The Liverpool Care Pathway for the Dying Patient (LCP) was an integrated care pathway for patients in the final days or hours of life, developed at the Royal Liverpool University Hospital in conjunction with the Marie Curie Palliative Care Institute, Liverpool. The LCP became increasingly the normative style of care for patients in the terminal stage across NHS England from the 1990s onwards. Following significant questions raised in Parliament, by the media and other stakeholders, an independent (...) review panel was established under Baroness Neuberger in 2013 to investigate the LCP. The findings of the panel were published as More Care Less Pathway: a Review of the Liverpool Care Pathway identifying significant failings in the delivery of the LCP thus leading to it being phased out some six months later. Rather than being euthanasia through the backdoor, many of the criticisms of the LCP and its poor implementation are indicative of poor communication, limited knowledge of the dying process and a paucity of death education. (shrink)

Background The Liverpool Care Pathway is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing (...) homes and for dying people with dementia. Methods This systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science. Results The search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available. Conclusion LCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia. (shrink)

BackgroundThe Liverpool Care Pathway is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes (...) and for dying people with dementia.MethodsThis systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science.ResultsThe search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available.ConclusionLCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia. (shrink)

The Liverpool Care Pathway is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes (...) and for dying people with dementia. This systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science. The search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available. LCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia. (shrink)

The Liverpool Care Pathway is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes (...) and for dying people with dementia. This systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science. The search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available. LCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia. (shrink)

The Liverpool Care Pathway for the Dying has recently been the topic of substantial media interest and also been subject to the independent Neuberger Review. This review has identified clear failings in some areas of care and recommended the Liverpool Care Pathway be phased out. I argue that while the evidence gathered of poor incidences of practice by the Review is of genuine concern for end of life care, the inferences drawn from this evidence are inconsistent (...) with the causes for the concern. Seeking to end an approach that is widely seen as best practice and which can genuinely deliver high quality care because of negative impressions that have been formed from failing to implement it properly is not a good basis for radically overhauling our approach to end of life care. I conclude that improvements in training, communication, and ethical decision-making, without the added demand to end the Liverpool Care Pathway would have resulted in a genuine advance in end of life care. (shrink)

Can a competent individual refuse care in order to make their natural death reasonably foreseeable in order to qualify for medical assistance in dying (MAiD)? Consider a competent patient with left-side paralysis following a right brain stroke who is not expected to die for many years; normally his cause of death would not be predictable. However, he refuses regular turning, so his physician can predict that pressure ulcers will develop, leading to infection for which he will refuse treatment and (...) consequently die. Is he now eligible for MAiD? Consider a competent patient with spinal stenosis (a non-fatal condition) who refuses food (but not liquids in order not to lose capacity from dehydration). Consequently, her physician can predict death from starvation. Is she now eligible for MAiD? Answering these questions requires that we answer three sub-questions: 1) do competent patients have the right to refuse care?; 2) do healthcare providers have a duty to respect such refusals?; and 3) are deaths resulting from refusals of care natural for the purposes of determining whether a patient is eligible for MAiD? If a competent patient has the right to refuse some particular care, and healthcare providers have a duty to respect that refusal, and if the death that would result from the refusal of that care is natural, then that refusal of care is a legal pathway to MAiD. However, if the competent patient does not have the right to refuse some particular care, or if healthcare providers do not have a duty to respect that refusal, or if the death that would result from the refusal of that care is not natural, then that refusal of care is not a legal pathway to MAiD. In this paper, we explore this complex legal terrain with the most profound of ethical implications – access to MAiD. (shrink)

Though largely a theoretical endeavour, environmental ethics also has a practical agenda to help humans achieve environmental sustainability. Environmental ethicists have extensively debated the grounds, contents and implications of our moral obligations to nonhuman nature, offering up different notions of an 'environmental ethic' with the presumption that, if humans adopt such an environmental ethic, they will then engage in less environmentally damaging behaviours. We assess this presumption, drawing on psychological research to discuss whether or under what conditions an environmental ethic (...) might engender pro-environmental behaviour. We focus discussion on three lines of scholarship in the environmental ethics literature, on 1) intrinsic value, 2) care ethics, and 3) the land ethic. We conclude by commenting generally on both the limits and transformative potential of an environmental ethic in its larger sociocultural context. (shrink)

