2005

Fetuses with neural tube defects: ethical approaches and the role of health care professionals in Turkish health care institutions.

Neural tube defects (NTDs) are very serious malformations for the fetus, causing either low life expectancy or a chance of survival only with costly and difficult surgical interventions. In western countries the average prevalence is 1/1000-2000 and in Turkey it is 4/1000. The aim of the study was to characterize ethical approaches at institutional level to the fetus with an NTD and the mother, and the role of health care professionals in four major centers in Turkey. The authors chose perinatology units of four university hospitals and prepared questionnaires for the responsible professionals concerning their own and their institution's ethical approaches to the fetus with an NTD and the mother. The investigation revealed that there were no institutional ethical frameworks or ethics committees available to professional teams in the units. The roles of the health care professionals and their individual decisions and approaches based on ethical principles are described. The ethical decision-making process concerning fetuses with NTDs, examples of institutional approaches to the topic and institutional frameworks, and the role of nurses and other health care professionals are all discussed, based on a literature review. The authors suggest that institutional ethical frameworks, ethics committees, professionals' ethics education and multidisciplinary teamwork should be established for critical situations such as fetuses with an NTD.

Decision Making↗
PubMed2005

The ethics of research using electronic mail discussion groups.

AIM: The aim of this paper is to identify and discuss the ethical considerations that have confronted and challenged the research team when researchers facilitate conversations using private electronic mail discussion lists. BACKGROUND: The use of electronic mail group conversations, as a collaborative data generation method, remains underdeveloped in nursing. Ethical challenges associated with this approach to data generation have only begun to be considered. As receipt of ethics approval for a study titled; 'Describing transition with people who live with chronic illness' we have been challenged by many ethical dilemmas, hence we believe it is timely to share the issues that have confronted the research team. These discussions are essential so we can understand the possibilities for research interaction, communication, and collaboration made possible by advanced information technologies. DISCUSSION: Our experiences in this study have increased our awareness for ongoing ethical discussions about privacy, confidentiality, consent, accountability and openness underpinning research with human participants when generating data using an electronic mail discussion group. We describe how we work at upholding these ethical principles focusing on informed consent, participant confidentiality and privacy, the participants as threats to themselves and one another, public-private confusion, employees with access, hackers and threats from the researchers. CONCLUSION: A variety of complex issues arise during cyberspace research that can make the application of traditional ethical standards troublesome. Communication in cyberspace alters the temporal, spatial and sensory components of human interaction, thereby challenging traditional ethical definitions and calling to question some basic assumptions about identity and ones right to keep aspects of it confidential. Nurse researchers are bound by human research ethics protocols; however, the nature of research by electronic mail generates moral issues as well as ethical concerns. Vigilance by researchers is required to ensure that data are viewed within the scope of the enabling ethics approval.

Confidentiality↗
PubMed2007

Ethics and the pediatric surgeon.

PURPOSE: Care of infants and children with life-impairing or life-threatening congenital and acquired disorders often raises ethical concerns for pediatric surgeons. The purpose of this survey was to determine the level of interest in clinical ethics and how respondents would manage ethical dilemmas within several clinical case scenarios. METHODS: A 12-item validated questionnaire developed by the Ethics and Advocacy Committee was provided for the American Pediatric Surgical Association (APSA; www.eapsa.org) members on the organizational website. General categories of questions included informed consent, patient privacy, and what constitutes research. RESULTS: The survey was completed by 235 of the 825 APSA members; a response rate of 28.4%. The majority (62%) were in academic practice, 22% had additional education or an advanced degree in ethics, and 11% were members of a hospital ethics committee. There was a clear majority response for seven questions. Topics generating the most controversy included the impact of consent by minors, decision making in the neurologically devastated child, what constitutes research in pediatric surgery, the use of interpreters for consent, and patient privacy. Respondents chose a well-referenced manuscript as the preferred modality for ethics education of the APSA members. CONCLUSION: Pediatric surgeons have a general interest in clinical ethics as it relates to the care of their patients. An important mission of the Ethics and Advocacy Committee can be to provide education that gives guidance and knowledge to the members of APSA on timely topics in surgical ethics.

Adolescent↗
PubMed2001

Organization ethics or compliance: which will articulate values for the United States' healthcare system?

