Objective We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments in order to build ethics capacity and provide a foundation for the development of an ethics education programme. Methods This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity. Results Of the (...) 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress, conflict management with patients or families and resource issues. Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams was the most desired method. Conclusions Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists. (shrink)

After many policy attempts to tackle the persistent rise in the costs of health care, physicians are increasingly seen as potentially effective resource stewards. Frameworks including the quadruple aim, value-based health care and choosing wisely underline the importance of positive engagement of the health care workforce in reinventing the system–paving the way to real affordability by defining the right care. Current programmes focus on educating future doctors to provide ‘high-value, cost-conscious care’ (HVCCC), which proponents believe is the future of (...) sustainable medical practice. Such programmes, which aim to extend population-level allocation concerns to interactions between an individual doctor and patient, have generated lively debates about the ethics of expanding doctors’ professional accountability. To empirically ground this discussion, we conducted a qualitative interview study to examine what happens when resource stewardship responsibilities are extended to the consulting room. Attempts to deliver HVCCC were found to involve inevitable trade-offs between benefits to the individual patient and (social) costs, medical uncertainty and efficiency, and between resource stewardship and trust. Physicians reconcile this by justifying good-value care in terms of what is in the best interest of individual patients–redefining the currency of value from monetary costs to a patient’s quality of life, and cost-conscious care as reflective medical practice. Micro-level resource stewardship thus becomes a matter of working reflexively and reducing wasteful forms of care, rather than of making difficult choices about resource allocation. (shrink)

Effective evaluation of any activity requires, first, that we understand what its objectives are, and second, that we can define and measure these objectives. For instance, a publicly listed compan...

The latest research in Spain indicates that the most advanced neuromarketing consulting companies in the sector are those that have been able to innovate in the development of their own technologies and methodologies. Despite their reduced volume of business compared to total investment in Marketing and market research in our country, there are signs that suggest these companies have great potential to improve this sector, which is still to be explored. For this reason, this research straddling the ethnographic method and (...) the theoretical-descriptive method, aims to help us better understand the characteristic features of this sector by actively listening to the professional voices that lead it. Its epistemological value lies in its contribution to understanding the business culture related to the professional development of neuromarketing in our country today. The study shows that the main human resources strategy of neuromarketing consulting companies is based on the creation of multidisciplinary work teams. In addition, most of them develop data analysis software, which they can safeguard under various types of copy right, and on other occasions they manage to patent them, to later apply them to the objectives and purposes of their company. This would also explain the widespread use of certain procedures and resources by the vast majority of the consulting companies investigated. Thus, the trend in the market is the implementation of different synchronization software to the available technological and methodological resources. Others have even gone so far as to create a new technological support to incorporate methodologies already in use. Therefore, this gives them exclusivity in their services and the necessary competitive advantage over their competitors. Among other factors, these inferences about how this sector really works are very likely to be very useful in the academic field, which will constitute a further step in generating critical thinking and in expanding the frontiers of knowledge around this disciplin. (shrink)

In The Philosophic Consultant, acclaimed business consultant, philosopher, and author Peter Koestenbaum links deep insights of philosophy with practical business issues. Throughout this one-of-a-kind resource, Koestenbaum shows consultants and human resource practitioners how they can foster philosophical leadership within their organizations to positively affect the business environment. The book promises tangible results-- credibility, trust, and thoughtful attention-- and demonstrates how to apply philosophy, share knowledge with others, and use this newfound thoughtfulness to achieve bottom-line results.

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe primary (...) objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

Clinical ethics consultation service remains undeveloped in developing countries. It is recognised that its introduction poses challenges. Malaysia, a multicultural society with diverse religions, values and perceptions further complicate the introduction of formal clinical ethics consultation service. Clinicians attending a national congress workshop completed a Strengths–Weaknesses–Opportunities–Threats analysis. The aim was to gain insight into clinician’s expectations and promote initiatives leading to the introduction of clinical ethics consultation service. Clinicians agree that clinical ethics consultation service can improve quality of care, reduce (...) healthcare costs and advocate for patients and providers. The analysis highlighted constraints in sufficient critical mass of relevant expertise and restricted opportunities for training. The opportunities lie in education, curriculum development and availability of dedicated proponents. Cultural barriers, limited resources, lack of awareness, differenc... (shrink)

Organisations face an increasingly competitive and uncertain global environment, after recent experience of unparalleled technological advances and political shifts. Increased dependence on Information Technology (IT) will require appropriate human resource strategies, to develop individuals who will be capable of operating successfully within new organisational structures, with reduced management layers and a requirement for teamworking.This paper presents a university-industry based partnership, revolving around a final year Group Consultancy project, in which undergraduate students work with an external client on a live (...) problem. The project involves the use ofaction research methodology, where academic ideas are applied in the ‘real’ world of business. This is described in the context of group projects, which examine thelegacy system problems faced by three multi-national organisations. (shrink)

One of the most striking findings of the study by Foglia and colleagues (2009) was that clinicians and managers were most concerned with limited resources while ethics committee chairpersons focuse...

