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)

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)

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)

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)

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)

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)

Metaphysics, morals and science -- The classics : value -- The neo-classics : utility -- The Keynesian revolution -- Development and under-development -- What are the rules of the game?

It is time for the noon conference. Your job is to impart a career-changing experience in ethics to a group of students and interns gathered from four different schools with varying curriculums in ethics. They have just finished 1½ h of didactic sessions and lunch. One third of them were on call last night. Your first job is to keep them awake. The authors argue that this “tragic case” approach to ethics education is of limited value because it limits understanding (...) of moral problems to dilemmas; negates the moral agency of the student; encourages solutions that are merely intellectual; and suggests that ethical encounters are a matter for experts. The authors propose an alternative that focuses on three issues: the provider-patient relationship, the relationships between providers in the everyday world of health work and, the social position of healthcare providers in society. In this approach, teachers are not experts but more like guides on a journey who help students to learn that much of ethical practice comprises living through difficult situations of caring for vulnerable others and who help students to navigate some of these difficulties. (shrink)

The authors developed this textbook in response to an increasing interest in ethics, and a growing number of courses on this topic that are now being offered in educational leadership programs. It is designed to fill a gap in instructional materials for teaching the ethics component of the knowledge base that has been established for the profession. The text has several purposes: First, it demonstrates the application of different ethical paradigms (the ethics of justice, care, critique, and the profession) through (...) discussion and analysis of real-life moral dilemmas that educational leaders face in their schools and communities. Second, it addresses some of the practical, pedagogical, and curricular issues related to the teaching of ethics for educational leaders. Third, it emphasizes the importance of ethics instruction from a variety of theoretical approaches. Finally, it provides a process that instructors might follow to develop their own ethics unit or course. * Part I provides an overview of why ethics is so important, especially for today's educational leaders, and describes a multiparadigm approach essential to practitioners as they grapple with ethical dilemmas. * Part II deals with the dilemmas themselves. Ethical dilemmas written by the authors' graduate students bring readers face-to-face with the kinds of dilemmas faced by practicing administrators in urban, suburban, and rural settings in an era full of complexities and contradictions. * Part III focuses on pedagogy and provides teaching notes for the instructor. The authors discuss the importance of self-reflection on the part of both instructors and students, and model how they thought through their own personal and professional ethical codes as well as reflected upon the critical incidents in their lives that shaped their teaching and frequently determined what they privileged in class. (shrink)

When (if ever) may a professional deceive a client for the client's own good? Under what conditions (if any) is whistle-blowing morally required? These are just some of the questions that scholars as diverse as Michael D. Bayles, Thomas Nagel, Sissela Bok, Jessica Mitford, and Peter A. French confront in this stimulating anthology. Organized around philosophical issues such as the moral foundations of professional ethics, models of the professional-client relationship, deception, informed consent, privacy and confidentiality, professional dissent, and professional virtue, (...) the volume illuminates the complex ethical issues that arise in journalism, law, health care, counselling, education, engineering, business, politics, and social science research. A variety of pedagogical aids--including clear introductions to and study questions for each set of readings, concrete cases designed to focus discussion, and an appendix on preparing cases and position papers--makes the text invaluable for both students and teachers of professional ethics. (shrink)

In spite of feminist recognition that hierarchical organizations are an important location of male dominance, most feminists writing about organizations assume that organizational structure is gender neutral. This article argues that organizational structure is not gender neutral; on the contrary, assumptions about gender underlie the documents and contracts used to construct organizations and to provide the commonsense ground for theorizing about them. Their gendered nature is partly masked through obscuring the embodied nature of work.jobs and hierarchies, common concepts in organizational (...) thinking, assume a disembodies and universal worker. This worker is actually a man; men's bodies, sexuality, and relationships to procreation and paid work are subsumed in the image of the worker. Images of men's bodies and masculinity pervade organizational processes, marginalizing women and contributing to the maintenance of gender segregation in organizations. The positing of gender-neutral and disembodied organizational structures and work relations is part of the larger strategy of control in industrial capitalist societies, which, at least partly, are built upon a deeply embedded substructure of gender difference. (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)

