Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision-making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real-life ethical issues, including those which do not fall within the ‘favourite’ ethical issues of the day. In this paper we attempt to (...) capture a comprehensive overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement-based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS. (shrink)

Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision‐making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real‐life ethical issues, including those which do not fall within the ‘favourite’ ethical issues of the day. In this paper we attempt to (...) capture a comprehensive overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement‐based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS. (shrink)

The specific features of adolescent depression - from developmental reaction to clinical syndrome Depression belongs to the most common mental disorders of young people. Yet, its analysis has given rise to many controversies among specialists. One of the crucial raised issues is the question whether it is justified to apply the diagnosis of depression in this age group, considering the fact that intrapsychic mechanisms in adolescents are not yet mature. The theoretical problem arises: to what degree adolescent depression (...) ought to be considered a clinical disorder, rather than a specific developmental reaction. In the present paper, the attempt has been undertaken to tackle the issue. It has been found that the diagnosis of adolescent depression cannot rely on clear-cut diagnostic criteria. Instead, it should rely on clinical assessment of an individual patient. (shrink)

The neuropathologies of the self are disorders of the self and identity that occur in association with neuropathology and include perturbations of the bodily, relational, and narrative self. Right, especially medial-frontal and orbitofrontal lesions, are associated with these conditions. The ego disequilibrium theory proposes this brain pathology causes a disturbance of ego boundaries and functions and the emergence of developmentally immature styles of thought, ego functioning, and psychological defenses including denial, projection, splitting, and fantasy that the NPS patient has in (...) common with the child. I hypothesize that during brain development between approximately ages 3 and 7 immature defensive functions and fantasies tend to be replaced by mature defenses and the inhibition of fantasy a process that depends upon maturational processes within the right hemisphere. I propose a four-tiered model of the NPS that emphasizes a multifactorial approach and includes both negative and positive, bottom up and top down, and neuropsychological and psychological factors. (shrink)

In an adaptive clinical trial , key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts’ views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the (...) opinions of clinical trial experts regarding their beliefs about ethical aspects of ACTs. (shrink)

Neonatal brain monitoring in the neonatal intensive care units (NICU) requires a continuous review of the spontaneous cortical activity, i.e., the electroencephalograph (EEG) background activity. This needs development of bedside methods for an automated assessment of the EEG background activity. In this paper, we present development of the key components of a neonatal EEG background classifier, starting from the visual background scoring to classifier design, and finally to possible bedside visualization of the classifier results. A dataset with 13,200 5-minute EEG (...) epochs (8–16 channels) from 27 infants with birth asphyxia was used for classifier training after scoring by two independent experts. We tested three classifier designs based on 98 computational features, and their performance was assessed with respect to scoring system, pre- and post-processing of labels and outputs, choice of channels, and visualization in monitor displays. The optimal solution achieved an overall classification accuracy of 97% with a range across subjects of 81–100%. We identified a set of 23 features that make the classifier highly robust to the choice of channels and missing data due to artefact rejection. Our results showed that an automated bedside classifier of EEG background is achievable, and we publish the full classifier algorithm to allow further clinical replication and validation studies. (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 blink response to visual threat is a standard bedside method for testing visual processing. In response to a sudden gesture directed toward the eyes, a person with a normal blink response will promptly contract both orbicularis oculi muscles to close the eyelids momentarily. There is no consensus as to whether blinking to visual threat (BVT) is purely reflex1 or a cognitively mediated behavior that heralds consciousness; i.e., is incompatible with the diagnosis of the vegetative state (VS).2,3 Some authors stated (...) that “one should be extremely cautious in making the diagnosis of the VS when there is . . . response to threatening gestures.”4 Others stated that “react(ion) to visual threat” is a “compatible but atypical feature” of VS.5 Similarly, other guidelines stated that the “threat response is usually absent” in VS.6 Finally, BVT was not mentioned in some workgroup criteria on the minimally conscious state.7 The aim of the study was to determine the incidence of BVT in patients whose clinical features are in all other respects typical of the VS, as assessed by means of validated testing.7 We also investigated whether the presence of BVT in patients considered vegetative is predictive of recovery of consciousness. (shrink)

