Nurse clinician‐scientists are increasingly expected to show leadership aimed at transforming healthcare. However, research on nurse clinician‐scientists' leadership (integrating researcher and practitioner roles) is scarce and hardly embedded in sociohistorical contexts. This study introduces leadership moments, that is, concrete events in practices that are perceived as acts of empowerment, in order to understand leadership in the daily work of newly appointed nurse clinician‐scientists. Following the learning history method we gathered data using multiple (qualitative) methods to get close to their daily (...) practices. A document analysis provided us with insight into the history of nursing science to illustrate how leadership moments in the everyday work of nurse clinician‐scientists in the “here and now” can be related to the particular histories from which they emerged. A qualitative analysis led to three acts of empowerment: (1) becoming visible, (2) building networks, and (3) getting wired in. These acts are illustrated with three series of events in which nurse clinician‐scientists' leadership becomes visible. This study contributes to a more socially embedded understanding of nursing leadership, enables us to get a grip on crucial leadership moments, and provides academic and practical starting points for strengthening nurse clinician‐scientists' leadership practices. Transformations in healthcare call for transformed notions of leadership. (shrink)

Clinicians have a convention whereby symptoms are subjective statements 'as told by' patients, whereas signs are outwardly observable facts. Yet both first-person reports and third-person observations are theory laden and can bias conclusions. Two aspects of the oft-mentioned unreliability of reports are the subject's interpretation of them and the experimenter's assumptions when translating introspective reports into scientifically useful characterizations. Meticulous training of introspectors can address their mischief, whereas investigators can become more attentive to their own theory-laden biases. In the (...) case of hallucinations, for example, ignoring some customary third-person constructs and focusing on the visual experience itself has led to fresh explanations of visual symptoms based on cortical physiology rather than conceptual categories. Constructs that historically have ignored the subject's state of mind are also problematic; an example is the so-called resting state during metabolic brain imaging, long believed to reflect a blank mental slate. Introspective reports, not accepted literally but properly interpreted and revised by investigators as necessary, are legitimate sources of data. (shrink)

Clinicians have good moral and professional reasons to contribute to pragmatic clinical trials (PCTs). We argue that clinicians have a defeasible duty to participate in this research that takes place in usual care settings and does not involve substantive deviation from their ordinary care practices. However, a variety of countervailing reasons may excuse clinicians from this duty in particular cases. Yet because there is a moral default in favor of participating, clinicians who wish to opt out (...) of this research must justify their refusal. Reasons to refuse include that the trial is badly designed in some way, that the trial activities will violate the clinician’s conscience, or that the trial will impose excessive burdens on the clinician. (shrink)

Australian immigration detention has been called state sanctioned abuse, cruel and degrading and likened to torture. Clinicians have long worked both within the system providing healthcare and outside of it advocating for broader social and political change. It has now been over 25 years and little, if anything, has changed. The government has continued to consolidate power to enforce these policies and has continued to attempt to silence dissent. It was in this context that a boycott was raised as (...) a possible course of action. Despite discussions among the healthcare community about the merits of such action, a number of questions have been overlooked. In this article, I will examine whether a boycott is both ethical and feasible. Taking into account the costs and benefits of current engagement and the potential impact of a boycott, more specifically the potential it has to further harm those detained, I conclude that under current circumstance a boycott cannot be justified. This however does not mean that a boycott should be dismissed completely or that the status quo should be accepted. I discuss potential ways forward for those seeking change. (shrink)

Background Older patients are often vulnerable and highly dependent on healthcare professionals’ assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy. Aim To describe ambulance clinicians’ understanding of older patients’ self-determination when the patient’s decision-making ability is impaired. Research design A (...) qualitative design with an inductive approach, guided by descriptive phenomenology. Participants In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews. Ethical considerations The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority. Findings The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient’s best interests. The clinicians’ interpretations are based on an understanding of the patient’s situation using substitute decision-making in emergency situations and conversations that reveal the patient’s explicit wishes. Sometimes the clinicians collaborate to validate the patient’s implicit will, while they at other times subordinate themselves to others’ opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient’s self-determination. Conclusion The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient’s unique needs based on a holistic perspective and their ability to be autonomous. (shrink)

Background Even though the traditional focus in emergency care is on life-threatening medical crisis, ambulance clinicians frequently encounter patients with mental illness, including suicidal ideation. A suicide is preceded by a complex process where most of the suicidal ideation is invisible to others. However, as most patients seek healthcare in the year before suicide, ambulance clinicians could have an important part to play in preventing suicide, as they encounter patients in different phases of the suicidal process. Aim The (...) aim of this study was to describe ambulance clinicians’ conceptions of responsibility when encountering patients in a suicidal process. Research design A qualitative inductive design using a phenomenographic approach was used. Participants and research context Twenty-seven ambulance clinicians from two regions in southern Sweden were interviewed. Ethical considerations The study was approved by the Swedish Ethical Review Authority. Findings Three categories of descriptions captured a movement from responding to a biological being to responding to a social being. Conventional responsibility was perceived as a primary responsibility for emergency care. In conditional responsibility, the patient’s mental illness was given only limited importance and only if certain conditions were met. Ethical responsibility was perceived to have its primary focus on the encounter with the patient and listening to the patient’s life story. Conclusions An ethical responsibility is favourable regarding suicide prevention in ambulance care, and competence development in mental illness and conversation skills could enable ambulance clinicians to have conversations with patients about suicidal ideation. (shrink)

