Background: Obtaining patients’ informed consent is an ethical and legal obligation in healthcare practice. Whilst the law provides prescriptive rules and guidelines, ethical theories of autonomy provide moral foundations. Models of practice of consent, have been developed in the bioethical literature to assist in understanding and integrating the ethical theory of autonomy and legal obligations into the clinical process of obtaining a patient’s informed consent to treatment.Aims: To review four models of consent and analyse the way each model incorporates the (...) ethical meaning of autonomy and how, as a consequence, they might change the actual communicative process of obtaining informed consent within clinical contexts.Methods: An iceberg framework of consent is used to conceptualise how ethical theories of autonomy are positioned and underpin the above surface, and visible clinical communication, including associated legal guidelines and ethical rules. Each model of consent is critically reviewed from the perspective of how it might shape the process of informed consent.Results and discussion: All four models would alter the process of obtaining consent. Two models provide structure and guidelines for the content and timing of obtaining patients’ consent. The two other models rely on an attitudinal shift in clinicians. They provide ideas for consent by focusing on underlying values, attitudes and meaning associated with the ethical meaning of autonomy.Conclusions: The paper concludes that models of practice that explicitly incorporate the underlying ethical meaning of autonomy as their basis, provide less prescriptive, but more theoretically rich guidance for healthcare communicative practices. (shrink)

Being a healthcare professional in both paediatric and adult hospitals will mean being exposed to human tragedies and stressful events involving conflict, misunderstanding, and moral distress. There are a number of different structured approaches to reflection and discussion designed to support healthcare professionals process and make sense of their feelings and experiences and to mitigate against direct and vicarious trauma. In this paper, we draw from our experience in a large children’s hospital and more broadly from the literature to identify (...) and analyse four established approaches to facilitated reflective discussions. Each of the four approaches seeks to acknowledge the stressful nature of health professional work and to support clinicians from all healthcare professions to develop sustainable skills so they continue to grow and thrive as health professionals. Each approach also has the potential to open up feelings of uncertainty, frustration, sorrow, anguish, and moral distress for participants. We argue, therefore, that in order to avoid unintentionally causing harm, a facilitator should have specific skills required to safely lead the discussion and be able to explain the nature, scope, safe application, and limits of each approach. With reference to a hypothetical but realistic clinical case scenario, we discuss the application and key features of each approach, including the goals, underpinning theory, and methods of facilitation. (shrink)

Bioethics, Volume 35, Issue 7, Page 696-703, September 2021.

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this (...) area. (shrink)

In this paper, we put forward the view that emotions have a legitimate and important role in health professional ethics education. This paper draws upon our experience of running a narrative ethics education programme for ethics educators from a range of healthcare disciplines. It describes the way in which emotions may be elicited in narrative ethics teaching and considers the appropriate role of emotions in ethics education for health professionals. We argue there is a need for a pedagogical framework to (...) productively incorporate the role of emotions in health professional ethics teaching. We suggest a theoretical basis for an ethics pedagogy that integrates health professional emotions in both the experience and the analysis of ethical practice, and identify a range of strategies to support the educator to incorporate emotion within their ethics teaching. (shrink)

“Probably Peirce’s best-known works are the first two articles in a series of six that originally were collectively entitled Illustrations of the Logic of Science and published in Popular Science Monthly from November 1877 through August 1878. The first is entitled ‘The Fixation of Belief’ and the second is entitled ‘How to Make Our Ideas Clear.’ In the first of these papers Peirce defended, in a manner consistent with not accepting naive realism, the superiority of the scientific method over other (...) methods of overcoming doubt and ‘fixing belief.’” — Robert Burch, “Charles Sanders Peirce,” entry in the Stanford Encyclopedia of Philosophy (2021 revision) -/- “Pragmatist epistemologies often explore how we can carry out inquiries in a self-controlled and fruitful way. (Where much analytic epistemology centres around the concept of knowledge, considered as an idealised end-point of human thought, pragmatist epistemology centres around the concept of inquiry, considered as the process of knowledge-seeking and how we can improve it.) So pragmatists often provide rich accounts of the capacities or virtues that we must possess in order to inquire well, and the rules or guiding principles that we should adopt. A canonical account is Peirce’s classic early paper ‘The Fixation of Belief‘. Here Peirce states that inquiry is a struggle to replace doubt with “settled belief“, and that the only method of inquiry that can make sense of the fact that at least some of us are disturbed by inconsistent beliefs, and will subsequently reflect upon which methods of fixing belief are correct is the Method of Science, which draws on the Pragmatic Maxim described above. This contrasts with three other methods of fixing belief: i) refusing to consider evidence contrary to one’s favored beliefs (the Method of Tenacity), ii) accepting an institution’s dictates (the Method of Authority), iii) developing the most rationally coherent or elegant-seeming belief-set (the A Priori Method).“ — Catherine Legg, “Pragmatism,” entry in the Stanford Encyclopedia of Philosophy (2021 revision). (shrink)

