Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The (...) aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers’ experiences and perceived importance of outcomes of Moral Case Deliberation. (shrink)

BackgroundThere is a lack of empirical research regarding the outcomes of such clinical ethics support methods as moral case deliberation. Empirical research in how healthcare professionals perceive potential outcomes is needed in order to evaluate the value and effectiveness of ethics support; and help to design future outcomes research. The aim was to use the European Moral Case Deliberation Outcome Instrument instrument to examine the importance of various MCD outcomes, according to healthcare professionals, prior to participation.MethodsA North European field survey (...) among healthcare professionals drawn from 73 workplaces in a variety of healthcare settings in the Netherlands, Norway and Sweden. The Euro-MCD instrument was used.ResultsAll outcomes regarding the domains of moral reflexivity, moral attitude, emotional support, collaboration, impact at organisational level and concrete results, were perceived as very or quite important by 76%–97% of the 703 respondents. Outcomes regarding collaboration and concrete results were perceived as most important. Outcomes assessed as least important were mostly about moral attitude. ‘Better interactions with patient/family’ emerged as a new domain from the qualitative analysis. Dutch respondents perceived most of the outcomes as significantly less important than the Scandinavians, especially regarding emotional support. Furthermore, men, those who were younger, and physician-respondents scored most of the outcomes as statistically significantly less important compared with the other respondents.ConclusionsThe findings indicate a need for a broad instrument such as the Euro-MCD. Outcomes related to better interactions between professionals and patients must also be included in the future. The empirical findings raise the normative question of whether outcomes that were perceived as less important, such as moral reflexivity and moral attitude outcomes, should still be included. In the future, a combination of empirical findings and normative reflection will contribute to the revision of the instrument. (shrink)

BackgroundBesides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit.MethodsAnalysis using the ‘Dilemma method’ and ‘wide reflective equilibrium’, on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals.Ethical analysisFour moral questions and associated value conflicts were (...) identified. Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient’s values conflicted with preventing short-term suffering and provision of security. To what extent should the intensivist gain others’ input? Professional independence versus a holistic approach to decision-making. Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised.ConclusionProactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis. (shrink)

The aim of this study was to evaluate agreement between nurses’ and physicians’ opinions regarding aggressiveness of treatment and to investigate and compare the rationales on which their opinions were based. Structured interviews regarding 714 patients were performed on seven general wards of a university hospital. The data gathered were then subjected to qualitative and quantitative analyses. There was 86% agreement between nurses’ and physicians’ opinions regarding full or limited treatment when the answers given as ‘uncertain’ were excluded. Agreement was (...) less (77%) for patients with a life expectancy of less than one year. Disagreements were not associated with professional status because the physicians considered limiting life-sustaining treatment as often as the nurses. A broad spectrum of rationales was given but the results focus mostly on those for full treatment. The nurses and the physicians had similar bases for their opinions. For the majority of the patients, medical rationales were used, but age and quality of life were also expressed as important determinants. When considering full treatment, nurses used quality-of-life rationales for significantly more patients than the physicians. Respect for patients’ wishes had a minor influence. (shrink)

The aim of this study was to describe nurses' conceptions of decision making with regard to life-sustaining treatment for dialysis patients. Semistructured interviews were conducted with 13 nurses caring for such patients at three hospitals. The interview material was subjected to qualitative content analysis. The nurses saw decision making as being characterized by uncertainty and by lack of communication and collaboration among all concerned. They described different ways of handling decision making, as well as insufficiency of physician—nurse collaboration, lack of (...) confidence in physicians, hindrances to patient participation, and ambivalence about the role of patients' next of kin. Future research should test models for facilitating communication and decision making so that decisions will emerge from collaboration of all concerned. Nurses' role in decision making also needs to be discussed. (shrink)

BackgroundMoral case deliberation is one form of clinical ethics support, and there seems to be different ways of facilitating the dialogue.PurposeThis paper aimed to explore Swedish facilitators' experiences of their role in moral case deliberations.MethodThis study had a qualitative approach with explorative design. Semi-structured interviews with eleven MCD facilitators were conducted. Their experiences were analyzed using thematic analysis.ResultBeing a facilitator was understood through the metaphor of sailing: against the wind or with it. The role was likened to a sailor's set (...) of skills: to promote security and well-being of the crew, to help crew navigate their moral reflections, to sail a course into the wind against homogeneity, to accommodate the crew's needs and just sail with the wind, and to steer towards a harbour with authority and expertise. Balancing the disparate roles of being accommodative and challenging may create a free space for emotions and ideas, including self-reflection and con... (shrink)

BackgroundVascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons’ moral reasoning of what ought to be done for the patient.MethodsQualitative, semi-structured interviews were conducted with 19 (...) vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation.ResultsThe surgeons’ moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient’s conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient’s conflicting needs implied weighing the patient’s independence and a sense of being whole against ease of suffering, respecting the patient’s will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one’s power of proficiency, and managing time during the illness course.ConclusionsThis study contributes to uncovering how moral reasoning is embodied in the vascular surgeons’ everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons’ clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care. (shrink)

In Moral Case Deliberation, healthcare professionals discuss ethically difficult patient situations in their daily practice. There is a lack of knowledge regarding the content of MCD and there is a need to shed light on this ethical reflection in the midst of clinical practice. Thus, the aim of the study was to describe the content of healthcare professionals’ moral reasoning during MCD. The design was qualitative and descriptive, and data consisted of 22 audio-recorded inter-professional MCDs, analysed with content analysis. The (...) moral reasoning centred on how to strike the balance between personal convictions about what constitutes good care, and the perceived dissonant care preferences held by the patient. The healthcare professionals deliberated about good care in relation to demands considered to be unrealistic, justifications for influencing the patient, the incapacitated patient’s nebulous interests, and coping with the conflict between using coercion to achieve good while protecting human dignity. Furthermore, as a basis for the reasoning, the healthcare professionals reflected on how to establish a responsible relationship with the vulnerable person. This comprised acknowledging the patient as a susceptible human being, protecting dignity and integrity, defining their own moral responsibility, and having patience to give the patient and family time to come to terms with illness and declining health. The profound struggle to respect the patient’s autonomy in clinical practice can be understood through the concept of relational autonomy, to try to secure both patients’ influence and at the same time take responsibility for their needs as vulnerable humans. (shrink)

Background There has been little attention paid to research on the outcomes of clinical ethics support or critical reflection on what constitutes a good CES outcome. Understanding how CES users perceive the importance of CES outcomes can contribute to a better understanding, use of and normative reflection on CES outcomes. Objective To describe the perceptions of Dutch healthcare professionals on important outcomes of moral case deliberation, prior to MCD participation, and to compare results between respondents. Methods This mixed-methods study used (...) both the Euro-MCD instrument and semi-structured interviews. Healthcare professionals who were about to implement MCD were recruited from nursing homes, hospitals, psychiatry and mentally disabled care institutions. Results 331 healthcare professionals completed the Euro-MCD instrument, 13 healthcare professionals were interviewed. The outcomes perceived as most important were ‘more open communication’, ‘better mutual understanding’, ‘concrete actions’, ‘see the situation from different perspectives’, ‘consensus on how to manage the situation’ and ‘find more courses of action’. Interviewees also perceived improving quality of care, professionalism and the organization as important. Women, nurses, managers and professionals in mentally disabled care rated outcomes more highly than other respondents. Conclusions Dutch healthcare professionals perceived the MCD outcomes related to collaboration as most important. The empirical findings can contribute to shared ownership of MCD and a more specific use of MCD in different contexts. They can inform international comparative research on different CES types and contribute to normative discussions concerning CES outcomes. Future studies should reflect upon important MCD outcomes after having experienced MCD. (shrink)

The evaluation of the European Moral Case Deliberation Outcomes project (Euro-MCD) has resulted in a revised evaluation instrument, knowledge about the content of MCD (moral case deliberation), and the perspectives of those involved. In this paper, we report on a perspective that has been overlooked, the facilitators’. We aim to describe facilitators’ perceptions of high-quality moral case deliberation and their Euro-MCD sessions. The research took place in Norway, Sweden, and the Netherlands using a survey combined with interviews with 41 facilitators. (...) Facilitators’ perceived that attaining a high-quality MCD implies fostering a safe and respectful atmosphere, creating a wondering mode, being an attentive authority, developing moral reflective skills, reaching a common understanding, and ensuring organisational prerequisites for the MCD sessions. Our central conclusion is that efforts at three levels are required to attain a high-quality MCD: trained and virtuous facilitator; committed, respectful participants; and organizational space. Furthermore, managers have a responsibility to prepare MCD participants for what it means to take part in MCD. (shrink)

