Applying bioethical principles can be difficult in resource-poor environments, particularly for Western doctors unfamiliar with these limitations. The challenges become even greater when clinicians must make rapid critical decisions. As the following case in Zambia illustrates, the Rapid Ethical Decisionmaking Model, long used in emergency medicine, is a useful tool in such circumstances.

In the rationalist tradition in ethics, the emotions are morally suspect. In a corrective swing of the pendulum, burgeoning philosophical interest is “rehabilitating” the emotions in ethical decisionmaking. The emotions and reason should be mutually correcting resources in moral reflection.

There is good news, and there is bad news. The good news is that in my experience, younger physicians generally are much more concerned about the cost of clinical tests and treatments, and about justly distributing finite medical resources, than were those who practiced medicine in the fee-for-service era. The bad news has at least three components. First, with respect to medically nonbeneficial treatment in the ICU, managed care has not yet given evidence of wanting to put the brakes on (...) unrealistic family demands for aggressive medical interventions. Second, managed care is frustrating many healthcare professionals as well as patients. And third, managed care has no apparent interest in addressing, and may even have contributed to, the problem of medical indigence. Let me develop these propositions more fully. (shrink)

Many ethical issues facing managers of multinational corporations are polycentric problems. That is, they involve a number of distinct centers -- each of which define rights and obligations of a multiplicity of affected parties -- and resolving matters around one center typically creates unpredictable repercussions around one or more of the other centers. Polycentricity is a normative phenomenon especially unsuited for adjudication, often requiring recourse to alternative processes of contract (or reciprocal adjustment) and managerial direction. This study explores how (...) such concerns about the limits of adjudication (and its various moral counterparts) apply to international decisionmaking connected to human rights obligations of multinational companies. The focus is on ethical problems such as controlling child labor in LDCs such as Bangladesh, India and Pakistan; setting wages in developing countries like Honduras; and conducting business transactions with rights-violating regimes, such as the governments of Nigeria and Myanmar. (shrink)

An evaluation of mental capacity is critical to a clinician's judgment about whether or not persons can make medical treatment decisions on their own behalf, and uncertainty about their ability to meaningfully participate in that process is one of the more common reasons an ethics consult is requested. The care of decisionally incapable patients—particularly those who lack advance care documents and no living relative who can speak for them—presents a quandary to healthcare personnel attempting to plan care in their best (...) interest, especially when options are multiple but none are ideal. These situations can be further complicated if involving a patient with a dual diagnosis of mental retardation and mental illness living in a community group home. (shrink)

Focusing on the work of one bioethics commission, the New York State Task Force on Life and the Law, this article explores the role played by moral consensus in public ethics. Task Force members, who were appointed to represent diverse interests in New York State, identified a culturally strong value of individual autonomy as the ethical basis for their work on life-sustaining treatment. This moral consensus permitted the members to unite across their differences and develop public policy recommendations that (...) substantially reformed a highly troubling New York law. However, the principle of autonomy insufficiently guides decisions by caring family members for incompetent adults in cases where little is known of patient preference. A different, more innovative moral vision is required – one that grants a more robust moral authority to the family. While government efforts that rely on moral consensus developed in a broadbased and well-reasoned manner can serve us well, in some cases the consensus will provide inadequate moral guidance. Government bioethical efforts must guard against the limits of moral vision in light of their disproportionate societal power. Keywords: autonomy, consensus, family decisionmaking, government bioethics, incompetent patients, life-sustaining treatment, surrogate decisionmaking CiteULike Connotea Del.icio.us What's this? (shrink)

The most important issue remains: Whether attorneys should serve on HECs? Will they tend to inhibit the development of other discussions, ethical discussions, regarding the issues brought before the HEC? D. Niemira (17, p. 982) suggests that what a hospital needs is not necessarily an attorney to help in their ethical deliberations, but an ethicist. This suggestion should receive further analysis. What types of ethical deliberations to which attorneys have not been exposed in their legal training are (...) important given the broader attorney-role (beyond giving legal opinion) in HEC discussions?The pro-active attorney faces many challenges, both in the current setting (as cases are brought to the HEC) and as future questions are raised (due to innovations in medical technology). These questions remain unclarified by the courts. The nature of the attorney's role is ever challenging; he or she remains in a key position that is currently needed (regarding the uncharted areas of HEC decisionmaking) and important for the future (as new cases emerge and require extensive deliberations). (shrink)

It is widely thought that genetic counselors should work with parents “nondirectively”: they should keep parents informed and support their decisions. But this view misconceives human decisionmaking by failing to recognize that value choices are constructed within and constrained by a community. Acknowledging that decisions involve interaction with and responsibility toward others leads to a “dialogical” model of counseling, in which genetic counselors may question and guide parents’ decisions.

