Moral distress has been covered extensively in the nursing literature and increasingly in the literature of other health professions. Cases that cause nurses’ moral distress that are mentioned most frequently are those concerned with prolonging the dying process. Given the standard of aggressive treatment that is typical in intensive care units (ICUs), much of the existing moral distress research focuses on the experiences of critical care nurses. However, moral distress does not automatically occur in all end-of-life circumstances, nor does every (...) critical care nurse suffer its damaging effects. What are the practices of these nurses? What specifically do they do to navigate around or through the distressing situations? The nursing literature is lacking an answer to these questions. This article reports a study that used narrative analysis to explore the reported practices of experienced critical care nurses who are skilled at and comfortable working with families and physicians regarding the withdrawal of aggressive treatment. A major finding was that these nurses did not report experiencing the dam-Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine Terri Traudt, MBC, MA, is a Communications Consultant specializing in bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis. [email protected] Joan Liaschenko, PhD, RN, FAAN, is a Professor at the Center for Bioethics and Nursing at the University of Minnesota. Cynthia Peden-McAlpine, PhD, ACNS, BC, is an Associate Professor in the School of Nursing at the University of Minnesota. © 2016 by The Journal of Clinical Ethics. All rights reserved. aging effects of moral distress as described in the nursing literature. The verbal communication and stated practices relevant to this finding are organized under three major themes: (1) moral agency, (2) moral imagination, and (3) moral community. Further, a total of eight subthemes are identified. The practices that constitute these themes and subthemes are further detailed and discussed in this article. Understanding these practices can help mitigate critical care nurses’ moral distress. (shrink)

Despite prevalent concerns about the ethical conduct of clinical trials, little is known about the day-to-day work of trials and the ethical challenges arising in them. This paper reports on a study designed to fill this gap and demonstrates a need to refine the oversight system for trials to reflect an understanding of this day-to-day work. It also illuminates ethical challenges that cannot be addressed by the oversight system and so necessitate a rethinking of the ethics of clinical trials.

It may be the case that the most challenging moral problem of the twenty‐first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which (...) they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency. (shrink)

Artificial persons are those who speak and act for others. Nurses speak and act for patients as well as for physicians and institutions, or, more aptly, institutionalized medicine. Yet, acting for institutionalized medicine can be harmful to nurses, due to the psychological experience of moral distress and the loss of integrity of their practice. This paper illustrates the harm to nurses as expressed in narratives of their practice, and suggests some initial steps we might take in resisting the artificial personhood (...) imposed by institutionalized medicine. (shrink)

The controversy over the so-called Ashley Treatment (AT), a series of medical procedures that inhibited both growth and sexual development in the body of a profoundly intellectually impaired girl, usually centers either on Ashley’s rights, including a right to an intact, unaltered body, or on Ashley’s parents’ rights to make decisions for her. The claim made by her parents, that the procedure would improve their ability to care for her, is often dismissed as inappropriate or, at best, irrelevant. We argue, (...) however, that caregiving is a central issue in the controversy, as Ashley’s need for caregiving is a defining characteristic of her life. In this article, we analyze the ethics of the Ashley Treatment within the context of family caregiving. Through the physical and emotional work of caregiving, families participate in the formation and maintenance of personal identity, a process that Hilde Lindemann recently called “holding.” We argue that, in an intellectually disabled person such as Ashley, who depends on her family for every aspect of her care, the family’s contribution to identity is an essential source of personhood. We believe that the treatment can be justified if it is indeed an instance of appropriate family “holding” for Ashley. (shrink)

Advance care planning (ACP) is a process that seeks to elicit patients’ goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and limitations. Focus (...) groups were conducted with 15 physicians as part of a larger study of adolescent and young adult ACP in hematopoietic stem cell transplant (HSCT) patients. This study identified two categories important to the utility of ACP in pediatric HSCT patients; (1) the temporal context of ACP and decision making and (2) the limitations of pediatric ACP, with subcategories identified as (a) embodied and witnessed knowing, (b) the impact of clinical cascades—when the treatment of one organ system creates complications in another system that needs to be treated—and a creation of a “new normal” following complications of illness and its treatment in the pediatric intensive care unit (PICU), (c) the balancing of adolescents’ autonomy with their capacity to make informed medical decisions, and (d) the epistemological frames that differ between HCP and patients and their families. These findings support ACP in adolescent and young adult HSCT patients, with a number of implications for practice as this process becomes more common. (shrink)

