Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients’ capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient’s identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level (...) decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth’s authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves. (shrink)

Background: To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature. Methods: A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociological Abstracts and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included. Ethical considerations: The review is conducted according to the Vancouver (...) Protocol. Results: There are few studies that study ethical challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good (beneficence) and inflicting harm (maleficence). In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion. Conclusion: There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress. (shrink)

Background In the UK, the solidaristic character of the NHS makes it one of the most trusted public institutions. In recent years, the introduction of data-driven technologies in healthcare has opened up the space for collaborations with private digital companies seeking access to patient data. However, these collaborations appear to challenge the public’s trust in the. Main text In this paper we explore how the opening of the healthcare sector to private digital companies challenges the existing social contract (...) and the NHS’s solidaristic character, and impacts on public trust. We start by critically discussing different examples of partnerships between the NHS and private companies that collect and use data. We then analyse the relationship between trust and solidarity, and investigate how this relationship changes in the context of digital companies entering the healthcare system. Finally, we show ways for the NHS to maintain public trust by putting in place a solidarity grounded partnership model with companies seeking to access patient data. Such a model would need to serve collective interests through, for example, securing preferential access to goods and services, providing health benefits, and monitoring data access. Conclusion A solidarity grounded partnership model will help establish a social contract or licence that responds to the public’s expectations and to principles of a solidaristic healthcare system. (shrink)

A notorious debate in the ethics of healthcare rationing concerns whether to address rationing decisions with substantial principles or with a procedural approach. One major argument in favour of procedural approaches is that substantial principles are indeterminate so that we can reasonably disagree about how to apply them. To deal with indeterminacy, we need a just decision process. In this paper I argue that it is a mistake to abandon substantial principles just because they are indeterminate. It is true (...) that reasonable substantial principles designed to deal with healthcare rationing can be expected to be indeterminate. Yet, the indeterminacy is only partial. In some situations we can fully determine what to do in light of the principles, in some situations we cannot. The conclusion to draw from this fact is not that we need to develop procedural approaches to healthcare rationing, but rather that we need a more complex theory in which both substantial principles and procedural approaches are needed. (shrink)

Ethics consultation is a commonly applied mechanism to address clinical ethical dilemmas. However, there is little information on the viewpoints of health care providers towards the relevance of ethics committees and appropriate application of ethics consultation in clinical practice. We sought to use qualitative methodology to evaluate free-text responses to a case-based survey to identify thematically the views of health care professionals towards the role of ethics committees in resolving clinical ethical dilemmas. Using an iterative and reflexive model we identified (...) themes that health care providers support a role for ethics committees and hospitals in resolving clinical ethical dilemmas, that the role should be one of mediation, rather than prescription, but that ultimately legal exposure was dispositive compared to ethical theory. The identified theme of legal fears suggests that the mediation role of ethics committees is viewed by health care professionals primarily as a practical means to avoid more worrisome medico-legal conflict. (shrink)

In this study, I explore the challenges that ideological hegemonies of personhood imbibed by nurses and other healthcare workers could pose for the nursing profession, particularly in terms of inhibiting the acknowledgment of difference. Dominant or hegemonic conceptions of personhood in particular spaces often consist of self‐contained ideas and essentialist ontologies and normativity of what it means to be a person, lack of which results in the denial of personhood and the othering as non‐person or sub‐person. The other as (...) the residue of such self‐contained notions of personhood is most often denied the quality of care that the one who fits within such conceptions enjoy. For nurses and other healthcare workers to overcome such exclusionary tendencies in healthcare, they must overcome hegemonies and ideological dominance and be more open to alternative viewpoints and theories of personhood. I develop these lines of thought by focusing on the rich ideological traditions of Continental and African philosophies showing how exclusion takes place within these traditions based on conceptions of personhood and how such exclusion on the basis of difference impacts negatively on healthcare. I conclude by highlighting the need to go beyond hegemonic philosophies of personhood by decolonizing and demasculinizing healthcare, thereby allowing difference to flourish in an ecology of medical knowledge. (shrink)

Background Biobank participants often do not understand much of the information they are provided as part of the informed consent process, despite numerous attempts at simplifying consent forms and improving their readability. We report the first assessment of biobank enrollees’ comprehension under an "integrated consent” process, where patients were asked to enroll in a research biobank as part of their normal healthcare experience. A number of healthcare systems have implemented similar integrated consent processes for biobanking, but it is (...) unknown how much patients understand after enrolling under these conditions. Methods: We recruited patients who enrolled in a biobank while in a healthcare setting when receiving ordinary care. We assessed knowledge of consent materials using 11 true/false questions drawn from a well-known biobank knowledge test. After reviewing the results from 114 participants, we revised the consent form and repeated the knowledge assessment with 144 different participants. Results: Participants scored poorly on the knowledge test in both rounds, with no significant differences in overall scores or individual items between the rounds. In Phase 1, participants answered 53% of the questions correctly, 25% incorrectly, and 22% “I don’t know.” In Phase 2, participants answered 53% of questions correctly, 24% incorrectly, and 23% “I don’t know.” Participants scored particularly poorly on questions about data sharing and accessing medical records. Conclusions: Enrollees under an integrated consent model had significant misunderstandings that persisted despite an attempt to improve information specifically about those topics in a consent form. These results raise challenges for current approaches that attribute misunderstanding to overly complex consent forms. They also suggest that the pressures of the clinic may compound other problems with patient understanding of biobank consent. As health systems increasingly blend research and care, they may need to rethink their approach to educating patients about participation in a biobank. (shrink)

