Inequitable access to health care, social inequities, and racist and discriminatory care has resulted in the trend toward poorer health outcomes for Indigenous infants and their families when compared to non‐Indigenous families in Canada. How Indigenous mothers experience care during an admission of their infant to the Neonatal Intensive Care Unit has implications for future health‐seeking behaviors which may influence infant health outcomes. Nurses are well positioned to promote positive health care interactions and improve (...) health outcomes by effectively meeting the needs of Indigenous families. This qualitative study was guided by interpretive description and the Two‐Eyed Seeing framework and aimed to understand how Indigenous mothers experience accessing and using the health care system for their infants. Data were collected by way of interviews and a discussion group with self‐identifying Indigenous mothers of infants less than two years of age living in Hamilton, Ontario, Canada. Data underwent thematic analysis, identifying nursing strategies to support positive health care interactions and promote the health and wellness of Indigenous infants and their families. Building relationships, providing holistic care, and taking a trauma‐informed approach to the involvement of child protection services are three key strategies that nurses can use to positively impact health care experiences for Indigenous families. (shrink)

Infectious disease outbreaks in residential care are complex to manage and difficult to control. Research in this setting that includes individuals who lack capacity must conform to national legislation. We report here on our study that is investigating outbreaks of scabies, an itchy skin infection, in the residential care setting in the southeast of England. There appears to be a gap in legislative advice regarding the inclusion of people who lack capacity in research that takes place during time-limited (...) acute scenarios such as outbreaks. We received inconsistent advice from experts regarding, in particular, the role of nominated consultees. There is a potential inequality for vulnerable populations who cannot themselves provide informed consent in terms of their access to participation in a range of health-related research. (shrink)

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like (...) TIC) is systematically sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

This ambitious book examines the notion of legal transparency from a unique cultural and historical perspective. Drawing from their combined academic and practical experience with both Chinese and Western legal traditions, authors John Head and Xing Lijuan explore how an intense debate — pitting legal transparency against legal opaqueness — unfolded in dynastic Chinese law, which began in the dark mists of history and ended formally just over a hundred years ago. They rely on a wide range of both (...) Western and Chinese sources to explain how that great debate was resolved in the early Han Dynasty (around the third century BCE) in a way that molded Chinese law into a sophisticated legal system that for roughly two millennia balanced definitiveness with vagueness, predictability with flexibility, and egalitarianism with privilege — and that reflected cultural values still resonating in China today. Legal Transparency in Dynastic China presents a clear narrative that assumes no prior expertise in Chinese law or history, and it caters to readers interested in issues of good governance, comparative studies, China, history, and law. The book begins by defining “legal transparency” and explaining where it fits into the larger context of the transparency-in-government movement that has gained such momentum in recent years, especially at the urging of Western powers. Then the book explains the fundamentally different values espoused by early Confucianists, for whom society is best governed not through written law but through the exemplary behavior of a highly educated, virtuous, and enlightened elite. After tracing the political and ideological challenges that the Confucianists faced from the Legalists, Head and Xing examine the compromise that resulted in the so-called “Confucianization of the Law” around 200 BCE. They then show how that alloy of competing ideologies characterized Chinese dynastic law for many centuries, resulting in what some would consider the most enduring and effective legal system in human history. (shrink)

We argue that multiple levels of trauma were present in Egypt before, during and after the 2011 revolution. Individual, social and political trauma constitute a triangle of traumatisation which was strategically employed by the Egyptian counter-revolutionary forces – primarily the army and the leadership of the Muslim Brotherhood – to maintain their political and economic power over and above the social, economic and political interests of others. Through the destruction of physical bodies, the fragmentation and polarisation of social (...) relations and the violent closure of the newly emerged political public sphere, these actors actively repressed the potential for creative and revolutionary transformation. To better understand this multi-layered notion of trauma, we turn to Habermas’ ‘colonisation of the lifeworld’ thesis which offers a critical lens through which to examine the wider political and economic structures and context in which trauma occurred as well as its effects on the personal, social and po... (shrink)

Migrant farmworkers dominate the horticultural workforce in many parts of the Minority (developed) World. The ‘manual’ work that they do—picking and packing fruits and vegetables, and pruning vines and trees—is widely designated unskilled. In policy, media, academic, activist and everyday discourses, hired farm work is framed as something anybody can do. We interrogate this notion with empirical evidence from the Sunraysia horticultural region of Australia. The region’s grape and almond farms depend heavily on migrant workers. By-and-large, the farmers and farmworkers (...) we spoke to pushed back against the unskilled tag. They asserted that farmworkers acquire knowledge and skills over time and that experienced farmworkers are valuable—their value being brought into sharp relief against accounts of inexperienced farmworkers’ errors. Our interviewees provided rich insights into farmworkers’ engagements with crops and the intricacies of picking and pruning well. Far from being bereft of knowledge and skills, they recognised that experienced farmworkers bring benefits. They improve productivity, product quality and ultimately profits. This is especially so when open communication channels exist across the farm hierarchy, when experienced farmworkers’ insights are taken seriously by their employers. Our research is informed by organisational studies literature and scholarship on craft/making. Like factory floor workers and artisans, experienced farmworkers bring accumulated knowledge and skills to their work, gained through repeat performance. They reflect on and adjust their activities in dialogue with their materials and the environment. Experienced farmworkers demonstrate care, dexterity and judgement. They are not unskilled, and they are more than labouring bodies. (shrink)

Having a premature or critically ill infant in a neonatal intensive care unit is a traumatic experience for parents that can alter their lives. Parents navigate complex emotions of fear, unc...

