Field Of Clinical Ethics Research Articles

Clinical Ethics Fellowship Programs in the United States and Canada: Program Directors’ Opinions About Accreditation and Funding

To succeed, an accreditation process for clinical ethics fellowship programs (CEFPs) would need support from CEFP directors. To assess CEFP directors’ opinions, we surveyed all 36 CEFP directors in the United States and Canada, achieving a 100% response rate. We found that support for accreditation is strong, with 30.6% strongly supportive, 44.4% supportive, 22.2% neutral, 2.8% opposed, and 0% strongly opposed. Most directors (77.8%) would be likely to apply for accreditation within the next five years regardless of the availability of government funding; even more (86.1%) would apply if government funding became available for accredited programs. Most directors thought that lack of a national accreditation process (75.0%), lack of agreed-upon standards (90.0%), and lack of funding for CEFPs (91.7%) were at least moderate problems for the field. When directors were asked what they thought was the greatest challenge or barrier to developing an accreditation process, many mentioned the diversity of programs and the challenge of achieving consensus on accreditation standards. Directors offered a variety of suggestions for how to overcome or manage challenges or barriers, including collecting data on existing programs, mirroring standards established for other health professions, and setting clear expectations on the need for compromise. When directors were asked how they expected that accreditation and government funding would affect their own programs, the field of clinical ethics, and patient care, directors mostly had very positive expectations; no director expected negative effects in any of these areas. Overall, this study provides evidence that developing an accreditation process for CEFPs would be both possible and desirable. Our findings have immediate practical implications for the field and will inform efforts that are already underway to establish an accreditation process for CEFPs.

Artificial Intelligence to support ethical decision-making for incapacitated patients: a survey among German anesthesiologists and internists

BackgroundArtificial intelligence (AI) has revolutionized various healthcare domains, where AI algorithms sometimes even outperform human specialists. However, the field of clinical ethics has remained largely untouched by AI advances. This study explores the attitudes of anesthesiologists and internists towards the use of AI-driven preference prediction tools to support ethical decision-making for incapacitated patients.MethodsA questionnaire was developed and pretested among medical students. The questionnaire was distributed to 200 German anesthesiologists and 200 German internists, thereby focusing on physicians who often encounter patients lacking decision-making capacity. The questionnaire covered attitudes toward AI-driven preference prediction, availability and utilization of Clinical Ethics Support Services (CESS), and experiences with ethically challenging situations. Descriptive statistics and bivariate analysis was performed. Qualitative responses were analyzed using content analysis in a mixed inductive-deductive approach.ResultsParticipants were predominantly male (69.3%), with ages ranging from 27 to 77. Most worked in nonacademic hospitals (82%). Physicians generally showed hesitance toward AI-driven preference prediction, citing concerns about the loss of individuality and humanity, lack of explicability in AI results, and doubts about AI’s ability to encompass the ethical deliberation process. In contrast, physicians had a more positive opinion of CESS. Availability of CESS varied, with 81.8% of participants reporting access. Among those without access, 91.8% expressed a desire for CESS.Physicians' reluctance toward AI-driven preference prediction aligns with concerns about transparency, individuality, and human-machine interaction. While AI could enhance the accuracy of predictions and reduce surrogate burden, concerns about potential biases, de-humanisation, and lack of explicability persist.ConclusionsGerman physicians frequently encountering incapacitated patients exhibit hesitance toward AI-driven preference prediction but hold a higher esteem for CESS. Addressing concerns about individuality, explicability, and human-machine roles may facilitate the acceptance of AI in clinical ethics. Further research into patient and surrogate perspectives is needed to ensure AI aligns with patient preferences and values in complex medical decisions.