This article is concerned with "all-or-nothing" approaches to female genital cosmetic surgeries, those that overemphasize either women's autonomy to defend total accessibility or the oppressive social context affecting women to defend the total banning of the procedures. By contrast, the author takes both phenomena into consideration. The author argues identifying patterns of false consciousness and weighing those against harm done to a patient provides a moral basis for a doctor to possibly deny their consent at face value. This also requires (...) a shift in understanding the doctor–patient relationship as a first step toward a feminist model for women's healthcare. (shrink)

Recent epidemiological research on the social determinants of health has been used to attack an important framework, associated with Norman Daniels, that depicts healthcare as special. My aim is to rescue the idea that healthcare has special importance in society, although specialness will turn out to be mainly limited to clinical care. I build upon the link between Daniels's theory and the work of John Rawls to develop a conception of public justification liberalism that is suitable to the (...) field of justice and health. I argue that, from the perspective of public justification liberalism, (clinical) healthcare deserves special status. (shrink)

Ubiquitous healthcare is an emerging area of technology that uses a large number of environmental and patient sensors and actuators to monitor and improve patients' physical and mental condition. Tiny sensors gather data on almost any physiological characteristic that can be used to diagnose health problems. This technology faces some challenging ethical questions, ranging from the small-scale individual issues of trust and efficacy to the societal issues of health and longevity gaps related to economic status. It presents particular problems (...) in combining developing computer/information/media ethics with established medical ethics. This article describes a practice-based ethics approach, considering in particular the areas of privacy, agency, equity and liability. It raises questions that ubiquitous healthcare will force practitioners to face as they develop ubiquitous healthcare systems. Medicine is a controlled profession whose practise is commonly restricted by government-appointed authorities, whereas computer software and hardware development is notoriously lacking in such regimes. (shrink)

UK-based research conducted within a healthcare setting generally requires approval from the National Research Ethics Service. Research ethics committees are required to assess a vast range of proposals, differing in both their topic and methodology. We argue the methodological benchmarks with which research ethics committees are generally familiar and which form the basis of assessments of quality do not fit with the aims and objectives of many forms of qualitative inquiry and their more iterative goals of describing social processes/mechanisms (...) and making visible the complexities of social practices. We review current debates in the literature related to ethical review and social research, and illustrate the importance of re-visiting the notion of ethics in healthcare research. (shrink)

The use of robotic technology in healthcare is increasing. The aim was to explore attitudes toward the use of humanoid robots in healthcare among patients, relatives, care professionals, school actors and other relevant actors in healthcare and to analyze the associations between participants’ background variables and attitudes. The data were collected through a cross-sectional survey (N = 264) in 2018 where participants met a humanoid robot. The survey was comprised of background variables and items from a modified (...) Robot Attitude Scale. Multiple linear regression analysis and Spearman’s Rho correlation were used to analyze associations between variables. Most of the participants were positive toward the use of humanoid robots in healthcare and only a few were negative. Attitudes toward the use of humanoid robots were more positive among other relevant actors, such as service personnel and politicians in healthcare, participants with a higher educational level and older adults. More research is needed on the reasons underlying negative attitudes because these might affect the introduction of humanoid robots in healthcare. A careful evaluation of appropriate first target groups as well as which tasks are appropriate for humanoid robots to perform in healthcare are needed. (shrink)

Traditional Chinese culture, Confucianism, in particular, has a non-individualist conception of what it is to be human. It conceives of people fundamentally as members of social groups—specifically, the family, the clan, the political community and the state—not as atomic individuals as perceived in modern society. The communist ideology since the middle of the last century also emphasizes the significance of ‘the common good’ of the state which describes a specific ‘good’ that is shared and beneficial for all (or most) members (...) of a given community. Nevertheless, marketization and decentralization in China today have significantly challenged the notion of a state-oriented community that directly impacts China's healthcare system, beginning with the dismantling of the rural collectives and state-owned enterprises as part of the reform and opening process. This article will address healthcare challenges in China today, examining the conceptual/ethical issues raised by public healthcare, and contending that public health concerns should go beyond the dichotomy between individualism and collectivism. The article will argue that the family-oriented model of Confucianism offers an alternative way to look at what constitute a community and common goods. The Confucian approach to ethics is relevant to healthcare today. For example, it will be much easier to find a shared idea of common good in terms of complicated issues like healthcare; it would make sense to give a larger role to families via family savings accounts, and not have everything determined by the government. (shrink)