The purpose is to identify common and distinctive features of concepts and methodology of the problem of subject within different discourses, implicitly or explicitly relevant to the definition of "clinical" mode of human existence. The research methodology combines techniques of discourse analysis and basic principles of historical and philosophical studies. Originality of the research lies in definition of the clinical philosophical discourse as a special communicative process, where utterances not only focus on disease syndromes, and reveal phenomenology (...) of inner experience of a pathological self, but also structure a certain type of sociality. Clinical discourse represents the space where the patient is treated not as a subject but as an object of disease. Ontology of clinical discourse prevails over ontology of disease, since its structures determine the notion of disease as such. Categorization of the disease, the idea of disease as a phenomenon subdued to professional authority leads to the idea of the need for patient’s isolation from the natural environment and removing him to special social institutions. The clinicist doctrines share the intention to reduce the patient’s self to its bodily dimension, while ignoring social determinants of psychological deviations. Conclusions of the study are summarized in the following positions: the current clinical discourse is based on the positivist-biological trend in humanitarian knowledge and it is the basis for the production and reproduction of medical and pharmaceutical repressive ideology; criticism of philosophical clinical discourse opens the possibility of overcoming the dominance of purely clinicist discourse; such a transformation is possible only after a paradigm shift in understanding the category of subject. (shrink)

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM approaches (...) recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

De Marco et al 1 argue that the standard account of medical ‘invasiveness’ (as ‘incision’ or ‘insertion’) fails to capture three aspects of its existing use, namely that invasiveness can come in degrees, often depends on features of alternative medical interventions and can be non-physical. They propose a new schematic account that suggests that medical interventions can possess ‘basic invasiveness’ (which can come in degrees and of which they suggest at least two types: physical and mental), and ‘threshold invasiveness’ (...) which can depend on the alternatives a specific intervention is being compared with. While we agree that the standard account of invasiveness fails to capture existing use and are supportive of their aim, here we express scepticism about the practical utility of De Marco et al ’s revised account. Our scepticism concerns the application of De Marco et al’s revised account in the narrow context of clinician–patient communication and deliberation about medical interventions within clinical practice, which we see as a crucial context for its use. While De Marco et al do not specify the contexts in which their revised account could be used, we assume from their discussion of treatment interventions (e.g. non-invasive prenatal testing, ventilation) and their comparison to ‘more or less invasive’ options, that at least one of the purposes in mind for …. (shrink)

Monothematic delusions involve a single theme, and often occur in the absence of a more general delusional belief system. They are cognitively atypical insofar as they are said to be held in the absence of evidence, are resistant to correction, and have bizarre contents. Empiricism about delusions has it that anomalous experience is causally implicated in their formation, whilst rationalism has it that delusions result from top down malfunctions from which anomalous experiences can follow. Within empiricism, two approaches to the (...) nature of the abnormality/abnormalities involved have been touted by philosophers and psychologists. One-factor approaches have it that monothematic delusions are a normal response to anomalous experiences whilst two-factor approaches seek to identify a clinically abnormal pattern of reasoning in addition to anomalous experience to explain the resultant delusion. In this paper we defend a one-factor approach. We begin by making clear what we mean by atypical, abnormal, and factor. We then identify the phenomenon of interest and overview one and two-factor empiricism about its formation. We critically evaluate the cases for various second factors, and find them all wanting. In light of this we turn to our one-factor account, identifying two ways in which ‘normal response’ may be understood, and how this bears on the discussion of one-factor theories up until this point. We then conjecture that what is at stake is a certain view about the epistemic responsibility of subjects with delusions, and the role of experience, in the context of familiar psychodynamic features. After responding to two objections, we conclude that the onus is on two-factor theorists to show that the one-factor account is inadequate. Until then, the one-factor account ought to be understood as the default position for explaining monothematic delusion formation and retention. We don’t rule out the possibility that, for particular subjects with delusions there may be a second factor at work causally implicated in their delusory beliefs but, until the case for the inadequacy of the single factor is made, the second factor is redundant and fails to pick out the minimum necessary for a monothematic delusion to be present. (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)

The shift away from paternalistic decision-making and toward patient-centered, shared decision-making has stemmed from the recognition that in order to practice medicine ethically, health care professionals must take seriously the values and preferences of their patients. At the same time, there is growing recognition that minor and seemingly irrelevant features of how choices are presented can substantially influence the decisions people make. Behavioral economists have identified striking ways in which trivial differences in the presentation of options can powerfully and (...) predictably affect people's choices. Choice-affecting features of the decision environment that do not restrict the range of choices or significantly alter the incentives have come to be known as “nudges.” Although some have criticized conscious efforts to influence choice, we believe that clinical nudges may often be morally justified. The most straightforward justification for nudge interventions is that they help people bypass their cognitive limitations—for example, the tendency to choose the first option presented even when that option is not the best for them—thereby allowing people to make choices that best align with their rational preferences or deeply held values. However, we argue that this justification is problematic. We argue that, if physicians wish to use nudges to shape their patients’ choices, the justification for doing so must appeal to an ethical and professional standard, not to patients’ preferences. We demonstrate how a standard with which clinicians and bioethicists already are quite familiar—the best-interest standard—offers a robust justification for the use of nudges. (shrink)

