Over several decades, ethics and law have been applied to medical education and practice in a way that reflects the continuation during the twentieth century of the strong distinction between facts and values. We explain the development of applied ethics and applied medical law and report selected results that reflect this applied model from an empirical project examining doctors’ decisions on withdrawing/withholding treatment from patients who lack decision-making capacity. The model is critiqued, and an alternative “constitutive” model is supported on (...) the basis that medicine, medical law, and medical ethics exemplify the inevitable entanglement of facts and values. The model requires that ethics and law be taught across the medical education curriculum and integrated with the basic and clinical sciences and that they be perceived as an integral component of medical evidence and practice. Law, in particular, would rank as equal in normative authority to the relevant clinical scientific “facts” of the case, with graduating doctors having as strong a basic command of each category as the other. The normalization of legal knowledge as part of the clinician’s evidence base to be utilized in practice may provide adequate consolation for clinicians who may initially resent further perceived incursions on their traditional independence and discretion. (shrink)

Background Victoria was the first Australian state to legalize voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). Some institutions indicated they would not participate in voluntary assisted dying. The Victorian government issued policy approaches for institutions to consider Objective To describe and analyse publicly available policy documents articulating an institutional objection to voluntary assisted dying in Victoria. Methods Policies were identified using a range of strategies, and those disclosing and discussing the nature of an institutional objection were thematically (...) analysed using the framework method. Results The study identified fifteen policies from nine policymakers and developed four themes: (1) extent of refusal to participate in VAD, (2) justification for refusal to provide VAD, (3) responding to requests for VAD, and (4) appeals to state-sanctioned regulatory mechanisms. While institutional objections were stated clearly, there was very little practical detail in most documents to enable patients to effectively navigate objections in practice. Conclusion This study demonstrates that despite having clear governance pathways developed by centralized bodies (namely, the Victorian government and Catholic Health Australia), many institutions’ public-facing policies do not reflect this guidance. Since VAD is contentious, laws governing institutional objection could provide greater clarity and regulatory force than policies alone to better balance the interests of patients and non-participating institutions. (shrink)

Much of the commentary in the wake of the Charlie Gard litigation was aimed at apparent shortcomings of the law. These include concerns about the perceived inability of the law to consider resourcing issues, the vagueness of the best interests test and the delays and costs of having disputes about potentially life-sustaining medical treatment resolved by the courts. These concerns are perennial ones that arise in response to difficult cases. Despite their persistence, we argue that many of these criticisms are (...) unfounded. The first part of this paper sets out the basic legal framework that operates when parents seek potentially life-sustaining treatment that doctors believe is against a child’s best interests, and describes the criticisms of that framework. The second part of the paper suggests an alternative approach that would give decision-making power to parents, and remove doctors’ ability to unilaterally withhold or withdraw life-sustaining treatment that they regard is futile. This proposal is grounded in several values that we argue should guide these regulatory choices. We also contend that the best interests test is justifiable and since the courts show no sign of departing from it, the focus should be on how to better elucidate the underlying values driving decisions. We discuss the advantages of our proposed approach and how it would address some of the criticisms aimed at the law. Finally, we defend the current role that the judiciary plays, as an independent state-sanctioned process with a precedent-setting function. (shrink)

Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on (...) a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying “regulatory space” theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers. (shrink)

In jurisdictions where voluntary assisted dying is legal, eligibility assessments, prescription and administration of a VAD substance are commonly performed by senior doctors. Junior doctors’ involvement is limited to a range of more peripheral aspects of patient care relating to VAD. In the Australian state of Victoria, where VAD has been legal since June 2019, all health professionals have a right under the legislation to conscientiously object to involvement in the VAD process, including provision of information about VAD. While this (...) protection appears categorical and straightforward, conscientious objection to VAD-related care is ethically complex for junior doctors for reasons that are specific to this group of clinicians. For junior doctors wishing to exercise a conscientious objection to VAD, their dependence on their senior colleagues for career progression creates unique risks and burdens. In a context where senior colleagues are supportive of VAD, the junior doctor’s subordinate position in the medical hierarchy exposes them to potential significant harms: compromising their moral integrity by participating, or compromising their career progression by objecting. In jurisdictions intending to provide all health professionals with meaningful conscientious objection protection in relation to VAD, strong specific support for junior doctors is needed through local institutional policies and culture. There are no data in this work. (shrink)