Levinas's ethics has in the last decades exerted a significant influence on Nursing and Caring Science. The core of Levinas's ethics – his analyses of how our subjectivity is established in the ethical encounter with our neighbour or the Other – is applied both to healthcare practice and in the project of building an identity of Nursing and Caring Science. Levinas's analyses are highly abstract and metaphysical, and also non‐normative. Thus, his analyses cannot be applied directly to practical problems (...) and questions. Theorists in Nursing and Caring Science are generally aware of this. Nevertheless, many of them use Levinas's analyses to explore and solve questions of practical and normative character. This article focuses on the challenges and dilemmas of using Levinas in this manner.The article is divided into two parts. The first part presents some central ideas of Levinas's ethics based on the latter part of his authorship. The main focus is on the radicalism of Levinas's critique of the symbolic order (which includes concepts, categories, knowledge, etc.) – or as he puts it ‘the said’ – as a basis for subjectivity and responsibility. Levinas's notions of saying, anarchy, and singularity accentuate this point of view. These notions refer to conditions in the language, which counteract the symbolic order in the ethical encounter to such an extent that it becomes an incomprehensible. Levinas gives the argumentation a metaphysical frame: The encounter with the incomprehensible is an encounter with the Holy, which is not the ontological God, but a metaphysical desire. It is a mystery as to what this means, and herein lies possibly the main challenge when using Levinas's ethics in science and research: How to maintain the radicalism of his critique of the symbolic order when this is to be communicated in a scientific context that expects clarification of statements and ideas? The second part of the article explores this question by examining how some theorists use Levinas's ethics on questions and problems in the area of healthcare and Nursing and Caring Science. The focus is especially on the theorists' reception and use of the just mentioned notions. The study reveals that these theorists to a large extent transform Levinas's ethics according to their own approaches, with the result that his ethics loses its critical radicalism. Thus, I question the reason why they use Levinas. (shrink)

Justifying his proposal for “health savings accounts,” which would allow individuals to set aside tax-free dollars against future healthcare needs, President Bush has said that “Health savings accounts all aim at empowering people to make decisions for themselves.” Who could disagree with such a sentiment? Although bioethicists may be among those who express skepticism that personal health savings accounts will be part of the needed “fix” of our healthcare financing system, self determination has long been part of their (...) mantra. Indeed, the field of bioethics played an important role in advancing this idea in the medical world when physician paternalism was regnant. Has its popularity caused it to become so vapid as to be ripe for misuse? (shrink)

Dr Caitríona L Cox’s recent article expounds the far-reaching implications of the ‘Healthcare Hero’ metaphor. She presents a detailed overview of heroism in the context of clinical care, revealing that healthcare workers, when portrayed as heroes, face challenges in reconciling unreasonable expectations of personal sacrifice without reciprocity or ample structural support from institutions and the general public. We use narrative medicine, a field primarily concerned with honouring the intersubjective narratives shared between patients and providers, in our attempt to (...) deepen the discussion about the ways Healthcare Heroes engenders military metaphor, antiscience discourse, and xenophobia in the USA. We argue that the militarised metaphor of Healthcare Heroes not only robs doctors and nurses of the ability to voice concerns for themselves and their patients, but effectively sacrifices them in a utilitarian bargain whereby human life is considered the expendable sacrifice necessary to ‘open the U.S. economy’. Militaristic metaphors in medicine can be dangerous to both doctors and patients, thus, teaching and advocating for the critical skills to analyse and alter this language prevents undue harm to providers and patients, as well as our national and global communities. (shrink)

While Austrian social and healthcare service nonprofit organizations are key performers in the COVID-19 pandemic, we also notice their vulnerability in terms of struggling with this disruptive extreme context. The particularity of disruptive extreme contexts is that organizations commonly can neither anticipate them, nor prepare specific countermeasures or specialized resources for fighting against them. Thus, we regard organizational resilience based on non-specialized resources as an appropriate approach for dealing with disruptive extreme contexts. Organizational resilience refers to an organization's ability (...) to resist disruptive extreme contexts while maintaining and adapting functionality and ultimately learning from these extreme contexts by mobilizing and accessing the required resources, behaviors and capabilities. Based on 33 expert interviews with NPO top and middle managers we aim to explore individual-based and interactional resilience mechanisms of NPOs in the pandemic. The qualitative content analysis yielded to following results: Individual personality traits and attitudes constitute individual-based resilience mechanisms. Moreover, a shared understanding, social connectedness and managerial staff orientation as interactional resilience mechanisms helped to maintain and adapt NPOs' functioning. Overall, this study reinforces the multilevel nature of resilience in terms of the crucial combination of individual and interactional resilience mechanisms for facing adversity. Moreover, it emphasizes the evolving nature of resilience in terms of the required time for, e.g., building trust. (shrink)

The pipeline model framework proposed by Char et al. makes a timely contribution to the literature in allowing one to take a step back and consider machine learning healthcare app...

is a new campaign devoted to reducing the environmental harmsgenerated by the healthcare industry. One of the leading local proponents of this effort is Michael Lerner, founder of Commonweal, a Bolinas, Californiagenius grant”).

Political interaction among citizens who hold opposing moral views commonly requires reaching beyond toleration, toward actual co‐operation with policies one opposes. On the more personal level, however, regarding (e.g.) interactions between healthcare providers and patients, several authors emphasise the importance of preserving integrity. But those who oppose any ‘complicity in evil’ often wrongly conflate instances in which the other's position is (and should be) totally rejected with instances of legitimate, although deep, disagreement. Starting with a striking example from the (...) context of a particular tradition, I argue generally that in the latter sort of disagreements, talk of ‘complicity’ should be largely replaced with a more co‐operative moral stance, grounded in a pluralistic framework. Co‐operation Despite Disagreement (CDD) should be sought either for institutional reasons – akin to the political – or for relational reasons. CDD involves sharing another's perspective and sometimes calls for adopting another's moral judgements in preference to one's own. I seek to identify some of the conditions and circumstances that would justify such a shift, particularly in scenarios involving assistance, such as physician‐assisted suicide (PAS) or the role of an anaesthesiologist in abortion. This discussion is meant to provide examples of the kind of second‐order reasons appropriate for determining the terms for CDD – in distinction from first‐order considerations (e.g., the much‐contested ‘active/passive’ distinction) which are likely to be the subject of the initial disagreement and hence cannot serve to resolve it. (shrink)