There have been two major stimuli leading to the institution of compliance/ethics programs. One has been Justice Department attention and the need for a government approved compliance program. The other has been the JCAHO's promulgation of standards addressing organization ethics issues. Many healthcare organizations have seen the requirements imposed on them by JCAHO (and the necessity to have a mechanism to address federal compliance as separate issues) and have developed two compartmentalized programs. But the intensity with which the government has pursued and will continue to pursue its "fraud and abuse" program means that most healthcare organizations now support and encourage the institution of compliance programs, while allowing organization ethics initiatives to become marginalized within the organization. This approach may ignore consideration of the larger issue of what each of these activities means for a healthcare organization that is attempting to define itself based on its stated values. Although using two separate groups to focus on these particular issues may fulfill the letter of the law for both the Federal Government and the JCAHO, we believe attention to these issues is better accomplished under the umbrella of a single committee. This pathway for attention to accreditation and compliance issues within an HCO is one that may serve the HCO better than two committees working on similar issues but with separate agendas. Nothing here should be construed as a suggestion that the goal of developing a comprehensive values-oriented organization ethics program should be abandoned. Instead, we have offered an assessment of the current environment and current direction of the healthcare organization--an assessment that leads us to the conclusion that instituting organization ethics programs that are not linked to or incorporated somehow within compliance programs will probably fail. This is a frustrating position for those who believe that compliance programs may ultimately undermine the goals of an organization ethics program. Nevertheless, it is important to realize that the legal compliance of an HCO, like its compliance to high standards of ethics, are considerations that determine the ethical climate of an organization. In the absence of a consensus concerning the values that should inform the larger healthcare system, it may be the only consideration that all healthcare organization stakeholders can agree upon, and so may represent the only stable and consistent platform ethically to evaluate the activities of the healthcare organization at the present time. This can be the basis for each HCO to develop its values-oriented ethical program which will define and support the organization's ethical climate for the organization, its staff, its patients, and its community.

Accreditation↗
PubMed2000

[Does nursing need its own ethics?].

In contrast to a medicine and medical ethics dominated by the physician, nurses claim more professional autonomy, domains of independent responsibility and recognition of their own moral judgment and ethical reflection. In my article I endorse these claims, but I object to the widespread opinion that their fulfillment requires a nursing ethics of its own, in the sense of a specific moral theory for nursing. Such a "special ethics" would be counterproductive to the concerns of nurses, and just as mistaken as a special medical or physicians ethics. Instead, a critique of medicine on the basis of a general ethics is required both for nurses and physicians. Part I presents arguments against mistaken conceptions of a special nursing ethics. Part II outlines elements of a general ethics for medicine and nursing. Part III explains my understanding of an ethical critique of medicine, which is founded upon the distinction of three conceptual dimensions of medicine: as science, institution and practice. This critique focuses the ethical attention on the life situation of the patient. Consequences for argumentative support and political fulfillment of the nurses' claims mentioned will thereby become evident.

Ethics, Medical↗
PubMed2002

Ethical and professional issues in pathology: a survey of current issues and educational efforts.

Professionalism, including ethics, has assumed greater importance in residency education, and the Accreditation Council for Graduate Medical Education now requires its incorporation into residency training. Insight into current ethics education, as well as those ethical issues important to pathology, would be efficacious. A mail survey was sent to all members of the Association of Pathology Chairs that asked for specific information related to pathology resident education in ethics and identification of important ethical issues in the current practice of pathology. A total of 148 surveys were mailed, and 53 (35.8%) were returned. Formal instruction in ethics is provided by approximately 62% of pathology residency training programs, and 94% provide informal ethics education. However, 84% of programs believed that ethical issues were underrecognized, and 38% believed that current ethics training was inadequate. Issues regarding the use of tissue for research, confidentiality and privacy, and professionalism were identified as the most important ethical issues currently encountered in pathology.

Bioethics↗
PubMed1999

Analysis of Texas & New Mexico Hospice Organization's new Code of Ethics.

Unique among professional codes of ethics is the Texas & New Mexico Hospice Organization's Code of Ethics. Where other codes concentrate only on principles-based ethics, this new code identifies five models of bioethics currently used in resolving ethical dilemmas. This report's primary purpose analyzes the code's four precepts in the context of (1) principles-based ethics, (2) casuistic-based ethics, (3) covenant-based ethics, (4) evidence-based ethics and narrative-based ethics. The second purpose is to present the practicality of these often esoteric concepts in the day-to-day work of palliative care providers. Indications are that this code of ethics, because of its broad scope, is more useful than other principles-based-only codes.

Ethics, Institutional↗
PubMed2006

Ethical codes in nursing practice: the viewpoint of Finnish, Greek and Italian nurses.

AIM: This paper is a report of a study exploring the use of ethical codes and obstacles to their use in nursing practice as perceived by Finnish, Greek and Italian nurses. BACKGROUND: In all European countries nurses are responsible for the well-being of patients, for their own technical and ethical competence and, for their own part, for the high standard of health care in society. These points illustrate the central content areas of nursing codes of ethics. Recent advances in medical technology have added to the complexity of nursing. Nurses today are increasingly confronted with ethical dilemmas, underlining the role and meaning of ethical codes in their decision-making. However, there is only very limited research literature on codes of ethics, their use in nursing practice and obstacles to their use. METHODS: Twenty-three focus group interviews were conducted in 2003 with a total of 138 Registered Nurses: 35 in Finland, 54 in Greece and 49 in Italy. The data were content analysed. FINDINGS: Two main categories emerged from our analysis of the use of ethical codes: (1) conscious and (2) unconscious use. Seven main categories described the obstacles to the use of ethical codes: (1) the codes themselves, (2) nurses themselves, (3) multiprofessional teamwork, (4) patients' family members, (5) the organization, (6) the nursing profession and (7) society/healthcare policy. Participants in all three countries were firmly committed to the values expressed in ethical nursing codes. Nonetheless, continued efforts are needed in all these countries to remove the remaining obstacles so that nursing care can be provided in keeping with the requirements of ethical codes. CONCLUSION: The use of codes is connected with the changes in nursing profession and in society at large. The core of nursing, however, has remained stable. Future studies should be conducted in order to generalize the findings to a broader population.