Ontological realism aims at the development of high quality ontologies that faithfully represent what is general in reality and to use these ontologies to render heterogeneous data collections comparable. To achieve this second goal for clinical research datasets presupposes not merely (1) that the requisite ontologies already exist, but also (2) that the datasets in question are faithful to reality in the dual sense that (a) they denote only particulars and relationships between particulars that do in fact exist and (...) (b) they do this in terms of the types and type-level relationships described in these ontologies. While much attention has been devoted to (1), work on (2), which is the topic of this paper, is comparatively rare. Using Referent Tracking as basis, we describe a technical data wrangling strategy which consists in creating for each dataset a template that, when applied to each particular record in the dataset, leads to the generation of a collection of Referent Tracking Tuples (RTT) built out of unique identifiers for the entities described by means of the data items in the record. The proposed strategy is based on (i) the distinction between data and what data are about, and (ii) the explicit descriptions of portions of reality which RTTs provide and which range not only over the particulars described by data items in a dataset, but also over these data items themselves. This last feature allows us to describe particulars that are only implicitly referred to by the dataset; to provide information about correspondences between data items in a dataset; and to assert which data items are unjustifiably or redundantly present in or absent from the dataset. The approach has been tested on a dataset collected from patients seeking treatment for orofacial pain at two German universities and made available for the NIDCR-funded OPMQoL project. (shrink)

Clinical practice is where the clinical encounter and decision-making occur. Thus, it constitutes the focus of medicine. Since the time of Hippocrates, it has been composed of five activities that have come to be known as anamnesis, i.e., history taking or clinical interview, diagnosis, prognosis, therapy, and prevention. These five activities are fundamental features of the healing relationship. The present chapter is devoted to the analysis and discussion of their logical, methodological, and philosophical problems. Usually, the (...) patient expects the physician to be an expert of her specialty devoid of a bad reputation. This constitutes what may be called a good doctor, i.e., one whose clinical decisions are right and good in most cases, at least in as many cases as another expert in the same area also achieves. In what follows, we shall analyze the characteristics and presuppositions of such right and good clinical decisions. To this end, we shall undertake a conceptual analysis of the clinical encounter and its outcomes, in order to develop a theory of clinical practice. Our analysis consists of the following five parts: 9.1 The Clinical Encounter; 9.2 Anamnesis and Diagnosis; 9.3 Prognosis; 9.4 Therapy; 9.5 Prevention. (shrink)

Problems with clinical research that create conflicts between doctors' therapeutic and research obligations may be fueled by a rigid view of science as determiner of truth, a heavy reliance on statistics, and certain features of randomized clinical trials. I suggest some creative, feminist approaches to such research and explore ways to provide choice for patients and to use values in directing both therapy and science - to enhance the effectiveness of each.

Background The COVID-19 pandemic continues to disrupt every society as SARs-CoV-2 variants surge among the populations. Health care providers are exhausted, becoming ill themselves, and in some instances have died. Indeed, hospitals are struggling to find staff to care for critically ill patients most in need. Previous work has reported on the unending work-related conditions that hospital staff are laboring under and their subsequent mental and physical health strains. Health care providers need support, but it is not clear where that (...) support is to come from. While much research has reported on the COVID-19-related fears of nurses and physicians, fewer studies have focused on supportive features of the hospital work environment and how it may provide relief to front-line health care providers.Purpose This purpose of this study was to explore an often-overlooked resource within hospital systems across the United States—clinical ethicists—and examine their many roles during COVID-19 and the types of ethical issues they addressed with nurses, physicians, administrators, and others.Methods This was a primary analysis of semi-structured, qualitative interviews with 23 clinical ethicists across the United States. The interviews were conducted from November 2020–April 2021 and were audiotaped, transcribed verbatim, and de-identified; both inductive and deductive analyses were used to identify qualitative themes.Results Five major themes were identified: ethical issues that were increasingly more complex, moral distress that was “endemic,” shifting ethical paradigms from the focus on the individual to the population, fostering a supportive environment, and organizational ethics: variation in the value, roles, and policy input of clinical ethicists.Conclusions Our findings report on the integral and expanded role of clinical ethicists at an unprecedented time in our nation, and how they stepped forward to support front-line clinicians in hospitals across the country. (shrink)