In lieu of an abstract, here is a brief excerpt of the content:Whisper Before You GoJohn K PettyDavid came with a bang.1A momentary prelude from a dysphonic chorus of pagers announce “Level 1 Pediatric Trauma—MVC ejected” before the abrupt crescendo of the trauma bay doors opening. He is maybe two. Maybe three–years–old. It is hard to tell when a child is strapped in, strapped down, nonverbal, intubated, and alone.The flight team speaks for him, “Four–year–old boy improperly restrained in (...) a single–vehicle crash into a ditch. He was partially ejected. He was unresponsive and pulseless at the scene. He got CPR and code drugs, and they got a pulse back. Emergency medical service (EMS) took him to the nearest hospital where they needled his chest, called for air transport, and scanned him up. He has been shocky for us since we picked him up. Glasgow Coma Scale (GCS) has been three the whole time. They said his head scan showed subarachnoid hemorrhage.”With the words of the flight team as background narrative, we get about doing our thing—hopefully more method and less madness. Bang, bang, bang! Check the tube. Vital signs. IV fluids. Place a chest tube. Hang the blood. Quick X–ray. Neuro exam—nothing. Get him off the board. Warm him up. Place the orogastric (OG) tube. Bang, bang, bang!The neurosurgery resident opens the CT scans from the other hospital. The brain and cervical spine scans show a disaster: some swelling and bleeding in the higher brain, but the worst damage is in the lower brain, brainstem, and top of the spinal cord. I have heard a neurosurgeon describe this pattern before as “internal decapitation.” Such language never makes it into the patient’s chart. For David the last two words of the neurosurgery consult note will eventually read, “Prognosis grim.”He remains unstable in the trauma bay. Inaction is death. We ultrasound his heart, abdomen, and pelvis. He has fluid that shouldn’t be around his heart. He is dying of the neuro injury we cannot control, but the pericardial fluid might be giving him shock, and we can control that. We can’t ignore the fluid. Shouldn’t ignore it. At least, wouldn’t ignore it. So, we bang up to the operating room. Squeezing blood. Spiking fluid. Oxygen tank and crash cart. Up we go.In the operating room, we do much and we do well. We release the fluid around the heart and find it was CPR, not heart injury that put it there. In the pericardial flash we get a view of the cardiac athlete, pounding like the 26th mile of the marathon. We explore the abdomen and find it swollen but innocent of an injury that would take his life. We place our lines and tubes as the neurosurgeons place theirs. If nothing else, we will be able to measure what lies ahead.“Good work, team,” and we bump the door on the way to the pediatric intensive care unit (PICU).The care in the PICU is more Apache brave than Gaelic knight—more bottles, fewer scissors. The curtains and carpets mute the tones. Our efforts continue, but I get a word that David’s father has arrived. He is sitting in a small, private waiting room off of the main PICU waiting room. The PICU staff colloquially refer to this as “the bad news room.” I take a seat next to a solitary man who is having the worst day of his life. His worst day so far.“I am Dr. Petty, and I am one of the doctors who is taking care of your son. I am very sorry about what has happened. Maybe you can tell me a little bit about what you understand is going on, and I’ll tell you what I know.” [End Page 17]He tells me that his wife was driving David back from her sister’s house, just the two of them. He doesn’t know what happened, but he got a call from the other hospital about the crash. His wife was badly hurt. He heard that David had died, but they got him back. Both were transferred up to the... (shrink)

Background:Moral distress is a significant concern for nurses as it can lead to burnout and intentions to leave the profession. Pediatric nurses encounter stressful and ethically challenging situations when they care for suspected victims of child maltreatment. Data on pediatric nurses’ moral distress are limited, as most research in this field has been done in adult inpatient and intensive care units.Aim:The purpose of this study was to describe pediatric nurses’ moral distress and evaluate the impact of caring (...) for suspected victims of child maltreatment on nurses’ moral distress, burnout, and intention to leave. Design and method: This descriptive cross-sectional correlational study was conducted in a mid-Atlantic, urban area Magnet pediatric level I trauma center that cares for over 1800 cases of suspected child maltreatment annually. An anonymous electronic survey was sent to all the nurses working at the hospital.Ethical considerations:Institutional Review Board approval was received from the first author’s university and the hospital where the study was conducted.Findings:Overall, nurses ( N = 146) reported low levels of moral distress with a mean score of 59.54 (SD = 49.22) and a range of 0–300 on the Moral Distress Scale Neonatal–Pediatric version. Although the frequency of caring for suspected child maltreatment victims did not affect nurses’ moral distress, caring for victims with fatal maltreatment contributed to nurses’ intention to leave, χ2(1) = 5.35, p = 0.02.Conclusion:The results of this study add to the understanding of moral distress in pediatric nursing. Caring for victims with fatal maltreatment impacts pediatric nurses’ intention to leave. (shrink)

Layers of complexity arise when a person arrives in an Intensive Care Unit (ICU) due to self-harm intended to end their life and when there is known past personal trauma. We highlight three importa...