A holobiont is a composite organism consisting of a host together with its microbiome, such as a coral with its zooxanthellae. To explain the often intimate integration between hosts and their microbiomes, some investigators contend that selection operates on holobionts as a unit and view the microbiome’s genes as extending the host’s nuclear genome to jointly comprise a hologenome. Because vertical transmission of microbiomes is uncommon, other investigators contend that holobiont selection cannot be effective because a holobiont’s microbiome is an (...) acquired condition rather than an inherited trait. This disagreement invites a simple mathematical model to see how holobiont selection might operate and to assess its plausibility as an evolutionary force. This paper presents two variants of such a model. In one variant, juvenile hosts obtain microbiomes from their parents (vertical transmission). In the other variant, microbiomes of juvenile hosts are assembled from source pools containing the combined microbiomes of all parents (horizontal transmission). According to both variants, holobiont selection indeed causes evolutionary change in holobiont traits. Therefore, holobiont selection is plausibly an effective evolutionary force with either mode of microbiome transmission. The modeling employs two distinct concepts of inheritance, depending on the mode of microbiome transmission: collective inheritance whereby juveniles inherit a sample of the collected genomes from all parents, as contrasted with lineal inheritance whereby juveniles inherit the genomes from only their own parents. A distinction between collective and lineal inheritance also features in theories of multilevel selection. (shrink)

In this article, the author addresses two feminist issues: first, how to conceptualize intersectionality, the mutual reproduction of class, gender, and racial relations of inequality, and second, how to identify barriers to creating equality in work organizations. She develops one answer to both issues, suggesting the idea of “inequality regimes” as an analytic approach to understanding the creation of inequalities in work organizations. Inequality regimes are the interlocked practices and processes that result in continuing inequalities in all work organizations. Work (...) organizations are critical locations for the investigation of the continuous creation of complex inequalities because much societal inequality originates in such organizations. Work organizations are also the target for many attempts to alter patterns of inequality: The study of change efforts and the oppositions they engender are often opportunities to observe frequently invisible aspects of the reproduction of inequalities. The concept of inequality regimes may be useful in analyzing organizational change projects to better understand why these projects so often fail and why they succeed when this occurs. (shrink)

This book undertakes an extensive study of the constellation of two eminent thinkers of post-idealism for the first time. The contributions in this volume analyze the relationship between Schopenhauer and Kierkegaard systematically and historically from a number of thematic perspectives: metaphysics and ethics, freedom and original sin, existential philosophy and the theory of suffering, art and aesthetics, religion and science. The book also goes into Kierkegaard s explicit disagreement with Schopenhauer and last but not least discusses the conflicting poles of (...) idealism and modernity. The volume is rounded off by a first complete and annotated German translation of the notes on Schopenhauer, which Kierkegaard wrote in his late journals.". (shrink)

En 1994, Sue Rodriguez se suicide avec l’aide d’un médecin après une intense bataille judiciaire en Cour suprême du Canada dont l’objet était la décriminalisation du suicide assisté. À la suite de ce suicide, aucune accusation criminelle ne fut portée contre la ou les personnes ayant présumément aidé Sue Rodrigues à mettre fin à ses jours, et ce malgré le fait que le suicide assisté est un acte criminel au Canada. Cette non-intervention du droit pénal est examinée en fonction du (...) rôle que l’affaire Rodriguez a pu jouer dans la transformation des moralités au Canada. Dans ce livre, le suicide assisté de Sue Rodriguez est envisagé comme un « crime » utile (au sens durkheimien du terme), car il met en évidence une inconsistance entre les moralités dominantes inscrites dans le droit pénal et les conditions sociales qui ont rendu ce « crime » possible. Apparenté au crime de Socrate, le « crime » de Sue Rodriguez est analysé comme un héraut annonciateur de nouvelles moralités, comme un prélude préparant directement la voie à des changements dans le poids accordé aux moralités dominantes. Dans ce contexte, le rôle du droit pénal comme mode privilégié de régulation morale est remis en question. (shrink)

