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PubMedDate not supplied

[Discursiveness and co-authority in clinical ethics].

Clinical ethics, as instituted in committees, aims to solve ethical problems by means of interdisciplinary deliberation. Elucidation and deliberation are used a s pragmatic means whose finality is decision-making. This being so, it may be wondered if clinical ethics has not been pruned of its more global critical potential. Narrative approaches open some ways of thinking of this critical function, but they seem to us to be nevertheless still insufficient for the task. We propose to explore the heuristic and practical fertility of the concepts of discursiveness--more inclusive than narrativity--, and co-authority--that we will have to situate and relate to notions of power, expertise and normativity--, in order to give fresh thought to the role and functions of a clinical ethics committee in a health care institution, and consequently the possible contribution of clinical ethics both as deliberation process and critical reflection of practices. To achieve this result, we propose the following approach. First of all, we will identify the limits of current narrative proposals. Secondly, we will present the concept of discursiveness based on work that follows on from the ethics of discussion. Thirdly, we will expose our definition of the concept of co-authority in a discursive space which includes both the actors of the clinical situation and the actors of the deliberation. Fourthly and finally, we will draw the consequences for a critical theory of the role and functions of a clinical ethics committee.

Bioethics↗
PubMed1994

Clinical ethics as medical hermeneutics.

There are several branches of ethics. Clinical ethics, the one closest to medical decisionmaking, can be seen as a branch of medicine itself. In this view, clinical ethics is a unitary hermeneutics. Its rule is a guideline for unifying other theories of ethics in conjunction with the clinical context. Put another way, clinical ethics interprets the clinical situation in light of a balance of other values that, while guiding the decisionmaking process, also contributes to the very weighting of those values. The case itself originates ideas, not only about which value ought to predominate in its resolution, but also provides the origin of clinical rules that can be used in other cases. These are interpretive rules. Some examples of these rules are presented as well.

Beneficence↗
PubMed1999

Communicating their individual results to participants in an environmental exposure study: insights from clinical ethics.

The objective of this study was to formulate a framework for determining what information to communicate to individual subjects of a study measuring biomarkers of exposure, consistent with the principles of ethical clinical and research practice. Methods consisted of review of the scope of environmental exposure studies, including the use of biomarker measurement in clinical medicine and environmental research and the relevant principles of clinical ethics and research practice. An exposure biomarker study is designed to elucidate constitutional, behavioral, and environmental determinants of tissue concentrations of exogenous substances. Of itself, it is not designed to measure risk relations, those being the relation between biomarker levels and health outcomes. In many settings, measured tissue biomarker concentrations fall below those known or reasonably predicted to cause disease. Ethical clinical and research practice, aiming to maximize autonomy and beneficence and to minimize harm, requires that study findings concerning the determinants of exposure be communicated to study participants. In addition, investigators should reference clinical action levels beyond which individual biomarker results are routinely communicated to participants. When biomarkers have no known relation to risk, or when levels fall below action levels, it may be preferable not to communicate individual results, if this arrangement has been formalized at the time of informed consent.

Biomarkers↗
PubMed2005

Project examining effectiveness in clinical ethics (PEECE): phase 1-- descriptive analysis of nine clinical ethics services.

OBJECTIVE: The field of clinical ethics is relatively new and expanding. Best practices in clinical ethics against which one can benchmark performance have not been clearly articulated. The first step in developing benchmarks of clinical ethics services is to identify and understand current practices. DESIGN AND SETTING: Using a retrospective case study approach, the structure, activities, and resources of nine clinical ethics services in a large metropolitan centre are described, compared, and contrasted. RESULTS: The data yielded a unique and detailed account of the nature and scope of clinical ethics services across a spectrum of facilities. General themes emerged in four areas-variability, visibility, accountability, and complexity. There was a high degree of variability in the structures, activities, and resources across the clinical ethics services. Increasing visibility was identified as a significant challenge within organisations and externally. Although each service had a formal system for maintaining accountability and measuring performance, differences in the type, frequency, and content of reporting impacted service delivery. One of the most salient findings was the complexity inherent in the provision of clinical ethics services, which requires of clinical ethicists a broad and varied skill set and knowledge base. Benchmarks including the average number of consults/ethicist per year and the hospital beds/ethicist ratio are presented. CONCLUSION: The findings will be of interest to clinical ethicists locally, nationally, and internationally as they provide a preliminary framework from which further benchmarking measures and best practices in clinical ethics can be identified, developed, and evaluated.

Benchmarking↗
PubMed2005

Clinical ethics, information, and communication: review of 31 cases from a clinical ethics committee.

OBJECTIVES: To summarise the types of case brought to the Clinical Ethics Committee of the National Hospital of Norway from 1996 to 2002 and to describe and discuss to what extent issues of information/communication have been involved in the ethical problems. DESIGN: Systematic review of case reports. FINDINGS: Of the 31 case discussions, (20 prospective, 11 retrospective), 19 cases concerned treatment of children. Twenty cases concerned ethical problems related to withholding/withdrawing of treatment. In 25 cases aspects of information/communication were involved in the ethical problem, either explicitly (n = 3) or implicitly (n = 22). CONCLUSION: Problems related to information/communication may underlie a classic ethical problem. Identification of these "hidden" problems may be important for the analysis, and hence, the solution to the ethical dilemma.

Adult↗
PubMed2006

[Legal repercussions of Clinical Ethics Committees reports].

