The clinical relationship has been underexplored in dementia care. This is in part due to the way that the clinical relationship has been articulated and understood in bioethics. Robert Veatch’s social contract model is representative of a standard view of the clinical relationship in bioethics. But dementia presents formidable challenges to the standard clinical relationship, including ambiguity about when the clinical relationship begins, how it weathers changes in narrative identity of patients with dementia, and how (...) the intimate involvement of family fits alongside a paradigmatically dyadic relationship. Drawing on work in recent feminist theory, a critique is offered of the standard clinical relationship in bioethics as underwritten by an individualistic conception of autonomy. An alternative view of the clinical relationship in dementia, one that embraces a relational account of autonomy, is put forward. (shrink)

This article discusses the response of our ethics consultation service to an exceptional request by a patient to have his implantable cardioverter defibrillator removed. Despite assurances that the device had saved his life on at least two occasions, and cautions that without it he would almost certainly suffer a potentially lethal cardiac event within 2 years, the patient would not be swayed. Although the patient was judged to be competent, our protracted consultation process lasted more than 8 months as we (...) consulted, argued with, and otherwise cajoled him to change his mind, all to no avail. Justifying our at times aggressive paternalistic intervention helped us to reflect on the nature of autonomy and the dynamics of the legal, moral, and personal relationships in the clinical decision-making process. (shrink)

The American Journal of Bioethics, Volume 12, Issue 2, Page 26-27, February 2012.

The issue of boundaries in clinician–patientencounters is considered through narrativeanalysis of four clinical stories in whichboundaries crossings are a self-conscioustopic. One story is by a physician as patient,two are by physicians, and one is by apalliative care nurse. The stories arediscussed using Walter Benjamin''s distinctionbetween the painter, who maintains distance andsees the whole, and the cameraman, who usestechnology to penetrate realities and thenreassembles fragments. The essay argues thatdistance and closeness are ethical issues thatconstitute the possibility of clinicalencounters but the (...) encounter also changes theclinician''s sense of boundaries. The relevantethics of boundary decisions in most clinicalencounters are not procedural ethics but anethics of self-creation: in orienting toboundaries as doctors do, they createthemselves in their relations to others. (shrink)

Background Nurses are challenged with many situations that require them to solve ethical dilemmas and make moral decisions based on professional values and a sense of accountability and responsibility. To support their decisions, it is important to know how they perceive and relate their ethical ideology, professional values, and clinical accountability in their workplace. Purpose The study’s aim was twofold: to investigate the ethical ideology and perceived importance of professional values and accountability among nurses. Further, explore the relationship between (...) each of ethical ideology and professional values with nurses’ work accountability. Methods A correlational study was conducted in an Egyptian hospital. All nurses were invited to participate = 192, and 150 nurses (78.3%) completed the study questionnaires. The Ethical Position Questionnaire, the Professional Values Scale, and the Clinical Vignettes Assessment for Clinical Accountability were proven to be reliable study measures. Ethical considerations Ethics Committee approval, written informed consent, data privacy and confidentiality, and participants’ right to voluntary participation and withdrawal were maintained. Results Nurses showed good ethical ideology (75 ± 6.2) and are more idealistic while maintaining professional values (108 ± 10.8). Most nurses believed they were accountable for documenting errors, completing incident reports, and calling physicians to discuss or manage the situations. Ethical ideology and the idealism subscale were positively correlated with overall nurses’ professional values (r = 0.321, p < 0.004, r =0.464, p 0.000), respectively. On the other hand, work accountability showed a partial correlation in some areas with ethical ideology and professional values. Discussion Professional values and nurses' accountability appear to be influenced by ethical positions and ideology. Conclusion Healthcare organizations should provide a supportive work environment to help nurses develop self-awareness, and knowledge of their ethical ideologies, which improve professional values and clinical accountability in their practice. Ethical ideology and professional values should be emphasized more in nursing curricula. (shrink)

The nature of the relationship between clinical investigator and research participant continues to be contested. The related discussions have largely focused on the doctor-researcher dichotomy thought to permeate the work of a clinical investigator with research participants, whom in turn occupy two corresponding roles: patient and subject. This paper contributes to current debates on the topic by providing a voice to research participants, whose perspectives have been largely invisible. It draws on 42 in-depth interviews conducted in Ghana and (...) South Africa with respondents at different stages of involvement in clinical research, ranging from no experience in clinical research to enrollment in several clinical trials. The perspectives of all respondents were largely congruent and rooted in the common view that clinical research contributed to the improvement of local health. They went beyond the researcher/participant versus doctor/patient dichotomy, long established in research ethics, and preferred to view participants and investigators as partners working together to find ways to address local health needs. The conceptualization of investigator-participant relations as a partnership reinforced expectations of care, transparency and accountability, which were viewed as necessary expressions of mutuality and respect within equal collaborations. It is important to engage with these views in order to avoid antagonizing societal expectations and to build up long-term public trust, crucial for the continuous operation of clinical research. (shrink)

