Objective—To identify and describe the current state of clinical ethics support services in the UK.Design—A series of questionnaire surveys of key individuals in National Health Service (NHS) trusts, health authorities, health boards, local research ethics committees and health professional organisations. Interviews with chairmen/women of clinical ethics committees identified in the surveys.Setting—The UK National Health Service.Results—Responses to the questionnaires were received from all but one NHS trust and all but one health authority/board. A variety of models of clinical ethics support were (...) identified including twenty formal clinical ethics committees (CECs). A further twenty NHS trusts expressed an intention to establish a CEC within the next twelve months. Most CECs in the UK have been in existence less than five years and are still defining their role. The chairmen identified education of committee members and contact with other ethics committees as important requirements for committee development. Problems were identified around lack of support for the committee and with raising the profile of the committee within the institution. There has been little evaluation of clinical ethics support services either in the UK or in other countries with longer established services. What evaluation has occurred has focused on process rather than outcome measures.Conclusions—Clinical ethics support services are developing in the UK. A number of issues have been identified that need to be addressed if such support services are to develop effectively. (shrink)

Background In 2001 a report on the provision of clinical ethics support in UK healthcare institutions identified 20 clinical ethics committees. Since then there has been no systematic evaluation or documentation of their work at a national level. Recent national surveys of clinical ethics services in other countries have identified wide variation in practice and scope of activities. Objective To describe the current provision of ethics support in the UK and its development since 2001. Method A postal/electronic questionnaire survey administered (...) to the chairs of all 82 clinical ethics services registered with the UK Clinical Ethics Network in July 2010. Results Response rate was 62% with the majority of responding services situated in acute trusts. All services included a clinical ethics committee with one service also having a clinical ethicist. Lay members were present in 72% of responding committees. Individual case consultation has increased since 2001 with 29% of chairs spending more than 50% of their time on this. Access to and involvement in the process of case consultation is less for patients and families than for clinical staff. There is wide variation in committee processes and levels of institutional support. Over half of the responding committees undertook some form of evaluation. Conclusion Clinical ethics services in the UK are increasing as is their involvement in case consultation. However, the significant variation in committee processes suggests that further qualitative research is needed to understand how these committees function and the role they play in their institution. (shrink)

Hannah James makes a persuasive case for the use of donated bodies and body parts in surgical training, enabling high fidelity training, improved competency of surgeons and reduced risk of harm to patients from trainees ‘learning on the job’.1 She also identifies some pertinent ethical questions that arise from this practice that should be considered by training organisations, regulatory authorities and the trainees themselves. Many countries throughout the world have regulated programmes, governed by strict ethical principles, for donating bodies, usually (...) to academic institutions for the purposes of medical education.2 In the UK the Human Tissue Authority sets out guiding principles for institutions licensed to handle human tissue including donation of bodies for anatomical examination, education and research; consent, dignity, quality, and honesty and openness.3 The Nuffield Council on Bioethics, in its 2011 report, Human Bodies: donation for medicine and research, identified a number of relevant ethical values including autonomy, altruism, justice, dignity, reciprocity, maximising welfare, and honesty and respect.4 While this report did not focus specifically on donation of human tissue for education and training the principles identified are equally relevant in this context. In terms of maximising welfare whole body donation for education and training provides benefit to many patients over a relatively short time frame …. (shrink)

The development of ethics case consultation over the past 30 years, initially in North America and recently in Western Europe, has primarily taken place in the secondary or tertiary healthcare settings. The predominant model for ethics consultation, in some countries overwhelmingly so, is a hospital-based clinical ethics committee. In the United States, accreditation boards suggest the ethics committee model as a way of meeting the ethics component of the accreditation requirement for payment by Health Maintenance Organizations, and in some European (...) countries, there are legislatory requirements or government recommendations for hospitals to have clinical ethics committees. There is no corresponding pressure for primary care services to have ethics committees or ethics consultants to advise clinicians, patients, and families on the difficult ethical decisions that arise in clinical practice. (shrink)

Philosophers and others have questioned whether or not expertise in morality is possible. This debate is not only theoretical, but also affects the perceived legitimacy of clinical ethicists. One argument against moral expertise is that in a pluralistic society with competing moral theories no one can claim expertise regarding what another ought morally to do. There are simply too many reasonable moral values and intuitions that affect theory choice and its application; expertise is epistemically uniform. In this article, we discuss (...) how similar concerns have recently threatened to undermine expertise in medicine and science. In contrast, we argue that the application of values is needed to exercise medical, scientific, and moral expertise. As long as these values are made explicit, worries about a pretense to authority in the context of a liberal democracy are ill-conceived. In conclusion, we argue for an expertise that is epistemically diverse. (shrink)