As a gynecologic surgeon with a focus on infertility, I frequently hold complex discussions with patients, exploring with them the risks and benefits of surgical options. In the past, we physicians may have expected our patients to simply defer to our expertise and choose from the options we presented. In our contemporary era, however, patients frequently request options not favored by their physicians and even some they've found themselves online. In reproductive endocrinology and infertility, the range of options that may (...) be offered or that patients may themselves seek out is continuously widening. Physicians certainly seek to find the option that will result in the best outcome for their patients, but the information to guide us in achieving the best outcome can be vague or conflicting. Add to this the financial and emotional pressures bearing on patients seeking assisted reproduction. In this essay, I explore the extent to which clinicians in reproductive medicine should follow patient requests with which they disagree or instead try to persuade the patient to do something else or simply refuse outright to meet the request. And if persuasion is to be used, what would be legitimate methods? Clearly, coercion is unacceptable, but the line between persuasion and coercion can be elusive. At what point can or should clinicians resist such requests—and to what degree? (shrink)

Clinician gate-keeping is the process whereby healthcare providers prevent access to eligible patients for research recruitment. This paper contends that clinician gate-keeping violates three principles that underpin international ethical guidelines: respect for persons or autonomy; beneficence or a favourable balance of risks and potential benefits; and justice or a fair distribution of the benefits and burdens of research. In order to stimulate further research and debate, three possible strategies are also presented to eliminate gate-keeping: partnership with professional researchers; collaborative research (...) design and clinician education. (shrink)

Clinicians and patients and their families may disagree about a course of treatment, and the ensuing conflict may seem intractable. The parties may request mediation, or use mediation-based approaches, to help resolve the conflict. In the process of mediation, and at other times, parties in conflict may feel so pressured to accept a resolution that they acquiesce unwillingly—and such resolutions often unravel. In this article I investigate how “bullied acquiescence” might happen, and how to avoid it.

Clinicians, operating within complex systems, make mistakes, as people do in every human endeavor, and when they do, patients are sometimes harmed. One important question is how we as clinicians can find resolution in the wake of an error. The published literature has divided errors into those caused by “systems” and by “individuals.” But whereas both “systems” and “individual” approaches are important in understanding the cause of an error, neither alone can fully lead to resolution once an error (...) has occurred. Instead, both are necessary to understand, resolve, and prevent errors. (shrink)

In many countries, including patients are legally entitled to request copies of their clinical notes. However, this process remains time-consuming and burdensome, and it remains unclear how much of the medical record must be made available. Online access to notes offers a way to overcome these challenges and in around 10 countries worldwide, via secure web-based portals, many patients are now able to read at least some of the narrative reports written by clinicians (‘open notes’). However, even in countries (...) that have implemented the practice many clinicians have resisted the idea remaining doubtful of the value of opening notes, and anticipating patients will be confused or anxious by what they read. Against this scepticism, a growing body of qualitative and quantitative research reveals that patients derive multiple benefits from reading their notes. We address the contrasting perceptions of this practice innovation, and claim that the divergent views of patients and clinicians can be explained as a case of epistemic injustice. Using a range of evidence, we argue that patients are vulnerable to (oftentimes, non-intentional) epistemic injustice. Nonetheless, we conclude that the marginalisation of patients’ access to their health information exemplifies a form of epistemic exclusion, one with practical and ethical consequences including for patient safety. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinicians’ “Folk” Taxonomies and the DSM: Pick Your PoisonG. Scott Waterman (bio)Keywordsnosology, classification, diagnosis, psychopathologyWith attention turning to the process of formulating the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; e.g., Kendler et al. 2008), the study by Flanagan and Blashfield (2007) of the similarities and differences between clinicians’ “folk” taxonomies and psychiatry’s official one is timely, and its lessons are in (...) need of analysis. In this commentary I first address questions raised by the existence of multiple de facto taxonomies, and by the characteristics of those taxonomies themselves, before focusing attention on the DSM diagnostic system and its attributes that make acceptance by its constituencies far less than complete. Although the aim of Flanagan’s and Blashfield’s study is explicitly descriptive rather than normative, it provides an important opportunity to examine the extent to which our taxonomies serve the purposes for which they were constructed—whether by experts or by clinicians.There are certainly reasons to expect significant deviations between clinicians’ everyday taxonomies and the official one. Perhaps the most glaring reason is the fact that—even if it were desirable—no one can be familiar with the enormous number of categories codified by the DSM. On the other hand, the remarkable hegemony of the DSM—in the education and training of physicians and clinical psychologists, in clinical communication, and in the ubiquitous administrative functions of billing and coding—makes such deviations at least somewhat surprising and in need of scrutiny and explanation. The first question, however, is whether one should be concerned by the existence (surprising or otherwise) of multiple taxonomies. Flanagan and Blashfield make the compelling case that, given the high rate at which Americans seek clinical attention for psychiatric problems, the stakes are commensurately high for our efforts at categorizing those problems in valid and useful ways. And the extent to which a gulf exists between the way psychiatry and clinical psychology are written about and taught on the one hand, and conceptualized and practiced by clinicians on the other, invites a multitude of problems—among which cynicism about our disciplines may be one of the most pernicious.At least as important as their finding of only moderate correlations between clinicians’ taxonomies [End Page 271] and that of the DSM are the characteristics of clinicians’ diagnostic systems themselves. One potentially major artifact of their methodology, however, must be borne in mind: the instruction to the clinicians in their study to “[p]ut together the diagnoses that have similar treatments…” (emphasis mine). Although they cite previous work (Flanagan and Blashfield 2006) in defense of the proposition that such instruction did not unduly influence their findings, it was certainly an avoidable potential problem, which itself likely reflects the history of our clinical disciplines in which the treatment cart frequently pulled the diagnosis horse. It is, therefore, not unlikely that clinicians’ taxonomies might emphasize treatment considerations even if they had not been directed to do so. The fallacious reasoning behind such intuitively appealing practice, however, must be exposed. The implicit assumption that treatment response is a proxy for other important characteristics of illnesses is predicated on the false proposition that our treatments exert their effects via similar mechanisms across the various indications for their uses, thus allowing us to infer from such responses that what was awry in the first place among the conditions for which a given treatment is effective must be closely related. Categorizing mania and trigeminal neuralgia together by virtue of their shared responses to anticonvulsant therapy, or considering autoimmune platelet deficiencies to be closely related to abdominal trauma due to the fact that each sometimes requires splenectomy, are examples of the potential results of acting on that false premise.Another parameter on which the clinicians in the current study based their nosologies—most explicitly by the “dimensional experts”—is the “environmental” versus “biological” one. Given that a coherent dichotomy would either distinguish environmental from genetic etiological factors, or would contrast psychological (i.e., subjective or first-person) from biological (i.e., objective or third-person) manifestations of illness, a taxonomy one of whose axes purports to represent an environmental/biological continuum cannot... (shrink)

