Ethical Uncertainty Research Articles

The Ethics of Repurposing Previously Collected Research Biospecimens in an Infectious Disease Pandemic.

ABSTRACTIn the early days of a pandemic, repurposing biospecimens from established research projects could prove to be extraordinarily useful in achieving substantial and timely public health benefits. Nonetheless, there are potential ethical and regulatory uncertainties that may impede access to those valuable biospecimens. In this article, we argue that there should be a presumption in favor of using previously collected identifiable research biospecimens without reconsent to directly address an infectious disease pandemic, assuming certain conditions are met. This argument fills a unique yet critical gap in decision‐making where the specific consent accompanying the identifiable biospecimens would not otherwise permit repurposing. Further, it suggests that even if gaining reconsent is feasible, doing so in a fast‐moving crisis is not necessary. This analysis also attempts to address the ethical concerns of public health authorities who already may have the power to use such specimens but are reluctant to do so.

Withdrawal of intensive care during times of severe scarcity: Triage during a pandemic only upon arrival or with the inclusion of patients who are already under treatment?

Many countries have adopted new triage recommendations for use in the event that intensive care beds become scarce during the COVID-19 pandemic. In addition to establishing the exact criteria regarding whether treatment for a newly arriving patient shows a sufficient likelihood of success, it is also necessary to ask whether patients already undergoing treatment whose prospects are low should be moved into palliative care if new patients with better prospects arrive. This question has led to divergent ethical guidelines. This paper explores the distinction between withholding and withdrawing medical treatment during times of scarcity. As a first central point, the paper argues that a revival of the ethical distinction between doing and allowing would have a revisionary impact on cases of voluntary treatment withdrawal. A second systematic focus lies in the concern that withdrawal due to scarcity might be considered a physical transgression and therefore more problematic than not treating someone in the first place. In light of the persistent disagreement, especially concerning the second issue, the paper concludes with two pragmatic proposals for how to handle the ethical uncertainty: (1) triage protocols should explicitly require that intensive care attempts are designed as time-limited trials based on specified treatment goals, and this intent should be documented very clearly at the beginning of each treatment; and (2) lower survival prospects can be accepted for treatments that have already begun, compared with the respective triage rules for the initial access of patients to intensive care.

Videography – studying ethical uncertainty in alternative entrepreneurship

Purpose The purpose of this paper is to develop videographic methods for the study of alternative entrepreneurship, with a theoretical focus on “ethical uncertainties”, exemplified in this paper by the exploration of evolving actions and unpredictable outcomes in a specific case, the Hungarian company Prezi. Design/methodology/approach By first situating Prezi’s alternative entrepreneurship in the turbulent Hungarian political context and situation for the Roma population, this study presents how the methodological foundations of organizational videography have affirmed aesthetic immersion, which is of particular use for the study of ethical uncertainty. Findings Following a methodological exploration of the specific research design and ethnographic reflections on three ways in which ethical uncertainties arise, this study discusses the videographic possibilities to study something as elusive as ethical uncertainty and its link to alternative futures. Originality/value The political context in Hungary poses many challenges for organizations that attempt to “do good” and create alternative futures. This paper explains how this political context permeates Prezi’s entrepreneurship and research thereof, by highlighting “ethical uncertainty”. The combined contribution (paper and videography) invites the reader to think differently about the authority of research, become a viewer and reflect on their own experiences of ethical uncertainty in alternative entrepreneurship.

Ethical Responses to the Covid-19 Pandemic: Implications for the Ethos and Practice of Anatomy as a Health Science Discipline.

The move of much anatomy teaching online in response to the Covid‐19 pandemic has been successfully implemented within very short time frames. This has necessitated a high degree of dependence upon the use of digitized cadaveric resources, has entailed immense workload demands on staff, and has disrupted students' studies. These educational exigencies have been accompanied by ethical uncertainties for a discipline centered on study of the dead human body. An ethical framework for anatomy is suggested based on the principles of equal concern and respect, minimization of harm, fairness, and reciprocity, in which all staff and students are to be treated with respect and as moral equals. A series of ethical obligations are proposed as a means of maintaining the ethos of anatomy, coping with the suspension of body donation, providing adequate resources, and responding to increased dependence upon external providers. Good academic practice raises more general obligations stemming from the welfare of students, the increased workload of staff, and checking on online assessment and invigilation. As anatomists respond to the educational and ethical lessons prompted by this pandemic, they should plan for future disruptions to normal work patterns by adopting a sustainable and equitable course of action.

