Ethical Issues In Practice Research Articles

Medical ethics in a multicultural society.

Contemporary research and teaching in medical ethics is unduly influenced by the imagery of stability, order and uniformity. Many commentators presume the existence of a placid social order and pay little regard to differences in understandings of birth, illness, suffering, death and the nature of healing. Moral philosophers such as John Rawls and Norman Daniels, for example, argue that with the existence of an ‘overlapping consensus,’ morality is in a state of ‘side reflective equilibrium’1. Tom Beauchamp and James Childress, two of the earliest proponents of the ‘principlist’ approach to bioethics, take this view2, as do advocates of case-based moral reasoning (casuistry) such as Albert Jonsen and Stephen Toulmin3. Notwithstanding methodological differences in the manner these philosophers address practical ethical issues in medicine and healthcare, all of them presume the existence of a stable, settled moral order. ‘Society’ is discussed in monolithic terms, and both principlists and casuists pay remarkably little attention to the role of religion and culture or ethnicity in shaping understandings of such topics as abortion, physician-assisted suicide, prenatal genetic testing, stem-cell research or the withdrawal of treatment in end-of-life care. Relying upon philosphical approaches that presume the existence of shared principles and moral paradigms, contemporary ethicists commonly neglect to address important differences in the moral understandings of particular religious communities and ethnic groups4. The notion of ‘common morality’ tends to obfuscate the complex realities of providing medical care in multicultural, multifaith societies5. In pluralistic settings, different interpretive communities can exist, with distinctive understandings of what constitutes moral conduct, forms of evidence and reasoned arguments6. In short, commentators on the ethics of medicine and healthcare greatly over-simplify their task by presuming widespread social support for norms and practices that are in reality subject to vigorous dispute. Let us consider the position of a physician or nurse in London, New York, Sydney or Toronto, where patients come from diverse cultural and religious backgrounds. Some patients wish to receive detailed information about their diagnosis, prognosis, and treatment options. Other patients follow a different cultural script, expecting family members to make important health-related decisions and shield them from ‘bad news’. Some patients, fearful that they will become captive to sophisticated medical technologies, prepare advance directives refusing various possible medical interventions. Others, perhaps because of deep religious belief, want ‘everything done’, and insist on cardiopulmonary resuscitation even in circumstances deemed medically futile by healthcare providers. Some families seek to practise their religious traditions by asking physicians to circumcise their male children—an act that other groups see as child abuse and a violation of human rights. Members of some right-to-die organizations insist that compassionate healthcare providers and legislators would permit physician-assisted suicide, whereas members of many Jewish, Muslim and Christian religious communities declare that legalization of physician-assisted suicide would seriously devalue human life. To contribute usefully to contemporary debates, ethicists need to better address the multiethnic, multifaith character of contemporary social settings7. They need to recognize the existence of a plurality of ‘communities of interpretation’ and ‘local moral worlds’8.

Book Section: Essay and Review: Child Custody: Practice Standards, Ethical Issues, and Legal Safeguards for Mental Health Professionals

Book Section: Essay and Review: Child Custody: Practice Standards, Ethical Issues, and Legal Safeguards for Mental Health Professionals

Development of the ethical dimension in nursing theory.

Nurses encounter ethical dilemmas in their practice and need guidance in making relevant patient-care decisions. Nursing theory is believed to be the best source of such guidance. The aim of this paper is to describe the ethical dimension in nursing theory. A literature review shows the intricate relationship between ethics and nursing, yet there is lack of elaboration of ethical features in nursing theories. The identified elements of the ethical dimension include ethical theories and principles, values, ethical practice issues, moral reasoning and contextual factors. Criteria for the development and evaluation of the ethical dimension are presented, with an example using a middle range theory. The ethical components pertinent to a nursing theory need to be made explicit if theory is to guide practice. Nursing scholars are invited to elucidate the ethical dimension in their theories in order to enhance moral reasoning and provide a framework for ethical practice.

Lifelong learning in ethical practice: a challenge for continuing medical education.

Formal education in the identification, analysis, and resolution of ethical issues in clinical practice is now an essential component of undergraduate and postgraduate medical education. Physicians educated before the 1980s have had little or no formal education in ethics. This article describes a project for assessing the content and format appropriate for the continuing education needs of practicing physicians. A questionnaire and follow-up facilitated small-group discussions with a physician ethicist around case-based problems were used to identify the ethical issues in practice where participants felt the need for continuing education. The project confirmed that practitioners had very little formal ethics in medical school and less since starting practice despite encountering ethical issues. The most frequently used method of learning about ethics was informal discussion among those who have the same lack of formal education. Physicians did not feel that they needed a "very high" level of confidence and competence in handling ethical issues, even those commonly encountered. Participants indicated strongly that they lacked a systematic approach to the identification and analysis of ethical issues and suggest incorporation of the ethical component into regular CME. In spite of the small study population and the volunteer nature of the participants, the project demonstrated the identification of ethics content for CME similar to that used in medical education. Further work is needed to assess objective needs for ethics education in addition to the perceived needs of clinicians.

