Ethics in Patient Care, Vol 10, Issue 3

Good care is the reflection of care ethical. To improve the ethical quality of care, moral behavior is needed in addition to law and regulation. Personal involvement and motivation of care providers are considered an important element of good care. Thus, health care provider must change their perspective. Their education on medical ethics needs to be more practical oriented rather than theory. In addition, ethical reflection is contextual and experiential learning process. Bioethics training must be needed to foster inter alia and moral power of imagination of care providers.

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

Previous articleNext article FreeIntroductionIntroduction: The Journal of Clinical Ethics, the MacLean Center, and the Future of Clinical EthicsPeter AngelosPeter Angelos Search for more articles by this author PDFPDF PLUSFull Text Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinked InRedditEmailQR Code SectionsMoreBeginning with the current issue, and after 33 years, the publication of The Journal of Clinical Ethics (JCE) has moved from the capable hands of founding publisher and executive editor Norman Quist to the University of Chicago Press, and it is now published on behalf of the MacLean Center for Clinical Medical Ethics. The MacLean Center was founded in 1983 by Mark Siegler with the generous support of his patient Dorothy J. MacLean and her family. The MacLean Center was the first ethics center to focus squarely on ethical issues at the bedside. It is not surprising that as one reads through early issues of JCE, Mark Siegler and many of his colleagues from the MacLean Center were regular contributors. As the scope of JCE has expanded over the years, so has the scope of inquiry of the faculty and fellows of the MacLean Center.A Reflection on the Journey in Clinical EthicsAs I assume the position of director of the MacLean Center and stewardship of JCE, I have been reflecting on the journey and the future of clinical ethics. Thirty-eight years ago, I entered graduate school to begin doctoral studies in philosophy. It was a big change for me after spending the prior two years in medical school in the traditional preclinical medical curriculum. For those who have not experienced how medical school courses were taught in the first two years back then, most of the day was spent in hours of lectures in anatomy, physiology, biochemistry, histology, pathophysiology, and so on. Most of the time outside of the lecture hall was spent in anatomy labs or other labs learning what the structures look like and memorizing large lists of essential facts. After two years of such a rigorous medical curriculum, the graduate curriculum in philosophy was diametrically different. Although equally intellectually rigorous, graduate studies in philosophy challenged a different part of my brain. Through the talents of many philosophy professors, I explored topics in metaphysics, epistemology, and ethics. Many of these courses were designed to help students think about the world differently. The life of the mind, as opposed to solutions of practical problems, was emphasized.As I sought to find a value in my time studying philosophy, it was not surprising that I gravitated to applied ethics, since I believed that medical ethics would be most applicable to my ultimate desire to become a practicing physician. What I was not fully aware of at that time was the shift in the theoretical analysis of ethical problems in medicine toward a more practical application of ethical analysis to try to solve clinical medical problems. Only many years later did I recognize the impact of this practical turn in medical ethics. Rather than focusing so much on the analysis of concepts of health and disease (that is, questions such as “How do we define illness?”), the practical shift in ethics was a move to make ethical analysis helpful in answering what to do for a specific patient. Clinical ethics was the term applied to the move from theoretical ethical issues to the “bedside” issues of what to do for a specific patient. It was to fill the void in this new area of applied ethics scholarship that JCE was started.The Novelty of Clinical EthicsIn the spring of 1990, volume 1, issue 1 of JCE was published. This new journal was novel in its unabashed focus on the ethical issues that arise in the care of patients. JCE was focused not on scholarly work in “armchair ethics” (i.e., the theoretical exploration of ethical views), but rather on the application of ethical inquiry to solve problems “at the bedside” to help clinicians and patients. As editor in chief, Edmund G. Howe wrote in 1990, “The journal should have two goals: to provide state-of-the-art information to front-line practitioners and to advance the field.”1The novelty of this approach in 1990 ought not be taken for granted. Although ethics was a central area of philosophical inquiry, applied ethics was, in many philosophy departments, considered to be too practical and pragmatic and thus not amenable to rigorous philosophical analysis. JCE sought to elevate the ethical issues faced by physicians and patients to a new level of discourse where thoughtful people could learn from the analyses of others.What Clinical Ethics WasIn the early days of clinical medical ethics, the primary focus of attention was the clinical encounter between the doctor and the patient. Certainly, many patients, especially near the end of their lives, were not able to participate in decision-making with physicians. As a result, it was immediately apparent that the attention of clinical medical ethics had to include not only the patient and the physician but also the family or surrogates to make decisions for patients when the patients were not able to do so themselves.Some selected titles from the