Clinical ethics mediation is invaluable for resolving intractable disputes in the hospital. But it is also a critical day-to-day skill for clinicians, especially those who serve a disproportionate number of vulnerable patients. While mediation is typically reserved for intractable cases, there are two important opportunities to expand its use. First is preventative mediation, in which clinicians incorporate clinical ethics mediation into their daily routine in order to address value-laden conflicts before they reach (...) the point at which outside consultation becomes necessary. Second is guided mediation, in which clinical teams resolve conflicts with patients or surrogates with guidance from an ethics consultant, who operates at some distance from the conflict and, rather than recommending a single action, counsels clinicians on the process they can use to resolve the conflict on their own. These approaches build the capacity of all clinicians to use clinical ethics mediation to improve the care of vulnerable patients. (shrink)

Contrasting traditional and common forms of ethics consultation with bioethics mediation, I describe the case of a “second opinion” consultation in the care of a patient with advanced cancer for whom treatment was futile. While the initial ethics consultation, performed by a colleague, led to a recommendation that some may deem ethical, the process failed to involve key stakeholders and failed to explore the underlying values and reasons for the opinions voiced by various stakeholders. The process of (...) mediation ultimately led to creative solutions in which all stakeholders could reach consensus on a plan of care. (shrink)

Unlike bioethics mediators who are employed by healthcare organizations as outside consultants, mediators who are embedded in an institution must be authorized to chronicle a clinical ethics consultation (CEC) or a mediation in a patient’s medical chart. This is an important privilege, as the chart is a legal document. In this article I discuss this important part of a bioethics mediator’s tool kit in my presentation of a case illustrating how bioethics mediation may proceed, and what (...) this approach using both bioethics and mediation may add. (shrink)

Clinical ethics consultations are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of (...) adverse, lingering sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”. (shrink)

This article starts with a brief historical account of the ongoing debate about the status of clinical ethics: theory of practice. The author goes on to argue that clinical ethics is best understood as a practice. However, its practicality should not be measured by the extent to which clinical-ethical consultants manage to mediate or negotiate resolutions to ethical conflicts. Rather, clinical ethics is practical because it is characterized by a profound concern for the (...) well-being of individual patients as well as the moral parameters of swift and urgent medical action in the face of limited supportive information. (shrink)

Internationally, there is an on-going dialogue about how to professionalize ethics consultation services . Despite these efforts, one aspect of ECS-competence that has received scant attention is the liability of failing to adequately capture all of the relevant moral considerations in an ethics conflict. This failure carries a high price for the least powerful stakeholders in the dispute. When an ECS does not possess a sophisticated dexterity at translating what stakeholders say in a conflict into ethical concepts or (...) principles, it runs the risk of naming one side's claims as morally legitimate and decrying the other's as merely self-serving. The result of this failure is that one side in a dispute is granted significantly more moral weight and authority than the other. The remedy to this problem is that ECSs learn how to expand the diagnostic moral lens they employ in clinical ethics conflicts. (shrink)

Mediators utilize a wide range of skills in the process of facilitating dialogue and resolving conflicts. Among the most useful techniques for clinical ethics consultants (CECs)—and surely the least discussed—are those employed in acrimonious, hostile conversations between stakeholders. In the context of clinical ethics disputes or other bedside conflicts, good mediation skills can reverse the negative interactions that have prevented the creation of workable treatment plans or ethical consensus. This essay lays out the central framework (...) mediators use in distinguishing positions from interests and describes a set of strategies for managing contentious ethics consultations or working with “difficult” patients, families, or patient-careprovider interactions. (shrink)

Clinical ethics consultations are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of (...) adverse, lingering sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”. (shrink)

Evaluating clinical ethics support services has been hailed as important research task. At the same time, there is considerable debate about how to evaluate CESS appropriately. The criticism, which has been aired, refers to normative as well as empirical aspects of evaluating CESS. In this paper, we argue that a first necessary step for progress is to better understand the intervention in CESS. Tools of complex intervention research methodology may provide relevant means in this respect. In a first (...) step, we introduce principles of “complex intervention research” and show how CESS fulfil the criteria of “complex interventions”. In a second step, we develop a generic “conceptual framework” for “ethics consultation on request” as standard for many forms of ethics consultation in clinical ethics practice. We apply this conceptual framework to the model of “bioethics mediation” to make explicit the specific structural and procedural elements of this form of ethics consultation on request. In a final step we conduct a comparative analysis of two different types of CESS, which have been subject to evaluation research: “proactive ethics consultation” and “moral case deliberation” and discuss implications for evaluating both types of CESS. To make explicit different premises of implemented CESS interventions by means of conceptual frameworks can inform the search for sound empirical evaluation of CESS. In addition, such work provides a starting point for further reflection about what it means to offer “good” CESS. (shrink)