British community pharmacists' views of physician-assisted suicide (PAS)

Objectives— To explore British community pharmacists' views on PAS , including professional responsibility, personal beliefs, changes in law and ethical guidance. Design— Postal questionnaire Setting— Great Britain Subjects— A random...

Doing household research: interviewing couples together and apart

Summary The question of whether household members should be interviewed together or apart is hotly debated in ‘family’ studies. In this paper, I use my own experiences of both methods of interviewing in order to explore some of the practical problems, ethical issues and power dynamics of conducting household research, and to demonstrate how a household focus can contribute to the understanding of gender relations.

The Evolution of Social Work Ethics

Ethical issues have always been a central feature in social work. Throughout the profession's history social workers have been concerned with matters of right and wrong and matters of duty and obligation. The National Association of Social Workers' (NASW) recent ratification of a new code of ethics (NASW, 1996) signals social workers' remarkable progress in the identification and understanding of ethical issues in the profession. The 1996 code - the first major revision in nearly two decades and only the third code of ethics ratified in NASW's history - reflects the impressive growth in social workers' grasp of complex ethical issues in practice. The celebration of social work's 100th anniversary provides a particularly auspicious moment to reflect on the evolution of social work ethics. Social workers' core values and ethical beliefs are the profession's linchpin. Social workers' concern with ethics has matured considerably during the past century, moving from frequently moralistic preoccupation with clients' values to concern about complex ethical dilemmas faced by practitioners and strategies for dealing with these dilemmas. Social work's concern with ethics spans four major, sometimes overlapping, periods: (1) the morality period, (2) the values period, (3) the ethical theory and decision-making period, and (4) the ethical standards and risk management period. The Morality Period In the late 20th century, when social work was formally inaugurated as a profession, there was much more concern about the morality of the client than about the morality or ethics of the profession or its practitioners (Leiby, 1978; Lubove, 1965; Reamer, 1995a). Social workers' earliest practitioners focused on organized relief and responding to the curse of pauperism (Paine, 1880). Often this preoccupation took the form of paternalistic efforts to bolster poor people's morality and the rectitude of those who had succumbed to shiftless or wayward habits. Social workers' focus on the morality of poor people waned significantly during the settlement house movement in the early 20th century, when many social workers turned their attention to structural and environmental causes of individual and social problems, particularly social workers' ethical obligation to promote social justice and social reform. As has been well documented in the profession's literature, many social workers were concerned with cause rather than, or in addition to, case. This was evident in social workers' social reform efforts designed to address the toxic environmental determinants of problems related to poverty, inadequate housing and health care, mental illness, alcoholism, and violence (Brieland, 1995; Lee, 1930). Emphasis on clients' morality continued to weaken during the next several decades as social workers created and refined various intervention theories and strategies, training programs, and educational models. During this phase, many social workers were more concerned about cultivating perspectives and methods that would be indigenous to social work, partly in an effort to distinguish social work's approach to helping from those of allied professions, such as psychology and psychiatry. Exploration of Values Although a critical mass of serious scholarship on social work ethics did not appear until the 1950s, there were several efforts earlier in the 20th century to explore social work values and ethics (Frankel, 1959). As early as 1919 there were attempts to draft professional codes of ethics (Elliott, 1931). In 1922 the Family Welfare Association of America appointed an ethics committee in response to questions about ethical problems in social work (Elliott, 1931; Joseph, 1989). In addition, there is evidence that at least some schools of social work were teaching discrete courses on values and ethics in the 1920s (Elliott, 1931; Johnson, 1955). These efforts were consistent with Flexner's (1915) widely respected assertion that a full-fledged profession should have a clearly articulated, values-based ethical foundation. …

Lessons from the Shuttle [Books

This book examines engineering ethics and is based on the analytical consensus arrived at over the past three decades in medical ethics. The authors accordingly studied how the engineer perceives, articulates, and resolves moral dilemmas in practice. They also drew on Herbert A. Simon’s Nobel Prize-winning theory of organizational behavior, to shed light on how the organizational context—its formal structure, as well as political pressures— relates to engineers individually and their responses to ethical dilemmas they encounter. The authors have identified three basic ethical principles, which together serve as a framework for articulating and resolving ethical issues in practice. The first principle is the obligation to technical competence, both individual and organizational. The second principle is responsibility - the obligation of engineers to voice their concern when they identify an ethical dilemma. The third is what they call Cicero’s Creed II, an updated version of engineering’s oldest rule, “to insure the safety of the public.