Though largely a theoretical endeavour, environmental ethics also has a practical agenda to help humans achieve environmental sustainability. Environmental ethicists have extensively debated the grounds, contents and implications of our moral obligations to nonhuman nature, offering up different notions of an 'environmental ethic' with the presumption that, if humans adopt such an environmental ethic, they will then engage in less environmentally damaging behaviours. We assess this presumption, drawing on psychological research to discuss whether or under what conditions an environmental ethic (...) might engender pro-environmental behaviour. We focus discussion on three lines of scholarship in the environmental ethics literature, on 1) intrinsic value, 2) care ethics, and 3) the land ethic. We conclude by commenting generally on both the limits and transformative potential of an environmental ethic in its larger sociocultural context. (shrink)

Pathways in Philosophy is a unique introductory text that features both a historical and a topical approach to the central problems in the field--questions regarding existence, knowledge, and moral and political value. Organized into two parts, "Metaphysics and Epistemology" and "Ethics and Political Philosophy," the text addresses these problems by providing a guided tour through ten classic philosophical readings. Offering detailed critical commentary, Jacquette carefully explains and analyzes seminal works by Plato, Aristotle, Ockham, Descartes, Berkeley, Kant, Mill, Nietzsche, Moore, (...) and Rawls. He applies the "pathways" metaphor to the various intersecting and overlapping lines of thought represented by this selection of authors, drawing surprising connections between their ideas. This approach enables students to appreciate the relationships between what may otherwise appear to be disparate strands of thought in great works of philosophy and in different traditions of philosophical thought. By following the historical and philosophical narrative in each chapter, students learn how to interpret and critically evaluate difficult philosophical writings in their historical contexts--how to identify concepts, questions, definitions, arguments, and major components of philosophical reasoning in a systematic way. Offering a combination of historical coverage and rigorous critical evaluation, Pathways in Philosophy is ideal for courses in introductory philosophy. The text is enhanced by study questions, key terms, and suggested readings at the end of each chapter, as well as a glossary at the end of the book. (shrink)

This book, the first of its kind, offers a comprehensive introduction to the philosophy and practice of Zen Buddhism. It is written by an academic philosopher who, for more than a dozen years, practiced Zen in Japan while studying in universities with contemporary heirs of the Kyoto School. The book lucidly explicates the philosophical implications of Zen teachings and kōans, and critically compares Zen with other Asian as well as Western religions and philosophies. It carefully explains the original context and (...) sense of traditional Zen teachings and practices, and compellingly applies them to our twenty-first century lives. In addition to explaining the practice of Zen meditation, its twenty-four chapters treat perennial philosophical topics such as the self, nature, art, morality, language, peace, and death, as well as basic Buddhist teachings such as the four noble truths, the middle way, the no-self and true self doctrines, karma, mind and no-mind, rebirth, Nirvana, and the various meanings of the term “Buddha.” The chapters frequently engage Zen in interreligious dialogue with Christianity and with other religions and schools of Buddhism. The Zen inspired modern philosophies of the Kyoto School are introduced in one chapter and frequently referenced throughout the book. The concluding chapter reviews the entire path of Zen practice and enlightenment with an in-depth commentary on the beloved Zen classic, The Ten Oxherding Pictures. The book can be read in its entirety as a coherently organized introduction to the philosophy and practice of Zen, or chapters can be read independently according to the reader’s specific interests. While based on decades of scholarly study as well as practice and teaching, it is written in an accessible and engaging style. It is designed to be read by college students and lifelong learners as well as scholars and practitioners of the world’s great philosophical and spiritual traditions. (shrink)

