Saturday, March 29, 2014

The ethics of the missing straw.

This case report details the emergency department course of a 34 year-old female who presented with abdominal pain and vaginal bleeding after reportedly falling one week earlier. She was subsequently found to have a drinking straw within her uterus next to an eight week-old live intrauterine pregnancy on ultrasound. This case report and discussion reviews the literature on retained foreign bodies in pregnancy while addressing the added complications of an evasive patient and a difficult consultant with significant intra-specialty disagreement.

West J Emerg Med. 2014 Mar;15(2):131-3

Moral development of first-year pharmacy students in the United kingdom.

Objective. To investigate the moral development of pharmacy students over their first academic year of study at a university in the United Kingdom. Methods. Pharmacy students completed Defining Issues Test (DIT) at the start of their first year (phase 1) and again at the end of their first year (phase 2) of the program. Results. Pharmacy students (N=116) had significantly higher moral reasoning at the beginning of their first year than by the end of it. Scores differed by students' gender and age; however, these findings differed between phase 1 and phase 2. Conclusion. First-year pharmacy students in the United Kingdom scored lower on moral reasoning than did pharmacy students in the United States and Canada.

Am J Pharm Educ. 2014 Mar 12;78(2):36

Friday, March 21, 2014

Seeing Responsibility: Can Neuroimaging Teach Us About Morality?

As imaging technologies help us understand the structure and function of the brain, providing insight into human capabilities as basic as vision and as complex as memory, and human conditions as impairing as depression and as fraught as psychopathy, some have asked whether they can also help us understand human agency. Specifically, could neuroimaging lead us to reassess the socially significant practice of assigning and taking responsibility? While responsibility itself is not a psychological process open to investigation through neuroimaging, decision-making is. Over the past decade, different researchers and scholars have sought to use neuroimaging (or the results of neuroimaging studies) to investigate what is going on in the brain when we make decisions. The results of this research raise the question whether neuroscience-especially now that it includes neuroimaging-can and should alter our understandings of responsibility and our related practice of holding people responsible. It is this question that we investigate here.

Hastings Cent Rep. 2014 Mar;44 Suppl 2:S37-49

Wednesday, March 19, 2014

What does public health ethics tell (or not tell) us

Obesity has been described as pandemic and a public health crisis. It has been argued that concerted research efforts are needed to enhance our understanding and develop effective interventions for the complex and multiple dimensions of the health challenges posed by obesity. This would provide a secure evidence base in order to justify clinical interventions and public policy. This paper critically examines these claims through the examination of models of public health and public health ethics. I argue that the concept of an effective public health intervention is unclear and underdeveloped and, as a consequence, normative frameworks reliant on meeting the effectiveness criterion may miss morally salient dimensions of the problems. I conclude by arguing for the need to consider both an ecological model of public health and inclusion of a critical public health ethics perspective for an adequate account of the public health challenges posed by obesity.  J Bioeth Inq. 2013 Mar;10(1):19-28

Moral judgment modulation

Modern theories of moral judgment predict that both conscious reasoning and unconscious emotional influences affect the way people decide about right and wrong.

This research found that on average, subliminal priming of disgust facial expressions resulted in higher rates of utilitarian judgments compared to neutral facial expressions.

Front Psychol. 2014;5:194

Monday, March 17, 2014

The ethics of forgoing life-sustaining treatmen

Withholding or withdrawing a life-sustaining treatment tends to be very challenging for health care providers, patients, and their family members alike. When a patient's life seems to be nearing its end, it is generally felt that the morally best approach is to try a new intervention, continue all treatments, attempt an experimental course of action, in short, do something. In contrast to this common practice, the authors argue that in most instances, the morally safer route is actually to forego life-sustaining treatments, particularly when their likelihood to effectuate a truly beneficial outcome has become small relative to the odds of harming the patient. The ethical analysis proceeds in three stages. First, the difference between neglectful omission and passive acquiescence is explained. Next, the two necessary conditions for any medical treatment, i.e., that it is medically indicated and that consent is obtained, are applied to life-sustaining interventions. Finally, the difference between withholding and withdrawing a life-sustaining treatment is discussed. In the second part of the paper the authors show how these theoretical-ethical considerations can guide clinical-ethical decision making. A case vignette is presented about a patient who cannot be weaned off the ventilator post-surgery. The ethical analysis of this case proceeds through three stages. First, it is shown that and why withdrawal of the ventilator in this case does not equate assistance in suicide or euthanasia. Next, the question is raised whether continued ventilation can be justified medically, or has become futile. Finally, the need for the health care team to obtain consent for the continuation of the ventilation is discussed.

Multidiscip Respir Med. 2014 Mar 11;9(1):14

Thursday, March 13, 2014

Models of morality.

