Heuser, Eller and Byrne provide important descriptive ethics data about how physicians counsel women on the clinical management of pregnancies complicated by severe fetal anomalies. The authors present an account of what such counselling ought to be based on, the ethical concept of the fetus as a patient and the professional responsibility model of obstetric ethics. When there is certainty about the diagnosis and either a very high probability of either death as the outcome of the anomaly or (...) survival with severe and irreversible deficit of cognitive developmental capacity as a result of the anomaly diagnosed, the pregnant woman should be offered the alternatives of aggressive and non-aggressive obstetric management and induced abortion before viability. It is also ethically permissible to offer feticide followed by termination of pregnancy after viability in such cases. This ethically justified approach will reduce the variation in the actual practices of specialists in maternal–fetal medicine described by Heuser, Eller and Byrne. (shrink)

We describe and analyze 13 cases handled by our ethics consultation service (ECS) in which families requested continuation of physiological support for loved ones after death by neurological criteria (DNC) had been declared. These ethics consultations took place between 2005 and 2013. Patients’ ages ranged from 14 to 85. Continued mechanical ventilation was the focal intervention sought by all families. The ECS’s advice and recommendations generally promoted “reasonable accommodation” of the requests, balancing compassion for grieving families with other ethical and (...) moral concerns such as stewardship of resources, professional integrity, and moral distress. In cases we characterized as finitegoal accommodation, a “reasonable accommodation” strategy proved effective in balancing stakeholders’ interests and goals, enabling steady progress toward resolution. When a family objected outright to a declaration of DNC and asked for an indefinite accommodation, the “reasonable accommodation” approach offered clinicians little practical direction, and resolution required definitive action by either the family or the clinical team. Based on our analysis and reflections on these 13 cases, we propose ethically justified and practical guidelines to assist healthcare professionals, administrators, and ECSs faced with similar cases. (shrink)

Simona Giordano investigates the moral concerns raised by current clinical options available for transgender and gender diverse children and adolescents. From the time young children express gender incongruent preferences and attitudes, up to the time in which older adolescents might apply for medical or surgical treatment, moral questions are likely to be asked: should children be enabled to express themselves freely inside and outside the domestic environment? What are the implications of the choices that parents might make early on? (...) How should clinicians respond to distress around sexual anatomy? Is it ethical to suspend pubertal development? What level of evidence should we seek for medications to be used in paediatric care? What are the risks and benefits of various forms of hormonal treatment? Is it ethical to defer surgical interventions till adulthood? Giordano provides a detailed ethical analysis of these and many other questions that are likely to arise at various stages of a person's life and proposes a moral formula to answer these questions, as well as others, that are likely to arise in a fast-changing landscape. Children and Gender combines a detailed ethical analysis with an accurate clinical description of gender development and available clinical pathways. (shrink)

Name der Zeitschrift: Jahrbuch für Wissenschaft und Ethik Jahrgang: 19 Heft: 1 Seiten: 115-146.

Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support inspired by Habermas’ theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of (...) this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved. (shrink)

This study argues the thesis that a set of guidelines ‐ firmly rooted in a particular interpretation of African moral theory, specifically, Ubuntu – will do a better job than current medical ethics frameworks, in addressing ethical challenges around misattributed parentage within the clinical context. Incidental information such as information with significant personal/health implications raises unique challenges for medical professionals. For example, withholding information of misattributed paternity accidentally discovered in clinical interactions may be seen by a patient as (...) a violation of his/her right‐to‐know. Contrarily, disclosure where a patient has not requested information – or where establishing paternity is not the purpose of clinical visit/interaction – may be taken by the patient as a violation of his/her right ‘not‐to‐know’. Resolving these challenges remain a herculean task. African moral theory contains an under‐emphasized value for addressing such ethical challenges around misattributed parentage in the field of transplant. I seek to contribute this knowledge; and enhance clinician‐patient relationship. This study builds off three completed systematic reviews, which aimed to answer the following questions: “what are the ethical challenges regarding information health professionals face within the clinical contest?” and “what core aspects (or common themes) of Ubuntu can be identified in existing literature describing the same?” In this present study, I applied the definition of Ubuntu which captures the core aspects of the theory in ethical literature on the same, to address ethical issues around unsought information of misattributed parentage in the field of transplant. (shrink)

