A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the (...) implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared. (shrink)

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses not (...) only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim. (shrink)

Unable to answer the call of our patients: mental health nurses’ experience of moral distress When health practitioners’ moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non‐professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of (...) moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses’ possible responses to intolerable situations. (shrink)

Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care. In this paper it is argued that such a model is incommensurable with nursing conceived as a moral practice and ultimately places nurses at risk. Based upon understanding from ongoing research on compassion fatigue, it is proposed that compassion fatigue as currently experienced by nurses may not arise predominantly from too great a demand for compassion, but rather from (...) barriers to enacting compassionate care. These barriers are often systemic. The paradigm shift in which healthcare environments are viewed as marketplaces rather than moral communities has the potential to radically affect the evolution of nursing as a discipline. (shrink)

The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as (...) silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice. (shrink)

The term compassion fatigue has come to be applied to a disengagement or lack of empathy on the part of care-giving professionals. Empathy and emotional investment have been seen as potentially costing the caregiver and putting them at risk. Compassion fatigue has been equated with burnout, secondary traumatic stress disorder, vicarious traumatization, secondary victimization or co-victimization, compassion stress, emotional contagion, and counter-transference. The results of a Canadian qualitative research project on nurses? experience of compassion fatigue are presented. Nurses, self-identified as (...) having compassion fatigue, described a change in their practice by which they began to shield and distance themselves from the suffering of patients and families. Time to help patients and families cope with suffering seemed unavailable, and many felt they were running on empty and, ultimately, impotent as nurses. Feelings of irritability, anger, and negativity arose, though participants described denying or ignoring these emotions as a way to try to survive their work day. Difficulties with work carried over into the nurses? personal lives, affecting their relationships with family and friends. Such experiences invariably called into question the participants? identity, causing them to reflect on the kind of nurse they were. The participants? compassion fatigue created a sense of hopelessness regarding positive change, although some nurses described strategies that seemed to help alleviate their compassion fatigue. (shrink)

There are many ethical issues arising for practitioners in what are termed the boundaries of professional helping relationships. In this article, the authors argue that the boundary metaphor is not sufficient for conceptualizing these ethical issues and propose that alternative metaphors be considered. The use of a different metaphor might allow practitioners to re-vision the relationship issues in a more realistic, richer, and holistic way. Those explored here include highway, bridge, and territory. For the authors, it is territory that seems (...) to hold the greatest promise. (shrink)

Human rights may be the most globalized political value of our times. The rights paradigm has been criticized, however, for being theoretically unsound, legalistic, individualistic and based on the assumption that there is a given and universal humanness. Its use in the area of health is relatively new. Proponents point to its power to frame health as an entitlement rather than a commodity. The problems and the possibilities of a rights approach in addressing health ethics issues are explored in this (...) article. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

The movie, The terminal, is used to illustrate Mac Intyre's description of virtue ethics. The terminal is a mythical tale about a traveler, Viktor Navorski, who is stranded by circumstances in a New York airport. Viktor is a person who, without a strict reliance on duty or rules, has developed the disposition to act well despite variation in his circumstances. His character is revealed in contrast to that of three other characters: a cleaner, a flight attendant and the airport manager. (...) Stories like this one may be a good way to open dialogue among clinicians about being virtuous as a practitioner. Such dialogue may make striving to be virtuous an acceptable goal for practitioners and less like an idealistic, pseudo-goal for those aiming for sainthood. (shrink)

Experiences of moral distress encountered in psychiatric practice were explored in a hermeneutic phenomenological study. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychiatrists describe struggling ‘to do the right thing’ for individual patients within a societal system that places unrealistic demands on psychiatric expertise. Certainty on the part of the psychiatrist is an expectation when judgments of dangerousness and/or the need for coercive treatments are made. This assumption, however, ignores the uncertainty and (...) complexity of reality. Society entrusts psychiatrists to care for and treat those among its most vulnerable members: persons deemed to have a severely diminished capacity for autonomy due to a mental disorder. Simultaneously, psychiatrists are held accountable by society for the protection of the public. Moral distress arose for psychiatrists in their efforts to fulfill both roles. They described an ‘outsider/insider’ status and the ways in which they attempted to cope with moral distress. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common (...) themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

