Research question and aimClinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020,...

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, (...) the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here. (shrink)

American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict (...) or come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 14.1 (2004) 47-54 [Access article in PDF] Ethical Guidelines for Human Embryonic Stem Cell Research*(A Recommended Manuscript) Adopted on 16 October 2001Revised on 20 August 2002 Ethics Committee of the Chinese National Human Genome Center at Shanghai, Shanghai 201203 Human embryonic stem cell (ES) research is a great project in the frontier of biomedical science for the twenty-first century. Be- cause the (...) research involves the use of human embryos, it triggers serious debate on ethical issues. Opponents consider the embryo to be an early form of human life that should be respected and not destroyed. However, the majority of scientists support embryonic stem cell research, believing that it offers good prospects for the treatment of diseases that have remained incurable until now and so will benefit humankind. The Ethics Committee of the Department of Ethical, Legal, and Social Implications of the Chinese National Human Genome Center at Shanghai seriously discussed the ethical debate initiated by embryonic stem cell research. We concluded that we should support the scientists of our country in actively carrying out human embryonic stem cell research for the noble cause of "medicine being a beneficent art." For the healthy and orderly development of human embryonic stem cell research in our country, we put forward the following recommended Ethical Guidelines for Human Embryonic Stem Cell Research as a reference for leaders, administrative departments, and related scientists. Preface Article 1. Human embryonic stem cells are the primitive cells that play the main role in the growth and development of a human body. These [End Page 47] primitive cells have the potential for infinite proliferation, self-renewal, and multi-directional differentiation. If scientists can discover the mechanism of differentiation of human embryonic stem cells, it will be possible to induce differentiation of human embryonic stem cells to form various types of human cells for clinical cell therapy. If human embryonic stem cell research can be integrated with modern biomedical engineering techniques, it also will be possible to make repair and replacement of human tissues and organs a reality. Article 2. There are two ways to classify human embryonic stem cells. One way is to classify them according to their potential for differentiation. There could be three kinds of stem cells: totipotent stem cells, pluripotent stem cells, and unipotent stem cells.A totipotent stem cell has the potential to develop into a whole individual. It can differentiate into the more than 200 cell types in the whole body, construct any tissue or organ of the body, and finally develop into a whole individual. The fertilized egg and the cleavage cells at the very early stage of embryonic development are totipotent stem cells.A pluripotent stem cell has the potential to differentiate into many cell types derived from the three embryonic layers. However, it has lost the capacity to develop into a complete organism.A unipotent stem cell is derived from the further differentiation of the pluripotent stem cell. It can differentiate only into one cell type such as a hematopoietic stem cell, neural stem cell, and others.The other way is to classify human stem cells according to their source. There could be two kinds of human stem cells: embryonic stem cells and tissue stem cells (also called adult stem cells). The former involves experimentation with embryos, which has serious ethical implications. Ethical issues associated with the latter are mainly expressed in the various opinions regarding the allocation of health resources. Article 3. Human embryonic stem cells are the group of cells called the blastocyst inner cell mass during the early stage of embryonic development. They are the main source of totipotent stem cells, and hence the focal and hot point in stem cell research. Studies on the clinical application of embryonic stem cells probably will involve use of the somatic cell nucleus transfer (SCNT) technique, which destroys the early human embryo. At present, the ethical and moral debate is very serious in human embryonic stem cell research regarding whether the research will develop... (shrink)

This book is a comprehensive and unique text and reference in medical ethics. By far the most inclusive set of primary documents and articles in the field ever published, it contains over 100 selections. Virtually all pieces appear in their entirety, and a significant number would be difficult to obtain elsewhere. The volume draws upon the literature of history, medicine, philosophical and religious ethics, economics, and sociology. A wide range of topics and issues are covered, such as law (...) and medicine, truth-telling by the physician, research, population policy, genetics, abortion, dying, and individual rights in medical care. The selections span the centuries, beginning with material from the works of Hippocrates, continuing through Thomas Percival, John Stuart Mill, and Claude Bernard, down to modern commentators like Henry K. Beecher, Walsh McDermott, David L. Bazelon, Paul Freund, H. L. A. Hart, John Rawls, Paul Ramsey, Richard McCormick, Rashi Fein, and Bernard Barber. The text has eight major divisions, beginning with sections on the ethical dimensions of the physician-patient relationship in history; the moral bases of medical ethics; and regulation, compulsion, and protection of the consumer in clinical medicine and public health. Each of these sections includes key essays that appear for the first time. All of the book's major divisions contain primary documents: codes such as the Hippocratic Oath, Medieval Law for the Regulation of Medicine, and the first as well as the most recent code of the American Medical Association; court decisions, including those on Karen Quinlan and on abortion in the United States and West Germany; government documents such as the statement of the National Commission on the Protection of Human Subjects, the Tuskegee Syphilis Report, the British Parliamentary debate on euthanasia, and the Council of Europe on rights of the sick and dying; and various published guidelines such as the Harvard Medical School brain death criteria, the American Hospital Association on patient's rights, and Pope Pius XII on the prolongation of life. Cases that illustrate moral dilemmas are provided for discussion purposes. Each section is preceded by a succinct editor's introduction. The documents and essays are of practical value for practitioners and students in medicine, law, ethics, and counselling, and for individual patients and groups concerned with medical care. Through encompassing divergent viewpoints, the essays and primary documents were selected to encourage humane practices and deepen understanding of the multiple traditions that shaped and do shape the development of medicine. (shrink)