Objectives To determine the role played by law in medical specialists9 decision-making about withholding and withdrawing life-sustaining treatment from adults who lack capacity, and the extent to which legal knowledge affects whether law is followed. Design Cross-sectional postal survey of medical specialists. Setting The two largest Australian states by population. Participants 649 medical specialists from seven specialties most likely to be involved in end-of-life decision-making in the acute setting. Main outcome measures Compliance with law and the impact of legal knowledge (...) on compliance. Results 649 medical specialists (of 2104 potential participants) completed the survey (response rate 31%). Responses to a hypothetical scenario found a potential low rate of legal compliance, 32% (95% CI 28% to 36%). Knowledge of the law and legal compliance were associated: within compliers, 86% (95% CI 83% to 91%) had specific knowledge of the relevant aspect of the law, compared with 60% (95% CI 55% to 65%) within non-compliers. However, the reasons medical specialists gave for making decisions did not vary according to legal knowledge. Conclusions Medical specialists prioritise patient-related clinical factors over law when confronted with a scenario where legal compliance is inconsistent with what they believe is clinically indicated. Although legally knowledgeable specialists were more likely to comply with the law, compliance in the scenario was not motivated by an intention to follow law. Ethical considerations (which are different from, but often align with, law) are suggested as a more important influence in clinical decision-making. More education and training of doctors is needed to demonstrate the role, relevance and utility of law in end-of-life care. (shrink)

ObjectiveTo increase knowledge of how doctors perceive futile treatments and scarcity of resources at the end of life. In particular, their perceptions about whether and how resource limitations influence end-of-life decision making. This study builds on previous work that found some doctors include resource limitations in their understanding of the concept of futility.SettingThree tertiary hospitals in metropolitan Brisbane, Australia.DesignQualitative study using in-depth, semistructured, face-to-face interviews. Ninety-six doctors were interviewed in 11 medical specialties. Transcripts of the interviews were analysed using thematic (...) analysis.ResultsDoctors’ perceptions of whether resource limitations were relevant to their practice varied, and doctors were more comfortable with explicit rather than implicit rationing. Several doctors incorporated resource limitations into their definition of futility. For some, availability of resources was one factor of many in assessing futility, secondary to patient considerations, but a few doctors indicated that the concept of futility concealed rationing. Doctors experienced moral distress due to the resource implications of providing futile treatment and the lack of administrative supports for bedside rationing.ConclusionsDoctors’ ability to distinguish between futility and rationing would be enhanced through regulatory support for explicit rationing and strategies to support doctors’ role in rationing at the bedside. Medical policies should address the distinction between resource limitations and futility to promote legitimacy in end-of-life decision making. (shrink)

However, the barriers and facilitators of such changes - law reform perspectives - have been virtually ignored. Why do so many attempts to change the law fail but others are successful? International Perspectives on End-of-Life Law Reform aims to address this question by drawing on ten case studies of end-of-life law reform from the United Kingdom, the United States, Canada, the Netherlands, Belgium and Australia. Written by leading end-of-life scholars, the book's chapters blend perspectives from law, medicine, bioethics and sociology (...) to examine sustained reform efforts to permit assisted dying and change the law about withholding and withdrawing life-sustaining treatment. Findings from this book not only shed light on changing end-of-life law but also provide insight more generally into how and why law reform succeeds in complex and controversial social policy areas. (shrink)

