Background In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. Setting A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. Methods Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important (...) features were: all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. Results Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. Conclusion Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement. (shrink)

It is now common in health care for a diverse range of professions and disciplines to work together in regular and close contact. Thus, there are now calls in the literature for research that documents insights on the ethical dimension of multidisciplinary relationships. Recent Australian research has responded to this call by examining how a multidisciplinary team of health professionals define and operationalize the notion of ethics in an acute ward hospital setting. This article provides findings from the research (...) study that indicate that, although there is a shared conceptualization of ethics as "patient-centered care", there can be times of conflict and tension in determining what is best for the patient. The discussion begins to build an understanding of how a multidisciplinary mix of health professionals responds to ethical conflict and tension. The authors' hope and expectation is that, by keeping the research focus on what health professionals in a multidisciplinary team (MDT) actually do, rather than exclusively on how they philosophically think about ethical dilemmas, the insights can be translated into practical strategies that can be utilized to strengthen the process of ethical decision making within the health care system. (shrink)

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or (...) ethics consultation. In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making. (shrink)

The present study applied Ajzen's (1985) theory of planned behavior to the explanation of ethical decision making. Nurses in three hospitals were provided with scenarios that depicted inadequate patient care and asked if they would report health professionals responsible for the situation. Study results suggest that the theory of planned behavior can explain a significant amount of variation in the intent to report a colleague. Attitude toward performing the behavior explained a large portion of the variance; subjective norms explained (...) a moderate amount of the variance; and, perceived behavioral control added little to the explanation of variance. Implications for research and practice are discussed. (shrink)

OBJECTIVE: We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically ill or malformed neonates. DESIGN: Data were obtained by questionnaires divided into three sections: 1. sociodemographic; 2. Theoretical principles which might be utilised in the decision-making process; 3. Hypothetical case scenarios, each followed by possible treatment options. RESULTS: Pregnant women (n = 545) consistently requested less aggressive (...) class='Hi'>medical intervention for the hypothetical cases than did new mothers (n = 250) [Trisomy 18: 57% v 42%; p = 0.0004; Asphyxia: 75% v 63%; p = 0.0017; Down's syndrome 81% v 62%; p = 0.0001; LBW 85% v 75%; p = 0.004]. Significant differences were also observed in the responses to the theoretical principles, with pregnant women attributing less importance to preserving life at all cost, while being more concerned with physical and emotional pain and suffering, with financial cost, and with the infant's potential for future productivity. (shrink)

Philosophers have long recognized that the unique values of the individual physician effect medical-ethical decision-making. While not taking issue with this basic assumption, this article critically examines one discussion of how different philosophies (existential, utilitarian, and value realist) can influence a neurosurgeon's decision to operate upon a person having a malignant brain tumor. It also delineates and discusses a fund of ‘medical wisdom’ commonly available to any neurosurgeon and easily obtainable by both researcher and patient. The (...) article suggests that those in the humanities interested in studying the ethical decision-making process in a medical subspecialty become familiar with this fund of knowledge. It can provide a base for evaluating when and how individual medical decisions vary. In this specific instance, the medical knowledge base was used to direct attention to when and how ethical issues are identified and resolved within the staff clinical neurosurgical setting. An informal survey among resident and staff neurosurgeons supported the conclusion that philosophical analyses of medical-ethical decision-making are appreciated when case examples are carefully and accurately documented, when medical terminology is used correctly and when recognition of the practical limits placed on medical decision-making is given. CiteULike Connotea Del.icio.us What's this? (shrink)

BackgroundCommentators believe that the ethical decision-making climate is instrumental in enhancing interprofessional collaboration in intensive care units. Our aim was twofold: to determine the perception of the ethical climate, levels of moral distress, and intention to leave one's job among nurses and physicians, and between the different ICU types and determine the association between the ethical climate, moral distress, and intention to leave.MethodsWe performed a cross-sectional questionnaire study between May 2021 and August 2021 involving 206 nurses and physicians in (...) a large urban academic hospital. We used the validated Ethical Decision-Making Climate Questionnaire and the Measure of Moral Distress for Healthcare Professionals tools and asked respondents their intention to leave their jobs. We also made comparisons between the different ICU types. We used Pearson's correlation coefficient to identify statistically significant associations between the Ethical Climate, Moral Distress, and Intention to Leave.ResultsNurses perceived the ethical climate for decision-making as less favorable than physicians. They also had significantly greater levels of moral distress and higher intention to leave their job rates than physicians. Regarding the ICU types, the Neonatal/pediatric unit had a significantly higher overall ethical climate score than the Medical and Surgical units and also demonstrated lower moral distress scores and lower “intention to leave” scores compared with both the Medical and Surgical units. The ethical climate and moral distress scores were negatively correlated ; moral distress and "intention to leave" was positively correlated ; and ethical climate and “intention to leave” were negatively correlated.ConclusionsSignificant differences exist in the perception of the ethical climate, levels of moral distress, and intention to leave between nurses and physicians and between the different ICU types. Inspecting the individual factors of the ethical climate and moral distress tools can help hospital leadership target organizational factors that improve interprofessional collaboration, lessening moral distress, decreasing turnover, and improved patient care. (shrink)