It should surprise no one familiar with the problems in rural healthcare that 87% of a randomly selected sample of Nebraskans recently called for either fundamental or complete change of the healthcare system. Rural communities in the United, States have been hard hit by the rising cost of healthcare at a time of economic and demographic decline. Unable to sustain operating costs and personnel needs, rural hospitals and medical, practices have been forced to close their doors at (...) an, alarming rate.Furthermore, rural patients are decreasingly able to afford what services are available to them. Most must purchase insurance privately because they are unlikely to be insured through employment. Therefore, they pay dearly because they are not eligible for corporate rates and because insurance companies use experience instead of community rating to assess risk. (shrink)

Paul Bloom has famously argued against the need for empathy in clinicians, while Sally Dalton-Brown has argued that AI need not be capable of empathy in order to be a good carer. In this paper, the capacity for AI to substitute for human clinicians is assessed from a bioethical perspective, primarily through the evaluation of the arguments put forth by Dalton-Brown and Bloom concerning empathy in healthcare. In opposition to both Bloom and Dalton-Brown, this paper argues that (1) empathy (...) is essential to providing good care or deep care (that is, care that goes beyond the mere fulfillment of medical tasks), (2) deep care is a significant aspect of healthcare and yields important benefits, and (3) AI’s lack of capacity for empathy and mutual recognition prevents it from being able to provide deep care for patients, and for this reason, we ought to be extremely cautious about considering allowing AI to ultimately replace human health care providers. (shrink)

Demanding work-life and excessive workload, the conflict between professional and personal lives, problems with patients and those related to the occurrence of death and high risk for their own life are a few factors causing burnout, disengagement, and dissatisfaction in the professional lives of healthcare professionals. The situation worsened during the COVID-19 pandemic. It is of utmost importance to find effective solutions to mitigate the stress and anxiety adversely affecting the mental well-being and professional lives of HCPs. This study (...) was designed to examine the efficacy of Sudarshan Kriya Yoga for alleviating work exhaustion, improving Professional Fulfillment, and influencing positivity among HCPs during COVID-19. In a comparative observation before the intervention, after the intervention, and 30 days after the intervention in the Experimental Group and Control Group, it was found that immediately after SKY, HCPs experienced a significant improvement in Professional Fulfillment, work exhaustion, positive affect, and negative affect compared to the Control Group. The effect of SKY continued until Day 30 for Professional Fulfillment and had positive and negative effects. Findings suggest that SKY elevated Professional Fulfillment among HCPs during the COVID-19 pandemic and reduced their work exhaustion and the negative effect on their mental health. SKY can aid HCPs in maintaining their well-being when faced with unprecedented challenges. (shrink)

Background: Priority setting is necessary in current healthcare services. Discussion of fair process has highlighted the value of developing reasons for allocation decisions on the basis of experience gained from real cases.Aim: To identify the reasons that those with experience of real decision-making concerning resource allocation think relevant in deciding on the priority of a new but expensive drug treatment.Methods: Semistructured interviews with members of committees with responsibility for making resource allocation decisions at a local level in the British (...) National Health Service, analysed using modified grounded theory.Results: 22 interviews were carried out. 14 reasons were identified. Four reasons were almost universally considered most important: cost effectiveness; clinical effectiveness; equality and gross cost. No one reason was considered dominant. Some considerations, such as political directives and fear of litigation, were thought by many participants to distort decision-making. There was a substantial lack of agreement over the relevance of some reasons, such as the absence of alternative treatment for the condition.Conclusions: There is a clear consensus on the importance and role of a limited number of reasons in allocation decisions among participants. A focus on the process of decision-making, however, does not obviate the need for those involved in the process to engage with problematical ethical issues, nor for the importance of further ethical analysis. (shrink)

Pediatric palliative care is specialized medical care for children who live with serious and life-limiting illnesses, with the central goal to improve quality of life for both children and their families. Presently, a majority of pediatric palliative care referrals are based on the traditional consultative model, in which primary providers serve as the gatekeepers to palliative care access. It is well-known that racial and ethnic healthcare disparities exist across the continuum of care, fraught with healthcare providers’ biases that (...) impact the care delivered. This includes the referral practices, allocation and utilization of palliative care services, and leaving vulnerable children and families with potentially unmet palliative care needs. We make the moral argument that the establishment of standard referral criteria for pediatric palliative care services is one simple step that must be taken to begin to address and hopefully ameliorate the impact of providers’ biases and disparities that exist within pediatric palliative care. (shrink)

Reading and reflecting on real cases helps ethics come alive for students. Good cases grip our attention, engage our imagination, and show the real-life implications of abstract ethical theories, ideals, commitments, and policies. Finding good case studies is both difficult and time-consuming for instructors, so I was excited to learn about Glenn McGee’s book Bioethics for Beginners: 60 Cases and Cautions from the Moral Frontier of Healthcare. According to the publisher, its target audiences are “courses in bioethics, medical ethics, (...) and applied ethics.” The book sounded promising.McGee’s book contains ten chapters, or “cautions,” plus a conclusion. Each chapter consists of anywhere from three to nine loosely associated “cases.” The cases average about one and a half pages each, but they vary significantly in length. The shortest cases are less than a page while the longest is twelve pages .All sixty cases, as well as the two sections that compose the conclus .. (shrink)