Understanding and managing uncertainty in health care: revisiting and advancing sociological contributions.

In this collection we revisit the enduring phenomenon of uncertainty in health care, and demonstrate how it still offers coherence and significance as an analytic concept. Through empirical studies of contemporary examples of health care related uncertainties and their management, our collection explores the different ways in which uncertainty may be articulated, enacted and experienced. The papers address a diverse range of healthcare contexts - Alzheimer's disease, neonatal surgery, cardiovascular disease prevention, cancer, addiction (use of alcohol and other drugs during pregnancy), mental health/disorders and medical education - and many tackle issues of contemporary relevance, such as an ageing population, and novel medical interventions and their sequelae. These empirical papers are complemented by a further theoretical contribution, which considers the role of 'implicit normativity' in masking and containing potential ethical uncertainty. By mapping themes across the collection, in this introduction we present a number of core analytical strands: (1) conceptualising uncertainty; (2) intersections of uncertainty with aspects of care; (3) managing uncertainty; and (4) structural constraints, economic austerity and uncertainty work. We reflect on the methodological and theoretical stances used to think sociologically about uncertainty in health care, and the strengths, silences and gaps we observe in the collection. We conclude by considering the implications of the insights gained for 'synthesising certainty' in practice and for future research in this area.

"Hunting Down My Son's Killer": New Roles of Patients in Treatment Discovery and Ethical Uncertainty.

The past few years have witnessed several media-covered cases involving citizens actively engaging in the pursuit of experimental treatments for their medical conditions-or those of their loved ones-in the absence of established standards of therapy. This phenomenon is particularly observable in patients with rare genetic diseases, as the development of effective therapies for these disorders is hindered by the limited profitability and market value of pharmaceutical research. Sociotechnical trends at the cross-section of medicine and society are facilitating the involvement of patients and creating the digital infrastructure necessary to its sustainment. Such participant-led research (PLR) has the potential to promote the autonomy of research participants as drivers of discovery and to open novel non-canonical avenues of scientific research. At the same time, however, the extra-institutional, self-appointed, and, often, oversight-free nature of PLR raises ethical concern. This paper explores the complex ethical entanglement of PLR by critically appraising case studies and discussing the conditions for its moral justification. Furthermore, we propose a path forward to ensure the safe and effective implementation of PLR within the current research ecosystem in a manner that maximizes the benefits for both individual participants and society at large, while minimizing the risks.

The Absurdity of the Aftermath in Daoud's Meursault, contre-enquête

This essay interrogates the relationship between Kamel Daoud's novel Meursault, contre-enquête and Albert Camus's L'Étranger through an extended reading of Meursault's narrative form. I argue that the complexity of this relationship only fully emerges when Daoud's novel is read as such—not by tallying the aspects that are critical of Camus and those that are sympathetic, but by considering its narrative conception and unfolding. Attending in particular to the key features of its narrative instance and use of metalepsis, I show how Meursault approaches the project of postcolonial counternarrative differently than canonical remakes, emphasizing the experiences that render 'writing back' impossible. Through an exploration of the aftermath of colonial violence and the forms of irremediable epistemic and ethical uncertainty it produces, Daoud redefines absurdity, from the nihilistic universal articulated by the narrator of L'Étranger, to a historical condition linked to the history and legacies of colonial violence—a definition of absurdity that I argue places him in close relationship to Camus, and particularly the Camus of La Chute.

Ethical Considerations in the Use of Unclaimed Bodies for Anatomical Dissection: A Call for Action

Introduction: The continued practice of anatomical dissection in medical training has placed great demands on body acquisition. This paper aims to provide an overview of the ethical considerations in the use of unclaimed bodies for anatomical dissection. Materials and Methods: We explored major databases such as PubMed, MEDLINE, Ovid MEDLINE, Researchgate, Google Scholar, Web of Science, and Science Direct, from January 2004 to October 2019, using selected keywords to identify and extract articles relating and peculiar to the use of unclaimed bodies for anatomical dissection. Results: This review yielded 40 publications with 28 meetings of our quality and inclusion requirements. This paper highlighted the use of unclaimed bodies for anatomical dissection as seen in some medical schools, and the various ethical considerations associated with its continuous use in medical training globally. Conclusion: In conclusion, the continuous use of unclaimed bodies for anatomical dissection still carries strong ethical and legal uncertainties. It is therefore recommended that there is a need to formulate an all-inclusive regulation to control the use of cadavers for anatomical dissection. If appropriate legislation and guidelines are not put in place with strict monitoring, we may soon return to the cadaver trafficking era to meet up with the demand.