ObjectivesTo explore the objectives and outcomes most appropriate for evaluating clinical ethics support services (CESs) in the USA.MethodsA three-round e-Delphi was sent to two professional medical ethics listservs (Medical College of Wisconsin-Bioethics and American Society for Bioethics and Humanities) as well as 19 individual experts. The survey originally contained 15 objectives and 9 outcomes. In round 1, participants were asked to validate the content of these lists. In round 2, we had 17 objectives and 10 outcomes, and (...) participants were asked to rank them for appropriateness in a top 10 list of objectives and a top 5 list of outcomes.ResultsParticipants came to a high(at least 70%) level of agreement on seven objectives: mediate, educate, develop policy, improve the moral quality of a decision or action, counsel, create a moral space and manage moral distress. Participants came to a moderate (at least 51%) level of agreement on three objectives: empower, awareness of ethics and preventative ethics. Participants also came to a moderate (at least 51%) level of agreement on five outcomes: ethical justification, transformation of institution, improvement of quality of life, principled consensus and satisfaction with the expertise of a CES.ConclusionThis e-Delphi identified 10 objectives and 5 outcomes that are a good starting point for developing outcome measures to evaluate CESs in the USA, while reminding us of the diversity of perspectives still evident in the field. (shrink)

Several approaches to clinical ethics consultation (CEC) exist in medical practice and are widely discussed in the clinical ethics literature; different models of CECs are classified according to their methods, goals, and consultant’s attitude. Although the “facilitation” model has been endorsed by the American Society for Bioethics and Humanities (ASBH) and is described in an influential manual, alternative approaches, such as advocacy, moral expertise, mediation, and engagement are practiced and defended in the clinical (...) class='Hi'>ethics field. Our Clinical Ethics Center in Paris was founded in 2002 in the wake of the Patients’ Rights Act, and to date it is the largest center that provides consultation services in France. In this article we shall describe and defend our own approach to clinical ethics consultation, which we call the “Commitment Model,” in comparison with other existing models. Indeed commitment implies, among other meanings, continuity through time, a series of coherent actions, and the realization of important social goals. By drawing on a recent consultation case, we shall describe the main steps of our consultation procedure: interviews with major stakeholders, including patients and proxies; case conferences; and follow up. We shall show why we have chosen the term “commitment” to represent our approach at three different but interrelated levels: commitment towards patients, within the case conference group, and towards society as a whole. (shrink)

In this commentary on a clinical ethics case pertaining to a same-sex couple that does not have explicit surrogate decision-making or hospital-visitation rights (in the face of objections from the family-of-origin of one of the queer partners), the authors invoke contemporary legal and policy standards on LGBTQ health care in the United States and abroad. Given this historical moment in which some clinical rights are guaranteed for LGBTQ families whilst others are in transition, the authors advocate for (...) the implementation of clinical ethics mediation as the soundest and most humane form of resolution in matters where there is a dispute between family members about an incapacitated loved one. They argue that clinical ethics mediation is an ideal alternative solution because it works toward consensus about outcome, even where consensus about values is not achievable. (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 paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist’s perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending (...) on the demands of the specific case, and should avoid attempts to identify a ‘true’ methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism’s emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism’s relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation. (shrink)

Background Caring behaviour is critical for nursing quality, and the clinical internship environment is a crucial setting for preparing nursing students for caring behaviours. Evidence about how to develop nursing students’ caring behaviour in the clinical environment is still emerging. However, the mechanism between the clinical internship environment and caring behaviour remains unclear, especially the mediating role of moral sensitivity and the moderating effect of self-efficacy. Research objective This study aimed to examine the mediating effect of moral (...) sensitivity and the moderating function of self-efficacy on the association between the clinical internship environment and caring behaviours. Research design A cross-sectional design used acceptable validity scales. The hypothesised moderated mediation model was tested in the SPSS PROCESS macro. Participants and research context This survey collected data from 504 nursing students in an internship at a teaching hospital in Changsha, China. Ethical considerations This study was pre-approved by the ethics committee of the medical school (No. E2022210). Informed consent was obtained from all students. Results The clinical internship environment ( B = 0.450, 95% CI = [0.371, 0.530]) and moral sensitivity ( B = 1.352, 95% CI = [1.090, 1.615]) had positive direct effects on nursing students' caring behaviours. Clinical internship environment also indirectly influenced students’ caring behaviours via moral sensitivity ( B = 0.161, 95% CI = [0.115, 0.206]). In addition, self-efficacy played a moderating role between the clinical internship environment and caring behaviours ( B = 0.019, 95% CI = [0.007, 0.031]), as well as the relationship between the clinical internship environment and moral sensitivity ( B = 0.006, 95% CI = [0.003, 0.010]). Conclusion Moral sensitivity mediates the effect of the clinical internship environment on caring behaviour, and self-efficacy strengthens both direct and indirect effects. This study emphasises the importance of self-efficacy in developing moral sensitivity and caring behaviours in nursing students. (shrink)

