In this paper we introduce narrative and hermeneutical perspectives to clinical ethics support services (CESS). We propose a threefold consideration of ‘theory’ and show how it is interwoven with ‘practice’ as we go along. First, we look at theory in its foundational role: in our case ‘narrative ethics’ and ‘philosophical hermeneutics’ provide a theoretical base for clinical ethics by focusing on human identities entangled in stories and on moral understanding as a dialogical process. Second, we consider the role of theoretical (...) notions in helping practitioners to understand their situation in clinical ethics practice, by using notions like ‘story’, ‘responsibility’, or ‘vulnerability’ to make explicit and explain their practical experience. Such theoretical notions help us to interpret clinical situations from an ethical perspective and to foster moral awareness of practitioners. And, thirdly, we examine how new theoretical concepts are developed by interpreting practice, using practice to form and improve our ethical theory. In this paper, we discuss this threefold use of theory in clinical ethics support services by reflecting on our own theoretical assumptions, methodological steps and practical experiences as ethicists, and by providing examples from our daily work. In doing so, we illustrate that theory and practice are interwoven, as theoretical understanding is dependent upon practical experience, and vice-versa. (shrink)

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We (...) argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES. (shrink)

The current process towards formalization within evaluation research, in particular the use of pre-set standards and the focus on predefined outcomes, implies a shift of ownership from the people who are actually involved in real clinical ethics support services in a specific context to external stakeholders who increasingly gain a say in what ‘good CESS’ should look like. The question is whether this does justice to the insights and needs of those who are directly involved in actual CESS practices, be (...) it as receivers or providers. We maintain that those actually involved in concrete CESS practices should also be involved in its evaluation, not only as respondents, but also in setting the agenda of the evaluation process and in articulating the criteria by which CESS is evaluated. Therefore, we propose a participatory approach to CESS evaluation. It focuses on the concrete contexts in which CESS takes place, reflective and dialogical learning processes, and how to be democratic and inclusive. In particular, this approach to CESS evaluation is akin to realist evaluation, dialogical evaluation, and responsive evaluation. An example of a participatory approach to evaluating CESS is presented and some critical issues concerning this approach are discussed. (shrink)

Care Ethics ist eine ethische Theorie, Pflegeethik ein Disziplinbegriff. Aber gerade in der Disziplin der Pflegethik kann die Care Ethics ein wichtiges gedankliches Werkezeug darstellen. In der Care Ethics wird nicht der Prinzipienbezug in den Vordergrund gestellt, sondern das Anerkennen von Kontext, moralischer Verantwortung und Beziehungen. In diesem Denkparadigma spielt es für die Reflexion auch eine Rolle, wer man selbst ist, und mit welcher Perspektive man sich einer ethischen Problemsituation nähert.

Predictive genetic testing may confront those affected with difficult life situations that they have not experienced before. These life situations may be interpreted as ‘absurd’. In this paper we present a case study of a predictive test situation, showing the perspective of a woman going through the process of deciding for or against taking the test, and struggling with feelings of alienation. To interpret her experiences, we refer to the concept of absurdity, developed by the French Philosopher Albert Camus. Camus' (...) writings on absurdity appear to resonate with patients' stories when they talk about their body and experiences of illness. In this paper we draw on Camus' philosophical essay ‘The Myth of Sisyphus’, and compare the absurd experiences of Sisyphus with the interviewee's story. This comparison opens up a field of ethical reflection. We demonstrate that Camus' concept of absurdity offers a new and promising approach to understanding the fragility of patients' situations, especially in the field of predictive testing. We show that people affected might find new meaning through narratives that help them to reconstruct the absurd without totally overcoming it. In conclusion, we will draw out some normative consequences of our narrative approach. (shrink)

ABSTRACT The part played by time in ethics is often taken for granted, yet time is essential to moral decision making. This paper looks at time in ethical decisions about having a genetic test. We use a patient‐centred approach, combining empirical research methods with normative ethical analysis to investigate the patients' experience of time in (i) prenatal testing of a foetus for a genetic condition, (ii) predictive or diagnostic testing for breast and colon cancer, or (iii) testing for Huntington's disease (...) (HD). We found that participants often manipulated their experience of time, either using a stepwise process of microdecisions to extend it or, under the time pressure of pregnancy, changing their temporal ‘depth of field’. We discuss the implications of these strategies for normative concepts of moral agency, and for clinical ethics. (shrink)

