Ethics Consultation Research Articles

ChatGPT: aid to medical ethics decision making?

Physicians have to make countless decisions every day. The medical, ethical and legal aspects are often intertwined and subject to change over time. Involving an ethics committee or arranging an ethical consultation are examples of potential aids to decision making. Whether and how artificial intelligence (AI) and the large language model (LLM) of the company OpenAI (San Francisco, CA, USA), known under the name ChatGPT, can also help and support ethical decision making is increasingly becoming amatter of controversial debate. Based on acase example, in which afemale physician is confronted with ethical and legal issues and presents these to ChatGPT to come up with answers, the first indications of the strengths and weaknesses are ascertained. Due to the rapid technical development and access to ever increasing quantities of data, the utilization should be closely observed and evaluated.

Frequency of Perceived Conflict between Families and Clinicians at Time of Clinical Ethics Consultation in Hospitalized Children

Background Little is known about the frequency of conflict between clinicians and families at the time of pediatric clinical ethics consultation (CEC) and what factors are associated with the presence of conflict. Methods We conducted a retrospective cohort study at a single, tertiary urban US pediatric hospital that included all hospitalized patients between January 2008 and December 2019 who received CEC. Utilizing the hospital’s CEC database that requires documentation of the presence of conflict by the consultant at the time of CEC, we determined the frequency and types of perceived conflict between families and clinicians. We also assessed the bivariable association between conflict and patient age, patient- or family-reported race/ethnicity, language for care, insurance status, clinical setting, and consultant involvement. Results Perceived conflict between clinicians and families was present in 44% (91/209) of CEC. We observed a higher occurrence of clinician-family conflict within certain consult topics than others, in particular, informed consent/parental permission (69%), cultural considerations (67%), benefit/harm assessment (58%), and limitation of life-sustaining treatment (58%). We found no other significant associations between the presence of perceived conflict and patient sociodemographic factors or CEC factors. Conclusions Conflict between healthcare teams and families appears common in CEC, particularly with certain consult topics. Further study is needed to better understand conflict types, causes of conflicts, management and mediation strategies, and outcomes.

Clinical Ethics Consultation in Japan: What does it Mean to have a Functioning Ethics Consultation?

This research examines the current status of clinical ethics consultation (CEC) in Japan through a nationwide study conducted with chairs of ethics committees and clinical ethics committees among 1028 post-graduate clinical teaching hospitals. We also qualitatively analyzed their viewpoints of the CEC’s benefits and problems related to hospital consultation services to identify the critical points for CEC and inform the development of a correctly functioning system. The questionnaire included structured questions about hospital CEC organization and service purpose and operation and open-ended questions about the benefits and problems of initiating CEC. The questionnaire comprised the presence/absence of an ethics committee, CEC services and membership when services were implemented, users, and the number of cases handled since inception. In addition, the respondents also provided their impressions of the CEC system’s impact on their hospital by describing (a) the benefits of CEC services and (b) the ineffectual or harmful aspects of the CEC system. Qualitative data were examined using qualitative content analysis to determine the impact of establishing a CEC and the difficulties of practice. One hundred twenty-five questionnaires were returned from either the chair of the ethics committee or clinical ethics committee in teaching hospitals. Of these, 90 (72%) reported they provided CEC services. Additionally, 36 respondents (34.6%) reported that their existing research and clinical ethics committees had conducted CEC services, and 35 (33.7%) reported having a newly established clinical ethics committee conducting CEC services. Three positive effects of establishing and four challenges in managing CEC were also identified.

Toward a Social Bioethics Through Interpretivism: A Framework for Healthcare Ethics.

