Scholars and professional organizations in bioethics describe various approaches to “quality assessment” in clinical ethics. Although much of this work represents significant contributions to the literature, it is not clear that there is a robust and shared understanding of what constitutes “quality” in clinical ethics, what activities should be measured when tracking clinical ethics work, and what metrics should be used when measuring those activities. Further, even the most robust quality assessment efforts to date are idiosyncratic, in that they represent (...) evaluation of single activities or domains of clinical ethics activities, or a range of activities at a single hospital or healthcare system. Countering this trend, in this article we propose a framework for moving beyond our current ways of understanding clinical ethics quality, toward comprehensive quality assessment. We first describe a way to conceptualize quality assessment as a process of measuring disparate, isolated work activities; then, we describe quality assessment in terms of tracking interconnected work activities holistically, across different levels of assessment. We conclude by inviting future efforts in quality improvement to adopt a comprehensive approach to quality assessment into their improvement practices, and offer recommendations for how the field might move in this direction. (shrink)

The United Nations Educational, Scientific and Cultural Organisation’s Declaration on Bioethics and Human Rights refers to the importance of cultural diversity and pluralism in ethical discourse and care of humanity. The aim of this meta-narrative review is to identify indigenous ethical values pertaining to the Ojibway, Xhosa, and Mayan cultures from peer-reviewed sources and cultural review, and to ascertain if there are shared commonalities. Three main themes were identified, namely illness, healing, and health care choices. Illness was described with a (...) more complex and dynamic picture than from the western view, as illness is not considered to be one dimensional. Healing needs to take place on various levels in order to restore a state of equilibrium between the different spheres. Health care choices were also considered from a multi-level perspective. In all three of the indigenous cultures explored, good decision-making is seen to have occurred when choices are informed by commitments to one’s moral and ethical responsibilities towards the community, nature, and the spirit world. (shrink)

Cette étude de cas explore les complexités éthiques entourant le traitement de Mme H, une femme âgée atteinte d’un myélome multiple. Des objectifs divergents entre sa famille, ancrée dans des valeurs culturelles et religieuses, et l’équipe médicale ont suscité des délibérations éthiques. Les objectifs divergents étaient centrés sur le désir de la famille d’un traitement agressif du cancer, motivé par leurs croyances Ubuntu et chrétiennes dans le caractère sacré de la vie et l’espoir d’une intervention divine, contrastant avec l’accent mis (...) par l’équipe médicale sur les soins palliatifs, donnant la priorité au confort plutôt qu’à des interventions médicales agressives dont les bénéfices sont peu probables. Face à cette tension, l’équipe soignante, guidée par les principes de solidarité et d’humilité culturelle, s’est engagée dans un dialogue constructif facilité par un éthicien expérimenté. La résolution respecte les croyances culturelles et religieuses de la famille tout en adhérant à l’éthique médicale. Ce cas souligne l’importance de comprendre et d’intégrer les valeurs culturelles dans la prise de décision en matière de soins de santé, afin de parvenir à une approche centrée sur le patient qui respecte la diversité des points de vue. (shrink)

Les éthiciens cliniques doivent être à l’écoute des signaux non verbaux et des questions plus profondes qu’ils soulèvent, et être prêts et agiles pour changer de cap si nécessaire, de la discussion des objectifs de soins à l’établissement de la confiance. Nous présentons une étude de cas où une famille et une équipe de soins sont en désaccord sur la question de savoir si l’absence d’ordonnance de non-réanimation et de non-intubation (ONR/ONI) pour un patient dont le pronostic est en phase (...) terminale conduit à des décisions médicalement justifiables et éthiquement défendables. Un éthicien a convoqué une réunion de famille pour discuter de l’ordonnance, mais a déterminé, après avoir lu les remèdes non verbaux de la famille, qu’il fallait d’abord établir la confiance pour avoir cette discussion, et que cette confiance pouvait être établie en ne discutant pas de l’ordonnance. (shrink)