Megan1 is a young teenage patient who suffered a stillbirth at 28 weeks, leading to a year long police investigation dropped only after postmortem tests found that her pregnancy was lost due to natural causes. The stress of the investigation and her isolation from friends and support network following the seizure of her mobile and laptop compounded the trauma of the stillbirth, leaving her requiring emergency psychiatric care. Aisha1 is a vulnerable patient who suffered a premature delivery, having (...) experienced similar problems in earlier pregnancies. Things happened so quickly that Aisha delivered on her own at home, only then seeking medical care. She told hospital staff that earlier in her pregnancy she had considered an abortion. As a result, she found herself interviewed under police caution and was required to surrender her phone and tablet, limiting access to friend and family support just when most needed. Aisha was denied unsupervised access to her baby in the intensive care unit, needing to hand over expressed breast milk to a receptionist. These stories, which were reported in a recent meeting in Parliament,1 are sadly far from unusual. They reflect the collateral damage of a growing trend towards more enthusiastic enforcement of the archaic abortion laws of England and Wales.2–5 In such cases, women who present with miscarriage, stillbirth or a premature delivery have aroused the suspicion of health professionals, sometimes because—like Aisha—they speak honestly about having considered abortion earlier in their pregnancies. They then find themselves reported to the police, required to surrender electronic devices and sometimes advised by duty solicitors to speak to no one about events leading to their investigation, thus being denied emotional and full clinical support at a time of significant trauma. These women are not the only victims of British abortion laws: so …. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Providing Care to a Potential Aggressor: An Ethical DilemmaHandreen Mohammed SaeedFollowing the abrupt fall of almost a third of its territory in 2014 to armed militias, Iraq fell into civil war turmoil. As a direct result of the armed conflicts, hundreds of thousands of Iraqis were displaced or subjected to atrocious human rights violations with physical, sexual, and psychosocial abuse. While the scenes on the TV provided only (...) a glimpse of what was happening on the ground, the true stories circulating about people’s suffering left me personally in absolute shock. Among those who suffered the most from the offences were marginalized religious and ethnic minority groups, who were viewed and treated as infidels by the aggressor militants. Those marginalized communities not only endured displacement due to the armed conflicts but they were also mass-exterminated, sexually abused, and underwent massive destruction of their towns and villages.In 2016, I was working for Ministry of Health as a primary care physician in a small town in Iraqi Kurdistan, which hosted tens of thousands of internally displaced people (IDPs) from one of those marginalized minority communities. I had the opportunity to hear their tragic stories firsthand as they fled for their lives in 2014. Working in those communities as a primary care physician allowed me to truly understand their feelings and emotions and reflect on their experiences while providing healthcare services. This experience sparked an interest in humanitarian work, in which I could be close to areas of need and involved in providing physical health first-aid and also psychological and social first-aid; all crucial in addressing the future health consequences experienced by people going through humanitarian crises. In the same year, 2016, I joined an international medical organization and started working in remote and low-resource settings in northern Iraq as a humanitarian physician. Our projects included a variety of primary care, psychosocial, and urgent care services targeting refugees, IDPs, and vulnerable host communities in areas near conflict zones. The projects were designed and implemented with the hope that the most vulnerable populations have access to our services.In October 2016, the Iraqi authorities launched a massive military operation known as the “Battle of Mosul” to regain control of Mosul, the second-largest city in Iraq. As an emergency medical humanitarian organization, we had to be near the battlefield and respond to the unfolding humanitarian crisis on a daily basis. As the official security forces backed by the international alliance started to advance, tens of thousands of people, including some militants and their families, fled Mosul and headed towards areas controlled by the Kurdistan Regional Government’s forces in the north, where our organization was operational. Some of them sought refuge in one of our medical facilities in northern Iraq, which was operated by local staff, [End Page 172] including members from some of the minority communities that had suffered the most from the militants’ aggression in 2014. The patients entering our facilities were mainly older adults, women, and children, but we were also visited by a small group of potential militants who were either injured, malnourished, or just seeking help and refuge. As a neutral, impartial, independent, humanitarian organization compliant with medical ethics, we were committed to providing healthcare services to anybody in need without discrimination or judgment.As we responded to the humanitarian crisis unfolding before our eyes, some of our staff members came forward and raised valid questions about the ethics of treating patients potentially involved in serious human rights violations. With tears in her eyes, one nurse approached me and stated, “Seeing these people reminds me of all the girls and women who went missing from my village and are now being sold as sex slaves in Syria”. The staff expressed serious concerns about their ability to provide care to patients who may have been involved in mass killing, torture, and the destruction of their own towns, as well as sexual abuse against their family members, friends, and people in their communities. Due to the psychological and physical trauma caused by the militants’ conquest, the staff was reluctant to provide medical care to these patients, as seeing and hearing them brought back... (shrink)