Upholding public trust in clinical research necessitates that human subjects be protected from avoidable harm and that the design, interpretation and reporting of research results be shielded from avoidable bias. On both counts, managing financial conflicts of interest is critically important, especially in the modern era when the opportunities for investigators to benefit personally from the commercialization of their intellectual property are overtly encouraged and rapidly expanding. Efforts are underway in the United States to provide more useful guidance to (...) universities and medical schools for purposes of strengthening the oversight and management of financial conflicts of interest in clinical research. (shrink)

Hospitals are places where patients are unwell, where patients and their families may be upset, confused, frustrated, in pain, and vulnerable. The likelihood of these experiences and emotions manifesting in anger and aggressive behaviour is high. In this paper, we describe the involvement of a clinical ethics service responding to a request to discuss family aggression within a rehabilitation department in a large paediatric hospital in Australia. We suggest two key advantages of involving a clinical ethics service in (...) discussions about how to respond to family aggression. First, the process of ethics deliberation provides an opportunity for clinicians to be involved in the solution by articulating their perspectives, tolerance levels, and general concerns about the effects of family aggression towards staff. Second, supporting clinicians to articulate and identify the impact of parental aggression directly counters the disadvantages of the more blunt zero-tolerance policy response, which is necessarily imposed from the top down. (shrink)

The reliability of clinical practice guidelines has been disputed because guideline panel members are often burdened with financial conflicts of interest. Current recommendations for COI regulation advise not only detailed declaration but also active management of conflicts. To continuously assess COI declaration and management in German guidelines we established the public database LeitlinienWatch. We analyzed all German guidelines at the highest methodological level that included recommendations for pharmacological therapy according to five criteria: declaration and assessment of COI, (...) composition of the guideline development group, independence of the coordinators and lead authors, imposed abstentions because of COI and public external review. Each criterion was assessed using predefined outcome categories. Most guidelines contained a detailed declaration of COI. However, none of the guidelines provided full transparency of COI assessment results. The guideline group was composed of a majority of participants with COI in 55% of the guidelines, no guideline was free of participants with COI. Only 9% of guidelines had coordinators and lead authors without any financial COI. Most guidelines did not provide a rule for abstentions for participants with COI. In 21% of guidelines there was a rule, but abstentions were either not practiced or not documented, whereas in 7% partial abstentions and in 2% complete abstentions were documented. Two thirds of the guideline drafts were not externally reviewed via a public website. COI are usually documented in detail in German guidelines of the highest methodological level. However, considerable improvement is needed regarding active management of COI, including recruitment of independent experts for guideline projects, abstention from voting for participants with COI and external review of the guideline draft. We assume that the publicly available ratings on GuidelineWatch will improve the handling of conflicts of interest in guideline development. (shrink)

Background: Expanded newborn screening generates incidental results, notably carrier results. Yet newborn screening programmes typically restrict parental choice regarding receipt of this non-health serving genetic information. Healthcare providers play a key role in educating families or caring for screened infants and have strong beliefs about the management of incidental results. Methods: To inform policy on disclosure of infant sickle cell disorder (SCD) carrier results, a mixed-methods study of healthcare providers was conducted in Ontario, Canada, to understand attitudes regarding result (...) management using a cross-sectional survey (N = 1615) and semistructured interviews (N = 42). Results: Agreement to reasons favouring disclosure of SCD carrier results was high (65.1%–92.7%) and to reasons opposing disclosure was low (4.1%–18.1%). Genetics professionals expressed less support for arguments favouring disclosure (35.3%–78.8%), and more agreement with arguments opposing disclosure (15.7%–51.9%). A slim majority of genetics professionals (51.9%) agreed that a reason to avoid disclosure was the importance of allowing the child to decide to receive results. Qualitatively, there was a perceived “duty” to disclose, that if the clinician possessed the information, the clinician could not withhold it. Discussion: While a majority of respondents perceived a duty to disclose the incidental results of newborn screening, the policy implications of these attitudes are not obvious. In particular, policy must balance descriptive ethics (ie, what providers believe) and normative ethics (ie, what duty-based principles oblige), address dissenting opinion and consider the relevance of moral principles grounded in clinical obligations for public health initiatives. (shrink)