BackgroundAs the population of the United States ages, chronic diseases increase and treatment options become technologically more complicated. As such, patients’ autonomy, or the right of patients to accept or refuse a medical treatment, may become a more pressing and complicated issue. This autonomy rests upon a patient’s capacity to make a decision. As more older, cognitively and functionally impaired individuals enter healthcare systems, quality assessments of decision-making capacity must be made. These assessments should be done in a time-efficient (...) manner at a patient’s bedside by the patient’s own physician. Thus, a clinically practical tool to assist in decision-making capacity assessments could help guide physicians in making more accurate judgments.ObjectivesTo create a clinically relevant Bedside Capacity Assessment Tool (BCAT) to help physicians make timely and accurate clinical assessments of a patient’s decision-making capacity for a specific decision.SettingThe Department of Medicine, Division of Geriatrics and Palliative Medicine, Zucker School of Medicine at Hofstra/northwell.ParticipantsGeriatric medicine fellows, palliative medicine fellows, and internal medicine residents (n = 30).MeasurementsSubjects used the BCAT to assess the decision-making capacity of patients described in 10 written, clinically complex capacity assessment vignettes. Subjects’ conclusions were compared to those of experts.ResultsThe subjects’ and experts’ assessments of capacity had a 76.1 percent rate of agreement, with a range of 50 percent to 100 percent. With removal of three complex outlier vignettes, the agreement rate reached 83.2 percent.ConclusionThe strong correlation between the two groups—one of physicians in training utilizing the BCAT and the other of specialists in this area—suggests that the BCAT may be a useful adjunct for clinicians who assess decision-making capacity in routine practice. The range indicates that further refinement and testing of this tool is necessary. The potential exists for this tool to improve capacity assessment skills for physicians in clinical practice. (shrink)

Ethics consultation services provide support to staff, patients, and family members who find themselves in morally difficult situations in healthcare settings. Not unlike other clinical consultation services, ethics consultation activities should be well documented. Good documentation allows for evaluation of the consultation process and the ability to refer back to consults when needed, and provides data for future research in healthcare ethics (HCE).In our exploration of existing HCE documentation systems, we identified two main points of interest. First, HCE (...) information documentation systems are powerful tools for providing information on ethics consultation services. These documentation systems can be used to produce detailed reports on various HCE activities both institutionally and cross-institutionally. Second, our findings indicate greater agreement in the language and terminology of HCE needs to be established. Cultivation of such common language is needed in order to develop a standard healthcare ethicists can use to document and categorize consults. Standardization of language would allow data to be readily comparable and lead to more consistency in documentation of ethics consultations. Ultimately, standardization of documentation can also constitute a standard of practice for HCE in general. The development of such standards is essential for any developing profession, and will be required for HCE as it moves in towards professionalization in Canada. (shrink)

IntroductionThe COVID-19 pandemic has led to unprecedented strain to healthcare systems worldwide and posed unique challenges to the healthcare professionals and the general public.ObjectivesThe aim of this study is to evaluate the impact of COVID-19 on the mental health, behavioral, and physical wellbeing of HCPs in the early and mid-term periods of the pandemic in comparison to non-HCPs. Thus, facilitating and guiding optimum planning and delivery of support to HCPs.Methods and AnalysisAn observational cross-sectional survey and cohort study aiming (...) to enroll over 1050 participants. Study questionnaires will be completed at baseline and after 6-weeks and 4-months. Recruitment initiated July 2020. The study was designed in London, United Kingdom, but open to participants worldwide. Baseline: Questionnaires comprising of validated self-administered screening tools for depression, anxiety, sleep-related issues, wellbeing, and burnout. The questionnaires also explore changes in behavior and physical wellbeing of the participants. In addition, associations of these mental health and behavioral factors with work-related factors and support will be explored. Six-weeks and 4-months follow-up: Follow-up questionnaires will assess change in symptoms of anxiety and depression, sleep disorders, use of alcohol and other substances, behavioral or interpersonal relationship changes. Physical wellbeing will be assessed through the presence of suspected or confirmed COVID-19 infection and absence from work. We will also evaluate the impact of variable provision of personal protection equipment, extended working hours, and concern for the wellbeing of family members, anxiety levels, and evidence of burnout.Statistical ConsiderationsThe study has 80% power to detect a 10% difference of combined depression and/or anxiety symptoms between the groups using two-sided type 1 error at 0.05 at baseline. Assuming that only 50% of these HCPs agree to be a part of a cohort survey, we will have 80% power to detect around 12% difference in the two groups in reported physical symptoms, or prevalence of depression and/or anxiety at the end of the study.EthicsThe study was approved by the Cambridge East, Research Ethics Committee.Trial Registration NumberClinicalTrials.gov, NCT04433260. (shrink)

This paper critically examines efforts to “professionalize” the field of healthcare management and its corresponding costs. Drawing upon the scholarly critiques of professionalization in medicine and the broader field of management, this paper seeks to explore the symbolic role professionalization might play in the psyche of its constituents, and specifically its function as a defense against uncertainty and anxiety. This psychodynamic heuristic is then deployed to put forth the hypothesis that an ongoing crisis of professional identity continues to both (...) propel and impede professionalization efforts in healthcare management, giving rise to a litany of standardization pressures that ultimately limit the field’s potential. To mitigate these pressures, the call is made for rekindling healthcare management’s moral, political, and existential aspects. Specifically, this entails engaging with the deeper themes that flow through the field: the experience of illness and what it means to suffer, the experience of life and what it means to have hope, and the experience of death and dying. It also entails squarely confronting questions of power, poverty and disease, and the pursuit of justice. (shrink)