A central challenge motivates this work: How, if at all, can philosophical ethics help in the moral development of health professionals?

A volume in Ethics in Practice Series Editors Robert A. Giacalone, Temple University and Carole L. Jurkiewicz, Louisiana State University Making sure that performance in business enterprise is achieved ethically is no small task. Leaders, managers, and employees at every level of the organization need to utilize systems and processes that support ethical strength, establishing a workplace where responsibility, accountability, and doing the right thing are genuinely valued and practiced. Management can help support ethical performance in workers' daily (...) task actions by underscoring the importance of rules and regulations, while also moving to ensure that employees understand and care about doing what's right. Given that most firms only emphasize compliance in ethics training, there is vast room for additional development. Training people to be less bad is not good enough. With the infusion of mandatory requirements for ethics training programs in some firms and self-imposed initiatives in others, we see a range of deliverables. To advance ethics in practice, a closer look at ethics training in the workplace is warranted. This volume attempts to better understand ethics in organizational settings by taking a focused look at the science of ethics training and best practices, areas for concern, specific techniques, application outcomes, how to cultivate an ethical work environment, and considering where opportunities for additional inquiry reside. Managers and practitioners reading this book will garner specific trends and useful techniques that can inform, guide, and improve their efforts to build ethical awareness and effective ethical decisionmaking within their organizations. Academic scholars will find this book useful, providing insight as to where additional research and empirical work is needed. (shrink)

This paper evaluates Sara Goering’s recent attempt to use the Rawlsian notion of the veil of ignorance as a tool for distinguishing permissible from impermissible forms of genetic engineering. I argue that her article fails due to a failure to include vital contextual information in the right way.

Patients with disorders of consciousness after severe brain injury need surrogate decision makers to guide treatment decisions on their behalf. Formal guidelines for surrogate decisionmaking generally instruct decision makers to first appeal to a patient’s written advance directive, followed by making a substituted judgment of what the patient would have chosen, and lastly, to make decisions according to what seems to be in the patient’s best medical interests. Substituted judgment is preferable because it is taken to preserve patient autonomy, (...) by using a patient’s past wishes and values to reconstruct what they would have chosen for themselves. In this paper, the author argues that for a certain population of patients, the standard interpretation of substituted judgment cannot ensure the preservation of patient autonomy. Patients with “covert awareness” may continue to have values and an authentic sense of self, which may differ from their past values and wishes. Accordingly, surrogate decision makers should make decisions based on how the patient is likely to experience their condition in the present, rather than their past wishes and values. (shrink)

Mackenzie Graham has made an important contribution to the literature on decisionmaking for patients with disorders of consciousness. He argues, and I agree, that decisions for unresponsive patients who are known to retain some degree of covert awareness ought to focus on current interests, since such patients likely retain the kinds of mental capacities that in ordinary life command our current respect and attention. If he is right, then it is not appropriate to make decisions for such patients by (...) appealing to the values they had in the past, either the values expressed in an advance directive or the values recalled by a surrogate. There are two things I wish to add to the discussion. My first point is somewhat critical, for although I agree with his general conclusion about how, ideally, such decisions should be approached, I remain skeptical about whether his conclusion offers decisionmakers real practical help. The problem with these cases is that the evidence we have about the nature of the patient’s current interests is minimal or nonexistent. However—and this is important—Graham’s conclusion will be extremely relevant if in the future, our ability to communicate with such patients improves, as I hope it will. This leads to my second point. Graham’s conclusion illustrates a more general problem with our standard framework for decisionmaking for previously competent patients, a problem that has not been adequately recognized. So, in what follows, I explain the problem I see and offer some brief thoughts about solutions. (shrink)