Cette étude de cas aborde les défis de la prise de décision en fin de vie dans la pratique, en se concentrant sur l’équilibre délicat entre le paternalisme médical, la prise de décision partagée et les droits des décideurs de substitution. La famille a d’abord du mal à saisir la gravité de l’état de santé de l’être cher, mais un moment charnière lors de la réunion sur les objectifs de soins apporte une clarté soudaine. Ce cas explore la pertinence et (...) les implications de la pratique du non-dissentiment éclairé. Cette analyse suggère que cette pratique est inappropriée à moins qu’il n’y ait des preuves irréfutables de paralysie de la décision. Des stratégies pratiques sont proposées pour faciliter l’accompagnement de la mort dans la compassion, tout en tenant compte des contraintes de l’urgence clinique. (shrink)

CITATION: Van Niekerk, A. A. & Nortje, N. 2013. Phronesis and an ethics of responsibility. South African Journal of Bioethics and Law, 6:28-31, doi:10.7196/SAJBL.262.

Although current literature about the “cure versus care” issue tends to promote a patient-centered approach, the disease-centered approach remains the prevailing model in practice. The perceived dichotomy between the two approaches has created a barrier that could make it difficult for medical students and physicians to integrate psychosocial aspects of patient care into the prevailing disease-based model. This article examines the influence of the formal and hidden curricula on the perception of these two approaches and finds that the hidden curriculum (...) perpetuates the notion that “cure” and “care” based approaches are dichotomous despite significant changes in formal curricula that promote a more integrated approach. The authors argue that it is detrimental for clinicians to view the two approaches as oppositional rather than complementary and attempt to give recommendations on how the influence of the hidden curriculum can be reduced to get a both-cure-and-care-approach, rather than an either-cure-or-care-approach. (shrink)

The aim of this psychobiography was to uncover, reconstruct and illustrate significant trajectories of psychosocial development and historical events over the lifespan of Emily Hobhouse (1860-1926). The British-born Hobhouse later became an anti-war campaigner and social activist who exposed the appalling conditions of the British concentration camps during the Anglo-Boer War (1899-1902), as evidenced by primary and secondary historical data. Purposive sampling was used to select Hobhouse as a significant and exemplary subject. Levinson’s four eras or seasons of lifespan development (...) served as the theoretical psychological approach. The study was undertaken against the background of Merleau-Ponty’s ontological philosophy that elucidates a human science phenomenology where the individual cannot be separated from her social world. Alexander’s model of identifying salient biographical themes was utilized and a conceptual psycho-historical framework, based on both the life cycle theory of Levinson and significant historical periods throughout Hobhouse’s life, was employed to assist with data gathering, categorisation, and analyses. The findings highlight significant psychosocial and historical events in the life of Hobhouse that shaped her development as an anti-war campaigner. These include: The role of her strong-willed and determined mother; the denial of an opportunity to study and pursue a formal education; her management of painful feelings of abandonment and grief; the care of her father during his illness and his eventual death; the abrupt ending of her failed romantic relationship; her networking capacity; and her open-mindedness and capacity for independent humanitarian thought. Against the philosophical background of Merleau-Ponty’s phenomenological ontology, Levinson’s theory and eras proved valuable in identifying these particular psychosocial life experiences and historical events as having shaped Emily Hobhouse into an antiwar campaigner. (shrink)

This book assists health care providers to understand the specific interplay of the roles and relationships currently forming the debates in pediatric clinical ethics. It builds on the fact that, unlike adult medical ethics, pediatric ethics begins within an acutely and powerfully experienced dynamic of patient-family-state-physician relationship. The book provides a unique perspective as it interacts with established approaches as well as recent developments in pediatric ethics theory, and then explores these developments further through cases. The book first focuses on (...) setting the stage by introducing a theoretical framework and elaborating how pediatric ethics differ from non-pediatric ethics. It approaches different theoretical frameworks in a critical manner drawing on their strengths and weaknesses. It helps the reader in developing an ability to engage in ethical reasoning and moral deliberation in order to focus on the wellbeing of the child as the main participant in the ethical deliberation, as well as to be able to identify the child’s moral claims. The second section of the book focuses on the practical application of these theoretical frameworks and discusses specific areas pertaining to decision-making. These are: the critically ill child, new and enduring ethical controversies, and social justice at large, the latter of which includes looking at the child’s place in society, access to healthcare, social determinants of health, and vaccinations. With the dynamic changes and challenges pediatric care faces across the globe, as well as the changing face of new technologies, no professional working in the field of pediatrics can afford not to take due note of this resource. (shrink)