Despite prevalent concerns about the ethical conduct of clinical trials, little is known about the day-to-day work of trials and the ethical challenges arising in them. This paper reports on a study designed to fill this gap and demonstrates a need to refine the oversight system for trials to reflect an understanding of this day-to-day work. It also illuminates ethical challenges that cannot be addressed by the oversight system and so necessitate a rethinking of the ethics of clinical trials.

It may be the case that the most challenging moral problem of the twenty‐first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which (...) they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency. (shrink)

Artificial persons are those who speak and act for others. Nurses speak and act for patients as well as for physicians and institutions, or, more aptly, institutionalized medicine. Yet, acting for institutionalized medicine can be harmful to nurses, due to the psychological experience of moral distress and the loss of integrity of their practice. This paper illustrates the harm to nurses as expressed in narratives of their practice, and suggests some initial steps we might take in resisting the artificial personhood (...) imposed by institutionalized medicine. (shrink)

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based practice. (...) Following a brief history of the transition from the paper record to the EHR, the authors discuss unintended or contested consequences resulting from this change. These changes primarily reflect changes in the organization and amount of clinician work and clinician‐patient relationships. The paper is not a research report but was informed by an institutional ethnography the aim of which was to understand how the EHR impacted clinicians and administrators in a large, urban hospital in the United States. The paper was also informed by other sources, including the philosophies of Jacques Ellul, Don Idhe, and Langdon Winner. (shrink)

Surgical “buy-in” is an “informal contract between surgeon and patient in which the patient not only consents to the operative procedure but commits to the post-operative surgical care anticipated by the surgeon.”1 Surgeons routinely assume that patients wish to undergo treatment for operative complications so that the overall treatment course is “successful,” as in the treatment of a post-operative infection. This article examines occasions when patients buy-in to a treatment course that carries risk of complication, yet refuse treatment when complications (...) arise. We coin this counter-phenomenon “cashing-out.” Cashing-out may elicit negative feelings among careproviders. We question why patients or families may wish to cash-out. One reason may be the changing epistemological position of patients as they experience a complication. The shift from the hypothetical discussion of complications during the initial informed-consent process to the experience of having a complication represents new knowledge. Patients and families may use this knowledge as the basis to revoke consent for some or all of the remaining treatment course. This article seeks to understand cashing-out in terms of the patients’ experiences. We hope to prompt recognition of this phenomenon across medical contexts and to provide impetus for further work to understand why patients may wish to cash-out. (shrink)

The controversy over the so-called Ashley Treatment (AT), a series of medical procedures that inhibited both growth and sexual development in the body of a profoundly intellectually impaired girl, usually centers either on Ashley’s rights, including a right to an intact, unaltered body, or on Ashley’s parents’ rights to make decisions for her. The claim made by her parents, that the procedure would improve their ability to care for her, is often dismissed as inappropriate or, at best, irrelevant. We argue, (...) however, that caregiving is a central issue in the controversy, as Ashley’s need for caregiving is a defining characteristic of her life. In this article, we analyze the ethics of the Ashley Treatment within the context of family caregiving. Through the physical and emotional work of caregiving, families participate in the formation and maintenance of personal identity, a process that Hilde Lindemann recently called “holding.” We argue that, in an intellectually disabled person such as Ashley, who depends on her family for every aspect of her care, the family’s contribution to identity is an essential source of personhood. We believe that the treatment can be justified if it is indeed an instance of appropriate family “holding” for Ashley. (shrink)

Advance care planning (ACP) is a process that seeks to elicit patients’ goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and limitations. Focus (...) groups were conducted with 15 physicians as part of a larger study of adolescent and young adult ACP in hematopoietic stem cell transplant (HSCT) patients. This study identified two categories important to the utility of ACP in pediatric HSCT patients; (1) the temporal context of ACP and decision making and (2) the limitations of pediatric ACP, with subcategories identified as (a) embodied and witnessed knowing, (b) the impact of clinical cascades—when the treatment of one organ system creates complications in another system that needs to be treated—and a creation of a “new normal” following complications of illness and its treatment in the pediatric intensive care unit (PICU), (c) the balancing of adolescents’ autonomy with their capacity to make informed medical decisions, and (d) the epistemological frames that differ between HCP and patients and their families. These findings support ACP in adolescent and young adult HSCT patients, with a number of implications for practice as this process becomes more common. (shrink)