This latest volume in the Oxford Readings in Feminism series presents the results of the multi-disciplinary feminist exploration of the distinction between public and private. Contributors demonstrate the significance of the distinction in feminist theory, its articulation in the modern and late modern public sphere, and its impact on identity politics within feminism in recent years. Feminism, the Public and the Private offers an essential perspective on feminist theory for students and teachers of women's and gender studies, cultural studies, history, (...) political theory, geography and sociology. (shrink)

Geroscience and philosophy of aging have tended to focus their analyses on the biological and chronological dimensions of aging. Namely, one ages with the passage of time and by experiencing the cellular-molecular deterioration that accompanies this process. However, our concept of aging depends decisively on the social valuations held about it. In this article, we will argue that, if we study social aging in the contemporary world, a novel phenomenon can be identified: the paradox of aging in the digital era. (...) If the social understanding of aging today is linked to unproductivity and obsolescence; then there is a possibility that, given the pace of change of digital technologies, we become obsolete at an early chronological and biological age, and therefore, feel old at a younger age. First, we will present the social dimension of aging based on Rowe and Kahn's model of successful aging. We will also show that their notion of social aging hardly considers structural aspects and weakens their approach. Second, departing from social aging in its structural sense, we will develop the paradox of aging in the digital era. On the one hand, we will explain how the institutionalization of aging has occurred in modern societies and how it is anchored in the concepts of obsolescence and productivity. On the other hand, we will state the kind of obsolescence that digitalization produces and argue that it can make cohorts of biologically and chronologically young individuals obsolete, and thus they would be personally and socially perceived as old. (shrink)

Not only can the influence of Gottlob Frege be found in contemporary work in logic, the philosophy of mathematics, and the philosophy of language, but his projects—and the very terminology he employed in pursuing those projects—are still current in contemporary philosophy. This is undoubtedly why it seems so reasonable to assume that we can read Frege' s writings as if he were one of us, speaking to our philosophical concerns in our language. In Joan Weiner's view, however, Frege's words (...) can be accurately interpreted only if we set that assumption aside. Weiner here offers a challenging new approach to the philosophy of this central figure in analytic philosophy. Weiner finds in Frege's corpus, from Begriffsschrift on, a unified project of remarkable ambition to which each of the writings in that corpus makes a distinct contribution—a project whose motivation she brings to life through a careful reading of his Foundations of Arithmetic. The Frege that Weiner brings into clear view is very different from the familiar figure. Far from having originated one of the standard positions on the nature of reference, Frege turns out not to have had positive doctrines on anything like what contemporary philosophers mean by "reference." Far from having served as a standard-bearer for those who take the realists' side of contemporary disputes with anti-realists, Frege turns out to have had no stake in either side of the controversy. Through Weiner's lens, Frege emerges as a thinker who has principled reasons for challenging the very assumptions and motivations that animate philosophers to dispute these doctrines. This lucidly written and accessible book will generate controversy among all readers with an interest in epistemology, philosophy of language, history of philosophy, and the philosophy of mathematics. (shrink)

Sovint el humans ens hem somiat déus. I Déu n'hi do si hem fet coses admirables: ciència, organització social, art,...motius n'hi ha per estar orgullosos. La vida, però, també ens mostra amb insistència la cara més fosca de nosaltres mateixos, i en aquests moments el més fàcil és passar de l'orgull a la desesperança més absoluta. El camí, però, no pot ser el de l'abandonament. Ni déus ni bèsties! Els déus no trien i, sense esforç ni dubtes, coneixen i realitzen (...) sempre el millor. Els animals, empresonats en la seva naturalesa, tampoc no trenquen gaire el cap a decidir què faran amb les seves vides. Nosaltres no tenim la sort dels uns ni la dels altres, i ens toca amb feines i treballs anar bastint la nostra realitat, aquella que nosaltres farem. Per això existeix l'ètica. "Coneix-te a tu mateix", ordenava l'oracle: només amb les nostres llums i amb les nostres ombres, amb l'instint, amb la ràbia, amb el sentiment, amb la paraula, amb la raó; només coneixent i assumint tot allò que som, tindrem la possibilitat, tal vegada, de construir un món més humà. (shrink)