Everyone, it seems, is talking and arguing about Evidence-Based Practice. Those therapies and assessments designated as EBP increasingly determine what is taught, researched, and reimbursed in health care. But exactly what is it, and how do you do it? The second edition of Clinician's Guide to Evidence-Based Practices is the concise, practitioner-friendly guide to applying EBPs in mental health. Step-by-step it explains how to conduct the entire EBP process-asking the right questions, accessing the best available research, appraising the research, translating (...) that research into practice, integrating that research with clinician expertise and patient characteristics, evaluating the entire enterprise, attending to the ethical considerations, and when done, moving the EBP process forward by teaching and disseminating it. This book will help you:. Formulate useful questions that research can address. Search the research literature efficiently for best practices. Make sense out of the research morass, sifting wheat from chaff. Incorporate patient values and diversity into the selection of EBP. Blend clinician expertise with the research evidence. Translate empirical research into practice. Ensure that your clients receive effective, research-supported services. Infuse the EBP process into your organizational setting and training methods. Identify and integrate ethics in the context of EBP Coauthored by a distinguished quartet of clinicians, researchers, and a health care librarian, the Clinician's Guide has become the classic for graduate students and busy professionals mastering EBP. ". (shrink)

Some 30 years ago the role of the clinical ethics consultant (CEC) was formalized. At the time, the perception of the role differed between two groups serving in that capacity, clinicians and nonclinicians. Differences in their roles reflected their training and experience.These divergent views were resolved semantically by designating the role of the CEC as “ethics facilitation.” In practice the different perspectives have remained. However, the subsequent published literature on clinical ethics consultation has not adequately reflected the activity of (...) the clinician as a CEC.There have been recurring unanswered calls for the acquisition of empirical data on the nature of the problems that prompt ethics consultation requests and the functions required to address them. The authors introduce a template that provides a means to acquire such data for clinician ethicists. A similar instrument could be constructed to reflect the role of the nonclinician ethicist serving in that capacity. (shrink)

Clinician scientists have gained institutional support in the era of translational research, as the key solution to closing the ‘translational gap’ between biomedical research and medical practice. However, clinician scientists remain an ‘endangered species’ in search of a secure niche, while new grants and training programs attempt to counteract their measurable decline in numbers over the past decades. Our study asks how an occupational space for clinician scientists is currently situated between the politics of translation, professional dynamics, and the specialization (...) of academic disciplines. We interviewed clinician scientists, their adjacent professions—clinicians and biomedical researchers—, and contrast their views with expectations from the discourse on clinician scientists in the biomedical and policy literature. We identify professionalizable work and tasks that relate to, first, being able to speak the two languages of both clinic and research, second, translating patients’ needs and clinical experience for further research, and third, counteracting the trends towards specialization by providing an inclusive point of view. We find that clinician scientists are overburdened with fulfilling a hybrid role of simultaneously being clinicians and scientists. Based on these findings, we suggest a path for the future professional development of clinician scientists towards the role of a translator. (shrink)