BackgroundIn terms of ethical decision making, every clinical case, when seen as an ethical problem, may be analyzed by means of four topics: medical indications, patient preferences, quality of life, contextual features. The aim of this study was to compare the performance of 4th year dental students on Ethical Decision Making before and after a course on ethics.MethodsFourth year dental students from academic year 2013–2014 participated in the study. A 3-h lecture, which was about four topics (...) approach to clinical ethical case analysis, was given to the students. The lecture was based on case scenarios related with dental ethics. After the completion of lectures,a case scenario was presented to the students to assess their ethical decision making abilities. At the end of the exam, four topics and ethical judgment were evaluated. Their performances on this examination were evaluated before and after lectures. Statistical evaluation was performed with the significance level set at p 0.05). The mean total score of the students after the course was significantly higher than before course.ConclusionMore lectures should be implemented to the curriculum to increase the student awareness of ethical issues and to reach the ultimate goals of dental education. (shrink)

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to deal with (...) every day, ethical decision-making has become an inevitable challenge. The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method. The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight sub-categories signifying participants’ experiences with regard to EDM. According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties. (shrink)

As the implementation of new approaches and procedures of medical ethics is as complex and resource-consuming as in other fields, strategies and activities must be carefully planned to use the available means and funds responsibly. Which facilitators and barriers influence the implementation of a medical ethics decision-making model in daily routine? Up to now, there has been little examination of these factors in this field. A medical ethics decision-making model called METAP was (...) introduced on three intensive care units and two geriatric wards. An evaluation study was performed from 7 months after deployment of the project until two and a half years. Quantitative and qualitative methods including a questionnaire, semi-structured face-to-face and group-interviews were used. Sixty-three participants from different professional groups took part in 33 face-to-face and 9 group interviews, and 122 questionnaires could be analysed. The facilitating factors most frequently mentioned were: acceptance and presence of the model, support given by the medical and nursing management, an existing or developing ethics culture, perception of a need for a medical ethics decision-making model, and engaged staff members. Lack of presence and acceptance, insufficient time resources and staff, poor inter-professional collaboration, absence of ethical competence, and not recognizing ethical problems were identified as inhibiting the implementation of the METAP model. However, the results of the questionnaire as well as of explicit inquiry showed that the respondents stated to have had enough time and staff available to use METAP if necessary. Facilitators and barriers of the implementation of a medical ethics decision-making model are quite similar to that of medical guidelines. The planning for implementing an ethics model or guideline can, therefore, benefit from the extensive literature and experience concerning the implementation of medical guidelines. Lack of time and staff can be overcome when people are convinced that the benefits justify the effort. (shrink)

Through discourse with international groups of physicians, we conducted a cross-cultural analysis of the types of ethical dilemmas physicians face. Qualitative analysis was used to categorise the dilemmas into seven themes, which we compared among the physicians by country of practice. These themes were a-theoretically-driven and grounded heavily within the text. We then subjected the dilemmas to an analysis of moral intensity, which represents an important theoretical perspective of ethical decision making. These constructs represent salient determinants of ethical behaviour (...) and our cross-cultural sample afforded us the opportunity to consider both the pragmatic aspects of culture, as they are perceived by physicians, as well as the theory-driven concept of moral intensity. By examining both culture and moral intensity, we hope to better elucidate the complexities of ethical decision-making determinants among physicians in their daily practice. Doing so may potentially have practical implications for ethics training of medical students and foreign physicians. (shrink)