Surgical “buy-in” is an “informal contract between surgeon and patient in which the patient not only consents to the operative procedure but commits to the post-operative surgical care anticipated by the surgeon.”1 Surgeons routinely assume that patients wish to undergo treatment for operative complications so that the overall treatment course is “successful,” as in the treatment of a post-operative infection. This article examines occasions when patients buy-in to a treatment course that carries risk of complication, yet refuse treatment when complications (...) arise. We coin this counter-phenomenon “cashing-out.” Cashing-out may elicit negative feelings among careproviders. We question why patients or families may wish to cash-out. One reason may be the changing epistemological position of patients as they experience a complication. The shift from the hypothetical discussion of complications during the initial informed-consent process to the experience of having a complication represents new knowledge. Patients and families may use this knowledge as the basis to revoke consent for some or all of the remaining treatment course. This article seeks to understand cashing-out in terms of the patients’ experiences. We hope to prompt recognition of this phenomenon across medical contexts and to provide impetus for further work to understand why patients may wish to cash-out. (shrink)

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based practice. (...) Following a brief history of the transition from the paper record to the EHR, the authors discuss unintended or contested consequences resulting from this change. These changes primarily reflect changes in the organization and amount of clinician work and clinician‐patient relationships. The paper is not a research report but was informed by an institutional ethnography the aim of which was to understand how the EHR impacted clinicians and administrators in a large, urban hospital in the United States. The paper was also informed by other sources, including the philosophies of Jacques Ellul, Don Idhe, and Langdon Winner. (shrink)

Clinical trials are a central mechanism in the production of medical knowledge. They are the gold standard by which such knowledge is evaluated. They are widespread both in the United States and internationally; a National Institute of Health database reports over 106,000 active industry and government-sponsored trials (National Institutes of Health n.d.). They are an engine of the economy. The work of trials is complex; multiple people with diverse interests working across multiple settings simultaneously participate in them, and they are (...) underwritten by multiple organizational structures and diverse funding mechanisms. In the past several years, concern about the ethics of clinical trials has spiked dramatically .. (shrink)

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and (...) responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

The ethical ‘eye’ of nursing, that is, the particular moral vision and values inherent in nursing work, is constrained by the preoccupations and practices of the superordinate biomedical structure in which nursing as a practice discipline is embedded. The intimate, situated knowledge of particular persons who construct and attach meaning to their health experience in the presence of and with the active participation of the nurse, is the knowledge that provides the evidence for nurses’ ethical decision making. It is largely (...) invisible to all but other nurses. Two nurse researchers, Joan Liaschenko of the University of Minnesota and Patricia Rodney of the University of Victoria, have investigated the ethical concerns of practising nurses and noted in their separate enquiries the invisible nature of critical aspects of nursing work. Noting the similarities in their respective observations, and with the feminist ethics of Margaret Urban Walker as a theoretical framework, this article examines the concept of ‘invisibility’ as it relates to nursing work and nursing ethics. (shrink)

Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine’s study contributes to a much-needed reorientation in thinking about and working with the challenges of moral distress. In providing a vital example of nurses able to navigate morally distressing situations in positive and constructive ways, and offering an analysis of the component elements of these nurses’ success, the study helps identify promising directions we might take in addressing the epidemic of moral distress. It also invites important questions, concerning the challenges faced (...) by clinicians who do not who work in healthy “moral communities,” who lack the ethical competencies, and who don’t have the presumptive authority and recognition enjoyed by the seasoned clinicians studied here. We explore some of these questions, and suggest ways we might build on the insights of Traudt and colleagues’ study. (shrink)

Lisa Freitag and Joan Liaschenko’s thoughtful and important article goes directly to the under-examined heart of Ashley’s case, namely to what sustains her in a habitable and intelligible identity. Though quite sympathetic with their conclusion and line of argument, I try to trouble their proceedings a bit, largely by wondering how having a specific such identity, out of several that may be inprinciple available, matters to someone with Ashley’s cognitive scope. I do this not simply to be contrary, (...) but because their article also seems to me to raise issues in the ethics of bioethics—in particular, what I call the dilemma of ethical endeavor: How ought one publicly pursue deeply important and complex issues, the very raising of which may offend interlocutors who indeed have grounds for resentment. Making a habit of second guessing oneself may be part of the answer. (shrink)

The need for informed analyses of health policy is now greater than ever. The twelve essays in this volume show that public debates routinely bypass complex ethical, sociocultural, historical, and political questions about how we should address ideals of justice and equality in health care. Integrating perspectives from the humanities, social sciences, medicine, and public health, this volume illuminates the relationships between justice and health inequalities to enrich debates. Understanding Health Inequalities and Justice explores three questions: How do scholars approach (...) relations between health inequalities and ideals of justice? When do justice considerations inform solutions to health inequalities, and how do specific health inequalities affect perceptions of injustice? And how can diverse scholarly approaches contribute to better health policy? From addressing patient agency in an inequitable health care environment to examining how scholars of social justice and health care amass evidence, this volume promotes a richer understanding of health and justice and how to achieve both. -/- The contributors are Judith C. Barker, Paula Braveman, Paul Brodwin, Jami Suki Chang, Debra DeBruin, Leslie A. Dubbin, Sarah Horton, Carla C. Keirns, J. Paul Kelleher, Nicholas B. King, Eva Feder Kittay, Joan Liaschenko, Anne Drapkin Lyerly, Mary Faith Marshall, Carolyn Moxley Rouse, Jennifer Prah Ruger, and Janet K. Shim. (shrink)

