Ethical Support Research Articles

임상윤리서비스를 위한 핵심역량*

Clinical Ethics Support Services (CESS) aim to assist those confronting ethical issues that arise in the course patient treatment. CESS enhances the quality of health care by identifying and resolving ethical issues in a systematic fashion. In Korea, while the function of Institutional Ethics Committees varies somewhat from one institution to the next, most committees focus mainly on administrative services related to life-sustaining treatment. Due to improvements in medical technology and a rapidly changing social environment, a multidisciplinary approach is essential to assisting medical personnel in the area of clinical ethics. This study examines the key participants and core competencies of CESS providers and considers what knowledge or skills could improve them. It is argued that the core competencies for CESS are the ability to investigate and evaluate ethical issues and the ability to reach agreements by means of arbitration and conciliation in the case of disputes. Understanding the suffering of individual patients and recognizing the uniqueness of each patient are also essential to effective mediation on critical life-related issues. CESS providers should be trained to understand the difficulties that patients facing existential problems experience and to advocate for those patients.

Evaluation of Research Accessibility and Data Elements of HIV Registries.

Patient registries represent a long-term data collection system that is a platform for performing multiple research studies to generate real-world evidence. Many of these registries use common data elements (CDEs) and link data from Electronic Health Records. This study evaluated HIV registry features that contribute to the registry's usability for retrospective analysis of existing registry data or new prospective interventional studies. We searched PubMed and ClinicalTrials.gov (CTG) to generate a list of HIV registries. We used the framework developed by the European Medical Agency (EMA) to evaluate the registries by determining the presence of key research features. These features included information about the registry, request and collaboration processes, and available data. We acquired data dictionaries and identified CDEs. We found 13 HIV registries that met our criteria, 11 through PubMed and 2 through CTG. The prevalence of the evaluated features ranged from all 13 (100%) having published key registry information to 0 having a research contract template. We analyzed 6 data dictionaries and identified 14 CDEs that were present in at least 4 of 6 (66.7%) registry data dictionaries. The importance of registries as platforms for research data is growing and the presence of certain features, including data dictionaries, contributes to the reuse and secondary research capabilities of a registry. We found some features such as collaboration policies were in the majority of registries while others such as, ethical support, were in a few and are more for future development.

Lessons learned from implementing a responsive quality assessment of clinical ethics support

BackgroundVarious forms of Clinical Ethics Support (CES) have been developed in health care organizations. Over the past years, increasing attention has been paid to the question of how to foster the quality of ethics support. In the Netherlands, a CES quality assessment project based on a responsive evaluation design has been implemented. CES practitioners themselves reflected upon the quality of ethics support within each other’s health care organizations. This study presents a qualitative evaluation of this Responsive Quality Assessment (RQA) project.MethodsCES practitioners’ experiences with and perspectives on the RQA project were collected by means of ten semi-structured interviews. Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of the decisions.ResultsThe main findings illustrate the relevance of the RQA with regard to fostering the quality of CES by connecting to context specific issues, such as gaining support from upper management and to solidify CES services within health care organizations. Based on their participation in the RQA, CES practitioners perceived a number of changes regarding CES in Dutch health care organizations after the RQA: acknowledgement of the relevance of CES for the quality of care; CES practices being more formalized; inspiration for developing new CES-related activities and more self-reflection on existing CES practices.ConclusionsThe evaluation of the RQA shows that this method facilitates an open learning process by actively involving CES practitioners and their concrete practices. Lessons learned include that “servant leadership” and more intensive guidance of RQA participants may help to further enhance both the critical dimension and the learning process within RQA.