The persistence of multiple educational pathways into the nursing profession continues to occupy scholars internationally. In the Netherlands, various groups within the Dutch healthcare sector have tried to differentiate nursing practice on the basis of educational backgrounds for over 50 years. Proponents argue that such reforms are needed to retain bachelor‐trained nurses, improve quality of care and strengthen nurses' position in the sector. Opponents have actively resisted reforms because they would mainly benefit bachelor‐trained nurses and neglect practical experience (...) and technical skills. This historical case study aims to provide insight in this apparent stalemate. Our analysis of this debate is informed by literature on institutional work and current debates within the historiography of nursing. This study contributes to a better understanding of this contemporary debate by examining a broader timeframe than is usually studied, and by highlighting nurses' roles in complex processes of change. We argue that, rather than being stuck in their professional development, different groups of nurses have forged their own path forward in their professional development, albeit via different strategies. (shrink)

In our recent article, together with more than 60 of our colleagues, we outlined a proposal for drug policy reform consisting of four specific yet interrelated strategies: (1) de jure decriminalization of all psychoactive substances currently deemed illicit for personal use or possession (so-called “recreational” drugs), accompanied by harm reduction policies and initiatives akin to the Portugal model; (2) expunging criminal convictions for nonviolent offenses pertaining to the use or possession of small quantities of such drugs (and releasing those serving (...) time for these offenses), while delivering retroactive ameliorative relief; (3) the ultimate legalization and careful regulation of currently illicit drugs; and (4) the delivery of a new “Marshall Plan” focused on community-building initiatives, expanded harm reduction programs, and social and health care support efforts (Earp et al. 2021). We were gratified to see so many thoughtful commentaries on our proposal, and we respond to them in part in this reply. (shrink)

Combining classical and contemporary readings with original essays, Pathways to Philosophy offers an imaginative introduction to the art of philosophical reflection and wonderment. The collection reflects the inherent multidisciplinary nature of the field - revealing and exploring the connections between philosophy, science, and literature. All material is carefully chosen, edited, and coordinated to ensure its accessibility to readers of all levels. The result is a presentation that is engaging, provocative, and fun. There are four main sections divided into twelve (...) chapters held together by a common thread: analysis and exploration of concepts and dimensions of the Self. The readings cover Eastern as well as Western traditions, and include selections by both women and men. In the process, it provides coverage of a number of topics which, though important, are often omitted from introductory texts. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Zen Pathways: An Introduction to the Philosophy and Practice of Zen Buddhism (禅道の千路) by Bret W. Davis (review)Steve G. LoftsBret W. Davis, Zen Pathways: An Introduction to the Philosophy and Practice of Zen Buddhism (禅道の千路)There is no shortage of books on Zen from almost every imaginable angle. And so, what makes Zen Pathways: An Introduction to the Philosophy and Practice of Zen Buddhism (禅道の千路) by Bret (...) W. Davis unique enough to take up and read, and even re-read? And who should read it? The answers to these questions depend on who you are and what you are looking for. If you are simply curious about what Zen philosophy and practice is or is not, a student, a professor looking for a textbook on Zen Buddhism for your course, or a practitioner seeking to deepen your understanding of what it is that you are practicing, then you will almost certainly enjoy and profit greatly from this book. Davis brings to the page over thirty years of active engagement with Zen Buddhism as a practitioner, teacher of philosophy and Zen Buddhism, and scholar. Davis provides his reader with an accessible, comprehensive, and well-documented introduction to the teachings and practices of Zen Buddhism. What makes this introduction stand out and be particularly effective is that Davis provides us with a scholarly and philosophical account of Zen Buddhism that is animated by his personal experience as a long-term practitioner in Japan at the Rinzai Zen monastery of Shōkokuji and as a teacher and director of the Heart of Zen Meditation Group at Loyola University Maryland. However, as the Japanese subtitle of this work, 禅道の千路, makes clear, there are “a thousand paths of the way of Zen,” and Davis is careful to show us the paths he has traveled while leaving it to the reader to find their own paths along the way.In the course of the book’s twenty-four chapters, Davis provides his reader with a clear account and philosophical interpretation of [End Page 159] the core teachings of Buddhism (the four noble truths, impermanence, the no-self doctrine, co-origination and interconnection of the one and the many, nirvana and samsara, the great death, and so on), always relating his theoretical explanations to the concrete perspective of the practice of Zen Buddhism. His account of Zen Buddhism situates it in the historical tradition of Buddhism as it was transplanted from India to China, from China to Japan, and today from Japan to other places in the world. Davis connects these teachings to the practice of Zen, providing readers with a concrete and firsthand introduction to such Zen practices as zazen (seated meditation), kinhin (walking meditation), sanzen (interviews with a teacher), koān work, and samu (meditative work), and to the Zen practice of cultivating naturalness (jinen) in and through such art forms as karate and flower arrangement (ikebana), the Japanese aesthetics of “cut-continuance” and wabi-sabi, as well as Zen-inspired gardens, painting, and music. The book also explores a number of classical and contemporary philosophical issues from the standpoint of Zen Buddhism: the problem of the one and the many, the ethical relation to the other, the problem of evil, the nature of love, freedom and determinacy, what is God, our relation to nature, and so on. Finally, the presentation of the core teachings of Zen Buddhism and the discussion of philosophical issues is undertaken in and through an intercultural and interreligious dialogue in which the similarities and dissimilarities between different cultural and faith traditions are explored and used to help illustrate the unique standpoint of Zen Buddhism. One can mention here Chapter 12 titled “Dying to Live: Zen, Pure Land Buddhism, and Christianity.” This synoptic view of Zen Buddhism is presented in an elegant, personal style that is clear, concise, and expresses a genuine passion and spirit of openness. In copious endnotes, Davis has also provided the reader with a wealth of material for further study that has been judiciously selected from good English translations of readings in the classical works as well as contemporary scholarship. Finally, with an eye to the use of this text in a classroom or in study groups, Davis has... (shrink)