Legal responsibilities for educational psychologists

This paper considers the legal responsibilities of educational psychologists which fall mainly in relation to pupils with special educational needs. The first section introduces the work of educational psychologists, with some discussion of the professional and ethical difficulties posed by many aspects of their practice. An outline of the legal framework for their work in the England and Wales is provided, as an example of the application of those professional and ethical issues in practice, followed by and outline of potential areas of legal challenge and their implications. Reference is finally made to problems being experienced in policy, principle and practice arising from the tensions and dilemmas inherent in the legislation.

Development and testing of the ethical reasoning tool (ERT): an instrument to measure the ethical reasoning of nurses

Ascertaining the thinking of professionals as they are confronted with ethical practice issues is a prerequisite to understanding ethical decision making. Before researchers or educators can examine the effectiveness of various approaches to ethics teaching and learning, there is a need for reliable and valid tools to assess practitioners' cognition. A potential problem with the few measuring instruments currently available is the fact that they ask subjects to rank order existing lists of issues. This says little about an individuals' own thinking about ethical issues and may prompt thinking or responses which would not otherwise have occurred. This paper reports the results of a study to test the psychometric properties of a new instrument, the Ethical Reasoning Tool (ERT) that measures ethical reasoning of nurses. The ERT demonstrates a promising way to reveal unprompted ethical thinking about a practice dilemma, thereby clarifying 'real' versus 'assumed' professional reasoning. The tool allows nurse educators to identify areas of student learning/reasoning deficiency that can be addressed by educational interventions. The ERT also allows nurse educators to evaluate the effectiveness of nursing ethics study units in a trustworthy way.

An educational intervention in the surgical intensive care unit to improve ethical decisions.

The objective of this study was to determine whether an educational intervention on medical ethics offered during a surgical intensive care unit (SICU) rotation could effect meaningful change in a tertiary SICU. A case-based education program was presented weekly to the surgical residents during their SICU rotation. Cases for study were designed to deal with specific ethical issues common to the SICU. Cases were studied with the residents in a group facilitated by a SICU attending physician and a nursing director. The effect of the course was monitored by case review and by the length of stay (LOS) assessment for patients who died in the SICU during 1990, the base year, through 1993. Discussions of an ethical nature occurred more regularly and earlier during these 4 years as determined by case reviews. For patients who died after being in the SICU a minimum of more than 30 days, a marked decrease occurred in the SICU LOS from 27.8 +/- 3.7 days in 1990 to 15.7 +/- 2.4 days in 1993 (p < 0.05). The number of deaths per year and the average acuity measured by the diagnosis related group score were similar during the 4 years. The LOS in the hospital for dying patients from non-SICU services remained similar during the same time frame. These changes resulted in the dying patients using 1003 SICU days in 1993, down from the 2028 days used in 1990 (p < 0.05). We conclude that through offering a clinical ethics program during the SICU portion of the residency training, residents increased knowledge and skill in addressing and integrating practical ethical issues into their surgical resident practice. In addition, patient care directly improved with an associated reduced SICU LOS and reduced cost.

Practical ethical issues related to the care of elderly people with dementia.