Role of Clinical Ethics Support Services in End-of-Life Care and Organ Transplantation

At times, clinical expertise may not be sufficient to find a way out of a moral impasse, especially in the context of end-of-life and organ transplantation decisions. Advances in medical knowledge and technology, and highly pluralistic and multicultural societies, have led to the emergence of new ethical problems in daily clinical practice along with the need to manage them in a prompt and effective manner. Clinical ethics developed in the late 1970s and early 1980s in North American health care contexts with the aim of identifying, analyzing, and attempting to resolve ethical conflicts and dilemmas at the patient’s bedside. At present, only a few regions in Italy have established clinical ethics committees, and Italy may count on a very small number of clinical ethics services fully devoted to ethics case consultation, guidelines development, and the education of health care providers and citizens. Despite this situation, one has to acknowledge both the increasing request for ethics support coming from health care providers who experience an “ethical vacuum” in the Italian health care system and the cultural change that is affecting Italy nowadays. By highlighting clinical examples and sharing experiences, we show and encourage the potential benefits of establishing clinical ethics services in Italian health care contexts.

The unlikely legalization of medical cannabis in Albania: a case study.

Cannabis abuse has been an issue of major concern for the Albanian society in recent years, following the wide illegal planting of the species. Legal lacunas, weaknesses from the drug-controlling agencies, and the easiness of harvesting Cannabis sativa plants have contributed to the creation of a general negative opinion toward a potential use of its active principles for medical purposes. Professionals of the field and policymakers are largely focused on harm reduction activities, thus bypassing the option of legalizing cannabinoids for clinical conditions that might find relief in their use. The discussion of a case suffering from postherpetic neuralgia shows how this negative opinion is depriving Albanian patients from an otherwise helpful pharmacological option whose efficacy has been confirmed by an important bulk of research. Uncovering the roots of this misperception will help address the issue. Clinicians with expertise need to have their say in the debate, since for the majority of countries where medicinal cannabis is legalized, this was due to consumer-led initiatives. Ensuring patients’ freedom as implied within the principle of autonomy is also a sound ethical support of such legalization.

Clinical ethics dilemmas in a low-income setting - a national survey among physicians in Ethiopia

BackgroundEthical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals.MethodA national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used and the responses to the open-ended question “If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?” were analyzed using a template analysis process.ResultsA total of 587 physicians responded (response rate 91,7%), and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results.DiscussionEthiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe.

Key Success Factors the Implementation of Performance Measurement System for Lecturer: Evidence from Indonesia

The phenomenon of low performance of university lecturers in Indonesia has led to the emergence of an initiative by universities to develop a performance measurement system for lecturers (PMSL). Any factor that becomes the key success to the policy for implementing the PMSL is still an interesting research gap to be studied further. For that reason, this study aimed to examine ethical leadership, organizational support, and participative decision-making policies as PMSL implementation determinants. The latter variable was also analyzed as an intervening variable. Using 203 data from a questionnaire completed by lecturers at Indonesian top private universities (accredited A and in possession of the internationalization program), we tested the hypothesis using Partial Least Square (PLS) approach. The results of this study indicated that there was a positive influence of ethical leadership, organizational support, and participative decision-making for the successful PMSL implementation. Moreover, participative decision-making also played a prominent role in making PMSL implementation a success, namely as an intervening variable. Further discussion is presented in this paper.

Developing a 'moral compass tool' based on moral case deliberations: A pragmatic hermeneutic approach to clinical ethics.

Although moral case deliberation (MCD) is evaluated positively as a form of clinical ethics support (CES), it has limitations. To address these limitations our research objective was to develop a thematic CES tool. In order to assess the philosophical characteristics of a CES tool based on MCDs, we drew on hermeneutic ethics and pragmatism. We distinguished four core characteristics of a CES tool: (a) focusing on an actual situation that is experienced as morally challenging by the user; (b) stimulating moral inquiry into the moral concepts, questions and routines in the lived experience of the CES tool user; (c) stimulating moral learning by exploring other perspectives; and (d) incorporating contextual details. We provide an example of a CES tool developed for moral dilemmas over client autonomy. Our article ends with some reflections on the normativity of the CES tool, other application areas and the importance of evaluation studies of CES tools.