Career transitions in psychiatry have rarely been discussed openly. Yet, in the light of health care reform and other forces affecting clinical practice, it is more important than ever that psychiatrists have information about the career options within their specialty. _Career Pathways in Psychiatry: Transition in Changing Times_ serves that purpose. It explores the professional development and career choices of prominent American psychiatrists, each of whom is identified with a particular career track and many of whom have themselves (...) experienced one or more career transitions. The autobiographical accounts of the contributors survey a wide range of career pathways in psychiatry, including clinical practice, HMO practice, research, administration, entrepreneurism, psychoanalysis, organized medicine, the pharmaceutical industry, public psychiatry, occupational psychiatry, forensic psychiatry, and military psychiatry. These accounts are as engaging as they are informative; their anecdotal nature and conversational tone make for pleasurable reading. References at the end of each chapter serve as recommended reading for those who wish to learn more about specific career options. Intended for psychiatric residents and psychiatrists early in their careers, _Career Pathways in Psychiatry_ will also appeal to their more experienced colleagues, including seasoned clinicians who have contemplated career changes. With a preface summarizing research on career transitions in medicine and numerous chapters shedding light on factors contributing to resistance to change, this book will also be of interest to social scientists, mental health administrators, and professional recruiters. (shrink)

Career transitions in psychiatry have rarely been discussed openly. Yet, in the light of health care reform and other forces affecting clinical practice, it is more important than ever that psychiatrists have information about the career options within their specialty. _Career Pathways in Psychiatry: Transition in Changing Times_ serves that purpose. It explores the professional development and career choices of prominent American psychiatrists, each of whom is identified with a particular career track and many of whom have themselves (...) experienced one or more career transitions. The autobiographical accounts of the contributors survey a wide range of career pathways in psychiatry, including clinical practice, HMO practice, research, administration, entrepreneurism, psychoanalysis, organized medicine, the pharmaceutical industry, public psychiatry, occupational psychiatry, forensic psychiatry, and military psychiatry. These accounts are as engaging as they are informative; their anecdotal nature and conversational tone make for pleasurable reading. References at the end of each chapter serve as recommended reading for those who wish to learn more about specific career options. Intended for psychiatric residents and psychiatrists early in their careers, _Career Pathways in Psychiatry_ will also appeal to their more experienced colleagues, including seasoned clinicians who have contemplated career changes. With a preface summarizing research on career transitions in medicine and numerous chapters shedding light on factors contributing to resistance to change, this book will also be of interest to social scientists, mental health administrators, and professional recruiters. (shrink)