Two pediatric accidents in Jane Austen’s Persuasion and one in Margaret Oliphant’s The Doctor’s Family are examined from the point of view of trauma management with analysis of contributing risk factors, medical management, concerns of parents and bystanders, and course of recovery. Risk factors for injury are impulsivity, poor supervision, and parents who are unable to set limits. Medical attention is swift and competent, but no heroic measures are used; the management of the injuries, concussion with loss of consciousness (...) and dislocation of the collar bone, is consistent with the way these conditions are, for the most part, still managed today, and successful recovery depends on careful nursing and rest. Louisa Musgrove, who suffers a severe head injury, requires ten weeks of convalescence and undergoes a marked personality change, which we might today attribute in part to post-concussion syndrome but which may reflect contemporary debate about the biological basis of personality and behavior. A sudden traumatic injury to a child or adolescent changes the narrative abruptly, in fiction or in life, dividing a story into before and after, introducing grief and anxiety, and requiring that plans be rethought and personal relationships reshuffled with decisions about caretaking and nursing. (shrink)

Background:Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses’ sources of distress is important when planning interventions to support them.Purpose:To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic.Design:Qualitative descriptive component within a larger mixed-methods study.Participants and research context:Participants were invited to write down their experiences of a critical incident, which distressed them (...) when providing nursing care. Thematic analysis was used to analyze the data.Ethical considerations:The study was approved by the ethics committee at the researchers’ university in eastern Canada.Results:A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families’ grief, (3) our safety, and (4) futility of care. Many nurses’ stories also focused on the organizational preparedness of their institutions and concerns over their own safety.Discussion:Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed.Conclusion:Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses’ well-being. (shrink)

Coronavirus disease 2019 (COVID‐19) has placed significant strain on United States’ health care and health care providers. While most Americans were sheltering in place, nurses headed to work. Many lacked adequate personal protective equipment (PPE), increasing the risk of becoming infected or infecting others. Some health care organizations were not transparent with their nurses; many nurses were gagged from speaking up about the conditions in their workplaces. This study used a descriptive phenomenological design to describe the lived (...) experience of acute care nurses working with limited access to PPE during the COVID‐19 pandemic. Unstructured interviews were conducted with 28 acute care nurses via telephone, WebEx, and Zoom. Data were analyzed using thematic analysis. The major theme, emotional roller coaster, describes the varied intense emotions the nurses experienced during the early weeks of the pandemic, encompassing eight subthemes: scared and afraid, sense of isolation, anger, betrayal, overwhelmed and exhausted, grief, helpless and at a loss, and denial. Other themes include: self‐care, ‘hoping for the best’, ‘nurses are not invincible’, and ‘I feel lucky’. The high levels of stress and mental assault resulting from the COVID‐19 crisis call for early stress assessment of nurses and provision of psychological intervention to mitigate lasting psychological trauma. (shrink)

BackgroundResuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit, meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people regarding resource allocation decisions in the NICU.MethodsThe study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. (...) There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.ResultsThe majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival, life expectancy, and cost of treatment. In the classic ‘lifeboat’ scenario, all but two respondents were utilitarian.ConclusionsThis survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment. (shrink)

Background Moral distress has negative effects on physical and mental health. However, there is little information about nurses’ coping strategies reducing moral distress. Aim The purpose of this study was to investigate the coping strategies of intensive care unit nurses reducing moral distress in Iran. Study design This is a qualitative study with a content analysis approach. Participants and research context The research sample consisted of nurses working in intensive care units of teaching hospitals affiliated to (...) Tehran University of Medical Sciences. Samples were selected among eligible nurses by purposive sampling. Data were obtained through 17 in-depth, individual, and semi-structured interviews with 17 nurses. Graneheim and Lundman’s (2004) 6-step content analysis method was used to analyze the data. Data management was also performed by MAXQDA software version 20. The COREQ checklist was used to report the study. Ethical considerations This project was approved by the Ethics Committee of Tehran University of Medical Sciences. All ethical guidelines in research were followed. Finding The data analysis resulted in the formation of two main categories of desirable coping strategies (with two subcategories of compensation and rejuvenation) and less desirable coping strategies (with three subclasses of indifference over time, escape and concealment). Discussion The intensive care unit nurses in dealing with ethical problems first try to solve the problem through discussion, but when they fail to resolve it peacefully, they resort to several coping strategies. Factors, such as increasing experience, lack of support from hospital managers and officials, poor communication between colleagues, the need to maintain hierarchy, fear of reprimand, and a sense of powerlessness, changed the nurses’ preferred strategies. It is important for managers to provide a blame/punishment-free atmosphere for expression of ethical experiences; a supportive atmosphere in which staff can engage in ethical discussions without fear of punishment. They should also provide opportunities for rest, rejuvenation, and adequate training for their employees. (shrink)