Introduction Ethical climate in medical contexts is referred to the organizational environment consisting of medical staff interpersonal relationships regarding patient care. This element affects staff behavior in an organization. The investigation and comparison of the effects of the interventions promoting ethical climate are among important nursing challenges that should be considered by researchers. The present study was conducted to compare the effect of nurses’ ethical decision-making skills and interpersonal communication training on their ethical climate. Materials and methods (...) This experimental study was performed on 90 nurses working in the general teaching hospitals of Mashhad, Iran. The sampling process was conducted in two stages. Nurses were divided into three groups: intervention 1 (ethical decision-making skills group), intervention 2 (interpersonal communication skills group) and control group. The intervention was separate 12-h workshops for each of the intervention groups. The ethical climate questionnaire by Victor and Cullen was used to assess the score of ethical climate in the three groups both at the beginning and 4 weeks after the workshop. The data were analyzed in Statistical Package for Social Sciences software (version 16) using descriptive statistics, analysis of variance, Kruskal–Wallis, paired sample t-test, Wilcoxon test, and post hoc Tukey’s test. Ethical considerations were as follows: The study design was approved by the Research Ethics Committee of Mashhad University of Medical Sciences. Informed consent was obtained from all subjects, and they were ensured about the confidentiality terms. Results The mean scores of the ethical climate test at the first stage were obtained as 66.0 ± 5.5, 67.8 ± 6.9, and 67.7 ± 7.2 in the ethical decision-making, interpersonal communication, and control groups, respectively. Accordingly, the three groups were not significantly different in terms of this variable (df = 87, f = 0.70, P = 0.005). However, after the intervention (i.e. second stage), a significant difference was observed among the three groups regarding the mean scores of the ethical climate test In this regard, the calculated mean scores in the ethical decision-making, interpersonal communication, and control groups were 99.3 ± 6.3, 90.4 ± 7.7, and 67.4 ± 7.9, respectively (df = 87, f = 152.00, P < 0.001). Conclusion Training workshops about ethical decision-making skills and interpersonal communication on the ethical professional climate of nurses was effective. Nonetheless, the effect of ethical decision-making skill training was found to be higher than interpersonal communication skill training. Therefore, it is recommended that nursing managers hold training workshops to improve the ethical climate for nurses. (shrink)

Background: Hospices are based on a holistic approach which places the physical, psychological, social and spiritual welfare of their patients at the forefront of their work. Furthermore, they draw up their own mission statements which they are at pains to follow and seek to conduct their work in accordance with codes of ethics and standards of care. Research question and design: Our study researched what form the processes and degrees of latitude in decision-making take in practice when questions (...) of an ethical and ethically relevant nature arise. We used a qualitative approach. Data collection and evaluation was based on the methods of grounded theory. Ethical considerations: The study was reported to the relevant Ethics Commission who had raised no objections following the submission of the study protocol. The study at the hospices was approved by the directors of the hospices and the nursing teams. The rights of the participants were protected by obtaining informed consent. Results: Medication in the prefinal phase and questions affecting the provision of solids and liquids in the end-of-life phase have an ethical dimension. In the context of these two fields, decisions are taken collectively. A nurse’s individual (and ethically relevant) leeway in decision-making processes is restricted to the nurse’s own style of administering care. The nurse’s decision-making often depends to a far greater degree on her ability to adapt her concept of ideal care to fit the practical realities of her work than to any conceptual framework. Discussion: An adaptive process is necessary for the nurse because she is required to incorporate the four pillars of hospice care – namely, physical, psychological, social and spiritual care – into the practice of her daily work. Conclusion: Ethically relevant decisions are often characterised by nurses adjusting their aspiration levels to the practical conditions with which they are confronted. (shrink)

In their recently published target article, Bowman-Smart et al. (2023) summarize the ethical issues at play in both the case for and the case against using NIPT to screen for non-medical traits.The...

Machine intelligence already helps medical staff with a number of tasks. Ethical decision-making, however, has not been handed over to computers. In this proof-of-concept study, we show how an algorithm based on Beauchamp and Childress’ prima-facie principles could be employed to advise on a range of moral dilemma situations that occur in medical institutions. We explain why we chose fuzzy cognitive maps to set up the advisory system and how we utilized machine learning to train it. We (...) report on the difficult task of operationalizing the principles of beneficence, non-maleficence and patient autonomy, and describe how we selected suitable input parameters that we extracted from a training dataset of clinical cases. The first performance results are promising, but an algorithmic approach to ethics also comes with several weaknesses and limitations. Should one really entrust the sensitive domain of clinical ethics to machine intelligence? (shrink)

Background: Increasing interest in empirical ethics has enhanced understanding of healthcare professionals’ ethical problems and attendant decision-making. A four-stage decision-making model involving ethical attention, reasoning, intention and action offers further insights into how more than reasoning alone may contribute to decision-making.Aims: To explore how the four-stage model can increase understanding of decision-making in healthcare and describe the decision-making of an under-researched professional group.Methods: 23 purposively sampled UK community pharmacists were asked, in semi-structured interviews, (...) to describe ethical problems in their work and how they were resolved. Framework analysis of transcribed interviews utilised the four decision-making stages, together with constant comparative methods and deviant-case analysis.Results: Pharmacists were often inattentive and constructed problems in legal terms. Ethical reasoning was limited, but examples of appeals to consequences, the golden rule, religious faith and common-sense experience emerged. Ethical intention was compromised by frequent concern about legal prosecution. Ethical inaction was common, typified by pharmacists’ failure to report healthcare professionals’ bad practices, and ethical passivity emerged to describe these negative examples of the four decision-making stages. Pharmacists occasionally described more ethically active decision-making, but this often involved ethical uncertainty.Discussion: The four decision-making stages are a useful tool in considering how healthcare professionals try to resolve ethical problems in practice. They reveal processes often ignored in normative theories, and their recognition and the emergence of ethical passivity indicates the complexity of decision-making in practice. Ethical passivity may be deleterious to patients’ welfare, and concerns emerge about improving pharmacists’ ethical training and promoting ethical awareness and responsibility. (shrink)