Moral distress has been covered extensively in the nursing literature and increasingly in the literature of other health professions. Cases that cause nurses’ moral distress that are mentioned most frequently are those concerned with prolonging the dying process. Given the standard of aggressive treatment that is typical in intensive care units (ICUs), much of the existing moral distress research focuses on the experiences of critical care nurses. However, moral distress does not automatically occur in all end-of-life circumstances, nor does every (...) critical care nurse suffer its damaging effects. What are the practices of these nurses? What specifically do they do to navigate around or through the distressing situations? The nursing literature is lacking an answer to these questions. This article reports a study that used narrative analysis to explore the reported practices of experienced critical care nurses who are skilled at and comfortable working with families and physicians regarding the withdrawal of aggressive treatment. A major finding was that these nurses did not report experiencing the dam-Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress Terri Traudt, Joan Liaschenko, and Cynthia Peden-McAlpine Terri Traudt, MBC, MA, is a Communications Consultant specializing in bioethics at the Center for Bioethics at the University of Minnesota, in Minneapolis. [email protected] Joan Liaschenko, PhD, RN, FAAN, is a Professor at the Center for Bioethics and Nursing at the University of Minnesota. Cynthia Peden-McAlpine, PhD, ACNS, BC, is an Associate Professor in the School of Nursing at the University of Minnesota. © 2016 by The Journal of Clinical Ethics. All rights reserved. aging effects of moral distress as described in the nursing literature. The verbal communication and stated practices relevant to this finding are organized under three major themes: (1) moral agency, (2) moral imagination, and (3) moral community. Further, a total of eight subthemes are identified. The practices that constitute these themes and subthemes are further detailed and discussed in this article. Understanding these practices can help mitigate critical care nurses’ moral distress. (shrink)

Clinical trials are a central mechanism in the production of medical knowledge. They are the gold standard by which such knowledge is evaluated. They are widespread both in the United States and internationally; a National Institute of Health database reports over 106,000 active industry and government-sponsored trials (National Institutes of Health n.d.). They are an engine of the economy. The work of trials is complex; multiple people with diverse interests working across multiple settings simultaneously participate in them, and they are (...) underwritten by multiple organizational structures and diverse funding mechanisms. In the past several years, concern about the ethics of clinical trials has spiked dramatically .. (shrink)

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and (...) responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

The ethical ‘eye’ of nursing, that is, the particular moral vision and values inherent in nursing work, is constrained by the preoccupations and practices of the superordinate biomedical structure in which nursing as a practice discipline is embedded. The intimate, situated knowledge of particular persons who construct and attach meaning to their health experience in the presence of and with the active participation of the nurse, is the knowledge that provides the evidence for nurses’ ethical decision making. It is largely (...) invisible to all but other nurses. Two nurse researchers, Joan Liaschenko of the University of Minnesota and Patricia Rodney of the University of Victoria, have investigated the ethical concerns of practising nurses and noted in their separate enquiries the invisible nature of critical aspects of nursing work. Noting the similarities in their respective observations, and with the feminist ethics of Margaret Urban Walker as a theoretical framework, this article examines the concept of ‘invisibility’ as it relates to nursing work and nursing ethics. (shrink)

It is time for the noon conference. Your job is to impart a career-changing experience in ethics to a group of students and interns gathered from four different schools with varying curriculums in ethics. They have just finished 1½ h of didactic sessions and lunch. One third of them were on call last night. Your first job is to keep them awake. The authors argue that this “tragic case” approach to ethics education is of limited value because it limits understanding (...) of moral problems to dilemmas; negates the moral agency of the student; encourages solutions that are merely intellectual; and suggests that ethical encounters are a matter for experts. The authors propose an alternative that focuses on three issues: the provider-patient relationship, the relationships between providers in the everyday world of health work and, the social position of healthcare providers in society. In this approach, teachers are not experts but more like guides on a journey who help students to learn that much of ethical practice comprises living through difficult situations of caring for vulnerable others and who help students to navigate some of these difficulties. (shrink)

On the Contemplative Life is known for its depiction of a philosophical group of Jewish men and women known as the 'Therapeutae'. Yet the reasons for their depiction have been little understood. In the first commentary on the treatise in English for over 100 years, the social, cultural and political background of the times in which Philo lived are shown to be crucial in understanding Philo's purposes. As Alexandrian Jews were vilified and attacked, Philo went to Rome to present the (...) case for his community, faced with intense opposition. Side-stepping direct confrontation, Philo here cleverly presents the Therapeutae as the pinnacle of excellence, most especially in their communal meal, while ridiculing his accusers in a stinging parody of a festive banquet. (shrink)

In spite of feminist recognition that hierarchical organizations are an important location of male dominance, most feminists writing about organizations assume that organizational structure is gender neutral. This article argues that organizational structure is not gender neutral; on the contrary, assumptions about gender underlie the documents and contracts used to construct organizations and to provide the commonsense ground for theorizing about them. Their gendered nature is partly masked through obscuring the embodied nature of work.jobs and hierarchies, common concepts in organizational (...) thinking, assume a disembodies and universal worker. This worker is actually a man; men's bodies, sexuality, and relationships to procreation and paid work are subsumed in the image of the worker. Images of men's bodies and masculinity pervade organizational processes, marginalizing women and contributing to the maintenance of gender segregation in organizations. The positing of gender-neutral and disembodied organizational structures and work relations is part of the larger strategy of control in industrial capitalist societies, which, at least partly, are built upon a deeply embedded substructure of gender difference. (shrink)

Women and religion -- Reproductive futurism -- Political emancipation -- From the Cold War to the clash of civilizations -- Sexual emancipation.