Patients with amyotrophic lateral sclerosis (ALS) face many difficult, timing-sensitive decisions over the course of their illness, weighing present versus future harms and benefits. Supplemented by interviews with people with ALS, we argue for a relational approach to understanding these decisions and their effects on identity. We highlight two critical aspects of the patient–caregiver relationship: (1) the extent to which each may rely on the other leaves their wellbeing intimately intertwined and (2) patients often require others to help with the (...) imaginative task of considering possible futures for each therapeutic option. We show why family involvement in decisionmaking practices can be so critical, and shed light on the ways intimate others help preserve and protect people’s identities amidst the destabilizing uncertainty illness and treatment can bring. (shrink)

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of (...) Jordan, a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: "conservative" and "pragmatic" styles of decision-making; "traditional" approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world. (shrink)

This CQ department is dedicated to bringing noted bioethicsts together in order to debate some of the most perplexing contemporary bioethics issues. You are encouraged to contact department editor, D. Micah Hester, UAMS/Humanities, 4301 W. Markham St. #646, Little Rock, AR 72205, with any suggestions for debate topics and interlocutors you would like to see published herein.

As part of an effort to look at for bioethicists interested in clinical decisionmaking, Erik Parens, the editor of this special section, asked us to look at social class. When we began our research for this paper, we were surprised to find that although bioethicists have written much on social class and such macrolevel issues as access to healthcare and the distribution of scarce resources, and have paid some attention to the effects of class on patient-provider relationships, bioethicists have (...) written little specifically that looks at the implications of social class for medical decisions in individual cases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Ethics Committees in HospitalsPat Milmoe McCarrick (bio)(Literature about hospital ethics committees has grown enormously since Scope Note 3 first appeared. This update provides new information about resources and documents now available while continuing to include important earlier sources.)Hospital ethics committees increasingly have taken hold in the United States since 1983, when the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research encouraged (...) their creation in its report, Deciding to Forego Life-Sustaining Treatment (III, 1983, p. 5).The President's Commission report (pp. 160-64) suggested the following roles for ethics committees: 1) review of treatment decisions made on behalf of incompetent, terminally ill patients; 2) review of medical decisions having ethical implications with the option, in cases of disagreement, to refer cases to a court with proper jurisdiction; 3) provision of social, psychological, spiritual, or other counseling for patients, family members, physicians, or other hospital staff; 4) establishing guidelines regarding treatment or other medical decisions; and 5) sponsoring or conducting educational programs to inform all concerned, including the public, about ethical problems in medicine.No exact count of these committees is available. According to estimates cited by Donald F. Phillips, managing editor of Hospital Ethics, about two-thirds to three-fourths of hospitals with more than 200 beds have ethics committees, as do about one-third of hospitals under 200 beds. He thinks that about half of the 6,000 hospitals in the United States now have working ethics committees.Several journal articles and a court decision in the late 1970s influenced their formation. A 1975 journal article by pediatrician Karen Teel (VII A) urged the use of hospital ethics committees to provide for dialogue in individual care situations as an appropriate sharing of responsibility. Another early article suggested that beyond parents and treating physicians, a "disinterested," mixed lay and medical committee could consider cases about defective newborns to improve the ethical decisionmaking process (VII A, Robertson and Fost, 1976). Three 1977 discussions in the Hastings Center Report highlighted this new concept (VII A, Levine; Shannon; Veatch).Produced at the National Reference Center for Bioethics Literature, Kennedy Institute of Ethics, Georgetown University, Washington, DC 20057. It is supported by funds provided under grant number LM04492 from the National Library of Medicine, National Institutes of Health. Literature available through June 1992 is represented in this Scope Note. [End Page 285]The court decision was the March 31, 1976 ruling by the New Jersey Supreme Court in the Karen Quinlan case. The parents of a young woman in a persistent vegetative state had requested that she be taken off a respirator. The court designated a "prognosis" role for the hospital ethics committee and stipulated that the committee must concur that the patient will never return to a "cognitive, sapient state" before the life-support system can be withdrawn (In the Matter of Karen Quinlan, 70 N.J. 10, 355 A.2d 647, cert. denied sub nom. Garger v. New Jersey, 429 U.S. 922 (1976)). Shortly after the Quinlan decision, Massachusetts General Hospital's Clinical Care Committee created an ad hoc subcommittee (a psychiatrist, a legal counsel, an ICU nurse, an oncologist/internist, a surgeon, and a lay person who had recovered from serious cancer disease) which looked at 15 cases. Based on the subcommittee's success, establishment of a permanent committee to review treatment of the terminally ill was recommended by the critical care committee (VII A, Clinical Care Committee 1976).In its 1984 Baby Doe rules, the federal government recommended establishment of infant care review committees, which promoted the growth of hospital ethics committees (VII C, Povar 1991). In July 1987 Maryland became the first state to require by law that hospitals establish patient care advisory committees to offer advice about choices available in the care of life-threatening illnesses; this requirement was extended to nursing homes in 1990 [codified as amended at Md. Health-Gen. Code Ann. Sections 19-370 to -374 (1990)] (VII C, Hollinger 1991).Recently the role for these committees has been noted in the Accreditation Manual for Hospitals, 1992 Supplement (p. 10, Patient Rights, Section RI. 1.1.6.1) of the Joint Commission... (shrink)