Background Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice. Research objective To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness. Ethical considerations The research was conducted in accordance (...) with the Declaration of Helsinki. Research design This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan Participants The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users. Findings The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive. Discussion The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants. Conclusion This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses’ moral distress, building ethics into decision-making. (shrink)

Healthcare ethics consultants in the Veterans Health Administration (VHA) document consults in an enterprise-wide web-based database entitled IEWeb, serving as a system of record for healthcare ethics documentation at 1300 VA facilities. The need arose to evolve the database from an ethics process training resource into a more streamlined documentation repository that captures essential consult elements. A VHA National Center for Ethics in Health Care (NCEHC) Improvement Team convened for three tasks: (1) Specify and prioritize IEWeb changes (occurred (...) via six focus groups composed of “new user” and “super user” cohorts with analysis of existing documentation patterns); (2) Pilot the changes regionally (via regional communication, training, and reviews of pre-post use patterns); and (3) Measure the impact of national change implementation on user perspectives (via pre-and post-change implementation polls). Focus groups identified six implementable priority areas for ethics consult documentation improvement, including the development of a usable consult summary note for ready conversion from IEWeb fields into the electronic health record. Post-IEWeb updates showed an increased number of consults documented, a reduction in “time to consult documentation closure” by a mean of 4.5 days, and a clinically-meaningful improvement in the quality of documentation (78% of ethics questions scored “above-bar” on the validation tool pre- vs. 89% scored “above-bar” post-IEWeb changes, n = 140). According to national survey findings, the number of consultants documenting “all” consults in IEWeb increased, satisfaction increased, and perception of documentation difficulty decreased. IEWeb simplification enabled ethics consultants to re-focus their documentation completion efforts by decreasing perception of documentation burden while improving documentation frequency and quality in a clinically-meaningful way. (shrink)

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their (...) skills in this area. (shrink)

Systematic study of the intersection of ethics consultation services and solid organ transplants and recipients can identify and illustrate ethical issues that arise in the clinical care of these patients, including challenges beyond resource allocation. This was a single-centre, retrospective cohort study of all adult ethics consultations between January 1, 2007, and December 31, 2017, at a large academic medical centre in the north-eastern United States. Of the 880 ethics consultations, sixty (6.8 per cent ) involved solid organ transplant, (...) thirty-nine (65.0 per cent) for candidates and twenty-one (35.0 per cent ) for recipients. Ethics consultations were requested for 4.3 per cent of heart, 4.9 per cent of lung, 0.3 per cent of liver, and 0.3 per cent of kidney transplant recipients over the study period. Nurses were more likely to request ethics consultations for recipients than physicians (80.0 per cent vs 20.0 per cent, p = 0.006). The most common reason for consultation among transplant candidates was discussion about intensity of treatment or goals of care after the patient was not or was no longer a transplant candidate. The most common reason for ethics consultation among transplant recipients was disagreement between transplant providers and patients/families/non-transplant healthcare professionals over the appropriate intensity of treatment for recipients. Very few consultations involved questions about appropriate resource allocation. Ethics consultants involved in these cases most often navigated communication challenges between transplant and non-transplant healthcare professionals and patients and families. (shrink)

Both linguistic and extralinguistic consultations are essential in translation practice and have been commonly investigated as an integral topic in previous studies. However, since extralinguistic information is usually longer in extent and not specifically designed for a linguistic purpose, extralinguistic consultations involve different search strategies compared with linguistic consultations. Drawing on eye-tracking and screen-recording data, this study compares linguistic and extralinguistic consultations in terms of cognitive resources allocation and information processing patterns in English–Chinese translation. It also explores the differences among (...) 17 language learners, 20 student translators, and 21 professional translators, and the effect of extralinguistic consultation on their translation quality. The findings are as follows: all participants allocate more attention and lower cognitive load to extralinguistic consultations than to linguistic consultations; participants’ translation experience levels and their attention allocated to extralinguistic consultation show an inverted U-shaped relationship; and participants who consult extralinguistic information before drafting or devote more attention to extralinguistic consultation produce target texts with significantly higher scores. (shrink)

In this paper, I investigate whether there are nonreligious, epistemic reasons that could justify consulting religious traditions. In this way, I supplement the ongoing debate on the value of tradition, which has focused mostly on practical values for maintaining traditions, with an examination of epistemic reasons for consulting traditions. To do so, I focus on the problem-solving aspect of religious traditions and their epistemic resources. I discuss whether consulting traditions of religious wisdom, religious practical knowledge, religious institutions, or religious rationalities (...) can be justified based on their continuous transmission, the test of time, an intergenerational learning process, or moral enquiry. (shrink)

Background: Prior research has explored reasons why health care providers may or may not choose to seek an ethics consultation. Although low-quality communication is evident in many ethics consultations, it is unknown whether poor communication in clinical settings is related to health care providers' requests for ethics involvement. Objective: To assess the relationship between self-reported ratings of health care providers' inter- and intraprofessional communication and ethics consultation requests. Method: This cross-sectional survey was conducted using a self-administered questionnaire of physicians and (...) nurses in six intensive care units at one academic medical center in the United States. The questionnaire assessed perceptions about requesting ethics consultations and how health care providers perceive communication. Results: Two hundred sixty-two participants (228 nurses and 34 physicians) responded to the survey (response rate 55%; 59% for nurses and 41% for physicians). Requests for an ethics consult were positively associated with perceived quality of interprofessional communication (r =.13, p <.05), but perceptions of the number of ethical dilemmas that occur on participants' units each month were negatively associated with the perceived quality of intra-professional communication (r = −.17, p <.01). Conclusion: The relationship that was hypothesized between perceived poor communication and increased number of ethics consultations was not borne out by these data. Indeed, we found the opposite; these finding suggests that good inter- and intraprofessional communication may promote the use of outside resources, such as ethics, when they are needed. (shrink)

