_Rhetoric_ is the sixth volume in The New Hackett Aristotle series, a series featuring translations, with Introductions and Notes, by C. D. C. Reeve, Delta Kappa Epsilon Distinguished Professor of Philosophy at The University of North Carolina at Chapel Hill. The series will eventually include all of Aristotle's works.

Little is known about the consequences of moral distress. The purpose of this study was to identify clinical situations that caused nurses to experience moral distress, to understand the consequences of those situations, and to determine whether nurses would change their practice based on their experiences. The investigation used a descriptive approach. Open-ended surveys were distributed to a convenience sample of 204 critical care nurses employed at a university medical center. The analysis of participants’ responses used an inductive approach and (...) a thematic analysis. Each line of the data was reviewed and coded, and the codes were collapsed into themes. Methodological rigor was established. Forty-nine nurses responded to the survey. The majority of nurses had experienced moral distress, and the majority of situations that caused nurses to experience moral distress were related to end of life. The nurses described negative consequences for themselves, patients, and families. (shrink)

In this commentary on a clinical ethics case pertaining to a same-sex couple that does not have explicit surrogate decision-making or hospital-visitation rights (in the face of objections from the family-of-origin of one of the queer partners), the authors invoke contemporary legal and policy standards on LGBTQ health care in the United States and abroad. Given this historical moment in which some clinical rights are guaranteed for LGBTQ families whilst others are in transition, the authors advocate for the implementation of (...) clinical ethics mediation as the soundest and most humane form of resolution in matters where there is a dispute between family members about an incapacitated loved one. They argue that clinical ethics mediation is an ideal alternative solution because it works toward consensus about outcome, even where consensus about values is not achievable. (shrink)

The article by Professor Fiester (2015) expresses concern about the long-term moral distress or negative moral emotions, both aspects of moral residue, that linger in some stakeholders’ experiences...

In a previously published multicenter, prospective, randomized, controlled trial of more than 500 intensive care unit patients involved in conflicts over treatment decisions, ethics consultations were found to be helpful in resolving the conflicts and reducing nonbeneficial treatments. The intervention received favorable reviews by 80% of patient surrogates and more than 90% of physicians and nurses. Nevertheless, several participants in the ethics consultation process expressed dissatisfactions with the intervention. In this paper, we report our efforts to determine the factors associated (...) with these negative responses in hopes that we might provide insights of future use to ethics consultants. (shrink)

Autumn Fiester's “Neglected Ends: Clinical Ethics Consultation and the Prospects for Closure” (2015) demonstrates how a focus on recommendations in clinical ethics consultations (CECs) can fail to...

Autumn Fiester (2015) argues that when an ethics consult simply issues a recommendation it may leave a vacuum then filled by moral distress or moral emotion. “Assisted conversation”—a dialogue-focu...

This commentary shows how philosophical counseling offers an alternative way for consultants to facilitate "closure" in bioethical disputes.

This paper will examine the concepts of integrity and moral residue as they relate to nursing practice in the current health care environment. I will begin with my definition and conception of ethical practice, and, based on that, will go on to argue for the importance of recognizing that nurses often find themselves in the position of compromising their moral integrity in order to maintain their self‐survival in the hospital or health care environment. I will argue that moral integrity is (...) necessary to a moral life, and is relational in nature. When integrity is threatened, the result is moral distress, moral residue, and in some cases, abandonment of the profession. The solution will require more than teaching bioethics to nursing students and nurses. It will require changes in the health care environment, organizational culture and the education of nurses, with an emphasis on building a moral community as an environment in which to practise ethically. (shrink)

An ethics consultant’s scope of practice is best understood as equipping stakeholders to achieve closure over time following after the ethics consultation. This is in contrast to Autumn Fiester’s position in the article, “Neglected Ends: Clinical Ethics Consultation and the Prospects for Closure,” where she claims that moral closure is a necessary condition for the proper completion of an ethics consultation case.

Neutrality is held to be the touchstone of good mediation. True neutrality is elusive, however, and probably not even desirable, at least when applied to patient‐provider disputes over medical care. In this context, mediators should not posture as “neutrals”; they should strive instead to protect their clients’ autonomy.