Notwithstanding fundamental methodological advancements, scientific information about disorders of consciousness (DOCs)—e.g. Vegetative State/Unresponsive Wakefulness Syndrome (VS/UWS) and Minimally Conscious State (MCS)—is incomplete. The possibility to discriminate between different levels of consciousness in DOC states entails treatment strategies and ethical concerns. Here we attempted to investigate Italian clinicians’ and basic scientists’ opinions regarding some issues emerging from the care and the research on patients with DOCs. From our survey emerged that Italian physicians working with patients with DOCs give a central (...) role to ethics. Current Italian regulation regarding basic research conducted in patients with DOCs apparently risks to be inadequate to support scientific advancement, and would deserve a different assessment compared to ordinary treatments. We think the results of our survey deserve attention from an international audience because they exemplify the difficulty to define a shared approach to the issues related to patients with DOCs and the necessity to better assess both the ordinary and experimental treatment of patients with DOCs at the ethical and legal level. (shrink)

Despite medical leaders’ increasing acceptance of the idea that the whole person should be the focus of care, empirical studies show clinicians generally remain focused on narrower goals: disease categories, standardized treatment procedures, and objective measurements of health improvements. We assume doctors want to do a good job, consistent with their perception of the goals and norms of their profession, so they practice medicine based on the illusion that clinical medicine is “knowledge treating disease,” not people treating people. We (...) believe that doctors’ seeming reduction of patients to clinical objects results from not seeing themselves as leaders for their patients or accepting their constructive power in clinical encounters. (shrink)

Background Informed consent is considered to be the standard method for respecting the autonomy of individual participants in research and practices and is thought to be based on several conditions: (1) providing information on the purpose of the research or a specific treatment, what it will entail, (2) the participants being mentally competent to understand the information and weigh it in the balance, and (3) the participants to be free from coercion. While there are studies of informed consent in other (...) countries, especially Low and Middle Income Countries (LMICs), this study explored the experiences of clinicians regarding the process of obtaining informed consent to participate in a Randomised Controlled Trial (RCT) in particular and treatment in general in healthcare settings, both general and mental health, specifically focusing on the tension between individualistic concept of autonomy and collectivist values in cultures such as Pakistan. Methods Qualitative interviews with 20 clinicians from healthcare settings in Pakistan who also served as recruiters in a suicide prevention RCT in Pakistan. The interviews were guided by semi-structured topic guide. All interviews were audio-recorded and transcribed verbatim. Results The interviews revealed that shared decision making was more morally important than individual autonomy, the role of the family played a dominant part in the consent-taking procedure, the decision of the elder and/or family patriarch took prominence, and that clinician-researchers encountered significant challenges in consent process in Pakistan, while recruiting patients into the trial as well as during routine treatment processes in healthcare settings. Four distinct themes emerged which were (1) Family deciding for patients, (2) Benefits of involving family in consent process, (3) Gender disparity in consent process, (4) Challenges experienced by clinician-researchers during consent process in Pakistan. Conclusions The concept of consent is generally considered important in many cultures, however, there are two strands of understanding. There seems to be consensus that participant agreement is necessary to protect the participant but with regards to autonomy there are significant cultural differences whether it is the right for autonomy of the individual (individualistic concept) or family, community, or expert authority in other cultures. In Pakistan clinician-researchers sometimes preferred one approach and sometimes the other as they appreciated the interests of the patient to be. (shrink)

Due to their financial incentive, clinicians who earn income from a firm that markets medical devices, pharmaceuticals, tests, etc. might inappropriately prescribe their products or services. The Cleveland Clinic’s conflict of interest (CI) policy creates rules governing clinicians who accept compensation from outside firms that market products they prescribe or use in their practice (hereafter, covered financial relationships). The CI policy is implemented by the Innovation Management and Conflict of Interest Program (IM&COI) (hereafter the Committee).

Caruso Brown brings forward an argument that clinicians and ethicists have a duty to consider decision-makers marginalized by hierarchical structures. The author presents a pragmatic approac...

Clinical ethics committees have existed in Norway since 1996. By now all hospital trusts have one. An evaluation of these committees’ work was started in 2004. This paper presents results from an interview study of eight clinicians who evaluated six committees’ deliberations on 10 clinical cases. The study indicates that the clinicians found the clinical ethics consultations useful and worth while doing. However, a systematic approach to case consultations is vital. Procedures and mandate of the committees should be (...) known to clinicians in advance to ensure that they know what to expect. Equally important is bringing all relevant facts, medical as well as psychosocial, into the discussion. A written report from the deliberation is also important for the committees to be taken seriously by the clinicians. This study indicates that the clinicians want to be included in the deliberation, and not only in the preparation or follow-up. Obstacles for referring a case to the committee are the medical culture’s conflict aversion and its anxiety of being judged by outsiders. The committees were described as a court by some of the clinicians. This is a challenge for the committees in their attempt to balance support and critique in their consultation services. (shrink)

