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PubMed1993

Clinical ethics and happiness.

Most contemporary accounts of clinical ethics do not explain why clinicians should be ethical. Those few that do attempt an explanation usually claim that clinicians should be ethical because ethical behavior provides an important good for the patient--better care. Both these approaches ignore the customary traditional reason for being ethical, namely, the good of the moral agent. This good was commonly called 'happiness'. The following article shows how the personal happiness of the moral agent provided a major reason for being ethical in the ancient philosophical and biblical traditions and how it continues to play a role in the more modern rights-based, Kantian and utilitarian theories. This history suggests that the personal happiness of the clinician, rightly understood, is a legitimate and important goal of clinical ethics.

Ethical Analysis↗

PubMed2000

Ethics consultation on demand: concepts, practical experiences and a case study.

Despite the increasing interest in clinical ethics, ethics consultation as a professional service is still rare in Europe. In this paper I refer to examples in the United States. In Germany, university hospitals and medical faculties are still hesitant about establishing yet another "committee". One of the reasons for this hesitation lies in the ignorance that exists here about how to provide medical ethics services; another reason is that medical ethics itself is not yet institutionalised at many German universities. The most important obstacle, however, may be that medical ethics has not yet demonstrated its relevance to the needs of those caring for patients. The Centre for Ethics and Law, Freiburg, has therefore taken a different approach from that offered elsewhere: clinical ethics consultation is offered on demand, the consultation being available to clinician(s) in different forms. This paper describes our experiences with this approach; practical issues are illustrated by a case study.

Beneficence↗

PubMed1997

Toward a hermeneutic model of ethical decision making in clinical practice.

Documented ethical violations and empirical research have demonstrated that, despite professional standards and formal training in ethical principles, some psychotherapists engage in unethical behaviors that compromise the welfare of clients. It appears that competing values and interests that emerge in the therapeutic endeavor can interfere with therapists' considerations of ethical standards and their willingness to act ethically. Expanding current models of ethical decision making, this article offers a hermeneutic model that recognizes that in addition to moral reasoning, the context of the therapeutic relationship and the therapist's subjective responses are fundamental considerations in the interpretation and application of ethical interventions. Implications for understanding and training of ethics in psychotherapy in this broader context are explored.

Altruism↗

PubMed1993

Today's ethics committees face varied issues. A CHA survey reveals committees' functions, authority, and structure.

In a survey of Catholic Health Association member hospitals, 92 percent indicated they have formal ethics committees at their institutions. Sixty-two percent said their ethics committees were formed between 1983 and 1989. The survey found that current ethics committees are still committed to their traditional roles--education, policy development, and case review--but the education is directed to more diverse audiences than in the past. Support for medical and nursing staffs may be emerging as another possible function of ethics committees. The issues that precipitated the formation of institutional ethics committees have become more complex. In particular, questions involving the appropriate use of technology, the renewed awareness of patients' rights, changing relationships among healthcare providers, and conflicting social values have continued to require the intervention of ethics committees. However, the frequency with which respondents said their committees provide case consultations seems lower than it should be if committees were used to their full advantage. The institutional ethics committee can play a part in enlarging the current healthcare reform debate and promoting moral values. It can address such important questions as, Should the well-being of individuals take precedence over the well-being of communities?

Bioethical Issues↗

PubMedDate not supplied

Ethics in the management of health care organizations.

This article introduces the topic of ethics in the management of health care institutions and provides a glimpse at how issues of ethics have grown in recent years and are apt to be applied in the future. Ethics and some of its basic conceptual and practical tools are defined. A brief history of the ethics of managing health care institutions, a crucial context for understanding the contemporary ethics of health care institutions, is provided. What has changed in the past 10 years and how those changes have resulted in the ethical heterogeneity of contemporary health care institutions is discussed. Finally, some preventive ethics strategies for the management of health care institutions are suggested.

Beneficence↗

PubMed1981

Frequency of ethical dilemmas in a medical inpatient service.

We studied the frequency of ethical problems in a general medical ward at a university hospital, using a quasi-experimental prospective design. In the baseline period, ethical problems were determined by self-report of residents. In the intervention period, one of us (B.L.) was a participant-observer during attending rounds. Ethical problems were determined by consensus among the attending physician, resident, and participant observer. No significant differences between baseline and intervention periods were found in patient variations, admissions per resident, or rating of each resident's sensitivity to ethical issues. In the baseline period, seven (3.9%) of 179 cases involved ethical problems. In the intervention period, 16 (17%) of 92 cases involved ethical problems. This difference was significant. The data imply that residents underidentify ethical problems but that sensitization, sympathetic listening, information, and advice increase physician recognition of ethical problems.