The majority of healthcare professionals regularly witness fragility, suffering, pain and death in their professional lives. Such experiences may increase the risk of burnout and compassion fatigue, especially if they are without self-awareness and a healthy work environment. Acquiring a deeper understanding of vulnerability inherent to their professional work will be of crucial importance to face these risks. From a relational ethics perspective, the role of the team is critical in the development of professional values which can help to cope (...) with the inherent vulnerability of healthcare professionals. The focus of this paper is the role of Communities of Practice as a source of resilience, since they can create a reflective space for recognising and sharing their experiences of vulnerability that arises as part of their work. This shared knowledge can be a source of strength while simultaneously increasing the confidence and resilience of the healthcare team. (shrink)

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children’s pain experiences, the relationships nurses share with children who are suffering, (...) and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end. (shrink)

Integrated developmental and elemental information in teeth provide a unique framework for documenting breastfeeding histories, physiological disruptions, and neurotoxicant exposure in humans and our primate relatives, including ancient hominins. Here we detail our method for detecting the consumption of mothers’ milk and exploring health history through the use of laser ablation‐inductively coupled plasma‐mass spectrometry (LA‐ICP‐MS) mapping of sectioned nonhuman primate teeth. Calcium‐normalized barium and lead concentrations in tooth enamel and dentine may reflect milk and formula consumption with minimal modification during (...) subsequent tooth mineralization, particularly in dentine. However, skeletal resorption during severe illness, and bioavailable metals in nonmilk foods, can complicate interpretations of nursing behavior. We show that explorations of the patterning of multiple elements may aid in the distinction of these important etiologies. Targeted studies of skeletal chemistry, gastrointestinal maturation, and the dietary bioavailability of metals are needed to optimize these unique records of human health and behavior. (shrink)

Building from J.L. Austin's concept of ‘performative,’ this essay explores the production of subjectivity and of educational subjects by applying important work from Judith Butler on Foucault, Derrida, and as centrally illustrative, through an analysis of sex and gender. Given this analytical framework, the turn is then to queer performativity and the possibility of performative power in pedagogy. The last draws assistance from Valerie Walkerdine, Homi Bhabha and especially James Donald.

Concerns over conflicts of interest in academic research and medical practice continue to provoke a great deal of discussion. What is most obvious in this discourse is that when COIs are declared, or perceived to exist in others, there is a focus on both the descriptive question of whether there is a COI and, subsequently, the normative question of whether it is good, bad or neutral. We contend, however, that in addition to the descriptive and normative, COI declarations and accusations (...) can be understood as performatives. In this article, we apply J.L. Austin’s performative speech-act theory to COI discourses and illustrate how this works using a contemporary case study of COI in biomedical publishing. We argue that using Austin’s theory of performative speech-acts serves to highlight the social arrangements and role of authorities in COI discourse and so provides a rich framework to examine declarations, accusations and judgements of COI that often arise in the context of biomedical research and practice. (shrink)

For this second edition, the editors have returned to Austin's original lecture notes, amending the printed text where it seemed necessary.

This book is the one to put into the hands of those who have been over-impressed by Austin 's critics....[Warnock's] brilliant editing puts everybody who is concerned with philosophical problems in his debt.