This book discusses feature films that enrich our understanding of doctor-patient dilemmas. The book comprises general clinical ethics themes and principles and is written in accessible language. Each theme is discussed and illuminated in chapters devoted to a particular film. Chapters start with a discussion of the film itself, which shares details behind the making of the film; critical reception; casting and other facts about production. The chapter situates the film in a history of medicine and medical sociology context, (...) analyzes ethical issues raised in the film from a clinical ethics lens, and explains to readers how to use each film as a teaching aid for clinical ethics. Readers will understand how each film in this collection served to bring particular clinical ethics issues to the public’s attention, or reflected medico-legal issues that were part of the public discourse. The book is a perfect instructor's guide for anyone teaching bioethics, healthcare ethics, medical sociology, medical history, healthcare systems narrative medicine, or nursing ethics. (shrink)

Selective mutism is a psychiatric condition that is characterized by a failure to speak in specific social situations despite speaking normally in other situations. There is abundant evidence that anxiety, and social anxiety in particular, is a prominent feature of SM, which is the main reason why this condition is currently classified as an anxiety disorder. Meanwhile, there is increasing support for the notion that autism-related problems are also involved in SM. The present study examined the relations between SM and (...) social anxiety, autistic features, and behavioral inhibition to the unfamiliar. Parents of 172 3- to 6-year-old preschool children completed an online survey for measuring the relevant constructs. Results showed that there were positive and statistically significant correlations between SM and social anxiety, autistic features, and behavioral inhibition. Regression analyses revealed that both social anxiety and autistic features accounted for a significant and unique proportion of the variance in SM scores, and that both of these variables no longer made a significant contribution once behavioral inhibition was added to the model. It can be concluded that while the involvement of social anxiety is unambiguous in SM, autism-related problems are also implicated. Furthermore, behavioral inhibition seems to play a key role in the non-speaking behavior of non-clinical young children. (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)

For some time, clinical ethics committees (CECs) have been a prominent feature of hospitals in North America. Such committees are less common in the United Kingdom and Europe. Focusing on the UK, this paper evaluates why CECs have taken so long to evolve and assesses the roles that they should play in health care policy and clinical decision making. Substantive and procedural moral issues in medicine are differentiated, the former concerning ethicolegal principles and their paradigmatic application to (...) class='Hi'>clinical practice and the latter dealing with how such application should be negotiated in the face of disagreement and/or uncertainty. It will be argued that the role of CECs is both substantive and procedural. Provided that they do not overstep their appropriate moral and professional boundaries, CECs will be shown to have an important and positive function in improving hospital care within the UK and elsewhere. (shrink)

Many extant theories of placebo focus on their causal structure wherein placebo effects are those that originate from select features of the therapy (e.g., client expectations or “incidental” features like size and shape). Although such accounts can distinguish placebos from standard medical treatments, they cannot distinguish placebos from everyday occurrences, for example, when positive feedback improves our performance on a task. Providing a social-epistemological account of a treatment context can rule out such occurrences, and furthermore reveal a new (...) way to distinguish clinical placebos from standard medical treatments. (shrink)

The UN Convention against Torture defines torture as “any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person” by someone acting in an official capacity for purposes such as obtaining a confession or punishing or intimidating that person.1 It is unethical for healthcare professionals to participate in torture, including any use of medical knowledge or skill to facilitate torture or allow it to continue, or to be present during torture.2-7 Yet medical participation (...) in torture has taken place throughout the world and was a prominent feature of the US interrogation practice in military and Central Intelligence Agency (CIA) detention facilities in the years after the attacks of 11 September 2001.8-11 Little attention has been paid, however, to how a regime of torture affects the ability of health professionals to meet their obligations regarding routine clinical care for detainees. -/- The 2016 release of previously classified portions of guideline from the CIA regarding medical practice in its secret detention facilities sheds light on that question. These show that the CIA instructed healthcare professions to subordinate their fundamental ethical obligations regarding professional standards of care to further the objectives of the torturers. (shrink)

The recent interest in wisdom in professional health care practice is explored in this article. Key features of wisdom are identified via consideration of certain classical, ancient and modern sources. Common themes are discussed in terms of their contribution to ‘clinical wisdom’ itself and this is reviewed against the nature of contemporary nursing education. The distinctive features of wisdom (recognition of contextual factors, the place of the person and timeliness) may enable their significance for practice to be (...) promoted in more coherent ways in nursing education. Wisdom as practical knowledge (phronesis) is offered as a complementary perspective within the educational preparation and practice of students of nursing. Certain limitations within contemporary UK nursing education are identified that may inhibit development of clinical wisdom. These are: the modularization of programmes in higher education institutions, the division of pastoral and academic support and the relationship between theory and practice. (shrink)