California↗

PubMed2000

Physicians' ethical beliefs about cost-control arrangements.

BACKGROUND: Although much has been written about the ethics of new methods of health care financing, little is known about the extent to which physicians experience these cost-control arrangements as ethical problems. METHOD: A cross-sectional telephone survey of 1,549 physicians, 8 to 17 years after residency, randomly selected from 75 US metropolitan service areas (response rate, 74.0%). RESULTS: Only 17.0% believed that financial incentives to limit services are ethically acceptable. Although 52.9% thought that physicians should try to abide by guidelines discouraging the use of interventions with possible but unproven benefit, only 14.5% thought such guidelines should be enforced by payers. Only 5.7% thought that it was morally acceptable for payers to discourage physicians from telling patients about their personal financial incentives, and only 9.1% found compliance with such restrictions morally acceptable. Changes in the health care system in the past 5 years were believed to have had a negative impact on their own patients' trust in them by 50.6%, and 80.8% believed that changes in the health care system in the past decade have diminished physicians' commitment to an ethic of undivided loyalty to patients. In multiple regression analysis, physicians who reported that the overall personal financial incentives in their practices encouraged them to reduce services were significantly more likely to have ethical objections to such incentives, to believe their own patients' trust in them had diminished, and to believe that the ethic of undivided loyalty to patients had diminished. CONCLUSIONS: Many of the methods now commonly used to influence medical decision making are considered ethically objectionable by most midcareer physicians. Whether their ethical disquiet about these arrangements is justified cannot be answered from these data.

Attitude of Health Personnel↗

PubMed1995

Use of ethical criteria in medical decision making. Corneal transplantation.

OBJECTIVES: To determine for a defined procedure the prevalence of the use of 15 criteria currently or historically relied on to select recipients of scarce medical resources, and to compare this use with the determinations of a report of the American Medical Association Council on Ethical and Judicial Affairs identifying many of these criteria as ethically appropriate or inappropriate for such use. DESIGN: Survey. PARTICIPANTS: All US members of a national cornea society were sent survey instruments. Approximately 63% (214/340) responded. MAIN OUTCOME MEASURES: Mean ratings on a scale of 1 to 5 (not important to very important) for each of the allocation criteria with regard to degree of influence on the decision to perform a corneal transplantation. RESULTS: Ethically appropriate criteria tended to receive high overall ratings, and inappropriate criteria, low ratings. Three ethically inappropriate criteria received relatively high ratings: previous use of resources, perceived obstacles to treatment, and contribution of patient to disease. High percentages of respondents applied ratings other than not important to all criteria deemed ethically inappropriate. CONCLUSIONS: Certain ethically inappropriate criteria may have been viewed as influencing graft survival and thus thought to have ethically appropriate aspects, mitigating to some degree the aforementioned three ratings. Nonetheless, the study supports the need for standard setting and educational efforts about criteria for the allocation of medical resources to ensure that ethically inappropriate criteria are consciously excluded from decision making and to stimulate discussion and raise consciousness regarding this important issue.

Beneficence↗

PubMed1995

Ethics of research training for NIH T32 surgical investigators.

As part of the revised curriculum of the NIH T32 Training Grant mechanism, 6 hr of formal instruction in ethics of research are now required. We therefore implemented a four-session seminar (6 hr total time) structured around assigned readings, didactic presentations, and group discussions. The objective of this research project was to assess whether this new program provided our trainees with a framework for ethical conduct in research. Twelve trainees completed the ethics course; 8 trainees who had not yet taken the ethics course served as a control group. All trainees answered a 72-item questionnaire of our own design that examined a variety of issues in research ethics. We compared the responses of seminar participant and nonparticipant groups using the Fisher exact test and Student t test for nominal and ordinal data, respectively. Both groups of trainees perceived that too much emphasis was placed on quantity rather than quality of publications. Both groups felt that this pressure emanated from department chairmen rather than laboratory mentors (P < 0.0001). In contrast to these shared perceptions, the two groups demonstrated many differences in their comprehension of research ethics. For example, compared to the controls, trainees who participated in the ethics course believed that they could define potential NIH standards for data storage and research mentorship (P < 0.05), understood gratuitous manuscript authorship (P < 0.05), were comfortable in dealing with outlier or discordant data (P < 0.10), and, most pertinently, were fully prepared to seek third-party input into an ethical dilemma involving their own work (P < 0.006).(ABSTRACT TRUNCATED AT 250 WORDS)

Animal Experimentation↗

PubMedDate not supplied

Ethical responsibilities in nursing: research findings and issues.