Background Belonging to the clinical environment and the professional values of the performers play a role in forming a professional identity. Therefore, it is necessary to understand the degree of connection among these concepts. Aim This study aimed to examine the mediating effects of professional values on the relationship between nurses’ clinical environment belongingness and professional identity. Design In the present study, a descriptive cross-sectional multicenter design was used. Participants and research context A convenient sample of 635 nurses (...) recruited from three hospitals in Fars Province, Southern Iran, from September 2023 to January 2024. Nurses Professional Values Scale–Revised, Clinical Environment Belongingness Scale, and Professional Identity Scale were used to collect the data. The mediation model was analyzed using SPSS v27 and the Process Macro 4.0. Ethical considerations The protocol of this study was approved by the Research Ethics Committee of Fasa University of Medical Sciences, and informed consent was obtained from all nurses. The study conforms to the principles outlined in the Declaration of Helsinki. Results Based on the results of regression analysis, clinical environment belongingness had a positive and significant impact on professional identity (β = 0.366, p < 0.001) and professional value (β = 0.676, p < 0.001). Professional value significantly predicted professional identity (β = 0.170, p < 0.001). The indirect effect of clinical environment belongingness on professional identity via professional values was statistically significant (β = 0.115, SE = 0.024, 95% CI = [0.068, 0.162]), and this effect was directly (β = 0.336, SE = 0.034, 95% CI = [0.297, 0.434]) significant. Conclusions The new theoretical framework for nurses developed in this study can contribute to professional development. It is further recommended that the promotion of professional value and clinical environment belongingness may be effective in enhancing the professional identity of the nursing staff, as indicated by the results. (shrink)

The idea of patient advocacy as a function of clinical ethics consultation (CEC) has been debated in the bioethics literature. In particular, opinion is divided as to whether patient advocacy inherently is in conflict with the other duties of the ethics consultant, especially that of impartial mediator. The debate is complicated, however, because patient advocacy is not uniformly conceptualized. This article examines two literatures that are crucial to understanding patient advocacy in the context of bioethical deliberations: the (...) CEC literature and the literature on advocacy in the social work profession. A review of this literature identifies four distinct approaches to patient advocacy that are relevant to CEC: (1) the best interest approach, (2) the patient rights approach, (3) the representational approach, and (4) the empowerment approach. After providing a clearer understanding of the varied meanings of patient advocacy in the context of CEC, we assert that patient advocacy is not inherently inconsistent with the function of the ethics consultant and the CEC process. Finally, we provide a framework to help consultants determine if they should adopt an advocacy role. (shrink)

In this article, we explore alternative conflict resolution strategies to assist families and clinicians in cases of intractable dissent in paediatric health care decision-making. We focus on the ethical and legal landscape using cases from the Australian jurisdiction in New South Wales, while referencing some global sentinel cases. We highlight a range of alternative means of addressing conflict, including clinical ethics support, and contrast and contextualise facilitative or interest-based mediation, concluding that legal intervention via the courts can (...) be protracted and distressing and should be a ‘last resort’. We acknowledge many might view this as the current status quo, but we go further to recommend strategies optimal for all parties to recognise early signs of conflict and prevent its harmful escalation. While more empirical research is needed, we contend that interest-based mediation may be a valuable adjunctive method of conflict resolution. If judiciously distinguished from and utilised with clinical ethical support, it can be an effective tool to address dissent and its negative sequelae in paediatric healthcare decision-making. (shrink)

Rarely do ethics consults focus on genuine moral puzzlement in which people collectively wonder what is the right thing to do. Far more often, consults are about conflict. Each side knows quite well what is “right.” The problem is that the other side is too blind or stubborn to recognize it. And so the ethics consultant is called, perhaps in the hope that s/he will throw the weight of ethics toward one side and end the controversy so (...) everyone can get on with other business. Perhaps the greater problem in these scenarios is that even if one side “wins” by gaining the power to dictate what happens next, the toxicity permeating the relationships often markedly worsens and other conflicts erupt, major and minor. (shrink)

The increasing complexity of human subjects research and its oversight has prompted researchers, as well as institutional review boards, to have a forum in which to discuss challenging or novel ethical issues not fully addressed by regulations. Research ethics consultation services provide such a forum. In this article, we rely on the experiences of a national Research Ethics Consultation Collaborative that collected more than 350 research ethics consultations in a repository and published 18 challenging cases with accompanying (...) ethical commentaries to highlight four contexts in which REC can be a valuable resource. REC assists: 1) investigators before and after the regulatory review; 2) investigators, IRBs, and other research administrators facing challenging and novel ethical issues; 3) IRBs and investigators with the increasing challenges of informed consent and risk/benefit analysis; and 4) in providing flexible and collaborative assistance to overcome study hurdles, mediate conflicts within a team, or directly engage with research participants. Institutions that have established, or plan to establish, REC services should work to raise the visibility of their service and engage in open communication with existing clinical ethics consult services as well as the IRB. While the IRB system remains the foundation for the ethical review of research, REC can be a valuable service for investigators, regulators, and research participants aligned with the goal of supporting ethical research. (shrink)