In British Columbia, Canada, many physicians providing care to individuals with high-risk opioid use disorder adopted safer supply (SS) opioid prescribing in the spring of 2020 with the goal of facilitating public health measures for COVID-19. This prescribing practice continued after measures were lifted. This study aimed to explore prescribers’ perspectives following several years of local experience in prescribing SS opioids, primarily in the form of hydromorphone tablets, and to apply ethical concepts to explore current challenges and ongoing sources of (...) provider distress. Addiction medicine SS prescribers participated in individual or small group semi-structured interviews. Each interview was transcribed and analysed for recurrent themes. Themes were then integrated into a narrative ethics discussion. Eleven addiction medicine physicians practicing in various settings within Vancouver participated in this study. Six themes were identified: clinical assessment, clinician distress, gaps in care, models of safer supply, research, and special populations. Ethical dilemmas in prescribing SS are identified and explored through a discussion of biomedical ethics principles and the physician role. (shrink)

: The "difference position" holds that clinical research and therapeutic medical practice are sufficiently distinct activities to require different ethical rules and principles. The "similarity position" holds instead that clinical investigators ought to be bound by the same fundamental principles that govern therapeutic medicine—specifically, a duty to provide the optimal therapeutic benefit to each patient or subject. Some defenders of the similarity position defend it because of the overlap between the role of attending physician and the role of investigator in (...) a research trial. This overlap is maximal when the same physician occupies both roles with respect to a particular patient-subject. We address the ethical tensions inherent in that role conflict and argue that the tensions are real but manageable. The difference position provides a sound ethical framework within which to manage those tensions, while the similarity position is unsatisfactory because it seeks to deny the existence of the tensions. (shrink)

This paper defends four lines of argument that establish an ethical obligation for clinicians to be vaccinated against COVID-19. They are: (1) The obligation to protect patients against COVID-19 spread; (2) The obligation to maintain professional competence and remain available for patients; (3) Clinicians’ role and place in society in relation to COVID-19; (4) The obligation to encourage societal vaccination uptake. These arguments stand up well against potential objections and provide a compelling case to consider acceptance of COVID-19 (...) vaccination a duty for all clinicians. This duty brings with it the implication that vaccine refusal amounts to a dereliction of the professional’s ethical obligations, which means such clinicians should be subject to disciplinary action. Furthermore, this duty provides grounding for mandatory vaccination policies for clinicians. (shrink)

A number of recent developments in our understanding of the biology of heritability question commonly held views on the immutability of genetic factors. These have numerous potential implications for improving understanding and practice in pre- and postconceptional care and for infant and child mental health, and they carry a cautionary message against overgeneralization.

_Thinking for Clinicians_ provides analysts of all orientations with the tools and context for working critically within psychoanalytic theory and practice. It does this through detailed chapters on some of the philosophers whose work is especially relevant for contemporary theory and clinical writing: Emmanuel Levinas, Martin Buber, Ludwig Wittgenstein, Maurice Merleau-Ponty, and Hans-Georg Gadamer. Orange presents the historical background for their ideas, along with clinical vignettes to help contextualize their theories, further grounding them in real-world experience. With a hermeneutic sensibility (...) firmly in mind, _Thinking for Clinicians_ rewards as it challenges and will be a valuable reference for clinicians who seek a better understanding of the philosophical bases of contemporary psychoanalytic theory. (shrink)

Moral distress names a widely discussed and concerning clinician experience. Yet the precise nature of the distress and the appropriate practical response to it remain unclear. Clinicians speak of their moral distress in terms of guilt, regret, anger, or other distressing emotions, and they often invoke them interchangeably. But these emotions are distinct, and they are not all equally fitting in the same circumstances. This indicates a problematic ambiguity in the moral distress concept that obscures its distinctiveness, its relevant (...) circumstances, and how individual clinicians and the medical community should practically respond to it. We argue that, in a range of situations that are said to be morally distressing, the characteristic emotion can be well‐understood in terms of what Bernard Williams calls “agent‐regret.” We show what can thereby be gained in terms of a less ambiguous concept and a more adequate ethical response to this distinctive and complex clinician experience. (shrink)

Although long touted as an ethical and legal requirement, some clinicians still seem to offer less than fully adequate informed consent processes; similarly the counseling of patients and families, particularly about post-intervention scenarios, is often perfunctory at best. Keyed to a narrative of a patient's experience with surgery for a deviated septum, this article reflects on why such less than adequate clinician behaviors tend to occur and what might be done about them. Certain legal misconceptions about informed consent are (...) highlighted in this reflection, as well as why certain clinicians seem to take such a narrow view of their responsibilities to patients. Further reference in this regard is also made to a recently constructed module on informed consent for medical residents. In it, though legal requirements for informed consent are reviewed, the basic perspective taken regards informed consent as a clinical intervention that pursues certain basic goods and values, only one of which lies in determining when legal closure for such processes has occurred. (shrink)