In this article, the author addresses two feminist issues: first, how to conceptualize intersectionality, the mutual reproduction of class, gender, and racial relations of inequality, and second, how to identify barriers to creating equality in work organizations. She develops one answer to both issues, suggesting the idea of “inequality regimes” as an analytic approach to understanding the creation of inequalities in work organizations. Inequality regimes are the interlocked practices and processes that result in continuing inequalities in all work organizations. Work (...) organizations are critical locations for the investigation of the continuous creation of complex inequalities because much societal inequality originates in such organizations. Work organizations are also the target for many attempts to alter patterns of inequality: The study of change efforts and the oppositions they engender are often opportunities to observe frequently invisible aspects of the reproduction of inequalities. The concept of inequality regimes may be useful in analyzing organizational change projects to better understand why these projects so often fail and why they succeed when this occurs. (shrink)

Este artículo analiza el prólogo de 1812 a la Ciencia de la lógica (WdL) y responde a los planteos: ¿de qué trata esta obra?, ¿qué hay de lógico en la expresión “lógica”?, ¿es ”lógica” un nombre sustituto para “metafísica” o, más bien, la WdL es la inauguración de una disciplina completamente nueva y que dista de la metafísica en el sentido tradicional? Concluyo que la lógica es aquí el desarrollo del concepto expresada como libertad social.

After watching the 2017 Charlottesville riots, Joan Wallach Scott began thinking about our standard views of history as progressive, and the culmination of progress in the Western European nation-state since the 18th century. The return of once-discredited ideas-Nazism, white supremacy, nationalism-poses serious threats to democratic institutions and values, and upends our commonly-used adages about "the judgment of history" or being "on the right side of history." The three chapters examine the Nuremberg Tribunal, South Africa's Truth and Reconciliation Commission, and (...) the movement for reparations for slavery in the U.S. Scott examines how our association of these events with the expectation that history moves in an ever-improving linear direction. Instead, Scott forces us to reassess the history of these cases, not as an appeal to how history will ultimately judge these events, but rather as a need to perpetuate the nation-state and its claims to morality. (shrink)

When Carol Gilligan (1982) first introduced the ethic of care she did so from the discipline of psychology using empirical data that questioned Kohlberg's (1981) negative assumptions about the mora...

The inquiry into the moral status of artificial intelligence (AI) is leading to prolific theoretical discussions. A new entity that does not share the material substrate of human beings begins to show signs of a number of properties that are nuclear to the understanding of moral agency. It makes us wonder whether the properties we associate with moral status need to be revised or whether the new artificial entities deserve to enter within the circle of moral consideration. This raises the (...) foreboding that we are at the gates of an anthropological crisis: the properties bound to moral agency have been exclusively possessed in the past by human beings and have shaped the very definition of being human. In this article, I will argue that AI does not lead us to an anthropological crisis and that, if we adhere to the history and philosophy of technology, we will notice that the debate on the moral status of AI uncritically starts from an anthropology of properties and loses sight of the relational dimension of technology. First, I will articulate three criteria for analyzing different anthropological views in philosophy of technology. Second, I will propose six anthropological models: traditional, industrial, phenomenological, postphenomenological, symmetrical, and cyborg. Third, I will show how the emergence of AI breaks with the dynamics of increased relationality in the history and philosophy of technology. I will argue that this aspect is central to debates about the moral status of AI, since it sheds light on an aspect of moral consideration that has been obscured. Finally, I will reject entirely relational approaches to moral status and propose two hybrid possibilities for rethinking it. (shrink)