Developing countries need to reform legislation to ensure the global supply firms in ready-made garment industry is adequately addressing obligations of social responsibility. Literature typically focuses on strategies for raising responsible standards in global buying firms within the RMG industry, but fails to focus on implementing strategies for suppliers in developing countries. This article addresses this gap by specifically focusing on the RMG industry in Bangladesh, the home of the third largest RMG supplier in the world. It concentrates on analysing (...) how and to what extent the law can assist in developing social responsibility performance of the RMG manufacturing firms in developing countries. It ultimately concludes that a new governance approach in laws can effectively increase the social responsibility practice standards of an industry where global buying firms are profit-driven and governmental agencies are either inadequate or corrupt. (shrink)

The notion of harm has been a recurring and a significant notion in the characterization of mental disorder. It is present in eminent diagnostic manuals such as DSM and ICD, as well as in the discussion on mental disorders in philosophy of psychiatry. Recent demotion of harm in the definition of mental disorders in DSM-5 shows a general trend towards reducing the significance of harm when thinking about the nature of mental disorders. In this paper, we defend the relevance of (...) the notion of harm in the characterization of mental disorder against some of these attacks. We approach this issue by using the method of conceptual explication pioneered by Rudolf Carnap. Within this framework, we argue that keeping the notion of harm not only helps to discriminate what is pathological from the nonpathological but also prevents potential misuses of psychiatric authority. (shrink)

Objective: To evaluate one ethics rounds model by describing nurses’ and doctors’ experiences of the rounds. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to promote mutual understanding and stimulate ethical reflection, without giving any recommendations or solutions. Interviews with seven doctors and 11 nurses were conducted regarding their experiences from the rounds, which were then analysed using content analysis. Findings: The goal of the rounds was partly (...) fulfilled. Participants described both positive and negative experiences. Good rounds included stimulation to broadened thinking, a sense of connecting, strengthened confidence to act, insight into moral responsibility and emotional relief. Negative experiences were associated with a sense of unconcern and alienation, as well as frustration with the lack of solutions and a sense of resignation that change is not possible. The findings suggest that the ethics rounds above all met the need of a forum for crossing over professional boundaries. The philosophers seemed to play an important role in structuring and stimulating reasoned arguments. The nurses’ expectation that solutions to the ethical problems would be sought despite explicit instructions to the contrary was conspicuous. Conclusion: When assisting healthcare professionals to learn a way through ethical problems in patient care, a balance should be found between ethical analyses, conflict resolution and problem solving. A model based on the findings is presented. (shrink)

This paper provides frameworks for understanding how ethics might be expressed in gameplay situations, and how we can study the ethical frameworks that games offer to players. There are many ways to delve into such topics, and this paper considers only a few approaches. It briefly surveys some of the important ques-tions and critiques arising from audience studies, theories of play and games, and work on cheating, and begins to build a framework for considering ethics in relation to games and (...) players that transcends the “place apart” that games are often constructed as. (shrink)

Despite societal concerns about the welfare of commercial laying hens, little attention has been paid to the welfare implications of the choices made by the genetics companies involved with their breeding. These choices regarding trait selection and other aspects of breeding significantly affect living conditions for the more than 7 billion laying hens in the world. However, these companies must consider a number of different commercial and societal interests, beyond animal welfare concerns. In this article we map some of the (...) relevant dilemmas faced by genetics companies in order to outline the scope of opportunities to improve welfare under current market conditions. This includes identifying cases where different animal welfare concerns conflict. We discuss the moral responsibility of laying hen genetics companies and the welfare implications that derive from the choices they make and the policies they follow. In addition to evaluating a selection of predominant current practices and breeding goals, we outline different angles from where to assess the moral legitimacy of various industry practices and policies. We discuss specific issues such as injurious pecking, bone health, induced moulting, chick culling and the circumstances of breeding stock. (shrink)

Even though Corporate Social Responsibility (CSR) has become a widely accepted concept promoted by different stakeholders, business corporations' internal strategies, known as corporate self-regulation in most of the weak economies, respond poorly to this responsibility. Major laws relating to corporate regulation and responsibilities of these economies do not possess adequate ongoing influence to insist on corporate self-regulation to create a socially responsible corporate culture. This book describes how the laws relating to CSR could contribute to the inclusion of CSR principles (...) at the core of the corporate self-regulation of these economies in general, without being intrusive in normal business practice. It formulates a meta-regulation approach to law, particularly by converging patterns of private ordering and state control in contemporary corporate law from the perspective of a weak economy. It proposes that this approach is suitable for alleviating regulators' limited access to information and expertise, inherent limitations of prescriptive rules, ensuring corporate commitment, and enhance the self-regulatory capacity of companies. This book describes various meta-regulation strategies for laws to link social values to economic incentives and disincentives, and to indirectly influence companies to incorporate CSR principles at the core of their self-regulation strategies. It investigates this phenomenon using Bangladesh as a case study. (shrink)

