Despite over three decades of research into the sources and costs of what has become an “epidemic” of moral distress among healthcare professionals, spanning many clinical disciplines and roles, there has been little significant progress in effectively addressing moral distress. We believe the persistent sense of frustration, helplessness, and despair still dominating the clinical moral distress narrative signals a need for re-orientation in the way moral distress is understood and worked with. Most fundamentally, moral distress reveals moral investment and energy. (...) It is the troubled call of conscience, an expression of fidelity to moral commitments seen as imperiled or compromised.It is crucial that we find ways to empower clinicians in heeding this call—to support clinicians’ moral agency and voice, foster their moral resilience, and facilitate their ability to contribute to needed reform within the organizations and systems in which they work. These objectives must inform creative expansion in the design of strategies for addressing moral distress in the day-to-day of clinical practice. We include suggestions about promising directions such strategies might take in the hope of spurring further innovation within clinical environments. (shrink)

Undisputedly, the United States’ health care system is in the midst of unprecedented complexity and transformation. In 2014 alone there were well over thirty‐five million admissions to hospitals in the nation, indicating that there was an extraordinary number of very sick and frail people requiring highly skilled clinicians to manage and coordinate their complex care across multiple care settings. Medical advances give us the ability to send patients home more efficiently than ever before and simultaneously create ethical questions about the (...) balance of benefits and burdens associated with these advances. Every day on every shift, nurses at the bedside feel an intense array of ethical issues. At the same time, administrators, policy‐makers, and regulators struggle to balance commitments to patients, families, staff members, and governing boards. Ethical responsibilities and the fiduciary, regulatory, and community service goals of health care institutions are not mutually exclusive; they must go hand in hand. If they do not, our health care system will continue to lose valued professionals to moral distress, risk breaking the public's trust, and potentially undermine patient care. At this critical juncture in health care, we must look to new models, tools, and skills to confront contemporary ethical issues that impact clinical practice. The antidote to the current reality is to create a new health care paradigm grounded in compassion and sustained by a culture of ethical practice. (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)

This narrative symposium illuminates the problem of clinician moral distress. NIB editorial staff and narrative symposium editors, Cynda Rushton, PhD, RN, FAAN and Renee Boss, MD, MHS, developed a call for stories, which was sent to several list serves and posted on Narrative Inquiry in Bioethics’ website. The request for personal stories from inter–professional healthcare providers asked them to: identify specific clinical situations that give rise to moral distress; discuss the sources of this distress; reflect on how they (...) experienced moral distress—physically, psychologically, socially, or spiritually; assess how they managed their situations; and offer suggestions for avoiding future problems of a similar nature. Twelve stories are found in the print version of the journal and an additional eight supplemental stories are published online only through Project MUSE. The clinicians describe a wide range of experiences with patients, other clinicians, and their own professional and personal identities. Embedded in each of the narratives are deeply felt emotions that accompany their experiences of moral distress. Katherine Brown-Saltzman (a nurse), Alisa Carse (a philosopher), Zhanna Bagdasarov and Shane Connelly (industrial–organizational psychologists), and Nancy Berlinger (a bioethicist) provided commentaries. (shrink)

Although the concept of dignity is commonly invoked in clinical care, there is not widespread agreement—in either the academic literature or in everyday clinical conversations—about what dignity means. Without a framework for understanding dignity, it is difficult to determine what threatens patients’ dignity and, conversely, how to honor commitments to protect and promote it. This article aims to change that by offering the first conceptual model of dignity for patients in the intensive care unit. The conceptual model we present is (...) based on the notion that there are three sources of patients’ dignity—their shared humanity, personal narratives, and autonomy—each of which independently warrants respect. The article describes each source of dignity and draws on examples to illustrate how clinician attitudes, actions, and behaviors can either contribute to, or detract from, expressions of respect for patient dignity. (shrink)

The COVID-19 pandemic has inspired numerous opportunities for telehealth implementation to meet diverse healthcare needs, including the use of virtual communication platforms to facilitate the growth of and access to clinical ethics consultation (CEC) services across the globe. Here we discuss the conceptualization and implementation of two different virtual CEC services that arose during the COVID-19 pandemic: the Clinical Ethics Malaysia COVID-19 Consultation Service and the Johns Hopkins Hospital Ethics Committee and Consultation Service. A common strength experienced by both platforms (...) during virtual delivery included improved ability for local practitioners to address consultation needs for patient populations otherwise unable to access CEC services in their respective locations. Additionally, virtual platforms allowed for enhanced collaboration and sharing of expertise among ethics consultants. Both contexts encountered numerous challenges related to patient care delivery during the pandemic. The use of virtual technologies resulted in decreased personalization of patient-provider communication. We discuss these challenges with respect to contextual differences specific to each service and setting, including differences in CEC needs, sociocultural norms, resource availability, populations served, consultation service visibility, healthcare infrastructure, and funding disparities. Through lessons learned from a health system in the United States and a national service in Malaysia, we provide key recommendations for health practitioners and clinical ethics consultants to leverage virtual communication platforms to mitigate existing inequities in patient care delivery and increase capacity for CEC globally. (shrink)

Discussion of the ethics of forgoing medically provided nutrition and hydration tends to focus on adults rather than infants and children. Many appellate court decisions address the legal propriety of forgoing medically provided nutritional support of adults, but only a few have ruled on pediatric cases that pose the same issue.The cessation of nutritional support is implemented most commonly for patients in a permanent vegetative state ). An estimated 4,000 to 10,000 American children are in the permanent vegetative state, compared (...) to 10,000 to 25,000 adults. Yet the dearth of literature, case reports, and court decisions suggests that physicians and families of pediatric patients stop medically provided nutrition or seek court orders much less frequently. (shrink)

