Health care is provided in many contexts—not just hospitals, clinics, and community health settings. Different institutional settings may significantly influence the design and delivery of health care and the ethical obligations and practices of health care practitioners working within them. This is particularly true in institutions that are established to constrain freedom, ensure security and authority, and restrict movement and choice. We describe the results of a qualitative study of the experiences of (...) doctors and nurses working within two women’s prisons in the state of New South Wales (NSW), Australia. Their accounts make clear how the provision and ethics of health care may be compromised by the physical design of the prison, the institutional policies and practices restricting movement of prisoners and practitioners, the focus on maintaining control and security, and the very purpose of the prison and prison system itself. The results of this study make clear the impact that context has on professional practice and illustrate the importance of sociology and anthropology to bioethics and to the development of a more nuanced account of professional ethics. (shrink)

During the last two decades there has been an enormous development in treatment possibilities in the field of neonatology, particularly for (extremely) premature infants. Although there are cross-cultural differences in treatment strategy, an overview of the literature suggests that every country is confronted with moral dilemmas in this area. These concern decisions to initiate or withhold treatment directly at birth and, later on, decisions to withdraw treatment with the possible consequence that the child will die. Given that the neonate cannot (...) express his or her own will, who will decide? And on the basis of what information, values and norms? We explored some of these issues in daily practice by interviewing a small sample of health care practitioners in a Dutch university Neonatal Intensive Care Unit (NICU). It turned out that experiencing moral dilemmas is part of their daily functioning. Nurses underline the suffering of the newborn, whereas physicians stress uncertainty in treatment outcome. To make the best of it, nurses focus on their caring task, whereas physicians hope that future follow-up research will lead to more predictable outcomes. As for their own offspring, part of these professionals would hesitate to bring their own extremely premature newborn to a NICU. For the most oppressing dilemma reported – terminating an already initiated treatment – we propose the concept of ‘evidence shift’ to clarify the ambiguous position of uncertainty in decision making. (shrink)

Completely updated and revised, the third edition of Catholic Health Care Ethics: A Manual for Practitioners sets the standard for Catholic bioethicists, physicians, nurses, and other health care workers. In thirty-nine chapters (many with subchapters), leading authors in their fields discuss a wide range of topics relevant to medicine and health care. The book has six parts covering foundational principles, health care ethics services, beginning-of-life issues, end-of-life issues, selected clinical issues, and (...) institutional issues. Some highlights from the third edition include new entries on the Ethical and Religious Directives for Catholic Health Care Services, certitude in moral decision-making, the principle of double effect, clinical ethics consultation, natural family planning, prenatal testing and diagnosis, care of fetal remains, challenges to neurological criteria, the use of ventilators, POLST, alkaline hydrolysis, opportunistic salpingectomy, so-called lethal prenatal diagnoses, transgenderism, and new age medicine. The volume continues to provide insightful information on the topics previously covered in the second edition, but with significant updates throughout. (shrink)

During the last two decades there has been an enormous development in treatment possibilities in the field of neonatology, particularly for (extremely) premature infants. Although there are cross-cultural differences in treatment strategy, an overview of the literature suggests that every country is confronted with moral dilemmas in this area. These concern decisions to initiate or withhold treatment directly at birth and, later on, decisions to withdraw treatment with the possible consequence that the child will die. Given that the neonate cannot (...) express his or her own will, who will decide? And on the basis of what information, values and norms? We explored some of these issues in daily practice by interviewing a small sample of health care practitioners in a Dutch university Neonatal Intensive Care Unit (NICU). It turned out that experiencing moral dilemmas is part of their daily functioning. Nurses underline the suffering of the newborn, whereas physicians stress uncertainty in treatment outcome. To make the best of it, nurses focus on their caring task, whereas physicians hope that future follow-up research will lead to more predictable outcomes. As for their own offspring, part of these professionals would hesitate to bring their own extremely premature newborn to a NICU. For the most oppressing dilemma reported – terminating an already initiated treatment – we propose the concept of ‘evidence shift’ to clarify the ambiguous position of uncertainty in decision making. (shrink)