Background: Ethical behaviour in nursing practice is integral to establishing a harmonious nurse-patient relationship and improving the quality of care. A multitude of factors shapes such behaviour. Therefore, it is crucial to understand the interplay between these factors. Research objectives: This study aimed to explore the mechanisms underlying the influence of moral sensitivity on nurses’ ethical behaviour and clarify the mediating role of moral courage. Research design: This cross-sectional quantitative study was conducted between July and August 2023. Participants and Research (...) Context: The sample comprised 465 clinical nurses from three tertiary hospitals in Zhengzhou City, Henan Province, China. Data were collected using the Chinese version of the Moral Sensitivity Questionnaire-Revised Version, Nurses’ Moral Courage Scale, and Ethical Behaviour Scale for Nurses. Data analysis was performed with SPSS 26.0 and AMOS 24.0, using descriptive statistics, Pearson correlation analysis, structural equation modelling, and bootstrapping methods. Ethical considerations: This study was approved by the Ethical Review Committee of Life Sciences of Zhengzhou University, China. Results: The participants were predominantly female (95.1%), with a mean age of 31.9 years. Moral courage and moral sensitivity were positively correlated with ethical behaviour. Moral sensitivity was positively associated with moral courage. Moral courage partially mediates the relationship between moral sensitivity and ethical behaviour. The indirect effect of nurses’ moral sensitivity on ethical behaviour was quantified through moral courage (indirect effect = 0.290). Conclusion: Moral courage intermediates nurses’ moral sensitivity and ethical behaviour. This conclusion provides nursing administrators with the insight that improving clinical nurses’ moral sensitivity and courage can contribute to ensuring appropriate ethical behaviour. (shrink)

In a recent, currently unpublished, research project that sought to examine the meaning and enactment of ethical nursing practice across a variety of clinical settings, the significance of moral identity was highlighted. This article describes the findings and illuminates how the moral identities of the nurse participants arose and evolved as they navigated their way through the contextual and systemic forces that shaped the moral situations of their practice. The study revealed the socially-mediated process of identity development and the (...) narrative, dialogical, relational and contextual nature of nurses’ moral identities. (shrink)

In the case described here, an often recurring and unresolved scenario is presented where communication issues are underpinned by pre-existing perceptions of mistrust between the caregivers and the surrogate family members in the intensive care unit. Racial factors play into this mistrust, when a family feel that their loved one is “yet again” not being treated in the best way possible. The perspectives of all stakeholders are considered in the discussion and relevant literature is cited.

Recently, Chinese researchers published the results of their research using a gene-editing technology on abnormal human zygotes. The research team believes this research has prospective clinical application, viz., for gene therapy for?-thalassemia, a white blood cell disorder, and plan to persist with further studies, despite technical problems in this experiment. The research has elicited international criticism from both scientific and bioethics domains, because it innovates beyond the current global consensus against human germ line modification. This paper comments on some (...) ethical issues presented by the research report and concludes that, under present circumstances, the Chinese research team did not meet a standard of scientific responsibility.Bangladesh Journal of Bioethics 2015 Vol.6 (1):22-26. (shrink)

Bioethics mediators manage a wide range of clinical conflict emanating from diverse sources. Parties to clinical conflict are often not fully aware of, nor willing to express, the true nature and scope of their conflict. As such, a significant task of the bioethics mediator is to help define that conflict. The ability to assess and apply the tools necessary for an effective mediation process can be facilitated by each mediator’s creation of a personal compendium of sources that (...) generate clinical conflict, to provide an orientation for the successful management of complex dilemmatic cases. (shrink)

While ethical conflicts in the provision of healthcare are common, the current third-party mediator model is limited by a lack of expert ethical mediators, who are often not on site when conflict escalates. In order to improve clinical outcomes in situations such as conflicts at the end of life, we suggest that clinicians—physicians, nurses and social workers—be trained to prevent and deescalate emerging conflicts. This can be achieved using a mediation model framed by a communication-training approach. A case (...) example is presented and the model is discussed. The implication of this preventative/early intervention model for improving clinical outcomes, in particular end-of life conflict, is considered. (shrink)

I write this article as a postgraduate researcher undertaking a doctorate in Education, with an interest in research as a transformative process, and fascinated by the debate as to whether reality is objective or subjective. In reflecting on this, I recalled a significant incident that occurred when I was Professional Education Lead in an NHS hospital. I had been asked to work with a nurse, who had been disciplined as a consequence of talking about her Christian faith with a patient. (...) The nurse was assuming that, in sharing experiences that were transformative for her, she might also transform the patient’s perception of her own illness and its meaning. As a Christian myself, I was caught in a situation where I could understand the conflicting perspectives of all key players, including the patient, her family, the nurse, and the NHS managers. I explore how I mediated my way through this situation, aiming to do justice to all perspectives, and the ethical dilemmas I faced when having to choose between personal and professional values. As a consequence of this incident, I have learned that, not only is transformation a deeply personal experience, but because it is either influenced by, or leads to, a specific world view, it supports the idea of reality being subjective rather than objective. (shrink)