Recent global events demonstrate that analytical frameworks to aid professionals in healthcare ethics must consider the pervasive role of social structures in the emergence of bioethical issues. To address this, the authors propose a new sociologically informed approach to healthcare ethics that they term "social bioethics." Their approach is animated by the interpretive social sciences to highlight how social structures operate vis-à-vis the everyday practices and moral reasoning of individuals, a phenomenon known as social discourse. As an exemplar, the authors use social bioethics to reframe common ethical issues in psychiatric services and discuss potential implications. Lastly, the authors discuss how social bioethics illuminates the ways healthcare ethics consultants in both policy and clinical decision-making participate in and shape broader social, political, and economic systems, which then cyclically informs the design and delivery of healthcare.

It’s Worth What You Can Sell It for: A Survey of Employment and Compensation Models for Clinical Ethicists

This article reports results of a survey about employment and compensation models for clinical ethics consultants working in the United States and discusses the relevance of these results for the professionalization of clinical ethics. This project uses self-reported data from healthcare ethics consultants to estimate compensation across different employment models. The average full-time annualized salary of respondents with a clinical doctorate is $188,310.08 (SD=$88,556.67), $146,134.85 (SD=$55,485.63) for those with a non-clinical doctorate, and $113,625.00 (SD=$35,872.96) for those with a masters as their highest degree. Pay differences across degree level and type were statistically significant (F = 3.43; p < .05). In a multivariate model, there is an average increase of $2,707.84 for every additional year of experience, controlling for having a clinical doctorate (ß=0.454; p < .01). Our results also show high variability in the backgrounds and experiences of healthcare ethics consultants and a wide variety of employment models. The significant variation in employment and compensation models is likely to pose a challenge for the professionalization of healthcare ethics consultation.

Fostering moral resilience through moral case deliberation

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience.

Perspectives on the role of the nurse ethicist

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between ‘nurse ethicist’ and ‘clinical ethicist’ is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the ‘tacit knowledge’ and ‘lived experience’ they bring to clinical ethics consultation. However, the second author also warns that the ‘nurse ethicist’ must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as ‘nurse ethicist’ on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.

Beyond the consult question: Nurse ethicists as architects of moral spaces

Nurse Ethicists bring a unique perspective to clinical ethics consultation. This perspective provides an appreciation of ethical tensions that will exist beyond the consult question into the moral space of patient care. These tensions exist even when an ethically preferable plan of action is identified. Ethically appropriate courses of action can still lead to moral dilemmas for others. The nurse ethicist provides a lens well suited to identify and respond to these dilemmas. The nurse–patient relationship is the ethical foundation of nursing practice and this relational ontology is well suited to addressing ethical dilemmas that exist prior to and beyond the initial consult question. This paper will describe one nurse ethicist’s phronetic and pragmatic approach to a clinical ethics consult elucidated through feminist ethics and systems thinking. This paper will describe the theoretical basis for this method, present a case, and describe how this consultation approach provides a rich analysis based around relationships and responsibilities that also highlights the important ethical tensions within the social structure that exists around the patient and continue after the consult question is answered.

Changes in the routine work and moral distress in psychiatric care during the COVID-19 pandemic : A survey among physicians active in inpatient care in Germany

During the COVID-19 pandemic anumber of ethical challenges have arisen in the healthcare system. Apsychological response to moral challenges is termed moral distress (MD). Identification of causes of MD in inpatient psychiatric care in the context of the COVID-19 pandemic in Germany. Asurvey was conducted using aself-administered non-validated online questionnaire as part of across-sectional study, in which 26items about the experience of MD were examined and open questions about the handling of the pandemic and its effects on everyday work were posed. Physicians who worked in inpatient psychiatric care during the COVID-19 pandemic in Germany were surveyed anonymously with aconvenience sample. The data acquisition took place between 17 November 2020 and 6 May 2021. A total of 141participants were included. They indicated multiple pandemic-related changes in their daily work partly resulting in MD. MD is aneglected potential burden of inpatient psychiatric care under pandemic conditions (and beyond), which requires further research and an adequate handling. These results include implications for decision makers in crisis teams as well as aneed for support services such as clinical ethics consultation services.

Declining to Provide or Continue Requested Life-Sustaining Treatment: Experience With a Hospital Resolving Conflict Policy.