AI as a Co-Author? We Should Also Ask Philosophical (and Ethical) Questions

Dear Editors With great interest and attention, I read authors’ short but stimulating editorial articles, which also contain extremely valuable questions [1]. The questions posed by the authors and the emphasis on referred articles reflecting different perspectives seem to reflect content about the practical benefits, risks, and inevitability of the use of technology. In addition, it is seen that the valuable comments on the article focus on issues such as the risk of harm and publication ethics issues in academic use of AI [2,3]. Considering the discourse of the article’s authors, which invites discussion, it is seen that questions that go beyond mere responsibility or practical benefits or risks should also be asked. In this context, I think that questions based on philosophical and ethical foundations should also be asked. For example, What is AI’s ontological position as a writer is a very fundamental question. That is, does AI reflect a “particular” individual/entity as “a writer”, or does it reflect cognitive domination that has the power to access and process the knowledge of entire humanity easily, or does AI reflect a collective mind or "universal" as a product of the knowledge and cognitive history of humanity as a whole? I think these questions are notable for AI’s position as an author and whether that position is acceptable. Again, should AI be considered a tool (is given instrumental purpose) or as a value in itself (has intrinsic value)? As a fundamental question, this is also important for the acceptability or position of AI as an author. Without going into deep discussions for now, for example, how or what is the difference between AI as a tool and a classical data analysis tool? Does such a difference, if any, really warrant the attribution of authorship to AI? Questions like these seem important. Although different ethical discussions seem possible, the concept of responsibility to which the authors refer seems worth discussing. For example, it is also remarkable whether AI, as a responsible subject in itself, can also become a tool for other authors to avoid some responsibilities in research and publication ethics. It is known that such a debate exists in the field of clinical ethics [4]. As a result, as the article authors said, the authorship of artificial intelligence will lead to important discussions. Therefore, it will be necessary to consider philosophical (and ethical) questions about the position of artificial intelligence. Yours sincerely,

Evaluation of clinical ethics in Iranian hospitals: Employing a 360° approach-A cross-sectional study.

Clinical ethics is defined as recognizing and resolving value conflicts that arise from providing care in medical centers. This study aimed to evaluate the practice of clinical ethics in Iranian hospitals with a 360° approach. The study was conducted by employing a descriptive-analytical method in 2019. The statistical population included staff, patients, and managers of public, private, and insurance hospitals in Mazandaran province. The sample size for each group was 317, 729, and 36, respectively. The data collection tool was a researcher-made questionnaire. The appearance and content validity of the questionnaire were confirmed by expert opinion and construct validity was confirmed by confirmatory factor analysis. The reliability was confirmed by Cronbach's alpha coefficient. Data were analyzed by one-way analysis of variance and Tukey's post-hoc test. We used SPSS software version 21 to analyse the data. The obtained mean score of clinical ethics from the perspective of service providers (0.56 ± 4.45) was higher than the perspective of service presenters (4.35 ± 0.65) and service recipients (0.79 ± 4.22), which was statistically significant (p < 0.05). Among the eight dimensions of clinical ethics, respect for the patient's right (0.68 ± 4.09) illustrated the highest score and medical error management (0.63 ± 4.33) presented the lowest score. Based on the findings of the study, the level of clinical ethics in the hospitals of Mazandaran province is favorable, and among the dimensions of clinical ethics, respect for patient rights gained the lowest score and communication with other colleagues gained the highest score. Therefore, informing and teaching medical professionals in the field of clinical ethics, formulating binding laws, and paying serious attention to this issue in ranking and accrediting hospitals are recommended.

The Need for Specialized Oncology Training for Clinical Ethicists.

Numerous ethical issues are raised in cancer treatment and research. Informed consent is challenging due to complex treatment modalities and prognostic uncertainty. Busy oncology clinics limit the ability of oncologists to spend time reinforcing patient understanding and facilitating end-of-life planning. Despite these issues and the ethics consultations they generate, clinical ethicists receive little if any focused education about cancer and its treatment. As the field of clinical ethics develops standards for training, we argue that a basic knowledge of cancer should be included and offer an example of what cancer ethics training components might look like. We further suggest some specific steps to increase collaboration between clinical ethicists and oncology providers in the outpatient setting to facilitate informed consent and proactively identify ethical issues.