BackgroundThis paper investigates the content of Australian policies that address withholding or withdrawing life-sustaining treatment to analyse the guidance they provide to doctors about the allocation of resources.MethodsAll publicly available non-institutional policies on withholding and withdrawing life-sustaining treatment were identified, including codes of conduct and government and professional organization guidelines. The policies that referred to resource allocation were isolated and analysed using qualitative thematic analysis. Eight Australian policies addressed both withholding and withdrawing life-sustaining treatment and resource allocation.ResultsFour resource-related themes were (...) identified: doctors’ ethical duties to consider resource allocation; balancing ethical obligations to patient and society; fair process and transparent resource allocation; and legal guidance on distributive justice as a rationale to limit life-sustaining treatment.ConclusionOf the policies that addressed resource allocation, this review found broad agreement about the existence of doctors’ duties to consider the stewardship of scarce resources in decision-making. However, there was disparity in the guidance about how to reconcile competing duties to patient and society. There is a need to better address the difficult and confronting issue of the role of scarce resources in decisions about life-sustaining treatment. (shrink)

BackgroundJunior medical doctors have a key role in discussions and decisions about treatment and end-of-life care for people with dementia in hospital. Little is known about junior doctors’ decision-making processes when treating people with dementia who have advance care directives, or the factors that influence their decisions. To describe among junior doctors in relation to two hypothetical vignettes involving patients with dementia: their legal compliance and decision-making process related to treatment decisions; the factors influencing their clinical decision-making; and the factors (...) associated with accurate responses to one hypothetical vignette. MethodA cross-sectional survey of junior doctors, including trainees, interns, registrars and residents, on clinical rotation in five public hospitals located in one Australian state. The anonymous, investigator-developed survey was conducted between August 2018 and June 2019. Two hypothetical vignettes describing patients with dementia presenting to hospital with an ACD and either: bacterial pneumonia; or suspected stroke were presented in the survey. Participants were asked to indicate whether they would commence treatment, given the ACD instructions described in each vignette.ResultsOverall, 116 junior doctors responded. In Vignette 1, 58% of respondents selected the legally compliant option. Participants who chose the legally compliant option perceived ‘following patient wishes’ and ‘legal requirements to follow ACDs’ as equally important reasons for complying with the ACD. The most common reason for not selecting the legally compliant option in Vignette 1 was the ‘ACD is relevant in my decision-making process, but other factors are more relevant’. In Vignette 2, 72% of respondents indicated they would commence treatment and 18% selected they would not commence treatment.. Similar reasons influenced participant decision-making in Vignette 2, a less legally certain scenario.ConclusionsThere are critical gaps in junior doctors’ compliance with the law as it relates to the implementation of ACDs. Despite there being differences in relation to the legal answer and its certainty, clinical and ethical factors guided decision-making over and above the law in both vignettes. More education and training to guide junior doctors’ clinical decision-making and ensure compliance with the law is required. (shrink)

Background In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these “institutional objections”, however, very little research has examined their nature and impact. Methods This study reports on findings from 48 semi-structured qualitative interviews conducted with (...) MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis. Results Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions’ objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners. Conclusions This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice. (shrink)