In 2015, the major critical care societies issued guidelines outlining a procedural approach to resolving intractable conflict between healthcare professionals and surrogates over life-sustaining treatments (LST). We report our experience with a resolving conflict procedure. This was a retrospective, single-centre cohort study of ethics consultations involving intractable conflict over LST. The resolving conflict process was initiated eleven times for ten patients over 2,015 ethics consultations from 2000 to 2020. In all cases, the ethics committee recommended withdrawal of the contested LST. In seven cases, the patient died or was transferred or a legal injunction was obtained before completion of the process. In the four cases in which LST was withdrawn, the time from ethics consultation to withdrawal of LST was 24.8 ± 12.2 days. Healthcare provider and surrogate were often distressed during the process, sometimes resulting in escalation of conflict and legal action. In some cases, however, surrogates appeared relieved that they did not have to make the final decision regarding LST. Challenges regarding implementation included the time needed for process completion and limited usefulness in emergent situations. Although it is feasible to implement a due process approach to conflict over LST, there are factors that limit the procedure's usefulness.

Clinical Ethics Committee in an Oncological Research Hospital: two-years Report.

Clinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020, a CEC was established in an Oncology Research Hospital in the North of Italy. This paper describes the development process and the activities performed 20months from the CEC's implementation, to increase knowledge about CEC's implementation strategy. We collected quantitative data related to number and characteristics of CEC activities carried out from October 2020 to June 2022 using the CEC internal database. Data were reported descriptively and compared with data from the literature to provide a complete overview of the CEC's development and implementation process. The study has been conducted at the local health authority (LHA) of Reggio Emilia. It is a report of the activities provided by the CEC, where no HPs or patients were involved. The report is part of a larger study named EVAluating a Clinical Ethics Committee implementation process (EvaCEC), which has been approved by the Local Ethics Committee (AUSLRE Protocollo n° 2022/0026554 of 24/02/2022). EvaCEC is also the first author's PhD project. In total, the CEC performed 7 ethics consultations (EC), published three policies related to particular ethical questions of clinical and organizational practice, provided one educational online course on ethics consultation targeting employed HPs, and promoted a specific dissemination process among the different departments of the LHA. According to our results, the CEC widely fulfilled the standard threefold set of clinical ethics support services tasks (namely, ethics consultation, ethics education, and policy development), but further investigations are needed to evaluate the CEC's impact on clinical practice. Our findings may increase knowledge regarding the composition, role, and tasks of a CEC in an Italian setting, informing future strategies and efforts to regulate these institutions officially.

Recommendations for documentation and report drafting of clinical ethics consultation cases

Recommendations for documentation and report drafting of clinical ethics consultation cases

가톨릭 의료기관 임상윤리자문 활성화를 위한 지침과 방안에 대한 고찰

In the pluralistic society where the medical technology is highly advanced, the role of clinical ethics consultation that helps to solve the ethical conflicts in health care is getting important. Clinical ethics consultation is an activity to support informed, deliberative decision making on the part of patients, families, and the health care team in the patient care. In Korea, clinical ethics consultation was regulated as an activity of the institutional ethics committee with the enforcement of the 「Act on Hospice and Palliative Care and Decisions on Life-sustaining Treatment for Patients at the End of Life」 in 2018, However, most health care institutions in Korea do not provide clinical ethics consultation, and this situation is the same even for Catholic health care institutions, which account for 8 percent of health care in Korea. In particular, Catholic health care institutions should be able to provide effective ethical consultation with specific ethical guidelines and activation plans that are consistent with Catholic spirituality, even in the midst of rapid medical development and social/institutional changes. Therefore, it is judged appropriate to apply the 『Ethics and Religious Directive for catholic Health Care Service : ERDs』 published by United Conference of Catholic Bishops as an appropriate model for the corresponding ethical guidelines. In addition, the specific case of the Catholic Medical Center, which is making progress in activating clinical ethics consultation, can suggest a direction for the activation of clinical ethics consultation in other Catholic healthcare institutions and can be a exemple worth sharing with all medical institutions pursuing holistic health care. If clinical ethics advice is activated and properly operated in Catholic health care institutions, it will become the conscience of the institution communicating to realize the best interests of patients, and high quality health care services will be achieved by protecting the rights and conscience of medical staff. This will be of great help in protecting the identity of a Catholic health care institution serving human dignity and value in the increasingly industrialized medical field.