No healthcare system has sufficient funds to provide the best possible treatment for all patients in all situations. Three new pharmaceutical products are licensed each month, on average, in the U.K. Most have some benefits over existing drugs but many are expensive. When is the extra benefit worth the extra cost? Managed care systems such as seen in the U.S., and publicly funded systems such as the British National Health Service (NHS), face this fundamental issue. Several governments (for example those (...) in New Zealand, Sweden, and the Netherlands) have taken a lead both in acknowledging that rationing healthcare is necessary, and in outlining how priorities are to be determined. In addition, the state of Oregon addressed the issue of rationing with considerable public involvement. (shrink)

Failings in patient care and quality in NHS Trusts have become a recurring theme over the past few years. In this paper, we examine the Care Quality Commission’s Guidance about Compliance: Essential Standards of Quality and Safety and ask how NHS Trusts might be better supported in fulfilling the regulations specified therein. We argue that clinical ethics committees (CECs) have a role to play in this regard. We make this argument by attending to the many ethical elements that are highlighted (...) in the Commission’s Regulations and by providing practical examples of how CECs can (and in some case already do) provide ethics support to health professionals and trusts. Although CECs have been traditionally associated with case consultation, i.e., discrete problems caused by individual circumstances, in the previous 10 years the literature suggests that clinical ethics services have become more integrated into the life of the health care organization and are increasing construed as proactive agents of systematic change. We provide evidence from a recent survey of UK clinical ethics services that this trend is present in the UK. (shrink)

Digital communication between a patient and their clinician offers the potential for improved patient care, particularly for young people with long term conditions who are at risk of service disengagement. However, its use raises a number of ethical questions which have not been explored in empirical studies. The objective of this study was to examine, from the patient and clinician perspective, the ethical implications of the use of digital clinical communication in the context of young people living with long-term conditions. (...) A total of 129 semi-structured interviews, 59 with young people and 70 with healthcare professionals, from 20 United Kingdom -based specialist clinics were conducted as part of the LYNC study. Transcripts from five sites were read by a core team to identify explicit and implicit ethical issues and develop descriptive ethical codes. Our subsequent thematic analysis was developed iteratively with reference to professional and ethical norms. Clinician participants saw digital clinical communication as potentially increasing patient empowerment and autonomy; improving trust between patient and healthcare professional; and reducing harm because of rapid access to clinical advice. However, they also described ethical challenges, including: difficulty with defining and maintaining boundaries of confidentiality; uncertainty regarding the level of consent required; and blurring of the limits of a clinician’s duty of care when unlimited access is possible. Paradoxically, the use of digital clinical communication can create dependence rather than promote autonomy in some patients. Patient participants varied in their understanding of, and concern about, confidentiality in the context of digital communication. An overarching theme emerging from the data was a shifting of the boundaries of the patient-clinician relationship and the professional duty of care in the context of use of clinical digital communication. The ethical implications of clinical digital communication are complex and go beyond concerns about confidentiality and consent. Any development of this form of communication should consider its impact on the patient-clinician-relationship, and include appropriate safeguards to ensure that professional ethical obligations are adhered to. (shrink)

Since the 1980s, there has been an increasing acknowledgement of the importance of recognising the ethical dimension of clinical decision-making. Medical professional regulatory authorities in some countries now include ethical knowledge and practice in their required competencies for undergraduate and post graduate medical training. Educational interventions and clinical ethics support services have been developed to support and improve ethical decision making in clinical practice, but research evaluating the effectiveness of these interventions has been limited. We undertook a systematic review of (...) the published literature on measures or models of evaluation used to assess the impact of interventions to improve ethical decision making in clinical care. We identified a range of measures to evaluate educational interventions, and one tool used to evaluate a clinical ethics support intervention. Most measures did not evaluate the key impact of interest, that is the quality of ethical decision making in real-world clinical practice. We describe the results of our review and reflect on the challenges of assessing ethical decision making in clinical practice that face both developers of educational and support interventions and the regulatory organisations that set and assess competency standards. (shrink)