The COVID-19 pandemic has strained healthcare resources the world over, requiring healthcare providers to make resource allocation decisions under extraordinary pressures. A year later, our understanding of COVID-19 has advanced, but our process for making ethical decisions surrounding resource allocation has not. During the first wave of the pandemic, our institution uniformly ramped-down clinical activity to accommodate the anticipated demands of COVID-19, resulting in resource waste and inefficiency. In preparation for the second wave, we sought to make such ramp down (...) decisions more prudently and ethically. We report the development of a tool that can be used to make fair and ethical decisions in times of resource scarcity. We formed an interprofessional team to develop and use this tool to ensure that a diverse range of stakeholder perspectives were represented in this development process. This team, called the clinical activity recovery team, established institutional objectives that were combined with well-established procedural values, substantive ethical principles and decision-making criteria by using a variation on the well-known accountability for reasonableness ethical framework. The result of this is a stepwise, semiquantitative, ethical decision tool that can be applied to resource allocation challenges in order to reach fair and ethically defensible decisions. This ethical decision tool can be applied in various contexts and may prove useful at both the institutional and the departmental level; indeed this is how it is applied at our centre. As the second wave of COVID-19 strains healthcare resources, this tool can help clinical leaders to make fair decisions. There are no data in this work. (shrink)

Background Ethical decision making in intensive care is a demanding task. The need to proceed to ethical decision is considered to be a stress factor that may lead to burnout. The aim of this study is to explore the ethical problems that may increase burnout levels among physicians and nurses working in Portuguese intensive care units . A quantitative, multicentre, correlational study was conducted among 300 professionals.Results The most crucial ethical decisions made by professionals working in ICU were (...) related to communication, withholding or withdrawing treatments and terminal sedation. A positive relation was found between ethical decision making and burnout in nurses, namely, between burnout and the need to withdraw treatments , to withhold treatments and to proceed to terminal sedation . This did not apply to physicians. Emotional exhaustion was the burnout subdimension most affected by the ethical decision. The nurses' lack of involvement in ethical decision making was identified as a risk factor. Nevertheless, in comparison with nurses , it was the physicians who more keenly felt the need to proceed to ethical decisions in ICU.Conclusions Ethical problems were reported at different levels by physicians and nurses. The type of ethical decisions made by nurses working in Portuguese ICUs had an impact on burnout levels. This did not apply to physicians. This study highlights the need for education in the field of ethics in ICUs and the need to foster inter-disciplinary discussion so as to encourage ethical team deliberation in order to prevent burnout. (shrink)

Background: Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision. Objectives: The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel. Methods: In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and (...) the data were collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach. Ethical considerations: Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality. Findings: The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes. Conclusion: Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them. (shrink)

Background: Research suggests that nurses generally do not participate in ethical decision-making in accordance with ethical guidelines for nurses. In addition to completing their training, nurses need to reflect on and use ethically grounded arguments and defined ethical values such as patient’s dignity in their clinical work. Objectives: The purpose of this article is to gain a deeper understanding of how nurses deal with ethical decision-making in daily practice. The chosen research question is “How do nurses participate in (...) ethical decision-making for the patient?” Design and method: We use Gadamer’s philosophical hermeneutics as well as Kvale and Brinkmann’s three levels of understanding in interpreting the data material. Nine registered nurses were interviewed. Ethical considerations: The Ombudsman of Norwegian Social Science Data and the head of the hospital approved the investigation. The participants received both oral and written information about the study and they gave their consent. We informed the participants that the participation was voluntary and that they were free to withdraw at any point in the course of the study. The requirement of anonymity and proper data storage was in accordance with the World Medical Association Declaration of Helsinki (1964). The participants were assured that privacy, and confidentiality would be duly protected. Results: Four key themes emerged: (1) confusion in relation to professional and operational expectations of role, (2) ideal somnolence, (3) inadequate argumentation skills, and (4) compound pressure. Conclusion: Ethical ideals appear to be latent in the mindset of the participants; however, the main finding of this investigation is that nurses need to activate the ideals and apply them into practice. Furthermore, management needs to initiate professional reasoning and interdisciplinary discussions leading to common goals for patients. (shrink)