Discussions in the literature assert that nurses are becoming increasingly cognizant of their ethical responsibilities, but that they are often ill prepared to participate in ethical decision making. A review of selected research literature from 1970 to 1987 was undertaken to validate these assertions. A total of 12 studies related to ethical responsibilities was identified in the review; all studies were published between 1980 and 1987. The majority of studies were at the descriptive and exploratory levels and employed Kohlberg's cognitive theory of moral development as their conceptual framework. Significant findings related to educational level and ethical responsibilities were consistent across studies. Findings related to age and clinical experience were mixed; the effects of economic level, religion-religiosity, ethnicity, and other variables on ethical responsibilities were not significant. Issues raised in the light of the existing research include the use of Kohlberg's theory as a conceptual orientation in nursing groups and limited data on the reliability and validity of instruments used in measuring ethical constructs. Recommendations for future research on ethical responsibilities include the validation of Kohlberg's theory for nursing investigations, exploration of other frameworks for developing a multidimensional view of ethical responsibilities, and the use of qualitative research designs.

Behavioral Research↗

PubMedDate not supplied

Ethics committees in long-term care facilities.

Biomedical ethical dilemmas occur in long-term care facilities (LTCFs), particularly in the absence of residents' advance directives. Ethics committees are required in hospitals and long-term care facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), but many LTCFs do not have JCAHO accreditation. A survey of LTCFs in one county in a Southwestern state found that only 29% of those LTCFs responding had an organized ethics committee. This article discusses the purpose, membership, and meetings of an ethics committee in LTCFs. A sample process for resolving a biomedical ethical dilemma is presented. Nurses can initiate the development of an ethics committee using available resources or combining resources with other local LTCFs. The ethics committee should consider the education of all persons involved to facilitate resolution of clinical ethical dilemmas.

Advance Directives↗

PubMed2005

Members of research ethics committees accepted a modification of the randomized consent design.

BACKGROUND AND OBJECTIVE: The use of randomized consent designs has been subject of methodologic and ethical controversy. In most Western countries, research ethics committees make the decision as to whether a randomized consent design can be applied. The purpose of the study is to assess to what extent a randomized consent design and a modification of this design is accepted by research ethics committees, in terms of ethics, health law, and methodology. METHODS: A postal survey was conducted among members of research ethics committees in the United Kingdom, and in The Netherlands, with professional competence in ethics, (health) law, methodology, or clinical practice. RESULTS: In both the UK and in The Netherlands, the modified randomized consent design appears to be statistically significantly more acceptable than the randomized consent design, with respect to ethical and judicial aspects. The overall rejection rate of the randomized consent design was 66% in the UK and 59% in The Netherlands. However, the modified randomized consent design was rejected by 47 and 41% in the two countries, respectively. CONCLUSION: the modified randomized consent design appears to be more acceptable than the randomized consent design. To increase consistency in the way research ethics committees handle study protocols, a discussion about the use of randomized consent designs appears necessary.

Ethics Committees, Research↗

PubMed1992

Ethical conflicts in the prehospital setting.

STUDY OBJECTIVE: To assess the range of ethical conflicts that confront prehospital care providers. DESIGN: Convenience sample, from October 1989 to January 1990. SETTING: An urban advanced life support emergency medical service that transports approximately 3,000 patients per month. METHODS: Six hundred seven paramedic responses were analyzed by a single observer. An ethical conflict was identified when the paramedic faced a dilemma about what "ought to be done" and the paramedic's values conflicted or potentially conflicted with the patient's. Cases with potential ethical consequence were brought to experts in medical ethics and epidemiology for further analysis and classification. RESULTS: Ethical conflicts arose in 14.4% of paramedic responses (88 of 607 cases). Twenty-seven percent of the conflicts involved issues of informed consent, such as refusal of treatment or transport, conflicts of hospital destination, treatment of minors, and consent for research. Difficulties regarding the duty of the paramedics, usually under threatening circumstances, accounted for 19% of the dilemmas encountered. Requests for limitation of resuscitation accounted for 14%. Other circumstances that presented ethical conflicts involved questions of patient competence (17%), resource allocation (10%), confidentiality (8%), truth telling (3%), and training (1%). CONCLUSION: The data demonstrate a range of ethical conflicts in the prehospital setting and point to areas in which policy needs to be developed. The data also can be used in a prehospital ethics curriculum for paramedics and physicians. Because case sampling was not strictly random, absolute conclusions should not be drawn regarding the frequency of the dilemmas.

Beneficence↗

PubMed2003

Public health ethics: teaching survey and critical review.