Moral dilemmas engender conflicts between two traditions: 

  • consequentialism, which evaluates actions based on their outcomes, and
  • deontology, which evaluates actions themselves.
These strikingly resemble two distinct decision-making architectures: a model-based system that selects actions based on inferences about their consequences; and a model-free system that selects actions based on their reinforcement history. Here, I consider how these systems, along with a Pavlovian system that responds reflexively to rewards and punishments, can illuminate puzzles in moral psychology.

Trends Cogn Sci. 2013 Aug;17(8):363-6

Wednesday, March 12, 2014

Japanese and American Children's Moral Evaluations

This research study looked at American and Japanese children in terms of the reporting of peers' transgressions to authority figures. 
  • In both countries, participants across all age groups considered it appropriate to report major transgressions.
  • Compared with older children, younger children thought it was appropriate to tattle. 
  • Japanese children were more likely to consider it appropriate to report minor transgressions.
Dev Psychol. 2014 Mar 3

Monday, March 10, 2014

Enhancing Moral Conformity and Enhancing Moral Worth.

Enhancing Moral Conformity and Enhancing Moral Worth.
Neuroethics. 2014;7:75-91
Authors: Douglas T

It is plausible that we have moral reasons to become better at conforming to our moral reasons. However, it is not always clear what means to greater moral conformity we should adopt. John Harris has recently argued that we have reason to adopt traditional, deliberative means in preference to means that alter our affective or conative states directly-that is, without engaging our deliberative faculties. One of Harris' concerns about direct means is that they would produce only a superficial kind of moral improvement. Though they might increase our moral conformity, there is some deeper kind of moral improvement that they would fail to produce, or would produce to a lesser degree than more traditional means. I consider whether this concern might be justified by appeal to the concept of moral worth. I assess three attempts to show that, even where they were equally effective at increasing one's moral conformity, direct interventions would be less conducive to moral worth than typical deliberative alternatives. Each of these attempts is inspired by Kant's views on moral worth. Each, I argue, fails.

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Giving consent without getting informed: a cross-cultural issue in research ethics.

Giving consent without getting informed: a cross-cultural issue in research ethics.
J Empir Res Hum Res Ethics. 2013 Jul;8(3):12-21
Authors: Ghandour L, Yasmine R, El-Kak F

Informed consent forms (ICFs) maintain the integrity of research ethics and preserve participants' rights. Using cross-sectional online survey data on sexuality and sexual practices of private university students from Lebanon, this paper questions whether participants thoroughly read ICFs, and whether time taken to read ICFs is associated with data completeness. A total of 2,534 surveys were completed; a median time of 18.66 seconds was taken to read the 815-word ICF; 65% of participants consented within the first 30 seconds and 90% in less than the minimum predicted time (2.7 minutes). Our data indicates potential participant neglect of ICFs, raising the question of whether participants who endorse an informed consent form are truly informed of the study objectives and their rights.

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Charting a moral life

Charting a moral life: the influence of stigma and filial duties on marital decisions among Chinese men who have sex with men.
PLoS One. 2013;8(8):e71778
Authors: Steward WT, Miège P, Choi KH

INTRODUCTION: Stigma constitutes a critical challenge to the rising rates of HIV among Chinese men who have sex with men (MSM). It reduces willingness to disclose one's sexual orientation and can lead to concurrent sexual partnerships. Disclosure decisions are also affected by cultural norms that place pressures on sons to marry. In this manuscript, we characterize how stigma and cultural factors influenced Chinese MSM's decisions around disclosure and marriage. We seek to show that MSM's actions were motivated by moral considerations, even when those choices posed HIV transmission risks.
METHODS: We conducted qualitative interviews with 30 MSM in Beijing, China. Interviews were audio-recorded, transcribed, and translated into English for analysis. Transcripts were coded using a procedure that allowed for themes to emerge organically.
RESULTS: Participants struggled with feelings of shame and believed that others possessed stigmatizing attitudes about homosexuality. They had experienced relatively little discrimination because they infrequently disclosed their MSM status. In response to marital pressures, participant had to reconcile same-sex attractions with filial expectations. Their choices included: not being involved with women; putting on the appearance of a heterosexual relationship by marrying a lesbian; or fulfilling family expectations by marrying a heterosexual woman. Regardless of the decision, many rooted the justifications for their choices in the considerations they had given to others' needs.
CONCLUSION: The growing epidemic among MSM in China requires action from the public health community. As programs are scaled up to serve these men, it is critical to remember that MSM, who often fear social sanction if they were to reveal their sexual orientation, continue to face the same pressures from culturally normative social duties as heterosexual men. Interventions must find ways to help men navigate a balance between their own needs and the responsibilities they feel toward their parents and others.

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Sunday, March 9, 2014

A Health Care Chaplain's Pastoral Response to Moral Distress.

