In previous literature, ethicists mention several goals of Clinical Ethics Support (CES). It is unknown what key persons in healthcare institutions see as main–—and sub-goals of CES. This article presents the goals of CES as perceived by board members and members of ethics support staff. This is part of a Dutch national research using a mixed methods design with questionnaires, focus groups and interviews. Quantitative and qualitative data were analyzed and combined in an iterative process. Four main clusters of goals (...) were found: 1) encouraging an ethical climate, 2) fostering an accountable and transparent organization, 3) developing professionalism and a final goal, overarching the previous three, 4) good care. Most important sub-goals of CES were: attention for ethical issues, raising awareness of ethical issues, fostering ethical reflection and supporting employees. The article ends with a discussion on the desirability to further operationalize the general goal of good care, the context-boundedness of our findings and the need to relate goals of CES to the features of organizational cultures to further improve the integration of CES in healthcare institutions. (shrink)

There is growing interest in clinical ethics. However, we still have sparse knowledge about what is actually going on in the everyday practice of clinical ethics consultations. This paper introduces a descriptive evaluation tool to present, discuss and compare how clinical ethics case consultations are actually carried out. The tool does not aim to define ‘best practice’. Rather, it facilitates concrete comparisons and evaluative discussions of the role, function, procedures and ideals inherent in clinical ethics case consultation practices. The tool (...) was developed during meetings of the European Clinical Ethics Network. Based on written reports and participation in the network meetings, the development and the content of the tool and the results of its application in presenting and discussing 10 case consultations are summarized. The tool facilitated understanding of the details of clinical ethics case consultations across individuals and institutions with various experiences and cultures, and comparison between various practices. (shrink)

This paper responds to the commentaries from Stacy Carter and Alan Cribb. We pick up on two main themes in our response. First, we reflect on how the process of setting standards for empirical bioethics research entails drawing boundaries around what research counts as empirical bioethics research, and we discuss whether the standards agreed in the consensus process draw these boundaries correctly. Second, we expand on the discussion in the original paper of the role and significance of the concept of (...) ‘integrating’ empirical methods and ethical argument as a standard for research practice within empirical bioethics. (shrink)

Next SectionObjective The purpose of this article is to investigate the need for ethics support in Dutch healthcare institutions in order to understand why ethics support is often not used in practice and which factors are relevant in this context. Methods This study had a mixed methods design integrating quantitative and qualitative research methods. Two survey questionnaires, two focus groups and 17 interviews were conducted among board members and ethics support staff in Dutch healthcare institutions. Findings Most respondents see a (...) need for ethics support. This need is related to the complexity of contemporary healthcare, the contribution of ethics support to the core business of the organisation and to the surplus value of paying structural attention to ethical issues. The need for ethics support is, however, not unconditional. Reasons for a lacking need include: aversion of innovations, negative associations with the notion of ethics support service, and organisational factors like resources and setting. Conclusion There is a conditioned need for ethics support in Dutch healthcare institutions. The promotion of ethics support in healthcare can be fostered by focusing on formats which fit the needs of (practitioners in) healthcare institutions. The emphasis should be on creating a (culture of) dialogue about the complex situations which emerge daily in contemporary healthcare practice. (shrink)

BackgroundAs moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research.MethodsA multiple-case study was conducted in a care organization for people with (...) intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level.ResultsAccording to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up.ConclusionsConcretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences. (shrink)

Ethics support staff help others to deal with moral challenges. However, they themselves can also experience moral challenges such as issues regarding (breaching) confidentiality when practicing ethics support. Currently there is no insight in these confidentiality issues and also no professional guidance for dealing with them. To gain insight into moral challenges related to Moral Case Deliberation (MCD), we studied a) beliefs and experiences of MCD facilitators regarding breaching confidentiality, b) considerations for (not) breaching confidentiality, and c) needs for an (...) ethics support tool. Data collection consisted of qualitative research methods: six semi-structured interviews; analyses of a) two recorded MCD sessions, and b) a focus group with MCD facilitators. Findings: MCD facilitators mention different conceptions and interpretations of confidentiality and various moral challenges. Questions concerning confidentiality ultimately cause reflections on roles and responsibilities of facilitators. Needs for ethics support vary from seeking advice to procedural and sometimes normative guidance for MCD facilitators. Education for MCD facilitators should focus on developing a concrete tool that stimulates awareness and reflection(skills). (shrink)