BackgroundThe nature of the relationship between a clinical investigator and a research subject has generated considerable debate because the investigator occupies two distinct roles: clinician and scientist. As a clinician, the investigator has duties to provide the patient with optimal care and undivided loyalty. As a scientist, the investigator has duties to follow the rules, procedures and methods described in the protocol.Results and conclusionIn this article, I present a contextual approach to the investigator-subject relationship. The extent of the investigator's (...) duty to provide the patient/subject with clinical care can vary from one situation to the next, as a function of several factors, including: the research design, benefits and risks of the research; the subject's reasonable expectations, motivations, and vulnerabilities; the investigator's ability to benefit the subject; and the investigator's prior relationship with the subject. These and other factors need to be considered when determining the clinical investigator's obligations to provide clinical care to human research subjects. In some research contexts, the investigator has extensive clinical obligations to the patient/subject; in others, the investigator has minimal ones. (shrink)

In interprofessional clinical teams, the patients have interpersonal relationships with several practitioners. The aim of this study was to explore patients’ and practitioners’ perceptions of how such relationships may contribute to promote the whole team’s respect for the patient’s autonomy, as interpersonal patient–provider relationships may contribute to enhance patient autonomy. Sixteen qualitative in-depth interviews were conducted with 12 informants, including patients, nurses, physiotherapists, and physicians from three rehabilitation teams. Data were analysed according to Grounded Theory procedures. (...) The informants discussed interpersonal relationships as an integral and significant part of the team work. The practitioners tried to adjust their professional approach to the patients’ genuine opinions and let patients decide the teams’ goals. Close relationships with patients could be important to accomplish this, particularly described by nurses and physiotherapists, who could facilitate the communication with the rest of the team. (shrink)

In interprofessional clinical teams, the patients have interpersonal relationships with several practitioners. The aim of this study was to explore patients’ and practitioners’ perceptions of how such relationships may contribute to promote the whole team’s respect for the patient’s autonomy, as interpersonal patient–provider relationships may contribute to enhance patient autonomy. Sixteen qualitative in-depth interviews were conducted with 12 informants, including patients, nurses, physiotherapists, and physicians from three rehabilitation teams. Data were analysed according to Grounded Theory procedures. (...) The informants discussed interpersonal relationships as an integral and significant part of the team work. The practitioners tried to adjust their professional approach to the patients’ genuine opinions and let patients decide the teams’ goals. Close relationships with patients could be important to accomplish this, particularly described by nurses and physiotherapists, who could facilitate the communication with the rest of the team. (shrink)

Ethical issues in biomedical research are traditionally examined as distinct from those of clinical care. However, this traditional framing may obscure questions of equity and fairness in both rese...

Meaningful relationships are centrally important for human functioning. It remains unclear, however, which aspects of meaningful relationships impact wellbeing the most and whether these differ between psychiatric patients and members of the community. Information about relationship attributes and functions were collected in community members and psychiatric patients. Relationship attributes and functions were examined for differences between groups, their impact on wellbeing and symptoms, and the size of network. Community members reported fewer relationships, higher frequency of contact and (...) less desire for change when compared to the psychiatric patients. Nevertheless, both groups reported relatively high levels of fulfilled functions. Quality of the relationship and investment into the relationship was associated with both wellbeing and symptoms for both the community and the patient group. Almost all functions were associated with wellbeing and symptoms for the community group. However, for the patient group, only few functions were associated with wellbeing and no functions were associated with symptoms. Contrary to our hypotheses, the results show that psychiatric patients do not have a deficit in fulfilling relationships. Most people report a well-functioning network of meaningful, high-quality relationships. Patients benefit from meaningful, function-fulfilling relationships just as much as community members. Results are discussed with respect to how targeting relationships can be used clinically. (shrink)

The considerable attention to financial interests in clinical research has focused mostly on academic medical centers, even though the majority of clinical research is conducted in community practice settings. To fill this gap, this article maps the practices and policies in 73 community hospitals and several hundred specialized facilities around the country for reviewing clinical investigators’ financial relationships with research sponsors. Community hospitals face a substantially different mix of issues than academic medical centers do because their (...) physician researchers are usually not employees, and more of their studies are later-phase, multicenter trials. Accordingly, community physicians stand to benefit personally from per capita payments, but they tend to have less direct influence over research findings when compared with their academic peers. These and other contrasts require separate guidance for community-based organizations that takes into account their particular needs, circumstances, and institutional capacities. (shrink)