Adult↗
PubMed2004

Institutional ethics review of clinical study agreements.

Clinical Study Agreements (CSAs) can have profound effects both on the protection of human subjects and on the independence of investigators to conduct research with scientific integrity. Sponsors, institutions, and even investigators may fail to give adequate attention to these issues in the negotiation of CSAs. Despite the key role of CSAs in structuring ethically important aspects of research, they remain largely unregulated and unreviewed for adherence to ethical norms. Academic institutions routinely enter into research contracts that fail to meet adequate ethical standards. This is a failing that can have serious consequences. Accordingly, it is necessary that some independent body have the authority both to review research contracts for compliance with norms of subject protection and ethical integrity, and to reject studies that fail to meet ethical standards. Such review should take place prior to the start of research, not later. Because of its expertise and authority, the institutional ethics review board (IRB or REB) is the appropriate body to undertake such review. Much recent commentary has focused on contractual restrictions on the investigator's freedom to publish research findings. The Olivieri experience, and that of other investigators, has brought freedom of publication issues into sharp focus. Clinical study agreements also raise a number of other ethical issues relating to human subjects and research integrity, however, including disclosures relating to patient safety, data analysis and reporting, budget, confidentiality, and premature termination of the study. This paper describes the ethical issues at stake in structuring such agreements and suggests ethical standards to guide institutional ethics review.

Bioethical Issues↗
PubMed1995

Chinese Confucian culture and the medical ethical tradition.

The Confucian culture, rich in its contents and great in its significance, exerted on the thinking, culture and political life of ancient China immense influences, unparalleled by any other school of thought or culture. Confucian theories on morality and ethics, with 'goodness' as the core and 'rites' as the norm, served as the 'key notes' of the traditional medical ethics of China. The viewpoints of Confucianism on benevolence and material interests, on good and evil, on kindheartedness, and on character cultivation were all inherited by the medical workers and thus became prominent in Chinese traditional medical ethics. Hence, it is clear that the medical profession and Confucianism have long shared common goals in terms of ethics. Influenced by the excellent Confucian thinking and culture, a rather highly-developed system of Chinese traditional medical ethics emerged with a well-defined basic content, and the system has been followed and amended by medical professionals of all generations throughout Chinese history. This system, just to mention briefly, contains concepts such as the need: to attach great importance to the value of life; to do one's best to rescue the dying and to heal the wounded; to show concern to those who suffer from diseases; to practise medicine with honesty; to study medical skills painstakingly; to oppose a careless style of work; to comfort oneself in a dignified manner; to respect local customs and to be polite; to treat patients, noble or humble, equally, and to respect the academic achievements of others, etc. Of course, at the same time, Confucian culture has its own historical and class limitations, which exerted negative influences on traditional medical ethics. Now, if we are to keep up with the development of modern medicine, a serious topic must be addressed. That is how to retain the essence of our traditional medical ethics so as to maintain historic continuity and yet, at the same time, add on the new contents of medical ethics so as to incorporate modern features into our system. Therefore, when trying to reform medical practice in China, we are faced with the urgent need to inherit and promulgate the essence of Confucian ethics--discarding its obsolete concepts--while at the same time building up the new medical ethics that can meet the requirements of the outside world and the future.

Beneficence↗
PubMed2002

Ethical activism: strategies for empowering medical social workers.

Little empirical research examines the extent medical social workers try to change attitudes, norms, expectations, and protocols to create a hospital environment that encourages their participation in ethical deliberations. The researchers developed an ethical activism scale that measured the extent medical social workers engaged in such ethical activism, confirming its reliability from data obtained from a sample of 162 medical social workers in 37 hospitals in the Los Angeles basin. They tested seven hypotheses that probed the extent specific ethics-training, organizational, and demographic variables influence the extent social workers engage in ethical activism. Data strongly suggest the need to expand ethics training to include tactics of ethical activism, since many social workers do not engage in ethical activism. Data also suggest the need to target such training to social workers in hospitals that are relatively unreceptive to social workers' participation in ethical deliberations, since social workers are least likely to engage in ethical activism in such settings.

Decision Making, Organizational↗