Suffering repeated experiences of moral distress in intensive care units due to applications of futility reflects on nurses’ patient care negatively, increases their burnout, and reduces their job satisfaction. This study was carried out to investigate the levels of job satisfaction and exhaustion suffered by intensive care nurses and the relationship between them through the futility dimension of the issue. The study included 138 intensive care nurses. The data were obtained with the futility (...) questionnaire developed by the researchers, Maslach Burnout Inventory and Minnesota Satisfaction Questionnaire. It was determined that nurses who agreed to the proposition that the application of futility demoralizes health-care professionals had low levels of job satisfaction but high levels of depersonalization. It was determined that nurses had moderate levels of job satisfaction, emotional exhaustion, and personal achievements but high levels of sensitivity. Nurses’ job satisfaction and sensitivities are positively affected when they consider that futility does not contradict the purposes of medicine. (shrink)

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the (...) types of moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses’ moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care. (shrink)

The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies (...) is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented. (shrink)

After the death of Prophet Muhammad (p.b.u.h), one of the most significant debated topics of Muslims was the institution of caliphate. This institution caused crucial argumentations through the ages from Abu Bakr to Abd-al-Majid who was the hundreth khalifa. Some prominent issues in that regard as follows: How khalifa comes to power, who becomes khalifa, whether he is descended from Quraysh or not, which kind of traits khalifa should have, and how khalifa should behave in certain circumstances. While these arguments (...) were going on, caliphate was maintained based on the reign under some certain dynasties’ responsibilities after the Rashidun (rightly guided) Caliphs. Umayyads, Abbasids and Ottoman Dynasties were the most well-known ones of these dynasties. Throughout history, even though caliphate passed in one another’s hands among aforementioned dynasties, none of them did attempt to abolish this position. However, Turkish Muslims who became defeated with European occupation of non-western territories decided to abolish caliphate for the sake of modernization activities within the period of transition from imperialism to nation state. This decision brought about a trauma, which was much more critical than former argumentation around the position in Muslim world. Many congresses were organized in Islamic world in order to recover from this trauma. While this kind of quests were continuing, Muhammad Hamīdullah proposed “High Caliphate Council” in relation to rearrangement of caliphate in accordance with the conditions of Islamic countries. This proposal offers an applicable model to today’s modern nation states by establishing unity among them and leaving aside their conflicts and differences. This proposal offers a resolution of much-discussed matters of the position within the limits of principals. It also draws attention by showing a possibility of Islamic union in contemporary Islamic thought. Summary: The matters of who undertakes the management of societies, how rulers come to power and in what manners the rulers maintain the management have been discussed throughout history. It is seen that rulers adopted kingdom as regime before the period of the Prophet Muhammad (p.b.u.h). There was also two-person management. The discussions about this matter were also seen around khalifas who were the rulers of Muslims after the death of Prophet Muhammad (p.b.u.h). Some debated issues in that regards as follows: Who becomes khalifa, how he is elected, which traits he should possess, and so on. Caliphate continued its existence despite the discussions until the first quarter of the 14th Hijra era. Abolition of caliphate was a trauma for Muslims undoubtedly. From Anatolia to Egypt and from India to the Balkans, many attempts were carried out to recover from this trauma. However, this matter was oversimplified in the conditions of that period since it became a topic which was hushed over in just congresses and conventions. One of the people who wrote on this topic, which maintains its vitality even today was Muhammad Hamīdullah. He was an important Islamic scholar, a lawyer and a historian in Indian geography. Hamīdullah did deal caliphate by indicating its history broadly. The distinctive feature of Hamīdullah from others who wrote on this topic is that he also presented a considerable offer to solve the matter. In this sense, Hamīdullah experienced the trauma in his own life as all muslims did it with the abolition of caliphate. Hence he mentioned this matter in his writings in the mood of care and dignity of a scientist and also in feeling of a heartbroken muslim. Hamīdullah made clear that the method of election of the ruler differed throughout history. Indeed, the verses of Holy Qur’ān, the applications of the Prophet Muhammad (p.b.u.h) and the differences of Four Great Chaliphs on coming to power testified this claim. According to Hamīdullah, it is quite normal that the method of regime can vary according to the conditions of societies. He recommended acting based on timeless rules rather than the changes that vary according to conditions and places. He also stated that the regime which Islam approves is a combination of kingdom and democracy in his lines dealing with methods of regime. To him, kingdom is the method of regime of empire. Empire is the regime in which various nationalities live together with all their differences and interact with one another intensely and in which the rulers rule over wide borders. On the other hand, Islamic world lost its edges of empire, changed its regime and divided to nation states after the decline of the Ottoman Empire and Mughal Empire which were established by Muslims. On the contrary, westerners attempted to establish a head empire several times after building nation states in Europe. Some of them are UN, NATO, EU, to name but a few. In our opinion, in the transition process of Muslim rulers from empire to nation state, Hamīdullah made an offer to accomodate Islamic law in state law, Islamic politic and administrative principles in politics and administration practices, Islamic education system in education system, and principles of Islamic economics in economic decisions of government using the Prophet Muhammed’s life as a base. He also explained to Muslims that the method of regime can be changed and the essential matter is to apply Islamic management principles in such a new situation. He played a role in clearing the way for Muslims by indicating that the method of Islamic regime can be changed according to conditions but the principles of Islam are unalterable. To the writer of these lines, Hamīdullah intimates that it is not so true to stick to the form of the process in Muslim territories in which a compulsory transition from the empires or multinational social structures to the nation state structures have been experienced for the last two ages. However, the first matter to dwell on should be whether the ruler of the government behaves in accoradance with the principles of Islam or not. To Hamīdullah, the second matter is that even though Muslim countries had to enter in the process of becoming nation states, Muslims should make an effort to establish supra-state associations as required by Islam. In this respect, Hamīdullah’s proposal is “High Caliphate Council”. This council is a considerable offer presented to Muslim countries in the age when a universal caliphate is not possible and Muslims head towards a unified state form all over the world. Today, this offer recommends countries of which great majority is Muslims and in which Muslims are minority to meet on a common ground rather than conflict because of differences among them. The High Caliphate Council is an institute consists of presidents or hereditary administrators as leading and regular members and so it avoids regional competition. It is established by Muslim presidents who shares the chair alternately. Based on this, all Muslim presidents play a role altogether in this council without need to be Sunni, Shia, or from Quraysh. The High Caliphate Council is a reflection of a dream, which started a century and half a century ago but is required more today. It is also a reflection of the discourse of “Islamic Union” in Contemporary Islamic Thought. The Caliphate Council and International Islamic Legists’ Association, which is the first practical step of the council can be seen as the theory of a new world order based on the unity principle of Islam. Hamīdullah does not consider this order not only in the range of belief but also with the aim of institutionalizing ‘ijmā (consensus of Islamic legists) and qiyās(legal analogy). He stated that International Islamic Legists’ Association, which is a scientific institution could not be established beforetime by Muslims spread on three continents due to lacking of communication among them. However, thanks to today’s possibilities, the establishment of such association is easier today. Hamīdullah found dynamic solutions such these two institutions for the realization of caliphate, which is a religious necessity. He marked an era for Muslims in the period of time when they are on a quest. (shrink)