ObjectivesHostile attribution bias is reportedly common from non-clinical population to those with serious mental illness, such as schizophrenia, and is known to be closely related to theory of mind. This study aimed to investigate whether ToM skills mediate the relationship among neurocognitive ability, personality traits, and attribution bias.MethodsA total of 198 non-clinical youths were recruited. To assess their neurocognitive ability and ToM skills, the participants were asked to complete Raven’s Standard Progressive Matrices and the Korean version of the (...) Reading the Mind in Eyes Test. To determine their personality traits, the Eysenck Personality Questionnaire and interpersonal reactivity index were used. To evaluate hostile attribution bias, the Ambiguous Intentions Hostility Questionnaire was administered. Path analysis and bias-corrected percentile bootstrap methods were used to estimate model fit and the parameters of the mediating effects.ResultsBased on model comparison, the best model characterized two direct pathways from psychoticism and the K-RMET to hostility attribution bias and three indirect pathways, wherein SPM, perspective taking, and psychoticism influenced hostile attribution bias through K-RMET. The final model fit indices were good [x2/df = 1.126; comparative fit index = 0.996; root mean square error of approximation = 0.026; standard root mean square residual = 0.026 and Akaike information criterion = 28.251] and the K-RMET fully mediated the association between SPM, perspective taking, psychoticism, and hostile attribution bias.ConclusionThe main findings suggested that ToM skills, such as the RMET, play an important role in explaining the relationship among neurocognitive ability, personality traits, and hostile attribution bias. ToM skills and a remediation strategy may need to be developed to balance the enhanced hostility bias that underlies the paranoia. (shrink)

This article will explore a pregnant woman's experience of relationship with the fetus, using a clinical case study in which abortion would have been clinically indicated because of severe fetal abnormality. Emphasizing the pregnant woman's actual experience in this case study helps to highlight inadequacies in how the debate about abortion is usually conducted.

The interface between genetic research results and clinical practice occurs when patients present them- selves to physicians. When patients ask their doctors about the potential impact of a family disease on themselves, their children, and their grandchildren, physicians have an opportunity to be helpful. Unfortunately, the scientific discoveries are occurring faster than most physicians can read about them in their speciality journals and hence adjust their practice. Meanwhile, the press and media are proclaiming the latest scientific breakthroughs, creating a (...) preventive and curative expectation that physicians cannot fulfill.In this time of health system reorganization and consolidation, many people do not know who their primary caregiver is, no less which insurer is likely to cover which visit or genetic test. (shrink)

This paper examines a number of questions about the degree to which the clinical practice of medicine is affected, if at all, by the legal systems in four countries: Chile, Germany, Japan and the United States. The focus on these four countries in four different regions of the world offers a unique perspective within which to examine medical treatment decisions made by patients and their proxies or surrogates, the potential role for universal written instruments such as advance directives, the (...) cross-professional tensions between clinical and legal concerns in very distinct cultures, and the degree to which legal activities can change or affect clinical realities in the context of these different political and health care systems. We have incorporated, whenever relevant, the insights of many disciplines, including the social sciences, in analyzing the existing interrelations between law and behavior in this specific context. Der Beitrag untersucht, inwieweit die klinische Praxis in vier Ländern mit unterschiedlichen Rechtssystemen und Berufskulturen durch Rechtsnormen oder das Verständnis von Recht beeinflußt wird. Es wird gefragt, welche Funktion rechtliche Interventionen bei der Veränderung von Verhaltensnormen in unterschiedlichen Gesundheitssystemen haben können. Folgende Themenbereiche werden diskutiert: Entscheidungen über die medizinische Behandlung, die von Patienten und ihren Angehörigen oder Stellvertretern getroffen werden; die mögliche Rolle umfassender schriftlicher Verfügungen wie z.B. der Patiententestamente ; die berufsübergreifenden Spannungen zwischen medizinischen und rechtlichen Belangen in sehr unterschiedlichen Kulturen; der Einfluß, den gesetzgeberische Aktivitäten im Kontext der verschiedenen politischen und Gesundheitssysteme auf die medizinische Wirklichkeit haben. Bei ihrer Analyse der in diesem Zusammenhang bestehenden Beziehungen im Verhältnis von Recht und Verhalten haben die Autoren die Erkenntnisse vieler Disziplinen unter Einschluß der Sozialwissenschaften, soweit sie als relevant erscheinen, in ihren Beitrag eingearbeitet. (shrink)