Central concepts and consensus views in clinical ethics are marked by instability. The papers in this number of the Journal take up two such central concepts, quality of life and moral status, and two such consensus views, that germ-line gene transfer should not be undertaken for the purposes of enhancement of human traits and that the ethical obligation of physicians to treat HIV infected patients rests on consent of the physician. One outcome of these philosophical investigations is that these (...) two concepts and consensus views are less stable than one might have thought. I explore the possibility of generalizing this outcome in a reflection on clinical ethics as the management of instability and incompleteness, including the instability and incompleteness of clinical ethics itself. In the course of this reflection I liken clinical ethics to abstract expressionism in mid-twentieth century Western art. (shrink)

The prevalence of pain in patients presenting to Emergency Departments has been well documented by both Cordell and Johnston. Equally well documented has been the apparent failure to adequately control that pain. In 1990 Selbst found that patients with long bone fractures received little analgesia in the ED, and Ngai, et al., showed that the under-treatment of pain continued after discharge. In a prospective study, Ducharme and Barber found that up to one third of patients presented with severe pain and (...) were often unrelieved at discharge. Even though specific patient subgroups appear to be at greater risk, all patients are potential victims of oligoanalgesia - the under-treatment of pain. Despite an ever increasing volume of research about pain in emergency medicine, dissemination of relevant information with widespread change in practice patterns has not been witnessed. Recent studies continue to affirm that pain management in the ED is suboptimal. (shrink)

It is well-recognized that uncertainty is an endemic feature and limitation of clinical judgment and practice that cannot be eliminated in many cases. Among the tasks of clinical ethics is the responsible management of uncertainties, first articulated in E. Haavi Morreim’s very nice concept of the "moral management of medical uncertainty." The papers in the 2012 Clinical Ethics issue of the Journal provide philosophically innovative and clinically applicable accounts of the varieties of uncertainty in (...) class='Hi'>clinical medicine and therefore in clinical ethics: epistemic uncertainty, metaphysical uncertainty, and relational uncertainty. (shrink)

The prevalence of pain in patients presenting to Emergency Departments has been well documented by both Cordell and Johnston. Equally well documented has been the apparent failure to adequately control that pain. In 1990 Selbst found that patients with long bone fractures received little analgesia in the ED, and Ngai, et al., showed that the under-treatment of pain continued after discharge. In a prospective study, Ducharme and Barber found that up to one third of patients presented with severe pain and (...) were often unrelieved at discharge. Even though specific patient subgroups appear to be at greater risk, all patients are potential victims of oligoanalgesia - the under-treatment of pain. Despite an ever increasing volume of research about pain in emergency medicine, dissemination of relevant information with widespread change in practice patterns has not been witnessed. Recent studies continue to affirm that pain management in the ED is suboptimal. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is designed to provide practitioners who prescribe controlled substances for (...) pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Current management of people with prolonged disorders of consciousness is failing patients, families and society. The causes include a general lack of concern, knowledge and expertise; a legal and professional framework which impedes timely and appropriate decision-making and/or enactment of the decision; and the exclusive focus on the patient, with no legitimate means to consider the broader consequences of healthcare decisions. This article argues that a clinical pathway based on the principles of the English Mental Capacity Act 2005 (...) and using time-limited treatment trials could greatly improve patient management and reduce stress on families. There needs to be early and continuing use of formal best interests meetings, starting between 7 and 21 days after onset of unconsciousness. The treatment options need to evolve as the clinical state and prognosis becomes more certain. A formal discussion of treatment withdrawal should occur when the upper bound of predicted recovery falls below a level the patient would have considered acceptable, and it should always be discussed when the condition is considered permanent. Any decision to stop treatment should be contingent on a formal second opinion from an independent expert who should review the clinical situation and expected prognosis, but not the best interests decision. The article also asks how, if at all, the adverse effects on the family and the resource implications of long-term care of people left in a prolonged state of unconsciousness should be incorporated in the process. (shrink)