Blind Spots Reconsidered – Epistemic Injustice in Clinical Ethics Support

"Conducting ethical case discussions is a core aspect of any clinical ethics support service or work as an ethical consultant in a hospital. Numerous case discussion methods can be used to do this, many of which are based on Beauchamp and Childress’ four biomedical principles. Other commonly used types are the ‘moral case deliberations’ by prominent authors such as Widdershoven, Molewijk et al. However, based on our practical work as clinical ethicists, and doctoral students in the field of clinical ethics, we would like to hypothesize that most of the methods seem to be in need of philosophical supplementation, especially on the blind spots regarding the is-ought fallacy, i.e. how to relate empirical data to normative conclusions. A further weakness may be found in the inadequate handling of power structures, which may lead to an unjust handling of opinions. In our talk, we will therefore present Miranda Fricker’s conceptual idea of ‘epistemic injustice’ and we will apply these insights to clinical cases of our everyday practice. Epistemic injustice is injustice related to knowledge. The concept focuses on exclusion and silencing people in public discourse. This silencing leads to a systematic distortion or misrepresentation of one’s meanings or contributions and/or to an undervaluing of someone’s status in communicative practices. We think that this concept has not been considered in clinical ethics thus far, and we would like to discuss whether ethical case discussions should not help to avoid epistemic injustice. If so, then the case discussion methods of our discipline should be adapted accordingly. "

Antiracist Activism in Clinical Ethics: What's Stopping Us?

Although justice is a central principle in clinical ethics, work that centers social justice is often marginalized in clinical ethics. In addition to institutional barriers that may be preventing clinical ethicists from becoming the activists that Meyers argues we should be, we must also recognize the barriers embedded in the field of clinical ethics itself. As clinical ethicists, we have an opportunity to support anti-racism work in particular by altering our own organizational structures to be more inclusive and reflective of the Black, Indigenous, and other communities of color we serve, enhancing clinical ethics education and training by making critical theories foundational, and decolonizing our clinical ethics consultation tools and practices.

Competencies and Milestones for Bioethics Trainees: Beyond ASBH’s Healthcare Ethics Consultant Certification and Core Competencies

Clinical ethics training programs are responsible for preparing their trainees to be competent ethics consultants worthy of the trust of patients, families, surrogates, and healthcare professionals. While the American Society for Bioethics and Humanities (ASBH) offers a certification examination for healthcare ethics consultants, no tools exist for the formal evaluation of ethics trainees to assess their progress toward competency. Medical specialties accredited by the Accreditation Council for Graduate Medical Education (ACGME) use milestones to report trainees’ progress along a continuum of professional development as a means of “operationalizing and implementing” medical competencies. Utilizing the Core Competencies for Healthcare Ethics Consultation and the ACGME and American Board of Pediatrics’ (ABP) Pediatric Milestones Project, we developed milestones for 17 subcompetencies in clinical ethics consultation and academic bioethics. As the field of clinical ethics becomes more standardized, such tools will be needed to promote the development of robust training programs and to certify that their graduates are competent practitioners.

Engaging Tomorrow\u2019s Doctors in Clinical Ethics: Implications for Healthcare Organisations

Clinical ethics can be viewed as a practical discipline that provides a structured approach to assist healthcare practitioners in identifying, analysing and resolving ethical issues that arise in practice. Clinical ethics can therefore promote ethically sound clinical and organisational practices and decision-making, thereby contributing to health organisation and system quality improvement. In order to develop students’ decision-making skills, as well as prepare them for practice, we decided to introduce a clinical ethics strand within an undergraduate medical curriculum. We designed a programme of clinical ethics activities for teaching and assessment purposes that involved using ethical frameworks to analyse hypothetical and real-life cases in uni- and inter- professional groups. In this paper, we draw on medical student feedback collected over 6 years to illustrate the appeal to students of learning clinical ethics. We also outline the range of benefits for students, healthcare organisations, and the field of clinical ethics arising from tomorrow’s doctors experiencing clinical ethics early in their training. We conclude by briefly reflecting on how including clinical ethics within tomorrow’s doctors curricular can secure and continue future engagement in clinical ethics support services in the UK, alongside the dangers of preparing students for organisational cultures that might not (yet) exist. We anticipate the findings presented in the paper will contribute to wider debates examining the impact of ethics teaching, and its ability to inform future doctors’ practice.