early volumes of JCE make clear the journal’s attention to the ethical dimensions of the clinical encounter. Jeffry R. Botkin wrote “Delivery Room Decisions for Tiny Infants: An Ethical Analysis,”2 and Susan S. Braithwaite and colleagues wrote “The Ethics of Surreptitious Diagnostics for Factitious Hypoglycemia,”3 just to name two of many early examples. These articles explored ethical topics in the actual care of patients and were designed to help clinicians think about them more clearly and thus improve patient care. As one looks back at many of these early papers in JCE, one sees a common thread in identifying a set of challenging patient care decisions and recasting the issues raised as ethical issues. These many thoughtful early attempts at defining and unpacking “tough cases” as ethically challenging were instrumental in leading scholarship and establishing a method of analyses in clinical medical ethics.Over time, JCE also became an important place to publish empirical research that helped to inform the ethical issues arising in caring for many patients. For example, Janet M. Teno and colleagues wrote “Do Formal Advance Directives Affect Resuscitation Decisions and the Use of Resources for Seriously Ill Patients?”4 and Lawrence J. Schneiderman and colleagues wrote “Attitudes of Seriously Ill Patients toward Treatment That Involves High Costs and Burdens on Others,”5 both in 1994. Although these and other empirical studies did not use evidence to answer what was the “right” thing to do, they nevertheless clarified, and sometimes challenged, many of the assumptions about how patients and their surrogates actually made medical decisions.Early on, it became clear that clinical ethics could not be focused solely on physicians and patients/surrogates. In fact, there were many other “clinicians” involved in the care of patients. Nurses, therapists, medical assistants, social workers, ethics consultants, chaplains, and others interacted in meaningful ways with patients. Thus, the scope of inquiry of clinical ethics necessarily had to include these many other care providers who were involved with patients and part of the “clinical” team.Over time, it was also evident that clinical ethics could not focus solely on what happened in the patient’s room with the clinical team. Whether in the inpatient or outpatient setting, patients, families/surrogates, and clinicians were always interacting within a healthcare delivery environment and system that had a powerful impact on care: how decisions were made and who made them. Consequently, it became clear that questions of health policy were also frequently central to clinical medical ethics, and the scope of the field expanded accordingly.Most commentators in clinical ethics would argue that societal issues are also central to the field of clinical ethics. If anyone were to doubt this assertion, the events of the last two and a half years as the world has responded to the COVID pandemic have clearly shown that patients are cared for within individual societies, and the political and social issues that impact public policy also can dramatically impact the care of individual patients. Although years ago many clinicians who worked in resource-rich environments would have argued that rationing and other challenging decisions about allocating scarce resources were not central to clinical ethics (except perhaps in organ transplantation), we now all clearly see that the decisions about how we allocate resources are important in all societies and thus central to the concerns of clinical ethics.Contemporary Perspective on Clinical EthicsIn view of the broadening scope of clinical medical ethics over the past several decades, one can appropriately ask where the future of clinical ethics analysis is headed. Although none of us are good at predicting the future, many signs suggest that the scope of clinical ethics will continue to expand in response to “hard questions” and societal changes. Central to the future of clinical ethics will be not only a renewed engagement with some long-standing topics but also an openness to recognizing and exploring new territory and, in some instances, to navigating territory we have missed:1. How does racial and gender bias impact patient care?2. How can medicine overcome years of structural racism?3. How can disparities in access and outcomes be mitigated?4. How does the organization of a health system encourage or discourage meaningful interactions between clinicians and patients?5. In what ways does the country or clinical environment in which care is rendered affect the decisions that patients and clinicians make?6. How ought decision-making for individual patients be influenced by global climate change?The list above is not exhaustive but representative; it hints at the broad range of questions that scholarship and practice in clinical ethics must attend to in the future. All the issues noted above (and certainly many others) may be conceptualized in the realm of clinical ethics insofar as the decisions made (or deferred) will impact the care and outcomes of individual patients. Clinical ethics is about what ought to be done. Thus, although a purely theoretical analysis of gender bias, for example, has value, the extent to which the analysis affects individual patients and the decisions that are made by and on behalf of individual patients and families makes these topics central to clinical ethics.The Compelling Question of Clinical EthicsThe contemporary practice of medicine in complex systems within numerous societies in this interconnected world that we now live in requires us to adopt a more expansive view of clinical medical ethics than early proponents of the field might have considered. We are challenged to focus on how the decisions we make on multiple levels of healthcare impact