Objective: To evaluate whether ethics rounds stimulated ethical reflection. Methods: Philosopher-ethicist-led interprofessional team ethics rounds concerning dialysis patient care problems were applied at three Swedish hospitals. The philosophers were instructed to stimulate ethical reflection and promote mutual understanding between professions but not to offer solutions. Questionnaires directly before and after rounds were answered by 194 respondents. The analyses were primarily content analysis with Boyd’s framework but were also statistical in nature. Findings: Seventy-six per cent of the respondents reported a moderate (...) to high rating regarding new insights on ethical problem identification, but the ethics rounds did not seem to stimulate the ethical reflection that the respondents had expected (p<0.001). Dominant new insights did not seem to fit into traditional normative ethics but were instead interpreted as hermeneutic ethics. This was illustrated in the extended perspective on the patient and increased awareness of relations to other professions. Regarding insights into how to solve ethical problems, the request for further interprofessional dialogue dominated both before and after rounds. Conclusion: The findings show the need for interprofessional reflective ethical practice but a balance between ethical reflection and problem solving is suggested if known patients are discussed. Further research is needed to explore the most effective leadership for reflective ethical practice. (shrink)

Mandalas in the Making: The Visual Culture of Esoteric Buddhism at Dunhuang, by Michelle C. Wang. Leiden: Brill, 2018. xviii + 318 pages. Hb. $147.00, ISBN-13: 9789004357655; Ebook $25.00, ISBN-13: 9789004360402.

Much work on intellectual humility has focused on its epistemic benefits. We suggest that displaying (or failing to display) intellectual humility also has effects on how others perceive us and that, as a result, intellectual humility can serve reputation management purposes, in at least four ways: (i) Intellectual humility can be used to signal we are a good source of information; (ii) Intellectual humility can be used to signal we are competent through countersignaling; (iii) Intellectual humility can be used to (...) make sure others do not believe we are overclaiming superiority; (iv) lack of intellectual humility (or intellectual arrogance) can be used to signal dominance. The evidence suggests that intellectual humility (or lack thereof) can have each of these effects. Seeing intellectual humility as (inter alia) a reputation management tool predicts that people will be more or less likely to display intellectual humility in some contexts. For instance, people in a position of power might stand to lose less if they fail to be intellectual humble; accordingly, evidence suggests that they tend to display less intellectual humility. In conclusion, we speculate that understanding intellectual humility as reputation management could help construct environments more conducive to displays of intellectual humility. (shrink)

Based on a case study of a large multinational group, this paper addresses the way in which social and environmental reporting systems were changed and the consequences and controversies associated with this change. Drawing on Power’s work on the processes by which things are made auditable via underlying systems, we focus on how and why a specific programme with auditability as its ultimate aim changed the basis on which the external social and environmental report was prepared. Our analysis demonstrates that (...) the perceived alignment with the financial report preparation and the explicit pursuit of auditability legitimized SER and paved the way for data systems to be changed. The programme borrowed authority from financial accounting technologies not only to make a system change but also to push SER internally, as we suggest that an intraorganizational group used the programme to ensure the existence and organizational status of SER. However, we also illustrate some of the practical challenges associated with this change, which include issues related to internal control and the establishment of organizational boundaries. (shrink)

The semantic of the terms “sustainable development” and “corporate social responsibility” have changed over time to a point where these concepts have become two interrelated processes for ensuring the far‐reaching development of society. Their convergence has given dimension to the environmental and corporate regulation mechanisms in strong economies. This article deals with the question of how the ethos of this convergence could be incorporated into the self‐regulation of businesses in weak economies where nonlegal drivers are either inadequate or inefficient. It (...) proposes that the policies for this incorporation should be based on the precepts of meta‐regulation that have the potential to hold force majeure, economic incentives, and assistance‐related strategies to reach an objective from the perspective of weak economies. (shrink)

In inclusive dance settings, where people with different abilities and talents come together, the role of facilitators is essential in guiding the process of inclusion. Their behavior gives sensitive information to the individual about one’s status within the own-group affiliation. Even today, very little research on the motivation for facilitating inclusivity in dance contexts exists. This case study will examine the facilitator’s motivation by juxtaposing current theory next to experiences of seven experts of contemporary dance facilitation in Europe. Good opportunities (...) for meaningful interactions can be created in a dance setting: it promotes a deeper sense of community, gives us the feeling of belonging, generates respect and inclusion, and helps to prevent the feeling of loneliness. This research report sheds light on the motivation of being the facilitator of dance for heterogeneous groups and reveals three factors from the data. First, to be led by an artistic motivation, second, to have a vision in terms of changing the society, and third, to have another personal motivation. The motivation of the facilitator is regarded as highly important for inclusive work, as the person who facilitates plays a key role in these successful processes of inclusion. (shrink)