Introduction Currently, The nature and scope of Clinical Ethics Protocols in Madrid are not well understood.Objectives The main objective is to describe the features of ‘guideline/recommendation’ type CEPs that have been or are being developed by existing Clinical Ethics Committees in Madrid. Secondary objectives include characterisation of those CECs that have been the most prolific in reference to CEP creation and implementation and identification of any trends in future CEP development.Methods We collected CEPs produced and in process (...) by CECs accredited in the public hospitals in Madrid, Spain, from 1996 to 2008.Results CECs developed 30 CEPs, with 10 more in process. The most common topic is refusal of treatment . If CEPs addressing terminal illness, Do-Not-Resuscitate orders and advance directives are placed into a separate ‘ethical problems at the end of life’ category, this CEP subject emerges as the most common . There is a relationship between the age of the CEC and the development of CEPs . CECs now seem to be more likely to engage in CEP development.Conclusions The CECs in Madrid, Spain, have developed a significant number of CEPs and there is a trend towards continued development. The most frequent topics are ethical problems at the end of life and refusal of treatment by the patient. (shrink)

Clinical research is thought to be ethically problematic and is subject to extensive regulation and oversight. Despite frequent endorsement of this view, there has been almost no systematic evaluation of why clinical research might be ethically problematic. As a result, it is difficult to determine whether the regulations to which clinical research is subject address the ethical concerns it raises. Commentators who consider this question at all tend to assume that clinical research is ethically problematic because (...) it exposes some individuals to risks for the benefit of others. Yet, many other activities that expose some individuals to risks for the benefit of others are not subject to extensive regulation and oversight. This difference raises the question of whether clinical research is distinct from these activities in normatively relevant ways and, if so, what implications this difference (or differences) has for how clinical research should be regulated and conducted. The present manuscript attempts to answer this question by comparing clinical research to two other activities that expose some individuals to risks for the benefit of others. This comparison highlights an aspect of clinical research which has received relatively little attention, namely, the active role investigators play in exposing subjects to risks. I argue that this aspect explains much of the ethical concern expressed regarding clinical research. I end by considering the normative significance of this feature and the implications it has for how clinical research should be regulated and conducted. (shrink)

As support for clinical ethics committees in the UK grows, care must be taken to define their function, membership and method of working and the status of their decisions.The modern practice of medicine raises a plethora of complex issues—medical, ethical and legal. Doctors and other healthcare professionals increasingly must try to resolve these and may sometimes have to do so in the face of contrary opinion expressed by patients and/or their surrogates. While clearly qualified in the medical arena, and (...) although there is now more ethics teaching in the medical curriculum, healthcare professionals are seldom qualified to adjudicate on ethical or legal matters, or even, perhaps, to recognise them when they arise. Yet, as Doyal says, “clinical life must go on and moral and legal indeterminacy within medicine cries out for practical resolution.”1 Meanwhile, the expectations of patients and their families—and, indeed, of wider society—are that decisions about patient care, resources and therapeutic regimes should be soundly based on appropriate ethicolegal, as well as scientific, principle.Recognition of these additional burdens on healthcare professionals has generated some interest in the provision of ethics consultation. In the USA this has been undertaken by a variety of tribunals and individuals. Hospital ethics committees and ethics consultants feature in many US hospitals and perform a variety of roles. In Europe, a number of countries have also established clinical ethics committees and they are becoming more common in the UK—primarily in England and Wales for the moment. Whereas, however, “[i]n North America, CECs have … become an integral part of the organisational infrastructure of hospitals ...”,1 in the United Kingdom they remain essentially ad hoc bodies, generated for a variety of reasons and with different goals, structures, membership, methods of working and functions. The initial impetus for the …. (shrink)

When a patient's treatment decisions are the product of delusion, this is often taken as a paradigmatic case of undermined decisional capacity. That is to say, when a patient refuses treatment on the basis of beliefs that in no way reflect reality, clinicians and ethicists tend to agree that their refusal is not valid. During the COVID-19 pandemic, however, we have witnessed many patients refuse potentially life-saving interventions not based on delusion but on conspiracy beliefs. Importantly, many of the beliefs (...) espoused by conspiracy theorists resemble delusions in a number of relevant ways. For instance, conspiracy beliefs often posit states of affairs that could not possibly exist in the world, they are recalcitrant in the face of disconfirming evidence, and they tend to put the believer in a state of paranoia. Given these similarities, how should we think about conspiracy theorists' capacity for making clinical decisions? In this paper, I attempt to answer this question by first offering an account of just what makes some set of beliefs count as a conspiracy theory. Second, I attempt to disambiguate conspiracy beliefs from delusions by exploring important conceptual and psychological features of both. Finally, I apply standard criteria for assessing a patient's decision-making capacity to instances of conspiracy beliefs and argue that, although the picture is muddy, there may be cases in which conspiracy beliefs undermine capacity. I end by exploring the implications that this might have for surrogate decision-making and addressing potential objections. (shrink)