ФОРМИРОВАНИЕ КУЛЬТУРЫ ВЫБОРА ПРОФЕССИОНАЛЬНОГО ДЕЙСТВИЯ В ХОДЕ ОБУЧЕНИЯ СОТРУДНИКОВ СИЛОВЫХ СТРУКТУР НА ОСНОВЕ ДЕОНТОЛОГИЧЕСКИХ ПРИНЦИПОВ

The article examines the peculiarities of teaching the tactics of using physical force to law enforcement officers. Deontological orientations of professional ethics are analysed. The paper identifies the aspects of using the educational potential of training based on life situations modelling and aimed to train a student to apply the techniques of struggle. The authors emphasize the conception of ethical and psychological support of law enforcement officers’ educational process; such an approach is motivated by the necessity to introduce practically oriented tasks aimed to form the students’ individual law enforcement techniques.

Ethical Infrastructure for a Modern Judiciary

The ethical conduct of judicial officers has been traditionally seen as a matter for individual judges to determine for themselves. Today, judges are still frequently left to consider ethical dilemmas with little formal institutional support. They must rely on their own resources or informal advice and counsel from colleagues and the head of jurisdiction. This article will explore whether this arrangement continues to be appropriate. We consider a hypothesis that a number of factors, including the growing numbers and diversity of the judiciary mean that it is less likely that there will be common understandings of the ethical values to be employed in resolving difficult dilemmas. Thus, we further hypothesise, the traditional arrangements are likely to prove insufficient. Drawing on the findings of a survey of judicial officers across Australian jurisdictions conducted in 2016, we test these hypotheses by reference to the perceptions of Australian judicial officers as to the adequacy of the ethical support available to them. Finally, we consider the variety of supports that are available in comparable jurisdictions and also in the legal profession, before turning to possible solutions to the question our hypotheses raise, including the introduction of ‘ethical infrastructures’ in the form of more formal arrangements that provide ethical guidance to judges. We argue that these ethical support mechanisms have the potential to enhance the quality of ethical decision-making and foster an ethical culture within the judiciary.

Integrative Clinical Ethics Support in Gender Affirmative Care: Lessons Learned

Clinical ethics support (CES) for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria (CEGD) at Amsterdam University Medical Center. We specifically aimed to integrate CES into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice.

Meeting in a 'free-zone': Clinical ethical support in integrated heart-failure and palliative care.

Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams. Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare. The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis. The CES was found to offer possibilities for meeting in an ethical 'free-zone' where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints. Participating in CES was experienced as meeting in an ethical 'free-zone' and seemed to be a means of facilitating integration of palliative and heart-failure care.

What replaces the locked door? : Conceptual and ethical considerations regarding open door policies, formal coercion and treatment pressures

Mental health professionals use various strategies to prevent involuntarily committed persons from absconding under an open door policy. To provide an ethical framework for the evaluation of the replacement of locked ward doors by formal coercion or treatment pressures. Empirically informed conceptual and ethical analysis. The replacement of locked ward doors by formal coercive measures applied to individual persons, such as mechanical restraint or seclusion, is ethically problematic. The use of treatment pressures, for example in the context of intensified observational measures, requires adifferentiated ethical evaluation and does not necessarily constitute the milder means in comparison to locked ward doors. Unexplored conceptual, empirical and ethical issues surrounding open door policies and treatment pressures should be clarified by means of psychiatric and ethical research. In clinical practice, the choice of the least burdensome and least restrictive measures for involuntarily committed persons should be facilitated by appropriate ethical support services.

Beyond Research Ethics: Dialogues in Neuro-ICT Research.

The increasing use of information and communication technologies (ICTs) to help facilitate neuroscience adds a new level of complexity to the question of how ethical issues of such research can be identified and addressed. Current research ethics practice, based on ethics reviews by institutional review boards (IRB) and underpinned by ethical principlism, has been widely criticized. In this article, we develop an alternative way of approaching ethics in neuro-ICT research, based on discourse ethics, which implements Responsible Research and Innovation (RRI) through dialogues. We draw on our work in Ethics Support, using the Human Brain Project (HBP) as empirical evidence of the viability of this approach.