The aim of this study was to investigate patients' experiences of not being treated well in medical health care in Stockholm County, Sweden. The study was conducted by implementing qualitative content analysis using categorization of empirical material for 2006 and 2007 provided by the Patients' Advisory Committee (Patientnämnden) in Stockholm. Complaints about not being treated well accounted for 13% of all complaints to the Patients' Advisory Committee. A sample of those who complained about their medical treatment shows that (...) about 30% of these complaints also involved experiences of being badly received. Categorization of the complaints about being badly treated resulted in the following 11 categories: (1) rude, aggressive or arrogant behaviour; (2) being ignored; (3) being denied examinations or treatments; (4) lack of empathy among personnel; (5) lack of respect for personal integrity; (6) lack of time/waiting time; (7) personnel not separating private issues from their professional role; (8) injustice and discrimination; (9) sexual harassment; (10) coercion and violence and (11) unspecified bad treatment. In relation to the total number of patients, women were over-represented in all categories. In conclusion, what patients react most strongly against is when health-care personnel treat them disrespectfully by not abiding by established social norms. The results indicate that the combination of failure in medical treatment and not receiving an apology often leads patients to complain to the Patients' Advisory Committee. (shrink)

In this issue of the Hastings Center Report, Ann Hamric, John Arras, and Margaret Mohrmann highlight how contemporary accounts of the virtue of courage in health care often gloss over deeper problems in the underlying health care systems themselves. They express particular concerns about the appropriateness and personal costs of exhortations to health professionals to take courageous action in circumstances where this is “required only because of unethical institutional structures” (p. 39). They offer valuable points (...) that are not adequately recognized in discussions of courage as a professional virtue in health care practice. The call for more judicious appeals to health professionals to exercise courage in health care practice should clearly be heeded. A sole reliance on practitioner courage for exposing unethical workplace practices would be misguided. Nevertheless, there is still a legitimate place for encouraging health professionals to develop and act on courage. (shrink)

This paper1 aims to develop a model of practitioner narrative competence specifically for mental health care. I begin by considering the status of narratives as a form of evidence. Following Rita Charon and Cheryl Misak, I claim that there is no distinction to be made between evidence-based medicine and narrative medicine. I then explore Charon’s model of practitioner narrative competence, and suggest that it can be fruitfully adapted for mental health care contexts, a project for which (...) I employ Jennifer Radden and John Z. Sadler’s psychiatric ethics. This project brings together two independently promising accounts to develop what I refer to as the adapted model of... (shrink)

The European Biomedical Ethics Practitioner Education Project (EBEPE), funded by the BIOMED programme of the European Commission, is a five-nation partnership to produce open learning materials for healthcare ethics education. Papers and case studies from a series of twelve conferences throughout the European Union, reflecting the ‘burning issues’ in the participants' healthcare systems, have been collected by a team based at Imperial College, London, where they are now being edited into a series of seven activity-based workbooks for individual or group (...) study. These draft workbooks are now being read by a network of critical readers across Europe, whose comments will be incorporated into the final versions of the workbooks. The result will be the first European-wide and Europe-centred resource for teaching students, practitioners, and members of ethics committees. Topics covered include: • Resource allocation and rationing • The rights of children and young people • Long-term care of the elderly • Mental health and mental illness • Autonomy and patient choice • Decisions at the end of life • A study guide to using the workbooks The collaborative nature of the project has highlighted differentiated national approaches in medical ethics. Against the British and Dutch rights-orientated approach have emerged two other alternative models: the Nordic preference for administrative resolution of entitlement disputes, and the southern European emphasis on deontological codes. A genuinely European reconstruction of autonomy and rights, using hermeneutic, feminist and narrative approaches to counterbalance individualistic models, is emerging across the workbooks. The programme has also uncovered national differences in how ethics should be taught, with the workbooks' style being an experiential approach. Thus the EBEPE project is developing new models in both substantive and pedagogic senses, about both what should be taught and how it should be presented. (shrink)

Historically associated with military service, conscientious objection has become a significant phenomenon in health care. Mark Wicclair offers a comprehensive ethical analysis of conscientious objection in three representative health care professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from (...) performing any action contrary to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specified ethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of health care. (shrink)