The clinical ethics propounded by Richard Zaner is unique. Partly because of his phenomenological orientation and partly because of his own daily practice as a clinical ethicist in a large university hospital, Zaner focuses on the particular concrete situations in which patients and their families confront illness and injury and struggle toward workable ways for dealing with them. He locates ethical reality in the clinical encounter. This encounter encompasses not only patient and physician but also the patients (...) family and friends and indeed the entire lifeworld in which the patient is still striving to live. In order to illuminate the central moral constituents of such human predicaments, Zaner discusses the often-overlooked features of disruption and crisis, the changed self, the patients dependence and the physicians power, the violation of personal boundaries and their necessary reconfiguring, and the art of listening. (shrink)

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons “wise.” Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle’s intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of (...) psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the Other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom. (shrink)

To precisely define wisdom has been an ongoing task of philosophers for millennia. Investigations into the psychological dimensions of wisdom have revealed several features that make exemplary persons "wise." Contemporary bioethicists took up this concept as they retrieved and adapted Aristotle's intellectual virtue of phronesis for applications in medical contexts. In this article, we build on scholarship in both psychology and medical ethics by providing an account of clinical wisdom qua phronesis in the context of the practice of (...) psychoanalysis and psychodynamic psychotherapy. With the support of qualitative data, we argue that the concept of clinical wisdom in mental healthcare shares several of the key ethical dimensions offered by standard models of phronesis in medical ethics and serves as a useful, albeit overlooked, reference point for a broader development of virtue-based medical ethics. We propose that the features of clinical wisdom are pragmatic skills that include, but are not limited to, an awareness of balance, the acceptance of paradox, and a particular clinical manner that maintains a deep regard for the other. We offer several suggestions for refining training programs and redoubling efforts to provide long-term mentorship opportunities for trainees in clinical mental healthcare in order to cultivate clinical wisdom. (shrink)

Shared decision making has become the standard of care, yet there remains no consensus about how it should be conducted. Most accounts are concerned with threats to patient autonomy, and they address the dangers of a power imbalance by foregrounding the patient as a person whose complex preferences it is the practitioner's task to support. Other corrective models fear that this level of mutuality risks abdicating the practitioner's responsibilities as an expert, and they address that concern by recovering a nuanced (...) but genuinely directive clinical role. Cribb and Entwistle helpfully categorize models of shared decision making as ‘narrower’ and ‘broader’ and praise the latter's ‘open‐ended and fully dialogical ways of relating’. However, they stop short of providing a philosophical account of how that dialogue works. In this paper, a nurse–midwife and a philosopher collaborate to argue that the Socratic model of dialogue offers a solution to the practitioner–patient dilemma. In the Theaetetus, Socrates compares dialogical reasoning to ‘midwifery with all its standard features’. By means of a three‐way analogy, elements of midwifery practice are used to illuminate features of Socrates' claim that his dialogue is like midwifery; those features are then translated into an approach to shared decision making as the ‘midwifery of good thinking’ which both midwives and physicians would do well to adopt. A key concept that emerges is the need for practitioners to make a risk‐confidence assessment of the particular content of any decision to appropriately modulate their role in the practice of shared decision making. (shrink)

After the ‘empirical turn’ in bioethics, few specific approaches have been developed for doing clinical ethics research in close connection with clinical decision-making on a daily basis. In this paper we describe the ‘committed researcher’ approach to research in clinical ethics that we have developed over the years. After comparing it to two similar research methodological approaches, the ‘embedded researcher’ and ‘deliberative engagement’, we highlight its main features: it is patient-oriented, it is implemented by collegial and (...) multidisciplinary teams, it uses an ethical grid to build the interview guide, and it is geared towards bringing the results to bear on the public debate surrounding the issue at stake. Finally, we position our methodological approach with respect to the ‘is vs. ought’ distinction. We argue that our ‘commitment researcher’ approach to clinical ethics research takes concerned people’s life-building values as the main data, and compares them to the larger normative framework underlying the medical practice at stake. (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)