Systems medicine, which is based on computational modelling of biological systems, is emerging as an increasingly prominent part of the personalized medicine movement. It is often promoted as ‘P4 medicine’. In this article, we test promises made by some of its proponents that systems medicine will be able to develop a scientific, quantitative metric for wellness that will eliminate the purported vagueness, ambiguity, and incompleteness—that is, normativity—of previous health definitions. We do so by examining the most concrete and relevant evidence (...) for such a metric available: a patent that describes a systems medicine method for assessing health and disease. We find that although systems medicine is promoted as heralding an era of transformative scientific objectivity, its definition of health seems at present still normatively based. As such, we argue that it will be open to influence from various stakeholders and that its purported objectivity may conceal important scientific, philosophical, and political issues. We also argue that this is an example of a general trend within biomedicine to create overly hopeful visions and expectations for the future. (shrink)

The best framework for moral and political thought is the one that creates the best climate for good political judgments. I argue that universalistic theories of justice fall short in this regard because they cannot distinguish idealization from abstraction. After describing how an ethic of care guides judgments, I suggest the practical effects that make this approach preferable. The ethic of care includes more aspects of human life in making political judgments.

This study examines how our personal values influence our judgment of the morality of some workplace behaviours. Sixty-nine undergraduates were asked to rank order separately Rokeach''s instrumental and terminal values in terms of their importance as guiding principles in their life. Subjects then read four scenarios, each of which described ethically questionable behaviour of the sort that might be encountered in business. They were then asked to rate whether or not the behaviour of the person described in the scenario was (...) ethical, and whether or not they had any intentions to rectify the situation. People with different value hierarchies perceived the targeted behaviours differently. For example, subjects who valued honesty perceived the behaviour as more immoral than subjects who did not value honesty. While the ranking of the instrumental valuehonesty was the best predictor of people''s judgments about the morality of the behaviour, their ranking of the instrumental valueambition was the best predictor of their behavioural intentions. (shrink)

Universalistic claims about the nature of justice are presumed to require larger commitments from a global perspective than partialist claims. This essay departs from standard partialist accounts by anchoring partialist claims in a different account of the nature of responsibility. In contrast to substantive responsibility, which is akin to an obligation and derived from principles, relational responsibilities grow out of relationships and their complex intertwining. While such accounts of responsibility are less clear cut, they will prove in the long run (...) to be more valuable in thinking about global ethics. I illustrate this point by considering the moral issue surrounding abandoned relationships. The approach offered here—partiality that rests upon relational responsibilities—makes the responsibilities owed by those in higher income countries towards lower income countries much richer and more complex than is usually presumed. (shrink)

The graduate course in research ethics in the Graduate School for Integrative Sciences and Engineering at the National University of Singapore consists of a semester long mandatory course titled: “Research Ethics and Scientific Integrity.” The course provides students with guiding principles for appropriate conduct in the professional and social settings of scientific research and in making morally weighted and ethically sound decisions when confronted with moral dilemmas. It seeks to enhance understanding and appreciation of the moral reasoning underpinning various rules (...) and legislative constraints associated with research subjects and procedures. Further, students are trained to critically analyse cases and issues associated with scientific misconduct preparing them to act in a responsible and effective manner should they encounter such cases. The diverse background and training of the cohort also provide a unique setting and opportunity for student-initiated collaborative interdisciplinary learning. This article offers a reflective account of the course and some preliminary insights into learning outcomes. (shrink)

Frege begins Die Grundlagen der Arithmetik, the work that introduces the project which was to occupy him for most of his professional career, with the question, 'What is the number one?' It is a question to which even mathematicians, he says, have no satisfactory answer. And given this scandalous situation, he adds, there is small hope that we shall be able to say what number is. Frege intends to rectify the situation by providing definitions of the number one and the (...) concept of number. But what, exactly, is required of a definition? Surely it will not do to stipulate that the number one is Julius Caesar - that would change the subject. It seems reasonable to suppose that an acceptable definition must be a true statement containing a description that picks out the object to which the numeral '1' already refers. And, similarly, that an acceptable definition of the concept of number must contain a description that picks out precisely those objects that are numbers - those objects to which our numerals refer. Yet, while Frege writes a great deal about what criteria his definitions must satisfy, the above criteria are not among those he mentions. Nor does he attempt to convince us that his definitions of '1' and the other numerals are correct by arguing that these definitions pick out objects to which these numerals have always referred. Yet, while Frege writes a great deal about what criteria his definitions must satisfy, the above criteria are not among those he mentions. Nor does he attempt to convince us that his definitions of ‘1’ and the other numerals are correct by arguing that these definitions pick out objects to which these numerals have always referred. There is, as we shall see shortly, a great deal of evidence that Frege’s definitions are not intended to pick out objects to which our numerals already refer. But if this is so, how can these definitions teach us anything about our science of arithmetic? And what criteria must these definitions satisfy? To answer these questions, we need to understand what it is that Frege thinks we need to learn about the science of arithmetic. (shrink)