A considerable section of the population in India accesses the services of individual private medical practitioners (PMPs) for primary level care. In rural areas, these providers include MBBS doctors, practitioners of alternative systems of medicine, herbalists, indigenous and folk practitioners, compounders and others. This paper describes the profile, knowledge and some practices of the rural doctor in India and then discusses the reasons for lack of equity in health care access in rural areas and (...) possible solutions to the problem. (shrink)

BackgroundWith the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers’ perspectives on honouring eligible patients’ request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity. (...) MethodA critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-related care.ResultsThemes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencing ethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden.DiscussionTo our knowledge, this is the first study in Canada to explore healthcare providers’ perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people’s access to MAiD following loss of capacity, as they believed it would improve the patients’ comfort and minimize suffering. However, the lack of patients’ input at the time of provision and related ethical and legal challenges may impact healthcare providers’ moral agency and reduce some patients’ access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD. (shrink)

Restructured health care reimbursement systems and new requirements for nonprofit hospitals are transforming the U.S. health system, creating opportunities for enhanced integration of public health and health care goals. This article explores the role of public health practitioners and lawyers in this moment of transformation. We argue that the population perspective and structural strategies that characterize public health can add value to the health care system but could get lost (...) in translation as changes to tax requirements and payment systems are rapidly implemented. We urge public health leaders to take a more active role in hospital assessments of community health needs and evaluation of the patient outcomes for which providers are accountable. (shrink)

Analyzes the moral problems confronting health care practitioners from a wide variety of perspectives, especially those connected by four major ethical principles--respect for autonomy, beneficence, non-maleficence and justice.

In his 1917 lecture “Science as a Vocation,” Max Weber challenged current and aspiring scholars to abandon any pretense that science bears within itself any meaning. In a disenchanted age, he argued, science could at best offer “knowledge of the techniques whereby we can control life... through calculation,” and any meaning or moral direction to scientific research—including religious meaning—must be imposed on it from without. Weber presciently anticipated that many present-day health care practitioners would struggle to find (...) meaning for their work within complex “state-capitalist” health care systems, along with predictable quasi-religious responses. But how are Christian practitioners to practice faithfully in a disenchanted age? The authors of this special issue lean deeply into the loci of Christian theology and Christian practice, some challenging the views of the body and of nature that informed Weber’s theory of disenchantment, and all offering resources and paths by which practitioners might “look the fate of the age full in the face” with courage and wisdom. (shrink)

This book sheds light on various ethical challenges military and humanitarian health care personnel face while working in adverse conditions. Contexts of armed conflict, hybrid wars or other forms of violence short of war, as well as natural disasters, all have in common that ordinary circumstances can no longer be taken for granted. Hence, the provision of health care has to adapt, for example, to a different level of risk, to scarce resources, or uncommon approaches due (...) to external incentives or requirements. This affects the practice of health care as well as its ethics. This book offers a panoramic overview on various challenges healthcare faces in extraordinary situations and provides new insights from practitioners’ as well as from academic scholars’ perspectives. (shrink)

This study aims to compare and contrast how specific information health technologies (IHTs) have been debated, how they have proliferated, and what they have enabled in Germany’s and England’s healthcare systems. For this a discourse analysis was undertaken that specifically focussed on future-scenarios articulated in policy documents and strategy papers released by relevant actors from both healthcare systems. The study reveals that the way IHTs have been debated and how they have proliferated depends on country-specific regulatory structures, their respective (...) values, actors’ and institutions’ organized interests, and the status of health professionals. These conditions have enabled IHTs to promote a new and similar concept of patienthood in both countries, although they tend to affect practitioners’ practices more dramatically in England. The conclusion is drawn that with the usage of IHTs, healthcare systems reproduced existing patterns of health provision while also enabling a sort of convergence. Future research should investigate whether the new concept of patienthood emerging in both welfare states actually suits patients’ and professionals’ needs and requirements. (shrink)