Not only can the influence of Gottlob Frege be found in contemporary work in logic, the philosophy of mathematics, and the philosophy of language, but his projects—and the very terminology he employed in pursuing those projects—are still current in contemporary philosophy. This is undoubtedly why it seems so reasonable to assume that we can read Frege' s writings as if he were one of us, speaking to our philosophical concerns in our language. In Joan Weiner's view, however, Frege's words (...) can be accurately interpreted only if we set that assumption aside. Weiner here offers a challenging new approach to the philosophy of this central figure in analytic philosophy. Weiner finds in Frege's corpus, from Begriffsschrift on, a unified project of remarkable ambition to which each of the writings in that corpus makes a distinct contribution—a project whose motivation she brings to life through a careful reading of his Foundations of Arithmetic. The Frege that Weiner brings into clear view is very different from the familiar figure. Far from having originated one of the standard positions on the nature of reference, Frege turns out not to have had positive doctrines on anything like what contemporary philosophers mean by "reference." Far from having served as a standard-bearer for those who take the realists' side of contemporary disputes with anti-realists, Frege turns out to have had no stake in either side of the controversy. Through Weiner's lens, Frege emerges as a thinker who has principled reasons for challenging the very assumptions and motivations that animate philosophers to dispute these doctrines. This lucidly written and accessible book will generate controversy among all readers with an interest in epistemology, philosophy of language, history of philosophy, and the philosophy of mathematics. (shrink)

Changing paradigms about moving forward -- The notion of progress in the past -- The notion of progress today -- Self-leadership and progress -- Toward a moral compass -- The right thing in pre-millennial context -- The right thing in current context -- Defining and polishing our moral compass -- Moving forward while doing the right thing -- About choice and reality -- Five moral pitfalls to avoid -- Moral theories : some pros and cons -- Five moral handles for (...) every type of decision-making. (shrink)

There is a section in Samuel Delany’s magnificent autobiographical meditation, The Motion of Light in Water, that dramatically raises the problem of writing the history of difference, the history, that is, of the designation of “other,” of the attribution of characteristics that distinguish categories of people from some presumed norm.1 Delany recounts his reaction to his first visit to the St. Marks bathhouse in 1963. He remembers standing on the threshold of a “gym-sized room” dimly lit by blue bulbs. The (...) room was full of people, some standing, the rest an undulating mass of naked, male bodies, spread wall to wall. My first response was a kind of heart-thudding astonishment very close to fear. I have written of a space at certain libidinal saturation before. That was not what frightened me. It was rather that the saturation was not only kinesthetic but visible.2Watching the scene establishes for Delany a “fact that flew in the face” of the prevailing representation of homosexuals in the 1950s as “isolated perverts,” as subjects “gone awry.” The “apprehension of massed bodies” gave him a “sense of political power”:what this experience said was that there was a population—not of individual homosexuals … not of hundreds, not of thousands, but rather of millions of gay men, and that history had, actively and already, created for us whole galleries of institutions, good and bad, to accommodate our sex. [M, p. 174] 2. Samuel R. Delany, The Motion of Light in Water: Sex and Science Fiction Writing in the East Village, 1957-1965 , p. 173; hereafter abbreviated M. Joan W. Scott is professor of social science at the Institute for Advanced Study in Princeton, New Jersey. She is the author, most recently, of Gender and the Politics of History and is currently at work on a history of feminist claims for political rights in France during the period 1789-1945 as a way of exploring arguments about equality and difference. (shrink)

In this book Joan Wallach Scott discusses the role history has played as an arbiter of right and wrong and of those who claim to act in its name-- "in the name of history." Scott investigates three different instances in which repudiation of the past was conceived as a way to a better future: the International Military Tribunal at Nuremberg in 1946, the South African Truth and Reconciliation Commission in 1996, and the ongoing movement for reparations for slavery in (...) the United States. Scott shows how in these cases history was not only used to explain the past but to produce a particular future. Yet both past and future were subject to the political realities of their time and defined in terms of moral absolutes, often leading to deep contradictions. These three instances demonstrate that history is not an impartial truth, rather its very meaning is constructed by those who act in its name. (shrink)

This book deals with the theoretical, methodological, and empirical implications of bounded rationality in the operation of institutions. It focuses on decisions made under uncertainty, and presents a reliable strategy of knowledge acquisition for the design and implementation of decision-support systems. Based on the distinction between the inner and outer environment of decisions, the book explores both the cognitive mechanisms at work when actors decide, and the institutional mechanisms existing among and within organizations that make decisions fairly predictable. While a (...) great deal of work has been done on how organizations act as patterns of events for (boundedly) rational decisions, less effort has been devoted to study under which circumstances organizations cease to act as such reliable mechanisms. Through an empirical strategy on open-ended response data from a survey among junior judges, the work pursues two main goals. The first one is to explore the limits of "institutional rationality" of the Spanish lower courts on-call service, an optimal scenario to observe decision-making under uncertainty. The second aim is to achieve a better understanding of the kind of uncertainty under which inexperienced decision-makers work. This entails exploring the demands imposed by problems and the knowledge needed to deal with them, making this book also a study on expertise achievement in institutional environments. This book combines standard multivariate statistical methods with machine learning techniques such as multidimensional scaling and topic models, treating text as data. Doing so, the book contributes to the collaboration between empirical social scientific approaches and the community of scientists that provide the set of tools and methods to make sense of the fastest growing resource of our time: data. (shrink)