Importance of Nurses' Eye Witness in Health Care System of Pakistan

Background: Eye witness is an act that helps to provide justice, beneficence, non-maleficence and autonomy to any victim thus prevents misconduct and crimes from the society. Crime is an act of planning, preparing, stealing, harming and destroying individuals, groups or societies rights. Crime is one of the social and ethical issue that is prohibited in every religion and society. Healthcare professionals are suffering from different kind of workplace violence, harassments and abuses by patient attendants. Moreover, taking medicines or equipments from wards, and errors during surgical procedure is again consider crime. Nurses usually deal with issues and situations that have elements of ethical and moral uncertainty. Unfortunately such kind of crimes are not reported and remain unnoticed. It is our responsibility to become eye witness and report all those act which can prevent deviation from the standard of care as well as insure safety of health care providers. Methodology: Data were collected through systematic data search technique. Publication from 2001 to 2018 regarding eye witness were included in this study for review. After in depth screening, 22 articles were finally selected for review. Quality analyses were done according to pre-identified criteria. Result: Findings from retrieved and analyzed articles revealed that individuals cognitive power, confident level and theoretical knowledge is essential to become eye witness of any crime and misdeed. It is also evident from literatures that the outcome of telling lie and become fake eye witness has contextual consequences and punishment is different from context to context and person to person. According to three articles in this review, providing accurate and truth information regarding any crime is our responsibility and every religion possess and direct to provide correct information and become eye witness to prevent such acts which harm others. Conclusion: Nursing profession is facing number of challenges thus bulling and leg pulling is one of the issue which we seen in nursing profession. To take any decision and sharing any misconduct and immoral act by any person or health care providers we must have enough knowledge, confident, cognitive integrity to identify our personal values, moral development and knowledge of ethical theories for decision making in nursing to be a eye witness or not.

Critical evaluation of the new legal regulation of pharmaceutical trials with adults who lack decision-making capacity: asurvey of human research ethics committees in Germany

In Germany, the drug law was revised in 2016 to include new regulations on clinical drug trials with adults who lack decision-making capacity. For the first time, trials with amerely indirect benefit (benefit for other patients with similar characteristics) will be possible if several safeguards are respected. The ethical justification and practicality of this regulation are controversially discussed. (1)Eliciting the current pertinent practice of research ethics committees in Germany regarding research with indirect benefit on adults without decision-making capacity; (2)exploring the possibilities and difficulties of implementing the new law. Semiquantitative, anonymous questionnaire among 249 members of all 53human research ethics committees in Germany. Eighty-fourquestionnaires were analyzed (response rate 34%). The participants disagreed on assigning research projects to the categories of research with direct benefit to the subject, with an indirect benefit, and without any benefit. Moreover, the criteria of minimum risk and minimum burden were interpreted heterogeneously. More than half of the participants judged the newly introduced research advance directive to be unnecessary, given the legal safeguards in place. The applicability of these directives was doubted because of the strict requirements for anticipatory informed consent and the restricted predictability of future research. In spite of the new legal regulation, significant ethical uncertainties remain concerning research with indirect benefit on adults without decision-making capacity. It remains an open question whether we need abetter explanation of the law, additional legal regulation, practice evaluation, or acompletely new law.

Managing ethical uncertainty: implicit normativity and the sociology of ethics.

This article illustrates and discusses the idea of ‘implicit normativity’, and specifically its relevance to the management of ethical uncertainty. In particular I consider (i) the role implicit normativity plays in masking and containing potential ethical uncertainty and (ii) the contrast and boundary between implicit normativity and ‘overt ethics’ where ethical contestation – as well as particular processes and agents – are highlighted as salient. Using examples I show how the idea of implicit normativity can be applied not only to specific practices but also to whole fields of practice. The notion of ‘moral settlements’ – along with the explanatory role of the threat of ‘chaos’ – is introduced and elucidated to develop these points. I argue that attention to the management of ethical uncertainty shows the critically important contribution that an ambitious sociology of ethics can make to clinical ethics, including by helping to formulate and drive home questions about the ‘ethics of ethics’. The account presented here has resonances with work that seeks to use sociological lenses to move beyond conventional bioethics, including Petersen's (2013) call for a ‘normative sociology’.