Reasoning and judgement in health care entail complex responses to problems whose demands typically derive from several areas of specialism at once. We argue that current evidence- or value-based models of health care reasoning, despite their virtues, are insufficient to account for responses to such problems exhaustively. At the same time, we offer reasons for contending that health professionals in fact engage in forms of reasoning of a kind described for millennia under the concept of (...) wisdom. Wisdom traditions refer to forms of deliberation which combine knowledge, reflection and life experience with social, emotional and ethical capacities. Wisdom is key in dealing with problems which are vital to human affairs but lack prescribed solutions. Uncertainty and fluidity must be tolerated in seeking to resolve them. We illustrate the application of wisdom using cases in psychiatry, where non-technical aspects of problems are often prominent and require more systematic analysis than conventional approaches offer, but we argue that our thesis applies throughout the health care field. We argue for the relevance of a threefold model of reasoning to modern health care situations in which multifaceted teamwork and complex settings demand wise judgement. A model based on practical wisdom highlights a triadic process with features activating capacities of the self, other and aspects of the problem itself. Such a framework could be used to develop current approaches to health care based on case review and experiential learning. (shrink)

Ethics of Health Care: A Guide for Clinical Practice, 3E is designed to guide health care students and practitioners through a wide variety of areas involving ethical controversies. It provides a background in value development and ethical theories, including numerous real-life examples to stimulate discussion and thought.

Refining the model for an emergency department‐based mental health nurse practitioner outpatient service The mental health nurse practitioner (MHNP) role based in the emergency department (ED) has emerged in response to an increase in mental health‐related presentations and subsequent concerns over waiting times, co‐ordination of care and therapeutic intervention. The MHNP role also provides scope for the delivery of specialised primary care. Nursing authors are reporting on nurse‐led outpatient clinics as a method of healthcare delivery (...) that allows for enhanced access to health‐care, particularly following hospital discharge. However, due to a lack of in‐depth substantiation, this mode of service delivery requires more thorough investigation. This study describes the refinement phase undertaken before the implementation and pilot evaluation of a formalised and structured MHNP outpatient service in the ED of a large inner‐city hospital in Sydney, Australia. An expert advisory panel (EAP) consisting of key local informants was convened to provide feedback on and refinement to the proposed model. This related to issues such as target population, structure and process considerations, outcome measures and interface within the overall health service. Findings from the EAP meeting are presented and discussed. The importance of linking methods with the appropriate methodology in evaluating a healthcare program is highlighted. (shrink)

Humanitarian health care practitioners working outside familiar settings, and without familiar supports, encounter ethical challenges both familiar and distinct. The ethical guidance they rely upon ought to reflect this. Using data from empirical studies, we explore the strengths and weaknesses of two ethical models that could serve as resources for understanding ethical challenges in humanitarian health care: clinical ethics and public health ethics. The qualitative interviews demonstrate the degree to which traditional teaching and values (...) of clinical health ethics seem insufficient for addressing all the realities of health care practice during humanitarian missions. They equally suggest that greater good orientations of public health ethics can thwart the best intentions of health care professionals wanting to attend to the interests of individual patients. Even though neither is complete on its own for helping guide health professionals on field missions, taken together these models have much to offer. At the same time, the narratives of the humanitarian health care workers illustrate how some of the crucial differences between public health ethics and clinical ethics generate tensions in humanitarian health practice. We offer an analysis of some of the complexities this creates for humanitarian health care ethics, and consider ways of adjudicating between the two models. (shrink)

In the Caribbean as in many other areas costly biomedical resources and personnel are limited, and more and more people are turning to alternative medicine and folk practitioners for health care. To meet the goal of providing health care for all, research on nonbiomedical therapies is needed, along with legal recognition of folk practitioners to establish standards of practice.

