Medical Ethical Decision-making Research Articles

To withhold resuscitation – The Swedish system’s rules and challenges

The aim of this article is to describe current Swedish legalisation, clinical practice and future perspectives on the medical ethical decision “Do-Not-Attempt-Cardio-Pulmonary-Resuscitation” (DNACPR) in relation to prevent futile resuscitation of in-hospital cardiac arrests. Sweden has about 2200 in-hospital cardiac arrests yearly, with an overall 30-day survival ratio of 35%. This population is highly selected, although the frequency of DNACPR orders for hospitalized patients is unknown, resuscitation is initiated in only 6–13% of patients dying in Swedish hospitals.According to Swedish law and although shared decision making is sought, the physician is the ultimate decision-maker and consultation with the patient, her relatives and another licenced health care practitioner is mandatory. According to studies, these consultations is documented in only about 10% of the decisions. Clinicians lack tools to assess risk of IHCA, tools to predict outcome and we are not good at guessing patients own will.Future directives for clinical practice need to address difficulties for physicians in making decisions as well as the timing of decisions.We conclude that the principles in Swedish law needs to be fulfilled by a more systematic approach to documentation and planning of meetings between patients, relatives and colleagues.

Is there a particular pediatric otolaryngology ethic?

ObjectivesThis paper proposes that there is a specific pediatric otolaryngology ethic. MethodsIn support of this contention, traditional ethical frameworks are considered, before ethical issues specific to pediatric otolaryngology are addressed. ResultsFirst, there is a difference between child flourishing and family flourishing, parents have parental virtue (as parents), and where autonomy as a moral agent is vested, is contested. Parents act as both proxy decision-makers and as autonomous decision-makers for our patients. We are aware of the open future of a child. We worry about unvoiced and unvoicable concerns and distress in children. Second, we treat the not-yet-born and the recently born, so we need a philosophical understanding of what is a person, and when we become one. Third, traditional approaches to decision-making in medical ethics in Western settings are based upon the frameworks of duty and rules, or of consequences and outcomes, or are virtue-based. In our contemporary era, characterized by pronounced value pluralism, these ethical approaches no longer provide sufficient guidance in the complex milieu of our pediatric otolaryngology practice. In contemporary pediatric otolaryngology, a moral philosophical approach is needed to add meaning and normativity (a sense of oughtness or shouldness) to decision-making amongst the stakeholders in the clinical consultation. ConclusionDetermining the virtuous balance between a priori rules and empirical consequences is a possible solution. This is put into clinical practice via the process of dialogic consensus – an inclusive, non-coercive and reflective dialogue, aimed at reaching a consensual decision as how to maximize the good of our young patients and their family. Based upon differing ethical and moral considerations, and specific issues around children and their families, there is a particular pediatric otolaryngology ethic.

MEDICAL ETHICAL DILEMMA AND EMPLOYEE LOYALTY IN THE PRIVATE HOSPITALS IN BORI-OGONI, RIVERS STATE

This study investigates the relationship between medical ethical dilemma and employee loyalty in the private hospitals in Bori-Ogoni, Rivers State.The study used deontological theory of ethics and Alderfer ERG theory of employee loyalty. The quasi-experimental design was used. The population of this study consists of 210 workers in private hospitals in Bori-Ogoni. The sample size of 140 was determined using Taro Yame sample size determination method. The primary data and secondary sources of data collection were used. The formulated hypotheses were tested using the Spearman Rank Oder Correlation coefficient analysis. The study revealed that is a significant relationship between medical ethical dilemma and medical decisions and employee loyalty in private hospitals in Bori- Ogoni. Therefore, we concluded that there is a strong significant relationship between medical ethical dilemma and medical decisions and employee loyalty in private hospitals in Bori- Ogoni. We also recommended that private hospitals management should strictly monitor workers medical decision making to ensure that it is in accordance with medical ethics and should also guide employees in dilemma situations in order to retain a loyal medical officer and also achieve generic goals of the organization.

The Role of Parental Capacity for Medical Decision-Making in Medical Ethics and the Care of Psychiatrically Ill Youth: Case Report.