Gerade im Gesundheitswesen ist die Frage nach (Gestaltungs-)Macht heikel. Aber wer anderen Gutes tun möchte, der muss wirksam tätig werden können. Dies beinhaltet immer auch soziale Gestaltungsmacht. Wie gehen Pflegende mit der ihnen übertragenen bzw. auferlegten Macht um? Wie viel Macht ist im Kontext von Medizin, Pflege und Gesundheitssorge nötig? Und wie nehmen die Patientinnen und Patienten sie wahr? *Oft fühlen sich Menschen, die unter einer akuten Krankheit leiden, ohnmächtig. Und so wirkt der Begriff der Macht, den wir oft genug (...) mit Herrschaft und Gewalt verbinden, in einem Bereich, in dem es um Fürsorge und Behandlung geht, merkwürdig fehl am Platz. Gleichwohl bringen Ressourcen wie Wissen und finanzielle Mittel automatisch die Frage nach Macht in der Fürsorge aufs Tapet. Das Buch fragt nach der moralischen Bedeutung von Gestaltungsmacht und sucht das prekäre Verhältnis von Macht und Fürsorge ethisch auszuloten. (shrink)

In the three target articles, Ellen Fox et al. present data from their seminal study on ethics consultation in US general hospitals (Fox, Danis, et al. 2022, Fox and Duke 2022, Fox, Tarzian, et al....

Philosophical anthropologies that emphasise the role of the emotions can be used to expand existing notions of moral agency and learning in situations of great moral complexity. In this article we tell the story of one patient facing the tough decision of whether to be tested for Huntington’s disease or not. We then interpret her story from two different but compatible philosophical entry points: Aristotle’s conception of Greek tragedy and Karl Jaspers’ notion of Grenzsituationen (boundary situations). We continue by indicating (...) some ways in which these two positions may be used for reflecting upon different perspectives involved in clinical decision-making, those of patients, clinicians and bioethicists. We conclude that the ideas we introduce can be used as hermeneutic tools for situating learning and dialogue within a broader cultural field in which literature and art may also play important roles. (shrink)

BackgroundThe need for an ethical debate about the use of coercion in intensive care units (ICU) may not be as obvious as in other areas of medicine, such as psychiatry. Coercive measures are often necessary to treat critically ill patients in the ICU. It is nevertheless important to keep these measures to a minimum in order to respect the dignity of patients and the cohesion of the clinical team. A deeper understanding of what patients and their relatives perceive during their (...) ICU stay will shed different light on intensive care management. Patients' experiences of loss of control, dependency and abandonment may lead to a new approach towards a broader approach to the concept of coercion in intensive care. The aim of our research is to explore the experiences of patients and relatives in the ICU and to determine when it might be possible to reduce feelings and memories of coercion.MethodsWe conducted and analysed 29 semi-structured interviews with patients and relatives who had been in the ICU a few months previously. Following a coding and categorisation process in MAXQDA™, a rigorous qualitative methodology was used to identify themes relevant to our research.ResultsFive main themes emerged: memory issues; interviewees’ experiences of restricting measures and coercive treatment; patients’ negative perception of situational and relational dependency with the risk of informal coercion; patients’ perceptions of good care in a context of perceived dependency; progression from perception of coercion and dependency to respect for the person. All patients were grateful to have survived. However, coercion in the form of restraint, restriction of movement, and coercive treatment in the ICU was also acknowledged by patients and relatives. These included elements of informal coercion beyond restraints, such as a perceived negative sense of dependence, surrender, and asymmetrical interaction between the patient and health providers.ConclusionsTo capture the full range of patients' experiences of coercion, it is necessary to expand the concept of coercion to include less obvious forms of informal coercion that may occur in dependency situations. This will help identify solutions to avoid or reduce negative recollections that may persist long after discharge and negatively affect the patients' quality of life. (shrink)

The aim of this paper is to analyze an Intensive Care Unit case that required ethics consultation at a University Hospital in Northern Italy. After the case was resolved, a retrospective ethical analysis was performed by four clinical ethicists who work in different healthcare contexts. Each ethicist used a different method to analyze the case; the four general approaches provide insight into how these ethicists conduct ethics consultations at their respective hospitals. Concluding remarks examine the similarities and differences among the (...) various approaches and offer a reflection concerning the possibility of a shared resolution to the case. The authors’ efforts to come to a tentative consensus may serve as an example for professionals working in medical contexts that reflect an increasing pluralism of values. This article aims to respond to some of these concerns by illustrating how different methods in clinical ethics would be used when considering a real case. The goal is not to establish the best model on a theoretical level, but to learn from actual practice in order to see if there are common elements in the different methods, and to validate their pertinence to clinical ethics consultation. (shrink)