In this article, the question is discussed if and how Healthcare Ethics Committees (HECs) should be regulated. The paper consists of two parts. First, authors from eight EC member countries describe the status quo in their respective countries, and give reasons as to the form of regulation they consider most adequate. In the second part, the country reports are analysed. It is suggested that regulation of HECs should be central and weak. Central regulation is argued to be apt to improve (...) HECs’ accountability, relevance and comparability. To facilitate biomedical citizenship and ethical reflection, regulation should at the same time be weak rather than strict. Independence of HECs to deliberate about ethical questions, and to give solicited and unsolicited advice, should be supported and only interfered with by way of exception. One exception is when circumstances become temporary adversarial to ethical deliberation in healthcare institutions. In view of European unification, steps should be taken to develop consistent policies for both Eastern and Western European countries. (shrink)

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context (...) in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of “alibi ethics”. CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs. (shrink)

Clinical ethics support services are developing in Europe. They will be most useful if they are designed to match the ethical concerns of clinicians. We conducted a cross-sectional mailed survey on random samples of general physicians in Norway, Switzerland, Italy, and the UK, to assess their access to different types of ethics support services, and to describe what makes them more likely to have used available ethics support. Respondents reported access to formal ethics support services such as clinical ethics committees (...) (23%), consultation in individual cases (17.6%), and individual ethicists (8.8%), but also to other kinds of less formal ethics support (23.6%). Access to formal ethics support services was associated with work in urban hospitals. Informal ethics resources were more evenly distributed. Although most respondents (81%) reported that they would find help useful in facing ethical difficulties, they reported having used the available services infrequently (14%). Physicians with greater confidence in their knowledge of ethics (P = 0.001), or who had had ethics courses in medical school (P = 0.006), were more likely to have used available services. Access to help in facing ethical difficulties among general physicians in the surveyed countries is provided by a mix of official ethics support services and other resources. Developing ethics support services may benefit from integration of informal services. Development of ethics education in medical school curricula could lead to improved physicians sensititity to ethical difficulties and greater use of ethics support services. Such support services may also need to be more proactive in making their help available. (shrink)

Clinical ethics committees (CECs) are well established in North America where they are known as hospital or health care ethics committees. Similar groups and other kinds of clinical ethics support are now developing in Europe. This supplement to the Journal of Medical Ethics provides an overview of the issues arising from the provision of clinical ethics support services, and clinical ethics committees in particular. Its primary focus is the UK but contributors from North America and continental Europe provide an international (...) perspective. Clinical ethics committees are an emerging feature of UK health care. This supplement's first paper provides an overview of the current provision of clinical ethics support in the UK and an assessment of the way in which CECs are developing. Personal perspectives from five UK CECs provide insight into some of the issues that those considering setting up a committee in their …. (shrink)

Erarbeitet von Dominik Balg, Anne Burkard, Henning Franzen, Aenna Frottier, David Lanius, David Löwenstein, Hanna Lucks, Kirsten Meyer, Donata Romizi, Katharina Schulz, Stefanie Thiele und Annett Wienmeister. -/- Die Entwicklung argumentativer Fähigkeiten ist ein zentrales Ziel des Ethik- und Philosophieunterrichts, ja überhaupt ein zentrales Bildungsziel. Wie aber kann das gelingen? In vielen verfügbaren Unterrichtsmaterialien werden argumentative Fähigkeiten eher vorausgesetzt als systematisch gefördert. Auch curriculare Vorgaben bleiben zumeist sehr unspezifisch. Lehrpersonen werden so weitgehend allein gelassen mit der Aufgabe, Lernende beim (...) Erwerb argumentativer Fähigkeiten zu fördern. Die vorliegende Aufgabensammlung soll dazu beitragen, diese Lücke zu schließen. Sie bietet Lehrpersonen reichhaltige Materialien für die spiralcurricular angelegte, systematische Förderung argumentativer Fähigkeit anhand exemplarischer Inhalte. Orientiert an klaren fachlichen Standards finden sich hier Aufgaben auf vier Niveaustufen, jeweils in Verbindung mit übersichtlichen Merkblättern. Die Aufgaben der beiden unteren Niveaustufen lassen sich bereits für jüngere Lernende der Sekundarstufe einsetzen, Aufgaben der obersten Niveaustufe richten sich an Lernende von Abschlussklassen oder der Studieneingangsphase. Für die Hand der Lehrpersonen werden die Aufgaben und Merkblätter durch fachliche und didaktische Kommentare sowie Lösungshinweise ergänzt. (shrink)