A Health Care Chaplain's Pastoral Response to Moral Distress.
J Health Care Chaplain. 2014 January-March;20(1):3-15
Authors: Guthrie M

This article offers health care chaplains a pastoral response to moral distress experienced by health care professionals. The article offers a broad definition, explores its impact on health care professionals, and looks at various interventions to ameliorate its effects. The article goes on to clarify the concept of moral distress by differentiating it from the experience of moral dilemmas, and looking closer at the aspects of initial and reactive distress. After defining moral distress, the article explores two clinical models that create a better context to understand the phenomenon. Finally, the article proposes a pastoral response to moral distress from the integration of the five functions of pastoral care: "healing," "sustaining," "guiding," "reconciling," and "nurturing" based on the work of William Clebsch, Charles Jaekle, and Howard Clinebell. The author then applies the pastoral response to moral distress by illustrating the outcome of a scenario with a critical care nurse.

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Thursday, March 6, 2014

The nature of ethical conflicts and the meaning of moral community in oncology practice.

The nature of ethical conflicts and the meaning of moral community in oncology practice.
Oncol Nurs Forum. 2014 Mar 1;41(2):130-40
Authors: Pavlish C, Brown-Saltzman K, Jakel P, Fine A

Purpose/Objectives: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated.Research Approach: Ethnography.Setting: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota.Participants: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists.Methodologic Approach: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes.Findings: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources.Conclusions: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter.Interpretation: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

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Tuesday, March 4, 2014

Ethics support in institutional elderly care: a review of the literature.

Ethics support in institutional elderly care: a review of the literature.
J Med Ethics. 2014 Feb 27;
Authors: van der Dam S, Molewijk B, Widdershoven GA, Abma TA

Clinical ethics support mechanisms in healthcare are increasing but little is known about the specific developments in elderly care. The aim of this paper is to present a systematic literature review on the characteristics of existing ethics support mechanisms in institutional elderly care. A review was performed in three electronic databases (Pubmed, CINAHL/PsycINFO, Ethxweb). Sixty papers were included in the review. The ethics support mechanisms are classified in four categories: 'institutional bodies' (ethics committee and consultation team); 'frameworks' (analytical tools to assist care professionals); 'educational programmes and moral case deliberation'; and 'written documents and policies'. For each category the goals, methods and ways of organising are described. Ethics support often serves several goals and can be targeted at various levels: case, professional or organisation. Over the past decades a number of changes have taken place in the development of ethics support in elderly care. Considering the goals, ethics support has become more outreaching and proactive, aiming to qualify professionals to integrate ethics in daily care processes. The approaches in clinical ethics support have become more diverse, more focused on everyday ethical issues and better adapted to the concrete learning style of the nursing staff. Ethics support has become less centrally organised and more connected to local contexts and primary process within the organisation.

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Sunday, March 2, 2014

The desired moral attitude of the physician: care.

The desired moral attitude of the physician: (III) care.
Med Health Care Philos. 2013 May;16(2):125-39
Authors: Gelhaus P

In professional medical ethics, the physician traditionally is obliged to fulfil specific duties as well as to embody a responsible and trustworthy personality. In the public discussion, different concepts are suggested to describe the desired moral attitude of physicians. In a series of three articles, three of the discussed concepts are presented in an interpretation that is meant to characterise the morally emotional part of this attitude: "empathy", "compassion" and "care". In the first article of the series, "empathy" has been developed as a mainly cognitive and morally neutral capacity of understanding. In the second article, the emotional and virtuous core of the desired professional attitude-compassion-has been presented. Compassion as a professional attitude has been distinguished from a spontaneous feeling of compassion, and has been related to a general idea of man as vulnerable and solidary being. Thus, the dignity of the patient is safeguarded in spite of the asymmetry of compassion. In this article, the third concept of the triad-"care"-is presented. Care is conceived as an attitude as well as an activity which can be directed to different objects: if it is directed to another sentient being, it is regarded as intrinsically morally valuable; implying (1) the acceptance of being addressed, (2) a benevolent inclination to help and to foster, and (3) activity to realize this. There are different forms of benevolence that can underlie caring. With regard to the professional physician's ethos, the attitude of empathic compassion as developed in the two previous articles is proposed to be the adequate underlying attitude of care which demands the right balance between closeness and professionalism and the right form of attention to the person of the patient. 'Empathic compassionate care' does not, however, describe the whole of the desired attitude of a physician, but focuses on the morally-emotive aspects. In order to get also the cognitive and practical aspects of biomedicine into the picture, 'empathic compassionate care' has to be combined with an attitude of responsibility that is more directed to decision-making and outcome than a caring attitude alone can be. The reconstruction of the desired professional attitude in terms of "empathic compassionate care" and "responsibility" is certainly not the only possible description, but it is a detailed proposal in order to give an impulse for the discussion about the inner tacit values and the meaning of medicine and clinical healthcare professions.

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