This commentary provides a legal analysis of the extent to which changes proposed by scholars to promote care for substance use disorder or other under-treated illnesses through risk adjustment could be implemented administratively, without legislation, in federal risk adjustment systems: Medicare's privatized component, Medicare's pharmaceutical component, and the individual and small group market. As the article explains, federal laws governing risk adjustment provide broad discretion to regulators and can reasonably be interpreted to permit full and final implementation through the (...) administrative process of almost all of the changes that scholars have proposed. (shrink)

In their paper, Romanis and Adkins delve into the potential impact of artificial amnion and placenta technology (AAPT) on cases of pregnancy loss1 that do not involve procreative loss. First, they call for more recognition of the negative feelings a person might have due to the premature end of their pregnant state. They claim that, should AAPT minimise concerns about prematurity as anticipated, individuals might feel pressured to opt for partial ectogestation to preserve their or their fetus’ well-being; moreover, they (...) point out that the feelings of loss in the context of AAPT are likely to be worse than the ones reported in neonatal intensive care units cases. Finally, they advocate for care pathways focusing on how the transfer of a fetus to the AAPT could affect the pregnant person, with particular attention to managing the grief potentially caused by the pregnancy loss. I praise the authors for such a call to action—especially since partial ectogestation is expected to become a reality in the short-term future—and I share their demands for additional and more attentive care of (formerly) pregnant patients. However, I am concerned that their approach is so focused on negative feelings towards pregnancy loss that it risks becoming …. (shrink)

The Notch proteins play a vital role in cell fate decisions in both invertebrate and vertebrate development. Careful analysis of this role has led to a model of signalling downstream of these receptors, via the CSL (CBF1, Suppressor of Hairless, Lag-1) family of transcription factors. There have been suggestions, however, that Notch can signal through other pathways. In the current paper, Ramain et al.1 provide compelling evidence for Notch signalling through a CSL-independent pathway and they demonstrate that the cytoplasmic (...) protein, Deltex, is required for this signal. In addition, they show that Wnt signalling may regulate this Deltex-dependent signal. (shrink)

Adults who are incapacitated and alone, having no surrogates, may be known as “unbefriended.” Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for “public guardianship” or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on (...) the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: work to restore capacity; find previously unknown surrogates; work with agencies to obtain surrogates; and access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient’s values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population. (shrink)

Stigmatization of patients exists in nursing and results in less than optimal nursing care and poor patient outcomes. It is also a violation of our code of ethics. In order to eliminate stigmatization from nursing practice, it is necessary to understand how it develops. Two possible theoretical pathways are proposed to explain the development of stigmatization in nursing. These pathways are informed by a conceptual understanding of stigma and theories of professional socialization, professional formation, symbolic interactionism, and (...) social cognitive theory. Re‐labeling and role‐taking and moral disengagement are proposed as two possible processes that may lead to stigmatization of patients. Both proposed pathways have implications on professional socialization, formation, and the development of professional identity. Devoting attention to and reframing normative behavioral expectations, eliminating labeling, developing empathy, focusing on relationships, and cultivating ethical comportment and moral maturity during nursing formation may reduce the stigmatization of patients by nurses. (shrink)

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan (...) Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors. (shrink)