Significant scientific and technological advances in intensive care have been made. However, patients in the intensive care unit may experience discomfort, loss of control, and surreal experiences. This has generated relevant debates about how to humanize the intensive care units and whether humanization is necessary at all. This paper aimed to explore how humanizing intensive care is described in the literature. A scoping review was performed. Studies published between 01.01.1999 and 02.03.2020 were (...) identified in the CINAHL, Embase, PubMed, and Scopus databases. After removing 185 duplicates, 363 papers were screened by title and abstract. Full-text screening of 116 papers led to the inclusion of 68 papers in the review based on the inclusion criteria; these papers mentioned humanizing or dehumanizing intensive care in the title or abstract. Humanizing care was defined as holistic care, as a general attitude of professionals toward patients and relatives and an organizational ideal encompassing all subjects of the healthcare system. Technology was considered an integral component of intensive care that must be balanced with caring for the patient as a whole and autonomous person. This holistic view of patients and relatives could ameliorate the negative effects of technology. There were geographical differences and the large number of studies from Spain and Brazil reflect the growing interest in humanizing intensive care in these particular countries. In conclusion, a more holistic approach with a greater emphasis on the individual patient, relatives, and social context is the foundation for humanizing intensive care, as reflected in the attitudes of nurses and other healthcare professionals. Demands for mastering technology may dominate nurses’ attention toward patients and relatives; therefore, humanized intensive care requires a holistic attitude from health professionals and organizations toward patients and relatives. Healthcare organizations, society, and regulatory frameworks demanding humanized intensive care may enforce humanized intensive care. (shrink)

Intensive care units are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients (...) who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care. (shrink)

Background Moral distress is a serious problem for health care personnel. Surveys, individual interviews, and focus groups may not capture all of the effects of, and responses to, moral distress. Therefore, we used a new participatory action research approach—moral conflict assessment (MCA)—to characterize moral distress and to facilitate the development of interventions for this problem. Aim To characterize moral distress by analyzing responses of intensive care unit (ICU) personnel who participated in the MCA process. Research Design In (...) this qualitative study, we invited all ICU personnel at 3 urban hospitals to participate in individual or group sessions using the 8-step MCA tool. These sessions were facilitated by either a clinical ethicist or a counseling psychologist who was trained in this process. During each session, one of the researchers took notes and prepared a report for each MCA which were analyzed using qualitative content analysis. Participants and Research Context A total of 24 participants took part in 15 sessions, individually or in groups; 14 were nurses and nurse leaders, 2 were physicians, and 8 were other health professionals. Ethical Considerations This study was approved by the Providence Health Care/University of British Columbia Behavioural Research Ethics Board. Each participant provided written informed consent. Results The main causes of moral distress related to goals of care, communication, teamwork, respect for patient’s preferences, and the managerial system. Suggested solutions included communication strategies and educational activities for health care providers, patients, family members, and others about teamwork, advance directives, and end-of-life care. Participants acknowledged that using the MCA process helped them to reflect on their own thoughts and use their moral agency to turn a distressing situation into a learning and improvement opportunity. Conclusions Using the MCA tool helped participants to characterize their moral distress in a systematic way, and to arrive at new potential solutions. (shrink)