Ethical decision making in medicine has recently seen calls to move towards less prescriptive- based approaches that consider the particularities of each case. The main alternative call from the literature is for better understanding of phronesis concepts applied to decision making. A well-cited phronesis-based approach is Kaldjian’s five-stage theoretical framework: goals, concrete circumstances, virtues, deliberation and motivation to act. We build on Kaldjian’s theory after using his framework to analyse data collected from a three-year empirical study of phronesis (...) and the medical community. The data are a set of narratives collected in response to asking a medical community what making ethically wise decisions means to them. We found that Kaldjian’s five concepts are present in the accounts to some extent but that one of the elements, motivation, is constructed as playing a different, though still crucial role. Rather than being an end-stage of the process as Kaldjian’s framework suggests, motivation was constructed as initiating the process and maintaining the momentum of taking a phronesis-based approach. The implications for medical ethics decision-making education are significant as motivation itself is a highly complex concept. We therefore theorise that motivation is required for leading in, continuing and completing the actions of the ethical decision taken. Appreciating the central importance of motivation through the whole of Kaldjian’s framework has implications for cultivating the virtues of phronesis and courage to take the right course of action. (shrink)

The scope of noninvasive prenatal testing (NIPT) could expand in the future to include detailed analysis of the fetal genome. This will allow for the testing for virtually any trait with a genetic contribution, including “non-medical” traits. Here we discuss the potential use of NIPT for these traits. We outline a scenario which highlights possible inconsistencies with ethical decision-making. We then discuss the case against permitting these uses. The objections include practical problems; increasing inequities; increasing the burden of (...) choice; negative impacts on the child, family, and society; and issues with implementation. We then outline the case for permitting the use of NIPT for these traits. These include arguments for reproductive liberty and autonomy; questioning the labeling of traits as “non-medical”; and the principle of procreative beneficence. This summary of the case for and against can serve as a basis for the development of a consistent and coherent ethical framework. (shrink)

Walton offers a comprehensive, flexible model for physician-patient decision making, the first such tool designed to be applied at the level of each particular case. Based on Aristotelian practical reasoning, it develops a method of reasonable dialogue, a question- and-answer process of interaction leading to informed consent on the part of the patient, and to a decision--mutually arrived at--reflecting both high medical standards and the patient's felt needs. After setting forth his model, he applies it to three (...) vital ethical issues: acts of omission, the cessation of treatment, and possible side effects of treatments. In the final chapter, Walton shows how his method functions in light of the real-life complexities of the clinical encounter and how it bears on ethical questions concerning health-care policy, attitudes toward treatment and toward the medical profession, reasonableness of expectations, and the setting of realistic goals of treatment. (shrink)

Locked-in syndrome (LIS) is one of the most dramatic neurological outcomes and has a profound impact on patients and their families. Most patients have intact cognition and intellectual ability and perception. Communication is possible with eyelid and/or eyeball movement. According to the literature, the wish to die is not an important issue in acute and chronic LIS. This study describes and analyses the ethical decision-making process in two opposite cases of LIS in the intensive care unit. One patient expressed (...) the wish to prolong her life for as long as possible; the other patient asked for deliberate termination of life. Both wishes were honoured. In conclusion, most patients with LIS are competent and intellectually intact. In The Netherlands the autonomy of the patient is respected by law. In respecting this autonomy, medical choices can be different in comparable patients. (shrink)

There is very little literature on the actual decision-making frameworks used by general practitioners with respect to ethical issues and virtually none on the impact of personal experiences of illness on this. This study aimed to investigate what these frameworks might be and if and how they were altered by doctors’ own illness experience. Twenty general practitioners were recruited, 10 having had a previous serious medical illness and 10 having no such history. They participated in a semi-structured interview, (...) including case vignettes, recorded and analysed using qualitative thematic analysis. Being a patient themselves altered general practitioners’ decision-making by enhancing physician empathy, increasing ease at discussing difficult topics, having a greater willingness to support patient choice and a wider ability to provide a greater diversity of therapeutic strategies, with the role of empathy being the most noticeable difference between the groups. Doctors who had not had a severe personal illnes... (shrink)

We are living in an unprecedented era of biomedical revolution. Medicine is remaking humans, and controversy surrounds such topics as abortion, artificial organs, brain circuitry, eugenics, euthanasia, and gene therapy. At the same time, medical advances are posing complex ethical problems for both patients and professionals. The most comprehensive and up-to-date collection of its kind, Case Studies in Biomedical Ethics: Decision-Making, Principles, and Cases explores fundamental ethical questions arising from real situations faced by health professionals, patients, and (...) others. Featuring a wide range of more than 100 case studies drawn from current events, court cases, and physicians' experiences, the book is divided into three parts. Part I presents a basic framework for ethical decision-making in healthcare, covering such issues as separating evaluative questions from questions of fact; distinguishing between ethical and nonethical evaluations; and identifying the source of ethical judgments. Expanding upon this framework, Part II explains the ethical principles: beneficence and nonmaleficence, justice, respect for autonomy, veracity, fidelity, and avoidance of killing. Parts I and II provide students with the background to analyze the ethical dilemmas presented in Part III, which features cases on a broad spectrum of issues including abortion, genetics, mental health, confidentiality, health insurance, experimentation on humans, the right to refuse treatment, and death and dying. Each case is accompanied by the authors' commentary, which guides students in considering the issues. Ideal for undergraduate and graduate courses in biomedical ethics, bioethics, and medical ethics, Case Studies in Biomedical Ethics incorporates opening text boxes in each chapter that cross-reference relevant cases in other chapters. It also includes an appendix of important ethical codes and a glossary of key terms. (shrink)

The text is extensively referenced, but practical in its approach, giving real life examples and cases based on therapeutic practice.