Because most prominent theories of ethical decisionmaking posit that the process begins with anindividual's recognition of the ethical issuesinherent in a decision situation, and is followed bysome degree of individual cognitive processing, theconstructs ethical sensitivity and cognitive moraldevelopment assume great importance in the study ofbusiness ethics. Two recent developments in theethics literature suggest that these two constructswarrant additional examination. First, is the use ofrecognition-based measures of ethical sensitivity;second is the development of a new index for (...) theprincipal measure of cognitive moral development, theDefining Issues Test. In this paper, the authorsexamine issues of nomological validity related tothese two constructs in light of these recentdevelopments. Results of an empirical study showstrong support for the new index of cognitive moraldevelopment, but likely because of samplecharacteristics, support for the ethical sensitivitymeasure is inconclusive. (shrink)

Because of the emphasis on individualism and self-governance, medical interventions and medical research in Western nations are preceded by attempts to obtain informed consent from the individual patient or potential research subject. Individual autonomy expresses our belief that persons are ends in themselves and not merely instrumentalities to achieve the goals of others. By respecting the patient or potential research subject in the context of medical decisionmaking, we acknowledge that these individuals are moral agents. Thus, individual autonomy is an (...) important feature of morality as it is practiced in the West. However, there are at least two circumstances in which individual autonomy appears to be threatened. One is embodied in nonwestern societies that favor collective decisionmaking over that of the individual. The other is related to the need for family histories and family testing to determine the susceptibility of family members to some genetically based disease. In both cases, individual judgment appears to be made subordinate to collective judgment. (shrink)

This book is the most comprehensive treatment available of one of the most urgent - and yet in some respects most neglected - problems in bioethics: decision-making for incompetents. Part I develops a general theory for making treatment and care decisions for patients who are not competent to decide for themselves. It provides an in-depth analysis of competence, articulates and defends a coherent set of principles to specify suitable surrogate decisionmakers and to guide their choices, examines the value of advance (...) directives, and investigates the role that considerations of cost ought to play in decisions concerning incompetents. Part II applies this theoretical framework to the distinctive problems of three important classes of individuals, many of whom are incompetent: minors, the elderly and psychiatric patients. The authors' approach combines a probing analysis of fundamental issues in ethical theory with a sensitive awareness of the concrete realities of health care institutions and the highly personal and individual character of difficult practical problems. Its broad scope will appeal to health professionals, moral philosophers and lawyers alike. (shrink)

This case study focuses on how divergent cultural norms can impact ethical decisionmaking between a superior and subordinate in a high-pressure workplace. In order to ensure that today’s business students adhere to the highest standards of ethical conduct in an international and multicultural environment, it is imperative they recognize and respond appropriately to different cultural views of ethics. In the accompanying case, Jane, a Chinese national living and working in the United States, encounters multiple ethical dilemmas (...) during her employment at TrustUS. Readers are introduced to important cultural factors that differ between Eastern and Western societies and are asked to apply these concepts to gain insight into how cultural background might influence the ethical decision making of a professional in a managerial accounting context. (shrink)