Stakeholder consultation is part of the democratic process, embraces respect for persons, and is necessary for upholding the principle of justice. People are more likely to uphold standards they have participated in setting, so stakeholder consultation encourages adherence to societal and institutional standards as these evolve. Stakeholder consultation is also responsive to the call to “resocialize” ethics by contextualizing dilemmas and involving the destitute in choices about their healthcare. In resource-poor settings, such consultation promotes local “ownership” of, and leadership (...) within, development programs, which enhances effectiveness and sustainability. Stakeholder consultation is, therefore, a form of capacity building. To succeed, it must be responsive to regional, national, and individual constraints, including socioeconomic, cultural, and political ones. Several such constraints impact on the demand for, and availability of, palliative healthcare in the Caribbean. (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 Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged.Methods Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children’s hospitals and five programmatic domains.Results 104 children’s hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of (...) consultants. Academically-affiliated children’s hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5.Conclusions While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults. (shrink)

This book provides a careful and comprehensive, step-by-step method for providing clinical ethics consultation. This Guide can be applied in almost any healthcare setting and takes the reader from establishing an intake process and developing strategies for interviewing those involved in the situation, to undertaking a consultation meeting and following up on a clinical consult. The book is an invaluable resource to any clinical ethicist, or committee or consult team member who is seeking to provide their service with rigour (...) and quality. Written in simple language, the book explores ideas and concepts that will help the reader to understand, think through, and ultimately offer useful ethical consultation when facing ethically challenging issues. (shrink)

As a result of in-house discussions stimulated by previous Gonzaga engineering ethics conferences, Coffman Engineers began the implementation of what is to be a company-wide ethics training program. While preparing a curriculum aimed at consulting engineers, we found very little guidance as to how to proceed with most available literature being oriented towards the academic environment. We consulted a number of resources that address the teaching of engineering ethics in higher education, but questioned their applicability for the Consulting Engineering environment. (...) This lack of guidance led us to informal research into the ethical knowledge and attitudes of both consulting engineers and engineering students. Some of our findings were unexpected, and suggest that a simpler approach to teaching ethics to working professionals might be preferred to that typically promoted in higher education. (shrink)

Background Few studies have been conducted to assess the quality of orientation practices for ethics advisory committees that conduct ethics consultation. This survey study focused on several Harvard teaching hospitals, exploring orientation quality and committee members’ self-evaluation in the American Society of Bioethics and Humanities ethics consultation competencies. Methods We conducted a survey study that involved 116 members and 16 chairs of ethics advisory committees, respectively. Predictor variables included professional demographics, duration on committees and level of training. Outcome variables included (...) familiarity with and preparedness in the ASBH competencies and satisfaction with orientations. We hypothesised that responses would be associated with both the aforementioned predictors and whether or not participants had encountered the ASBH competencies in training. Results A majority of respondents found their orientation curricula to be helpful, although a significant portion of respondents did not receive any orientation or were unsatisfied with their orientation. Familiarity with ASBH competencies was a statistically significant predictor of respondents’ self-evaluation in particular categories. Standard educational materials were reported as offered during orientation, such as readings and case studies ; different medium resources were less evidenced such as videos on ethics consultation. Conclusions Institutions should re-evaluate orientation practices for ethics committee members that perform ethics consultation. Integrating ASBH competencies and useful methods into a resourceful pedagogy will help improve both member satisfaction with orientation and preparation in consultation. (shrink)

Before we commit significant resources of time and energy to clinical ethics consultation (CEC) certification, education, and the like, one of the questions we ought to be able to answer is how to...

Abstract Context: Established in 1997, Summa Health System’s Medical Ethics Committee (EC) serves as an educational, supportive, and consultative resource to patients/families and providers, and serves to analyze, clarify, and ameliorate dilemmas in clinical care. In 2009 the EC conducted its 100th consult. In 2002 a Palliative Care Consult Service (PCCS) was established to provide supportive services for patients/families facing advanced illness; enhance clinical decision-making during crisis; and improve pain/symptom management. How these services affect one another has thus far (...) been unclear. Objectives: This study describes EC consults: types, reasons, recommendations and utilization, and investigates the impact the PCCS may have on EC consult requests or recommendations. Methods: Retrospective reviews of 100 EC records explored trends and changes in types of consults, reasons for consults, and EC recommendations and utilization. Results: There were 50 EC consults each in the 6 years pre- and post-PCCS. Differences found include: (1) a decrease in number of reasons for consult requests (133–62); (2) changes in top two reasons for EC consult requests from ‘Family opposed to withdrawing life-sustaining treatment (LST)’ and ‘Patient capacity in question’ to ‘Futility’ and ‘Physician opposed to providing LST’; (3) changes in top two recommendations given by the EC from ‘Emotional Support for Patient/Family’ and ‘Initiate DNR Order’ to ‘Comfort Care’ and ‘Withdraw Treatment.’ Overall, 88% of recommendations were followed. Conclusion: PCCS availability and growth throughout the hospital may have influenced EC consult requests. EC consults regarding family opposition to withdrawing LST and EC recommendations for patient/family support declined. Content Type Journal Article Pages 1-16 DOI 10.1007/s10730-011-9170-9 Authors Jessica Richmond Moeller, Department of Psychiatry and Behavioral Sciences, Akron General Medical Center, 400 Wabash Ave, Akron, OH 44307, USA Teresa H. Albanese, Health Services Research and Education Institute, Summa Health System and Northeast Ohio Medical University, 55 Arch St., Suite 1A, Akron, OH 44304, USA Kimberly Garchar, Kent State University, 6000 Frank Ave., N.W, North Canton, OH 44720, USA Julie M. Aultman, Department of Family and Community Medicine, Northeast Ohio Medical University, P.O. Box 95, Rootstown, OH 44272, USA Steven Radwany, Palliative Care and Hospice Services, Summa Health System and Northeast Ohio Medical University, 55 Arch St., Suite 1A, Akron, OH 44304, USA Dean Frate, Internal Medicine, Palliative Care and Hospice Services, Summa Health System and Northeast Ohio Medical University, 55 Arch St., Suite 1A, Akron, OH 44304, USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737. (shrink)