Conflicts in the clinical setting can spiral downward with remarkable speed, as parties become ever more incensed and entrenched in their positions. Productive conversations seem unlikely at best. Nevertheless, such situations can sometimes be turned into collaborative problem solving with equally remarkable speed. For this to happen, those providing conflict-resolution services such as mediation need to bring, not just a set of skills, but also some key norms: the process must be voluntary for all; the mediator must abjure (...) giving advice or taking sides, and must honor the privacy of privately offered thoughts. This article describes a conflict that had reached the point of a hospital’s requesting judicial coercion. However, a conflict-resolution process was then initiated that, in the end, led to amicable resolution and mended relationships, obviating the need for court orders. This article describes that conflict and the resolution process in detail, along the way annotating specific strategies that are often highly effective. (shrink)

Analgesia and amnesia represent two complimentary pillars of anesthesia directed, respectively, at mitigating the experience of pain and the processes of encoding that experience into memory. These elements are typically combined in modern anesthetic techniques, but some circumstances exist – such as conscious sedation – in which the conditions of amnesia are satisfied while analgesia plays an auxiliary and often incomplete role. These activities reflect a widely held yet underrecognized belief in clinical practice that although pain experiences may be (...) short-lived, their representation in memory and its subsequent effects on thought and emotion can have enduring consequences for patients. In this exploratory article, we delineate phenomenal and abstract ontological categories of pain experience; advance a claim that they are treated by analgesic and amnestic agents, respectively; and describe how each class of experience is uniquely able to bring about individual harm. Beginning with the question of how it can be permissible to allow any preventable experiences or memories of pain, we identify that both phenomenal and abstract pain manifest on a spectrum of severity, each with an enigmatic threshold – unique to circumstance and individual – that determines whether or not pain will translate into harm, and what permissions therefore surround its treatment. Ultimately, we find that there are compelling physiological reasons for the concurrent use of analgesics and amnestics when pain experience exceeds these thresholds, while the treatment of “sub-threshold” experience in either class is a purely ethical imperative to be balanced with considerations of the potential harms posed by the treatments themselves. (shrink)

As groups around the country begin to craft standards for clinical ethics consultations, one focus of that work is the proper procedure for conducting ethics consults. From a recent empirical look into the workings of ethics consult services (ECSs), one worrisome finding is that some ECSs rely on a committee vote when making a recommendation. This article examines the practice of voting and its moral standing as a procedural strategy for arriving at a clinical (...) class='Hi'>ethics recommendation. I focus here on the type of clinical ethics conflicts that are most likely to lead an ECS to vote, namely, conflicts involving ethical uncertainty—or, in the Greek, aporia. I argue that in cases of aporia, voting on an ethics conflict is not a morally justifiable procedure. Then on the same grounds that I use to show that voting is ethically problematic, I raise broader concerns about the common practice of making recommendations by other procedures. In contrast to the standard approach of adjudicating between moral claims, I argue that ECSs can best resolve aporetic conflict through the process of clinical ethics mediation. (shrink)

Research question and aim Clinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020, a CEC was established in an Oncology Research Hospital in the North of Italy. This paper describes the development process and the activities performed 20 months from the CEC’s implementation, to increase knowledge about CEC’s implementation strategy. Research design We collected quantitative data related to number and characteristics of CEC (...) activities carried out from October 2020 to June 2022 using the CEC internal database. Data were reported descriptively and compared with data from the literature to provide a complete overview of the CEC’s development and implementation process. Participants and research context The study has been conducted at the local health authority (LHA) of Reggio Emilia. It is a report of the activities provided by the CEC, where no HPs or patients were involved. Ethical Considerations The report is part of a larger study named EVAluating a Clinical Ethics Committee implementation process (EvaCEC), which has been approved by the Local Ethics Committee (AUSLRE Protocollo n° 2022/0026554 of 24/02/2022). EvaCEC is also the first author's PhD project. Findings In total, the CEC performed 7 ethics consultations (EC), published three policies related to particular ethical questions of clinical and organizational practice, provided one educational online course on ethics consultation targeting employed HPs, and promoted a specific dissemination process among the different departments of the LHA. According to our results, the CEC widely fulfilled the standard threefold set of clinical ethics support services tasks (namely, ethics consultation, ethics education, and policy development), but further investigations are needed to evaluate the CEC’s impact on clinical practice. Conclusion Our findings may increase knowledge regarding the composition, role, and tasks of a CEC in an Italian setting, informing future strategies and efforts to regulate these institutions officially. (shrink)