Background Voluntary assisted dying became lawful in Victoria, the first Australian state to permit this practice, in 2019 via the Voluntary Assisted Dying Act 2017 (Vic). While conscientious objection by individual health professionals is protected by the Victorian legislation, objections by institutions are governed by policy. No research has been conducted in Victoria, and very little research conducted internationally, on how institutional objection is experienced by patients seeking assisted dying. Methods 28 semi-structured interviews were conducted with 32 family caregivers and (...) one patient about the experience of 28 patients who sought assisted dying. Participants were interviewed during August-November 2021. Data from the 17 interviews (all with family caregivers) which reported institutional objection were analysed thematically. Results Participants reported institutional objection affecting eligibility assessments, medication access, and taking the medication or having it administered. Institutional objection occurred across health settings and was sometimes communicated obliquely. These objections resulted in delays, transfers, and choices between progressing an assisted dying application and receiving palliative or other care. Participants also reported objections causing adverse emotional experiences and distrust of objecting institutions. Six mediating influences on institutional objections were identified: staff views within objecting institutions; support of external medical practitioners and pharmacists providing assisted dying services; nature of a patient’s illness; progression or state of a patient’s illness; patient’s geographical location; and the capability and assertiveness of a patient and/or caregiver. Conclusions Institutional objection to assisted dying is much-debated yet empirically understudied. This research found that in Victoria, objections were regularly reported by participants and adversely affected access to assisted dying and the wider end-of-life experience for patients and caregivers. This barrier arises in an assisted dying system that is already procedurally challenging, particularly given the limited window patients have to apply. Better regulation may be needed as Victoria’s existing policy approach appears to preference institutional positions over patient’s choice given existing power dynamics. (shrink)

Christian development agencies have been the primary vehicle of choice for holistic involvement and witness. This has played straight into an Enlightenment manner of thinking that compartmentalizes values, limiting the opportunities for explaining the theological and conceptual foundations for development practice and for public witness concerning religious faith. New institutional models appropriate to witness and holistic Christian service need to be considered. An `S4' type organization, explored in practice in Indonesia in an interfaith setting, allows for a more effective sharing (...) of the gospel and robust development work. (shrink)

Robert Putnam's work was a double-edged sword for social capital scholars. It brought unprecedented attention to the research agenda but also created conceptual confusion. Many scholars have tried to disentangle Coleman's concept of social capital from what some described as Putnam's “fuzzy psychological notion” of civic culture values. Despite the rigour of these efforts, Putnam's influence remains, because scholars and policy makers are drawn to the benefits his work promised. This article takes a different tack, and seeks to extricate Putnam's (...) early ideas from the social capital debates by offering an alternate theorization of his original findings. It returns to Making Democracy Work and argues that Putnam mis-stepped when he took the rational choice route and invoked Coleman's concept of social capital. It takes an ideational approach to explaining civic culture. The resulting “ideational social capital” suggests a different research agenda, which just might deliver on Putnam's early promise. (shrink)

The aim of this thematic literature review is to explore nurses' perceptions of ethical issues in the care of older people. Electronic databases were searched from September 1997 to September 2007 using specific key words with tight inclusion criteria, which revealed 17 primary research reports. The data analysis involved repeated reading of the findings and sorting of those findings into four themes. These themes are: sources of ethical issues for nurses; differences in perceptions between nurses and patients/relatives; nurses' personal responses (...) to ethical issues; and the patient—nurse relationship. The findings reveal that ageism is one of the major sources of the ethical issues that arise for nurses caring for older people. Education and organizational change can combat ageist attitudes. Wider training is required in the care of older people, workplace skills, palliative care and pain management for older people. The demands of a changing global demography will necessitate further research in this field. (shrink)

The paper interrogates the status, nature and significance of epistemological relativism as a key element of constructionism and critical realism. It finds that epistemological relativism is espoused by authorities in critical realism and marginalized or displaced in the field of management and organization studies, resulting in forms of analysis that are empirically, but not fully critically, realist. This evaluation prompts reflection on the question of whether, how and with what implications epistemological relativism might be recast at the heart of critical (...) realist studies of management and organization. (shrink)