According to most accounts of trust, you can only trust other people (or groups of people). To trust is to think that another has goodwill, or something to that effect. I sketch a different form of trust: the unquestioning attitude. What it is to trust, in this sense, is to settle one’s mind about something, to stop questioning it. To trust is to rely on a resource while suspending deliberation over its reliability. Trust lowers the barrier of monitoring, challenging, checking, (...) and questioning. Trust sets up open pipelines between yourself and parts of the external world. Trust permits external resources to have a similar relationship to one as one’s internal cognitive faculties. This creates efficiency, but at the price of exquisite vulnerability. We must trust in this way because we are cognitively limited beings in a cognitively overwhelming world. Crucially, we can hold the unquestioning attitude towards objects and technologies. When I trust my climbing rope, I stop worrying about its reliability. When I trust my online calendaring system, I simply go to the events indicated, without question. But, one might worry, how could one ever hold such a normatively loaded attitude as trust towards mere objects? How could it ever make sense to feel betrayed by an object? Trust is our engine for expanding and outsourcing our agency — for binding external processes into our practical selves. Thus, we can be betrayed by our smartphones in the same way that we can be betrayed by our memory. When we trust, we try to make something a part of our agency, and we are betrayed when our part lets us down. To unquestioningly trust something is to let it in—to attempt to bring it inside one’s practical functioning. This suggests a new form of gullibility: agential gullibility, which occurs when agents too hastily and carelessly integrate external resources into their own agency. (shrink)

Clinical ethics committees aim to resolve conflict, facilitate communication and ease moral distress in health care. Dialogue in committee discussions is complex and involves a balance between implicitly and explicitly expressed values of patients, families and professionals. Evaluating effectiveness and concrete outcomes is challenging and most studies focus on broad benefits such as quality of care and reduction of unnecessary or unwanted treatments. In this paper we propose ‘physician satisfaction’ as a valuable outcome. We refer to the clinical ethics approach (...) followed at one large paediatric hospital in Australia, propose reasons for the often-expressed feeling of satisfaction and discuss why this feeling matters. We conclude that physician satisfaction is a valid measure of an effective ethics consultation because it implies the person has been listened to and respected by others, and has perhaps developed greater understanding of and insights into their own work and values, and those of others. (shrink)

Hospitals are places where patients are unwell, where patients and their families may be upset, confused, frustrated, in pain, and vulnerable. The likelihood of these experiences and emotions manifesting in anger and aggressive behaviour is high. In this paper, we describe the involvement of a clinical ethics service responding to a request to discuss family aggression within a rehabilitation department in a large paediatric hospital in Australia. We suggest two key advantages of involving a clinical ethics service in discussions about (...) how to respond to family aggression. First, the process of ethics deliberation provides an opportunity for clinicians to be involved in the solution by articulating their perspectives, tolerance levels, and general concerns about the effects of family aggression towards staff. Second, supporting clinicians to articulate and identify the impact of parental aggression directly counters the disadvantages of the more blunt zero-tolerance policy response, which is necessarily imposed from the top down. (shrink)

Value capture occurs when an agent’s values are rich and subtle; they enter a social environment that presents simplified — typically quantified — versions of those values; and those simplified articulations come to dominate their practical reasoning. Examples include becoming motivated by FitBit’s step counts, Twitter Likes and Re-tweets, citation rates, ranked lists of best schools, and Grade Point Averages. We are vulnerable to value capture because of the competitive advantage that such crisp and clear expressions of value have in (...) our private reasoning and our public justification. There is, however, a price. In value capture, we take a central component of our autonomy — our ongoing deliberation over the exact articulation of our values — and we outsource it. And the metrics to which we outsource usually engineered for the interests of some external force, like a large-scale institution’s interest in cross-contextual comprehensibility and quick aggregability. That outsourcing cuts off one of the key benefits to personal deliberation. In value capture, we no longer adjust our values and their articulations in light of own rich experience of the world. Our values should often be carefully tailored to our particular selves or our small-scale communities, but in value capture, we buy our values off the rack. In some cases – like decreasing CO2 emissions – the costs of non-tailored values are outweighed by the benefit of precise collective coordination. In other cases, like in our aesthetic lives, they are not. This suggests that we should want different values suited to different scales. We should want value federalism. Some values are perhaps best pursued at the largest-scale level, others at smaller scales. The problem occurs when we exhibit an excess preference for the largest-scale values – when we consistently let the universal metrics swamp our quieter interests. (shrink)

Ethics education is recognized as an integral component of health professionals’ education and has been occurring in various guises in the curricula of health professional training in many countries since at least the 1970s. However, there are a number of different aims and approaches adopted by individual educators, programs, and, importantly, different health professions that may be characterized according to strands or trends in ethics education.