Informal political representation can be a political lifeline, particularly for oppressed and marginalized groups. Such representation can give these groups some say, however mediate, partial, and imperfect, in how things go for them. Coeval with the political goods such representation offers these groups are its particular dangers to them. Mindful of these dangers, skeptics challenge the practice for being, inter alia, unaccountable, unauthorized, inegalitarian, and oppressive. These challenges provide strong pro tanto reasons to think the practice morally impermissible. This paper (...) considers the question: On what conditions is the informal political representation of oppressed and marginalized groups permissible? By responding to skeptics’ challenges, I develop a systematic account of moral constraints that, if adopted, would make such representation permissible. The account that emerges shows that informal political representatives (IPRs) must aim to fulfill two sets of sometimes conflicting duties to the represented: democracy within duties, which concern how the representative treats and relates to the represented, and justice without duties, which concern how the representative’s actions advance the aims of the representation. (shrink)

Journal of Political Philosophy, Volume 29, Issue 4, Page 429-455, December 2021.

The landscape in which journalists now work is substantially different to that of the twentieth century. The rise of digital and social media necessitates a new way of considering the ethical questions facing practicing journalists. This volume considers the various individual, cultural and institutional influences that have an impact on journalistic ethics today. It also examines the links between ethics and professionalism, the organizational promotion of ethical values and the tensions between ethics, freedom of information and speech, and the need (...) to disseminate information. By comparing the theoretical underpinnings of journalistic ethics with a variety of international case studies, this volume provides a comparative global analysis of the ethical challenges faced by the media in the twenty-first century. It will be essential reading for students of journalism and practicing journalists. (shrink)

An underexamined insight of W. E. B. Du Bois’s John Brown is that John Brown worked for much of his life to cultivate democratic relationships with the Black Americans with and for whom he worked. Brown did so through practicing deference and deliberation, and by seeking authorization. However, Brown’s commitment to these practices faltered at a crucial moment in decision making: when he raided Harpers Ferry absent widespread support. Examining this aspect of John Brown brings into relief an overlooked tragic (...) choice Brown made: To act in accordance with his own substantive vision of what justice required, Brown eschewed democratic ideals and practices that grounded the distinctive relations of equality he had cultivated with the Black communities with and for whom he worked. (shrink)

As neuroscience methods begin to dominate emotion research it is critical for researchers to remember that peripheral embodiments are critical to understanding emotional experience and emotion—behavior links. Much of modern emotion research assumes reliable mind—body connections that suggest that changes in emotional states influence bodily responses and, vice versa, that somatovisceral information shapes emotional experiences. However, there may be important qualifications to the link between the mind and the (peripheral) body. For example, the ability to sense internal and external bodily (...) states declines in older age as does activation of physiological systems, all of which may contribute to an impairment in emotional experiences and how emotions influence behavior. I describe this phenomenon as maturational dualism and suggest implications of this for emotion in older adults. (shrink)

As artist-in-residence at the Zen Hospice Project Guest House, Wendy MacNaughton experienced firsthand how difficult it is to know what to do when we're sharing final moments with a loved one. In this tenderly illustrated guide to saying goodbye, with a foreword by renowned physician and author BJ Miller, MacNaughton shows how to make sure those moments are meaningful. Using a framework of "the five things" taught to her by a professional caregiver, How to Say Goodbye provides a model (...) for having conversations of love, respect, and closure: with the words "I forgive you," "Please forgive me," "Thank you," "I love you," and "Goodbye," each oriented toward finding mutual peace and understanding when it matters most. How to Say Goodbye features MacNaughton's drawn-from-life artwork from both the Zen Hospice Project Guest House and her own aunt's bedside as she died, each paired with hospice caregivers' gentle advice on creating a positive sensory experience, acknowledging what you can't control, and sharing memories and gratitude. A poignant guide to embracing the present and deepening relationships during great vulnerability, How to Say Goodbye shows that just as there is no one right way to live a good life, there is no one right way to say goodbye. Whether confused, scared, or uncertain, this book is a starting point. (shrink)