Recomendaciones para la elaboración de informes y documentación en los casos de consultoría de ética clínica

Recomendaciones para la elaboración de informes y documentación en los casos de consultoría de ética clínica

Liberal-democratic values and philosophers' beliefs about moral expertise.

In recent decades, the discipline of bioethics has grown rapidly, as has the practice of ethical consultation. Interestingly, this new recognition of the relevance of moral philosophy to our daily life has been accompanied by skepticism among philosophers regarding the existence of moral expertise or the benefits of philosophical training. In his recent article in Bioethics, William R. Smith suggested that this skepticism is rooted in philosophers' belief that moral expertise is inconsistent with liberal-democratic values, when in fact they are compatible. In this paper, we provide a unique opportunity to empirically examine Smith's observation by utilizing and extending global data on philosophers' beliefs about moral expertise, involving 4087 philosophers from 96 countries. Our findings support Smith's theoretical observation and show that societal levels of support for liberal-democratic values are associated with greater skepticism about moral expertise. We suggest that these findings might be explained by the cognitive process of motivated reasoning and an invalid inference of "is" from "ought." Consequently, the potential tension between moral expertise and liberal-democratic values is invalidly used for rejecting the existence of moral expertise, while its main and valid implication is for how moral expertise should be applied in liberal-democratic settings.

Sub-categories of moral distress among nurses: A descriptive longitudinal study.

There is ongoing debate regarding how moral distress should be defined. Some scholars argue that the standard "narrow" definition overlooks morally relevant causes of distress, while others argue that broadening the definition of moral distress risks making measurement impractical. However, without measurement, the true extent of moral distress remains unknown. To explore the frequency and intensity of five sub-categorizations of moral distress, resources used, intention to leave, and turnover of nurses using a new survey instrument. A mixed methods embedded design included a longitudinal, descriptive investigator-developed electronic survey with open-ended questions sent twice a week for 6weeks. Analysis included descriptive and comparative statistics and content analysis of narrative data. Registered nurses from four hospitals within one large healthcare system in Midwest United States. IRB approval was obtained. 246 participants completed the baseline survey, 80 participants provided data longitudinally for a minimum of 3 data points. At baseline, moral-conflict distress occurred with the highest frequency, followed by moral-constraint distress and moral-tension distress. By intensity, the most distressing sub-category was moral-tension distress, followed by "other" distress and moral-constraint distress. Longitudinally, when ranked by frequency, nurses experienced moral-conflict distress, moral-constraint distress, and moral-tension distress; by intensity, scores were highest for moral-tension distress, moral-uncertainty distress, and moral-constraint distress. Of available resources, participants spoke with colleagues and senior colleagues more frequently than using consultative services such as ethics consultation. Nurses experienced distress related to a number of moral issues extending beyond the traditional understanding of moral distress (as occurring due to a constraint) suggesting that our understanding and measurement of moral distress should be broadened. Nurses frequently used peer support as their primary resource but it was only moderately helpful. Effective peer support for moral distress could be impactful. Future research on moral distress sub-categories is needed.

Discussion Guide for the Rushton Article

Discussion Guide for the Rushton Article

Clinical ethics problems in psychiatry and the need for clinical ethics consultation in Japan: A cross-sectional study.