A couple and their five‐year‐old daughter are in a car accident. The parents are not expected to survive. The child is transported to a children's hospital, and urgent treatment decisions must be made. Whom should the attending physician approach to make decisions for the child? When such cases arise in, for example, the hospitals where we work, the social worker or chaplain is instructed to use the Illinois Health Care Surrogacy Act as a guidepost to identify a decision‐maker. But (...) in our state and the country overall, the limitations of such statutes leave hospital workers to make a judgment call among friends, family, and clergy who may come forward. While surrogate decision‐making statutes comprehensively address surrogate decision‐makers for adults, a patchwork of laws—permanency statutes, kinship provider statutes, standby guardianship statutes, and, in some cases, surrogate decision‐making statutes—provide variable decision‐making pathways for children. (shrink)

The increasing use of pharmacotherapy raises specific ethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primary care providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacological care and are differentially vulnerable to deleterious outcomes associated with misdiagnosis (...) and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental health care. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitable care across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy. (shrink)

Adults who are incapacitated and alone, having no surrogates, may be known as “unbefriended.” Decision-making for these particularly vulnerable patients is a common and vexing concern for healthcare providers and hospital ethics committees. When all other avenues for resolving the need for surrogate decision-making fail, patients who are incapacitated and alone may be referred for “public guardianship” or guardianship of last resort. While an appropriate mechanism in theory, these programs are often under-staffed and under-funded, laying the consequences of inadequacies on (...) the healthcare system and the patient him or herself. We describe a qualitative study of professionals spanning clinical, court, and agency settings about the mechanisms for resolving surrogate consent for these patients and problems therein within the state of Massachusetts. Interviews found that all participants encountered adults who are incapacitated and without surrogates. Four approaches for addressing surrogate needs were: work to restore capacity; find previously unknown surrogates; work with agencies to obtain surrogates; and access the guardianship system. The use of guardianship was associated with procedural challenges and ethical concerns including delays in care, short term gains for long term costs, inabilities to meet a patient’s values and preferences, conflicts of interest, and ethical discomfort among interviewees. Findings are discussed in the context of resources to restore capacity, identify previously unknown surrogates, and establish improved surrogate mechanisms for this vulnerable population. (shrink)

In this article, we discuss how we used institutional ethnography (Institutional ethnography as practice, Rowman & Littlefield, Lanham, MD and 2006) to map out powerful ruling relations that organize nurses’ wound care work. In recent years, the growing number of people living with wounds that heal slowly or not at all has presented substantial challenges for those managing the demands on Canada's publicly insured health‐care system. In efforts to address this burden, Canadian health‐care administrators and policy‐makers rely (...) on scientific evidence about how wounds heal and what treatments are most effective. Advanced wound care exemplifies the growing authorization of particular forms of evidence that change the ways in which nurses come to know about and conduct their work. The focus of this paper's nursing inquiry is a critique of registered nurses’ wound work as it arises within the established uptake of scientific evidence. (shrink)

BackgroundCaregivers may play a fundamental role in the clinical pathway of cancer patients. They provide emotional, informational, and functional support as well as practical assistance, and they might help mediate the interaction and communication with the oncologists when care options are discussed, or decisions are made. Little is known about the impact of dyadic dynamics on patient-doctor communication, patient's satisfaction, or adherence to the therapies. This study protocol aims to evaluate the efficacy of a psychological support intervention on patients-caregivers (...) relationship and their alignment in the treatment decision-making process and estimate related improvement in patient' compliance/adherence to treatments.MethodsA total of 102 patients-caregivers' dyads will be involved, among breast and prostate cancer patients. The study entails a pre- post- evaluation through psychological questionnaires, with a randomization of participants in two conditions, the experimental one in which subjects participate in a psychological support consultation, and the control one, where dyads do not receive any intervention. A follow up after 6 months from the enrollment is planned.DiscussionA positive impact of the psychological support intervention on patients' anxiety, depression, distress, and perceived social support is expected. Such improvements can directly affect patients' satisfaction and adherence to treatments. Data gathered from this study may inform health care providers, policy makers, and public health managers about the importance of caregiver's involvement in the cancer care pathway, and the best way to manage it. A further impact is to develop a specific intervention protocol to support caregivers' involvement in cancer care pathway, improve patient's wellbeing, the interaction with physicians and the compliance with the cancer treatment. (shrink)