In this paper, I argue that considerations of epistemic bubbles can give us reason to defend censorship of hate speech. Although censoring hate speech leads to epistemic bubbles (‘censorship bubbles’), they tend to be less epistemically problematic than epistemic bubbles generated by the circulation of hate speech (‘hate bubbles’). Because hate speech silences its target groups and creates the illusion that the dominant group identities are threatened, hate bubbles are likely more restrictive in structure than censorship bubbles and have a (...) stronger tendency to turn into echo chambers where opposing views are actively discredited. Therefore, I argue that censorship bubbles might be a minor price we ought to pay to avoid hate bubbles. Additionally, my analysis shows that we cannot focus exclusively on the content or the structure of epistemic bubbles, since their content can partly determine their structure, as is in the case of hate bubbles. (shrink)

The underreporting of suspected adverse drug reactions hinders pharmacovigilance. Solutions to underreporting are oftentimes directed at clinicians and health care professionals. However, given the recent rise of public inclusion in medical science, solutions may soon begin more actively involving patients. I aim to offer an evaluative framework for future possible proposals that would engage patients with the aim of mitigating underreporting. The framework may also have value in evaluating current reporting practices. The offered framework is composed of three criteria that (...) are bioethical, social-epistemic, and pragmatic: (i) patients should not be exposed to undue harms, e.g., nocebo effects; (ii) data should be collected, analyzed, and communicated prioritizing pharmacovigilance’s aims, i.e., free from industry bias; and (iii) proposals should account for existing and foreseeable pragmatic constraints like clinician ‘buy in’ and existing reporting infrastructure. Proposals to engage patients in pharmacovigilance that fulfil or address these criteria are preferable to those that do not. (shrink)

First published in 1962, contains the William James Lectures delivered at Harvard University in 1955. It sets out Austin's conclusions in the field to which he directed his main efforts for at least the last ten years of his life. Starting from an exhaustive examination of his already well- known distinction of performative utterances from statements, Austin here finally abandons that distinction, replacing it by a more general theory of 'illocutionary forces' of utterances which has important bearings on (...) a wide variety of philosophical problems. (shrink)

From Booker T. Washington to a neighbor who speaks up at a city council meeting, many of the people who represent us were never elected. Wendy Salkin provides the first systematic analysis of the ubiquitous phenomenon of informal political representation, a practice of immense political value that raises serious ethical concerns.

Moral injury occurs when a person perpetrates, bears witness to, or fails to prevent an act that transgresses their deeply held moral beliefs. The deeply held moral belief that physicians share is the oath they take when completing their lengthy training and embarking on their career: Put the needs of patients first. In today's American healthcare system, doctors, nurses, and other healthcare providers are increasingly forced to consider the demands of other stakeholders -- insurers, hospitals, even their own financial security (...) -- before the needs of their patients. Whenever they are forced to make a decision that contravenes their patient's best interest, they feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury. Moral injury and its causes help explain why healthcare workers started leaving the field in droves long before the COVID-19 pandemic exposed weaknesses in the US system, why a rich country has such poor outcomes in certain categories, why there is a shortage of young doctors training for critical areas, and why patients feel so frustrated. In If I Betray These Words, Wendy Dean explores and exposes the impacts of moral injury through vividly told stories that are at once bewildering and eye-opening. Her book serves as a roadmap through a healthcare landscape that can be confounding, and at times even hellish, for those who must navigate it, and it suggest alternative routes for healers and their patients. (shrink)

Written by experienced practitioners this resource for Theory of Knowledge for the IB Diploma offers comprehensive coverage of and support for the new subject guide. Decoding Theory of Knowledge (ToK) is an accessible new resource that explores Areas of Knowledge, Ways of Knowing, Personal and Shared Knowledge, the Knowledge Framework and Knowledge Questions. Written in succinct and clear language, this engaging book decodes ToK concepts and helps students develop their critical thinking skills. The book offers extensive support on the new (...) assessment criteria for the essay and presentation. Features include explanation of key concepts to consolidate knowledge and understanding; real-life situations to engage students; practical activities to develop students' thinking, writing and presentation skills; and top tips to provide further guidance and advice. (shrink)

This book strives to highlight the conditions that have turned schools into places that induce stress on all levels for children and staff.