There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors’ ethical challenges. The objective of this paper (...) is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors. (shrink)

The use of coercion is morally problematic and requires an ongoing critical reflection. We wondered if not knowing or being uncertain whether coercion is morally right or justified is related to professionals’ normative attitudes regarding the use of coercion. This paper describes an explorative statistical analysis based on a cross-sectional survey across seven wards in three Norwegian mental health care institutions. Descriptive analyses showed that in general the 379 respondents a) were not so sure whether coercion should be seen as (...) offending, b) agreed with the viewpoint that coercion is needed for care and security, and c) slightly disagreed that coercion could be seen as treatment. Staff did not report high rates of moral doubt related to the use of coercion, although most of them agreed there will never be a single answer to the question ‘What is the right thing to do?’. Bivariate analyses showed that the more they experienced general moral doubt and relative doubt, the more one thought that coercion is offending. Especially psychologists were critical towards coercion. We found significant differences among ward types. Respondents with decisional responsibility for coercion and leadership responsibility saw coercion less as treatment. Frequent experience with coercion was related to seeing coercion more as care and security. This study showed that experiencing moral doubt is related to some one’s normative attitude towards coercion. Future research could investigate whether moral case deliberation increases professionals’ experience of moral doubt and whether this will evoke more critical thinking and increase staff’s curiosity for alternatives to coercion. (shrink)

Background Clinical moral case deliberation consists of the systematic reflection on a concrete moral case␣by health care professionals. This paper presents the study of a 4-year moral deliberation project.Objectives The objectives of this paper are to: (a) describe the practice and the theoretical background of moral deliberation, (b) describe the moral deliberation project, (c) present the outcomes of␣the evaluation of the moral case deliberation sessions, and (d) present the implementation process.Methods The implementation process is both monitored and supported by an (...) interactive responsive evaluation design with: (a) in-depth interviews, (b) Maastricht evaluation questionnaires, (c) evaluation survey, and (d) ethnographic participant observation. In accordance with the theory of responsive evaluation, researchers acted both as evaluators and moderators (i.e. ethicists).Results Both qualitative and quantitative results showed that the moral case deliberations, the role of the ethics facilitator, and the train-the-facilitator program were regarded as useful and were evaluated as (very) positive. Health care professionals reported that they improved their moral competencies (i.e. knowledge, attitude and skills). However, the new trained facilitators lacked a clear organisational structure and felt overburdened with the implementation process. The paper ends with both practical and research suggestions for future moral deliberation projects. (shrink)

Background Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. Method Based on experiences and research into (...) MCD facilitators’ needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. Results The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. Conclusions This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools. (shrink)

Deliberative ways of dealing with ethical issues in health care are expanding. Moral case deliberation is an example, providing group-wise, structured reflection on dilemmas from practice. Although moral case deliberation is well described in literature, aims and results of moral case deliberation sessions are unknown. This research shows (a) why managers introduce moral case deliberation and (b) what moral case deliberation participants experience as moral case deliberation results. A responsive evaluation was conducted, explicating moral case deliberation experiences by analysing aims (...) (N = 78) and harvest (N = 255). A naturalistic data collection included interviews with managers and evaluation questionnaires of moral case deliberation participants (nurses). From the analysis, moral case deliberation appeals for cooperation, team bonding, critical attitude towards routines and nurses’ empowerment. Differences are that managers aim to foster identity of the nursing profession, whereas nurses emphasize learning processes and understanding perspectives. We conclude that moral case deliberation influences team cooperation that cannot be controlled with traditional management tools, but requires time and dialogue. Exchanging aims and harvest between manager and team could result in co-creating (moral) practice in which improvements for daily cooperation result from bringing together perspectives of managers and team members. (shrink)

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into (...) moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented. (shrink)