Since the mid-twentieth century, the ‘Scientific Revolution’ has arguably occupied centre stage in most Westerners’, and many non-Westerners’, conceptions of science history. Yet among history of science specialists that position has been profoundly contested. Most radically, historians Andrew Cunningham and Perry Williams in 1993 proposed to demolish the prevailing ‘big picture’ which posited that the Scientific Revolution marked the origin of modern science. They proposed a new big picture in which science is seen as a distinctly modern, western phenomenon rather (...) than a human universal, that it was invented in the Age of Revolutions 1760–1848, and that science be de-centred within the new big picture: treated as just one of many forms of human knowledge-seeking activity. Their paper is one of the most highly cited in the history of science field, and has the potential to transform the way that science educators, science communicators, science policy-makers and scientists view science. Yet the paper and historians’ scholarly response to it are not well-known outside the history discipline. Here I attempt to bridge that disciplinary gap with a review of scholarly papers published 1994–2014 that cited Cunningham and Williams or otherwise discussed the Scientific Revolution, to gauge the extent of support for the old and new big pictures. I find that the old big picture is disintegrating and lacks active defenders, while many scholars support aspects of the new big picture. I discuss the significance of this for scholars in ‘applied’ fields of science studies such as education, communication and policy. (shrink)

In this article we offer a single case study using an action research method for gathering and analysing data offering insights valuable to both design and research supervision practice. We do not attempt to generalise from this single case, but offer it as an instance that can improve our understanding of research supervision practice. We question the conventional ‘dyadic’ models of research supervision and outline a more collaborative model, based on the signature pedagogy of architecture: the design studio. A novel (...) approach to the supervision of creatively oriented postgraduate students is proposed, including new approaches to design methods and participatory supervision that draw on established design studio practices. This model collapses the distance between design and research activities. Our case study involving Master's Research Students supervision in the discipline of Architecture, shows how ‘connected learning’ emerges from this approach. This type of learning builds strong elements of creativity and fun, which promote and enhance student engagement. The results of our action research suggest that students learn to research more easily in such an environment and supervisory practices are enhanced when we apply the techniques and characteristics of design studio pedagogy to the more conventional research pedagogies imported from the humanities. We believe that other creative disciplines can apply similar tactics to enrich both the creative practice of research and the supervision of HDR students. (shrink)

Vast research has sought to better understand the origins and development of rape myth beliefs given the problematic influence of such misconceptions throughout global societies and criminal justice pathways. The current research aims to build on this body of literature by examining the contribution that psychopathic personality traits (affective responsiveness, cognitive responsiveness, interpersonal manipulation, egocentricity) and emotional intelligence may have upon rape myth beliefs. Furthermore, this study will investigate the extent to which sociodemographic characteristics (age, gender, ethnicity, education), and prior (...) experience of sexual victimisation, contribute to variance in rape myth acceptance scores. In total 251 participants (M Age = 31.66) completed an online, self-report questionnaire which included contemporary measures of psychopathy and rape myth acceptance, never previously tested in combination. Results of a hierarchical multiple regression analysis indicate that egocentricity, age, and gender were significantly associated with rape myth beliefs. Emotional intelligence, as well as affective and interpersonal traits of psychopathy, were not directly related with rape mythology. Findings are interpreted alongside previous research, where we suggest there is an urgent need for larger, nationally representative samples, systematically recruited from the general population to help clarify uncertainty in existing literature emerging from small-scale opportunistic datasets. (shrink)

'Critical Management Studies', or 'CMS', describes a diverse group of work that has adopted a critical or questioning approach to the traditional concerns of Management Studies, and the growing interest in CMS has produced a vibrant and exciting body of research. Christopher Grey and Hugh Willmott, leading authorities in this area, introduce seventeen readings which reflect these developments, and show CMS' importance. As an assessment of CMS, the Reader will be of interest to academics, researchers, and students of Management (...) Studies. As an introduction to CMS, it will prove invaluable to students taking courses requiring familiarity with the CMS literature. (shrink)

Many of the negative connotations of corporate social responsibility (CSR) are linked to its perceived role as a public relations exercise. Following on calls for more positive engagement by public relations professionals in organisational strategic planning and given the rapidly increasing interest in CSR as a business strategy, this article addresses the question of how the theory and practice of public relations can provide direction and support for CSR. To this end, this article explores leadership styles and motivations of a (...) sample of corporate leaden from prominent Australian-based corporations in relation to their chosen CSR activities to examine the current position of, and potential for, professional communicators' impact in shaping CSR-driven policies at a strategic level. We find that while public relations theory has evolved, many leaders still see public relations professionals only as a source of positive publicity. Our findings suggest that the model of distributive leadership has more relevance to an emerging idea of public relations involvement in CSR than more traditional understandings of leadership. We conclude that the public relations profession needs to develop a greater understanding of senior management approaches to the development and dissemination of CSR activities to support organisational leadership as it currently operates with respect to CSR. (shrink)