Introduction: Parents/legal guardians are medical decision-makers for their minor children. Lack of parental capacity to appreciate the implications of the diagnosis and consequences of refusing recommended treatment may impede pediatric patients from receiving adequate medical care. Child and adolescent psychiatrists (CAPs) need to appreciate the ethical considerations relevant to overriding parental medical decision-making when faced with concerns for medical neglect.Methods: Two de-identified cases illustrate the challenges inherent in clinical and ethical decision-making reflected in concerns for parental capacity for medical decision-making. Key ethical principles are reviewed.Case 1: Treatment of an adolescent with an eating disorder ethically complex due to the legal guardian's inability to adhere with treatment recommendations leading to the patient's recurrent abrupt weight loss.Case 2: Questions of parental decisional capacity amid treatment of an adolescent with schizoaffective disorder raised due to parental mistrust of diagnosis, disagreement with treatment recommendations, and lack of appreciation of the medical severity of the situation with repeated discharges against medical advice and medication nonadherence.Discussion: Decisions to question parental capacity for medical decision-making when risk of imminent harm is low but concern for medical neglect exists are controversial. Systematic review of cases concerning for medical neglect benefits from the assessment of parental decisional capacity, review of ethical standards and principles.Conclusion: Recognition of the importance of parental decision-making capacity as relates to parental autonomy and medical neglect and understanding key ethical principles will enhance the CAP's capacity in medical decision-making when stakes are high and absolute recommendations are lacking.

How do employees of psychiatric hospitals evaluate medical ethical conflicts in coercive measures

The practice of coercive treatment in psychiatric hospitals raises numerous medical, juridical and ethical questions. Moreover, coercive measures lead to the contradiction of certain medical ethical principles. We examined the attitudes of psychiatric hospital employees towards ethical conflicts in medicine and asked them how they decide for or against coercive measures through the help of a hypothetical case. In a questionnaire, 73 psychiatric hospital employees of various professions were asked about their attitudes towards several ethical conflicts in medicine. They were requested to decide for or against the use of coercive measures in the case of a hypothetical patient suffering from schizophrenia. The majority of the respondents agreed that in conflicts between principles of medical ethics the focus of treatment should be on the wellbeing of the patient (89 %) rather than on that of society (11 %). They also favored the principle of autonomy (58 %) over paternalism (42 %). The principle of nonmaleficence appeared to be equally important as beneficence (51 % vs. 49 %). Less invasive coercive measures (assistance through a person in charge) were preferred to more invasive ones (coercive medication), as our case vignette showed. There were no highly significant correlations found between sociodemographic factors (taking work experience and profession into account), judgement about medical ethical conflicts and the decision for or against coercive treatment. Both employees of closed wards with mid-long work experience (6-15 years) as well as nursing staff were more likely to choose coercive treatment. No statistically significant correlation could be determined between the preference of medical ethical principles and decisions about coercive treatment. Coercive treatment leads to ethical conflicts in medicine. The impact of such conflicts on the application of coercive measures through employees of psychiatric hospitals should be further explored and examined.

Medical Futility in Pediatric Care

The transition from the paternalistic paradigm of the Hippocratic tradition to the present model of shared decision making has altered the patient–doctor relationship. This change has engendered conflicts between patients and physicians, especially in pediatric medicine, where the patients are depen­dent on their parents because of their inability to consent to an intervention independently. Navigating this complex relationship can become particularly fraught when medical futility is invoked. This situation is complicated further by the divergent approaches to shared decision making among physicians and the ethical perspectives these positions reflect. Catholic doctrine on the role of parents in medical-ethical decision making provides insight into navigat­ing these difficult clinical issues and ideologies.

Neuromodulatie en narratieve identiteit

AbstractNeuromodulation and narrative identity: the importance of relational autonomyIn this paper, I discuss the impact of psychological and relational changes after neuromodulation for movement- and psychiatric disorders and the need to adequately address the possibility of such changes in clinical contexts. Based on ), ) and ), I outline a relational narrative identity perspective that can inform and support medical-ethical decisions. The narrative identity theory by Marya Schechtman in combination with a focus on the relational aspects that impact and constitute our identity, highlights the need to identify post-interventional identity changes both from the perspective of the patient, his or her family and loved ones and the medical team. I argue that a thorough informed consent process pre- and post-intervention and adequate psychological counseling allows for such identification and a step by step monitoring and guiding of the patient in this process. From a relational narrative perspective, neuromodulation does not by default pose a threat to our identity. However, this perspective highlights the need to take the relational autonomy of patients seriously and provide a substantial informed consent procedure and adequate psychological counseling.

Reality to a medical ethical decision-making and the factor of nurses’ participation in NICU: Consideration of the role of nurses

Reality to a medical ethical decision-making and the factor of nurses’ participation in NICU: Consideration of the role of nurses

Children's outcomes at 2-year follow-up after 4 years of structured multi-professional medical-ethical decision-making in a neonatal intensive care unit.