Background: In Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions. Objectives: We highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these (...) decisions ought to be made. Research design: This paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made. Participants and research context: We describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders. Ethical considerations: The case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient. Findings: As a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress. Discussion: We argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethical treatment of the patients for whom they care. Conclusions: One of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients. (shrink)

Healthcare ethics has become part of the standard curriculum of students in the health professions. The goals of healthcare ethics education are to give students the skills they need to identify, assess, and address ethical issues in clinical practice and to develop virtuous practitioners. Incorporating the medical humanities into medical school, for example, is intended to foster empathy and professionalism among students and to provide mechanisms for enhanced physician well-being. Yet, despite the long-standing inclusion of the humanities in (...) nursing curricula, increases in the amount and kinds of scientific knowledge essential for clinical practice has resulted in the erosion of the “humanistic arts” from nursing education. One potential solution to this challenge comes with the increase in interprofessional education, where students in a variety of healthcare professions programs come together to learn about issues common to all healthcare fields. (shrink)

As part of a project to examine health care ethics consultation in Canada, we surveyed individuals who were considered by themselves or others to play a significant role in health care ethics consultation. Since one goal of the project was to examine the education and abilities necessary for consultants, we sought to determine the qualifications and skills currently possessed by persons considered to be ethics consultants. For the purposes of the questionnaire, health care ethics consultation was defined broadly to include (...) consultation on ethical issues in clinical care or in clinical research, ethics consultation to Clinical Ethics Committees, Research Ethics Committees, and policy formulation committees in health care institutions; clinical ethics work was defined more broadly still to include, in addition to the above, ethics education, administration, research and writing on bioethics other than the above, and public speaking.Three hundred and fifty questionnaires were sent to individuals and institutions across Canada that were thought to have some involvement in health care ethics consultation. Two hundred and fifty-three questionnaires were returned for a response rate of 72%. This report presents initial findings of the study and attempts to provide a comprehensive overview of the current state of ethics consultation within Canada. The survey examines demographics, educational background, time spent on ethics, institutional affiliations, approaches to the role of consultation, research related issues, and attitudes toward certification. (shrink)

Healthcare professionals who feel psychologically safe believe it is safe to take interpersonal risks such as voicing concerns, asking questions and giving feedback. Psychological safety is a complex phenomenon which is influenced by organizational, team and individual level factors. However, it has primarily been assessed as a team-level phenomenon. This study focused on understanding healthcare professionals' individual experiences of psychological safety. We aim to gain a fuller understanding of the influence team leaders, interpersonal relationships and individual characteristics have (...) on individuals' psychological safety and their decisions to engage in voice or silence behavior. Thirty-four interviews were conducted with healthcare professionals from across five teams working within an acute, suburban hospital. Hybrid inductive-deductive thematic analysis focused on identifying themes which captured the complexities of individuals' varied experiences of psychological safety. The themes identified were: “Personal Characteristics,” “Past Experiences,” “Individual Perceptions of Being Valued,” and “Judged Appropriateness of Issues/Concerns.” These themes are explored within the context of motivating and inhibiting factors associated with the influence of leadership, interpersonal relationships and individual characteristics on experiences of psychological safety and voice behavior. These results extend existing theoretical frameworks guiding our understanding of psychological safety by accounting for the variation in individuals' experiences and studying these significant influences on voice behavior. Important considerations for the development of interventions to enhance psychological safety are discussed. (shrink)

Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Federal and state disability law provide alternative decision-making models that do not prevent persons with mild to moderate dementia from making their own healthcare decisions at the time the decision needs to be made. In order to better (...) promote autonomy and wellbeing, persons with dementia should be accommodated and supported so they can make their own healthcare decisions. (shrink)

Healthcare professionals’ capacity to protect themselves, while caring for infected patients during an infectious disease pandemic, depends on their ability to practise universal precautions. In turn, universal precautions rely on the availability of personal protective equipment (PPE). During the SARS-CoV2 outbreak many healthcare workers across the globe have been reluctant to provide patient care because crucial PPE components are in short supply. The lack of such equipment during the pandemic was not a result of careful resource allocation decisions (...) in the global north, where the short supply could be explained through their high cost. Instead, they were the result of democratically elected governments prioritising low tax regimes over an adequate resourcing of their healthcare delivery systems. Such decisions were made despite global health experts warning about the high probability of pandemics like SARS-CoV2 occurring during our lifetimes. Avoidable allocation decisions by democratically elected political leaders resulted in a lack of sufficient PPE for healthcare professionals. After discussing and discounting various ethical arguments in support of a professional obligation to treat, even without or with suboptimal PPE, I conclude that these policy decisions were sufficiently grave that they provide a sound ethical rationale to justify healthcare workers’ refusal to provide care to infected patients. (shrink)