Context: Although ethics consultation is commonplace in United States (U.S.) hospitals, descriptive data about this health service are lacking. Objective: To describe the prevalence, practitioners, and processes of ethics consultation in U.S. hospitals. Design: A 56-item phone or questionnaire survey of the "best informant" within each hospital. Participants: Random sample of 600 U.S. general hospitals, stratified by bed size. Results: The response rate was 87.4%. Ethics consultation services (ECSs) were found in 81% of all general hospitals in the U.S., and (...) in 100% of hospitals with more than 400 beds. The median number of consults performed by ECSs in the year prior to survey was 3. Most individuals performing ethics consultation were physicians (34%), nurses (31%), social workers (11%), or chaplains (10%). Only 41% had formal supervised training in ethics consultation. Consultation practices varied widely both within and between ECSs. For example, 65% of ECSs always made recommendations, whereas 6% never did. These findings highlight a need to clarify standards for ethics consultation practices. (shrink)

Clinical ethics consultations are sometimes deemed complete at the moment when the consultants make a recommendation. In CECs that involve actual ethical conflict, this view of a consult's endpoint runs the risk of overemphasizing the conflict's resolution at the expense of the consult's process, which can have deleterious effects on the various parties in the conflict. This overly narrow focus on reaching a decision or recommendation in consults that involve profound moral disagreement can result in two types of adverse, lingering (...) sequelae: moral distress or negative moral emotions. The problem, succinctly named, is that such consults have insufficient “closure” for patients, families, and providers. To promote closure, and avoid the ills of moral distress and the moral emotions, I argue that CECs need to prioritize assisted conversation between the different stakeholders in these conflicts, what is often referred to as “bioethics mediation.”. (shrink)

The American Journal of Bioethics, Volume 12, Issue 8, Page 10-11, August 2012.

In their systematic review of the work of the ASBH Core Competencies Update Task Force, Anita Tarzian and ASBH Core Competencies Update Task Force (2013) write, “The ethics facilitation approach do...

As groups around the country begin to craft standards for clinical ethics consultations, one focus of that work is the proper procedure for conducting ethics consults. From a recent empirical look into the workings of ethics consult services (ECSs), one worrisome finding is that some ECSs rely on a committee vote when making a recommendation. This article examines the practice of voting and its moral standing as a procedural strategy for arriving at a clinical ethics recommendation. I focus here on (...) the type of clinical ethics conflicts that are most likely to lead an ECS to vote, namely, conflicts involving ethical uncertainty—or, in the Greek, aporia. I argue that in cases of aporia, voting on an ethics conflict is not a morally justifiable procedure. Then on the same grounds that I use to show that voting is ethically problematic, I raise broader concerns about the common practice of making recommendations by other procedures. In contrast to the standard approach of adjudicating between moral claims, I argue that ECSs can best resolve aporetic conflict through the process of clinical ethics mediation. (shrink)

In “Surmounting Elusive Barriers: The Case for Bioethics Mediation,” Bergman argues that professionals trained in bioethics, reluctant to acquire the skills of mediation, would better be replaced by a cadre of mediators with some bioethics knowledge, to which I respond, “yes … but.”.

Recently, bioethics has become interested in engaging with narrative, but in this engagement, narrative is usually viewed as a mere helpmate to philosophy. In this precis to his book The Fiction of Bioethics, Tod Chambers argues that narrative theory should not be simply a helpful addition to medical ethics but instead should be thought of as being as vital and important to the discipline as moral theory itself. The reason we need to rethink the relationship of medical ethics to narrative (...) is that ethicists test their ideas by applying them to cases, and cases are a narrative genre. Recognizing the importance that cases have for the way medical ethicists do ethics is essential in order to appreciate the field as a form of applied philosophy. Like other forms of representation, narrative has distinct and defining features, which ethicists, in order to understand the data of their field, must learn to recognize and differentiate. Ethicists need to attend to the way decisions about the discourse of a narrative influences the kind of moral theories judged relevant to it. The author briefly examines six features of narrative discourse that rhetorically condition the way we understand medical ethics cases: filter, reportability, closure, characters, chronotope, and gender. (shrink)

While many have suggested that to withdraw medical interventions is ethically equivalent to withholding them, the moral complexity of actually withdrawing life supportive interventions from a patient cannot be ignored. Utilizing interplay between expository and narrative styles, and drawing upon our experiences with patients, families, nurses, and physicians when life supports have been withdrawn, we explore the changeable character of boundaries in end-of-life situations. We consider ways in which boundaries imply differences – for example, between cognition and performance – and (...) how the encounter with boundaries can generate altered meanings important for understanding decisions and actions in these contexts. We conclude that the reliance on mere roles to support the moral weight of withdrawing medical interventions is inadequate. Roles that lead us to such moments are exceeded by the responsibility encountered in such moments. And here, we suggest, is the momentous character of withdrawal: it presents the grave astonishment, the trembling awe, in the not-being-there of the other in death. (shrink)

This article describes, analyzes, and advocates for management of clinical healthcare conflict by a process commonly referred to as bioethics mediation. Section I provides a brief introduction to classical mediation outside the realm of clinical healthcare. Section II highlights certain distinguishing characteristics of bioethics mediation. Section III chronicles the history of bioethics mediation and references a number of seminal writings on the subject. Finally, Section IV analyzes barriers that have, thus far, limited the widespread implementation of bioethics mediation.