We reviewed our decisions about continuation/withdrawal of life-sustaining treatments in a group of critically ill newborns who were discussed in structured medical ethical decision-making meetings, and provide the surviving children's outcomes at 2-year follow-up. In an explorative observational study, 61 cases were evaluated. The children involved had been discussed in such a structured way from 2009 to 2012 in a level III-D neonatal intensive care unit. Decisions made were: full treatment (n=6), earlier restriction cancelled (n=3), treatment restriction (n=30) and palliative care (n=22). Parents of six children disagreed with the decision proposed. Thirteen (54%) of the 24 children who survived (39%) had moderate to severe neurological problems; 8 (33%) had additional sequelae; only one 2-year-old child was healthy. Decisions made varied to a large extent. The poor outcomes should be disseminated among decision makers. Future studies must explore new ways to improve outcome prediction, extend follow-up periods and consider what living with severe handicaps really means for both child and family.

Appropriateness of care and moral distress among neonatal intensive care unit staff: repeated measurements.

Perceived constraints to providing patient care in their own morally justified way may cause moral distress (MD) in neonatal nurses and physicians. Negative long-term effects of MD include substandard patient care, burnout and leaving the profession. To assess the immediate impact of perceived inappropriate patient care on nurses' and physicians' MD intensity, and explore a possible moderating effect of ethical climate. In a repeated measures design, after baseline assessment, each participant completed self-report questionnaires after five randomly selected shifts. Data were analysed with logistic and Tobit regression. Data were collected among 117 of 147 eligible nurses and physicians (80%) in a level-III neonatal intensive care unit in the Netherlands. At baseline, overall MD was relatively low; in nurses, it was significantly higher than in physicians. Few morally distressing situations were reported in the repeated measurements, but distress could be intense in these cases; nurses' and physicians' scores were comparable. Physicians were significantly more likely than nurses to disagree with their patients' level of care (p = 0·02). Still, perceived overtreatment, but not undertreatment, was significantly related to distress intensity in both professional groups; ethical climate did not moderate this effect. Substandard patient care due to lack of continuity, poor communication and unsafe levels of staffing were rated as more important causes of MD than perceived inappropriate care. Although infrequently perceived, overtreatment of patients caused considerable distress in nurses and physicians. Our unit introduced multidisciplinary medical ethical decision making 5 years ago, which may partly explain the low MD at baseline. MD might be prevented by improved continuity of care, safe levels of staffing and better team communication, along with other targeted interventions with demonstrated effectiveness, such as palliative care programs and facilitated ethics conversations.

Making sense, ritual, and improvisation at the end of life

In this essay, the author offers new possibilities for end of life care through sense making with patients that employs both ritual and improvisation in lieu of traditional medical ethical decision-making.

사회계약에 근거한 의료의 윤리적 의사결정:의료 전문직의 계약 책임의 형성과정을 통하여

The normative principles of medical ethics are classified into two categories: traditional ethical theories (utilitarianism and deontological ethics) and empirical principles like the Hippocratic Oath. Each of these two streams of medical ethics has strengths and limitations. This article presents social contract theory as a new approach to understanding medical ethics. On this view, medical professions are based on social contracts for protecting patients from therapists with no licenses. These social contracts consist of hyper-norms, general or whole social contracts, regulations, stewardships and personal contracts. Medical professionals and medical societies both must uphold all of the social responsibilities (including legal liability) of these contracts. In order to strengthen the observance of these social contracts, this article proposes a process of medical ethical decision-making based on social contracts. Additionally, to reduce patient-physician conflicts, this article identifies the appropriate decision-making participants and argues for the necessity of hierarchical clinical ethics committees.

Implementing structured, multiprofessional medical ethical decision-making in a neonatal intensive care unit

BackgroundIn neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical...

When four principles are too many: bloodgate, integrity and an action-guiding model of ethical decision making in clinical practice

Medical ethical analysis remains dominated by the principlist account first proposed by Beauchamp and Childress. This paper argues that the principlist model is unreflective of how ethical decisions are taken...

263 Benefits of Structured Multi Disciplinary Medical Ethical Decision Making

Background/aim: Until 2008, medical ethical decision making (MEDM) in the NICU lacked structure. Moral deliberation and effecting ethical decisions were not up to standard. A guideline to improve MEDM was developed, and evaluated one year after implementation. Method: The guideline consisted of multidisciplinary meetings presided by an independent chair, and uniform preparation and report. Meetings were structured following a five phase model: 1) exploration, 2) agreement on the ethical question, 3) analysis, 4) evaluating possible solutions, decision-making, 5) planning actions. Initially, health care workers (HCW) of the NICU were trained in ethical/legal aspects and practiced the method with a historical patient case. Before the training, HCW completed a 15-item questionnaire on ‘structure’, ‘role participants’, ‘parental representation’, ‘problems, solutions and deliberation’, and ‘decisions and documentation’. One year and 22 structured meetings after introduction, the same questionnaire was completed again. Results: Response before and after introduction of the guideline was 91/114 (80%) and 85/123 (69%) respectively. Nurses and physicians were equally represented in the two samples (N=63/63, and N=19/14; χ2=.601; p=.438). Evaluation of the guideline showed improvement in ‘structure of MEDM’ (p<.000 for all 5 items), ‘role participants’ (p<.000 for all 3 items), ‘parental representation’ (p<.000, for 1 item), and ‘problems, solutions and deliberation’ (p<.000, for 2 items; the 3rd item treatment options did not improve, p=.932). ‘Decisions and documentation’ showed no improvement (3 items, p=.215, p=.412 and p=.066 respectively). Conclusions: Ethical deliberation significantly improved after implementation of structured MEDM. Ongoing attention will be paid to ‘documentation of the decisions’.