The Council on Ethical and Judicial Affairs of the American Medical Association examines physicians’ professional ethical responsibility in the event that the security of patients’ electronic records is breached.

This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

This book is about the ethical issues that clinicians encounter as they care for patients and is written to assist those who serve on hospital ethics committees as they deliberate about appropriate action in difficult ethical cases.

In this paper I attempt to address what appears to be a novel theoretical and practical problem concerning physician-assisted suicide (PAS). This problem arises out of a newly created set of circumstances in which persons are hospitalized in jurisdictions where PAS, though now legally available to patients, remains morally contentious. When moral disagreements over PAS come to divide physicians, patients, and family members, it is quite likely they will today find their way to the hospital’s consulting ethicist, a member of (...) an emerging group of professionals charged with the responsibility (so we are told) of resolving moral conflict in the clinic. What can or should an ethics consultant do to fulfill this mandate in such circumstances? I argue that the now predominant conception of clinical ethics consultation is importantly deficient in that it provides no final guidance to ethicists on how they should respond in such cases. The ethicist may only recommend—or assist others to reach—solutions to moral disagreements falling within the limits of established norms. Since the normative landscape of PAS appears to be changing, whether it falls within these limits is unsettled. I conclude that the accepted goals of ethics consultation require a revised and expanded conception of the ethicist's role in cases involving PAS. I close by outlining what that revised understanding would look like and the further questions it raises. (shrink)

Book reviewed in this article: Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. By Albert R. Jonsen, Mark Siegler, and William J. Winslade.

This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics (...) support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a “bottom-up” perspective might give healthcare personnel opportunities to think and reflect more than a “top-down” perspective. A “bottom-up” approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a “top-down” approach risks removing such moral responsibility. (shrink)

The Clinical Ethics Credentialing Project (CECP) was intiated in 2007 in response to the lack of uniform standards for both the training of clinical ethics consultants, and for evaluating their work as consultants. CECP participants, all practicing clinical ethics consultants, met monthly to apply a standard evaluation instrument, the “QI tool”, to their consultation notes. This paper describes, from a qualitative perspective, how participants grappled with applying standards to their work. Although the process was (...) marked by resistance and disagreement, it was also noteworthy for the sustained engagement by participants over the year of the project, and a high level of acceptance by its conclusion. (shrink)

Clinical Ethics Consultations are an important tool for physicians in solving difficult cases. They are extremely common in North America and to a lesser extent also present in Europe. However, there is little data on this practice in Poland. We present results of a survey of 521 physicians practising in Poland concerning their opinion on CECs and related practices. We analysed the data looking at such issues as CECs’ perceived availability, use of CECs, and perceived usefulness of such (...) support. Physicians in our study generally encounter hard ethics cases, even—surprisingly—those who do not work in hospitals. Most physicians have no CEC access, and those that do still do not employ CECs. However, physicians perceive this form of support as useful—even more so among actual users of CECs. We compared these findings with similar studies from other European countries and the North America. We point out peculiarities of our results as compared to those in other countries, with some possible explanations. We hope the results may encourage regulatory debate on the need to formally introduce CECs into the Polish healthcare system. (shrink)

The attempt to critique the profession of clinical ethics consultation by establishing the impossibility of ethics expertise has been a red herring. Decisions made in clinical ethics cases are almost never based purely on moral judgments. Instead, they are all-things-considered judgments that involve determining how to balance other values as well. A standard of justified decision-making in this context would enable us to identify experts who could achieve these standards more often than others, and thus (...) provide a basis for expertise in clinical ethics consultation. This expertise relies in part on what Richard Zaner calls the “expert knowledge of ethical phenomena”. (shrink)