This essay focuses on how casuistry can become a useful technique of practical reasoning for the clinical ethicist or ethics consultant. Casuistry is defined, its relationship to rhetorical reasoning and its interpretation of cases, by employing three terms that, while they are not employed by the classical rhetoricians and casuists, conform, in a general way, to the features of their work. Those terms are (1) morphology, (2) taxonomy, (3) kinetics. The morphology of a case reveals the invariant structure (...) of the particular case whatever its contingent features, and also the invariant forms of argument relevant to any case of the same sort: these invariant features can be called topics. Taxonomy situates the instant case in a series of similar cases, allowing the similarities and differences between an instant case and a paradigm case to dictate the moral judgment about the instant case. This judgment is based, not merely on application of an ethical theory or principle, but upon the way in which circumstances and maxims appear in the morphology of the case itself and in comparison with other cases. Kinetics is an understanding of the way in which one case imparts a kind of moral movement to other cases, that is, different and sometimes unprecedented circumstances may move certain marginal or exceptional cases to the level of paradigm cases. In conclusion, casuistry is the exercise of prudential or practical reasoning in recognition of the relationship between maxims, circumstances and topics, as well as the relationship of paradigms to analogous cases. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and (...) Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

Obesity is a widespread and broadly consequential health condition associated with numerous medical complications that could increase mortality rates. As personality concerned individual’s patterns of feeling, behavior, and thinking, it may help in understanding how people with obesity differ from people with normal-weight status in their typical weight-relevant behavior. So far, studies about personality and BMI associations have mainly focused on broad personality traits. The main purpose of this study was to explore the personality and health associations among a (...) class='Hi'>clinical group composed of 46 outpatients with overweight/obesity in comparison to a healthy control group that included 46 subjects. Both the clinical and control groups were composed of 14 males and 32 females. Several personality and psychopathological aspects were assessed with the Personality Assessment Inventory. The results of the analysis of variance of aligned rank transformed showed that patients with overweight/obesity reported higher scores for Somatic Complaints, Depression, and Borderline Features than the control group. Logistic regression highlighted specifically that the subscales of the Borderline Features assessing the Negative Relationship contributed to the increased risk of belonging to the clinical group. For the purpose of this study, the role of gender was considered. The present findings highlight the importance of focusing on assessing personality functioning in the health context and on specific characteristics of interpersonal relationships to promote more tailored treatments. (shrink)

Ataxia is a kind of external characteristics when the human body has poor coordination and balance disorder, it often indicates diseases in certain parts of the body. Many internal factors may causing ataxia; currently, observed external characteristics, combined with Doctor’s personal clinical experience play main roles in diagnosing ataxia. In this situation, different kinds of diseases may be confused, leading to the delay in treatment and recovery. Modern high precision medical instruments would provide better accuracy but the economic cost (...) is a non-negligible factor. In this paper, novel non-contact sensing technique is used to detect and distinguish sensory ataxia and cerebellar ataxia. Firstly, Romberg’s test and gait analysis data are collected by the microwave sensing platform; then, after some preprocessing, some machine learning approaches have been applied to train the models. For Romberg’s test, time domain features are considered, the accuracy of all the three algorithms are higher than 96%; for gait detection, Principal Component Analysis is used for dimensionality reduction, and the accuracies of Back Propagation neural Network, Support Vector Machine, and Random Forest are 97.8, 98.9, and 91.1%, respectively. (shrink)

Investigations and commentaries on domestic violence and its sequelae have been featured in several recent medical journals. For discussion purposes, I will highlight aspects from three of them. According to Megan Bair-Merritt and her colleagues, in a recent issue of the Journal of Pediatrics, screening for domestic abuse in a pediatric practice can uncover cases that otherwise might not be identified.1 Of the women who brought their children to a pediatric clinic at Johns Hopkins Children’s Center, 23 percent disclosed that (...) they had been victims of either emotional or physical abuse; 57 percent of the abused women indicated that at least one child had been exposed to this violent interaction. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it (...) often comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

Importance Informed consent is essential to ethical, rigorous research and is important to recruitment and retention in cancer trials.Objective To examine cancer clinical trial (CCT) participants’ perceptions of informed consent processes and variations in perceptions by cancer type.Design and Setting and Participants Cross-sectional survey from mixed-methods study at National Cancer Institute–designated Northeast comprehensive cancer center. Open-ended and forced-choice items addressed: (1) enrollment and informed consent experiences and (2) decision-making processes, including risk-benefit assessment. Eligibility: CCT participant with gastro-intestinal or genitourinary, (...) hematologic-lymphatic malignancies, lung cancer, and breast or gynecological cancer (N = 334).Main Outcome Measures Percentages satisfied with consent process and information provided; and assessing participation’s perceptions of risks/benefits. Multivariable logistic or ordinal regression examined differences by cancer type.Results Most patient-participants felt well informed by the consent process (more than 90% overall and by cancer type) and. most (87.4%) reported that the consent form provided all the information they wanted, although nearly half (44.8%) reported that they read the form somewhat carefully or less. More than half (57.9%) said that talking to research staff (i.e., the consent process) had a greater impact on participation decisions than reading the consent form (2.1%). A third (31.1%) were very sure of joining in research studies before the informed consent process (almost half of lung cancer patients did—47.1%). Most patients personally assessed the risks and benefits before consenting. However, trust in physicians played an important role in the decision to enroll in CCT.Conclusions and Relevance Cancer patients rely less on written features of the informed consent process than on information obtained from the research staff and their own physicians. Research should focus on information and communication strategies that support informed consent from referring physicians, researchers, and others to improve patient risk-benefit assessment and decision-making. (shrink)

