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Ethics is the application of values and moral rules to human activities. Bioethics is a subsection of ethics, actually a part of applied ethics, that uses ethical principles and decision making to solve actual or anticipated dilemmas in medicine and biology. This article focuses on the primary principles of biomedical ethics and their implications for physicians in the ED.
Ethicists differ considerably in their reasons for using empirical data. This paper presents a brief overview of four traditional approaches to the use of empirical data: "the prescriptive applied ethicists," "the theorists," "the critical applied ethicists," and "the particularists." The main aim of this paper is to introduce a fifth approach of more recent date (i.e. "integrated empirical ethics") and to offer some methodological directives for research in integrated empirical ethics. All five approaches are presented in a table for heuristic purposes. The table consists of eight columns: "view on distinction descriptive-prescriptive sciences," "location of moral authority," "central goal(s)," "types of normativity," "use of empirical data," "method," "interaction empirical data and moral theory," and "cooperation with descriptive sciences." Ethicists can use the table in order to identify their own approach. Reflection on these issues prior to starting research in empirical ethics should lead to harmonization of the different scientific disciplines and effective planning of the final research design. Integrated empirical ethics (IEE) refers to studies in which ethicists and descriptive scientists cooperate together continuously and intensively. Both disciplines try to integrate moral theory and empirical data in order to reach a normative conclusion with respect to a specific social practice. IEE is not wholly prescriptive or wholly descriptive since IEE assumes an interdepence between facts and values and between the empirical and the normative. The paper ends with three suggestions for consideration on some of the future challenges of integrated empirical ethics.
The history of codes of ethics in health care has almost exclusively been told as a story of how medical doctors developed their own professional principles of conduct. Yet telling the history of medical ethics solely from the physicians' perspective neglects not only the numerous allied health care workers who developed their own codes of ethics in tandem with the medical profession, but also the role that gender played in the writing of such professional creeds. By focusing on the predominantly female organization of the American Physiotherapy Association (APA) and its 1935 "Code of Ethics and Discipline," I demonstrate how these women used their creed to at once curry favor from and challenge the authority of the medical profession. Through their Code, APA therapists engaged in a dynamic dialogue with the male physicians of the American Medical Association (AMA) in the name of professional survival. I conclude that, contrary to historians and philosophers who contend that professional women have historically operated under a gender-specific ethic of care, the physiotherapists avoided rhetoric construed as feminine and instead created a "business-like" creed in which they spoke solely about their relationship with physicians and remained silent on the matter of patient care.
Central concepts and consensus views in clinical ethics are marked by instability. The papers in this number of the Journal take up two such central concepts, quality of life and moral status, and two such consensus views, that germ-line gene transfer should not be undertaken for the purposes of enhancement of human traits and that the ethical obligation of physicians to treat HIV-infected patients rests on consent of the physician. One outcome of these philosophical investigations is that these two concepts and consensus views are less stable than one might have thought. I explore the possibility of generalizing this outcome in a reflection on clinical ethics as the management of instability and incompleteness, including the instability and incompleteness of clinical ethics itself. In the course of this reflection I liken clinical ethics to abstract expressionism in mid-twentieth century Western art.
Examples of ethical dilemmas, emerging in the context of a resident case-centered seminar, are used to illustrate a proposed approach to instruction in ethics for child and adolescent psychiatry residents. In addition to a rudimentary formal didactic curriculum, a teaching methodology is outlined that intentionally focuses on ethical problems, approaches to analyses, proposed courses of action, and attempts at resolution. Four representative issues are utilized: confidentiality, treatment refusal, treatment termination, and the interface of individual and family therapies. Educational objectives include the increased recognition by child and adolescent psychiatry trainees of potential ethical conflicts, of the utility of ethical analyses to inform choices of clinical interventions, and of the desirability of forestalling premature action before attempts at thoughtful resolution.
Nurses regularly are faced with ethical situations in their practice. Despite potentially having had as part of their educational programs an ethics course or specific classes addressing ethical issues, many nurses still feel ill-equipped when ethical dilemmas occur. This article discusses the Code for Nurses as a resource that nurses can use for determining the appropriate action(s) when an ethical dilemma arises.