This study examines the processes ofdecision-making used by intensive care(critical care) specialists. Ninety-ninespecialists completed a questionnaire involvingthree clinical cases, using a novel methodologyinvestigating the role of uncertainty andtemporal-related factors, and exploring a rangeof ethical issues. Validation and triangulationof the results was done via a comparison studywith a medically lay, but highly informed groupof 37 law students. For both study groups,constructing reasons for a decision was largelyan interpretative and imaginative exercise thatwent beyond the data (as presented), commonlyresulting in different reasons (...) supporting thesame conclusions and similar reasons supportingopposite conclusions. The skills of ethicalimagination and interpretation were related toan individual''s prior lived experience,construed in the broadest sense. Application ofthese skills of ethical imagination andinterpretation always occurred, to some degree,in a state of uncertainty and almost alwaysinvolved temporal relationships.Using these results, a theory of ethicaldecision-making is proffered. Three levels ortypes of reasoning processes may be present.Type I decision-making involves the applicationof rules, usually in a deductive fashion. TypeII decision-making is characterised by aprocess where a plurality of reasons arebalanced, weighed and sifted with each other.Type III decision-making is intimately linkedwith respondents lived experiences and `crafts''the content of type I and II reasoningprocesses, via the application of ethicalimagination and interpretation. Relationshipsbetween these three types of reasoningprocesses, and with narrative ethics, are alsodiscussed. (shrink)

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We (...) undertook a systematic review of the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards. (shrink)

Recent advances in life-sustaining treatments and technologies, have given rise to newly-emerged, critical and sometimes, controversial questions regarding different aspects of end-of-life decision-making and care. Since religious values are among the most influential factors in these decisions, the present study aimed to examine the Islamic scholars' views on end-of-life care. A structured interview based on six main questions on ethical decision-making in end-of-life care was conducted with eight Shiite experts in Islamic studies, and was analyzed through deductive content (...) analysis. Analysis revealed certain points in Islamic views on the definition of death and the persons making decisions about end-of-life care. According to the participants, in addition to conventional criteria such as absence of heartbeat and respiration, the irreversible cessation of human voluntary acts are considered to be the criteria in establishing death. The participants also recognized physicians as the main authorities in verifying signs of death. Furthermore, it was emphasized that life preservation and continuation of care must be sensible, and the patient can request not to have death-prolonging procedures started or continued. In the view of participants, patient's autonomy cannot be the sole basis for all measures, but Islamic ethical and jurisprudential principles should be relied upon to make correct and sensible decisions whether to continue or stop terminal patients' care. Final decisions should be made by a team of experts, and physicians must be at the center of such a team. Finally, we suggest that a guideline in keeping with Islamic norms on human life and death, purpose of life, God's will, boundaries of man's authority, and the physician's ethical duties and obligations should be developed. (shrink)

Many issues in ethics arise in relation to the contexts in which psychologists work. However, most ethical decision-making models reproduce the way in which psychologists tend to approach ethics by focusing on ethical dilemmas and proposing a step-by-step response to deal with them. Although these models might be useful, their emphasis on reactive approaches and their lack of contextualization constitute significant limitations on their applicability. In this article, an approach to ethical decision making that highlights the (...) importance of the context in developing proactive strategies to solve ethical issues is proposed. This approach is further explained through its application to medical and rural settings. The implications of these suggestions to the training in ethics are finally discussed. (shrink)

This article will be concerned with the phenomenon of vitality, which emerged as one of the main findings in a larger grounded theory study about life and death decisions in hospitals' neonatal units. Definite signs showing the new-born infant's energy and vigour contributed to the clinician's judgements about life expectancy and the continuation or termination of medical treatment. In this paper we will discuss the normative importance of vitality as a diagnostic cue and will argue that vitality, as a (...) sign perceived by doctors and nurses, has moral significance and represents a legitimate contribution to clinical decision-making in difficult cases where the child's life is at stake. We will argue that these clinical intuitions can be justified on a moral basis but only with certain qualifications that accounts for a certain objectivity and intersubjective reliability in the therapeutic judgements. (shrink)