The current experiments examine mental health clinicians’ beliefs about biological, psychological, and environmental bases of the DSM‐IV‐TR mental disorders and the consequences of those causal beliefs for judging treatment effectiveness. Study 1 found a large negative correlation between clinicians’ beliefs about biological bases and environmental/psychological bases, suggesting that clinicians conceptualize mental disorders along a single continuum spanning from highly biological disorders (e.g., autistic disorder) to highly nonbiological disorders (e.g., adjustment disorders). Study 2 replicated this finding by having (...) clinicians list what they thought were the specific causes of nine familiar mental disorders and rate their bio–psycho–environmental bases. Study 3 further found that clinicians believe medication to be more effective for biologically based mental disorders and psychotherapy to be more effective for psychosocially based mental disorders. These results demonstrate that even expert mental health clinicians make strong distinctions between psychological and biological phenomena. (shrink)

The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless (...) of specialty. First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. (shrink)

The antiabortion movement is increasingly using ostensibly scientific measurements such as ‘fetal heartbeat’ and ‘fetal pain’ to provide ‘objective’ evidence of the moral status of fetuses. However, there is little knowledge on how clinicians conceptualise and operationalise the moral status of fetuses. We interviewed obstetrician/gynaecologists and neonatologists on this topic since their practice regularly includes clinical management of entities of the same gestational age. Contrary to our expectations, there was consensus among clinicians about conceptions of moral status regardless (...) of specialty. First, clinicians tended to take a gradualist approach to moral status during pregnancy as they developed and viewed viability, the ability to live outside of the uterus, as morally significant. Second, in contrast to ‘fetal pain’ laws and philosophical discussions about the ethical salience of sentience, the clinicians in our study did not consider the ability to feel pain as a morally relevant factor in moral status determinations. Third, during previability and perviability, clinicians viewed moral status as a personal value decision, which should be made by pregnant people and parents of neonates. (shrink)

ContentTruth-telling is an integral part of medical practice in many parts of the world. However, recent public inquiries, including the Francis Inquiry reveal that a duty of candour in practise, are at times compromised. Consequently, the duty of candour became a statutory requirement in England. This study aimed to explore clinicians’ perspectives of the implications of the legislation for medical ethics education, as raising standards to improve patient safety remains an international concern.MethodsOne-to-one interviews with clinical educators from various specialties (...) who contribute to the MBChB programme at the authors’ university. Once data saturation had been assessed, transcripts were analysed using a thematic approach by the following concurrent activities: data reduction and coding into themes. Example quotations are used to illustrate that key themes are grounded in the data.ResultsEleven clinical educators were interviewed; three general practitioners, six physicians and two surgeons. Thematic... (shrink)

Using methods from anthropology and cognitive psychology, this study investigated the relationship between clinicians’ folk taxonomies of mental disorder and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Expert and novice psychologists were given sixty-seven DSM-IV diagnoses, asked to discard unfamiliar diagnoses, put the remaining diagnoses into groups that had “similar treatments” using hierarchical (making more inclusive and less inclusive groups) and dimensional (placing groups in a two-dimensional space) methodologies, and give names to the groups in their taxonomies. (...) Clinicians were familiar with a substantially smaller number of diagnoses than are in the DSM. Cultural consensus analysis and follow-up residual agreement analysis revealed similarities across clinicians’ folk taxonomies. Correlations between folk taxonomies and the DSM were moderate. Cluster analysis showed that clinicians preserved DSM higher order categories (e.g., mood disorders) but not the Axis I–Axis II distinction. This study suggests important differences between the way clinicians conceptualize mental disorders and the organization of the DSM-IV. (shrink)

Background: The parent of a child with profound cognitive disability will have complex decisions to consider throughout the life of their child. An especially complex decision is whether to place a tracheotomy to support the child’s airway. The decision may involve the parent wanting a tracheotomy and the clinician advising against this intervention or the clinician recommending a tracheotomy while the parent is opposed to the intervention. This conflict over what is best for the child may lead to a bioethics (...) consult. Objective: The study explores the conflicts that may arise around tracheotomy placements. Research design: This study is a retrospective cohort study of pediatric patients for whom a tracheotomy decision required a bioethics consult. Participants and research context: Pediatric patients aged birth to 18 years old with a bioethics consult for a tracheotomy decision conflict between April 2010 and December 2016. A standardized data collection tool was used to review notes entered by the palliative care team, social workers, primary clinical team interim summaries, and the bioethics consult service. Ethical considerations: The study was reviewed and approved by the medical center’s institutional review board. Results: There were 248 clinical bioethics consults during the identified study period. There were 31 consults involving 21 children where the word tracheotomy was mentioned in the consult, and 13 of the 21 consults were for children with profound cognitive disability. Discussion and conclusion: Clinicians need to be aware of their own biases when discussing a child’s prognosis and treatment options while also understanding the parents’ values and what the parent might consider to be burdensome in the care of their child and the acceptable burden for the child to experience. (shrink)

Bioethics, Volume 35, Issue 7, Page 696-703, September 2021.