Modern songs, films, novels and daily speech often use heart imagery to illustrate ‘inner self’ experiences, such as deeply felt emotions. Where do these ideas come from and what relevance do they have for medicine today? This article explores some of the key origins and periods of development of heart/‘inner self’ ideas before considering the significance of heart/‘inner self’ interactions in modern clinical practice: from Aristotelian anatomy and the translated Hebrew Scriptures; through Shakespeare, William Harvey and the Protestant Reformation; (...) to theories of emotion and modern-day cardiology. I conclude that heart/‘inner self’ interactions exist in clinically significant ways, but are poorly understood and under-recognised in healthcare settings. Greater integration of cardiovascular and psychosocial medicine would improve patient care. (shrink)

BackgroundCoronary heart disease is closely associated with cognitive impairment, especially in severe cases of heart failure. However, it is unclear whether cardiac systolic function plays a role in the relationship between pre-existing CHD and cognitive impairment in subjects without clinical heart failure.MethodsIn total, 208 subjects from the First Affiliated Hospital of Xi’an Jiaotong University were recruited from June 2014 to January 2015, and were divided into CHD and non-CHD groups according to the inclusion and exclusion criteria. The global cognitive (...) function of all subjects was assessed by the Mini-Mental State Examination and cognitive impairment was defined as the score lower than the cutoff value. Left ventricular ejection fraction was measured using transthoracic echocardiograms. The relationship among pre-existing CHD, LVEF, and cognitive impairment was analyzed by multivariate logistic regression.ResultsIn total, 34 subjects met the criteria of cognitive impairment. Univariate analysis showed that the cognitive impairment prevalence in the CHD group was significantly higher than that in the non-CHD group. Multivariate logistic analysis revealed that CHD was significantly associated with a higher risk of cognitive impairment after adjusting for confounds except for LVEF. However, the OR of CHD decreased when LVEF was further corrected as a continuous variable, and LVEF was negatively associated with the risk of cognitive impairment.ConclusionPre-existing CHD is associated with a higher risk of cognitive impairment, and such an association can be considerably explained by reduced LVEF. An impaired cardiac systolic function may play a key role in the relationship between CHD and cognitive impairment among patients with pre-heart failure conditions. (shrink)

The aim of this paper is to start a debate about ethical issues associated with the practice of clinical audit. This is an area that has not received much consideration. The role of clinical audit is to raise general clinical standards. The ethical issues of clinical audit may have far-reaching consequences for clinicians, patients, health care providers and purchasers. Guidance is required to provide consistency in approach so that those involved in clinical audit, at whatever (...) level, can be confident that they are following good practice. Clinicians and managers often think of good practice as being a technical matter. The main point of this paper is to bring out important ethical dimensions to good practice. (shrink)

How should clinical ethicists be trained? Scholars have stated that clinical ethics fellowships create well-trained, competent ethicists. While this appears intuitive, few features of fellowship programs have been publicly discussed, let alone debated. In this paper, we examine how fellowships can foster effective mentoring relationships. These relationships provide the foundation for the fellow’s transition from novice to competent professional. In this essay, we begin by discussing our pedagogical commitments. Next, we describe the structures our program has (...) created to assist our fellows in becoming competent ethicists. We then outline the kinds of knowledge, skills, and professional attributes mentors should possess. Following this, we focus on the knowledge, skills, and professional attributes that fellows develop as they co-create effective mentoring relationships. We will not prescribe a single approach to fellowship training; instead, our perspective will, we hope, become a catalyst for further conversation on training and mentoring clinical ethics fellows. (shrink)

Microethics is about the ethics of everyday clinical practice. The subtle nuances in communication between doctor and patient (the doctor’s choice of words, tone, body language, gestures, etc.) can influence the exercise of the patient’s autonomy. The four models of the doctor- patient/physician-patient relationship (paternalistic, informative, interpretive, deliberative) weigh respect for autonomy and beneficence in varying proportions. Each model may be appropriate in certain circumstances. This article considers these models from the perspective of microethics and the unique dimensions created (...) by the doctor-child-parent relationship. In particular, the article considers the nuances to the autonomy principle created by the child’s developing maturity and the parent’s role as a co-fiduciary of the child’s interests. Ultimately, the deliberative model seems most appropriate to the paediatric setting, since it accommodates the child’s developing maturity in making healthcare-related decisions. This model infuses care into the doctor’s communication with the child and parent. (shrink)

This vibrant collection of papers by an interdisciplinary group of authors -- psychologists, theologians, and social scientists -- presents brilliant new perspectives on spirituality, ethics, and relationship. In their diversity of views, their Intellectual and spiritual dynamism, the authors bring power and hope to this subject so central to the human experience.