This paper is based on linked qualitative studies of the donation of human embryos to stem cell research carried out in the United Kingdom, Switzerland, and China. All three studies used semi-structured interview protocols to allow an in-depth examination of donors’ and non-donors’ rationales for their donation decisions, with the aim of gaining information on contextual and other factors that play a role in donor decisions and identifying how these relate to factors that are more usually included in evaluations made (...) by theoretical ethics. Our findings have implications for one factor that has previously been suggested as being of ethical concern: the role of gratitude. Our empirical work shows no evidence that interpersonal gratitude is an important factor, but it does support the existence of a solidarity-based desire to “give something back” to medical research. Thus, we use empirical data to expand and refine the conceptual basis of bioethically theorizing the IVF–stem cell interface. (shrink)

A sample of tourists responded to a survey addressing purchasing intentions and consumption motives in relation to buying sustainable groceries at a local food market. These intentions and motives were contrasted for two consumption contexts: on vacation vs. at home. An initial analysis of the data indicated that self-reported purchasing intentions were weaker for a vacation scenario than for a home scenario. Further analyses suggested that motives associated with purchasing intentions were not universal between contexts. At home, normative motives were (...) positively associated with intentions, whereas other motives failed to explain significant variance. On vacation, associations with intentions followed a similar pattern, except for the finding that hedonic motives added explanatory variance. Despite the increased importance of hedonic motives on vacation compared to at home, normative motives showed the strongest association with purchasing intentions in both consumption contexts. The findings are discussed with reference to the literature on contextual discrepancies in environmental behavior, while noting possible implications for promoting sustainable consumption among tourists. (shrink)

Opponents of mainstream economics have not yet called attention to the lack of in-depth examination of the general scientific conception of modern economics. However, economic science cannot consistently fulfil the epistemological and ontological requirements of the scientific standards underlying this conception. What can be scientifically recognized as true cannot be answered, neither through the actual ontological structure of the object of observation nor through a methodological demarcation. These limitations necessarily lead to the claim for both a pragmatic and a radical (...) methodological pluralism. (shrink)

Management accounting and control seeks to provide information that substantiates decision-making at all firm levels and thus may also foster ethical decision-making. Against this background, this article presents a systematic literature review of research on management accounting and control and business ethics that has been published in the Journal of Business Ethics. Through this review, we intend to bring to the forefront a research topic that has been widely neglected in broader literature reviews on accounting ethics research and that has (...) been covered by a small number of articles published by traditional leading accounting journals only. Our systematic literature review is guided by a theoretical framework that integrates the decision-facilitating and decision-influencing roles of management accounting and control information and the stages of the ethical decision-making process. Through this theoretical lens, we analyze 64 management accounting and control articles published in the Journal of Business Ethics over more than three decades. Synthesizing and structuring this research, we discuss prior accomplishments and elaborate on avenues for future research. (shrink)

This paper explores the public perception of energy transition pathways, that is, individual behaviors, political strategies, and technologies that aim to foster a shift towards a low-carbon and sustainable society. We employed affective image analysis, a structured method based on free associations to explore positive and negative connotations and affective meanings. Affective image analysis allows to tap into affective meanings and to compare these meanings across individuals, groups, and cultures. Data were collected among university students in Norway (n = 106) (...) and Germany (n = 125), two countries that differ with respect to their socio-political contexts and histories concerning energy and energy systems. A total of 25 energy transition pathway components were presented to the participants who generated one free association to each component by indicating the first that came to mind when thinking of the component. Participants evaluated their associations by indicating whether they considered each association to be positive, negative, or neutral. These associations were coded by two research assistants, which resulted in 2650 coded responses in the Norwegian sample and 2846 coded responses in the German sample. Results for the two samples are remarkably similar. The most frequent type of association is a general evaluation of the component, for example concerning its valence or its importance. The second most frequent types of association are requirements needed to implement the component (e.g., national policies) and consequences of the component (e.g., personal or environmental consequences). Individual behaviors (e.g., walking) elicited thoughts about consequences and requirements, but also about the prevalence of such behaviors. Associations in response to technologies (e.g., carbon capture and storage) mainly referred to some descriptive aspect of the technology. Evaluations of the free responses were predominantly positive, but some components also elicited negative associations, especially nuclear power. The free associations that people generate suggest that they have vague and unspecific knowledge about energy transition pathways, that they process them in an automatic and intuitive rather than deliberative manner, and that they have clear affective evaluations of the presented components. (shrink)