Health professionals' experiences and perspectives on food insecurity and long-term conditions: A qualitative investigation.

Estimates suggest that over 10% of the UK population are affected by food insecurity. International evidence indicates that food insecurity is a risk factor for many long‐term health conditions, and can adversely affect people's ability to manage existing conditions. Food insecurity is thus not only a serious social concern but also a healthcare issue requiring the attention of UK health professionals. An exploratory qualitative study was undertaken to investigate the experiences and views of health professionals in north east Scotland, with a particular focus on support for people with long‐term conditions whom they believed were affected by food insecurity. Two focus groups and nine semi‐structured interviews were undertaken with a total of 20 health professionals between March and July 2016. Thematic analysis generated three main themes. The health professionals had (a) diverse levels of understanding and experience of food insecurity, but between them identified a range of (b) negative impacts of food insecurity on condition‐management, especially for diet dependent conditions or medication regimes, and for mental health. Even for those health professionals more familiar with food insecurity, there were various (c) practical and ethical uncertainties about identifying and working with food insecure patients (it could be difficult to judge, for example, whether and how to raise the issue with people, to tailor dietary advice to reflect food insecurity, and to engage with other agencies working to address food insecurity). This study indicates that health professionals working with food insecure patients have learning and support needs that warrant further investigation. Debates about health professionals’ responsibilities, and interventions to guide and support health professionals, including tools that might be used to screen for food insecurity, must also reflect the diverse lived needs and values of people who experience food insecurity.

Ethical Challenges of Germline Genetic Enhancement.

The new reproductive technologies have opened the door to different processes of germline genetic enhancement by which the characteristics of an individual according to the interests of the agents involved could be selected during its gestation. Although the initiative is apparently oriented towards developing individuals that would excel in society, critical voices raise the concerns about that this approach would generate and need for a reflection on the ethical, social and legal implications of these techniques and their implementation in society. We reviewed the literature about these issues throughout their historical records to date, focusing on the moral arguments and non-clinical aspects that affect the legal and social environment. We have observed various trends of thought with divergent positions (proactive, preventive, and regulatory) as well as a large number of articles that try to reconcile the different approaches. This review illustrates a series of concepts from the ethics and philosophy fields which are frequently used in studies that evaluate the ethical implications of germline genetic enhancement, such as dignity, benefit, autonomy, and identity. In addition, amongst the many unresolved controversies surrounding genetic enhancement, we identify procreative beneficence, genetic disassociation, gender selection, the value of disability, embryo chimerization, and the psychosocial inequality of potentially enhanced individuals as crucial. We also develop possible scenarios for future debate. We consider especially important the definition and specification of three aspects which are essential for the deployment of new reproductive technologies: the moral status of the embryo undergoing enhancement, the legal status of the enhanced individual, and the responsibility of the agents executing the enhancement. Finally, we propose the precautionary principle as a means to navigate ethical uncertainties.

Reflecting on the Reasons Pros and Cons Coercive Measures for Patients in Psychiatric and Somatic Care: The Role of Clinical Ethics Consultation. A Pilot Study.

Background and aim: Coercive measures in patient care have come under criticism leading to implement guidelines dedicated to the reduction of coercion. This development of bringing to light clinical ethics support is hoped to serve as a means of building up awareness and potentially reducing the use of coercion. This study explores the specific features of ethics consultation (EC) while dealing with coercion. Material and method: Basel EC documentation presents insight to all persons involved with a case. The EC database of two Basel university hospitals was developed on the grounds of systematic screening and categorization by two reviewers. One hundred fully documented EC cases databased from 2013 to 2016 were screened for the discussion of coercive measures (somatic hospital and psychiatry: 50% cases). Results: Twenty-four out of 100 EC cases addressed coercion in relation to a clinically relevant question, such as compulsory treatment (70.8%), involuntary committal (50%), or restricting liberty (16.6%). Only 58.3% of EC requests mentioned coercion as an ethical issue prior to the meeting. In no case was patient decisional capacity given, capacity was impaired (43.5%), not given (33.3%), or unclear (21.7%; one not available). Discussion: As clinical staff appears sensitive to perceiving ethical uncertainty or conflict, but less prepared to articulate ethical concern, EC meetings serve to “diagnose” and “solve” the ethical focus of the problem(s) presented in EC. Patient decisional incapacity proved to be an important part of reasoning, when discussing the principle of harm prevention. While professional judgment of capacity remains unsystematic, rationality or even ethicality of decision making will be hampered. The documented EC cases show a variety of decisions about whether or not coercion was actually applied. Ethical reasoning on the competing options seemed to be instrumental for an unprejudiced decision complying with the normative framework and for building a robust consensus. Conclusions: The recommendation is whether EC should be used as a standard practice whenever coercion is an issue—ideally before coercion is applied, or otherwise. Moreover, more efforts should be made toward early and professional assessment of patient capacity and advance care counseling including the offer of advance directives.