Background Patient dignity is sometimes neglected in intensive care unit (ICU) settings, which may potentially cause psychological harm to critically ill patients. However, no instrument has been specifically developed to evaluate the behaviors of dignified care among critical care nurses. Aim This study aimed to develop and evaluate ICU Dignified Care Questionnaire (IDCQ) for measurement of self-assessed dignity-conserving behaviors of critical care nurses during care. Methods The instrument was developed in 3 phases. Phase (...) 1: item generation; phase 2: a two-round Delphi survey and a readability pilot study; phase 3: cross-sectional survey with model estimation. The questionnaire was evaluated by item analysis, exploratory and confirmatory factor analysis, assessment of internal consistency reliability, and test-retest reliability. The investigation was conducted using a convenience sample of 392 critical care nurses from 6 cities in Zhejiang Province, China, of which 30 participated in the test-retest reliability survey 2 weeks later. Ethical considerations The study was approved by ethics committee. All participants provided written informed consent before the survey. The questionnaire survey was anonymous. Results The results showed acceptable reliability and validity of the IDCQ. The 17-item final version questionnaire was divided into 2 dimensions: absolute dignity and relative dignity. These two factors accounted for 62.804% of the total variance, and model fitting results were acceptable. The Cronbach’s alpha coefficient of the questionnaire was 0.94, and the test-retest intraclass correlation coefficient (ICC) was 0.88 after 2 weeks. Conclusions This study developed a brief and reliable instrument (IDCQ) to assess dignified care in ICU nursing. It can help critical care nurses identify their behaviors in maintaining patient dignity and discover their deficiencies. It may also serve as a clinical nursing management tool to help reduce patient disrespect experience in ICU. (shrink)

This study was conducted to gain opinions about euthanasia from nurses who work in intensive care units. The research was planned as a descriptive study and conducted with 186 nurses who worked in intensive care units in a university hospital, a public hospital, and a private not-for-profit hospital in Adana, Turkey, and who agreed to complete a questionnaire. Euthanasia is not legal in Turkey. One third (33.9%) of the nurses supported the legalization of euthanasia, whereas 39.8% (...) did not. In some specific circumstances, 44.1% of the nurses thought that euthanasia was being practiced in our country. The most significant finding was that these Turkish intensive care unit nurses did not overwhelmingly support the legalization of euthanasia. Those who did support it were inclined to agree with passive rather than active euthanasia (P = 0.011). (shrink)

In this article, we report findings from a qualitative study that explored how the relatives of intensive care unit patients experienced the nurses’ role and relationship with them in the end-of-life decision-making processes. In all, 27 relatives of 21 deceased patients were interviewed about their experiences in this challenging ethical issue. The findings reveal that despite bedside experiences of care, compassion and comfort, the nurses were perceived as vague and evasive in their communication, and the relatives missed (...) a long-term perspective in the dialogue. Few experienced that nurses participated in meetings with doctors and relatives. The ethical consequences imply increased loneliness and uncertainty, and the experience that the relatives themselves have the responsibility of obtaining information and understanding their role in the decision-making process. The relatives therefore felt that the nurses could have been more involved in the process. (shrink)

Not only is deception commonplace in medical encounters, according to Christopher Meyers (2021), but the clinical ethicist might have moral obligations to support and even enact deception. Descriptively Meyers is right that there are “opportunistic, self-interested and benevolent reasons” for deception through omission and commission in clinical medicine. But it is possible to retain this premise while rejecting the normative conclusion that the clinical ethicist “should sometimes be an active participant in the deception of patients and families.” One reason to (...) reject the normative conclusion is its incompatibility with providing trauma informed ethics consultation (TIEC). In the TIEC framework I developed with Uchenna Anani, we defend the integration of trauma informed care (TIC) into ethics consultation (Lanphier and Anani 2021). While ethicists narrowly attend to the question and scope of the ethics consults made to them, doing so in alignment with trauma informed principles is tantamount to providing good ethics consultation. According to Meyers, the clinical ethicist is an “advocate for the best ethical choices.” The best ethical choices are also trauma informed ones. (shrink)

Caring for a child in a pediatric intensive care unit is emotionally and physically challenging and often leads to conflict. Skilled mediators may not always be available to aid in conflict resolution. Careproviders at all levels of training are responsible for managing difficult conversations with families and can often prevent escalation of conflict. Bioethics mediators have acknowledged the important contribution of mediation training in improving clinicians’ skills in conflict management. Familiarizing careproviders with basic mediation techniques is an important (...) step towards preventing escalation of conflict. While training in effective communication is crucial, a sense of fairness and justice that may only come with the introduction of a skilled, neutral third party is equally important. For intense conflict, we advocate for early recognition, comfort, and preparedness through training of clinicians in de-escalation and optimal communication, along with the use of more formally trained third-party mediators, as required. (shrink)

Background:Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress (...) suffered by nurses nor a study conducted on the issue.Aim/objective:The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level.Method:The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale–Revised.Ethical considerations:The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.Results:In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.Conclusion:Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care. (shrink)

Background:Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress (...) suffered by nurses nor a study conducted on the issue.Aim/objective:The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level.Method:The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale–Revised.Ethical considerations:The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.Results:In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.Conclusion:Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care. (shrink)