Adequate treatment of pain is essential to alleviate suffering, yet studies show that patients with terminal or serious illness receive inadequate pain relief. In the case of terminally ill patients, adequate palliation of pain may be likely to reduce requests for physician-assisted suicide. This issue of the journal addresses barriers to effective pain relief and suggests how treatment of pain can be improved. The symposium features the Pain Relief Act, which is designed to provide practitioners who prescribe controlled substances for (...) pain with protection from inappropriate legal sanctions. The Act is the product of the Project on Legal Constraints on Access to Effective Pain Relief, whose principal investigators were Nancy Neveloff Dubler, LL.B., Sandra H. Johnson, J.D., LL.M., Robert J. Levine, M.D., and Benjamin W. Moulton, J.D., M.P.H.The Project was supported by the Mayday Fund and the Emily Davie and Joseph S. Kornfeld Foundation. (shrink)

Communication and Conflict Management Training for Clinical Bioethics Committees Content Type Journal Article Pages 341-349 DOI 10.1007/s10730-009-9116-7 Authors Lauren M. Edelstein, Johns Hopkins Medicine’s Howard County General Hospital 5755 Cedar Lane Columbia MD 21044 USA Evan G. DeRenzo, Washington Hospital Center Center for Ethics 110 Irving St Washington, D.C. NW 20010 USA Elizabeth Waetzig, Change Matrix Inc. 485 Maylin St. Pasadena CA 91105 USA Craig Zelizer, Georgetown University Department of Government 3240 Prospect St. Washington, D.C. NW 20057 USA (...) Nneka O. Mokwunye, Washington Hospital Center Center for Ethics 110 Irving St Washington, D.C. NW 20010 USA Journal HEC Forum Online ISSN 1572-8498 Print ISSN 0956-2737 Journal Volume Volume 21 Journal Issue Volume 21, Number 4. (shrink)

This case looks at the question of how to consider obligations of confidentiality by a mental health professional who works for an institution and learns that a student has been using a drug intended for an animal research project. Dr. Paul Appelbaum, MD, a psychiatrist at Columbia University, examines the issue of the limits of confidentiality. Nicholas Steneck, PhD, a scholar in research misconduct at the University of Michigan, explores the obligations to report research misconduct. Walter Limehouse, MD, an ethicist (...) at the Medical University of South Carolina, considers the systems issues raised by this case and offers some suggestions that might change the institutional environment. (shrink)

During the late twentieth century, drawing on C. P. Snow’s well-known concept of a “two cultures” divide between scientists and humanists, many psychologists identified polarizing divergences in their discipline. This essay traces how purported professional divides affected the understanding and management of mental retardation in clinical psychology. Previous work in the history of science has compared the differing cultures of disciplines, demonstrating that there is no one, unified science. Through an examination of multiple “two cultures” divides within the (...) discipline of psychology, the essay demonstrates that perceived divergences in the field were animated by considerations of professional identity, ambitions, and goals. It argues that differing views among clinical psychologists about mental retardation, and crucially the localization of its causes—in individual bodies, minds, and genomes or within social institutions—reflected their position among the multiple “cultures” of psychology. References to Snow’s two cultures spanned the late twentieth-century scientific and clinical literature and were often used to encourage a conversation about the nature and goals of research in a field. In considering these purported “two cultures” divides, the essay proposes that historians of science must take care to look beyond constructed polarities, to instead analyze the resulting discussions about professional training and purpose. (shrink)

The papers in the 2010 “Clinical Ethics” number of the Journal of Medicine and Philosophy explore issues along La Frontera, the borders and boundaries of clinical ethics. The first three papers in this “Clinical Ethics” number of the Journal explore borders and boundaries drawn within clinical ethics, concerning the moral standing of complementary and alternative medicine, palliative sedation, and induced abortion and feticide. The fourth and fifth papers explore the borders and boundaries between research ethics and (...) clinical ethics. (shrink)