There is a tendency in the business ethics literature to think of ethics in restrictive terms: what one should not do, and how to control this. Drawing on Lawrence Kohlberg''s theory of moral development, the paper focuses on, and draws attention to, another more positive aspect of ethics: the capacity of ethics to inspire and empower individuals, as well as groups. To understand and facilitate such empowerment, it is argued that it is necessary to move beyond Kohlberg''s justice reasoning so (...) as to appreciate the value and importance of feeling and care. Accordingly, we draw upon case study material to review the meaning of Kohlberg''s higher stages — 5, 6 and 7 — to question the meaning of ethical reasoning. With such deeper understanding of particular ethical codes or practices, it is thought that members of organisations may come closer to thespirit, as opposed to the letter, of ethical conduct in organisations. This, we argue, is consistent with the degree of trust and integrity demanded by leaner, post-bureaucratic ways of organizing and conducting business as well as being personally beneficial to the people involved. (shrink)

This paper examines the marketization of higher education. It takes the curriculum development for a degree sponsored by industry as a focus for exploring the involvement of industry and, more specifically, prospective employers, in shaping higher education provision. Empirical material gathered from a three and a half-year ethnographic study is used to illustrate how mundane promotional work associated with sponsored curricula operates to reconstitute higher education. It is shown how, in the process of introducing sponsored curricula into the university, a (...) market relevance discourse is merged with traditional discourse to promote a new discursive order and thereby contribute to the reformation of university education. This hybrid discourse (of tradition and relevance) makes traditional resistance to the encroachment of "relevance" into university education more difficult to justify, and perhaps impossible to sustain. Nonetheless, it produces new antagonisms that provide future sites of resistance. (shrink)

This book examines the way in which new discoveries about genetic and neuroscience are influencing our understanding of human behaviour. As scientists unravel more about the ways in which genes and the environment work together to shape the development of our brains, their studies have importance beyond the narrow confines of the laboratory. This emerging knowledge has implications for our notions of morality and criminal responsibility. The extent to which "biological determinism" can be used as an explanation for our behaviour (...) is of interest to philosophers reflecting on the free will versus determinism debate. It also has repercussions for the criminal justice system; in courtrooms around the world, defence lawyers are beginning to appeal to genetic and brain imaging data as grounds for finding their clients not guilty. Can a defendant's genes or the structure of his brain be used as an excuse for his behaviour? Is criminality "hardwired"? Is it legitimate to claim "I couldn't help it, my genes made me do it"? This book appeals to anyone interested in the link between behaviour and genetics, the science and philosophy of moral responsibility and/or criminal law. (shrink)

Urban agriculture is an important source of food and income throughout Africa. The majority of cultivators on the continent are women who use urban agriculture to provide for their family. Much research on urban agriculture in Africa focuses on the material benefits of urban agriculture for women, but a smaller body of literature considers its social and psychological empowering effects. The present study seeks to contribute to this debate by looking at the ways in which urban agriculture empowers women on (...) the Cape Flats, a region of Cape Town where urban agriculture is supported by nongovernmental organisations. Based on interviews with cultivators, the findings show that NGO-run urban agriculture projects not only aid food security, but also help women to develop supportive networks that unlock benefits across the personal, social and economic spectrum. (shrink)

The book is divided into two parts, representing modern and postmodern periods. Willmott examines McLuhan's relationship to critical and aesthetic modernism, and political and historical sense of modernity in North America, from the early 1930s to the 1950s.