Exploring informal components of clinical reasoning, we argue that they need to be understood via the analysis of professional wisdom. Wise decisions are needed where action or insight is vital, but neither everyday nor expert knowledge provides solutions. Wisdom combines experiential, intellectual, ethical, emotional and practical capacities; we contend that it is also more strongly social than is usually appreciated. But many accounts of reasoning specifically rule out such features as irrational. Seeking to illuminate how wisdom operates, we (...) therefore build on Aristotle’s work on informal reasoning. His account of rhetorical communication shows how non-formal components can play active parts in reasoning, retaining, or even enhancing its reasonableness. We extend this account, applying it to forms of healthcare-related reasoning which are characterised by the need for wise decision-making. We then go on to explore some of what clinical wise reasoning may mean, concluding with a case taken from psychotherapeutic practice. (shrink)

Delusions are symptoms of psychiatric disorders such as schizophrenia and dementia. By and large, delusions are characterized by their behavioral manifestations and defined as irrational beliefs that compromise good functioning. In this overview paper, we ask whether delusions can be adaptive notwithstanding their negative features. Can they be a response to a crisis rather than the source of the crisis? Can they be the beginning of a solution rather than the problem? Some of the psychological, psychiatric, and philosophical literature (...) has recently suggested that they can. We consider different types of delusions and different ways in which they can be considered as adaptive: psychologically (e.g., by increasing wellbeing, purpose in life, intrapsychic coherence, or good functioning) and biologically (e.g., by enhancing genetic fitness). Although further research is needed to map the costs and benefits of adopting and maintaining delusional beliefs, a more nuanced picture of the role of delusions in people's lives has started to emerge. (shrink)

In order to effectively prepare students for medical decisions with complex, ethical disagreements and value-laden conflicts, a progression from simpler case analysis to multi-layered conflicts is often helpful. Presented here is a unique case of pregnancy in a true hermaphrodite from recent medical literature. The case is artificially layered with additional, medical and discoverable contextual issues to help analyze three distinct questions in medical ethics: 1) Is it ethically permissible to perform an elective termination of pregnancy (ETOP) on a minor, (...) 2) Is it ethically permissible to keep this information from the parents, and 3) are additional and complicating medical features included in confidentiality agreements involving minors? The pedagogical goals include introducing and effectively utilizing the Orr-Shelton, four box method of clinical ethics assessment, demonstrating the need to uncover/discover important contextual (cultural, religious, family, etc.) features not usually incorporated fully into patient charts, to prepare medical students to research and become familiar with the local legal environment, and to illustrate that what appears to be a single a single ethical dilemma is likely far more complex requiring a multi-focused assessment. (shrink)

Bioethical phenomena of current medicine re-evaluate the universal validity of the bioethical principles of autonomy and justice. Individual areas of medicine feature various degrees of inherent paternalism in clinical situations. External paternalism in itself is not ethical. Abstract principles of medical ethics need to be (re)interpreted. From the bioethical point of view, clinical situations require methodological plurality, i.e., a combination of principilism and inductive models (casuistic ethics, ethics of care). At present, the main ethical clinical approach to (...) patients is ethics of responsibility representing a holistic and continuous paradigm. (shrink)

In this brief commentary, I offer an appreciative yet critical analysis of Abram Brummett and Erica Salter's article, “Mapping the Moral Terrain of Clinical Deception.” I challenge the authors to clarify their choice of the term “deception” (as opposed to “lying” or “dishonesty”), and I explain how these different terms may affect one's moral analysis. I also draw attention to the authors’ claim that veracity is the ethical default of clinicians. I argue that their failure to defend this claim (...) renders their framework more limited in its usefulness than they seem to acknowledge. While their framework does an excellent job of identifying morally salient features of clinical deception, it cannot be used to measure the strength of justification for an act of deception apart from a normative conception of truthfulness. (shrink)