Debriefing as a Response to Moral Distress

There are few evidence-based interventions that have been developed that mitigate the negative effects of moral distress. Group debriefing is one approach that some clinical ethicists have adopted as a response. However, there is very little academic literature or empirical research that identifies best practices and approaches to debriefing as a response to moral distress. Our aim at the 2020 UnConference was to share our different approaches to debriefing with other clinical ethicists to identify best practices or guiding principles to enhance our respective approaches and meet the needs of healthcare professionals. In this article we share an overview of our respective approaches, reflect on our discussion with other clinical ethicists and healthcare professionals, and propose foundations to move debriefing forward as an intervention to address moral distress in the field of clinical ethics.

Clarifying a Clinical Ethics Service’s Value, the Visible and the Hidden

Our aim in this article is to define the difficulties that clinical ethics services encounter when they are asked to demonstrate the value a clinical ethics service (CES) could and should have for an institution and those it serves. The topic emerged out of numerous related presentations at the Un-Conference hosted by the Cleveland Clinic in August 2018 that identified challenges of articulating the value of clinical ethics work for hospital administrators. After a review these talks, it was apparent that the field of clinical ethics may be at a crisis of sorts due to increased pressure to provide explicit measures to healthcare institutions to concretely demonstrate that CESs make a valuable difference in healthcare delivery. In this article we grapple with how to satisfy the need for demonstrable value in a field in which metrics alone may not capture the scope of clinical ethics practice. We suggest that capturing the value of a CES has been difficult because the benefits of ethics consultation may be overt or attributable to the CES, but are often hidden due to the systems-level and process-oriented nature of clinical ethics work. Part of the difficulty in demonstrating the value of CESs is capturing and conveying all of the ways the integration of a CES throughout an institution positively affects patients, families, visitors, healthcare professionals, administrators, and the institution itself. Our aim is to (1) elucidate the multifaceted value added by a CES, including value that tends to be hidden and (2) suggest how to demonstrate value to others in a way that is not simplistic or reductionistic.

What Is the Minimal Competency for a Clinical Ethics Consult Simulation? Setting a Standard for Use of the Assessing Clinical Ethics Skills (ACES) Tool

Background: The field of clinical ethics is examining ways of determining competency. The Assessing Clinical Ethics Skills (ACES) tool offers a new approach that identifies a range of skills necessary in the conduct of clinical ethics consultation and provides a consistent framework for evaluating these skills. Through a training website, users learn to apply the ACES tool to clinical ethics consultants (CECs) in simulated ethics consultation videos. The aim is to recognize competent and incompetent clinical ethics consultation skills by watching and evaluating a videotaped CEC performance. We report how we set a criterion cut score (i.e., minimally acceptable score) for judging the ability of users of the ACES tool to evaluate simulated CEC performances.Methods: A modified Angoff standard-setting procedure was used to establish the cut score for an end-of-life case included on the ACES training website. The standard-setting committee viewed the Futility Case and estimated the probability that a minimally competent CEC would correctly answer each item on the ACES tool. The committee further adjusted these estimates by reviewing data from 31 pilot users of the Futility Case before determining the cut score.Results: Averaging over all 31 items, the proposed proportion correct score for minimal competency was 80%, corresponding to a cut score that is between 24 and 25 points out of 31 possible points. The standard-setting committee subsequently set the minimal competency cut score to 24 points.Conclusions: The cut score for the ACES tool identifies the number of correct responses a user of the ACES tool training website must attain to “pass” and reach minimal competency in recognizing competent and incompetent skills of the CECs in the simulated ethics consultation videos. The application of the cut score to live training of CECs and other areas of practice requires further investigation.