Advance decisions to refuse treatment and suicidal behaviour in emergency care: 'it's very much a step into the unknown'.

Complex challenges may arise when patients present to emergency services with an advance decision to refuse life-saving treatment following suicidal behaviour. To investigate the use of advance decisions to refuse treatment in the context of suicidal behaviour from the perspective of clinicians and people with lived experience of self-harm and/or psychiatric services. Forty-one participants aged 18 or over from hospital services (emergency departments, liaison psychiatry and ambulance services) and groups of individuals with experience of psychiatric services and/or self-harm were recruited to six focus groups in a multisite study in England. Data were collected in 2016 using a structured topic guide and included a fictional vignette. They were analysed using thematic framework analysis. Advance decisions to refuse treatment for suicidal behaviour were contentious across groups. Three main themes emerged from the data: (a) they may enhance patient autonomy and aid clarity in acute emergencies, but also create legal and ethical uncertainty over treatment following self-harm; (b) they are anxiety provoking for clinicians; and (c) in practice, there are challenges in validation (for example, validating the patient's mental capacity at the time of writing), time constraints and significant legal/ethical complexities. The potential for patients to refuse life-saving treatment following suicidal behaviour in a legal document was challenging and anxiety provoking for participants. Clinicians should act with caution given the potential for recovery and fluctuations in suicidal ideation. Currently, advance decisions to refuse treatment have questionable use in the context of suicidal behaviour given the challenges in validation. Discussion and further patient research are needed in this area. D.G., K.H. and N.K. are members of the Department of Health's (England) National Suicide Prevention Advisory Group. N.K. chaired the National Institute for Health and Care Excellence (NICE) guideline development group for the longer-term management of self-harm and the NICE Topic Expert Group (which developed the quality standards for self-harm services). He is currently chair of the updated NICE guideline for Depression. K.H. and D.G. are NIHR Senior Investigators. K.H. is also supported by the Oxford Health NHS Foundation Trust and N.K. by the Greater Manchester Mental Health NHS Foundation Trust.

Clinician, student and faculty perspectives on the audiology-industry interface: implications for ethics education

Objective: Supporting audiologists to work ethically with industry requires theory-building research. This study sought to answer: How do audiologists view their relationship with industry in terms of ethical implications? What do audiologists do when faced with ethical tensions? How do social and systemic structures influence these views and actions?Design: A constructivist grounded theory study was conducted using semi-structured interviews of clinicians, students and faculty.Study sample: A purposive sample of 19 Canadian and American audiologists was recruited with representation across clinical, academic, educational and industry work settings. Theoretical sampling of grey literature occurred alongside audiologist sampling. Interpretations were informed by the concepts of ethical tensions as ethical uncertainty, dilemmas and distress.Results: Findings identified the audiology–industry relationship as symbiotic but not wholly positive. A range of responses included denying ethical tensions to avoiding any industry interactions altogether. Several of our participants who had experienced ethical distress quit their jobs to resolve the distress. Systemic influences included the economy, professional autonomy and the hidden curriculum.Conclusions: In direct response to our findings, the authors suggest a move to include virtues-based practice, an explicit curriculum for learning ethical industry relations, theoretically-aligned ethics education approaches and systemic and structural change.

Developing clinical ethics support for an Australian Health Service: A survey of clinician’s experiences and views

Background: International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. Methods: Health professionals at a large regional health service completed an online survey containing questions about the frequency of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. Results: The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). Conclusions: A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education.