Although moral case deliberation (MCD) is evaluated positively as a form of clinical ethics support (CES), it has limitations. To address these limitations our research objective was to develop a thematic CES tool. In order to assess the philosophical characteristics of a CES tool based on MCDs, we drew on hermeneutic ethics and pragmatism. We distinguished four core characteristics of a CES tool: (a) focusing on an actual situation that is experienced as morally challenging by the user; (b) stimulating moral (...) inquiry into the moral concepts, questions and routines in the lived experience of the CES tool user; (c) stimulating moral learning by exploring other perspectives; and (d) incorporating contextual details. We provide an example of a CES tool developed for moral dilemmas over client autonomy. Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation studies of CES tools. (shrink)

Recently, moral deliberation within care institutions is gaining more attention in medical ethics. Ongoing dialogues about ethical issues are considered as a vehicle for quality improvement of health care practices. The rise of ethical conversation methods can be understood against the broader development within medical ethics in which interaction and dialogue are seen as alternatives for both theoretical or individual reflection on ethical questions. In other disciplines, intersubjectivity is also seen as a way to handle practical problems, and methodologies have (...) emerged to deal with dynamic processes of practice improvement. An example is responsive evaluation. In this article we investigate the relationship between moral deliberation and responsive evaluation, describe their common basis in dialogical ethics and pragmatic hermeneutics, and explore the relevance of both for improving the quality of care. The synergy between the approaches is illustrated by a case example in which both play a distinct and complementary role. It concerns the implementation of quality criteria for coercion in Dutch psychiatry. (shrink)

This new edition of Introduction to Lattices and Order presents a radical reorganization and updating, though its primary aim is unchanged. The explosive development of theoretical computer science in recent years has, in particular, influenced the book's evolution: a fresh treatment of fixpoints testifies to this and Galois connections now feature prominently. An early presentation of concept analysis gives both a concrete foundation for the subsequent theory of complete lattices and a glimpse of a methodology for data analysis that is (...) of commercial value in social science. Classroom experience has led to numerous pedagogical improvements and many new exercises have been added. As before, exposure to elementary abstract algebra and the notation of set theory are the only prerequisites, making the book suitable for advanced undergraduates and beginning graduate students. It will also be a valuable resource for anyone who meets ordered structures. (shrink)

The first book to be devoted to the logic behind the application of ethical theories, this collection of essays explores the question of how many different moral traditions (utilitarianism, natural rights theory, Marxism, Christian moral theology, and Kantianism among others) view the relation between theory and concrete judgments. By considering many applications of moral theory in medical ethics the authors illustrate their point.

Muzykalʹnai︠a︡ ėstetika i kulʹturologii︠a︡ -- Istorii︠a︡ muzyki -- Istorii︠a︡, teorii︠a︡ muzykalʹnogo ispolnitelʹstva -- Tradit︠s︡ionnai︠a︡ kulʹtura.

In this paper, I consider a variety of objections against the covering-law model of scientific explanation, show that Aristotle was already aware of them and had solutions for them, and argue that these solutions are correct. These solutions involve the notions of nonHumean causality and of essential properties. There are a great many familiar objections, both methodological and epistemological, to introducing these concepts into the methodology of science, but I show that these objections are based upon misunderstandings of these concepts.

The techniques of natural duality theory are applied to certain finitely generated varieties of Heyting algebras to obtain optimal dualities for these varieties, and thereby to address algebraic questions about them. In particular, a complete characterisation is given of the endodualisable finite subdirectly irreducible Heyting algebras. The procedures involved rely heavily on Priestley duality for Heyting algebras.