Ética de las virtudes y medicina (II)

El presente trabajo se propone establecer la actualidad de una ética de las virtudes de estilo aristotélico en el ámbito de la ética clínica. La relación establecida por Maclntyre entre las prácticas y los “patrones de excelencia” que rigen internamente su ejercicio, juntamente con el enfoque de Pellegrino y Thomasma de la medicina como “comunidad moral” en la que las habilidades técnico-científicas y la disposición moral del agente configuran una unidad indisoluble en el acto médico, son la base del análisis sobre la especificidad de la práctica médica y los consecuentes requerimientos morales de quienes la ejercen. La crisis de la medicina occidental que en los últimos treinta años provocó importantes puntos de fractura con la tradición hipocrática, ofrece una posibilidad de salida reinterpretando sus propios fines. De ello se sigue la necesidad de retomar líneas de la tradición que el ideal de la medicina científica, las reglas del mercado y la burocratización de la atención sanitaria parecieran haber obturado. En esta encrucijada es donde el énfasis puesto por la ética de las virtudes en el ethos profesional, anclado en el compromiso con las personas concretas cuyo beneficio da sentido a la actividad y a las instituciones médicas, resulta imprescindible para balancear las falencias de una ética fundada en principios, sin que ello implique renunciar a los efectivos logros del universalismo moral. AbstractThis work is meant to set up the present importance of the ethic of virtues, which follows the Aristotelian style in the field of clinical ethics. The relationship established by Maclntyre between the practices and the “patterns of excellence” which internally guides these practices, together with the view of Pellegrino and Thomasma about medicine as a “moral community” in which the technical-scientific skills and the agent’s moral dispositions shape an indissoluble link in the medical act, are the basis for the analysis on the specificity of the medical practice and the moral requirements of the practitioners. The crisis of western medicine that in the last thirty years has given rise to important break points with the hippocratic tradition, offers a possible resolution by the re-interpretation of its proper ends. Therefore, it is a need to return to traditional ways that seem to have lost vigour for the dominance of the ideal of a scientific medicine, for the market rules and bureaucratized health care. In this intersection, the emphasis on a virtue ethic on the professional ethos, grounded on the engagement with the patient whose benefit gives meaning to the activity and medical institutions, is indispensable for the balance of the failures of a principle-based ethic without renouncing to the effective achievement of moral universalism.

Philosophical Provocation: The Lifeblood of Clinical Ethics.

The daily work of the clinical ethics teacher and clinical ethics consultant falls into the routine of classifying clinical cases by ethical type and proposing ethically justified alternatives for the professionally responsible management of a specific type of case. Settling too far into this routine creates the risk of philosophical inertia, which is not good either for the clinical ethicist or for the field of clinical ethics. The antidote to this philosophical inertia and resultant blinkered vision of clinical ethics is sustained, willing exposure to philosophical provocation. The papers in this clinical ethics issue of the Journal of Medicine and Philosophy provide just such philosophical provocation related to core topics in clinical ethics: the distinction between clinical practice and clinical research; telemedicine, or medicine at a distance; illness narratives; the concept of the placebo effect; and sex reassignment.

Cancer and the computerized family: towards a clinical ethics of “indirect” Internet use

The normative dimensions of Internet use among patients and their families have not been studied in much depth in the field of clinical ethics. This study considers cancer-related Internet use among families and friends of cancer patients, and how that use of the Internet may affect patients and patient care. Interviews were conducted with 120 cancer patients, most of whom (76%) reported that family, friends, and others in their social network used the Internet in some way related to the patient's cancer. Many patients (73%) did not request this online help from their social networks, yet found it helpful and comforting nonetheless. Other patients were less positive about the helpfulness of the online efforts of friends and relatives. A significant proportion of patients (39%) also felt that the online information they received was prescreened or edited in some way. Very few patients recalled that their clinicians ever discussed these and other issues with them. The study illustrates that indirect Internet use is a central feature of the cancer experience. In contrast to other literature in this area, the study suggests that indirect Internet use may have normatively positive and negative implications for patients. These implications point towards the importance of studying and understanding indirect Internet use-and Internet use in general-in the field of clinical ethics.