From polarization to reluctant acceptance–bioenergy with carbon capture and storage (BECCS) and the post-normalization of the climate debate

ABSTRACTThe paper covers the public debate on BECCS (bioenergy with carbon capture and storage) between 2008 and 2018. Through a qualitative analysis of around 800 feature articles, editorials, and opinion pieces published in English, German, Swedish, Danish, and Norwegian in news media and debates sections of scientific media, we highlight conspicuous aspects of the debate and relate them to the theoretical concept of post-normal science. We find that the debate is characterized by an emphasis on values, scientific uncertainty and the integrity of science, premised on a pervading sense of urgency. To a significant extent, the debate can be understood as a “normal” view of science questioning what it perceives to be unscientific model-based climate scenarios, and the scenarios, in turn, can be seen as a response to post-normal circumstances. The urgency permeating the debate provides conditions for open debate about ethical and epistemological uncertainty. The debate goes through a period of polarization – corroborating findings from previous studies on the climate science debate after COP21 – between an intense critique of BECCS inclusion in climate scenarios and reluctant acceptance thereof. Towards the end of the studied period, emphasis shifts towards reluctant acceptance, indicating that post-normal debate may only occur as a temporary state always tending towards new consensus.

New graduate occupational therapists' narratives of ethical tensions encountered in practice.

Professionals in health and social care have high workloads and are working with diverse populations in hierarchical and complicated service delivery systems. There is increasing pressure on new graduates because they are expected to be immediately work ready and may not receive adequate support or supervision. It is well known that there can be issues with satisfaction and retention rates of new graduates due to the challenges they experience. Ethical tensions are an unavoidable part of occupational therapy practice and may contribute to unique challenges for new graduates who may not yet have the personal resources to make sense of these independently. New graduate occupational therapy perceptions of ethical tensions have not yet been explored and this study sought to fill this gap. Exploring the ethical tensions experienced by new graduates can inform appropriate policies, procedures, preparedness and standards. A qualitative study using narrative enquiry was undertaken in which stories were gathered from eight new graduate occupational therapists who had been working for 6-24months. Semi-structured in-depth interviews were used to gather data. Transcripts were analysed following narrative analysis guidelines. Member checking, reflexivity and keeping an audit trail of methodological and analytical decisions were employed to strengthen the rigour of the study. Analysis revealed six predominant themes: working in a business model, respecting client choice, dealing with aggression and death, mandatory reporting is hard to do, differing team values, and feeling devalued and unsupported. The findings highlight the importance of understanding the ethical tensions faced by new graduates and of exploring ways to assist new graduates to respond constructively to ethical dilemmas, distress and uncertainties. To address the risk of attrition, graduates need systems in place for accessing support to increase preparedness to respond to ethical tensions when they do arise.

Ethical challenges experienced by public health nurses related to adolescents' use of visual technologies.

Visual technologies are central to youth culture and are often the preferred communication means of adolescents. Although these tools can be beneficial in fostering relations, adolescents' use of visual technologies and social media also raises ethical concerns. We explored how school public health nurses identify and resolve the ethical challenges involved in the use of visual technologies in health dialogues with adolescents. This is a qualitative study utilizing data from focus group discussions. We conducted focus group discussions using two semi-structured discussion guides with seven groups of public health nurses (n = 40) working in Norwegian school health services. The data were collected during January and October 2016. Discussions were audio recorded, transcribed, and coded into themes and subthemes using systematic text condensation. The leader of the public health nursing service who agreed to provide access for the study and the Norwegian Center for Research Data that reviewed and approved the study. All participants gave informed consent. In adolescents' use of visual materials with public health nurses, ethical concerns were raised regarding suicide ideations, socially unacceptable content, violation of privacy, and presentations of possible child neglect. The nurses utilized their professional knowledge and experience when identifying and navigating these ethical dilemmas; they resolved ethical uncertainties through peer discussion and collaboration with fellow nurses and other professionals. We discussed the findings in light of Annemarie Mol's interpretation of the ethics of care. Mol expands the notion of ethical care to include the action of technologies. Although the increasing use of visual technologies offered benefits, school nurses faced ethical challenges in health dialogues with adolescents. To address and navigate these ethical issues, they relied on their experience and caring practices based on their professional ethics. Uncertainties were resolved through peer dialogue and guidance.