Person‐centred practice indubitably seems to be the antithesis of technology. The ostensible polarity of technology and person‐centred practice is an easy road to travel down and in their various forms has been probably travelled for decades if not centuries. By forging ahead or enduring these dualisms, we continue to approach and recede, but never encounter the elusive and the liminal space between technology and person‐centred practice. Inspired by Haraway's work, we argue that healthcare practitioners who critically consider their cyborg (...) ontology may begin the process to initiate and complicate the liminal and sought after space between technology and person‐centred practice. In this paper, we draw upon Haraway's idea that we are all materially and ontologically cyborgs. Cyborgs, the hybridity of machine and human, are part of our social reality and embedded in our everyday existence. By considering our cyborg ontology, we suggest that person‐centred practice can be actualized in the contextualized, embodied and relational spaces of technology. It is not a question of espousing technology or person‐centred practice. Such dualisms have been historically produced and reproduced over many decades and prevented us from recognizing our own cyborg ontology. Rather, it is salient that we take notice of our own cyborg ontology and how technological, habitual ways of being may prevent (and facilitate) us to recognize the embodied and contextualized experiences of patients. A disruption and engagement with the habitual can ensure we are not governed by technology in our logics and practices of care and can move us to a conscious and critical integration of person‐centred practice in the technologized care environments. By acknowledging ourselves as cyborgs, we can recapture and preserve our humanness as caregivers, as well as thrive as we proceed in our technological way of being. (shrink)

Conscientious objection in health care is a form of compromise whereby health care practitioners can refuse to take part in safe, legal, and beneficial medical procedures to which they have a moral opposition (for instance abortion). Arguments in defense of conscientious objection in medicine are usually based on the value of respect for the moral integrity of practitioners. I will show that philosophical arguments in defense of conscientious objection based on respect for such moral (...) integrity are extremely weak and, if taken seriously, lead to consequences that we would not (and should not) accept. I then propose that the best philosophical argument that defenders of conscientious objection in medicine can consistently deploy is one that appeals to (some form of) either moral relativism or subjectivism. I suggest that, unless either moral relativism or subjectivism is a valid theory—which is exactly what many defenders of conscientious objection (as well as many others) do not think—the role of moral integrity and conscientious objection in health care should be significantly downplayed and left out of the range of ethically relevant considerations. (shrink)

This paper explores the notion of ‘expert’ health care practitioner in the context of critical thinking and health care education where scientific rather than philosophical inquiry has been the dominant mode of thought. A number of factors have forced are appraisal in this respect: the challenge brought about by the identification of complex ethical issues in clinical situations; medicine's `solving' of many of the simple health problems; the recognition that uncertainty is a common and perhaps (...) innate feature of clinical practice; debate about the concepts of illness and disease; plus insights from psychology,sociology and medical anthropology. Together these have prompted alternative ways of thinking which have the aim of identifying the best rather than the right decision (where best equates to good and right equates to correct in the sense of true or approved). It is argued that phronesis adds a necessary corrective dimension to modern Western medicine's over-emphasis on techne and is one of the factors that differentiates novice from expert practitioner. However, this attracts certain conflicts of interest: phronesis can only be gained and assessed from experience of praxis; agencies with legitimate interests in medicine such as government and professional registering bodies require more substantive criteria. (shrink)

Even a brief consideration of the nature of nursing will indicate that an ethical dimension underlies much, if not all, of nursing practice. It is therefore important that students and practitioners are facilitated in developing an ethical awareness and sensitivity from early in their professional development. This paper argues that Aristotelian virtue theory provides a practice-based focus for health care ethics for a number of reasons. Also, because of his emphasis on the character of the moral agent, (...) and on the importance of perception and emotion in moral decision-making, Aristotelian virtue theory provides a useful supplement to the traditional duty-based approaches to health care ethics analysis, which are increasingly being identified in the literature as having limits to their application within the health care context. (shrink)

Objective: To explore the ways in which health care practitioners working within the morally contested area of prenatal screening balance their professional and private moral values.Design: Qualitative study incorporating semistructured interviews with health practitioners followed by multidisciplinary discussion groups led by a health care ethicist.Setting: Inner city teaching hospital and district general hospital situated in South East England.Participants: Seventy practitioners whose work relates directly or indirectly to perinatal care.Results: Practitioners managed (...) the interface between their professional and private moral values in a variety of ways. Two key categories emerged: “tolerators”, and “facilitators”. The majority of practitioners fell into the “facilitator” category. Many “facilitators” felt comfortable with the prevailing ethos within their unit, and appeared unlikely to feel challenged unless the ethos was radically challenged. For others, the separation of personal and professional moral values was a daily struggle. In the “tolerator” group, some practitioners sought to influence the service offered directly, whereas others placed limits on how they themselves would contribute to practices they considered immoral.Conclusions: The “official” commitment to non-directiveness does not encourage open debate between professionals working in morally contested fields. It is important that practical means can be found to support practitioners and encourage debate. Otherwise, it is argued, these fields may come to be staffed by people with homogeneous moral views. This lack of diversity could lead to a lack of critical analysis and debate among staff about the ethos and standards of care within their unit. (shrink)