Background Artificial intelligence-driven Clinical Decision Support Systems (AI-CDSS) are being increasingly introduced into various domains of health care for diagnostic, prognostic, therapeutic and other purposes. A significant part of the discourse on ethically appropriate conditions relate to the levels of understanding and explicability needed for ensuring responsible clinical decision-making when using AI-CDSS. Empirical evidence on stakeholders’ viewpoints on these issues is scarce so far. The present study complements the empirical-ethical body of research by, on the one hand, investigating the requirements (...) for understanding and explicability in depth with regard to the rationale behind them. On the other hand, it surveys medical students at the end of their studies as stakeholders, of whom little data is available so far, but for whom AI-CDSS will be an important part of their medical practice. Methods Fifteen semi-structured qualitative interviews (each lasting an average of 56 min) were conducted with German medical students to investigate their perspectives and attitudes on the use of AI-CDSS. The problem-centred interviews draw on two hypothetical case vignettes of AI-CDSS employed in nephrology and surgery. Interviewees’ perceptions and convictions of their own clinical role and responsibilities in dealing with AI-CDSS were elicited as well as viewpoints on explicability as well as the necessary level of understanding and competencies needed on the clinicians’ side. The qualitative data were analysed according to key principles of qualitative content analysis (Kuckartz). Results In response to the central question about the necessary understanding of AI-CDSS tools and the emergence of their outputs as well as the reasons for the requirements placed on them, two types of argumentation could be differentiated inductively from the interviewees’ statements: the first type, the clinician as a systemic trustee (or “the one relying”), highlights that there needs to be empirical evidence and adequate approval processes that guarantee minimised harm and a clinical benefit from the employment of an AI-CDSS. Based on proof of these requirements, the use of an AI-CDSS would be appropriate, as according to “the one relying”, clinicians should choose those measures that statistically cause the least harm. The second type, the clinician as an individual expert (or “the one controlling”), sets higher prerequisites that go beyond ensuring empirical evidence and adequate approval processes. These higher prerequisites relate to the clinician’s necessary level of competence and understanding of how a specific AI-CDSS works and how to use it properly in order to evaluate its outputs and to mitigate potential risks for the individual patient. Both types are unified in their high esteem of evidence-based clinical practice and the need to communicate with the patient on the use of medical AI. However, the interviewees’ different conceptions of the clinician’s role and responsibilities cause them to have different requirements regarding the clinician’s understanding and explicability of an AI-CDSS beyond the proof of benefit. Conclusions The study results highlight two different types among (future) clinicians regarding their view of the necessary levels of understanding and competence. These findings should inform the debate on appropriate training programmes and professional standards (e.g. clinical practice guidelines) that enable the safe and effective clinical employment of AI-CDSS in various clinical fields. While current approaches search for appropriate minimum requirements of the necessary understanding and competence, the differences between (future) clinicians in terms of their information and understanding needs described here can lead to more differentiated approaches to solutions. (shrink)

In their thoughtful and well-supported target article, Andrew Garland, Stephanie Morain, Jeremy Sugarman (2023) argue that clinicians have a duty to participate in pragmatic clinical trials. This d...

Today, modern Western medicine is facing a quality-of-care crisis that is undermining the patient–physician relationship. In this paper, a notion of the epistemically virtuous clinician is proposed in terms of both the reliabilist and responsibilist versions of virtue epistemology, in order to help address this crisis. To that end, a clinical case study from the literature is first reconstructed. The reliabilist intellectual virtues, including the perceptual and conceptual virtues, are then discussed and applied to the case study. Next, a similar (...) method is employed to examine the responsibilist intellectual virtues, including curiosity, courage, honesty, and humility, and to apply them to the case study. To round out the discussion, the love of knowledge and both theoretical and practical wisdom are explored and applied to the case study. The paper concludes with a brief discussion of how the notion of an epistemically virtuous clinician addresses the quality-of-care crisis, in terms of the connection between ethical and intellectual virtues, and of the notion’s implications for medical education. (shrink)

BACKGROUND Patients with chronic pain face significant barriers in finding clinicians to manage long-term opioid therapy (LTOT). For patients on LTOT, it is increasingly common to have them sign opioid treatment agreements (OTAs). OTAs enumerate the risks of opioids, as informed consent documents would, but also the requirements that patients must meet to receive LTOT. While there has been an ongoing scholarly discussion about the practical and ethical implications of OTA use in the abstract, little is known about how (...) clinicians use them and if OTAs themselves modify clinician prescribing practices. OBJECTIVE To determine how clinicians use OTAs and the potential impacts of OTAs on opioid prescribing. DESIGN We conducted qualitative analysis of four focus groups of clinicians from a large Midwestern academic medical center. Groups were organized according to self-identified prescribing patterns: two groups for clinicians who identified as prescribers of LTOT, and two who did not. PARTICIPANTS 17 clinicians from General Internal Medicine, Family Medicine, and Palliative Care were recruited using purposive, convenience sampling. APPROACH Discussions were recorded, transcribed, and analyzed for themes using reflexive thematic analysis by a multidisciplinary team. KEY RESULTS Our analysis identified three main themes: (1) OTAs did not influence clinicians’ decisions whether to use LTOT generally but did shape clinical decision-making for individual patients; (2) clinicians feel OTAs intensify the power they have over patients, though this was not uniformly judged as harmful; (3) there is a potential misalignment between the intended purposes of OTAs and their implementation. CONCLUSION This study reveals a complicated relationship between OTAs and access to pain management. While OTAs seem not to impact the clinicians’ decisions about whether to use LTOT generally, they do sometimes influence prescribing decisions for individual patients. Clinicians shared complex views about OTAs’ purposes, which shows the need for more clarity about how OTAs could be used to promote shared decision-making, joint accountability, informed consent, and patient education. (shrink)