Dispositional forgiveness is positively associated with many facets of wellbeing and has protective implications against depression and anxiety in adolescents. However, little work has been done to examine neurobiological aspects of forgiveness as they relate to clinical symptoms. In order to better understand the neural mechanisms supporting the protective role of forgiveness in adolescents, the current study examined the middle frontal gyrus, which comprises the majority of the dorsolateral prefrontal cortex and is associated with cognitive regulation, and its relationship (...) to forgiveness and clinical symptoms in a sample of healthy adolescents. In this cross-sectional study, larger MFG volume was significantly associated with higher self-reported dispositional forgiveness scores and lower levels of depressive and anxiety symptoms. Forgiveness mediated the relationship between MFG volume and both depressive and anxiety symptom levels. The mediating role of forgiveness in the relationship between MFG volume and clinical symptoms suggests that one way that cognitive regulation strategies supported by this brain region may improve adolescent mental health is via increasing a capacity for forgiveness. The present study highlights the relevance of forgiveness to neurobiology and their relevance to emotional health in adolescents. Future longitudinal studies should focus on the predictive quality of the relationship between forgiveness, brain volume and clinical symptoms and the effects of forgiveness interventions on these relationships. (shrink)

Background Nursing students spend approximately half of their time in clinical practice. It is important that clinical supervisors understand nursing students’ path of learning and can support their growth and development during the different and multifaceted learning situations offered in the clinical-practice period. Objective Based on nursing students’ perspective and rooted in the didactics of caring science, to examine how a learning and constructive caring relationship between nursing students and supervisors in clinical practice can be formed. (...) Design Qualitative and quantitative concurrent triangulation design of mixed methods. Methods Focus group interviews with Finnish nursing students (n = 21) in the qualitative part of the study. In the quantitative part, a closed questionnaire with closed answers was analysed using descriptive statistics. The analysis process was conducted using inductive content analysis. Ethical considerations Ethical issues were considered throughout the research process according to ethical principles and scientific guidelines. Informed consent was obtained from the informants, confidentiality regarding the data material was guaranteed and quotations were anonymized. Results A caring relationship between nursing students and supervisors is based on mutual respect, the ethos of responsibility, motivation, willingness and professionalism. Dignity and a caring ethical approach, where nursing students feel they belong, are recognized, seen and heard enables learning and professional development. It is also significant that the supervisor’s actions and reflections are ethically defensible, equal and protect nursing students from suffering and various power relationships in clinical practice. Conclusion A good cooperative relationship and shared responsibility between the nurse education institution, which offers theory and prepares nursing students for the encounter with clinical practice and the healthcare organizations is crucial for enabling a caring relationship in clinical supervision. (shrink)

Recognizing the importance of health‐promoting relationships in engaging people who are experiencing homelessness in care, most research on health clinics for homeless persons has involved some recognition of client–provider relationships. However, what has been lacking is the inclusion of a critical analysis of the policy context in which relationships are enacted. In this paper, we question how client–provider relationships are enacted within the culture of community care with people who are experiencing homelessness and how clinic‐level and (...) broader social and health policies shape relationships in this context. We explore these questions within a critical theoretical perspective utilizing a critical ethnographic methodology. Data were collected using multiple methods of document review, participant observation, in‐depth interviews and focus groups. The participants include both clients at a community health clinic, and all clinic service providers. We explore how clients and providers characterized each other as ‘good’ or ‘bad’. For providers, this served as a means by which they policed behaviours and enforced social norms. The means by which both providers’ and clients’ negotiated relationships are explored, but this is couched within both local and system‐level policies. This study highlights the importance of healthcare providers and clients being involved in broader policy and systemic change. (shrink)

This paper examines how the application of legal fiduciary principles , can serve as a framework to promote management of clinical genomic “incidental” or secondary target findings that is patient-centered and consistent with recognized patient autonomy rights. The application of fiduciary principles to the clinical genomic testing context gives rise to at least four physician fiduciary duties in conflict with recent recommendations by the American College of Medical Genetics and Genomics . These recommendations have generated much debate among (...) lawyers, clinicians, and bioethicists hence I believe this publication will be of value and interest to your readership. (shrink)

The seven articles included in the AJOB Neuroscience special issue map important ethical issues that have and will continue to emerge with advances in neuroscience and neurotechnology. A critical c...