The aim of this study is to investigate the effects of personal values on auditor's ethical decisionmaking in two countries, namely, Pakistan and Turkey. This study is the first that empirically addresses the role of values in the ethical decision-making processes of Pakistani and Turkish Professional auditors. This study surveys a random sample of these countries' professional certified auditors to assess their value preferences and reactions to an ethical dilemma. This study measures practicing auditors' value preferences (...) by using the Rokeach value survey, and a case study is used to measure the reactions to an ethical dilemma involving client pressure for aggressive financial reporting. This study did not find statistically significant difference between the mean values of moral intensity in these two countries. On the other hand, we found statistically significant differences between the terminal and instrumental values of the auditors in the countries studied. This study suggests that perceptions of moral intensity influenced both ethical judgments and behavioral intensions. (shrink)

An emerging literature in behavioral ethicsconceptualizes ethical perception or sensitivity as acritical part of the decision making process. Thisstudy appears to be the first to empirically test thisconcept in organization and management decisionmaking. A measure of ethical sensitivity is developedand tested in a decision making exercise. Subjectsfor the study are 156 students from programs inbusiness management, public administration, andengineering. The relationship of ethical sensitivityto decision outcome is assessed.

The principle of respect for autonomy is increasingly under siege as a valuable component of healthcare ethics. Its critics charge that it has been elevated to a position out of proportion to its contribution, so that the individual's wishes and rights have come to dominate healthcare decisionmaking, while obligations and responsibilities are ignored or devalued. If we are to salvage respect for autonomy we must find a way to reconnect the individual and the community, rights and responsibilities, in the (...) way we think about, discuss, and make healthcare decisions. (shrink)

Initial reflections on ethics, morality, and justice in an adversary system -- Undertaking a case -- Communication and confidentiality -- Loyalties and conflicts of interest -- Who controls the case? How should lawyers and clients share decisionmaking? -- What price truth? What price justice? What price advocacy? -- Tactics, free speech, and playing by the rules -- The special problems of the government lawyer -- The lawyer acting as advisor -- The lawyer as part of the law firm structure (...) -- Mental health, substance abuse, and the realities of modern practice -- The economics of lawyering -- Admissions, discipline, and some other rules of lawyering. (shrink)

This cross-sectional study of three generations of healthcare executives examines whether age cohort is the key determiner of ethical values. Responses to a national survey using the Rokeach Value Survey indicate that, contrary to widely reported beliefs that suggest otherwise, the age cohort groups in this sample exhibit virtually identical value preferences. The concept of career attraction is introduced to explain the similarities in value preference, and it is further suggested that generational differences may be nullified by the homogeneous (...) demands of organizational life in a healthcare setting. Implications for ethical decisionmaking are discussed.Does age cohort affiliation influence healthcare executive values and consequent ethical judgements? The greater body of literature clearly suggests the answer is yes, yet an empirical assessment of the question has never before been reported. The attention given this issue to date has been focused on the generational differences between the three age cohorts in the workplace today: Matures, Boomers, and Generation Xers (1). Defined as a group of people who share a given historical or socially structured life experience, an age cohort is believed to have a relatively stable influence over the decisionmaking of individuals, and serves to distinguish one generation from another (2)(3)(4). Generation X, or GenXers as they are commonly referred to, are comprised of individuals born between 1961 and 1981. Baby Boomers, or Boomers as they are popularly known, are those born between 1943 and 1960. Matures is the name given to characterize the group of people born between born 1925 and 1942. [Birth dates defining generational cohorts vary slightly among multiple sources. The dates used in this study are from Strauss and Howe (1991), though the nomenclature is not.]. (shrink)

Abstract:While the medical ethics literature has well explored the harm to patients, families, and the integrity of the profession in failing to disclose medical errors once they occur, less often addressed are the moral and professional obligations to take all available steps to prevent errors and harm in the first instance. As an expanding body of scholarship further elucidates the causes of medical error, including the considerable extent to which medical errors, particularly in diagnostics, may be attributable to cognitive sources, (...) insufficient progress in systematically evaluating and implementing suggested strategies for improving critical thinking skills and medical judgment is of mounting concern. Continued failure to address pervasive thinking errors in medical decisionmaking imperils patient safety and professionalism, as well as beneficence and nonmaleficence, fairness and justice. We maintain that self-reflective and metacognitive refinement of critical thinking should not be construed as optional but rather should be considered an integral part of medical education, a codified tenet of professionalism, and by extension, a moral and professional duty. (shrink)