As obstetric medicine has become more sophisticated, so Caesarean section (CS) has become safer. It is now seen as equally safe or, in some circumstances, safer than vaginal birth. Under the new National Institute for Clinical Excellence (NICE) guidelines on CS that were published in November 2011, requests for CS are to be given more weight. Women requesting CS can no longer be seen as compromising their control over birth. Rather, they are merely exercising their power, with the new (...) guidelines offering them an increasing role in the decision-making process regarding how they give birth. However, these new guidelines also present new problems, bringing the rights of patients and obstetricians into conflict. In order to mediate these tensions, a virtue-based approach to obstetric ethics is needed as a supplement to the rule- and right-based guidance provided by NICE. (shrink)

Bioethics mediation is increasingly used as a method in clinical ethics cases. My goal in this paper is to examine the implicit theoretical assumptions of the bioethics mediation method developed by Dubler and Liebman. According to them, the distinguishing feature of bioethics mediation is that the method is useful in most cases of clinical ethics in which conflict is the main issue, which implies that there is either no real ethical issue or if (...) there were, they are not the key to finding a resolution. I question the tacit assumption of non-normativity of the mediation method in bioethics by examining the various senses in which bioethics mediation might be non-normative or neutral. The major normative assumption of the mediation method is the existence of common morality. In addition, the four-principle formulation of the theory articulated by Beauchamp and Childress implicitly provides the normative content for the method. Full acknowledgement of the theoretical and normative assumptions of bioethics mediation helps clinical ethicists better understand the nature of their job. In addition, the need for a robust philosophical background even in what appears to be a purely practical method of mediation cannot be overemphasized. Acknowledgement of the normative nature of bioethics mediation method necessitates a more critical attitude of the bioethics mediators towards the norms they usually take for granted uncritically as valid. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical Ethicists: Can They Help Families in Their Times of Need?Tracy R. WilsonI am a doctorally-prepared nurse practitioner with over 20 years in healthcare, and I am currently pursuing my MS in Bioethics and Medical Humanities at Tulane University, with an anticipated graduation of May 2023. In the fall of 2022, I had the pleasure of taking a Clinical Ethics course. As part of that course, (...) I shadowed a Clinical Ethicist for a week. It was a valuable experience, and I gained some insights about a role I didn’t know about previously. The last two years have been difficult for my family and me. I lost my dad in November 2020 and then a “sister cousin” in May 2021. In both instances, we had the team involved in their care and helping with the decision-making process.The role of the Clinical Ethicist Consultant (CEC) service is to help families process medical decisions—most of those decisions deal with endof-life care. The CEC works as the mediator between the family and the medical team. This is how I saw the CEC role play out in my experience.During my shadowing experience, my preceptor was phenomenal at his role because 1) he listened to the patient and the family, and 2) he consulted with the appropriate team members. My shadowing experience was virtual due to the restrictions of the healthcare facility. However, I was able to attend ethical team meetings. I was able to listen to multiple family calls and consultations. During my experience, my clinical ethicist was very conscientious of taking inventory of the feelings of everyone involved. Before he provided an opinion on a case, he did a deep dive into the patient’s chart to gain the patient’s historical context. He always asked for my opinion while we discussed a case, which made me feel included even as a student. It made me feel like my opinion had some weight, and it did in one of the cases. When I returned the next day, the feelings I had about a patient and her family using her for financial gain turned out to be true. Elder abuse was taking place.My personal experiences were more complicated, in which we didn’t always have a medical team that always heard what we needed for our loved ones. In the case of my sister cousin, she entered the hospital and was diagnosed with COVID-19. Our family never thought she would die from it, so it was shocking to us when she was placed on a ventilator and never came off. When the critical care MD stated that “there was nothing else he could do for her,” I could not understand how that could be when lung transplants were being done all over the US and even less than 100 miles away.We needed a CEC team then. I was the medical expert for my family, and I felt the medical team was not listening to what we wanted. The medical team believed that to continue treatment would be futile and their belief about this exceeded their need to continue treating my sister cousin. However, having a CEC mediate by first understanding the clinical team’s perspective, explaining those considerations to us, and then helping our family relay back our [End Page 23] wants, needs, and values to the clinical team could have helped. Unfortunately, my cousin never got this option. There was a palliative care team implemented but never a Clinical Ethicist. Having faced both, from a student perspective and from a personal experience, I would say that having a CEC present allows a family to have an advocate in the room, someone who knows the medical language and can explain to you and will explain to the medical team your perspective, which can sometimes be lost in translation or not heard.When my father passed away, he did not have a Clinical Ethicist as a part of his medical team either. My dad was a Vietnam Vet and a very prideful man. So, when my dad became ill in 2018 with vascular dementia, it took a toll on me and my sisters. To... (shrink)

Community-based participatory research is growing in popularity as a research strategy to engage communities affected by health issues. Although much has been written about the benefits of using CBPR with diverse groups, this research has usually taken place in community-based organizations which offer social services and programs. The purpose of this article is to explore the opportunities and challenges encountered during a CBPR project conducted in a small hospital serving people living with HIV and addictions issues. The structure of hospital-based (...) care delivery required the team to account for participants’ health-related limitations, including adopting recruitment strategies built on clinical care, and modifying the original research design to better protect participant confidentiality in a small space. Although CBPR offers an important strategy for researching with members of hospitalized communities, it requires research teams to develop context-relevant approaches to ethically engaging community members that recognize the ways clinical space mediates the research process. (shrink)

