...that experimental treatments should potentially be embarked upon without delay. 9 In Charlie's case, it is ironic that delayed decision-making means that he could have received nucleoside ...treatment months ago, and by the time the case was finally concluded in court it would have been possible to assess if it had led to any improvement, or not. ...there are of course limits to aggressively offering experimental treatment, particularly where the side effects of treatment may make it highly likely not to be in the individual's interests. Is there an alternative? Because of the formidable epistemic and normative challenges in determining when treatment is futile, 12 one solution in some jurisdictions has been to focus on developing a fair and legally supported due process for decision-making. 13 14 There are two key components to this process that could and arguably should be adopted in the UK for future disputes about treatment. ...they are to have 'sympathetic knowledge… of those human interests which, by conflicting in particular cases, give rise to the need to make a moral decision'.
Questions about the dignity of the human person give rise to
many of the most central and hotly disputed topics in bioethics. In
A Defense of Dignity: Creating Life, Destroying Life, and
Protecting ...the Rights of Conscience , Christopher Kaczor
investigates whether each human being has intrinsic dignity and
whether the very concept of "dignity" has a useful place in
contemporary ethical debates. Kaczor explores a broad range of
issues addressed in contemporary bioethics, including whether there
is a duty of "procreative beneficence," the ethics of ectopic
pregnancy, and the possibility of "rescuing" human embryos with
human wombs or artificial wombs. A Defense of Dignity also
treats issues relevant to the end of life, including
physician-assisted suicide, provision of food and water to patients
in a persistent vegetative state, and how to proceed with organ
donation following death. Finally, what are the duties and
prerogatives of health care professionals who refuse in conscience
to take part in activities that they regard as degrading to human
dignity? Should they be forced to do what they consider to be
violations of the patient's well being, or does patient autonomy
always trump the conscience of a health care professional? Grounded
in the Catholic intellectual and moral tradition, A Defense of
Dignity argues that all human beings from the beginning to the
end of their lives should be treated with respect and considers how
this belief should be applied in controversial cases.
John Dewey, widely known as "America's philosopher," provided important insights into education and political philosophy, but surprisingly never set down a complete moral or ethical philosophy. ...Gregory Fernando Pappas presents the first systematic and comprehensive treatment of Dewey's ethics. By providing a pluralistic account of moral life that is both unified and coherent, Pappas considers ethics to be key to an understanding of Dewey's other philosophical insights, especially his views on democracy. Pappas unfolds Dewey's ethical vision by looking carefully at the virtues and values of ideal character and community. Showing that Dewey's ethics are compatible with the rest of his philosophy, Pappas corrects the reputation of American pragmatism as a philosophy committed to skepticism and relativism. Readers will find a robust and boldly detailed view of Dewey's ethics in this groundbreaking book.
Incommensurability is the impossibility to determine how two options relate to each other in terms of conventional comparative relations. This book features new research on incommensurability from ...philosophers who have shaped the field into what it is today, including John Broome, Ruth Chang and Wlodek Rabinowicz. The book covers four aspects relating to incommensurability. In the first part, the contributors synthesize research on the competing views of how to best explain incommensurability. Part II illustrates how incommensurability can help us deal with seemingly insurmountable problems in ethical theory and population ethics. The contributors address the Repugnant Conclusion, the Mere Addition Paradox and so-called Spectrum Arguments. The chapters in Part III outline and summarize problems caused by incommensurability for decision theory. Finally, Part IV tackles topics related to risk, uncertainty and incommensurability. Value Incommensurability: Ethics, Risk, and Decision-Making will be of interest to researchers and advanced students working in ethical theory, decision theory, action theory, and philosophy of economics.
Objective
To describe health‐care personnel's (HCP's) perceptions of the ethical climate at their workplace in paediatric oncology.
Methods
A cross‐sectional survey was conducted using the Swedish ...version of the shortened Hospital Ethical Climate Survey (HECS‐S). HCP at all six paediatric oncology centres (POCs) in Sweden were invited to participate. Analysis included descriptive statistics, the Mann‐Whitney U test (differences between groups) and Spearman's rank correlation. Informed consent was assumed when the respondents returned the survey.
Results
A high response rate was achieved as 278 HCP answered the questionnaire. Medical doctors perceived the ethical climate to be more positive than registered nurses and nursing assistants. At the POC with the significantly lowest values concerning immediate manager, no significant correlation with the other items was found. At the POC with the poorest ethical climate, HCP also had the lowest perception of the possibility of practicing ethically good care.
Conclusions
Differences between centres and professional groups have been demonstrated. A negative perception of the immediate manager does not necessarily mean that the ethical climate is poor, but the manager's ability to provide the conditions for an open dialogue within the health‐care team is key to achieving an ethical climate.