Over the past decade or so, the predominant patient-centered ethos in American bioethics has come under attack by critics who claim that it is morally deficient in certain respects, particularly when viewed in the context of acute-care decisionmaking. One line of criticism has been that the current ethic of patient autonomy gives an individual competent patient far too much decisional authority over the terms of his own treatment so that the patient is at complete liberty to neglect the ways (...) in which his medical decisions can drastically and negatively affect the lives of other family members. Given that family members must help shoulder the financial, emotional, and rehabilitative burdens involved in the patient's care, it has been argued that they too have a legitimate interest in choosing what sort of medical treatment the patient eventually receives. Another closely related line of criticism is that the prevailing focus on patient autonomy gives short shrift to the moral significance of the family as a genuine community. Echoing a view of the person advanced by most communitarian political theorists, some commentators have argued that the patient comes to the clinic so thoroughly embedded in a complex web of familial relationships and obligations that it does not make sense to identify him as the only person in the family to make decisions about treatment. (shrink)

Basing itself upon a virtue-ethics approach, this paper questionsthe value of syllogistic or deductive approaches to teachingbusiness ethics and to the modelling of the kinds of judgmentsthat executives are asked to make in situations of moralcomplexity. It urges that the teaching of ethical theories, ofethical principles, and of logical methods of moral thinking, andthe use of hypothetical or historical scenarios, be augmented bythe method of `Real Case Dialogue' which more nearly models thereal and intense existential realities of ethical (...) decisionmaking. A brief description of such a dialogue is offered so asto provide an example. (shrink)

The objective of the paper is to provide a critical exposition of Henry Sidgwick's theory of "proof" in ethics, by means of a restatement and a critique of relevant sections of Book IV of The Methods of Ethics and an article in the 1879 volume of Mind. It is concluded that Sidgwick's thought contains two fundamental unresolved tensions. One of these relates to whether "proof" is to be treated as a normative or an empirical matter. On the one hand, Sidgwick (...) clearly wants to offer a ground for ethics whose epistemic force would be universal; on the other, he accepts Mill's "considerations determining the mind to accept" as a definition. The second unresolved tension relates to the question whether abstract transcendent axioms or the familiar rules of common sense morality constitute the ultimate court of appeal in ethical decisionmaking. (shrink)

There has been increasing interest in developing practical, non-theoretical tools for analyzing ethical problems in public health, biomedicine, and other scientific disciplines so that professionals can make and justify ethical decisions in their own research or practice. Tools for ethical decisionmaking, together with case studies on ethics, are often used in graduate education programs and in continuing professional education. Students can benefit from opportunities to further develop their analytical skills, to recognize ethical issues, and to (...) develop their moral sensitivity. One practical approach for illustrating and facilitating ethical analysis uses cases with contrary facts and circumstances, an approach which complements rather than replaces theoretical approaches to moral reasoning. Cases with contrary facts and circumstances are presented in two or more alternative ways so that the facts, circumstances, or framing of one version runs counter to that of the other version (s). Cases with contrary facts, together with practical steps for identifying and analyzing ethical issues, are likely to be useful tools for illustrating and facilitating ethics analysis and stimulating the moral imagination. (shrink)

Documenting capacity assessments and identifying substitute decisionmakers in healthcare facilities is ethically required for optimal patient care. Lack of such documentation has the potential to generate confusion and contention among patients, their family members, and members of the healthcare team. An overview of our research at the Ottawa Hospital and issues that influence the consistency of documentation in the Canadian context are presented here, as well as ideas for the mitigation of these issues and ways to encourage better documentation.

When talking about decisionmaking for children with a life-threatening condition, the death of children with brain tumors deserves special attention. The last days of the lives of these children can be particularly harsh for bystanders, and raise questions about the suffering of these children themselves. In the Netherlands, these children are part of the group for whom a wide range of end-of-life decisions are discussed, and questions raised. What does the end-of-life for these children look like, and what motivates (...) physicians and parents to make decisions that may affect the life and death of these children? This article highlights the story of the parents of the sisters Roos and Noor. When both their daughters were diagnosed with a hereditary brain tumor, they had to make similar decisions twice. Their story sheds light on the suffering of children in the terminal phase, and how this suffering may motivate parents and physicians to make decisions that influence the end of life of these children’s lives.We argue that complete knowledge about suffering in the terminal phase of children with brain tumors is impossible. However, by collecting experiences like those of Roos and Noor, we can move toward an experienced-based understanding and better guide parents and physicians through these hardest of decisions. (shrink)