ABSTRACT In this article, we will first give a historic overview of the concept of benefit sharing and its appearance in official agreements, particularly with respect to crop genetic resources. It will become clear that, at present, benefit sharing is primarily considered as an instrument of compensation or exchange, and thus refers to commutative justice. However, we believe that such a narrow interpretation of benefit sharing disregards, and even undermines, much of its (historical) content and potency, especially where crop genetic (...) resources are concerned. We argue that benefit sharing should not be based merely on commutative justice but rather on a broader model that is also grounded in the concept of distributive justice. This has repercussions for the application of benefit sharing, which we try to clarify by distinguishing between downstream and upstream benefit sharing. Upstream benefit sharing is not so much inspired by compensation for actions done, or the distribution downstream of benefits developed, but by the idea of shared decision‐making on the research and development of resources fundamental to human welfare. Going upstream in the research process of crop genetic resources, and determining research agendas and improving crops according to the needs of the poor, benefit sharing may well be a tool to contribute to world food security and global justice. We concretize our ideas on upstream benefit sharing by introducing a set of criteria that determine the success of consultations on agricultural research agenda setting. (shrink)

Ongoing evaluation of a clinical ethics consultation service (ECS) allows for continuous quality improvement, a process-based, data-driven approach for improving the quality of a service. Evaluations by stakeholders involved in a consultation can provide realtime feedback about what is working well and what might need to be improved. Although numerous authors have previously presented data from research studies on the effectiveness of clinical ethics consultation, few ECSs routinely send evaluations as an ongoing component of their everyday clinical activities. The primary (...) purpose of this article is to equip and encourage others to engage in ongoing evaluation of their own ECS. Toward that end, the following resources are shared: (1) the survey tool used to gather the evaluation data, (2) the procedure used to elicit and collate responses, and (3) how the resulting data are used to support continuous quality improvement and justify the continued financial support of the ECS to hospital administration. (shrink)

Moral distress reflects often recurrent problems within a healthcare environment that impact the quality and safety of patient care. Examples include inadequate staffing, lack of necessary resources, and poor interprofessional teamwork. Recognizing and acting on these issues demonstrates a collaborative and organizational commitment to improve. Moral distress consultation is a health system-wide intervention gaining momentum in the United States. Moral distress consultants assist healthcare providers in identifying and strategizing possible solutions to the patient, team, and systemic barriers behind moral (...) distress. Moral distress consultants offer unique perspectives on the goals, successes, areas for improvement, and sustainability of moral distress consultation. Their ideas can help shape this intervention’s continued growth and improvement. This qualitative descriptive study features 10 semi-structured interviews with moral distress consultants at two institutions with longstanding, active moral distress consultation services. Themes from consultant transcripts included consultant training, understanding the purpose of moral distress consultation, interfacing with leadership teams, defining success, and improving visibility and sustainability of the service. These findings describe the beginnings of a framework that organizations can use to either start or strengthen moral distress consultation services, as well as the first steps in developing an evaluation tool to monitor their utility and quality. (shrink)