the outcomes of patients. The goal of clinical ethics ought to be the improvement of the care of patients regardless of where among the many levels of a system the changes are being made.In the Summer 2015 issue of JCE, editor in chief Edmund G. Howe wrote the first of an ongoing series of commentaries entitled “At the Bedside.”6 This regular column of JCE that continues today exemplifies the central focus amid the large set of topics appropriately within the field of clinical ethics—namely, those items that have an impact on the patient.The MacLean Center and The Journal of Clinical EthicsHow will the acquisition of JCE by the University of Chicago Press and the new partnership with the MacLean Center for Clinical Medical Ethics affect the journal? I am hopeful that this collaboration will lead to significant advantages on both sides. We are very fortunate that Edmund G. Howe and Norman Quist will continue their central involvement in the journal. The high journalistic standards of double-blinded review of manuscripts will allow the editors and editorial board to continue to actively engage with authors to bring both important cases and analytical and empirical studies in the broad field of clinical ethics to the readers of JCE. Over the ensuing issues, readers will see changes in the editorial board, for example, as I discuss with my colleagues how to take full advantage of JCE to further the work and goals of the MacLean Center. The goal of broadening and strengthening scholarship and discussion in a broad range of areas of practical significance for patient care will remain central to the mission of JCE.In the years ahead, the MacLean Center will continue its important mission of training healthcare providers in clinical medical ethics to improve patient care. It will continue to focus on increasing the scholarship in clinical medical ethics and disseminating that scholarship widely to improve outcomes for patients. Just as JCE has broadened its scope of attention as the field of clinical ethics has grown, so has the MacLean Center widened its purview to address the many ways in which patient care is affected by the multiple levels on which decisions are made. In the years to come, the MacLean Center will continue to address new problems that affect patient care not only in the United States but throughout the world. The MacLean Center faculty will strive to increasingly engage in an interdisciplinary fashion with clinicians and scholars across the globe to improve the care of patients.ConclusionsThe scope of clinical ethics has broadened over the past 35 years. In that time, JCE has expanded its purview, and the MacLean Center has similarly expanded its scope of concern. In the first issue of JCE in 1990, Mark Siegler, Edmund D. Pellegrino, and Peter A. Singer wrote, “When we review the field of clinical ethics a decade from now, we hope that the focus will have shifted from ethics courses, committees, and consultants to an understanding on the part of most physicians and medical students that ethics is an inherent and inseparable part of good clinical medicine.”7 I believe that medical education and the practice of medicine today clearly acknowledge that ethics is essential to outstanding patient care. However, a continued focus on distinctive ethical issues in patient care remains warranted to ensure that we recognize new issues as they arise and equip clinicians and patients to address them in a thoughtful and ethical manner.In the decades to come, we hope that the formal collaboration between JCE and the MacLean Center will improve the care of patients and increase the level of scholarship in clinical ethics in the United States and internationally. Our goal will be consistent with that articulated in the first issue of JCE in 1990: “there should be a journal applying medical ethics to clinical practice primarily for care providers.”8 Although JCE will strive to engage medical ethics scholars and practitioners in thoughtful debate about substantive issues, it will also continue to focus on being valuable to clinicians, regardless of their discipline or type of clinical practice. Both JCE and the MacLean Center will continue to be guided by the very practical goal of clinical ethics: to improve the outcomes of patients and, in so doing, improve the world we live in.Notes1. E.G. Howe, “The Journal of Clinical Ethics: Genesis, Purposes, and Scope,” Journal of Clinical Ethics 1, no. 1 (Spring 1990): 3–4.2. J.R. Botkin, “Delivery Room Decisions for Tiny Infants: An Ethical Analysis,” Journal of Clinical Ethics 1, no. 4 (Winter 1990): 306–11.3. S.S. Braithwaite et al., “The Ethics of Surreptitious Diagnostics for Factitious Hypoglycemia,” Journal of Clinical Ethics 1, no. 2 (Summer 1990): 116–21.4. J.M. Teno et al., “Do Formal Advance Directives Affect Resuscitation Decisions and the Use of Resources for Seriously Ill Patients?,” Journal of Clinical Ethics 5, no. 1 (Spring 1994): 23–30.5. L.J. Schneiderman et al., “Attitudes of Seriously Ill Patients toward Treatment That Involves High Costs and Burdens on Others,” Journal of Clinical Ethics 5, no. 2 (Summer 1994): 109–12.6. E.G. Howe, “How to Retain the Trust of Patients and Families When We Will Not Provide the Treatment They Want,” Journal of Clinical Ethics 26, no. 2 (Summer 2015): 89–99.7. M.S. Siegler, E.D. Pellegrino, and P.A. Singer, “Clinical Medical Ethics,” Journal of Clinical Ethics 1, no. 1 (Spring 1990): 5–9.8. Howe, “The Journal of Clinical Ethics,” see note 1 above, p. 3. Previous articleNext article DetailsFiguresReferencesCited by Volume 34, Number 1Spring 2023 Published on behalf of the MacLean Center for Clinical Medical Ethics Article DOIhttps://doi.org/10.1086/723843 © 2023 The University of Chicago. All rights reserved.PDF download Crossref reports no articles citing this article.