Psychiatrists often encounter ethical dilemmas in their daily clinical practice. Clinical ethics consultations (CECs) have been recently increasing, especially in general hospitals. However, the current situation in the psychiatric field is unclear. This study clarifies clinical ethics problems in psychiatry and determines the need for CECs. We conducted an anonymous self-administered questionnaire survey in February 2022, which targeted directors and supervisors of psychiatric specialty training programs at 1224 psychiatry facilities. Responses were received from 311 facilities (response rate: 25.4%). CEC systems existed in 223 (72.2%) facilities, and medical safety committees were the most common. Clinical ethics problems occurred at 248 (80.3%) facilities; the most common method for managing the problems was discussions at case conferences without using CECs. The top four reasons for psychiatrists to solicit advice were conflicts with patients' relatives, treating a patient with cognitive impairment, discontinuation of treatment, and suicide/attempted suicide. Most respondents (89.9%) considered CECs necessary. Although CECs exist in psychiatry, they may not meet the needs of clients. Future studies are needed to investigate client satisfaction and CEC evaluation methods in facilities where psychiatric CECs are provided.

Disparities in Clinical Ethics Consultation among Hospitalized Children: A Case-Control Study

To identify sociodemographic factors associated with pediatric clinical ethics consultation (CEC). Matched, case-control study at a single center, tertiary pediatric hospital in the Pacific Northwest. Cases (patients hospitalized January 2008-December 2019 with CEC) were compared with controls (those without CEC). We determined the association of the outcome (CEC receipt) with exposures (race/ethnicity, insurance status, and language for care) using univariate and multivariable conditional logistic regression. Of 209 cases and 836 matched controls, most cases identified as white (42%), had public/no insurance (66%), and were English-speaking (81%); most controls identified as white (53%), had private insurance (54%), and were English-speaking (90%). In univariate analysis, patients identifying as Black (OR: 2.79, 95% CI: 1.57, 4.95; P<.001), Hispanic (OR: 1.92, 95% CI: 1.24, 2.97; P=.003), with public/no insurance (OR: 2.21, 95% CI: 1.58, 3.10; P<.001), and using Spanish language for care (OR: 2.52, 95% CI: 1.47, 4.32; P<.001) had significantly increased odds of CEC, compared with patients identifying as white, using private insurance, and using English for care, respectively. In multivariable regression, Black race (adjusted OR: 2.12, 95% CI: 1.16, 3.87; P=.014) and public/no insurance (adjusted OR: 1.81, 95% CI: 1.22, 2.68; P=.003) remained significantly associated with receipt of CEC. We found disparities in receipt of CEC by race and insurance status. Further study is needed to determine the causes of these disparities.

480 Integrating a Research Ethics Program within an Academic Health Science Center

OBJECTIVES/GOALS: Research ethics services are critical to the clinical, research, and educational missions of an academic health science center. Our ethics program aims to develop a culture where investigators are as intellectually engaged in ethical issues of scientific integrity as they are in study design, data collection, and implementation. METHODS/STUDY POPULATION: This descriptive analysis depicts the historical development, from 2010 to 2022, of our research ethics program as an exemplar of ethics integration into the research enterprise of an academic health science center that engages in translational research. In this culture, clinicians, translational researchers and their scientific peers, research participants, and community members become involved in ethics investigation, deliberation, and innovation. RESULTS/ANTICIPATED RESULTS: There are four pillars to our research ethics program: 1) research ethics consultation service, which fosters the development of ethical best practices and standards for the practice of translational research; 2) education, which provides customized training and educational opportunities in research ethics to diverse stakeholders; 3) leadership, through collaboration and partnerships; 4) scholarly engagement, in the pursuit of innovative ethics research and professional development. Through these initiatives we can engage a broad constituency of stakeholders, become an integral component of research oversight, engage as active participants in the research enterprise, and have a critical role in guiding institutional culture. DISCUSSION/SIGNIFICANCE: The integration of our ethics program mirrors the translational science continuum which promotes the multidirectional flow of ideas among ethics consultants, laboratory/clinical scientists, implementation researchers and the community.