A special report of The Hastings Center and the Association of American Medical Colleges addressed the ethical oversight of learning health systems, which seek to combine high‐quality patient care with routine data collection aimed at improving patient outcomes. The report contained two position papers, authored by a number of distinguished bioethicists, and several commentaries. The position papers urged two changes. First, they urged a rethinking of our approach to the regulation of human subjects research, so as to make it easier (...) in the future for learning health systems to function well. Second, they argued that the rethinking required dispensing with a strict distinction between research and therapy, which has been a major tenet of bioethics since the Belmont Report, which explicated basic ethical principles governing human subjects research. We fully support the objectives of the authors, and we agree that the learning health system is an important advance that serves patients well. Unnecessary regulatory burden ought not impede this progress. We disagree, however, that the best way to bring about these needed changes in the regulatory environment is to reject the basic distinction between research and treatment. Unfortunately, we find the arguments in favor of that strategy to be, in places, reminiscent of what we take to be basic conceptual errors that hampered the ethical understanding of human subjects research prior to adoption of the Belmont Report. To see why one need not reject the research‐treatment distinction in order to promote learning health systems, we first investigate in some detail the arguments offered for eliminating the distinction. We next turn to an issue not addressed by those authors, namely, the relationship between the physician or investigator and the patient or subject, to illustrate why the distinction is important and what is lost if it is jettisoned. (shrink)

The relationship between the ethical standards for the governance of clinical trials and market forces can be complex and problematic. This article uses India as a case study to explore this nexus. From the mid-2000s, India became a popular destination for foreign-sponsored clinical trials. The Indian government had sought to both attract clinical trials and ensure these would be run in line with internationally accepted ethical norms. Reports of controversial medical research, however, triggered debate about the robustness (...) and suitability of India's regulatory system. In response to civil society pressure and interventions by the Supreme Court, the Indian government proposed additional measures aimed at strengthening protections for clinical trial participants. Whilst the reforms can be seen as a victory for human rights activists, they have also been criticised as being overly burdensome for sponsors. Indeed, their announcement prompted an exodus of clinical trials from India. Fearful of losing business to ‘rival’ countries, the Indian government is revisiting some of its proposals. The Indian example suggests that research ethics frameworks and national policies for economic development are increasingly intertwined. Host countries are in theory free to improve the lot of research participants, but doing so may make them appear less attractive to foreign sponsors, who can simply shift their activities to more industry-friendly jurisdictions. Although these economic pressures are unlikely to lead to a regulatory ‘race to the bottom’, they may limit host countries' ability to enact socially desirable reforms. (shrink)

Background At the beginning of the coronavirus (Covid-19) pandemic, many non-Covid healthcare services were suspended. In April 2020, the Department of Health in England mandated that non-Covid services should resume, alongside the continuing pandemic response. This ‘resetting’ of healthcare services created a unique context in which it became critical to consider how ethical considerations did (and should) underpin decisions about integrating infection control measures into routine healthcare practices. We draw on data collected as part of the ‘NHS Reset Ethics’ project, (...) which explored the everyday ethical challenges of resetting England’s NHS maternity and paediatrics services during the pandemic. Methods Healthcare professionals and members of the public participated in interviews and focus group discussions. The qualitative methods are reported in detail elsewhere. The focus of this article is our use of Frith’s symbiotic empirical ethics methodology to work from our empirical findings towards the normative suggestion that clinical ethics should explicitly attend to the importance of relationships in clinical practice. This methodology uses a five-step approach to refine and develop ethical theory based on a naturalist account of ethics that sees practice and theory as symbiotically related. Results The Reset project data showed that changed working practices caused ethical challenges for healthcare professionals, and that infection prevention and control measures represented harmful barriers to the experience of receiving and offering care. For healthcare professionals, offering care as part of a relational interaction was an ethically important dimension of healthcare delivery. Conclusions Our findings suggest that foregrounding the importance of relationships across a hospital community will better promote the ethically important multi-directional expression of caring between healthcare professionals, patients, and their families. We offer two suggestions for making progress towards such a relational approach. First, that there is a change of emphasis in clinical ethics practice to explicitly acknowledge the importance of the relationships (including with their healthcare team) within which the patient is held. Second, that organisational decision-making should take into account the moral significance afforded to caring relationships by healthcare professionals, and the role such relationships can play in the negotiation of ethical challenges. (shrink)

Treatment informed consent aims to preserve the autonomy of patients in the clinician – patient relationship so as to ensure valid consent. An acceptable method of evaluating understanding of consent information is by assessing the extent of recall by patients of the pieces information believed to have been passed across. When concerns are not satisfactorily addressed from the patients’ perspective, recall of consent information may be low. This study is a questionnaire – based cross – sectional interview of consecutive adult (...) surgical patients who could give their respective medical histories and who were booked for elective major surgical procedures over a period of 7 months in a tertiary health institution in southeastern Nigeria. Four to five days after a formal consent session, during ward admission, extent of recall of information on the nature of the disease condition or diagnosis, the nature of the planned procedure and the risks involved in the planned procedure were assessed and analyzed on the background of how satisfying the consent sessions were from individual patient’s perspective. Generally, the recall of nature of disease condition and nature of planned procedure is better than recall of risks involved in the planned procedure. More specifically however, recall in these 3 domains is significantly better among the patients that affirmed that their concerns were satisfactorily addressed. The findings from this study support that no effort should be spared in ensuring that the consent information are satisfying to the patients from the patients’ viewpoint. (shrink)