Background: Ethical care is concerned with aspects of work that may influence nurses’ ethical behavior. Intensive care units might expose nurses to moral judgment while caring. This qualitative study aimed to explain the nurses’ experience of moral judgment in intensive care units. Methods: The present qualitative study was conducted using the conventional content analysis method. The participants of the study included 23 nurses working in the intensive care units (ICU, CCU, NICU) of four hospitals affiliated with Sabzevar University of Medical Sciences who were selected using purposive sampling. The data were collected through semi-structured interviews. The questions asked in the interviews included, "Would you please describe one working day of yours caring in the intensive care units?" and "While caring, did you have to hesitate to make a decision ethically? If yes, would you describe that situation?" The Data were analyzed using the qualitative content analysis method proposed by Graneheim and Lundman. Results: Data collection and analysis led to the identification of 1 theme, 6 categories, and 23 subcategories. The identified theme was "intensified tension and conflict following ethical patient care in the intensive care units" and the categories were "repeated exposure to stress in ethical patient care in the intensive care units", "ethical care originated from the nurses’ beliefs", "moral judgment in care affected by the patient’s clinical condition", "moral judgment as a consequence of clinical judgment", "ethical care based on organizational and legal conditions in the moral environment", and "requirements of ethical care". Conclusion: The nurses in the intensive care units deal with ethical issues and are under a lot of stress. The results of this study can help nursing authorities pay more attention to developing ethical knowledge and ethical considerations in hospitals and provide organizational support to identify the moral tensions of nurses in intensive care units.