Research ethics review is a critical aspect of the research governance framework for human subjects research. This usually requires that research protocols be submitted to a research ethics committee for review and approval. This has led to very rapid developments in the domain of research ethics, as RECs proliferate all over the globe in rhyme with the explosion in human subjects research. The work of RECs has increasingly become elaborate, complex, and in many cases urgent, necessitating supporting rules and procedures (...) of operation. Guidelines for elaborating standard operating procedures for the functioning of RECs have also been proposed. The SOPs of well-placed and well-resourced RECs have tended to pay much attention to details, resulting, as a consequence, in generally long, elaborate, intricate and complex SOPs; a model that can hardly be replicated by other committees, equally under ethics review pressures, but working under much more constraining conditions in resource-destitute environments. In this paper, we looked at the content and length of SOPs from African RECs and compared them to the World Health Organization ’s guidelines as the gold standard. We also looked at the SOPs from the Ethics Review and Consultancy Committee of the Cameroon Bioethics Initiative that we elaborated in a simplified way in 2013, and compared them to the WHO’s guidelines and to the other SOPs. Sixteen SOPs from 14 African countries were collected from various sources. Their average length was of 30 pages. By comparison to the guidance of the WHO, only six of them were found acceptable with more than 70 % of the criteria from the gold standard that were fully described. Among those six, two of them were very long and detailed, while the four remaining SOPs ranged from 16 to 24 pages. The ERCC SOPs are seven pages long but maintain all that is of essence for the rigorous, efficient and timely review of protocols. We are convinced that, because of their brevity, simplicity, clarity and user-friendliness, the ERCC SOPs recommend themselves as a model template to, at least, committees similarly situated and/or circumstanced as the ERCC of the Cameroon Bioethics Initiative is. In fact, brevity, clarity, simplicity and user-friendliness are recognized values. Whatever is brief and clear is better than what is not and saves time. What is simple and user-friendly is better than what is not even though the two have the same aims because it saves both time and mental energy. And if this be true in general, it is even truer of the context and its peculiar constraints that we are addressing. (shrink)

The conflicts of interest that may arise in relationships between academic researchers and industry continue to prompt controversy. The bulk of attention has focused on financial aspects of these relationships, but conflicts may also arise in the legal obligations that faculty acquire through consulting contracts. However, oversight of faculty members' consulting agreements is far less vigorous than for financial conflicts, creating the potential for faculty to knowingly or unwittingly contract away important rights and freedoms. Increased regulation could prevent this, but (...) it is unclear what forms of oversight universities view as feasible and effective. In this article, we report on a Delphi study to evaluate several approaches for oversight of consulting agreements by medical schools. The panel was comprised of 11 senior administrators with responsibility for oversight of faculty consulting relationships. We found broad agreement among panelists regarding the importance of institutional oversight to protect universities' interests. There was strong support for two specific approaches: providing educational resources to faculty and submitting consulting agreements for institutional review. Notwithstanding the complexities of asserting authority to regulate private consulting agreements between faculty members and companies, medical school administrators reached consensus that several approaches to improving institutional oversight are feasible and useful. (shrink)

Although clinical ethics consultation has existed for more than 40 years in the USA and Europe, it was not available in Bulgaria until recently. In introducing clinical ethics consultation into our country, the Modular, Ethical, Treatment, Allocation of resources, Process (METAP) methodology has been preferred because of its potential to be used in resource-poor settings and its strong educational function. This paper presents the results of a METAP evaluation in a hospital palliative care ward in the town of Vratsa. (...) The evaluation was based on Beauchamp and Childress’ four principles of biomedical ethics and involves implementation of specific instruments for clinical ethics decision-making. Research tasks emphasised analyses of ethics meetings in the ward. Data were processed by SPSS v.24 using descriptive statistical analysis. Altogether, 32 ethics meetings of an average duration 20.63 min were conducted on cases involving critically ill patients. Most of the participants (86.0%) expressed satisfaction with the ethics process. The principlist approach supported resolution of conflicts between autonomous patients and their relatives, clarified definitions of “medical benefit” and “social good,” and enabled assessments of the risk of unequal treatment. Even as the specific research tasks were achieved, further participant follow-up is necessary to identify any improvement in healthcare personnel’s ethical competence. METAP worked well in end-of-life care settings. Participants experienced several benefits, including improved team communication, better understanding of patient preferences, and confidence in the correctness of decisions. Despite the significant educational potential of METAP, the need for additional and ongoing ethics training of health professionals should not be underestimated. (shrink)

While a significant literature has appeared discussing theoretical ethical concerns regarding COVID-19, particularly regarding resource prioritization, as well as a number of personal reflections on providing patient care during the early stages of the pandemic, systematic analysis of the actual ethical issues involving patient care during this time is limited. This single-center retrospective cohort mixed methods study of ethics consultations during the first surge of the COVID 19 pandemic in Massachusetts between March 15, 2020 through June 15, 2020 aim (...) to fill this gap. Results indicate that there was no significant difference in the median number of monthly consultation cases during the first COVID-19 surge compared to the same period the year prior and that the characteristics of the ethics consults during the COVID-19 surge and same period the year prior were also similar. Through inductive analysis, we identified four themes related to ethics consults during the first COVID-19 surge including (1) prognostic difficulty for COVID-19 positive patients, (2) challenges related to visitor restrictions, (3) end of life scenarios, and (4) family members who were also positive for COVID-19. Cases were complex and often aligned with multiple themes. These patient case-related sources of ethical issues were managed against the backdrop of intense systemic ethical issues and a near lockdown of daily life. Healthcare ethics consultants can learn from this experience to enhance training to be ready for future disasters. (shrink)

Originally published in 1999, this classic textbook includes twenty-six cases with commentary and bibliographic resources designed especially for medical students and the training of ethics consultants. The majority of the cases reflect the day-to-day moral struggles within the walls of hospitals typically described as community hospitals; as a result, the cases do not focus on esoteric, high-tech dilemmas--viz., genetic engineering or experimental protocols--but rather on fundamental problems that are pervasive in basic healthcare delivery in the United States: where to (...) send a frail, elderly patient who refuses to go to a nursing home; what role the family should play in making a treatment decision; what a hospital should do when it is getting stuck with too many unpaid bills. This thoroughly revised and updated second edition includes thirteen new cases, five of which are designated as "skill builder" cases aimed specifically for those participants in the Neiswanger Institute for Bioethics' web-based instructional program. This edition has also been restructured for teachability, and will feature reformatted and revised commentaries. (shrink)