Using video to facilitate data collection has become increasingly common in health research. Using video in research, however, does raise additional ethical concerns. In this paper we utilize family therapy data to provide empirical evidence of how recording equipment is treated. We show that families made a distinction between what was observed through the video by the reflecting team and what was being recorded onto videotape. We show that all parties actively negotiated what should and should not go ‘on the (...) record’, with particular attention to sensitive topics and the responsibility of the therapist. Our findings have important implications for both clinical professionals and researchers using video data. We maintain that informed consent should be an ongoing process and with this in mind we present some arguments pertaining to the current debates in this field of health-care practice. (shrink)

CITATION: Ewuoso, C., Hall, S. & Dierickx, K. 2017. How do healthcare professionals manage ethical challenges regarding information in healthcare professional/patient clinical interactions? a review of concept- or argument-based articles and case analyses. South African Journal of Bioethics and Law, 10:75-82, doi:10.7196/SAJBL.2017.v10i2.610.

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered here, (...) the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. (shrink)

Background There has been considerable investment and strategic planning to introduce genomic testing into Australia’s public health system. As more patients’ genomic data is being held by the public health system, there will be increased requests from researchers to access this data. It is important that public policy reflects public expectations for how genomic data that is generated from clinical tests is used. To inform public policy and discussions around genomic data sharing, we sought public opinions on using genomic (...) data contained in medical records for research purposes in the Australian state of Queensland. Methods A total of 1494 participants completed an online questionnaire between February and May 2019. Participants were adults living in Australia. The questionnaire explored participant preferences for sharing genomic data or biological samples with researchers, and concerns about genomic data sharing. Results Most participants wanted to be given the choice to have their genomic data from medical records used in research. Their expectations on whether and how often they needed to be approached for permission on using their genomic data, depended on whether the data was identifiable or anonymous. Their willingness to sharing data for research purposes depended on the type of information being shared, what type of research would be undertaken and who would be doing the research. Participants were most concerned with genomics data sharing that could lead to discrimination, data being used for marketing, data security, or commercial use. Conclusions Most participants were willing to share their genomic data from medical records with researchers, as long as permission for use was sought. However, the existing policies related to this process in Queensland do not reflect participant expectations for how this is achieved, particularly with anonymous genomics data. This inconsistency may be addressed by process changes, such as inclusion of research in addition to clinical consent or general research data consent programs. (shrink)

This paper examines how the application of legal fiduciary principles , can serve as a framework to promote management of clinical genomic “incidental” or secondary target findings that is patient-centered and consistent with recognized patient autonomy rights. The application of fiduciary principles to the clinical genomic testing context gives rise to at least four physician fiduciary duties in conflict with recent recommendations by the American College of Medical Genetics and Genomics . These recommendations have generated much debate (...) among lawyers, clinicians, and bioethicists hence I believe this publication will be of value and interest to your readership. (shrink)

The invisibility of nursing work has been discussed in the international literature but not in relation to learning clinical skills. Evans and Guile's (Practice‐based education: Perspectives and strategies, Rotterdam: Sense, 2012) theory of recontextualisation is used to explore the ways in which invisible or unplanned and unrecognised learning takes place as newly qualified nurses learn to delegate to and supervise the work of the healthcare assistant. In the British context, delegation and supervision are thought of as skills which are (...) learnt “on the job.” We suggest that learning “on‐the‐job” is the invisible construction of knowledge in clinical practice and that delegation is a particularly telling area of nursing practice which illustrates invisible learning. Using an ethnographic case study approach in three hospital sites in England from 2011 to 2014, we undertook participant observation, interviews with newly qualified nurses, ward managers and healthcare assistants. We discuss the invisible ways newly qualified nurses learn in the practice environment and present the invisible steps to learning which encompass the embodied, affective and social, as much as the cognitive components to learning. We argue that there is a need for greater understanding of the “invisible learning” which occurs as newly qualified nurses learn to delegate and supervise. (shrink)