Since the publication of Carol Gilligan's In a different voice in 1982, there has been much discussion about masculine and feminine approaches to ethics. It has been suggested that an ethics of care, or a feminine ethics, is more appropriate for nursing practice, which contrasts with the 'traditional, masculine' ethics of medicine. It has been suggested that Nel Noddings' version of an 'ethics of care' (or feminine ethics) is an appropriate model for nursing ethics. The 'four principles' approach has become a popular model for medical or health care ethics. It will be suggested in this article that, whilst Noddings presents an interesting analysis of caring and the caring relationship, this has limitations. Rather than acting as an alternative to the 'four principles' approach, the latter is necessary to provide a framework to structure thinking and decision-making in health care. Further, it will be suggested that ethical separatism (that is, one ethics for nurses and one for doctors) in health care is not a progressive step for nurses or doctors. Three recommendations are made: that we promote a health care ethics that incorporates what is valuable in a 'traditional, masculine ethics', the why (four principles approach) and an 'ethics of care', the 'how' (aspects of Noddings' work and that of Urban Walker); that we encourage nurses and doctors to participate in the 'shared learning' and discussion of ethics; and that our ethical language and concerns are common to all, not split into unhelpful dichotomies.

The possibility of medical-moral controversy in contemporary health care delivery is occasioned by the interfacing of expanding technology with both professional and personal value systems, frequent and significant knowledge deficits on the part of health care consumers, and increased circumspection of and economic constraints experienced by health care providers. Particularly in an era of increasing regulatory mandates and the frequent and lamentable decrease in the availability of human, natural, and institutional resources, an understanding of the function of ethical analysis is indigenous to care, which is simultaneously medically appropriate and morally indicated. But while a familiarity with and an appreciation of the potential contribution of ethical reasoning is essential in all health care delivery, it assumes critical importance in supportive care. In that venue, where the rigors and demands of aggressively therapeutic interventions have ceased and the goal and the demeanor of care have shifted to the palliative mode, heightened attention to the principles of medical ethics is necessary for the balancing of rights and responsibilities for health care consumers and providers alike. This issue ultimately can be singularly salient in providing care that is patient centered and directed. Individuals acting as moral agents, suggesting what "ought" to be done in a given situation, either for themselves or as they are involved in rendering or supporting decisions proffered for or by other moral agents, particularly those in extremis, those in the throes of terminal illness following the collapse of the curative mode, need recourse to principles to facilitate their reasoning. Although the employment of each principle of medical ethics offers guidelines for reflection on the most comprehensive and appropriate care, it is attention to autonomy, informed consent, and beneficence that promotes the most effective supportive care. For even as the question of medical viability is settled in favor of palliation over aggression, there remain the entanglements of psychological stability, conflicting value systems, and the impact of the social milieu as well as the issues of economic responsibility and resource accountability. It is in the attention to the medical ethical principles of autonomy and informed consent, especially as amplified by the creation of and respect for advance directives, that the most holistic and productive supportive care can be offered. It is also in this posture that appeal to the principle of beneficence is made. Just as the progress of disease and, therefore, the realistic goals of care change, so too can an individual's considered opinion with regard to end-of-life decisions. Preserving the integrity of patients and caregivers alike and engaging in fruitful and informative dialog prior to seeking volitional authorization or operationalizing a supportive approach demonstrates renewed concern for both patient autonomy and professional accountability in the provision of a comprehensive end-of-life care plan. Discussions will not be avoided until they can no longer effectively take place, salient questions will not go unanswered, and decisions around end-of-life questions, in the mode of supportive care, will not be absent where care was exercised to engage patients in significant dialog earlier rather than later in their disease processes.

The marketing of health care services raises the Prospect that an ethic of will govern relations between providers and patient& A fiduciary model that emphasizes honesty and public accountability, as well as the patient's good and avoiding unnecessary services, keep marketing consistent with the ethical tradition of medicine. The natural limit to any person's moral universe, for Tolstoy, is the distance he or she walk, or at most ride. By taking the train, a moral agent leaves the sphere of truly moral actions for a world of strangers, toward whom he or she has few real obligations and with whom dealings be only casual or commercial.' For hospitals, physicians, and patients, the times. are more than a'changing. The American health care system is undergoing an economic revolution.2 Fewer patients, fewer occupied acute care beds, and fewer reimbursement dollars have converged to push health care providers from peaceful coexistence into outright competition. Hospitals and physicians, to remain competitive, are now marketing their services like commercial sellers. We believe it is time to evaluate health care marketing from an ethical perspective. Health care marketing raises the fundamental questions of whether caring for the sick is actually just another commercial endeavor to be sold effectively and profitably to the public and whether the conduct of health care providers should be governed by the same basic ethical values that apply to any other business. Put differently, should health care providers take the train to a world where providers and patients are whose obligations to each other are few and whose dealings can be only casual or commercial? A Moral Exemption for Business? All human activity is subject to ethical evaluation. Any human act violate someone's rights, show disrespect for persons, or have harmful consequences for the agent or others. At a minimum, an of strangers applies to all equally with attendant basic obligations that are limited, anonymous, and chiefly negative: namely, not to act offensively, violently, or deceitfully. Persons conducting business are subject to the same negative moral obligations as everyone else.4 PoSitive ethical obligations, such as doing good by donating money to charity or maximizing shareholders'interests, may govern business activity, but their applicability is controversial. It is unarguable, however, that all persons, including those conducting business, are ethically obligated to refrain from fraud, coercion, violence, or otherwise doing harm to others. Assuming that basic moral obligations are met, it is not unethical for a business to conduct arm'slength transactions with under the assumption that both parties are (more or less) independent, equally positioned, and admittedly self-interested individuals who decide for themselves the value of the commercial transactions they make. Nor is it intrinsically unethical for a business to sell a product by intentionally associating it with a desirable extrinsic feature: for example, linking possession of a certain object (a sports car) with romantic or sexual success. (Such promotion is perhaps open to question as to whether it intentionally deceives consumers.) There is no special relationship between a business and its customers that generally obligates the former to comply with greater or higher ethical duties than those imposed by the common ethics of strangers. Health Care Providers, Patients, and Ethics We will use the term provider to include both individual persons and corporate institutions that provide health care services to patients. The basic ethical obligations of all providers are similar because all are engaged in the special activity of caring for patients. Furthermore, the status of health care institutions as for-profit or not-for-profit entities does not affect the ethical obligations imposed upon them insofar as they all hold themselves out as caring for patients. …