The correctness of application of orientalist discourse of E. Said to the colonial policy of the Russian Empire is analyzed in the article on the example of P. I. Rychkov research. By studying integration of Bashkirs in the structure of the Russian state, the author came to the conclusion that Russia’s policy in the East was based on the experience of the management of non-Russian peoples, which was developed in the 16-17th centuries. The establishment of ‘cultural distance‘ is typical only (...) for a small group of educated administrators of past-Petrine era. Most of the officials of the region, as in the preceding period, and during the time of Rychkov and Tatishchev preferred to rely on traditional methods of Bashkir management, which was developed in the period of their voluntary accession. Managerial stereotypes of 16-17th centuries, had significant influence on policy towards South-Eastern peoples of Russia even in the 19th century. The Russian administration inherent in the desire to integrate the non-Russian peoples in the General class structure of the state on the basis of analogies or correspondences, the objective of which was social and cultural rapprochement of the two societies. (shrink)

Psychoactive drugs are being prescribed to millions of Americans at an increasing rate. In many cases these drugs are necessary in order to overcome debilitating emotional problems. Yet in other instances, these drugs are used to supplant, not supplement, interpersonal therapy. The process of overcoming emotional obstacles by introspection and the attainment of self knowledge is gradually being eroded via the gratuitous use of psychoactive medication in order to rapidly attain a release from the common problems that life inevitably presents (...) us with. In this paper, I argue that Kant’s formula of humanity, which maintains that persons ought never to treat others or themselves soley as a means to an end, proscribes this. Moreover, Kant argues that we have an imperfect duty of self development, and I argue that we fail to adhere to such a duty whenever we seek to evade the process of introspection and self knowledge in favour of the expedient results that drugs may provide us with as we attempt to overcome the emotional hurdles in our lives. (shrink)

Both syntactic and semantic solutions are given for the entailment problem of duality theory. The test algebra theorem provides both a syntactic solution to the entailment problem in terms of primitive positive formulae and a new derivation of the corresponding result in clone theory, viz. the syntactic description of $\operatorname{Inv(Pol}(R))$ for a given set R of finitary relations on a finite set. The semantic solution to the entailment problem follows from the syntactic one, or can be given in the form (...) of an algorithm. It shows, in the special case of a purely relational type, that duality-theoretic entailment is describable in terms of five constructs, namely trivial relations, intersection, repetition removal, product, and retractive projection. All except the last are concrete, in the sense that they are described by a quantifier-free formula. It is proved that if the finite algebra $\underline{M}$ generates a congruence-distributive variety and all subalgebras of $\underline{M}$ are subdirectly irreducible, then concrete constructs suffice to describe entailment. The concept of entailment appropriate to strong dualities is also introduced, and described in terms of coordinate projections, restriction of domains, and composition of partial functions. (shrink)

Georgians' acquaintance with Islam was with the first Arab raids. From the first Muslim Arab domination, Georgians started to become Muslims with cultural interaction. Islam spread especially in Eastern Georgia during the time of Muslim Arabs, Seljuks and Mongols. The spread of Islam in Western Georgia started with the Ottomans. The Ottoman Empire's contact with Georgia begins with the conquest of Trabzon by Fatih Sultan Mehmed. When the Ottomans contacted the region, the geography of Georgia was divided into small kingdoms. (...) With the conquest of Trabzon, the Georgian border was reached and in 1479, Acaristan, Borcka and Maçahel surroundings joined the Ottoman lands. On the one hand, Sukhumi was captured from the north. Then, continuing to advance in the region, Yavuz Sultan Selim paid tribute to the Kingdom of Güryel and Imeret (Açıkbaş) in 1508 during his governorship of Trabzon. Thus, the Ottoman borders had reached beyond the Black Sea coast into Western Georgia. As a result of the increasing relations around Adjaria, which came under Ottoman rule, Islamization began to spread rapidly among the people. Contrary to what is claimed, the spread of Islam in the region did not spread from the ruling strata to the lower, but from the popular strata to the ruling strata. This process was surprisingly fast. In the process of Islamization, many mosques, masjids and schools were built in Adjara, especially with the help of the people. The foundations operating in the region and the mosques and masjids serving under them show that, contrary to the claims of Russian and Georgian historians, Islamization took place rapidly at the beginning of the 17th century in Adjara. In this process, many mosques, masjids and schools were built in the region. In this research, based on the numerous Hurufat records belonging to Adjara, Batumi, Gönye, Çürüksu and Maçahel, the Islamization process will be evaluated by making a social reading with the data obtained from the religious structures established in the rural settlements of the Adjara geography and their officials. Evaluations were made on the Islamization process in Adjara by making a social reading. (shrink)