While the effects of COVID-19 are being felt globally, the pandemic disproportionately affects lower- and middle-income countries (LMICs) by exacerbating existing global health disparities. In this article, we illustrate how intersecting upstream social determinants of global health form a disparity pathway that compromises LMICs’ ability to respond to the pandemic. We consider pre-existing disease burden and baseline susceptibility, limited disease prevention resources, and unequal access to basic and specialized health care, essential drugs, and clinical trials. Recognizing that ongoing and (...) underlying disparity issues will require long-term correction efforts, this pathway approach is nonetheless helpful to inform ethical responses to this global pandemic. It can facilitate international cooperation during the pandemic to reduce the disparate burdens among different regions without imposing significant burden on any particular contributor. The pathway approach allows international stakeholders in various social positions to respond to different components of the pathway based on their respective strengths and resources to help break the cycle of global health inequity. Guided by the ethical principles of relational and pragmatic solidarity, we argue for a coordinated global division of labor such that different stakeholders can collaborate to foster equitable healthcare access during this pandemic. (shrink)

In this paper, we explore how the prospect of artificial placenta technology (nearing clinical trials in human subjects) should encourage further consideration of the loss experienced by individuals when their pregnancy ends unexpectedly. Discussions of pregnancy loss are intertwined with procreative loss, whereby the gestated entity has died when the pregnancy ends. However, we demonstrate how pregnancy loss can and does exist separate to procreative loss in circumstances where the gestated entity survives the premature ending of the pregnancy. In outlining (...) the value that can be attached to pregnancy beyond fetal-centric narratives, we illustrate how pregnancy loss, separate to procreative loss, can be experienced. This loss has already been recognised among parents who have experienced an unexpected early ending of their pregnancy, resulting in their child being cared for in neonatal intensive care unit. Artificial placentas, however, may exacerbate these feelings and make pregnancy loss (without procreative loss) more visible. We argue that pregnancy is an embodied state in which gestation is facilitated by the body but gestation itself should be recognised as a process—and one that could be separable from pregnancy. In demarcating the two, we explore the different ways in which pregnancy loss can be understood. Our objective in this paper goes beyond contributing to our philosophical understanding of pregnancy towards practical-orientated conclusions regarding the care pathways surrounding the artificial placenta. We make recommendations including the need for counselling and careful consideration of the language used when an artificial placenta is used. (shrink)

Artificial intelligence has dramatically changed the way organizations communicate, understand, and interact with their potential consumers. In the context of this trend, the ethical considerations of advertising when applying AI should be the core question for marketers. This paper discusses six dominant algorithmic purchase decision pathways that align with ethical philosophies for online customers when buying a product/goods. The six ethical positions include: ethical egoism, deontology, relativist, utilitarianism, virtue ethics, and ethics of care. Furthermore, this paper launches an (...) “intelligent advertising” AI theme by examining its present and future as well as identifying the key phases of intelligent advertising. Several research questions are offered to guide future research on intelligent advertising to benefit ethical AI decision-making. Finally, several areas that can be widely applied to ethical intelligent advertising are suggested for future research. (shrink)

Following the Second Summit on Human Gene Editing in Hong Kong in 2018, where the birth of two girls with germline genome editing was revealed, the need for a responsible pathway to the clinical application of human germline genome editing has been repeatedly emphasised. This paper aims to contribute to the ongoing discussion on research ethics issues in germline genome editing by exploring key issues related to the initial applications of CRISPR in reproductive medicine. Following an overview of the current (...) discussion on bringing germline genome editing into clinical practice, we outline the specific challenges associated with such interventions and the features that distinguish them from conventional clinical testing of new medical treatments. We then review proposed ethical requirements for initial heritable genome editing, such as the absence of reasonable alternatives, the existence of sufficient and reliable preclinical data, appropriate informed consent, requirements related to safety, and long-term follow-up. (shrink)