Cultural beliefs significantly influence perceptions of health, illness, and care delivery, impacting medical ethics and patient care. These beliefs often intersect with core ethical principles such as autonomy, beneficence, non-maleficence, and justice, creating complexities in clinical practice. Autonomy, commonly emphasized in Western medical ethics, may conflict with cultural norms that prioritize collective decision-making, particularly within family-centered cultures. Similarly, practices surrounding end-of-life care, reproductive health, and traditional healing reflect the profound influence of cultural frameworks on patient choices and healthcare provider actions. The tension between cultural sensitivity and medical ethics often arises when cultural practices conflict with evidence-based medicine. For instance, preferences for non-disclosure of diagnoses in certain cultures challenge principles of informed consent, while requests for life-prolonging treatments can create ethical dilemmas around non-maleficence. Language barriers and institutional policies further compound these challenges, highlighting the importance of integrating cultural competence into healthcare systems. Effective strategies for integrating cultural competence include targeted training programs for healthcare providers, fostering workforce diversity, and developing inclusive institutional policies. Community engagement and culturally tailored interventions have shown bridges in understanding and improve patient-provider relationships. Technology, such as culturally adapted telemedicine platforms, further enhances accessibility and equity in care delivery. Addressing these complexities requires a systemic approach to align care delivery with patients’ cultural values while maintaining ethical integrity. Prioritizing cultural competence fosters trust, enhances communication, and supports equitable healthcare outcomes across diverse populations. By acknowledging and addressing the influence of cultural beliefs, healthcare systems can navigate ethical challenges effectively, ensuring patient-centered care that respects individual and collective values.

BACKGROUND AND OBJECTIVESLittle is known about the implementation of the patient bill of rights (PBR) in Saudi Arabia. Therefore, this study was conducted to explore to what extent health care recipients and providers know about the bill and its implementation.DESIGN AND SETTINGA cross-sectional survey conducted on health care professionals and patients at Primary Health Care Centers in Riyadh, Saudi Arabia, during July 2010.PATIENTS AND METHODSThe study employed a self-administered questionnaire to collect data from 500 patients (aged 18 years or older) and 500 health care providers (physicians and nurses) in primary health care (PHC) centers in Riyadh. Data was collected on the respondents’ knowledge of the existence and contents of the bill, the extent to which the bill is implemented, and the obstacles that may hinder bill implementation. The data was analyzed and presented in a descriptive fashion.RESULTSMore than three quarters of patients and one third of PHC providers did not know about the existence of the bill. Among those who knew about its existence, about three quarters of patients and almost half of PHC providers had little (or very little) knowledge about the bill contents. In general, patients scored lower means of perception than PHC staff about the implementation of the bill’s aspects. PHC staff reported several obstacles that may hinder the implementation of the PBR in Saudi Arabia.CONCLUSIONSPatients and health care providers lack necessary knowledge about the PBR. More dissemination of information about the bill, taking into account the particularities of the Saudi population is needed. Future research is required to establish measures that are effective in ensuring that patients rights are ensured.