Many observers have argued that the US health care system could be more efficient, and achieve better outcomes if providers focused more on improving the community's health, not just the welfare of individual patients. The passage of the Affordable Care Act in 2010 seemed to herald the promise of such reforms, and greater integration of the health care and public systems. In this article, we reassess the quest for integration, a quest we call the (...) “integration project.” After examining the modest steps taken so far toward integration, we consider some conceptual barriers to integration as well as some of the risks it might portend for the public health system. Our assessment contributes to wide-ranging debates among public health advocates, practitioners, and policymakers as to the health care system's role in protecting public health, and how the public health system can best be organized to meet expected population health challenges. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Introduction:Developing Health Care in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences of health care providers working in resource-poor settings, with stories written by those on the frontlines of global health. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of global health (...) class='Hi'>practitioners within the frameworks of sociology and medical anthropology respectively.The burgeoning interest in global health among students, health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantial moral claims. People working in global health often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to quality health care services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among global health equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basic health services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the local moral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewer health-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducing health disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes of health inequity.We believe that global health must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of global health as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by global health leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of global health work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic and moral—involved in this work. The profound scarcity of resources available to health providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and other health care workers, who make difficult choices every day about what to do with the few resources they have. These are the ethical dilemmas of mortal dramas at their most dire. Global health work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of global health practitioners. They highlight the translation of the moral and programmatic challenges of health care delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-up care. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)

Nurses and other medical practitioners often experience moral distress: they feel an anguished sense of responsibility for what they take to be their own moral failures, even when those failures were unavoidable. However, in such cases other people do not tend to think it is right to hold them responsible. This is an interesting mismatch of reactions. It might seem that the mismatch should be remedied by assuring the practitioner that they are not responsible, but I argue that this (...) denies something important that the phenomenon of moral distress tells us. In fact, both the practitioners’ tendencies to hold themselves responsible and other people’s reluctance to hold the practitioners responsible get something right. The practitioners may be right that they are responsible in the sense of having failed to meet a binding moral requirement, even when the requirement was impossible to meet. This makes moral distress a fitting response because it correctly represents their own action as a wrongdoing. However, others may meanwhile be right that the practitioners are not responsible in the sense of being culpable and blameworthy. To blame others, or oneself, for certain failures, including those that are unavoidable, would be unfair. My claim depends on distinguishing between the fittingness and the fairness of holding someone (including oneself) responsible for moral failure. Having drawn the distinction, I suggest that moral distress should be addressed in a way that both recognizes it as a fitting response and avoids the unfairness of blame. (shrink)

Despite the recent increased emphasis on ethics in health care, the subject of community health care is rarely specifically addressed. Yet it is in the community that many ethical issues arise, both in the particular practice situation and in the wider social issues connected with changes in government policy. This edited text discusses these questions and looks at the whole range of community health nursing in the UK. The multidisciplinary group of contributors explore the issues (...) of theory and practice that arise in community health care. They encourage critical reflection on the differences between hospital-based care and community care. Everyday issues are addressed that confront health practitioners working in the community, such as discrimination, mental health, standard setting, rationing in health care, public health, health promotion and discharge decision making. This book will be essential reading for practitioners on post-registration courses in community health and students following courses in health care ethics and nursing studies. (shrink)