If the new and rapidly expanding discipline of neuroethics is to have a signii cant impact on patient care, the neuroscience clinicians must become familiar with the discipline, and be competent and comfortable in applying its cognitive base and principles to clinical decisionmaking. Familiarity with and practical experience in the application of basic biomedical knowledge and principles to clinical decision- making in the neurosciences becomes the essential foundation on which to begin to integrate neuroethics into medical education. The place (...) where the building of this foundation and the initial exposure to neuroethics must begin is in the residency program. This article describes the approach developed in the neurology residency education program at the University of Calgary to move toward achieving this goal. The key elements for the development and successful implementation of the program are outlined and a brief overview of the topics covered in the sessions is described. (shrink)

Background Informed consent is an integral component of good medical practice. Many researchers have investigated measures to improve the quality of informed consent, but it is not clear which techniques work best and why. To address this problem, we propose developing a core outcome set to evaluate interventions designed to improve the consent process for surgery in adult patients with capacity. Part of this process involves reviewing existing research that has reported what is important to patients and doctors in the (...) informed consent process. Methods This qualitative synthesis comprises four phases: identification of published papers and determining their relevance; appraisal of the quality of the papers; identification and summary of the key findings from each paper while determining the definitiveness of each finding against the primary data; comparison of key themes between papers such that findings are linked across studies. Results Searches of bibliographic databases returned 11,073 titles. Of these, 16 studies met the inclusion criteria. Studies were published between 1996 and 2016 and included a total of 367 patients and 74 health care providers. Thirteen studies collected data using in-depth interviews and constant comparison was the most common means of qualitative analysis. A total of 94 findings were extracted from the primary papers and divided into 17 categories and ultimately 6 synthesised findings related to: patient characteristics, knowledge, communication, the model patient, trust and decision making. Conclusions This qualitative meta-aggregation is the first to examine the issue of informed consent for surgery. It has revealed several outcomes deemed important to capture by patients and clinicians when evaluating the quality of a consent process. Some of these outcomes have not been examined previously in research comparing methods for informed consent. This review is an important step in the development of a COS to evaluate interventions designed to improve the consent process for surgery. Registration The study protocol was registered on the international prospective register for systematic reviews. (shrink)

Reasons for the limited uptake of the clinician–scientist role within nursing are examined, specifically: the lack of consensus about the nature of nursing science; the varying approaches to epistemology; and the influence of post-modern thought on knowledge development in nursing. It is suggested that under-development of this role may be remedied by achieving agreement that science is a necessary, worthy pursuit for nursing, and that rigorous science conducted from a clinical perspective serves nursing well. Straddling practice and research is a (...) powerful strategy for ensuring relevant research while forging strong links with practice. The clinician–scientist role, typically requiring a 75:25 ratio between research and clinical activities, is well established in medicine. Nursing, however, has been slow to institute the role; it is rare within North America, Australia, and western European countries, and almost non-existent outside those areas. Beyond structural obstacles, philosophical issues may explain nursing's reluctance to implement the role. Following a survey of clinician–scientist roles throughout the world, the nature of nursing science and epistemology, and the influence of post-modern thought on nursing attitudes to research are examined with respect to their influence on this role. The nurse clinician–scientist role holds promise for making strides in clinically relevant research, and for accelerating the knowledge cycle from clinical problem to research question to change in clinical practice. (shrink)

The application of machine learning and artificial intelligence in healthcare domains has received much attention in recent years, yet significant questions remain about how these new tools integrate into frontline user workflow, and how their design will impact implementation. Lack of acceptance among clinicians is a major barrier to the translation of healthcare innovations into clinical practice. In this systematic review, we examine when and how clinicians are consulted about their needs and desires for clinical AI tools. Forty-five (...) articles met criteria for inclusion, of which 24 were considered design studies. The design studies used a variety of methods to solicit and gather user feedback, with interviews, surveys, and user evaluations. Our findings show that tool designers consult clinicians at various but inconsistent points during the design process, and most typically at later stages in the design cycle. We also observed a smaller amount of studies adopting a human-centered approach and where clinician input was solicited throughout the design process. A third of all studies reported on clinician trust in clinical AI algorithms and tools. The surveyed articles did not universally report validation against the “gold standard” of clinical expertise or provide detailed descriptions of the algorithms or computational methods used in their work. To realize the full potential of AI tools within healthcare settings, our review suggests there are opportunities to more thoroughly integrate frontline users’ needs and feedback in the design process. (shrink)