Background:Despite the existence of ethical codes in the clinical environment, the rate of unethical behaviors in practice is alarmingly high today. An exploration of the experiences from multiple perspectives (patients, patients’ companions, and different groups of care providers) can result in a more comprehensive and holistic understanding of the concept of ethical behaviors toward patients. The present study was conducted to investigate the experiences of patients, patient companions, and care providers with ethical and unethical behaviors toward patients using a qualitative study.Materials and Methods:This was a qualitative study with a conventional content analysis design. The setting of the study was different departments of teaching hospitals in Shiraz, Iran. The participants consisted of 25 individuals: nine patients, three patient companions, and 13 healthcare providers. The subjects were selected via the purposeful sampling method until data saturation was reached. Data were collected through face-to-face, in-depth, and semi-structured interviews and observation from March 2022 to April 2023. Data analysis was performed using MAXQDA.Results:Analysis of the data resulted in three main categories: respect for human dignity (seven subcategories), professional duty of care (five subcategories), and effective interaction (four subcategories).Conclusions:The findings of the present study stress the need for on-the-job training programs for healthcare providers to raise their awareness of the role of ethical behaviors in caregiving. Establishment of clinical ethics committees and arrangement of ethical rounds with doctors and nurses can promote ethical behaviors in clinical environments.

Reply by Carol Gilligan

Bunk beds with dirty, cigarette scarred mattresses blocked windows. Mold stained the ceiling of a bathroom at New Lots… Some homes had broken sinks, holes in the wall… bed bugs crawling on walls and beds. [1] Yury Baumblit and his company Back on Track Group featured in a recent exposé by the New York Times violated the central tenet of medicine and patient care: do no harm. It may be easy to view the current investigation as a microcosm of exploitation and corruption—a law enforcement issue not indicative of a flaw in the larger system. In reality, there has been a recent epidemic of kickback schemes and assistance program fraud. [2],[3] A larger issue is at stake with shifts in healthcare administration to outpatient settings. Under the new Affordable Care Act (ACA), Ascension Health, a Catholic healthcare provider has reported growth in Medicaid revenues from outpatient care outpacing increases from inpatient revenue, which suggests increased Medicaid outpatient demand.[4] The estimated 30 million newly insured people under the ACA are expected to increase outpatient visits by 2.6% nationwide under the ACA, while the overall volume of Medicaid beneficiaries increased by 15% from July through September 2013. [5],[6]The dominant trend in health care delivery is decentralization into primary care clinics, extended-care facilities, nursing homes and specialized treatment facilities (such as Mr. Baumblit’s New Lot homes). Less attention has been paid to ethical challenges in these settings because the cases often lack the drama and urgency common to inpatient care. Ethics consultations are infrequent and the moral questions are minute: requests for unneeded services, non-compliance etc.Clinical ethics, known for addressing flashy cases, arose in the moral vacuum of the 1970’s. The alliance between patients and physicians had been weakened and trust in the medical guild eroded due to entrenched paternalism. Hard-fought mandates protecting patient autonomy and novel ethical principles (non-malevolence, beneficence etc.) stood to prevent abuses. The hospital setting served as the primary incubator for the norms of bioethics. These practices, however, did not translate to the outpatient setting.[7] Structural constraints and lack of ethics resources make traditional, ethics board review and legal intervention seem cumbersome and costly. Thus, a lack of regulatory oversight coupled with an absence of an ethical framework left a void to be filled by unscrupulous entrepreneurs. Rather than attending to the impoverished, the current system incentivizes waste and encourages treating patients as commodities. Kim Barker’s investigation deals with the most invisible, vulnerable population in the United States: patients suffering from drug addiction. She uncovers a slue of ineffective bureaucracy and a network of scammers associated with Mr. Baumblit involved in Medicaid and disability fraud. The unregulated, “hands-off” environment, contributing to the development of the private, for-profit residences known as “three-quarter houses” (a term derived from being in between a halfway home and the street), has a long history. In the fall of 2008, Mayor Michael Bloomberg announced a 51% reduction in overnight shelter capacity.[8] Options for individuals struggling with homelessness was drastically reduced, which forced many to exchange their “shelter allowance” paid for by the NYC Human Resource Administration for bunk space in three-quarter homes. Operators of these houses profit by neglecting maintenance and almost 90% of suspect addresses had a building code complaint between 2005 and 2012 resulting in a violation.[9]Remind you; these statistics include only documented cases. Three-quarter homes are also allegedly responsible for flagrant violation of tenant rights. According to patient testimonial, landlords illegally evict inhabitants who do not report to mandatory substance abuse treatment. Drug users are among the most socially despised members of society. Their illicit activity, however, does not justify obviating their right to informed consent. The essential moral function of outpatient addiction treatment facilities should be reintegration of outcasts into society rather than subjecting them to a continuous cycle of relapse for the sake of profit. Christopher Vogt, a Professor of Theology at St. John’s University, argues that society ought to view the addict as a ‘neighbor’ and has a moral imperative to participate in harm-reduction.[10] The issue of funding outpatient facilities or even properly regulating addiction treatment with taxpayer dollars is politically tenuous. Since the 1980’s, New York City has undergone substantial changes in legislation leading to the promulgation of three-quarter houses. Patients in public mental health facilities were deinstitutionalized and the City phased out Single Room Occupancy Hotels while prison populations expanded significantly.[11] The Department of Homeless Services until 2009 responded by outsourcing to unregulated homes by offering rent vouchers.[12] Government officials are reluctant to expand the already taxed shelter system because of its dangerous reputation. The policy hurdles are apparent and the situation seems bleak—only after a New York Times published its investigation did Mayor de Blasio follow-up with his own. In order to shape an appropriate solution an ethics for outpatient care must be envisioned. The crucial issue for further scholarly discussion is whether clinical ethics can be adapted to the outpatient setting. Bioethics is best designed to resolve conflict and address questions in a resource-rich environment. How will our moral considerations need to change to create ethical policy for vulnerable populations? Caregiver disloyalty, for-profit care and the consequences of outsourcing are just a sampling of the problems that will need to be addressed in the coming years. Fraud arises when the system allows for it and can be prevented by restructuring incentives. In 2011, the Centers for Medicare & Medicaid Services (CMS) announced that it would be phasing out the “pay and chase” model: claims are paid within 30 days before investigating for inappropriate billing.[13] If providers’ claims are analyzed and audited before payment is made for services, revenue flow to physicians or treatment facilities involved in fraud and abuse can be pre-emptively detected. This may imply even greater compliance issues for outpatient facilities with greater scrutiny and larger costs. However, the economics are more complex. The Obama administration reported that for every dollar spent investigating health care fraud and abuse from 2011-2013 resulted in a recovery of $8.10.[14] A comprehensive law enforcement action lead by Mayor DeBlasio against three-quarter homes might prove to have latent economic benefits for the City. Public assistance programs must be given the proper funding to implement treatment for stabilization and reintegration. Successful programs do exist. Utah has reduced chronic homelessness by 72 percent since 2005 through extensive collaboration between community service partners and by providing permanent supportive housing.[15] In-home counseling for drug addiction and unemployment has been highly effective. New York City ought to take note and respond to exploitation by three-quarter homes with an ethics of care and empathy.

