Background:Moral distress occurs when constraints prevent healthcare providers from acting in accordance with their core moral values to provide good patient care. The experience of moral distress in nurses might be magnified during the current Covid-19 pandemic.Objective:To explore causes of moral distress in nurses caring for Covid-19 patients and identify strategies to enhance their moral resiliency.Research design:A qualitative study using a qualitative content analysis of focus group discussions and in-depth interviews. We purposively sampled 31 nurses caring for Covid-19 patients in (...) the acute care units within large academic medical systems in Maryland and New York City during April to June 2020.Ethical considerations:We obtained approval from the Institutional Review Board at the University of Maryland, Baltimore.Results:We identified themes and sub-themes representative of major causes of moral distress in nurses caring Covid-19 patients. These included (a) lack of knowledge and uncertainty regarding how to treat a new illness; (b) being overwhelmed by the depth and breadth of the Covid-19 illness; (c) fear of exposure to the virus leading to suboptimal care; (d) adopting a team model of nursing care that caused intra-professional tensions and miscommunications; (e) policies to reduce viral transmission (visitation policy and PPE policy) that prevented nurses to assume their caring role; (f) practicing within crisis standards of care; and (g) dealing with medical resource scarcity. Participants discussed their coping mechanisms and suggested future strategies.Discussion/Conclusion:Our study affirms new causes of moral distress related to the Covid-19 pandemic. Institutions need to develop a supportive ethical climate that can restore nurses’ moral resiliency. Such a climate should include non-hierarchical interdisciplinary spaces where all providers can meet together as moral peers to discuss their experiences. (shrink)

A commentary on “SUPPORT: Risks, Harms, and Equipoise,” by Robert M. Nelson; “The Controversy over SUPPORT Continues and the Hyperbole Increases,” by Alan R. Fleischman; and “SUPPORT and the Ethics of Study Implementation,” by John D. Lantos and Chris Feudtner, all in the January‐February 2015 issue.

Available in paperback for the first time, this landmark volume examines the course of Western philosophy over the past 2,500 years. A Critical History of Western Philosophy focuses on the most significant thinkers and philosophical movements while emphasizing key ideas of permanent interest and relevance. Arranged chronologically from early Greece to the twentieth century, this comprehensive work includes expert histories of all major figures from Socrates and Plato to G.E. Moore and Bertrand Russell, and of every important school from the (...) Epicureans to the Existentialists. (shrink)

Multiple -conclusion logic extends formal logic by allowing arguments to have a set of conclusions instead of a single one, the truth lying somewhere among the conclusions if all the premises are true. The extension opens up interesting possibilities based on the symmetry between premises and conclusions, and can also be used to throw fresh light on the conventional logic and its limitations. This is a sustained study of the subject and is certain to stimulate further research. Part I reworks (...) the fundamental ideas of logic to take account of multiple conclusions, and investigates the connections between multiple - and single - conclusion calculi. Part II draws on graph theory to discuss the form and validity of arguments independently of particular logical systems. Part III contrasts the multiple - and the single - conclusion treatment of one and the same subject, using many-valued logic as the example; and Part IV shows how the methods of 'natural deduction' can be matched by direct proofs using multiple conclusions. (shrink)

This book explores how Modernist movements all across the Mediterranean basin differed from those of other regions. The chapters show how the political and economic turmoil of a period marked by world war, revolution, decolonization, nationalism, and the rapid advance of new technologies compelled artists, writers, and other intellectuals to create a new hybrid Mediterranean Modernist aesthetic which sought to balance the tensions between local and foreign, tradition and innovation, and colonial and postcolonial.

The effects in a quantum-mechanical system form a partial algebra and a partially ordered set which is the prototypical example of the effect algebras discussed in this paper. The relationships among effect algebras and such structures as orthoalgebras and orthomodular posets are investigated, as are morphisms and group- valued measures (or charges) on effect algebras. It is proved that there is a universal group for every effect algebra, as well as a universal vector space over an arbitrary field.

A commentary on “Were There ‘Additional Foreseeable Risks’ in the SUPPORT Study?,” by Henry J. Silverman and Didier Dreyfuss; “SUPPORT: Risks, Harms, and Equipoise,” by Robert M. Nelson; “The Controversy over SUPPORT Continues and the Hyperbole Increases,” by Alan R. Fleischman; and “SUPPORT and Comparative Effectiveness Trials: What's at Stake?,” by Lois Shepherd, all in the January‐February 2015 issue.

Background: The traditional approach to resolving ethics concerns may not address underlying organisational issues involved in the evolution of these concerns. This represents a missed opportunity to improve quality of care “upstream”. The purpose of this study was to understand better which organisational issues may contribute to ethics concerns. Methods: Directed content analysis was used to review ethics consultation notes from an academic children’s hospital from 1996 to 2006 (N = 71). The analysis utilised 18 categories of organisational issues derived (...) and modified from published quality improvement protocols. Results: Organisational issues were identified in 68 of the 71 (96%) ethics consult notes across a range of patient settings and reasons for consultation. Thirteen of the 18 categories of organisational issues were identified and there was a median of two organisational issues per consult note. The most frequently identified organisational issues were informal organisational culture (eg, collective practices and approaches to situations with ethical dimensions that are not guided by policy), policies and procedures (eg, staff knows policy and/or procedural guidelines for an ethical concern but do not follow it) and communication (eg, communication about critical information, orders, or hand-offs repeatedly does not occur among services). Conclusions: Organisational issues contribute to ethical concerns that result in clinical ethics consults. Identifying and addressing organisational issues such as informal culture and communication may help decrease the recurrence of future similar ethics concerns. (shrink)

Recent studies using functional magnetic resonance imaging of patients in a vegetative state have raised the possibility that such patients retain some degree of consciousness. In this paper, the ethical implications of such findings are outlined, in particular in relation to decisions about withdrawing life-sustaining treatment. It is sometimes assumed that if there is evidence of consciousness, treatment should not be withdrawn. But, paradoxically, the discovery of consciousness in very severely brain-damaged patients may provide more reason to let them die. (...) Although functional neuroimaging is likely to play an increasing role in the assessment of patients in a vegetative state, caution is needed in the interpretation of neuroimaging findings. (shrink)

The physician-patient relationship has changed over the last several decades, requiring a systematic reevaluation of the competing demands of patients, physicians, and families. In the era of genetic testing, using a model of patient care known as the family covenant may prove effective in accounting for these demands. The family covenant articulates the roles of the physician, patient, and the family prior to genetic testing, as the participants consensually define them. The initial agreement defines the boundaries of autonomy and benefit (...) for all participating family members. The physician may then serve as a facilitator in the relationship, working with all parties in resolving potential conflicts regarding genetic information. The family covenant promotes a fuller discussion of the competing ethical claims that may come to bear after genetic test results are received. (shrink)

We bring out the fact that the essential new quality implied by the quantum theory is nonlocality; i.e., that a system cannot be analyzed into parts whose basic properties do not depend on the state of the whole system. This is done in terms of the causal interpretation of the quantum theory, proposed by one of us (D.B.) in 2952, involving the introduction of the “quantum potential.” We show that this approach implies a new universal type of description, in which (...) the standard or canonical form is always supersystem-system-subsystem; and this leads to the radically new notion of unbroken wholeness of the entire universe. Finally, we discuss some of the implications of extending these notions to the relativity domain, and in so doing, we indicate a novel concept of time, in terms of which relativity and quantum theory may eventually be brought together. (shrink)