Background Clinical empathy is an essential part of healthcare, and patient-centered care models require clinical empathy to be established. Despite this, little is known about its measurement in the neonatal scenario. Research Aim To measure clinical empathy in health professionals who work with medium and high-risk neonates and build a construct of this empathy. Research Design Single-center survey study. Participants and Research Context The Jefferson Scale of Empathy for Health Professionals questionnaire was applied to health professionals who (...) work in an intensive care unit and a medium-risk unit, in Brazil. Analysis was done using descriptive statistics and a factor analysis model, to build the construct of empathy. Overall empathy was calculated, and the domains’ punctuations were analyzed and compared to the maximum punctuation possible. The study followed the STROBE checklist. Ethical Considerations This study was approved by the Research Ethics Committee of the institution. All participants signed the informed consent form. Participants’ confidentiality and anonymity were protected. Findings Median empathy was 117 (IQR 113–124). The domain of Walking in the Patient’s Shoes had lower scores and represented 77.6% of the maximum punctuation possible. The factor analysis included three factors named Understanding, Experiences, and Treatment, and Emotional Relationships, explaining 64.3% of the overall variance. The domain Walking in the Patient’s Shoes was not included in the model. Conclusions In this scenario, clinical empathy should improve. There is a need to improve the domain of Walking in the Patient’s Shoes, in this case, the neonate, and provide more empathic care to them. (shrink)

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way (...) and used to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)

The possible dysfunction of [gamma] aminobutyric acid (GABA) and opioid inhibitory mechanisms following central and peripheral nervous system injury is an important and potentially useful finding. However, effective clinical application must take into account the specific characteristics of the models used in the studies and the relationship of these models to specific clinical conditions. [dickenson; wiesenfeld-hallin et al.].

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of (...) claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. (shrink)

The prevalence and negative impact of brain disorders are increasing. Clinical Neuropsychology is a specialty dedicated to understanding brain-behavior relationships, applying such knowledge to the assessment of cognitive, affective, and behavioral functioning associated with brain disorders, and designing and implementing effective treatments. The need for services goes beyond neurological diseases and has increased in areas of neurodevelopmental and psychiatric conditions, among others. In Europe, a great deal of variability exists in the education and training of Clinical Neuropsychologists. (...) Training models include master’s programs, continuing education courses, doctoral programs, and/or post-doctoral specialization depending on the country, with no common framework of requirements, although patients’ needs demand equal competencies across Europe. In the past five years, the Standing Committee on Clinical Neuropsychology of the European Federation of Psychologists’ Association has conducted a series of surveys and interviews with experts in the field representing 30 European countries. The information, along with information from the existing literature, is used in presenting an overview of current and relevant topics related to policy and guidelines in the training and competencies in Clinical Neuropsychology. An option for the way forward is the EuroPsy Specialist Certificate which is currently offered in Work- and Organizational psychology and Psychotherapy. It builds upon the Basic Certificate and complements national standards without overriding them. General principles can be found that can set the basis for a common, solid, and comprehensive specialty education/training, sharpening the Neuropsychologists’ competencies across Europe. The requirements in Clinical Neuropsychology should be comparable to those for the existing specialty areas in the EuroPsy model. Despite the perceived challenges, developing a Specialist Certificate appears a step forward for the development of Clinical Neuropsychology. Recommendations are proposed towards a shared framework of competencies by the means of a common level of education/training for the professionals in Europe. Benchmarking training standards and competencies across Europe has the potential of providing protection against unqualified and ethically questionable practice, creating transparency, raising the general European standard, and promoting mobility of both Clinical Neuropsychologists and patients in Europe, for the benefit of the professional field and the population. (shrink)

This book offers an easy-to-read, yet comprehensive introduction to practical issues in doctor–patient relationships in a typical low- and middle-income country setting in India, examining in detail the reasons for erosion of trust and providing guidance on potential research areas in the field. It strikes a balance between empirical work and theoretical normative analysis, while adopting mixed-method research in exploring important constructs in the doctor–patient relationship, such as trust, solidarity, advocacy, patient-centeredness, privacy, and confidentiality. Since the concept of trust (...) has direct implications for the ethical practice of medicine, the book is a valuable resource for academics and researchers in the field of medical, clinical, and applied ethics. (shrink)