The past decade has seen a burgeoning of scholarly interest in conscientious objection in health care. Specifically, several commentators have discussed the implications that conscientious objection has for the delivery of timely, efficient, and nondiscriminatory medical care. In this paper, I discuss the main argument put forward by the most prominent critics of conscientious objection—what I call the Professional Duty Argument or PDA. According to proponents of PDA, doctors should place patients’ well-being and rights at the center (...) of their professional practice. Doctors should be prepared to set their personal moral or religious beliefs aside where these beliefs conflict with what is legal and considered good medical practice by relevant professional associations. Conscientious objection, on this account, should be heavily restricted, if even allowed at all. I discuss two powerful objections against PDA. The first objection, which I call the fallibility objection, notes that law and professional codes of conduct are fallible guides for ethical conduct and that conscientious objection has in the past and continues today to provide a check on aberrations in law and professional convention. The second, which I call the professional discretion objection, states that restrictions on conscientious objection undermine one of the cornerstones of good medical practice, namely, a practitioner’s right to independent professional judgment. I argue that these two objections give us reason to retain conscience clauses in professional codes of conduct. (shrink)

This article discusses the challenging context that health care professionals are confronted with, and the impact of this context on their emotional experiences. Care ethics considers emotions as a valuable source of knowledge for good care. Thinking with care ethical theory and looking through a care ethical lens at a practical case example, the authors discern reflective questions that shed light on a care ethical approach toward the role of emotions in care (...) practices, and may be used by practitioners and facilitators for care ethical reflection on similar cases, in the particular and concrete context where issues around emotional experiences arise. The authors emphasize the importance of allowing emotions to exist, to acknowledge them and to not repress them, so that they can serve as a vehicle for ethical behavior in care practices. They stress the difference between acknowledging emotions and expressing them limitlessly. Formational practices and transformational research practices are being proposed to create moral space in care institutions and to support health care professionals to approach the emotionally turbulent practices they encounter in a way that contributes to good care for all those involved. (shrink)

In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?

Illness and hospitalization are sources of vulnerability; they arguably endow nurses and midwives with the moral obligation to develop caring relationships with patients. Fairness and the equal treatment of patients are central to moral practice; current government publications are giving this political emphasis. This article argues that patient partiality is one factor that may result in insidiously unequal caregiving. Data generated during a qualitative study into professional caring suggest that patient partiality is an accepted part of everyday practice. Factors such (...) as the patient’s personality, nurse-patient familiarity and the perceived level of patients’ understanding and interest in their illness emerged as possible sources of partiality and influence on practitioners’ interactions with patients. The article argues that patient partiality can be managed morally if practitioners develop self-awareness and constantly reflect on the moral integrity of everyday practice. Throughout the article, unless it is stated that specific reference is being made to either nurses or midwives, reference to a nurse or practitioner denotes both. It is also emphasized that no implication is intended that any study participants provided unequal care. Rather, data are utilized solely to generate focused discussion around the concept of patient partiality. (shrink)

This essay examines the interconnected nature of salvation and health, and it does so by engaging both recent qualitative research and three scriptural accounts from the life, death, and resurrection of Jesus. In doing so, the essay argues that salvation and health—and their conceptual pairings, sin and disease—are never individualistic. These realities are always cosmic, communal, and interpersonal, even as sin and disease are fundamentally disintegrating and isolating. The salvation and health of people suffering with substance use (...) issues are bound up with the transformations of governing principalities and powers, social realities, and relationships. Health care practitioners and clergy should be wise, communal guides offering care and accompaniment in the pursuit of salvation and health. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the border between several (...) disciplines, such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

There are numerous ways in which “the particular”—particular individuals, particular ideologies, values, beliefs, and perspectives—are sometimes overlooked, ignored, or even driven out of the healthcare profession. In many such cases, this is bad for patients, practitioners, and the profession. Hence, we should seek to find a place for the particular in health care. Specific topics that I examine in this essay include distribution of health care based on the particular needs of patients, the importance of (...) protecting physicians’ right to conscientious objection, the value in tolerating a plurality of moral and medical perspectives within the field, and more. Ultimately, as the imagery in the essay’s title suggests, I argue that if one cares about the “well-being” of the medical profession, then one should seek to avoid destroying the many diverse and particular entities that constitute it. (shrink)