Background: In the variegated legislative framework on advance directives, the first specific regulation in Italy on this issue came into force only in 2018. Research objective: This qualitative study aimed to investigate the implications of the new Italian law on advance directives in clinical practice from the perspective of those who deal with this delicate ethical issue on an everyday basis, that is, Italian healthcare professionals. Research design: A qualitative research design using semi-structured audio-recorded interviews was adopted. The data (...) collection and analysis were performed according to the Grounded Theory approach. Participants: Nineteen healthcare professionals (16 nurses, 3 physicians) working in a palliative care unit of a research and clinical institute in Italy. Ethical considerations: The study is part of the WeDistress HELL Project (WEllness and DISTRESS in HEalth care professionals dealing with end of Life and bioethicaL issues) approved by the Ethical Committee of ICS Maugeri - Institute of Pavia (Italy). Findings: The authors identified a main overall category, ‘Pros and Cons of the Italian law on advance directives’, composed of six constituent categories: Positive welcome, Self-determination and protection, Prompts for future betterment, Uncertainties, Lack of knowledge, and Neutrality and no suggestions. Discussion: The Italian law n. 219/2017 on advance directives was seen as a legal instrument possessing both strengths and weaknesses, but able to guarantee the patient’s self-determination and support healthcare professionals in providing care according to patients’ wishes. Conclusion: An understanding of the healthcare providers’ perspective may support the discussion on advance directives and bridge the gaps that currently persist in handling ethical issues. (shrink)

During the COVID-19 pandemic, the media have repeatedly praised healthcare workers for their ‘heroic’ work. Although this gratitude is undoubtedly appreciated by many, we must be cautious about overuse of the term ‘hero’ in such discussions. The challenges currently faced by healthcare workers are substantially greater than those encountered in their normal work, and it is understandable that the language of heroism has been evoked to praise them for their actions. Yet such language can have potentially negative consequences. (...) Here, I examine what heroism is and why it is being applied to the healthcare workers currently, before outlining some of the problems associated with the heroism narrative currently being employed by the media. Healthcare workers have a clear and limited duty to treat during the COVID-19 pandemic, which can be grounded in a broad social contract and is strongly associated with certain reciprocal duties that society has towards healthcare workers. I argue that the heroism narrative can be damaging, as it stifles meaningful discussion about what the limits of this duty to treat are. It fails to acknowledge the importance of reciprocity, and through its implication that all healthcare workers have to be heroic, it can have negative psychological effects on workers themselves. I conclude that rather than invoking the language of heroism to praise healthcare workers, we should examine, as a society, what duties healthcare workers have to work in this pandemic, and how we can support them in fulfilling these. (shrink)

Background: This article combines foundational and empirical aspects of healthcare education and develops a framework for teaching ethical theories inspired by pragmatist learning theory and recent work on the concept of moral resilience. It describes an exemplary implementation and presents data from student evaluation. Objectives: After a pilot implementation in a regular ethics module, the feasibility and acceptance of the novel framework by students were evaluated. Research design: In addition to the regular online module evaluation, specific questions referring to (...) the teaching of ethical theories were added using simple (yes/no) and Likert rating answer formats. Participants and research context: At the Bern University of Applied Sciences, a total of 93 students from 2 parallel sub-cohorts of the bachelor’s program in nursing science were sent the online survey link after having been exposed to the same modular contents. A total of 62% of all students participated in the survey. Ethical considerations: The survey was voluntary and anonymous. Students were free to write their name and additional comments. Findings: Students consider ethical theories—as taught within the proposed framework—as practically applicable, useful, and transferable into practice. Discussion: Teaching ethical theories within the proposed framework overcomes the shortcomings described by current research. Students do not consider the mutually exclusive character of ethical theories as an insurmountable problem. Conclusion: The proposed framework is likely to promote the effectiveness of healthcare ethics education. Inspired by pragmatist learning theory, it enables students to consider ethical theories as educative playgrounds that help them to “frame” and “name” the ethical issues they encounter in daily practice, which is seen as an expression of moral resilience. Since it does not advocate a single ethical theory, but is open to the diversity of traditions that shape ethical thinking, it promotes a culturally sensitive, ethically reflected healthcare practice. (shrink)

Abstract Aim: The COVID-19 infection is transmitted either by human-to-human contact, social-physical contact, and respiratory droplets or by touching items touched by the infected. This has triggered some conflicted behaviors such as stigma, violence, and opposite behavior applause. The aim of this study is to explore several newspaper articles about stigma, violence, or insensitive behavior against healthcare professionals and to analyze the reason for these behaviors during these COVID-19 pandemics. Method: The website of the Turkish Medical Association "Press Releases (...) News" and online newspaper articles have been scanned using keywords and have been classified and analyzed according to the content of articles between the periods of March 11 to April 28, 2020. This is a qualitative study with content analysis. No official ethical permission was obtained as the study was conducted through open access internet news sites. Result: 16 reports were selected from online reports that matched the keywords of the study. 13 of these reports included desensitization, violence, lack of precaution, stigmatization, and applause, and 3 reports included doctors’ statements. After being categorized, content analyses were conducted. Conclusion: This study revealed the necessity of a multi-faceted evaluation of the problems faced by healthcare professionals who are at the forefront of the COVID-19 outbreak. This study has a primary role in the detection, diagnosis, and treatment of the pandemic and reveals that doctors are trying to fulfill their duties in an ethical framework despite stigmatized behavior. Authorities should provide various supports to protect healthcare professionals before, during, and after the epidemic for the success of the COVID-19 outbreak struggle. (shrink)