There is the world of ideas and the world of practice; the French are often for sup pressing the one and the English the other; but neither is to be suppressed. -Matthew Arnold The Function of Criticism at the Present Time From its inception, bioethics has confronted the need to reconcile theory and practice. At first the confrontation was purely intellectual, as writers on ethical theory (within phi losophy, theology, or other humanistic disciplines) turned their attention to topics from the (...) world of medical practice. Recently the confrontation has grown more intense. The ap pointment of clinical ethicists in hospitals and other health care settings is an accelerating trend in North America. Concomitantly, those institutions involved in training peo ple in clinical ethics have added organized exposure to the world of practice, in the form of placement requirements, to the normal academic course load. In common with other dis ciplines, bioethics has begun to see clinical training as a con dition of didactic theory and apprenticeship. (shrink)

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants (...) felt that they gained an increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented. (shrink)

Since Clinical Ethics Consultation has become important in the public health sector in the last decade in Germany, there are on-going questions about effectiveness. Targets have been established by the Ethics Committees, in regard to assisting patients, families and health care teams at times of ethical conflicts during the decision-making process in medical care. Of all the ethics consultations over the last eight years at Erlangen University Hospital the consultations carried out in the pediatric department were (...) chosen to be reviewed by a pediatrician and an ethicist. These were evaluated on the basis of team formation, interdisciplinary orientation, ethical criteria, completeness and methods of documentation. Results of the analysis of those records show a well-organized consultation team with regard to its personnel composition. Discrepancies with ethical questions posed in the literature are revealed, and also some partially incomplete documentation regarding medical facts and descriptions of the patients' or parents' opinion. (shrink)

Hospital ethics committees were created in the United States of America in the 1970s. Their aims were the education of the hospital personnel in the field of ethics, the development of policies and the publication of guidelines concerning ethical issues, as well as consultations and case reviews of hospitalized patients when an ethical concern was present. During the last thirty years, these committees disseminated, particularly in Western Europe. In this manuscript, we describe the benefit, but also some difficulties (...) with these committees, and we propose some solutions. The characteristics of these committees are discussed (i.e. typology of members, functioning and legitimacy). Finally, we carefully describe our local hospital clinical ethics committee in Geneva (Switzerland), which was founded in 1994 and it still very active. After fifteen years of experience, we remain strongly in favour of the implementation of such committees in any modern hospital. (shrink)

Background: International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. Methods: Health professionals at a large regional health service completed an online survey containing questions about (...) the frequency of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. Results: The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). Conclusions: A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education. (shrink)

Essays by Thomasma and ten Have recommend hermeneutical clinical ethics. The use Thomasma makes of hermeneutics is not radical enough because it leaves out basic interpretation of clinical practice and focuses narrowly on ethical principles and rules. Ten Have, while failing to notice that the hyperreality of clinical ethics is a feature of all language, rightly distinguishes four characteristic parameters of a thoroughgoing interpretive clinical ethics: experience, attitudes and emotions, community, and ambiguity. Suggestions (...) are made for implementing hermeneutical ethics in clinical teaching. (shrink)

Can machine intelligence do clinical ethics? And if so, would applying it to actual medical cases be desirable? In a recent target article (Meier et al. 2022), we described the piloting of our advisory algorithm METHAD. Here, we reply to commentaries published in response to our project. The commentaries fall into two broad categories: concrete criticism that concerns the development of METHAD; and the more general question as to whether one should employ decision-support systems of this kind—the debate (...) we set out to ignite with our target article. (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)

The British National Institute for Health and Clinical Excellence has recently released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder. Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in refraining from emphasising (...) uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE. (shrink)

The first clinical ethics committees in Norway were established in 1996. This started as an initiative from hospital clinicians, the Norwegian Medical Association, and health authorities and politicians. Norwegian hospitals are, by and large, publicly funded through taxation, and all inpatient treatment is free of charge. Today, all the 23 hospital trusts have established at least one committee. Center for Medical Ethics , University of Oslo, receives an annual amount of US$335,000 from the Ministry of Health and (...) Care Services to coordinate the committees and to facilitate competency building for committee members. (shrink)

Clinical ethics has developed significantly in Europe over the past 15 years and remains an evolving process. While sharing our experiences in different European settings, we were surprised to discover marked differences in our practice, especially regarding the position and role of patients. In this paper, we describe these differences, such as patient access to and participation or representation in ethics consults. We propose reasons to explain these differences, hypothesizing that they relate to the historic and sociocultural (...) context of implementation of clinical ethics consultation services (Cecs), as well as the initial aims for which each structure was established. Then, we analyse those differences with common ethical arguments arising in patient involvement. We conclude that there is no unique model of best practice for patient involvement in clinical ethics, as far as Cecs reflect on how to deal with the challenging ethical issues raised by patient role and position. (shrink)