Controversies still exists within the research fraternity on the form and level of incentives, compensation and reimbursement to study participants in resource-constrained settings. While most research activities contribute significantly to advancement of mankind, little has been considered in rewarding directly the research participants from resource-constrained areas. A study was conducted in Zimbabwe to investigate views and expectations of various stakeholders on study participation incentives, compensation and reimbursement issues. Data was collected using various methods including a survey of about (...) 1,008 parents/guardians of school children participating in various immunological cohort studies and parasitology surveys. Community advisory boards (CABs) at 9 of the sites were also consulted. Further, information was gathered during discussions held at a basic research ethics training workshop. The workshop had 45 participants that including 40 seasoned Zimbabwean researchers and 5 international research collaborators. About 90% (907) of the study participants and guardians expected compensation of reasonable value, in view of the researchers' value and comparison to other sites regardless of economic status of the community. During discussion with researchers at a basic ethics training workshop, about 80% (32) believed that decisions on level of compensation should be determined by the local research ethics committees. While, the few international research collaborators were of the opinion that compensation should be in accordance with local guidelines, and incentives should be in line with funding. Both the CAB members and study participants expressed that there should be a clear distinction between study incentive and compensation accorded to individual and community expectations on benefits from studies. However, CABs expressed that their suggestions on incentives and compensation are often moderated by the regulatory authorities who cite fear of unknown concerns. Overall, both personal and community benefits need to be considered colectively in future studies to be conducted in resource-constrained communities. There is projected fear that recruitment in future may be a challenge, now that almost every community, has somehow been reached and participated in some form of studies. A major concern on reimbursement, compensation or incentives should be internationally pegged regardless of different economic status of the individuals or communities where the study is to be conducted. (shrink)

Objective: To identify the frequency and nature of care conflict dilemmas that United States long-term care providers encounter, response strategies, and use of ethics resources to assist with dispute resolution. Design: An online cross-sectional survey was distributed to the Society for Post-Acute and Long-Term Care Medicine (AMDA). Results: Two-thirds of participants, primarily medical directors, have rejected surrogate instructions and 71% have managed family conflict. Conflict over treatment decisions and issues interpreting advance directives were frequently reported. Half of facilities lack a (...) formal dispute mediation policy. Only five respondents have called an ethics consult for assistance. Conclusion: Ethically tense care conflicts commonly arise in long-term and post-acute care facilities. Few facility procedures incorporate ethics resources into actual practice. Recommendations are made to create actionable policy, increase access to ethics services, and support staff skill development in order to improve the end-of-life care experiences for patients, families, and care facility staff. (shrink)

A significant amount of discussion in the bioethics community has been devoted to the question of whether individuals performing ethics consultations in healthcare institutions have any special expertise. In addition, articles in the lay press have questioned the “added value” that bioethicists bring to ethical dilemmas. Those at the forefront of the bioethics community have argued repeatedly that those doing ethics consults cannot simply be well-intentioned individuals, that some training in bioethics, group process, and facilitation is necessary to competently execute (...) a consult. As one bioethicist commented:if you approach any endeavor as an amateur activity, you will get, in the end, an amateurish version of the activity. Without a sufficient commitment of personnel, time, support, and financial resources, a healthcare organization will get the ‘ethics’ program … it set out to create: an inept, unskilled, inefficient, and highly risky ‘program’ in healthcare ethics and bioethics. (shrink)

Background: An ongoing challenge for clinical ethics consultation is learning how colleagues in other healthcare professions understand, make use of, and evaluate clinical ethics consultation services. Aim: In pursuing such knowledge as part of clinical ethics consultation service quality assessment, clinical ethics consultation services can learn important information about the issues and concerns that prompt colleagues to request ethics consultation. Such knowledge allows for greater outreach, education, and responsiveness by clinical ethics consultation services to the concerns of clinician colleagues. Design: (...) This quality assessment project explores consultation requests and follow-up questionnaire responses voluntarily submitted from nurses who requested clinical ethics consultation. We present qualitative data analyzed using content analysis and constant comparison methods to identify key concerns that prompted requests as well as common themes among nurse requestors’ evaluations of what was most important in clinical ethics consultations. Participants and context: A total of 41 nurses requesting clinical ethics consultation and 15 who returned the follow-up questionnaire. Ethical considerations: Our Office of Research Compliance and Quality Improvement determined that our project was not considered human subjects research and so did not require institutional review board approval or exemption. However, efforts were made to avoid any sense of coercion and all data were de-identified prior to analysis. Findings: Our analysis revealed six main categories of issues that prompted nurses’ requests for ethics consultation, as well as unifying themes around nurses’ experiences, advocacy, and family support while caring for patients in the intersections of patients, families, and physicians. Discussion: The insights gained from analyzing nurses’ requests for and responses to clinical ethics consultation may serve as a resource for clinical ethics consultation services seeking to identify, respond to, and educate regarding issues of importance to nurse colleagues and may be a resource for nursing administrators and leadership seeking to identify and address common ethical issues nurses face. Conclusion: Ongoing work on clinical ethics consultation service quality improvement and engagement with our nursing colleagues about their concerns prompting—and their evaluations of—clinical ethics consultation are necessary. (shrink)