As clinical ethics consultants move toward professionalization, the process of certifying individual consultants or accrediting programs will be discussed and debated. With certification, some entity must be established or ordained to oversee the standards and procedures. If the process evolves like other professions, it seems plausible that it will eventually include a written examination to evaluate the core knowledge competencies that individual practitioners should possess to meet peer practice standards. The American Society for Bioethics and Humanities has published core (...) knowledge competencies for many years that are accepted by experts as the prevailing standard. Probably any written examination will be based upon the ASBH core knowledge competencies. However, much remains to be done before any examination may be offered. In particular, it seems likely that a recognized examining board must create and validate examination questions and structure the examination so as to establish meaningful, defensible parameters after dealing with such challenging questions as: Should the certifying examination be multiple choice or short-answer essay? How should the test be graded? What should the pass rate be? How may the examination be best administered? To advance the field of health care ethics consultation, thought leaders should start to focus on the written examination possibilities, to date unaddressed carefully in the literature. Examination models—both objective and written—must be explored as a viable strategy about how the field of health care ethics consultations can grow toward professionalization. (shrink)

Going through reproductive experiences (especially pregnancy and childbirth) in contemporary Western societies almost inevitably involves interaction with medical practitioners and various medical technologies in institutional context. This has important consequences for women as embodied subjects. A critical appraisal of these consequences—coming dominantly from feminist scholarship—relied on a problematic theory of both technology and the subject, which are in contemporary approaches no longer considered as given, coherent and well individualized wholes, but as complex constellations that are locally situated and that (...) can only be described empirically. In this study, we will be relying on the developments in phenomenological theory to reconceptualize women as technologically mediated embodied subjects and on the new paradigms in philosophy of technology and STS to reconstruct medical technology as situated—with the aim of reconceptualizing their relationship and exploring different possibilities for the mediating role of medical technology. It will be argued that technologization of female reproductive processes and alienating consequences for women are not necessary or directly interrelated. The role of technology varies from case to case and depends mainly on the nontechnological and relational aspects of institutional context, in which medical practitioners play a decisive role. (shrink)

Trust in the nurse—patient relationship is maintained not by how professionals perceive their actions but rather by how the public perceives them. However, little is known about the public's view of nurses and other health care professionals who participate in pharmaceutical marketing. Our study describes public perceptions of health care providers' role in pharmaceutical marketing and compares their responses with those of a random sample of licensed family nurse practitioners. The family nurse practitioners perceived (...) their participation in marketing activities as significantly more ethically appropriate than did the public responders. Further research is warranted before conclusions can be drawn, but these early findings suggest that nurse practitioners should consider a conservative approach to participating in pharmaceutical marketing. (shrink)

Cultural appropriateness has become an important conceptual tool for health care professionals serving diverse patient populations. Physicians and other health care providers working in urban communities are increasingly challenged to provide care that is responsive to the health needs and beliefs of immigrants, refugees and other newcomers to mainstream health services. This paper argues that notions of cultural 'sensitivity' or 'competency' help health practitioners acknowledge professional and biomedical biases, but also risk (...) dehistoricizing and hence disempowering newcomers by failing to recognize culture as a dynamic process. Without attention to the ways in which newcomers actively produce culture and make sense of illness experience, health care workers ignore the contexts in which people. become ill and hence cannot act as healers. By presenting the case of one newcomer to the Canadian health care system, I argue that narratives provide a valuable tool for health practitioners to understand how newcomers actively engage and come to terms with illness, without defining them as determined by a set of cultural beliefs or practices. (shrink)

Well and Good presents a combination of "classic" and little-known cases in health care ethics. These cases, accompanied by information about the major ethical theories, give students a chance to grapple with the ethical challenges faced by health care practitioners, policy makers, and recipients. The authors' narrative style and leading questions provoke student interest and engagement, while allowing instructors the freedom to draw from the theoretical perspectives they consider most useful. This fourth edition includes an (...) expanded discussion of feminist ethics, and new cases addressing pandemic ethics, humanitarian aid, the social determinants of health, research and aboriginal communities, and a number of other emerging issues. (shrink)