The last decade has witnessed development of the new field of public health ethics, as well as growing emphasis on the importance of ethics education to both students and graduates of the health care professions. Using a topic-based interpretation of public health ethics this paper presents a questionnaire survey of the nature and content of teaching of public health ethics to medical undergraduates and public health postgraduate students in the United Kingdom. Completed questionnaires were returned by 76.9% (20/26) of medical schools and 76.7% (23/30) of institutions teaching postgraduate public health courses. Public health ethics was described as being taught in 75% of medical schools and 52% of institutions providing postgraduate education. However, in both types of location the content and nature of teaching was patchy and often minimal. If medical schools and postgraduate institutions are serious about improving the discussion and teaching of ethical issues in public health, there will need to be considerable investment and commitment, accompanied by creativity and imagination. In parallel, the debate about the meaning of, and approaches to, public health ethics needs to be broadened and enriched. The topic-based interpretation of public health ethics has limitations. Alternatives are explored and critically reviewed.

Curriculum↗

PubMed2003

Nurse supervisors' actions in relation to their decision-making style and ethical approach to clinical supervision.

AIM: The aim of the study was to explore the decision-making style and ethical approach of nurse supervisors by focusing on their priorities and interventions in the supervision process. BACKGROUND: Clinical supervision promotes ethical awareness and behaviour in the nursing profession. METHODS: A focus group comprised of four clinical nurse supervisors with considerable experience was studied using qualitative hermeneutic content analysis. FINDINGS: The essence of the nurse supervisors' decision-making style is deliberations and priorities. The nurse supervisors' willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors' ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors' interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings. CONCLUSION: Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees' professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

Decision Making↗

PubMed2001

Medical ethics education: to what ends?

The goals of medical ethics education comprise several dimensions: legal duties to secure informed consent, tell the truth and protect confidentiality; objective competencies that include an understanding of DNR regulations and surrogate decision-making procedures; discursive moral skills such as moral sensitivity, reciprocity and moral development that combine into the capacity for moral dialogue and debate; and finally, behavioural goals that challenge moral education to nurture a more humane, sensitive and communicative physician. Part one of this paper describes each of these goals, together with some of the inherent difficulties affecting implementation. Part two presents survey data from medical ethics instructors (n = 126) who were asked about the importance of each goal and their ability to successfully achieve each aim. While each goal is highly rated, only those goals associated with legal duties and objective competencies are thought to be achieved with any degree of relative success. Goals associated with character transformation, unique to medical ethics education, are among the most difficult to achieve. Additional empirical data corroborate these impressions. Moreover, it is not clear that medical ethics education has much to do with good care. Empirical data are scarce and the conceptual relationship between ethics and care remains highly problematic. Part three offers a number of divergent interpretations of care and concludes that they have little to do with medical ethics. There is no reason to expect that medical competence should be affected by moral competence. Medical ethics therefore might then be viewed as an educational enhancement: unnecessary for healthy doctoring but desirable among a small percentage of the profession who maintain an interest in ethical problems.

Character↗

PubMedDate not supplied

Rural health care ethics: is there a literature?

To better understand the available publications addressing ethical issues in rural health care we sought to identify the ethics literature that specifically focuses on rural America. We wanted to determine the extent to which the rural ethics literature was distributed between general commentaries, descriptive summaries of research, and original research publications. We identified 55 publications that specifically and substantively addressed rural health care ethics, published between 1966 and 2004. Only 7 (13%) of these publications were original research articles while (12) 22% were descriptive summaries of research and 36 (65%) were general commentaries. The majority of publications examined (55%) were clinically focused while 27% addressed organizational ethics and 18% addressed ethical ramifications of rural health care policy at a national or community level. Our findings indicate that there are a limited number of publications focusing on rural health care ethics, suggesting a need for scholars and researchers to more rigorously address rural ethics issues.

Bibliometrics↗

PubMed2001

Managed mental health care: attitudes and ethical beliefs of child and pediatric psychologists.

OBJECTIVE: To examine child and pediatric psychologists' ethical beliefs and attitudes toward managed mental health care. METHODS: In a survey mailed in spring 1997, 252 child and pediatric psychologists responded to three vignettes depicting ethical dilemmas related to working with managed mental health care (confidentiality, restriction of services, misdiagnosis). Data were collected about psychologists' ethical choices and reasons given for choices, attitudes toward managed care, the extent to which managed care affected ethical decision making, and level of managed care involvement. RESULTS: Differences were found in choices made for the ethical dilemmas in regard to what participants thought they should do, would do, and actually did do. Overall, participants endorsed negative attitudes toward managed care. Participants reported that managed care somewhat affected their ethical decision making for the vignettes. Level of managed care involvement was not related to ethical decision making or attitudes toward managed care. CONCLUSIONS: The findings suggest areas for examination as new ethical standards are created for work in managed care environments.

Adult↗