This paper, through a discussion of the IRA's proxy bomb campaigns, challenges the way martyrdom is and has been constructed and forces us to examine terrorist events without preconceived notions. It is important to note that when we witness an event that on the surface appears to be an instance of martyrdom, the reality might be far more complex. Part of the problem has been the current inductive logic associated with the study of terrorism in which attacks are a given (...) and experts will engage in a psychological autopsy to trace perpetrators' intentions and motives after the fact. If they are religious, we assume that this act was one of self-sacrifice for a religious cause. However, this is not always the case. We argue that we need to question the intent of the action rather than assume that the event is automatically an act of martyrdom. While attacks in Kabul or Baghdad may appear as deliberate jihadi operations by the Taliban or by Al Qaeda in Iraq, our investigation has determined that a portion of such attacks are the product of coercion and not martyrdom in the traditional sense although observers may understand them to be martyrdom operations. (shrink)

Microfinance is a preferred development tool in many developing countries around the world; however, the industry has been facing many challenges in recent years, including the attainment of financial sustainability. Therefore, this study is aimed at investigating the effect of employee turnover on the financial performance of microfinance institutions (MFIs). The study utilized unbalanced panel data of 1561 unique MFIs from 2010 to 2018. The data were then analyzed by conventional econometric techniques such as the pooled ordinary least squares, random (...) effects model, fixed effects model, Hausman–Taylor, and the two-step system generalized method of moments. Considering the linear relationship, it was discovered that employee turnover has a negative effect on the financial performance of MFIs. However, this relationship is dependent on the proxies of financial performance, legal status, location, profit orientation of the MFIs (for subsample analysis), and the technique(s)/model(s) employed in the analysis. Furthermore, the study did not find empirical evidence to support the quadratic relationship between employee turnover and the financial performance of MFIs. The outcome of this study advances important policy implications for concerned stakeholders. (shrink)

In an era where autonomous technologies are progressively taking over more complex tasks and decision-making previously done by humans, the mastering of paradox-based skills and effectively reconciling paradoxical situations in everyday life will become increasingly important. This paper asserts that understanding and living with paradox is not only necessary for the future of work but also for human flourishing. While work is the primary means by which humans flourish in the traditional sense, there are deeper and more holistic understandings of (...) human flourishing which requires the acceptance and learning of paradoxical realities. Those who are steeped in the understanding and reality of paradox in everyday life can also be more open to these deeper and more holistic understandings of human flourishing. (shrink)

The problem of political apathy and poor representation of women in the Belgian parliament bas been focused and seriously challenged with the 1974 parliamentary elections. Two different strategies hereby have been developed: on the one hand a separate, exclusive feminist party ; on the other hand a strategy of female candidates on the more conventional ballots. The effects of both strategies are quite remarkable : whereas the newcoming feminist party was struggling with breakthrough problems, the female candidate strategy strongly effected (...) the amount of female candidates, elected women, as well as the votes given to women, compared to previous elections. The accurate relationship between the women's campaign and its election effect can hardly be determined for the election determinant is too complex. The propaganda however, was an attempt to change the traditional image of women and to increase the political participation and emancipation of women via the instrument of parliamentary elections. The 1977 results, however, hardly equated the optimistic prospects of 1974 : the feminist party didn't survive its second participation and the candidate strategyurgently needs permanent action and political sensibilisation. (shrink)

The convergence of corporate social responsibility (CSR) and corporate governance (CG) has changed the corporate accountability mechanism. This has developed a socially responsible ‘corporate self-regulation’, a synthesis of governance and responsibility in the companies of strong economies. However, unlike in the strong economies, this convergence has not been visible in the companies of weak economies, where the civil society groups are unorganised, regulatory agencies are either ineffective or corrupt and the media and non-governmental organisations do not mirror the corporate conscience. (...) Using the case of Bangladesh, this article investigates the convergence between CSR and CG in the self-regulation of companies in a less vigilant environment. (shrink)

Cognitive models of social anxiety disorder suggest that memory biases for negative social information contribute to symptoms of social anxiety. However, it remains unclear whether memory bias...