Background Working in neonatal intensive care units (NICUs) or pediatric intensive care units (PICUs) entails making difficult decisions about children at the end of their lives that raise significant ethical issues. This review identified the ethical content of the papers containing expert guidelines and recommendations in relation to end-of-life decisionmaking in NICUs and PICUs, by analyzing ethical positions and ethical principles behind them. Methods Systematic search was limited to the period from 1990 to 2023 and (...) encompassed 6 bibliographic databases (Medline, PubMed, CINAHL, APA PsycINFO, Web of Science Core Collection, and Scopus), grey literature sources and relevant reference lists. The international, national, or institutional papers providing expert guidelines and recommendations comprehensively addressing either withholding/withdrawing of life sustaining treatment, palliative care, and/or intentional life terminating actions in NICUs and PICUs were included in analysis. Also, only papers published in English language were considered. Papers that were not developed by intensive care expert communities and those that were either too narrow (e.g., dealing with specific issues or specific patient groups) or broad (e.g., addressing issues of interest on general and abstract level) were excluded. The search data were gathered and deduplicated, partly by Mendeley software. Titles and abstracts were screened by three independent reviewers, and full-text papers further reviewed and assessed for eligibility. Subsequently, data of interest were extracted, and qualitative analysis was performed. Results Initial search retrieved 6784 papers from bibliographic databases and 363 from other utilized sources. Titles and abstracts from 2827 papers were screened. 17 full texts were further assessed resulting in a total number of 9 papers (6 from bibliographic databases and 3 from other sources) which met the inclusion criteria and were included for analysis. The papers were published from 2001 to 2021. Four papers primarily focus on NICU setting, while five on PICU. A total of 38 ethical positions were identified and were grouped under 5 themes according to the content of the positions, relating to: patients, parents, medical team, decision-making and treatment options. A total of 12 ethical principles were mentioned in the papers. The principle of beneficence emerged as the most prominent one. It was explicitly mentioned in all included papers except one. (shrink)

The purpose of this paper is to highlightthe complexities in making decisions in an ethical wayevidenced by the current dispute over native landrights in contemporary Australia. The caseillustrates an example of a moral issue that involvesmaking a management choice. One approach which givespractice in four questions that the managementpractitioner can ask when faced with a moral dilemmais described. The case involves an on-going situationin which the Australian Government was faced withsupporting the land claims of either indigenousgroups or land holding (...) pastoralists. TheGovernment, therefore, was on the horns of a classicdilemma, having to decide between two groups eachseeking `justice' and `fairness'.The paper refers to contemporary authorities such asRawls, De George, Paine and Badaracco (Jnr). In thecontext of ethical decision making, the main eventsleading to the present dilemma are presented. Thecase study includes a summary outlining the AustralianGovernment's Ten Point Plan response to thedilemma and a summary of the perceived problems forbusiness development where native title is recognised. These can be used to provide students in businessethics classes with an opportunity to recognise anddebate the rights, wrongs and complexities of moralissues as well as appropriate managerial decisionmaking. (shrink)

:In this paper, the author argues that Joseph Fins’ mosaic decisionmaking model for brain-injured patients is untenable. He supports this claim by identifying three problems with mosaic decisionmaking. First, that it is unclear whether a mosaic is a conceptually adequate metaphor for a decisionmaking process that is intended to promote patient autonomy. Second, that the proposed legal framework for mosaic decisionmaking is inappropriate. Third, that it is unclear how we ought to select patients for participation in (...) mosaic decisionmaking. (shrink)

The major dilemma for bioethics is choosing an appropriate method of ethical analysis, one that when applied to individual cases can illuminate if not resolve vexing ethical issues for providers and their patients. Two of these books offer direction in this regard. The framework Carson Strong adopts and makes a compelling case for in EthicsinReproductiveandPerinatalMedicine:ANewFramework is one of modified casuistry. Casuistry, imported to bioethics by Jonsen and Toulmin, is a practical, case-based method of ethical decisionmaking. It (...) relies on comparison between moral factors in a case under consideration and in paradigm cases with justifications for different outcomes. The preferred course of action is the one warranted by the paradigm case that most resembles the case under consideration. Strong's framework is a modified form of casuistry because it takes into account social and political views and allows for, upon occasion, a prioritization of values across cases. (shrink)