Navigating conflict in healthcare settings can be challenging for all parties involved. Here, we analyse disputes about the provision of healthcare to patients, specifically exploring how mediation might be used to resolve disputes where healthcare professionals may disagree with the patient themselves or the patient's family about what healthcare is in the patient's best interests. Despite concerns about compromise over the patient's best interests, there is often room for the parties to come together and think about how the dispute (...) might be resolved in a way that is acceptable to all. It is in this space where mediation might step in. We set out the potential benefits and risks of mediation in this article, and argue that there is a need for clearer, empirically grounded evidence on the use of mediation in healthcare disputes. (shrink)

Current clinical research lacks diversity in those that participate. This lack of diversity is concerning given its importance for successful drug development. The frequency and severity of many diseases, along with the pharmacological properties of therapies, can display significant differences based on patient diversity. A clinical trial population that is more reflective of these differences will help researchers better understand the therapeutic profile of the treatment and provide generalizable knowledge to the medical community. The advent of decentralized (...) class='Hi'>clinical trial designs is meant to help address this lack of diversity by using portable digital health technologies and virtual interactions to enhance clinical trial access and broaden participation. By leveraging these technologies, trial conduct can occur at locations other than traditional research sites. This shift in trial location may help address some of the logistical, educational, engagement, and trust barriers that have historically prevented enrollment of diverse populations. However, these types of trials still have limitations. Ethical concerns around justice, equity, and diversity will still exist with decentralized clinical trials, which could be mediated using clinical research vehicles. When utilized, this modality may enhance the scientific design and conduct of clinical trials and better follow these ethical principles. These enhancements and improved ethical direction could be accomplished through increasing community involvement, improving health literacy, supporting more diverse trial sites, creating community‐based research footholds, fostering connections with researchers, limiting technical challenges, and preventing data security issues. (shrink)

The approaches used in mediation may help ethics consultants, especially in difficult cases. In this piece, I primarily discuss these techniques. I also discuss how clinicians may be of the most help to parents of infants with severe genetic conditions, to research participants, and to patients who may be at risk for Alzheimer’s disease and their surrogate decision makers.

Chaplains who serve in a clinical context often minister to patients representing a wide variety of faiths. In order to offer the best pastoral care possible, the chaplain should first possess a set of personal theological convictions as a foundation for ministry. Second, he or she needs to be sensitive to the beliefs and practices of the patients. Third, it is vital to develop a relationship of acceptance and trust not only with patients under their care, but also with (...) family members and caregivers as well. At times, situations will arise that are purely religious or theological. In a clinical setting, however, the questions and problems that arise more often are both theological and ethical. It is beneficial for the chaplain to be involved in an ethics committee, where the specifics of each case can be discussed, and staff can offer counsel to patients and their families. This study examines issues that chaplains face at the bedside, such as terminal care, life-prolonging treatments, dementia, persistent vegetative state, and euthanasia/assisted suicide. We will discover that those who are involved in clinical pastoral ministry will be called upon to be a comforter, mediator, educator, ethicist, and counselor. (shrink)

Technology is pervasive and overwhelming in the intensive care setting. It has the power to inform and direct the nursing care of critically ill patients. Technology changes the moral and social dynamics within nurse—patient encounters. Nurses use technology as the main reference point to interpret and evaluate clinical patient outcomes. This shapes nurses’ understanding and the kind of care provided. Technology inserts itself between patients and nurses, thus distancing nurses from patients. This situates nurses into positions of power, granting (...) them epistemic authority, which constrains them as moral agents. Technology serves to categorize and marginalize patients’ illness experience. In this article, moral agency is examined within the technologically-mediated context of the intensive care unit. Uncritical use of technology has a negative impact on patient care and nurses’ view of patients, thus limiting moral agency. Through examination of technology as it frames cardiac patients, it is demonstrated how technology changes the way nurses understand and conceptualize moral agency. This article offers a new perspective on the ethical discussion of technology and its impact on nurses’ moral agency. Employing reflective analysis using the technique of embodied reflection may help to ensure that patients remain at the centre of nurses’ moral practice. Embodied reflection invites nurses critically to examine how technology has reshaped conceptualization, understanding, and the underlying motivation governing nurses’ moral agency. (shrink)

The Australian Royal Commission into Aged Care Quality and Safety acknowledged understaffing and substandard care in residential aged care and home care services, and recommendations were made that that the Australian Government should promote assistive technology within aged care. Robotic care assistants can provide care and companionship for the elderly—both in their own homes and within health and aged care institutions. Although more research is required into their use, studies indicate benefits, including enabling the elderly to live independently at home, (...) assistance with medication and monitoring of safety. Nevertheless, there are inherent ethical challenges in the use of robots as carers, including loss of privacy, unwarranted restrictions on autonomy, lack of dignity, deception, and the exacerbation of loneliness. Ethics by design can counter these issues in development of robotics and clinical ethics committees have been put forward as a way of dealing with the ethical use of robotic care in healthcare institutions. In this paper I outline the ethical challenges of robotic care assistants and how these may be mediated in their design and use. (shrink)