Although prisons provide on-site primary care, the corrections system relies on external hospitals to provide a variety of healthcare services. Compared to the general population, incarcerated patients experience higher rates of chronic medical conditions, mental illness, substance abuse, cancer, traumatic brain injury, assault, and communicable disease. Certain specialties of clinicians are likely to encounter patients who are incarcerated, which makes it important for clinicians to understand how medical decision-making may differ when the patient is a prisoner. The (...) corrections system retains custody of inmates and is responsible for their welfare, including facilitating necessary medical care. However, this does not permit corrections personnel or a warden to automatically assume the role of the patient's medical decision-maker. Except for narrow exceptions, prisoners do not lose their rights to medical decision-making. In some instances, corrections staff or the prison warden have improperly asserted authority to act as the patient's medical decision-maker, such as when the patient lacks decision-making capacity. This violates ethical principles of bodily integrity, respect, and fairness. This paper provides an overview of medical decision-making for incarcerated patients, how surrogate decision-maker hierarchies apply to incarcerated patients without decision-making capacity, and special considerations for this subset of patients. (shrink)

Ethical decision making is a complex issue because it strongly depends on the religion, beliefs, traditional laws and moral views of each society. The purpose of this study was to explore the experience of Iranian family caregivers of end stage cancer patients about ethical decision making. This qualitative study is based on van Manen’s method of hermeneutic phenomenology. In-depth interviews were carried out to collect data. Participants were 12 caregiver. Audiotapes were transcribed and analyzed for common themes that (...) represented the participants’ experiences. Trustworthiness of the findings was established using the Lincoln and Guba’s criteria. Three themes reflected the essence of caregivers’ lived experience including; fluctuating between hope and despair, wandering dilemma, and ethical decision making. Each of these themes consisted of several subthemes. The present study revealed that, the caregivers of terminally ill cancer patients need different information about prognosis and end of life decision making process. Our perception of how families negotiate ethical issues in their decision-making is still developing. Opportunities should be created to empowering caregivers to talk about their uncertainties and concerns. (shrink)

BackgroundAlthough nurses are crucial to ensure patients’ peaceful death in hospitals, many nurses experience various ethical conflicts during end-of-life care. Therefore, research on nurses’ entire ethical decision-making process is required to improve nurses’ ethical decision-making in end-of-life care. This study aimed to identify Korean nurses’ ethical decision-making process based on their moral sensitivity to end-of-life patients.MethodsIn total, 171 nurses caring for terminal patients responded to the survey questionnaire. To measure the participants’ moral sensitivity and ethical decision-making (...) process, we used the Korean version of the Moral Sensitivity Questionnaire and Nurses’ Ethical Decision-Making around End of Life Care Scale. Finally, multiple linear regression analysis was used to investigate the effect of moral sensitivity on nurses’ ethical decision-making.ResultsThe mean of moral sensitivity was 4.8 ± 0.5 (out of 7), and that of ethical decision-making was 4.6 ± 0.5 (out of 6). Among the sub-dimensions of ethical decision-making, the highest score was in perceived professional accountability (5.2 ± 0.5), and the lowest in moral reasoning and moral agency (3.9 ± 0.6); the score of moral practice was 4.4 ± 0.7. In the multiple linear regression model, moral sensitivity (β = 0.852, p <.001), clinical department (β = − 7.018, p =.035), ethics education (β = 20.450, p <.001), job satisfaction (β = 5.273, p <.001), and ethical conflict (β = − 2.260, p = 0.031) were influential ethical decision-making factors.ConclusionsThis study revealed a gap between nurses’ thoughts and practices through the ethical decision-making process. They failed to lead their thought to moral practice. It also implies that moral sensitivity could positively affect nurses’ ethical decision-making. To make nurses morally sensitive, exposing them to various clinical cases would be helpful. Additionally, ethics education and clinical ethics supporting services are valuable for improving nurses’ ethical decision-making. If nurses improved their ethical decision-making regarding end-of-life care, their patients could experience a better quality of death. (shrink)

A review of medical ethics literature relating to the importance of the participation of patients in decision-making introduces the role of rights-based mediation as a voluntary process now being developed innovatively in America. This is discussed in relation to the theory of communicative ethics and moral personhood. References are then made to the work of medical ethics committees and the role of mediation within these. Finally it is suggested that mediation is part of an (...) eirenic ethic already being used informally in good patient care, and that there is a case for developing it further. (shrink)

Bowman-Smart et al. (2023) outlined the scenario that with the content expansion of noninvasive prenatal testing (NIPT) in the future, its application is not limited to the screening for aneuploidi...