Clinical Ethics Committees and Research Ethics Committees have their own specific roles. The Clinical Ethics Committee's pronouncements have an advisory function, whereas Research Ethics Committees' decisions are binding. This article analyzes the legal impact of the Clinical Ethics Committees' reports. Legal and medical reasoning share the same practical nature. Both can have several correct answers to the same situation. Clinical Ethics Committees deliberate about these alternatives and analyze the involved values. Their conclusions are non-compulsory recommendations. They do not replace nor diminish the doctor's personal responsibility. Even though the Clinical Ethics Committees' reports are not binding, they constitute a sort of "expert's opinion", expressed by qualified professionals, who assume their own professional responsibility as advisors. The members' behavior is necessarily subject to constitutional and legal regulations. When judges review the Clinical Ethics Committee's reports, they must realize that their nature is advisory, and also consider them an essential element to reduce the gap between the medical and legal fields. In this way, the problem of increasingly transforming medicine into a legal issue can be prevented.

Ethics Committees, Clinical↗
PubMedDate not supplied

Developing clinical ethics committees.

Formal clinical ethics review first developed in the USA and most hospitals there have structures in place. This is often a clinical ethics committee. Developments have been slower in the UK, where there has been uncertainty and variability about the role of clinical ethics committees. Even in the USA, their exact role is uncertain. Although we now have a good idea of the mechanisms for ethical review of clinical issues in NHS trusts and health authorities, the desirability, composition and terms of reference for clinical ethics committees should be agreed as part of the clinical governance agenda.

Ethics Committees, Clinical↗
PubMed2001

Is there a future for clinical ethics services in Australia?

Clinical ethics refers to the consideration of ethical issues arising directly in the context of patient care. Health professionals are generally adept at effectively and sensitively managing ethical issues in clinical care. However, in some settings, multidisciplinary clinical ethics services may enhance clinical practice by assisting clinicians, patients and others to identify, understand and manage ethical issues. Clinical ethics services may be particularly valuable for situations in which moral perspectives diverge or communication has deteriorated. Such services may facilitate discussion and help the parties find mutually satisfactory solutions. Clinical ethics services may take various forms, including clinical ethics committees, ethics consultants, patient advocates or other mechanisms for responding to complaints and grievances. There is considerable disagreement about key aspects of clinical ethics services, including who should conduct them, how they should be run and what role they should play in decision-making.

Adult↗
PubMedDate not supplied

The business of ethics. Hospitals need to focus on managerial ethics as much as clinical ethics.

Business ethics begins with the recognition of the various values and "goods" involved in judgements of what to do. Four key values are individual rights, individual self-interest, the company's best interest, and the public good. Often a company has to choose which of these goals or values should be subordinated to another. Business ethics, then, must clarify priorities among these values and establish priority principles to resolve conflicts. One approach to contemporary business ethics emphasizes personal integrity, focusing on conflicts of interest; another approach stresses social responsibility, focusing on the effect of company policy on groups and individuals in society. In business, most of the attention to conflicts of interest focuses on the conflict between employee self-interest and the firm's interest. Healthcare organizations may need to focus on potential conflicts between the patient's interest and the institution's or physician's interest. Physician referrals and pharmaceutical companies' marketing practices are two areas with potential conflicts. Not-for-profit organizations have been quicker than the business world to acknowledge social responsibility. In many ways, however, the social impact of healthcare policies and decisions has not been as carefully considered as it should be. Institutionalizing deliberation about clinical ethical issues has helped to raise awareness about the ethical dimensions of medical care. It would also be useful to institutionalize attention to business ethics in healthcare.

Catholicism↗
PubMed1996

Performance-based assessment of clinical ethics using an objective structured clinical examination.

PURPOSE: To further examine the objective structured clinical examination (OSCE) as a performance-based assessment method for clinical ethics. METHOD: In the spring of 1993, a volunteer sample of 88 final-year medical students from all five Ontario medical schools took a four-station OSCE that used standardized patients and involved decisions to forego life-sustaining treatment. Performance was scored on a checklist of behaviors unique to each case. Data were analyzed for reliability using intraclass correlation coefficients and the Spearman-Brown prophecy formula. RESULTS: Reliability of the test was only .28 as a result of a low average inter-station correlation of .07. To achieve a test reliability of .8, 41 stations (almost seven hours of testing time) would be required. CONCLUSION: Because of its low test reliability, the OSCE is not a feasible stand-alone method for summative evaluation of clinical ethics. This performance-based evaluation method should be combined with other, more reliable evaluation methods. The OSCE has promise for formative evaluation.

Educational Measurement↗
PubMed2005

[What are the clinical ethics committees doing?].

BACKGROUND: Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. To assess the quality and function of the committees, a national research project was initiated in 2004. METHODS: A questionnaire on composition, resources, qualifications, tasks and routines was mailed to all committees. The response rate was 75% (21 out of 28). RESULTS: The committees are interdisciplinary and meet on average nine times per year. Only three (14%) chairs have been given dedicated time. Ten (48%) committees have separate budgets. Major tasks include getting the committee established, educating employees, deliberations (cases and more general questions), and guidelines. Main issues are withholding and withdrawing treatment, communication, patient autonomy, involuntary treatment, and priority setting. 16 committees have specific deliberation procedures. Minutes were taken in approximately half of the case deliberations. Systematic evaluation is scarce. INTERPRETATION: During a short period the committees have increased their competence and served over 2000 hospital employees, mainly through seminars. The committees probably already contribute to quality assurance in ethical decision making. The committees want more case consultations. Important challenges are obtaining sufficient resources, making the committees better known, and establishing routines.

Clinical Competence↗