Experts in Ethics

Madam: two articles on Experts in Ethics (HCR, November-December 1998) present an interesting view on the nature of expertise in the field of clinical ethics. first article (David J. Casarett, Frona Daskal, and John Lantos, The Authority of the Clinical Ethicist) stresses the importance of communication and consensus. second (Scot D. Yoder, The Nature of Ethical Expertise) defines expertise in terms of reasoning and providing justifications. As such, they make explicit some central aspects of clinical ethics work. Both articles try to give a foundation for clinical ethics by referring, respectively, to Habermas and Aristotle. Although the two contributions are certainly relevant, they also tend to be onesided, both in their view of clinical ethics practice and in their interpretation of philosophical theory. They tend to underestimate the fact that clinical ethics is highly contextual, and that its most important feature is the ethical assessment of concrete situations-an issue that makes the ethical theories of Habermas and Aristotle relevant for clinical ethics in ways the authors seem to overlook. According to Aristotle ethics is always about concrete situations. Clinical ethics is a splendid example of practical philosophy in the Aristotelian sense-that is, of a discipline that requires knowledge about particulars as well as knowledge about general rules and principles. essence of expertise in this field is to apply general rules to the concrete situation, to see how general principles fit to specific circumstances. This means that an expert in clinical ethics is not only able to establish relevant general rules, but also to see to it that they are applied in the right manner. This expertise can be called hermeneutic competence. Aristotelian perspective presupposes that ethics deals with truth. In this respect it is at odds with Yoder's suggestion that it is sufficient to provide a coherent justification for one's judgment. For Aristotle, coherence is not good enough; a recommendation is valid only if it is the best policy, given the concrete situation. It is, however, not easy to establish this. People need experience to apply rules and principles. Even experienced persons will have to know a lot about the details of the situation before they can give a sound judgment. This may explain the divergence in outcome when ethics consultants are asked to respond to hypothetical cases: such cases are probably too abstract and too thin for concrete recommendations. Habermas shares with Aristotle the presupposition that ethics is about truth. He claims that moral judgments can be right or wrong. He also agrees with Aristotle that ethics deals both with principles and with their application to concrete circumstances. Habermas gives ethics an intersubjective twist, however. Both the validity of general principles and the adequacy of their application to specific situations are not to be established through individual reasoning, but through dialogue and discussion. Habermas distinguishes between two kinds of institutionalized discussions regarding ethical issues: practical discourse and application discourse. Practical discourse is about the general validity of norms and principles; application discourse is about their application to a specific situation. Practical discourse aims at universalization, whereas application discourse aims at contextualization. In his theory of discourse ethics, Habermas puts most emphasis on the concept of practical discourse. This has given rise to the criticism that he tends to overlook the im-

THE MORAL ETHOS OF MEDICAL EDUCATION

The moral ethos of medial education refers to the fundamental values that pervade the field of medical education. There has been a dramatic expansion of both interest and activities related to the broad field of biomedical ethics, due largely to the sociocultural forces that have emerged as powerful influences during the last generation. In considering the ways in which ethics appears in medical education, it is necessary to consider first how it appears in the world of medicine. Dr Edmund Pellegrino provides us with a philosophy of medicine that is a thoughtful starting point for ethics in medicine. We then proceed to consider the field of clinical ethics, the place of ethics in the care of communities or populations, how these fields appear in medical education, and finally how these issues might relate to the ethical development of academic medical centres.

The Role of a Mobile Palliative Care Team in the Field of Clinical Ethics

The Role of a Mobile Palliative Care Team in the Field of Clinical Ethics

Issues in clinical ethics consultation: an introduction.

Any area that surges ahead as rapidly as this one [clinical ethics] has over the last five years is virtually certain to find that there are many problems which will need to be addressed. There will also be a need for persons working in this field (or studying it) to take some time to reflect on where it is going, as well as to examine some of the possible pitfalls -- both the obvious and the not so obvious -- which lie ahead. The series of papers in this issue of Theoretical Medicine have been written by a group of ethicists who have had a longstanding interest in the field of clinical ethics, and most of whom have spent many years working in the area. While all of the papers focus on the field of clinical ethics, they are very diverse in the topics covered. Some may be viewed as controversial by readers....