Background Developing confident capacity for ethical decision-making is vital in nursing education. However, no tool examines nursing students’ competence in ethical decision-making. Aim This study aimed to develop an Ethical Decision-Making Competence Scale (EDM-CS) to assess ethical care decision-making competencies in nursing students. Participants and research context Original items were obtained by employing a focus group and the Delphi method. A cross-sectional design was used to confirm the items remained on the scale. Additionally, the scale’s reliability (...) and validity were assessed. The EDM-CS was completed by 498 nursing students. An exploratory factor analysis (EFA) was used to examine the factor structure based on data from group 1 ( n = 250). A second-order confirmatory factor analysis (CFA) was used to examine the model’s fitness based on data from group 2 ( n = 248). This study was conducted between August 2022 and July 2023. Ethical considerations The Institutional Review Board of Chung Shan Medical University Hospital approved this study’s design and procedure. Results From the original 34 items, nine were deleted in the EFA. Thus, the EDM-CS had 25 items and a four-factor structure (ethical judgement, ethical sensitivity, ethical motivation, and ethical action), which explained 60.97% of the total variance. A second-order CFA identified a second-order factor termed ‘ethical decision-making competence’ with 18 items (root mean square residual = 0.052). The EDM-CS scores correlated significantly and positively with the scores on the Scale of Protective Factor-24 (r = 0.47, p <.001), which indicated good convergent validity. Cronbach’s alpha coefficient of the final EDM-CS was 0.90 and ranged from 0.73 to 0.80 for the four subscales. Discussion and conclusion The EDM-CS was validated to fit the data adequately. It can be used to evaluate clinical nursing students’ ethical decision-making abilities and to develop education strategies to improve their ethical care competence. (shrink)

Background Advance healthcare decision-making presumes that a prior treatment preference expressed with sufficient mental capacity (“T1 preference”) should trump a contrary preference expressed after significant cognitive decline (“T2 preference”). This assumption is much debated in normative bioethics, but little is known about lay judgments in this domain. This study investigated participants’ judgments about which preference should be followed, and whether these judgments differed depending on a first-person (deciding for one’s future self) versus third-person (deciding for a friend or stranger) (...) perspective. -/- Methods A vignette-based survey was conducted (N = 1445 US Americans; gender-balanced sample), in a 3 (relationship: self, best friend, stranger) × 2 (T1 preference: treat, do not treat) × 2 (T2 contrary preference: ambiguous, unambiguous) design. -/- Results Participants were more likely to defer to the incapacitated T2 preference of a third-party, while being more likely to insist on following their own T1 capacitated preference. Further, participants were more likely to conclude that others with substantial cognitive decline were still their “true selves,” which correlated with increased deference to their T2 preferences. -/- Conclusions These findings add to the growing evidence that lay intuitions concerning the ethical entitlement to have decisions respected are not only a function of cognition, as would be expected under many traditional bioethical accounts, but also depend on the relationship of the decision to the decision-maker’s true self. (shrink)

In discussions of medical decision making as it applies to people with disabilities, a major obstacle stands in the way: the perceptions and values of disabled people and of many nondisabled people, regarding virtually the whole range of current health and medical-ethical issues, seem frequently to conflict with one another. This divergence in part grows out of the sense, common among people with disabilities, that their interactions with “the helping professions,” medical and social service professionals, are (...) adversarial. But those differences of opinion also stem more basically from a clash of fundamental values.This paper addresses, in historical perspective, the ways in which the status of persons with disabilities as a stigmatized minority group affects medical decision making. It also examines the efforts of disability rights activists to prevent discrimination against persons with disabilities in current medical culture. Finally, it raises questions about how the rights of people with disabilities will fare as new care standards are developed and implemented. (shrink)

A study of clinical medical ethicists was conducted to determine the various philosophical positions they hold with respect to ethical decision making in medicine and their various positions' relationship to the subjective-objective controversy in value theory. The study consisted of analyzing and interpreting data gathered from questionnaires from 52 clinical medical ethicists at 28 major health care centers in the United States. The study revealed that most clinical medical ethicists tend to be objectivists in value theory, (...) i.e., believe that value judgments are knowledge claims capable of being true or false and therefore expressions of moral requirements and normative imperatives emanating from an external value structure or moral order in the world. In addition, the study revealed that most clinical medical ethicists are consistent in the philosophical foundations of their ethical decision making, i.e., in decision making regarding values they tend not to hold beliefs which are incompatible with other beliefs they hold about values. (shrink)

Unrepresented patients are some of the most vulnerable patients encountered in the healthcare system today. One of the challenges associated with healthcare for unrepresented patients is the lack of a standardized legal approach to decision making for this highly vulnerable population. Current statutory approaches vary widely without best practices or consensus guidelines. In 2016, Colorado passed a medical proxy law that established a process for the appointment of an independent physician to serve as a temporary proxy decision (...) maker for an unrepresented patient. Although this approach helps to identify a decision maker when no proxy is available, the appropriate standards for decision making remain uncertain. A peer-to-peer session at the Clinical Ethics Unconference in 2022 approached this conundrum with a focus on the best interests standard and the appropriate use of patients’ context in decision making. (shrink)