The care of elderly people with dementia poses ethical problems in several respects. This paper considers the problems in relation to treatment, withdrawal of treatment (including nutrition and hydration) in terminal care, and consent to involvement in research. It is ultimately the responsibility of the physician to take the decision about whether or not to proceed with treatment, according to the best interests of the patient, but nurses, families and significant others can be involved in making the decision. When withdrawal of treatment or withdrawal of nutrition and hydration in the terminal stages of dementia are being considered it is necessary to take into account the nature of the treatment, whether or not it is extraordinary, and the goals of continued nutrition. In some circumstances it may be possible for them to be withdrawn. Only research which is aimed at evaluating treatment for dementia may involve subjects who are suffering from dementia.Soigner des personnes âgés souffrant de la démence pose plusieurs problèmes éthiques. Cet article considère les problèmes concernant le traitement, cessation de traitement (y inclus nutrition et hydration) dans la phase terminale, et consentement de participation dans les recherches. C'est ultimement la décision du docteur si oui ou non de continuer avec le traitement selon les meilleurs intérêts du malade, mais les infirmiers/ères, les familles et les personnes importantes autour du malade peuvent jouer un rôle dans les décisions. Si la cessation de traitement ou cessation de nutrition et hydration dans la phase terminale de démence est envisagée il est nécessaire de tenir compte de la nature du traitement, s'il est 'extraordinaire' ou non, et le but de nutrition si on continuait. Dans quelques circonstances il est possible de les discontinuer. Seuls les recherches qui ont pour but d'évaluer les traitements pour la démence peuvent utiliser des personnes souffrant de démence.Die Pflege von älteren Personen mit Demenz stellt einige ethische Probleme. Dieser Artikel betrachtet die Probleme in Beziehung auf die Pflege, Zurückziehung von Pflege (auch von Nahrung und Getrank) der Sterbenden und der Entscheidung, in der Forschung beteiligt zu sein. Der Arzt hat die schlussendliche Verantwortung über die Entscheidung ob mit der Pflege weitergefahren werden soll oder nicht nach dem besten Interesse der Patienten. Aber das Krankenpflegepersonal, die Familie und bedeutende Andere können auch an dieser Entscheidung teilnehmen. Wenn es sich um Zurückziehung der Pflege, oder Zurückziehung von Nahrung oder Getrank in der Sterbepflege von Personen mit Demenz handelt, is es nötig, das Wesen der Pflege und die Ziele einer fortfahrenden Nahrung zu kennen. In gewissen Fällen ist es möglich, diese zurück zu ziehen. Es sollen nur Patienten mit Demenz an Forschungen teilnehmen die über die Pflege der Demenz einschätzt.

People with Disabilities as Subjects in Research

The purpose of this paper is to provide guidelines to facilitate the inclusion of people with disabilities as subjects in research. Practical suggestions and ethical issues are discussed. The guidelines are separated into components of the research process: (a) locating and selecting subjects, (b) communicating with caregivers and association personnel, (c) obtaining informed consent, (d) preparing subjects for participation in research, and (e) reporting research results. The guidelines ensure treatment of subjects with dignity and improve research quality.

"Is she fit to sign, doctor?"--practical ethical issues in assessing the competence of elderly patients.

The competence of elderly people to participate in medical decision-making is often called into question. This article explores the concept of competence as it relates to elderly people, and outlines the guiding ethical principles of autonomy and beneficence. Practical guidelines are offered on how competence can be assessed and some avoidable pitfalls are highlighted.

Ethics curricula: A national survey of graduate schools of social work

A survey of graduate schools of social work revealed that the predominant method for teaching ethical subject matter is through the pervasivelinfusion approach whereby ethical content is interwoven into the fabric of all or selected courses. Few programs use a discrete model in which professional ethical principles and decision making are the focus of a separate course. Analysis of syllabi of discrete ethics courses showed considerable variation in content and lack of systematic organization. Given the present concern with ethical issues in practice, there is serious question concerning the efficacy of current methods of instruction in preparing students for ethical practice.

Toward ethical practice: The relevance of ethical theory

In recent years, social workers have begun to explore the use of ethical theory to analyze ethical issues in practice. This article provides an overview of traditional schools of thought in moral philosophy and examines their relevance to social work practice. Although ethical theory may not provide unequivocal answers to complex moral questions, it can provide a rigorous framework for the analysis of ethical dilemmas in social work.

A code of ethics for nurse-midwives: A second proposal

This paper critically analyzes the proposed Code of Ethics for nurse-midwives that was published in the March/April 1986 issue of this journal by drawing upon the literatures of medical ethics, political economy, cognitive psychology, and the sociology of professions. Examples of practical ethical issues in nurse-midwifery are provided and an alternative Code of Ethics based on the ACNM Philosophy is offered.

The business of health promotion: ethical issues and professional responsibilities.

In the nine years since an entire issue of Health Education Quarterly (then Health Education Monographs) was devoted to considering ethical issues in health education, several important social changes have occurred which have substantially influenced the practice of that discipline. New practice contexts and ethical issues have resulted, which require a fresh look at both these new issues as well as those addressed in the earlier monograph. The importance of understanding the principles underlying the ethical dilemmas raised by the authors is emphasized as a concern for both the individual practitioner as well as the profession of health education itself. Recommendations for personal and professional action are made by the authors.

Some formal models of grading principles

The present paper offers an analysis of grading principles from the viewpoint of statistical decision theory and game theory. The mistaken notion is widely held that the plain man is really clear about practical ethical and moral issues and that philosophers need only tidy up certain wayward corners of the subject.2 Personally I find difficult the problem of devising any general ethical rules of behavior for simple two-person games; the ethical complexities of progressive taxation, tariff barriers, or treatment of sexual psychopaths are beyond any exact conceptual analysis. That decisions are and must be made about these issues no more proves that their ethical aspects are completely understood than does the fact that the Romans built bridges prove that they had any quantitative grasp of the mechanical theory of stress.