PURPOSE: To develop an instrument to measure how hospital nurses perceive the ethical climate of their work setting and to evaluate its psychometric properties. A way to measure ethical climate can help nurses understand the work setting influences on their practice and can be used to diagnose areas for organizational change as well as to evaluate effectiveness of organizational interventions. DESIGN: Descriptive. Instrument developed was the Hospital Ethical Climate Survey (HECS). Sampled were 360 RNs (48% response rate) employed in clinical practice at two acute-care hospitals in one U.S. midwestern city. The nurses completed a questionnaire in 1993-1994 consisting of items developed to assess their perceptions of ethical climate, along with the 43-item Integrity Audit, a social desirability scale, and a demographic inventory. METHODS: Construct validity was assessed by confirmatory factor analysis (CFA) using the LISREL 7 statistical program. RESULTS: The final CFA model consisted of 26 variables in five factors, which were organized according to the relationships of nurses with peers, patients, managers, hospital, and physicians. Internal consistency reliability, using Cronbach's alpha, for the final 26-item instrument was 0.91 (range 0.68 to 0.92) for the subscales. CONCLUSIONS: The Hospital Ethical Climate Survey has acceptable initial reliability and validity.
Despite the dramatic increase over recent years in the research and teaching of medical ethics, there exists no theoretical framework within which to conceptualize ethical problems in medicine, to say nothing of solutions to these problems. The model proposed here attempts to fill this void by developing a conceptual understanding of the nature of moral dilemmas that can be applied to both theoretical and practical problems in medicine. Practical applications are demonstrated in three areas: personal ethical problem solving, hospital ethics committees, and the teaching of medical ethics. Suggestions are offered for the extension of these and other applications of the model, a model proposed as a foundation to be built upon through further research and daily experiences in a world of conflicting values.
Ethics as a discipline and certainly morals as a force in decision-making is not new. However, the remarkable advances in science and technology that have occurred during the past 30 years have brought to the bedside unforeseen dilemmas, forcing health care professionals to take an ethical look at the care they deliver. Powerful diagnostic techniques, sophisticated surgical procedures, effective drugs, and worthwhile therapeutic interventions have enabled health care practitioners to eliminate many diseases and minimize disability. This progress has brought enormous human benefit. Unfortunately, coupled with these dramatic results is a reality that sometimes the quality of life produced is much less than what was desired. Our capacity to prolong life has not coincided with our ability to restore some level of health. Medical interventions have been able to maintain vital functions without always benefiting the underlying disease process. The rapidity with which technology has perpetuated ethical issues within the clinical setting has often lead to hasty and arbitrary decision-making. It is only with a thrust toward preventive ethics that decisions can be thoughtful and beneficial to patients and families. Thus, this article focuses on the implementation of policies that minimize and/or prevent ethical conflicts.
Institutional ethics committees are a well-established mechanism for dealing with ethical dilemmas at large health-care institutions. The presence of these committees at small rural hospitals is a recent phenomenon. Because such hospitals are nonspecialized and isolated and have limited resources, they do not naturally encourage the development and growth of ethics committees. The experience of larger institutions with such committees is not readily adaptable, and role models are lacking. The experience of rural Vermont hospitals with ethics committees shows that these committees can function fully at small hospitals and have three stages of development. To accelerate the evolution of ethics committees at small rural hospitals, networking between these hospitals and an association with academic centers are needed. State medical societies can also support these committees by endorsing and sharing resources.
During the 1990s medical ethics will undergo changes. Individual clinical issues, especially those related to death and dying, will continue to create conflict and preoccupy hospital staffs. But professional ethicists will focus on social concerns more frequently than they have in the past. Following are some of the most crucial ethical issues and directions they are likely to take in this decade: Clinical practice and the law will move toward less demanding standards of proof regarding the withdrawal of treatment from patients who are no longer competent. Public policy will set more lenient standards for judging whether a person would refuse artificial nutrition and hydration if he or she were able. Unless sensible people strengthen the distinction between active and passive euthanasia, more physicians and legislatures will move toward physician-assisted suicide. Those proposing a higher-brain definition of death, as opposed to whole-brain definitions, will gain ground with the general public, but not with legislators. New transplantation technologies will increase medical options but create more problems with paying for the procedures. As techniques are perfected, ethical questions will focus more on financing than on the source of transplantable material. AIDS treatment priorities will clash with other medical demands (e.g., treatment for breast cancer), and concerns about protecting both providers and patients from contracting AIDS will move policy toward routine testing. Progress in public argument will be made on the abortion issue. Members of ethics committees will have to be trained to address financing issues. Some medical schools and residency programs will add courses on the concept of character and on character development to their ethics programs.(ABSTRACT TRUNCATED AT 250 WORDS)