A case of conflict in pediatric end-of-life decision making is presented to compare the complementary roles of clinical ethics consultants and palliative care specialists. The progression of the case illustrates the differing structures, goals, and methods of the majority of such teams. The strengths of each of consultation are emphasized. Particularly in centers where palliative care services are not available, it can be important for careproviders and clinical ethics consultants to focus on alliance-building and a longitudinal relationship with (...) patients and families. (shrink)

Investigators and institutional review boards should integrate plans about the appropriate disclosure of individual genetic results when designing research studies. The ethical principles of beneficence, respect, reciprocity, and justice provide justification for routinely offering certain results to research participants. We propose a result-evaluation approach that assesses the expected information and the context of the study in order to decide whether results should be offered. According to this approach, the analytic validity and the clinical utility of a specific result determine (...) whether it should be offered routinely. Different results may therefore require different decisions even within the same study. We argue that the threshold of clinical utility for disclosing a result in a research study should be lower than the threshold used for clinical use of the same result. The personal meaning of a result provides additional criteria for evaluation. Finally, the context of the study allows for a more nuanced analysis by addressing the investigators' capabilities for appropriate disclosure, participants' alternative access to the result, and their relationship with the investigators. This analysis shows that the same result may require different decisions in different contexts. (shrink)

Background Working as an ambulance nurse involves facing ethically problematic situations with multi-dimensional suffering, requiring the ability to create a trustful relationship. This entails a need to be clinically trained in order to identify ethical conflicts. Aim To describe ethical conflicts in patient relationships as experienced by ambulance nursing students during clinical studies. Research design An exploratory and interpretative design was used to inductively analyse textual data from examinations in clinical placement courses. Participants The 69 participants attended (...) a 1-year educational programme for ambulance nurses at a Swedish university. Ethical considerations The research was conducted in accordance with the Declaration of Helsinki. Participants gave voluntary informed consent for this study. Findings The students encountered ethical conflicts in patient relationships when they had inadequate access to the patient’s narrative. Doubts regarding patient autonomy were due to uncertainty regarding the patient’s decision-making ability, which forced students to handle patient autonomy. Conflicting assessments of the patient’s best interest added to the conflicts and also meant a disruption in patient focus. The absence of trustful relationships reinforced the ethical conflicts, together with an inadequacy in meeting different needs, which limited the possibility of providing proper care. Discussion Contextual circumstances add complexity to ethical conflicts regarding patient autonomy, dependency and the patient’s best interest. Students felt they were fluctuating between paternalism and letting the patient choose, and were challenged by considerations regarding the patient’s communication and decision-making ability, the views of third parties, and the need for prioritisation. Conclusion The essence of the patient relationship is a struggle to preserve autonomy while focusing on the patient’s best interest. Hence, there is a need for education and training that promotes ethical knowledge and ethical reflection focusing on the core nursing and caring values of trust and autonomy, particularly in situations that affect the patient’s decision-making ability. (shrink)

One of the most important questions in the ethics of human clinical research asks what obligations investigators owe the people who enroll in their studies. Research differs in many ways from standard care - the added uncertainties, for instance, and the nontherapeutic interventions such as diagnostic tests whose only purpose is to measure the effects of the research intervention. Hence arises the question whether a physician engaged in clinical research has the same obligations toward research subjects that he (...) owes his medical patients, or whether they differ in any fundamental way.Perhaps the most common answer is that the relationship is the same. Investigators, like physicians, are said to be fiduciaries of the volunteers who enroll in research trials. Each owes the best available medical care, which means that a physician can only justify enrolling his patient in research if the study meets the requirements of clinical equipoise, namely, that there is legitimate disagreement within the medical community as to whether the standard treatment or the investigational intervention is superior. (shrink)

In light of the ongoing development and implementation of core competencies in bioethics, it is important to proceed with a clear sense of how bioethics knowledge is utilized in the functioning of hospital ethics committees (HECs). Without such an understanding, we risk building a costly edifice on a foundation that is ambiguous at best. This article examines the empirical relationship between traditional paradigms of bioethics theory and actual decision making by HEC members using survey data from HEC members. The assumption (...) underlying the standardization of qualifications and corresponding call for increased education of HEC members is that they will base imminent case decisions on inculcated knowledge. Our data suggest, however, that HEC members first decide intuitively and then look for justification, thereby highlighting the need to re-examine the pedagogical processes of ethics education in the process of standardizing and improving competencies. (shrink)