Public perceptions are well established as a key factor in support for climate change mitigation policies, and they tend to vary both within and between countries. Based on data from the European Social Survey Round 8 (N = 44 387), we examined the role of climate change beliefs and political orientation in explaining worry about climate change across 23 countries. We show that belief in anthropogenic climate change, followed by expectations of negative impacts from climate change, are the strongest predictors (...) of worry about climate change. While the strength of the association between political orientation and worry about climate change varies across countries, self-positioning further to the right of the political spectrum is associated with lower levels of worry in most of the countries included in the analysis. We further show that political orientation moderates the relationship between climate change beliefs and worry. While increased confidence in the anthropogenic nature of climate change and expectations of negative impacts are both associated with increased worry across the political spectrum, the relationship is weaker among right-leaning as compared to left-leaning individuals. Notably, the main effect of political orientation on worry about climate change is no longer statistically significant when the interaction terms are present. Finally, a relatively small amount of the explained variance in worry is attributable to differences between countries. The findings might inform strategies for climate change communication in a European context. (shrink)

Microplastics are an issue of rising concern, in terms of their possible implications for both the environment and human health. A survey was distributed among a representative sample of the adult Norwegian population to explore the public understanding of microplastics. Respondents were asked to report the first thing that came to mind when they read or heard the word “microplastics,” based on which a coding scheme was developed that served to categorize the obtained answers into thematic clusters. Results indicate that (...) the public seem to think of microplastics as something bad that might pollute the ocean and harm animal species. Awareness of the sources of microplastics appeared to be rather low, and few respondents mentioned potential ways to solve the problem. Responses differed across certain socio-demographic characteristics; for example, female and younger respondents were more likely to think about the spread and causes/sources of microplastics, whereas a higher educational level was associated positively with thinking of ways to solve the problem. Additional analyses indicated relationships between personal values and the identified thematic clusters; for example, endorsing self-transcendence and openness-to-change values was associated with thinking of ways to solve and of consequences of microplastics. These findings are informative to those wanting to design tailored communications and interventions aimed at reducing plastic pollution and plastic waste. (shrink)

This article reviews recent developments within a number of academic disciplines pointing toward an increasing importance of imagination for understanding morality and cognition. Using elements from hermeneutics and metaphor theory, it works toward a framework for a more context-sensitive understanding of human agency, especially focusing on moral deliberation and change. The analytic framework is used to analyze the story of a patient making tough decisions in the context of prenatal diagnosis. We show how a relatively stable outlook on the world, (...) here called the “baseline of choice,” is challenged by unexpected events and how imaginative processes enter into the active creation of a new moral order. The ensuing interpretation is then placed within a broader philosophical landscape. John Dewey’s notion of “dramatic rehearsal” is put forward as one particularly promising way of understanding moral imagination, deliberation, and decision-making. (shrink)

This book offers even more than its title promises. Embarrassed with my translation of échec, I emphasize that its authors not only reflect on "Man and Failure," but design a vast anthropological fresco by approaching their topic from psychological, economical, medical, religious and philosophical points of view. Jean Lacroix published a book on Failure some years ago; in 1968 he asked thirteen outstanding French writing personalities for contributions to an interdisciplinary study on the same issue. The result is a remarkable (...) collection of insights into this basic experience in human life. Joseph Nuttin, professor in experimental psychology, presents his most recent researches on the transformation of a person's needs and energies into a "project" of life. Failure, the unsuccess of such a project, gives cognitive information useful for subsequent conduct. Raymond Carpentier sees failure in the area of communication: it reveals the ambiguity of any information. On the level of consciousness, he writes, reality only exists in so far as its own failure is contained in its very structure. "Ambiguous like life itself, communication is what has reality only when it does not succeed in its materializations." François Perroux, economist, both calmly and alarmingly sketches the perhaps imminent failure of our economic system. Three other articles deal with ethnological and medical problems. The philosopher and psychoanalyst Mrs. Eliane Amado Lévy-Valenski, author of L'humanisme psychanalytique, le mythe grec et la phénoménologie biblique, pursues her threefold investigation: "Psychoanalysis, Phenomenology or Ontology of Failure?" To fail in one's efforts is both a trial and a temptation, but it also points toward the emergence of infinity within finitude. The three religious contributions give the most personal penetration of the subject. They are the center of the book. The last section deals with three philosophies: the failing thought of Being, the critique of humanism, the restoration of motivations in action. The first of them is due to Rouven Gilead, professor at the University of Tel-Aviv and author of one of the best books on Heidegger. His paper suggests what radical Failure would mean: not of man, nor of given historical situations, nor even of metaphysics, although these three approaches are true. But the "truth of Being" in modern subjectivity, in sciences and in philosophy remains hidden. Our horizon of thought is the nihilism of Being. The fundamental Failure, then, is the history of Being itself.--R. S. (shrink)