Avoiding bias in medical ethical decision-making. Lessons to be learnt from psychology research

When ethical decisions have to be taken in critical, complex medical situations, they often involve decisions that set the course for or against life-sustaining treatments. Therefore the decisions have far-reaching consequences for the patients, their relatives, and often for the clinical staff. Although the rich psychology literature provides evidence that reasoning may be affected by undesired influences that may undermine the quality of the decision outcome, not much attention has been given to this phenomenon in health care or ethics consultation. In this paper, we aim to contribute to the sensitization of the problem of systematic reasoning biases by showing how exemplary individual and group biases can affect the quality of decision-making on an individual and group level. We are addressing clinical ethicists as well as clinicians who guide complex decision-making processes of ethical significance. Knowledge regarding exemplary group psychological biases (e.g. conformity bias), and individual biases (e.g. stereotypes), will be taken from the disciplines of social psychology and cognitive decision science and considered in the field of ethical decision-making. Finally we discuss the influence of intuitive versus analytical (systematical) reasoning on the validity of ethical decision-making.

Patient characteristics and the allocation of scarce medical resources

This was the sixth study in a programmatic series (Furnham, 1996; Furnham & Briggs, 1993; Furnham & Ofstein, 1997; Furnham et al., 1999; 2000) that examined the effects of participant personality and patient characteristics on the preferential allocation of scarce medical resources. Patients differed in gender, personality, mental illness and intelligence. Participants favoured extraverts over introverts; those with no history of mental illness over those with a history; and the highly intelligent over the moderately intelligent. There was little evidence that the personality traits of participants affected their ratings of patients. Implications for socio-moral and medical ethical decision making are considered. Both the limitations of this methodology and the implications of these findings for real ethical committees are discussed.

Organ Transplantation: Thorny Ethical Issues

Organ Transplantation: Thorny Ethical Issues

Does pregnancy affect medical ethical decision making?

OBJECTIVE: We studied and compared the attitudes of pregnant women v new mothers in an attempt to confirm changing patterns of maternal response towards medical ethical decision making in critically...

Medical-Ethical Decisions and Life-Terminating Actions in The Netherlands 1990-1995

L’articolo tratta della valutazione critica del Secondo rapporto sulla pratica dell’eutanasia in Olanda. In primo luogo, gli autori sottolineano che la legge olandese richiede una notificazione o un rapporto sulla procedura eutanasica effettuata, tramite una scheda prevista dall’articolo 10 della legge. Tale procedura si applica anche ai casi di eutanasia praticata senza esplicita richiesta del paziente ed implica che i medici interessati non redigano un semplice certificato di morte, ma notifichino il fatto alla magistratura municipale per mezzo di un questionario comprendente cinquanta voci.&#x0D; Una delle principali critiche rivolte alla legge olandese sulla depenalizzazione dell’eutanasia concerne la questione se la procedura di notifica sopra citata consenta la verificabilità della pratica eutanasica. Dai dati finora disponibili (1990) risultava che soltanto una minoranza dei medici - il 25% dei medici di base ed il 35% degli specialisti - redigeva certificati di eutanasia, per evitare problemi legali e questioni con i parenti del paziente.&#x0D; Nel 1994, il governo olandese ha deciso di condurre una nuova inchiesta su larga scala riguardo la pratica eutanasica nel Paese e sulla efficacia della sua procedura di notifica. Il Secondo Rapporto sull’eutanasia, reso pubblico nel 1995: 1. evidenzia il sostanziale incremento dei casi di eutanasia; 2. conferma l’esiguo ricorso alle procedure di notifica dell’eutanasia. Senza considerare l’obiezione etica di fondo allo stato di necessità invocato per attuare le procedure eutanasiche, dal documento appare che in pratica la procedura di notifica dell’eutanasia non è nemmeno riuscita ad operare un qualche controllo sulla pratica eutanasica, come voleva il legislatore.