Lessons from the Holocaust for perinatal care today.

Confidential health care for adolescents: position paper of the Society for Adolescent Medicine

Ethical care involves respecting human values, professional conscience, cultural and religious beliefs, personal appearance, confidentiality, and providing high-quality nursing services. In pediatric wards, ethical challenges are often more intense and complex than in adult care, which can increase the risk of neglecting the rights of children and their families. To address this, healthcare centers employ various methods to enhance ethical care. Since there is little research on ethical pediatric care in Gorgan, northern Iran, this study aims to evaluate Ethical Pediatric Nursing Care and Associated Factors among Nurses in Pediatric. This cross-sectional study was conducted in 2024 among 133 nurses working in pediatric and neonatal departments in Specialized Children’s Educational and Therapeutic Center in Gorgan. According to the sampling framework and the estimated number of participants from each section, participants were selected through simple random sampling. Data were collected using a demographic-professional characteristics questionnaire and the Children’s dimensions Ethical Care Questionnaire developed by Khalili et al. (2023). Data analysis was performed using SPSS version 26 with Mann–Whitney U and Spearman correlation coefficient tests. A p-value of < 0.05 was considered statistically significant. The mean age of the participants was 35.30 ± 8.73 years. The mean total score of pediatric ethical care was 162.19 ± 14.39, which indicates a desirable level. Among the dimensions, the lowest and highest mean scores were observed in welfare needs (3.97 ± 0.86) and medical needs (4.53 ± 0.42), respectively. Pediatric ethical care was significantly associated with several personal and professional characteristics of nurses, including gender (p = 0.001), work shift (p = 0.042), job title (p = 0.025), employment type (p = 0.007), age (p = 0.001), and work experience (p = 0.001). Although pediatric nurses generally provided good ethical care, more attention is needed to address children’s welfare needs. Nurses should focus more on supporting the welfare of hospitalized children and infants, respecting their rights. Training programs targeting these areas are recommended to improve nurses’ performance.