_The Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants_ instructs clinical ethics consultants to preserve their professional integrity by “not engaging in activities that involve giving an ethical justification or stamp of approval to practices they believe are inconsistent with agreed-upon standards” (ASBH, 2014, p. 2). This instruction reflects a larger model of how to address value uncertainty and moral conflict in healthcare, and it brings up some intriguing and as yet unanswered questions—ones that (...) the drafters of the _Code_, and the profession more broadly, should seek to address in upcoming revisions. The objective of this article is to raise these questions as a way of urging greater clarification of the _Code’s_ overall approach to professional integrity, its meaning, and implications. (shrink)

Since 1989, clinical ethics consultation in form of hospital ethics committees was established in most of the transition countries of Central and Eastern Europe. Up to now, the similarities and differences between HECs in Central and Eastern Europe and their counterparts in the U.S. and Western Europe have not been determined. Through search in literature databases, we have identified studies that document the implementation of clinical ethics consultation in Central and Eastern Europe. These studies have (...) been analyzed under the following aspects: mode of establishment of HECs, character of consultation they provide, and their composition. The results show that HECs in the transition countries of Central and Eastern Europe differ from their western-European or U.S. counterparts with regard to these three aspects. HECs were established because of centrally imposed legal regulations. Little initiatives in this area were taken by medical professionals interested in resolving emerging ethical issues. HECs in the transition countries concentrate mostly on review of research protocols or resolution of administrative conflicts in healthcare institutions. Moreover, integration of non-professional third parties in the workings of HECs is often neglected. We argue that these differences can be attributed to the historical background and the role of medicine in these countries under the communist regime. Political and organizational structures of healthcare as well as education of healthcare staff during this period influenced current functioning of clinical ethics consultation in the transition countries. (shrink)

This paper focuses on the topic of evaluation of clinical ethics consultation. The concept of evaluation seems to contain an internal tension: On the one hand, evaluation is seen as distorting the conceptual and normative content of the case under scrutiny and, on the other, the evaluative act is the most important use of judgment and an inescapable part of everyday life. As such, we maintain that evaluation is essential.

Clinical ethics support for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria at Amsterdam University Medical Center. We specifically aimed to integrate CES (...) into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice. (shrink)

Clinical ethics support for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria at Amsterdam University Medical Center. We specifically aimed to integrate CES (...) into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice. (shrink)

A clinical ethics fit for the Anthropocene—our current geological era in which human activity is the primary determinant of environmental change—needs to incorporate environmental ethics to be fit for clinical practice. Conservationist Aldo Leopold’s essay ‘The Land Ethic’ is probably the most widely-cited source in environmental philosophy; but Leopold’s work, and environmental ethics generally, has made little impression on clinical ethics. The Land Ethic holds that “A thing is right when it tends to (...) preserve the integrity, stability, and beauty of the biotic community. It is wrong when it tends otherwise.” I argue that a Land Ethic helps to re-frame problems in clinical ethics that more common philosophical approaches struggle to handle, and that it can be incorporated into clinical ethics without succumbing to “environmental fascism”. I motivate viewing problems in clinical ethics from the perspective of the ‘integrity of the biotic community’, then illustrate how this perspective can offer guidance where more commonly-invoked theories—such as consequentialism and Kantian-inspired approaches—struggle, using antimicrobial resistance in nosocomial infection as a case study. The Land Ethic equips us to understand human values as arising within and inseparable from a social-ecological context, and by treating communities as valuable in themselves rather than just through the aggregate welfare of their individual participants, we can avoid problems with the ‘repugnant conclusion’ and utility monster that plague utilitarian accounts. (shrink)

Clinical ethics consultation is on the horns of a dilemma. One horn skewers the field for its lack of standards, while the other horn skewers it for proposing arbitrary or deeply contested foundations. I articulate the dilemma by discussing several critiques of the field and the challenge of formulating standards and suggest that the solution lies, at least until a robust consensus emerges, with establishing a list of proscriptive standards to guide the field.