This research aims to identify the ethical issues perceived by intensive care nurses in their everyday practice. It also aims to understand why these situations were considered an ethical issue and what interventions/strategies have been or are expected to be developed so as to minimize them. Data were collected using a semi-structured interview with 15 nurses working at polyvalent intensive care units in 4 Portuguese hospitals, who were selected by the homogenization of multiple samples. The qualitative (...) content analysis identified end-of-life decisions, privacy, interaction, team work, and health-care access as emerging ethical issues. Personal, team, and institutional aspects emerge as reasons behind the experience of these issues. Personal and team resources are used in and for solving these issues. Moral development and training are the most significant strategies. (shrink)

It had to happen. After two full decades of intense energy, business ethicists and business practitioners may actually have succeeded in suppressing the feeblest joke of the profession: “Business Ethics. Isn’t that an oxymoron?” Har har har.In the early days of business ethics, the oxymoron had actual embodiments. “Business” was represented by hard-nosed, thicks-kinnedmanagers with no inclination to adopt academia’s language and critiques. “Ethics” was embodied by ivory-towered theoreticians with an undisguised contempt for profit makers. What a joke to think (...) of these two groups as conceptually productive partners. (shrink)

It had to happen. After two full decades of intense energy, business ethicists and business practitioners may actually have succeeded in suppressing the feeblest joke of the profession: “Business Ethics. Isn’t that an oxymoron?” Har har har.In the early days of business ethics, the oxymoron had actual embodiments. “Business” was represented by hard-nosed, thicks-kinnedmanagers with no inclination to adopt academia’s language and critiques. “Ethics” was embodied by ivory-towered theoreticians with an undisguised contempt for profit makers. What a joke to think (...) of these two groups as conceptually productive partners. (shrink)

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

Background:Maintaining patient’s dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units.Objectives:The aim of this study was to uncover the cultural factors that impeded maintaining patients’ dignity in the cardiac surgery intensive care unit.Research Design:The study was conducted using a critical ethnographic method proposed by Carspecken.Participants and research context:Participants included all physicians, nurses and staffs working in the study setting. Data collection methods included participant (...) observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace.Ethical Consideration:Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained.Findings:The findings of the study fell into the following main themes: “Presence: the guarantee for giving enough attention to patients’ self-esteem”, “Instrumental and objectified attitudes”, “Adherence to the human equality principle: value-action gap”, “Paternalistic conduct”, “Improper language”, and “Non-interactive communication”. The final assertion was “Reductionism as a major barrier to the maintaining of patient’s dignity”.Discussion:The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches.Conclusion:Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships. (shrink)

BackgroundThe need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive (...) during their ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion.MethodsWe conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research.ResultsFive main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers.ConclusionsTo capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. (shrink)

Despite its invasive nature, specific consent for general anaesthesia is rarely sought—rather consent processes for associated procedures include explanation of risk/benefits. In adult intensive care, because no one can consent to treatments provided to incapacitated adults, standardised consent processes have not developed. In paediatric intensive care, despite the ready availability of those who can provide consent, no tradition of seeking it exists, arguably due to the specialty’s evolution from anaesthesia and adult intensive care. With (...) the current Montgomery-related focus on consent, this seems untenable. We undertook a qualitative study in a specialist children’s hospital colocated paediatric/neonatal intensive care (same medical team) in which parental acceptance of admission and entailed procedures is considered implied by virtue of that admission. Semistructured interviews were carried out with both staff and parents to investigate their views about consent, the current system and a proposedblanket consent system, in which parents actively consent at admission to routine procedures. Divergent views emerged: staff were worried that requiring consent at admission might prove a further emotional burden, whereas parents found providing consent a way of coping, feeling empowered and maintaining control. Inconsistencies were found in the way consent is obtained for your routine procedures. Practice does seem inconsistent with contemporary consent standards for medical intervention. Our findings support the introduction of a blanket consent system at admission together with ongoing bedside dialogue to ensure continuing consent. Both parents and staff expressed concern about avoiding possible harmful delays to children due to parental emotional overload and language difficulties. (shrink)

The ethics of treating the seriously and critically ill have not been static throughout the ages. Twentieth century medicine has inherited from the nineteenth century a science which places an inappropriate weight on diagnosis over prognosis and management, combined with a seventeenth century duty to prolong life. However other earlier ethical traditions, both Hippocratic and Christian, respected both the limitations of medicine and emphasised the importance of prognosis. This paper outlines some of the historical precedents for the treatment of the (...) critically ill, and also how the current paradigm limits clinical practice and causes ethical tensions. An understanding that other paradigms have been ethically acceptable in the past allows wider consideration and acceptance of alternatives for the future. However future alternatives will also have to address the role of technology, given its importance in this area of medicine. (shrink)

Margalit filosofeert in zijn essay over de vraag of er een ethiek van de herinnering bestaat. Hij onderscheidt daarbij een aantal vragen, zoals: zijn we verplicht ons mensen en gebeurtenissen uit het verleden te herinneren, en zo ja, wat is de aard van die verplichting, en wie zijn die 'wij'?

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying (...) process. Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)