Little is known about health care professionals’ perceptions regarding what it means to treat patients and families with respect and dignity in the intensive care unit (ICU) setting. To address this gap, we conducted nine focus groups with different types of health care professionals (attending physicians, residents/fellows, nurses, social workers, pastoral care, etc.) working in either a medical or surgical ICU within the same academic health system. We identified three major thematic domains, namely, intrapersonal (attitudes and beliefs), interpersonal (behaviors), and (...) system (contextual) factors that influence treatment with respect and dignity. Participants suggested strategies for improving treatment of patients and families in the ICU with respect and dignity, as well as the related need for enhancing respect among the multidisciplinary team of clinicians. Implementing these strategies will require innovative educational interventions and leadership. Future research should focus on the design and evaluation of such interventions on the quality of care. (shrink)

Analytic philosophy has become the dominant philosophical tradition in the English-speaking world. This book illuminates that tradition through a historical examination of a crucial period in its formation: the rejection of Idealism by Bertrand Russell and G.E. Moore at the beginning of the twentieth century, and the subsequent development of Russell's thought in the period before the First World War.

Quine was one of the foremost philosophers of the Twentieth century. In this outstanding overview of Quine's philosophy, Peter Hylton shows why Quine is so important and how his philosophical naturalism has been so influential within analytic philosophy. Beginning with an overview of Quine's philosophical background in logic and mathematics and the role of Rudolf Carnap's influence on Quine's thought, he goes on to discuss Quine's famous analytic-synthetic distinction and his arguments concerning the nature of the a priori. He (...) also discusses Quine's philosophy of language and epistemology, his celebrated theory of the indeterminacy of translation and his broader views of ontology and modality. This book is essential reading for anyone interested in Quine, twentieth century philosophy and the philosophy of language. (shrink)

In 'Two Dogmas of Empiricism', Quine attacks the analytic/synthetic distinction and defends a doctrine that I call epistemological holism. Now, almost fifty years after the article's appearance, what are we to make of these ideas? I suggest that the philosophical naturalism that Quine did so much to promote should lead us to reject Quine's brief against the analytic/synthetic distinction; I also argue that Quine misunderstood Carnap's views on analyticity. As for epistemological holism, I claim that this thesis does not follow (...) from the logical point that Duhem and Quine made about the role of auxiliary assumptions in hypothesis testing, and that the thesis should be rejected. \\\ [Peter Hylton] Section I of this essay discusses Quine's views about reference, contrasting them with those of Russell. For the latter, our language and thought succeed in being about the world because of our acquaintance with objects; the relation of reference-roughly, the relation between a name and its bearer-is thus fundamental. For Quine, by contrast, the fundamental relation by which our language comes to be about the world, and to have empirical content, is that between a sentence and stimulations of our sensory surfaces; reference, while important, is a derivative notion. Section II shows how this view of reference as derivative makes possible the notorious Quinean doctrine of ontological relativity. Section III raises the issue of realism. It argues that somewhat different notions of realism are in play for Quine and for Russell-for Russell, objects, and our knowledge of objects, play the fundamental role, while for quine objectivity and truth are fundamental, with ontology being derivative. (shrink)

[Elliott Sober] In 'Two Dogmas of Empiricism', Quine attacks the analytic/synthetic distinction and defends a doctrine that I call epistemological holism. Now, almost fifty years after the article's appearance, what are we to make of these ideas? I suggest that the philosophical naturalism that Quine did so much to promote should lead us to reject Quine's brief against the analytic/synthetic distinction; I also argue that Quine misunderstood Carnap's views on analyticity. As for epistemological holism, I claim that this thesis does (...) not follow from the logical point that Duhem and Quine made about the role of auxiliary assumptions in hypothesis testing, and that the thesis should be rejected. \\\ [Peter Hylton] Section I of this essay discusses Quine's views about reference, contrasting them with those of Russell. For the latter, our language and thought succeed in being about the world because of our acquaintance with objects; the relation of reference-roughly, the relation between a name and its bearer-is thus fundamental. For Quine, by contrast, the fundamental relation by which our language comes to be about the world, and to have empirical content, is that between a sentence and stimulations of our sensory surfaces; reference, while important, is a derivative notion. Section II shows how this view of reference as derivative makes possible the notorious Quinean doctrine of ontological relativity. Section III raises the issue of realism. It argues that somewhat different notions of realism are in play for Quine and for Russell-for Russell, objects, and our knowledge of objects, play the fundamental role, while for quine objectivity and truth are fundamental, with ontology being derivative. (shrink)

We explored teachers? views and students? experiences of going beyond the syllabus in Advanced (A) level Mathematics. Questionnaires were sent to teachers and students in a sample of 200 schools and colleges. Teachers were asked about the necessity, importance and benefits of additional teaching. Students were asked about the extra activities they undertook. Forty-seven teacher questionnaires and 299 student questionnaires were completed. Over half of the students claimed to undertake at least some extra activities. Although a few teachers thought teaching (...) beyond the syllabus was unimportant and unnecessary, over 70% felt it should be undertaken if time allowed. Teaching efficacy was measured by comparing each teacher?s students? Mathematics results with those students? results in other A level subjects. Significantly more teachers with relatively high Mathematics results than with relatively low results believed teaching beyond the syllabus strengthens and expands students? existing knowledge and adds interest to the course. (shrink)

The work of Bertrand Russell had a decisive influence on the emergence of analytic philosophy, and on its subsequent development. The prize-winning Russell scholar Peter Hylton presents here some of his most celebrated essays from the last two decades, all of which strive to recapture and articulate Russell's monumental vision. Relating his work to that of other philosophers, particularly Frege and Wittgenstein, and featuring a previously unpublished essay and a helpful new introduction, the volume will be essential for anyone (...) engaged with the history of twentieth-century ideas. (shrink)