This article proposes that the urgent task for feminist sociology is to recuperate those lost or residual `body matters' which lurk, unattended to, on the sidelines of the social. Feminist sociology must carefully negotiate the complex space between sociality and corporeality. The new feminist philosophies of the body tend sometimes to grate against this project by valorizing the body but de-valorizing gender. The new sociology of the body is recuperating the body within sociology, but pays insufficient attention to the ways (...) in which gendered bodies have always enjoyed varying degrees of absence or presence in the sociological imaginary - in the guise of `female corporeality' and `male embodiment'. By revisiting the classical texts of sociology, such as those of Durkheim, Weber and particularly Simmel, I explore the textual strategies whereby `the body' and `the social' were dissociated in the first place and how, simultaneously, woman is saturated with, while man is divested of, corporeality and she is divested while he is invested with sociality. The absent women in sociology were the women in the body excluded from the social. It is male bodies which animate the social - they appear for a fleeting moment, only to disappear immediately, in the space between `corporeality' and `sociality'. Thus, it is not simply a case of recuperating bodies into the social, but of excavating the gendered subtexts whereby gendered bodies were differently inscribed into and out of the social in the first place. The crucial point here is not the more familiar story of her saturation with corporeality but the less familiar one of what happened to his body - how, that is, did male sociologists effect the disappearance of their own bodies in the textual strategies of sociology? (shrink)

How many individuals are present where we see a pregnant individual? Within a substance ontological framework, there are exactly two possible answers to this question. The standard answer—two individuals—is typically championed by scholars endorsing the predominant Containment View of pregnancy, according to which the foetus resides in the gestating organism like in a container. The alternative answer—one individual—has recently found support in the Parthood View, according to which the foetus is a part of the gestating organism. Here I propose a (...) third answer: a pregnant individual is neither two individuals nor one individual but something in between one and two. This is because organisms are better understood as processes than as substances. With a special focus on the Parthood View, I explain why a Process View of pregnancy, according to which a pregnant individual is a bifurcating hypercomplex process, surpasses the substance ontological approaches. (shrink)

Focusing on the corporate social responsibility (CSR) implementation process, we analyze how institutional complexity that arises from tensions between social and environmental elements and economic and technical concerns is managed by CSR managers. We further question how these micro-level processes interact with organizational-level processes over time. Our research is a 24-month qualitative process study in which we followed CSR managers. The study’s results allow us to distinguish between four strategies that CSR managers use to promote CSR implementation and to cope (...) with tensions. Our results further indicate that organizational characteristics influence the intensity with which these strategies are applied and that the intensity of strategy application affects organizational behavior in the course of time. Through the discussion of these findings, our study contributes to the research on micro-level processes that occur in response to complex institutional demands as well as to the development of a comprehensive, multilevel approach to CSR implementation. (shrink)

We are occasionally responsible for our beliefs. But is this doxastic responsibility analogous to any non-attitudinal form of responsibility? What I shall call the consequential conception of doxastic responsibility holds that the kind of responsibility that we have for our beliefs is indeed analogous to the kind of responsibility that we have for the consequences of our actions. This article does two things, both with the aim of defending this somewhat unsophisticated but intuitive view of doxastic responsibility. First, it emphasizes (...) the advantage of preserving, as the consequential conception does, the analogy with the non-attitudinal realm, i.e., with the realm of actions and their consequences. Second, this article regiments the most important objections to the consequential conception and answers them. The upshot is that there are no serious drawbacks to the consequential conception. There is, therefore, no reason not to favour it over accounts of doxastic responsibility that do not preserve the analogy with the non-attitudinal realm. (shrink)

Situations where it is not obvious which of two incompatible actions we ought to perform are commonplace. As has frequently been noted in the contemporary literature, a similar issue seems to arise in the field of beliefs. Cases of doxastic divergence are cases in which the subject seems subject to two divergent oughts to believe: an epistemic and a practical ought to believe. This article supports the moderate pragmatist view according to which subjects ought, all things considered, to hold the (...) practically right belief in, at least, some cases of doxastic divergence. Unlike many defences of pragmatism, this paper does not aim to overcome exclusivism (briefly, the view that only epistemic, but not practical, considerations have an influence on what a subject ought to believe). Another major challenge that pragmatism faces is to show that the epistemic and the practical ought to believe are comparable. This article makes a case for their comparability. (shrink)