Although moral distress is now a well-recognized phenomenon among all of the healthcare professions, few evidence-based strategies have been published to address it. In morally distressing ...situations, the “presenting problem” may be a particular patient situation, but most often signals a deeper unit- or system-centered issue. This article describes one institution’s ongoing effort to address moral distress in its providers. We discuss the development and evaluation of the Moral Distress Consultation Service, an interprofessional, unit/system-oriented approach to addressing and ameliorating moral distress.
Ethics consultations increasingly are being used to resolve conflicts about life-sustaining interventions, but few studies have reported their outcomes.
To investigate whether ethics consultations in ...the intensive care setting reduce the use of life-sustaining treatments delivered to patients who ultimately did not survive to hospital discharge, as well as the reactions to the consultations of physicians, nurses, and patients/surrogates.
Prospective, multicenter, randomized controlled trial from November 2000 to December 2002.
Adult intensive care units (ICUs) of 7 US hospitals representing a spectrum of institutional characteristics.
Five hundred fifty-one patients in whom value-related treatment conflicts arose during the course of treatment.
Patients were randomly assigned either to an intervention (ethics consultation offered) (n = 278) or to usual care (n = 273).
The primary outcomes were ICU days and life-sustaining treatments in those patients who did not survive to hospital discharge. We examined the same measures in those who did survive to discharge and also compared the overall mortality rates of the intervention and usual care groups. We also interviewed physicians and nurses and patients/surrogates about their views of the ethics consultation.
The intervention and usual-care groups showed no difference in mortality. However, ethics consultations were associated with reductions in hospital (-2.95 days, P =.01) and ICU (-1.44 days, P =.03) days and life-sustaining treatments (-1.7 days with ventilation, P =.03) in those patients who ultimately did not survive to discharge. The majority (87%) of physicians, nurses, and patients/surrogates agreed that ethics consultations in the ICU were helpful in addressing treatment conflicts.
Ethics consultations were useful in resolving conflicts that may have inappropriately prolonged nonbeneficial or unwanted treatments in the ICU.
Background
Many hospitalized adults do not have the capacity to make their own health care decisions and thus require a surrogate decision-maker. While the ethical standard suggests that decisions ...should focus on a patient’s preferences, our study explores the principles that surrogates consider most important when making decisions for older hospitalized patients.
Objectives
We sought to determine how frequently surrogate decision-makers prioritized patient preferences in decision-making and what factors may predict their doing so.
Design and Participants
We performed a secondary data analysis of a study conducted at three local hospitals that surveyed surrogate decision-makers for hospitalized patients 65 years of age and older.
Main Measures
Surrogates rated the importance of 16 decision-making principles and selected the one that was most important. We divided the surrogates into two groups: those who prioritized patient preferences and those who prioritized patient well-being. We analyzed the two groups for differences in knowledge of patient preferences, presence of advance directives, and psychological outcomes.
Key Results
A total of 362 surrogates rated an average of six principles as being extremely important in decision-making; 77.8% of surrogates selected a patient well-being principle as the most important, whereas only 21.1% selected a patient preferences principle. Advance directives were more common to the
patient preferences
group than the
patient well-being
group (61.3% vs. 44.9%; 95% CI: 1.01–3.18;
p
= 0.04), whereas having conversations with the patient about their health care preferences was not a significant predictor of surrogate group identity (81.3% vs. 67.4%; 95% CI: 0.39–1.14;
p
= 0.14). We found no differences between the two groups regarding surrogate anxiety, depression, or decisional conflict.
Conclusions
While surrogates considered many factors, they focused more often on patient well-being than on patient preferences, in contravention of our current ethical framework. Surrogates more commonly prioritized patient preferences if they had advance directives available to them.
Biomedical research is increasingly globalized with ever more research conducted in low and middle-income countries. This trend raises a host of ethical concerns and critiques. While community ...engagement (CE) has been proposed as an ethically important practice for global biomedical research, there is no agreement about what these practices contribute to the ethics of research, or when they are needed.
In this paper, we propose an ethical framework for CE. The framework is grounded in the insight that relationships between the researcher and the community extend beyond the normal bounds of the researcher-research participant encounter and are the foundation of meaningful engagement. These relationships create an essential "human infrastructure" - a web of relationships between researchers and the stakeholder community-i.e., the diverse stakeholders who have interests in the conduct and/or outcomes of the research. Through these relationships, researchers are able to address three core ethical responsibilities: (1) identifying and managing non-obvious risks and benefits; (2) expanding respect beyond the individual to the stakeholder community; and (3) building legitimacy for the research project.
By recognizing the social and political context of biomedical research, CE offers a promising solution to many seemingly intractable challenges in global health research; however there are increasing concerns about what makes engagement meaningful. We have responded to those concerns by presenting an ethical framework for CE. This framework reflects our belief that the value of CE is realized through relationships between researchers and stakeholders, thereby advancing three distinct ethical goals. Clarity about the aims of researcher-stakeholder relationships helps to make engagement programs more meaningful, and contributes to greater clarity about when CE should be recommended or required.
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