Meaningful work is a key element of positive functioning of employees, but what makes work meaningful? Based on research on self-determination theory, basic psychological needs, and prosocial impact, we suggest that there are four psychological satisfactions that substantially influence work meaningfulness across cultures: autonomy (sense of volition), competence (sense of efficacy), relatedness (sense of caring relationships), and beneficence (sense of making a positive contribution). We test the relationships between these satisfactions and perceived meaningful work in Finland (n = 594, employees (...) of several organizations), India (n = 342, collected through Mturk), and the USA (n = 373, collected through Mturk). Regression analyses show that – except for competence in USA – all four satisfactions are significantly and independently associated with meaningful work. Moreover, structural equation modeling shows that they fully mediated the relationship between occupational position and work meaningfulness in India and in the USA. In sum, the results support the importance of these four satisfactions in explaining the psychological underpinnings of meaningful work. (shrink)

Criticisms of the traditional clinical research pathway and its extensive oversight often focus on proposals for deregulation or assert that as in clinical treatment, clinical research should always offer benefit to patient-subjects. Proponents of medical innovation take a different, middle path, arguing that innovation is distinguishable from both research and treatment. This article considers this third pathway by examining stem cell-based innovation.Stem cell-based medical innovation is one pathway toward clinical translation. In fact, such an approach was taken in developing umbilical (...) cord blood transplantation, which is now widely viewed as a safe and effective means for treating a range of malignant and non-malignant conditions. While the Guidelines for the Clinical Translation of Stem Cells created by the International Society for Clinical Research provide an approach to clinical translation that involves “responsible innovation” as an alternative to clinical research, there are at least four sets of unanswered questions regarding the use of an innovation pathway in this context that warrant careful attention. (shrink)

Growing evidence suggests the presence of a female leadership advantage (FLA), such that women leaders tend to be associated with more effective outcomes in uncertain conditions. However, mechanisms linking women's leadership to effective outcomes are less well understood. We integrate FLA insights with ethics of care philosophical framework to conceptualize how women leaders achieve effective outcomes in the context of the urban revitalization crisis in the United States. We propose and empirically test the mediating role of ethics of (...) class='Hi'>care leadership in the relationship between women mayors and economic health of their cities. We used data from the Urban Institute that includes 272 United States cities and measures of variables in our conceptual model at five points in time spanning 36 years (_n_ = 1185 city-year observations). We capture ethics of care leadership focused on racial inclusion with an index measure of a city’s racial spatial segregation, homeownership gap, poverty gap, and education gap, and we capture economic health with an index measure of a city’s employment growth, unemployment rate, housing vacancy rate, and median family income. We found that female-led cities were associated with better economic health, and this association was mediated by female-led cities’ association with greater racial inclusion. Ethics of care leadership appears to be one pathway through which a FLA manifests itself in the context of the urban revitalization crisis. This underscores the importance of city leadership that balances social and economic prerogatives. Implications are discussed. (shrink)

The main aim of this paper is to explore and discuss the interesting juxtaposition of patient involvement within a standardised Enhanced Recovery After Surgery care programme (ERAS). We address our aim by examining the work and strategies of nursing staff caring for patients during postoperative recovery from surgery, exploring how these two potentially competing priorities might effectively co‐exist within a hospital ward. This was a qualitative exploratory study, with data generated through 42 semi‐structured interviews with patients and nurses who (...) had taken part in an ERAS programme in one of three hospital wards in the United Kingdom, adopting a reflexive thematic approach to data analysis. We shine a light on the work undertaken by patients and nurses during the navigation of postoperative recovery, identifying strategies of collaboration and negotiation during this journey. Furthermore, we also identify and consider patients engaged in peer‐peer support during postoperative recovery. This paper adds to the existing literature and current ways of thinking in relation to the quest for standardised, clinically effective care balanced with the aspirations for individualised, patient‐centred care. This paper also helps inform thinking about the use of care pathways in relation to service delivery, considering how best to initiate and deploy best practice aimed at safe and effective postoperative recovery. (shrink)