In recent years, there have been growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts. Initially proposed in the cultural context of the USA where nurse ethicists have long been recognised, the idea is being advocated in other judications outside of the USA such as the UK, Australia and elsewhere. Such calls are not without controversy, however. Underpinning this controversy are ongoing debates about the theoretical, methodological and political dimensions of clinical ethics (...) support services generally, and more recently where nurses might ‘fit’ within such a service. In considering whether nurse ethicists ought to have a place in clinical ethics support services, a number of questions arise such as: Is such a role warranted? If so, what credentials should nurses assuming the title of ‘nurse ethicist’ be required to have? What standards of practice ought nurse ethicists be required to uphold? What is the ultimate role and function of nurse ethicists in hospital contexts? And in what contexts might a nurse ethicist be most useful? In this essay, brief attention will be given to addressing these questions. It will be concluded that, as a minimum, nurses wishing to assume an advanced nursing practice role as a nurse ethicist must have substantive grounding in the foundational knowledge of the disciplines of both moral philosophy and nursing ethics. They must also not lose sight of the ultimate goal of nursing ethics, notably, to promote and advance ethical nursing practice and the provision of ‘good’ nursing care. (shrink)

Recent literature has highlighted issues of racial discrimination in medicine. In order to explore the sometimes subtle influence of racial determinants in decisions about resource allocation, we present the case of a 53-year-old Australian Aboriginal woman with end-stage renal failure. The epidemiology of renal failure in the Australian Aboriginal population and amongst other indigenous peoples is discussed. We show that the use of utilitarian outcome criteria for resource allocation may embody subtle racial discrimination where consideration is not given (...) to issues of justice, race, culture and gender. It is only where the processes by which resources are allocated are transparent, clearly defined and based upon consultation with individual patients that issues and justice are likely to be adequately addressed. (shrink)

The carbon emissions of global health care activities make up 4–5% of total world emissions, placing it on par with the food sector. Carbon emissions are particularly relevant for health care because of climate change health hazards. Doctors and health care professionals must connect their health care delivery with carbon emissions and minimize resource use when possible as a part of their obligation to do no harm. Given that reducing carbon is a global ethical priority, the informed consent process (...) in health care delivery must change. I argue that the expanded role of bioethicists in this climate crisis is to promote and support “green informed consent:” the sharing of climate information with patients, offering options for lower-carbon health care, and accepting the patient’s right to decline treatments which are deemed too carbon intensive for their values. (shrink)

From mid-March through May 2020, New York City was the world’s epicenter of the COVID-19 pandemic, and its hospitals faced an unparalleled surge of patients who were critically ill with the virus. In addition to putting an enormous strain on medical resources, the pandemic presented many ethical issues to emotionally and physically stressed clinicians and hospital administrators. Analyses of the challenges faced by the ethics consultation services of the two campuses of New York Presbyterian Hospital, and how they assisted their (...) clinician and administrative colleagues, is the subject of the following four articles. (shrink)

In 2004, drug user representatives lobbied against the now stalled $17.5m Australian government Retractable Needle and Syringe Technology Initiative due to concerns about inadequate consultation and potential health risks to participants.1 Some drug user organisations have also recently withdrawn support for the Australian Illicit Drug Reporting System , ….

While previous studies highlight the dynamic nature of identity co-construction, how and especially why speakers construct and shift their own multiple identities still remains understudied. The present study argues that identity is part of speaker communicative resources as evidenced by radio program hosts’ strategic employment and shift among their different identities to facilitate their interactional purposes. Based on data drawn from radio medical consultations, this article attempts to reveal the dynamic adaptability of hosts’ identity construction. It is found that in (...) general, hosts of medical consultation programs construct three identities for themselves, namely an authoritative expert identity, a caring friend identity and a sales representative identity; the three identities constructed are respectively adaptable to power relationships, solidarity and role relationships between hosts and callers in conversation; the three identities shift in conversations to facilitate callers’ purchasing acts. (shrink)

BackgroundAfrica continues to bear a disproportionate share of the global HIV/AIDS, tuberculosis (TB) and malaria burden. The development and distribution of safe, effective and affordable vaccines is critical to reduce these epidemics. However, conducting HIV/AIDS, TB, and/or malaria vaccine trials simultaneously in developing countries, or in populations affected by all three diseases, is likely to result in numerous ethical challenges.MethodsIn order to explore convergent ethical issues in HIV/AIDS, TB and malaria vaccine trials in Africa, the Ethics, Law and Human Rights (...) Collaborating Centre of the WHO/UNAIDS African AIDS Vaccine Programme hosted a consultation on the Convergent Ethical Issues in HIV/AIDS, TB and Malaria Vaccine Trials in Africa in Durban, South Africa on the 10-11 February 2009.ResultsKey cross cutting ethical issues were prioritized during the consultation as community engagement; ancillary care obligations; care and treatment; informed consent; and resource sharing.ConclusionThe consultation revealed that while there have been few attempts to find convergence on ethical issues between HIV/AIDS, TB and malaria vaccine trial fields to date, there is much common ground and scope for convergence work between stakeholders in the three fields. (shrink)