: Are social movements responsible for their unfinished agendas? Feminist successes in opening the professions to women paved the way for the emergence of the upper middle-class two-career household. These households sometimes hire domestic servants to accomplish their child care work. If, as I shall argue, this practice is unjust and furthers social inequality, then it poses a moral problem for any feminist commitment to social justice.

Contributors to this volume demonstrate how the ethics of care factors into a variety of social policies and institutions, and can indeed be useful in thinking about a number of different social problems. Divided into two sections, the first looks at care as a model for an evaluative framework that rethinks social institutions, liberal society, and citizenship at a basic conceptual level. The second explores care values in the context of specific social practices or settings, as a framework that should (...) guide thinking. (shrink)

A standard view in ethics is that ethical issues concern a different range of human concerns than does politics. This essay goes beyond the long-standing dispute about the extent to which applied ethics needs a commitment to ethical theory. It argues that regardless of the outcome of that dispute, applied ethics, because it presumes something about the nature of authority, rests upon and is implicated in political theory. After internalist and externalist accounts of applied ethics are described, “mixed” approaches are (...) considered that contain inevitable political dimensions. A feminist alternative, Walker’s metaethic of responsibility, shows that authority is best understood as relational and that situations of unequal power are therefore often the places where applied ethics arises. Furthermore, in a democratic society, commitments to democracy should shape the account of authority, and, thus, the nature of applied ethics as well. (shrink)

RESUMEN:Este trabajo tiene por objeto analizar la articulación entre la afirmación del carácter racional de la fe, esto es, su dimensión latitudinaria, el escepticismo epistemológico, y su derivación práctica en un concepto de tolerancia restringido al interior del protestantismo. Se subrayará, en este sentido, el carácter estratégico de la articulación entre racionalidad de la fe y escepticismo, en cuanto permite apelar a la ignorancia con vistas a la tolerancia, sin por ello dejar de sostener la interpretación protestante del cristianismo, en (...) detrimento de la interpretación católica.PALABRAS CLAVE:LOCKE - LATITUDINARISMO - ESCEPTICISMO - TOLERANCIA - PROTESTANTISMOABSTRACT:This paper aims to analyze the articulation between faith rationality assertion, i.e. its latitudinarian aspect, its epistemological skepticism, and its practical implication in a restricted concept of tolerance within Protestantism. In this regard, we will emphasize the strategic feature of the link between faith rationality and skepticism, as it allows appealing to ignorance towards tolerance, without dropping the Protestant interpretation of Christianity, to the detriment of Catholic interpretation.KEYWORDS:LOCKE - LATITUDINARIANISM - SKEPTICISM - TOLERATION - PROTESTANTISM. (shrink)

Frege is celebrated as an arch-Platonist and arch-realist. He is renowned for claiming that truths of arithmetic are eternally true and independent of us, our judgments and our thoughts; that there is a third realm containing nonphysical objects that are not ideas. Until recently, there were few attempts to explicate these renowned claims, for most philosophers thought the clarity of Frege's prose rendered explication unnecessary. But the last ten years have seen the publication of several revisionist interpretations of Frege's writings (...) — interpretations on which these claims receive a very different reading. In Frege on Knowing the Third Realm, Tyler Burge attempts to undermine this trend. Burge argues that Frege is the very Platonist most have thought him — that revisionist interpretations of Frege's Platonism, mine among them, run afoul of the words on Frege's pages. This paper is a response to Burge's criticisms. I argue that my interpretation is more faithful than Burge's to Frege's texts. (shrink)

Diese Studie möchte eine existenzphilosophische Vorarbeit zu einer Phänomenologie der Normativität leisten. Durch Auslegungen vor allem griechischer, mittelhochdeutscher und klassischer deutscher Dichtung werden zunächst die Grundbegriffe von Faktizität und Existentialität herausgearbeitet. Auf dieser Grundlage erfolgt sodann die Beschreibung von Anlass und Gestalt normativer Praxis. Diese Beschreibung wird endlich als anthropologische Grundlage philosophischer Ethik vorgeschlagen.

Women and religion -- Reproductive futurism -- Political emancipation -- From the Cold War to the clash of civilizations -- Sexual emancipation.

1. This paper contributes to the broader debate about how elite school institutions manage to remain alert and responsive to changing education market conditions, locally and globally, by explicitl...