:A common goal of ethics education is to equip students who later become health practitioners to not only know about the ethical principles guiding their practice, but to also autonomously recognize when and how these principles might apply and assist these future practitioners in providing care for patients and families. This article aims to contribute to discussions about ethics education pedagogy and teaching, by presenting and evaluating the use of the visual arts as an educational approach designed to facilitate students’ (...) moral imagination and independent critical thinking about ethics in clinical practice. We describe a sequence of ethics education strategies over a 3 year Doctor of Physiotherapy program, focusing on the final year professional ethics assessment task, which involved the use of visual arts to stimulate the exploration of ethics in healthcare. The data were analyzed using both thematic and content analysis. Two key themes centered on emotional responses and lateral thinking. The use of artwork appeared to facilitate imaginative, emotional, and conceptual thinking about ethics and clinical experience. This study provides some evidence to support the effectiveness of the use of the visual arts in promoting students’ recognition of ethical dimensions within their clinical experience and reflection on their emerging professional identity. As one student noted, she left the museum “somewhat changed.”. (shrink)

Recent conversation has blurred two very different social epistemic phenomena: echo chambers and epistemic bubbles. Members of epistemic bubbles merely lack exposure to relevant information and arguments. Members of echo chambers, on the other hand, have been brought to systematically distrust all outside sources. In epistemic bubbles, other voices are not heard; in echo chambers, other voices are actively undermined. It is crucial to keep these phenomena distinct. First, echo chambers can explain the post-truth phenomena in a way that epistemic (...) bubbles cannot. Second, each type of structure requires a distinct intervention. Mere exposure to evidence can shatter an epistemic bubble, but may actually reinforce an echo chamber. Finally, echo chambers are much harder to escape. Once in their grip, an agent may act with epistemic virtue, but social context will pervert those actions. Escape from an echo chamber may require a radical rebooting of one's belief system. (shrink)

A notable feature of the COVID-19 pandemic is that children are less at risk of becoming infected or, if infected, less likely to become seriously unwell, so ethical discussions have consequently focused on the adult healthcare setting. However, despite a lower risk of children becoming acutely ill with COVID-19, there nevertheless may be significant and potentially sustained effects of COVID-19 on the physical, psychological, and emotional health and well-being of children. Focusing on the context of children’s cancer care, and specifically (...) bone marrow transplant, we describe some of these effects and then address one specific ethical challenge that arises. That is the question of what and how much to tell children whose cancer treatment has been changed because of COVID-19. Drawing on our previous work on the ethical reasons for telling the truth to younger children we link different ethical reasons to the different types of information that could be given to children in this context. We argue that children should be given an explanation of the changes that they will directly experience, including some changes to the process of their actual medical treatment; but not about increased risk associated with these changes, unless they specifically ask for this information. (shrink)

As is so often the case in a common law system, the legal protection conferred by one strand of law is undermined by other legal provisions. There is no blanket legal duty which compels health care professionals to undergo HIV/AIDS tests; on the other hand, appropriately drafted contracts of employment, duties imposed by courts on employees and the risk of litigation by patients with pressurise individual workers to submit to testing. Whereas in Italy the law clearly condemned any compulsory testing (...) of health care workeers, but must now be interpreted to support it, in England and Wales each individual worker's case must be examined in order to determine whether testing must be submitted to. (shrink)

One probable success (the case of Mrs Tonge) is not a great deal to set against the courts' overwhelming reluctance to play a part in challenging resource allocation decisions. Nevertheless, where such decisions are inherently unreasonable—for example, as Margaret Brazier has suggested,11 a refusal to treat patients because they are divorced, or because they are Labour Party members—a remedy would be available through the courts. Presumably gender biased rationing decisions would similarly be susceptible to judicial review, although there might be (...) evidential difficulties. Age-related denial of treatment would probably not in itself be considered to be ‘Wednesbury unreasonable’. If it could be shown that within the one health authority a particular patient or a group at a set age were denied treatment others at the same age received, there might be scope for an application to the courts. Evidence sufficient to satisfy judges ‘notoriously unwilling to overturn doctors' decisions’11 would be hard to collect.While courts cannot be expected to determine health care policy, their refusal to examine in any detail the decision-making processes of Health Service authorities has ratified ‘the opacity of current decision-making’.12 Instead of forcing authorities to take decisions in a reasoned and justified manner, the courts by their very conservative application of the Wednesbury decision have allowed them to hide from public scrutiny. (shrink)

The legal regulation of standards of medical practice has two main forms. The more direct of these comprises legislation and judicial precedents concerned with the delivery of medical care. Typically this form sets out the meaning of consent to treatment, establishes negligence thresholds and imposes duties of confidentiality. The second form of regulation is entrusted to a supervisory body, established by law and given jurisdiction to enforce standards of conduct by controlling entry to the profession and through the use of (...) disciplinary powers. (shrink)

As long as it remains mental health policy to offer care in the community rather than longterm hospitalisation, attention should focus on securing safe and supportive environments both for patients themselves and for their interactions with other members of the community. Yet such environments have proved hard to create and service users, providers and the wider public have recognised the isolation in which several patients live, the poor risk management, the lack of liaison between professionals, and state reluctance to resource (...) the policy. (shrink)