Ill persons suffer from a variety of epistemically-inflected harms and wrongs. Many of these are interpretable as specific forms of what we dub pathocentric epistemic injustices, these being ones that target and track ill persons. We sketch the general forms of pathocentric testimonial and hermeneutical injustice, each of which are pervasive within the experiences of ill persons during their encounters in healthcare contexts and the social world. What’s epistemically unjust might not be only agents, communities and institutions, but the (...) theoretical conceptions of health that structure our responses to illness. Thus, we suggest that although such pathocentric epistemic injustices have a variety of interpersonal and structural causes, they are also sustained by a deeper naturalistic conception of the nature of illness. (shrink)

Self-tracking-technologies can serve as a prominent example of how digital technologies put to test established practices, institutions, and structures of medicine and healthcare. While proponents emphasize the potentials, e.g., for individualized healthcare and new research data, opponents stress the risk that these technologies will reinforce gender-related inequalities. -/- While this has been made clear from—often intersectional—feminist perspectives since the introduction of such technologies, we aim to provide a queer-feminist perspective on self-tracking applications in healthcare by analyzing three (...) concrete cases. In this way, we want to show why such a perspective is helpful in assessing self-tracking technologies and how such a perspective might contribute to a queering of healthcare. -/- After a short introduction to self-tracking in healthcare and the corresponding risks of reproducing gender-related inequalities, we introduce queer bioethics as a methodology to examine structural discrimination and marginalization in bioethical research. We apply this framework in the analysis of three exemplary self-tracking applications from the areas of nutrition/fitness, reproductive health, and mental health. In the subsequent discussion of these results against the backdrop of already existing queer-sensitive technologies, we identify an equal access, a subversive design, an inclusive database, and a diversity-sensitive and discriminatory-critical definition of purposes as well as individualized usage possibilities as first possible starting points for a queering of self-tracking applications. Finally, we draw conclusions, how such a critical perspective on self-tracking applications might also contribute to a queering of the healthcare system at a structural level. (shrink)

Until recently, moral case deliberation (MCD) sessions have mostly been facilitated by external experts, mainly professional ethicists. We have developed a train the facilitator programme for healthcare professionals aimed at providing them with the competences needed for being an MCD facilitator. In this paper, we present the first results of a study in which we evaluated the programme. We used a mixed methods design. One hundred and twenty trained healthcare professionals and five trainers from 16 training groups working (...) in different healthcare organisations throughout the Netherlands were included. After completion of the programme, participants feel sufficiently confident and equipped to facilitate an MCD session. Feeling competent does not mean that participants have no doubts or questions left. Rather, they are aware of their limitations and see the need for continuous learning. According to the respondents, the actual exercise of facilitating MCD during and in between the training sessions contributed most to the development of competences necessary for being an MCD facilitator. Respondents without prior experience of participating in MCD sessions felt less competent after the training than those who had participated in MCD sessions before. Self-attributed competence varied between participants with different professional backgrounds. (shrink)

Why is healthcare ‘special’ to the extent that it should be distributed more equally than other social goods, as a matter of justice? Norman Daniels claims that healthcare is special because it protects the normal range of opportunities available to us, and therefore can be subsumed under a principle of justice which establishes that opportunity ought to be equally distributed. I argue that subsuming healthcare under such a principle leads to de facto discrimination against certain people in (...) virtue of their healthcare needs. This is because—as a critical discussion of health and healthcare needs importantly illustrates—much of the healthcare that people need simply cannot or does not protect normal species function, and therefore does not protect opportunity. And so, such healthcare needs go unfairly unmet on Daniels’ view. Instead, I suggest that we ought to subsume healthcare under a principle of equally distributing the social bases of self-respect. Though the healthcare that many of us need cannot protect opportunity, it can still protect our sense of self-respect; as such, those who need such care are entitled to it as a matter of justice on the self-respect view. The self-respect view thus avoids de facto discrimination and ultimately meets healthcare needs more fairly. And because it does so by eschewing a controversial conception of health and healthcare, instead appealing to a conception that appears freestanding with respect to the doctrines that citizens might reasonably disagree about, it better satisfies the requirements of public justification. (shrink)

climate are both linked to an organization's ability to retain healthcare professionals and increase their level of job satisfaction, leaders have a corollary responsibility to address moral distress. We recommend that leaders should provide access to ethics education and resources, offer interventions such as ethics debriefings, establish ethics committees, and/or hire a bioethicist to develop ethics capacity and to assist with addressing healthcare provider moral distress....

The concept of ‘humane healthcare’ cannot and may not be limited to a personal virtue. For elucidating its meaning and making it functional as a critical ethical criterion for healthcare as a social institution, it is necessary to reflect on the social, cultural, and historical conditions in which modern healthcare finds its offspring and its further development. Doing this is the object and aim of social ethics. Social ethics in itself covers a broad area of different approaches. A (...) main division can be made between a liberal and a communitarian approach. This article focuses on the latter and concentrates on one of its representatives, Charles Taylor. The paper starts with two clarifying paragraphs: one about the terms humane and human, a second about the scope of social ethics. Next, because the term humane presupposes a certain view of man, attention will be paid to the lack of consensus in this respect within modernity, using some reflections of Taylor. In his view, resigning in this lack is a threat for one of the main motives behind modernity: the pursuit of a good and meaningful life. In the following section Taylor's analysis is applied to contemporary healthcare, by means of two examples. At the end the question is raised how to promote humane healthcare? In a short and conclusive sketch, three suggestions are offered for further research: scrutiny of goals and meanings within healthcare and culture, the broadening of the concept of autonomy and the upholding of human dignity as an intrinsic and imperative value. (shrink)