Clinical ethics consultation service remains undeveloped in developing countries. It is recognised that its introduction poses challenges. Malaysia, a multicultural society with diverse religions, values and perceptions further complicate the introduction of formal clinical ethics consultation service. Clinicians attending a national congress workshop completed a Strengths–Weaknesses–Opportunities–Threats analysis. The aim was to gain insight into clinician’s expectations and promote initiatives leading to the introduction of clinical ethics consultation service. Clinicians agree that clinical ethics (...) consultation service can improve quality of care, reduce healthcare costs and advocate for patients and providers. The analysis highlighted constraints in sufficient critical mass of relevant expertise and restricted opportunities for training. The opportunities lie in education, curriculum development and availability of dedicated proponents. Cultural barriers, limited resources, lack of awareness, differenc... (shrink)

Clinical ethical consultants are subject to an unavoidable conflict of interest. Their work requires that they be independent, but incentives attached to their role chip relentlessly at independence. This that they be independent, is a problem without any solution, but it can at least be ameliorated through careful management.

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

Clinical ethics support (CES) for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria (CEGD) at Amsterdam University Medical Center. We specifically aimed to (...) integrate CES into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice. (shrink)

BackgroundClinical ethics consultations can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. ObjectiveThe (...) primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality, process factors, and clinical factors. The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

No matter how far medicine advances, incurable disease will inevitably exist; and the dying patient's last resort will likewise look to medical research. In this report, we examine a case concerning the use of experimental medical therapy on a critically ill child. We discuss the ethical argument pertaining to the recommending of experimental medical therapy to the family of a dying patient.Under the circumstances of having to face the impending death of one's own child, parents of a terminally ill child (...) are extremely vulnerable to suggestion and often loose the ability to make a composed decision._Moreover, there exists the possibility of not only patients, but also medical staff and researchers, to fall into therapeutic misconception. Likewise, for the terminal patient and his/her family though, experimental medical therapy is often the only hope, which is, however, always accompanied by a factor of uncertainty and is considered to be merely an unapproximated gamble. The proposing of experimental medical therapy can result in being cruel by shattering the parent's expectations of saving their child._We examine the issues involved in proposing an experimental medical therapy to patients who are in dire need of a last hope; and conclude that, in times of emergency, we must take great consideration in recommending an experimental medical therapy as an "innovative treatment." In extreme circumstances where an individual's life is on the line, doing nothing can be quite trying; yet, what is right is not necessarily doing something, but rather making the right decision. (shrink)

Healthcare workers are often assumed to have a duty to work, even if faced with personal risk. This is particularly so for professionals. However, the health service also depends on non-professionals, such as porters, cooks and cleaners. The duty to work is currently under scrutiny because of the ongoing challenge of responding to pandemic influenza, where an effective response depends on most uninfected HCWs continuing to work, despite personal risk. This paper reports findings of a survey of HCWs conducted across (...) three National Health Service trusts in the West Midlands, UK, to establish whether HCWs’ likelihood of working during a pandemic is associated with views about the duty to work. The sense that HCWs felt that they had a duty to work despite personal risk emerged strongly regardless of professional status. Besides a strong sense that everyone should pull together, all kinds of HCWs recognised a duty to work even in difficult circumstances, which correlated strongly with their stated likelihood of working. This suggests that HCWs’ decisions about whether or not they are prepared to work during a pandemic are closely linked to their sense of duty. However, respondents’ sense of the duty to work may conflict with their sense of duty to family, as well as other factors such as a perceived lack of reciprocity from their employers. Interestingly, nearly 25% of doctors did not consider that they had a duty to work where doing so would pose risks to themselves or their families. (shrink)

The procedures for structuring clinical ethics case reflections in a childhood cancer care setting are presented, including an eight-step model. Four notable characteristics of the procedures are: members of the inter-professional health care team, not external experts, taking a leading role in the reflections; patients or relatives not being directly involved; the model explicitly addressing values and moral principles instead of focussing exclusively on the interests of involved parties; using a case-based rather than principle-based method. By discusing the (...) advantages and disadvantages of the proposed procedures, our paper aims to contribute to the literature on models and procedures for ethical analysis that can be used in clinical settings. It is suggested that our proposed procedures have some advantageous features when it comes to promoting health care staff’s learning to structure their thinking about ethical issues. (shrink)

Would primary care services benefit from the aid of a clinical ethics committee (CEC)? The implementation of CECs in primary care in four Norwegian municipalities was supported and their activities followed for 2.5 years. In this study, the CECs’ structure and activities are described, with special emphasis on what characterizes the cases they have discussed. In total, the four CECs discussed 54 cases from primary care services, with the four most common topics being patient autonomy, competence and coercion; (...) professionalism; cooperation and disagreement with next of kin; and priority setting, resource use and quality. Nursing homes and home care were the primary care services most often involved. Next of kin were present in 10 case deliberations, whereas patients were never present. The investigation indicates that it might be feasible for new CECs to attain a high level of activity including case deliberations within the time frame. It also confirms that significant, characteristic and complex moral problems arise in primary care services. (shrink)