During the Second Industrial revolution, consulting professor bridged higher education institutions with industry and government. A concept like the utilitarian research regime by Terry Shinn can explain their material and intellectual production by allowing for a reconstruction of their social networks. Pierre‐Paul LeCointe and Louis Bourgoin , associates in an engineering consultancy office, institutionalised a consultation service at the Laboratory of Industrial Chemistry of the École Polytechnique of Montreal . The two industrial chemists were thereby able to obtain financial, material (...) and human resources through exchanges with industrialists, business men and civil servants; consequently, their material and intellectual production is marked by the preoccupations of the industries and government with whom they exchanged. Industrial development in Canada was, in part, based on the work of these consultants who helped private companies analyse primary resources, standardize fabrication procedures and adapt the production to regulations. The government also offered technological assistance to businesses thanks to consultants, while regulating the markets and producing industrial standards. The inception of a utilitarian research regime results from the conjunction of these different factors. Finally, on Bourgoin's initiative, the École Polytechnique created a research centre based on the model of consulting laboratories. (shrink)

This paper investigates the key drivers behind the origins of value-for-money (VFM) audit in Canada and the aims, intents, and logics ascribed by the original proponents. Drawing on insights from governmentality and New Public Management, the paper utilizes analysis methods adapted from case study research to review a wide range of primary documentation (e.g., Hansards from the Public Accounts Committee, House of Commons debates, the so-called Wilson report and the FMCS study) and secondary documentation (newspaper articles, Office of the Auditor (...) General internal publications, journal articles). Major findings indicate a rise of a management consulting culture within the Auditor General’s office following the appointment of James Johnson Macdonell. VFM legislation effectively operationalized practices drawn from management consulting expertise by invitation of the consultant. It was offered as an answer to the growing scope and size of government, which had become problematized by the Auditor General in terms of parliament losing control over the public purse. The Auditor General’s invocation of financial crisis led to a substantial broadening of mandate and increase in resources for that office. (shrink)

The COVID-19 pandemic has inspired numerous opportunities for telehealth implementation to meet diverse healthcare needs, including the use of virtual communication platforms to facilitate the growth of and access to clinical ethics consultation (CEC) services across the globe. Here we discuss the conceptualization and implementation of two different virtual CEC services that arose during the COVID-19 pandemic: the Clinical Ethics Malaysia COVID-19 Consultation Service and the Johns Hopkins Hospital Ethics Committee and Consultation Service. A common strength experienced by both platforms (...) during virtual delivery included improved ability for local practitioners to address consultation needs for patient populations otherwise unable to access CEC services in their respective locations. Additionally, virtual platforms allowed for enhanced collaboration and sharing of expertise among ethics consultants. Both contexts encountered numerous challenges related to patient care delivery during the pandemic. The use of virtual technologies resulted in decreased personalization of patient-provider communication. We discuss these challenges with respect to contextual differences specific to each service and setting, including differences in CEC needs, sociocultural norms, resource availability, populations served, consultation service visibility, healthcare infrastructure, and funding disparities. Through lessons learned from a health system in the United States and a national service in Malaysia, we provide key recommendations for health practitioners and clinical ethics consultants to leverage virtual communication platforms to mitigate existing inequities in patient care delivery and increase capacity for CEC globally. (shrink)

Ethical difficulties arise in health-care practices. However, despite extensive research findings that demonstrate that most nurses are involved in recurrent ethical problems, institutions are not always able to effectively support nursing care professionals. The limited availability of ethics consultation services and traditional nursing training fails to meet the frequent and strong requests by health workers to support their ethical dilemmas. A questionnaire was administered to 374 nurses attending a specialist training and a lifetime learning programme in Italy. The respondents reported (...) a high frequency of ethically sensitive situations, and they described the poor development of ethics support and a scarcity of ethics training programmes. The results suggest the importance of promoting ethics services that include consultation and ethics training. A need for systematic ethics educational activities was identified for improving the capacity of nurses to manage ethical issues in patient care. (shrink)

The COVID-19 global pandemic has led to significant disruptions in the lives of high-performance athletes, including the postponement of the Tokyo Olympic and Paralympic Games, the cancellation of many international and national competitions, and drastic changes in athletes’ daily training environment. The purpose of this research was to examine the interplay between the mental health and mental performance of Canadian national team athletes and the impact of the COVID-19 pandemic on these variables from the perspective of mental performance consultants (...) and mental health practitioners. Twelve individuals working in these roles with national team athletes participated in focus groups and interviews during the second wave of the COVID-19 pandemic in Canada. Findings from the inductive reflexive thematic analysis revealed three main themes: factors impacting athlete mental health, consequences of COVID-19 for athletes, and impact of the pandemic on practitioners. Interestingly, athletes with prior good mental performance skills were perceived to be more equipped to cope with challenges related to the pandemic, which concurrently seemed to facilitate good mental health throughout the pandemic. Furthermore, even though the pandemic had several debilitative consequences on athletes’ mental health, it imposed a break from training and competition that allowed them to rest and enjoy their life outside of sport. Finally, participants discussed the need for more mental health resources and better access to practitioners supporting mental performance and mental health in the Canadian sport system. (shrink)