BackgroundSystems medicine is the name for an assemblage of scientific strategies and practices that include bioinformatics approaches to human biology ; “big data” statistical analysis; and medical informatics tools. Whereas personalized and precision medicine involve similar analytical methods applied to genomic and medical record data, systems medicine draws on these as well as other sources of data. Given this distinction, the clinical translation of systems medicine poses a number of important ethical and epistemological challenges for researchers working to generate (...) systems medicine knowledge and clinicians working to apply it.DiscussionThis article focuses on three key challenges: First, we will discuss the conflicts in decision-making that can arise when healthcare providers committed to principles of experimental medicine or evidence-based medicine encounter individualized recommendations derived from computer algorithms. We will explore in particular whether controlled experiments, such as comparative effectiveness trials, should mediate the translation of systems medicine, or if instead individualized findings generated through “big data” approaches can be applied directly in clinical decision-making. Second, we will examine the case of the Riyadh Intensive Care Program Mortality Prediction Algorithm, pejoratively referred to as the “death computer,” to demonstrate the ethical challenges that can arise when big-data-driven scoring systems are applied in clinical contexts. We argue that the uncritical use of predictive clinical algorithms, including those envisioned for systems medicine, challenge basic understandings of the doctor-patient relationship. Third, we will build on the recent discourse on secondary findings in genomics and imaging to draw attention to the important implications of secondary findings derived from the joint analysis of data from diverse sources, including data recorded by patients in an attempt to realize their “quantified self.”SummaryThis paper examines possible ethical challenges that are likely to be raised as systems medicine to be translated into clinical medicine. These include the epistemological challenges for clinical decision-making, the use of scoring systems optimized by big data techniques and the risk that incidental and secondary findings will significantly increase. While some ethical implications remain still hypothetical we should use the opportunity to prospectively identify challenges to avoid making foreseeable mistakes when systems medicine inevitably arrives in routine care. (shrink)

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

Bioethics mediation training offers knowledge and skills valuable for clinical ethics consultants who are engaged in high conflict situations. Furthermore, clinicians with this training can support organizational efforts to create a culture that is centered on the values, needs, and care preferences of patients and their families, rather than on those of the clinician or organization. Patientcenteredness is a hallmark of quality and an essential component for patients’ safety. Clinicians with mediation training have the communication skills (...) to address the myriad needs of patients and their loved ones, needs that are challenging to meet in inpatient hospital settings. The author illustrates principles of mediation such as validating patients’ emotions, revealing the interests of all stakeholders, and shaping a shared solution to demonstrate how these skills have broad applicability in patient care settings. (shrink)

Pediatricians and parents have co-fiduciary obligations to decide on medical treatment for a child. When life-sustaining treatment is no longer beneficial in seriously ill infants, most pediatricians in Malaysia support parents in a shared decision-making process. Occasionally, it can be challenging to decide what is best, whose decisions to make, and how to navigate uncertainties, value conflicts, and social justice issues that arise. Some of the pediatric ethics themes in Malaysia include moral distress due to professional obligation, the moral (...) significance of withdrawing versus withholding life-sustaining treatment, decision-making for infants with elusive diagnoses or prognostic uncertainties, and infants of forced migrants with sociopolitical barriers to care. Several cases will be described to illustrate these ethical issues, as well as the pediatric ethics framework and approaches that can be considered to decide what is best for these infants. Pediatricians feel obligated to do their best, treat every child and family the same, and feel morally distressed if unable to do so. They can consider gathering more information and perspectives and utilize these frameworks to consider what is best for a child. In moments of conflict, respectfully seeking opinions, values, and concerns from the family through open communication is crucial to resolving disagreements. Clinical ethics deliberation can provide clarity in challenging moments and suggest ethically acceptable options. Clinical ethics mediation can facilitate difficult conversations and bring resolutions and closure for stakeholders. Within these moral spaces, the responsibility of heavy decision-making can thus be shared and reflected upon. (shrink)

Autumn Fiester identifies an important element in clinical ethics consultation (CEC) that she labels, from the Greek, aporia, “state of perplexity,” evidenced in CEC as ethical ambiguity. Fiester argues that the inherent difficulties of cases so characterized render them inappropriate for voting and more amenable to mediation and the search for consensus. This commentary supports Fiester’s analysis and adds additional reasons for rejecting voting as a process for resolving disputes in CEC including: it distorts the analysis by (...) empowering individual voters preferences and biases rather than focusing on the interests and wishes of the patient and family; it offers an insufficiently sensitive model for resolving the awesome, nuanced, conflicted, and ethically complex issues surrounding life and death; it marginalizes minority opinions that may have moral validity. (shrink)