Since World War II the Catholic Church and national and international study groups have issued separate sets of statements regarding the ethics of research involving human subjects. The Church and the study groups agree on several points, including the following: Research on human subjects is a vital part of scientific medicine. Ethical research requires the informed consent of the subject or proxy. Research on human subjects is therapeutic or nontherapeutic. The risk of harm involved in research must be considered in regard to the potential benefit. Research on human beings should be allowed only after appropriate research on animals. Researchers should practice equity in selecting subjects and scientific problems to be studied. The human subject or proxy should be free to withdraw from the research program at any time. The two sets of statements generally disagree about nontherapeutic research on embryos and about genetic research. They also disagree on the use of in vitro fertilization and embryo transplants to initiate pregnancy. The disagreements are due to dissimilar ethical systems. The Church bases ethical analysis on a study of the effect an action has on basic human goods. As a result of this analysis, the Church maintains that some human actions are good or evil in themselves. If the action is evil insofar as the natural needs and functions of a person are concerned, it is not ethically good simply because it results in a good outcome.(ABSTRACT TRUNCATED AT 250 WORDS)
High-quality care and concern for the poor are among the core values that all Catholic healthcare facilities share. And marketing is a proven tool for extending those values. In times past, healthcare providers, including Catholic facilities, were concerned about whether healthcare marketing was ethical. Much of the concern focused on advertising and promotion. A number of ethical violations do appear in hospital advertising. But government and professional organizations have established guidelines for ethics in advertising. Hospitals should encourage their marketing professionals to personally adhere to these codes. To ensure marketing activities are conducted ethically, a hospital must clearly articulate its commitment to ethical marketing; ensure that marketing professionals adhere to this commitment; and monitor activity. These steps should extend to a hospital's strategic plan, particularly its mission statement. Although strategic planning has many critical elements, the heart of the plan and the process is the mission statement, the expression of an organization's distinctiveness. For a Catholic hospital, this distinctiveness is found in two tiers of value: the core Catholic values, as articulated by its religious sponsors, and the institution's specific values flowing from its history, location, and services. If a religious healthcare provider is really committed to its values, it will actively affirm them in its marketing.
Giles Scofield's argument indicates ethics consultants may need to better clarify what in fact they are and what they are not doing, claiming, and striving for. But we must not step back too far. We must neither engage in putting in envious professional claims for exclusive rights in the area of difficult and momentous decisions in healthcare nor get stuck in discussing normative ethics at the level of metaphysics, ontology, and dogmatics (as has happened in Germany for decades). We must not do so especially in view of the achievements of ethics consultation and the growing demand for it by all parties involved, conceded even by sceptics. Ethics consultation, according to Scofield, appears to be dangerous....Let us look more closely at the logic of the argument by discussing the presumed "antidemocratic" nature. The "new tyranny" of thoughts, and the "proper" role of bioethics consultation. Some considerations about the possibility of ethics expertise shall be left for the end.
Moral problems in dentistry have both a technical and an evaluative component, but expertise in clinical dentistry does not confer expertise in clarifying evaluative issues. Ethical expertise consists of the capacity either to provide strong justifications for a range of ethical propositions or to perform a skill well according to the moral rules and virtues of a practice. I consider four areas of ethical expertise, the contributions that ethics experts might make to the practice of dentistry, and who the likely candidates to be ethics experts are.
Principles, values, and ethics constitute an ethical system that provides nurses a context in which to make ethical decisions. As the managed care environment generates new ethical issues and intensifies already existing ones, ethical education and decision-making skills become even more critical to nursing professionals, as well as physicians and hospital administrators.
Values are imbedded in our cultural background and environment. Yet each generation must rethink and reshape ethics in relation to the values of its own time. This is particularly true for healthcare professionals. National nurses' associations owe it to their members to keep them informed about ethical issues and to provide guidance. To be released by ICN at end-April, "Ethics in Nursing Practice" gives a detailed guide to ethical decision making (see advertisement on inside back cover). Below, how Swiss nurses are tackling the ethical issues.
BACKGROUND: Ethics consultation is a relatively new service in clinical medicine. Most such services have been developed in departments of internal medicine. Few studies have evaluated the results of such consultations, and none have examined whether a family practice perspective enhances the consultation process. METHODS: An ethics consultation service was established in the Department of Family Medicine at Loma Linda University School of Medicine in 1990. Data were collected from the consultations performed during the first year. A questionnaire was sent to the attending physicians for their evaluation of the service. RESULTS: Ethics consultations were provided to the health care teams of 46 patients in five clinical departments. The attending physicians found the consultations to be important in clarifying ethical issues, educating the team, increasing confidence in decisions, and in patient management in more than 90% of the cases; however, the consultations resulted in significant changes in patient management only 36% of the time. CONCLUSIONS: It is feasible to establish an ethics consultation service within a department of family medicine in a university hospital and to provide consultations to physicians in other specialties.