Ethical aporia of organ donation development

Aim.The Aim of the article is to investigate the ethical and epistemological problems that have arisen in recent years in connection with the emergence of incidents that have caused the problematization of traditional approaches to the definition and ascertainment of death (in particular, cases that reflect the history of Jahi McMath and Anahita Meshkin) and the spread in the West such practices, as «controlled donation» and «donation after euthanasia».Materials and methods.The article uses the method of socio-ethical analysis and the bioethical case study methodology.Results.The analysis of the development of ethical support for the practice of organ donation is presented.Conclusion.The conclusion is made about the pronounced liberalization of the ethics of organ donation, characterized by the dictates of local moral contingency, linguistic manipulations with the categories of «gift», «harm», «autonomy» and the threat of trends in technological instrumentality in the system of development of transplantology and organ donation with the initial minimum of ethical grounds.

The Role of Oncology Nurses as Ethicists: Training, Opportunities, and Implications for Practice.

Ethical challenges are inherent in oncology clinical practice. Ranging from transitions in care to code status and treatment decisions, these ethical challenges can have an acute effect on nurses, with well-established connections to moral distress and other psycho-emotional sequelae. The availability of a nurse ethicist can provide invaluable resources to support nurses in awareness of ethical challenges and support for ethical decision making in practice.

A pragmatist approach to clinical ethics support: overcoming the perils of ethical pluralism

In today’s pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today’s clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES.

СОВІСТЬ ПЕДАГОГА – ОДНА З ОСНОВНИХ ЦІННОСТЕЙ ЙОГО ОСОБИСТОСТІ

Nowadays, during the education reform and the establishment of market relations, it remains important to preserve Ukrainian culture, the nation and its spiritual rebirth. The human conscience, in particular the teacher's conscience, is to become the basis for the implementation of these important issues. It is Important in the education of youth was, is and remains a unique figure of a teacher, which combines two powerful forces – intelligence and conscience. If the word "conscience" will be studied in the morphological structure, it will be noticed, that it has the root of "news", which means – to know, to get knowledge, to rely on its intellectual development and mind. Conscience – the main teacher's value, his/her noble quality, which combines honor, intellect, dignity, kindness, justice, decency, education of the younger generation. The teacher pays the tremendous job to develop these qualities in the students so that they become reliable, solid and steady their ethical foundation in the mature years. It is not without purpose people say, that in the young age people find or don't find their main qualities and basic values; in the mature age, they develop these qualities or don't develop, or maybe they lose them at all; in the old age they rely on their experience and acquired values throughout life, or suffer from a reproach of conscience without having an ethical support. This article deals with main moral principles in the process of assessing the students' knowledge level, which are inherent in the teacher's personality, his/her scientific views and beliefs, respect and warmth in the formation of students' humanity as a unique personality; the teacher's conscience, which opposes immoral phenomena in society and inspires students for good deeds, highlights the quality of their professional self-improvement, in particular thorough mastering of educational subjects, the deep knowledge of the nature mysteries; the student's conscience is considered; the ideals of the Goodness, the Beautiful and the Justice in each person's life are analyzed.

Growing Older and Getting Wiser

Health care reform to provide long-term care supportive services for growing numbers of older Americans presents ethical, cultural, and political challenges. This paper draws lessons from Japan, the world’s oldest nation, to develop an ethical argument in support of enacting public long-term care in the U.S. Despite cultural and political challenges, the paper shows that the ethical case for reform is strong, with broad ethical support from a range of ethical perspectives.

A National Survey of Transplant Surgeons and Nephrologists on Implementing Apolipoprotein L1 (APOL1) Genetic Testing Into Clinical Practice.

There is debate over whether Apolipoprotein L1 (APOL1) gene risk variants contribute to African American (AA) live donors' (LD) increased risk of kidney failure. Little is known about factors influencing physicians' integration of APOL1 genetic testing of AA LDs into donor evaluation. We conducted a cross-sectional survey, informed by Roger's Diffusion of Innovations theory, among nephrology and surgeon members of the American Society of Nephrology, American Society of Transplantation, and American Society of Transplant Surgeons about their practices of and attitudes about APOL1 genetic testing of AA potential LDs. Descriptive statistics and bivariate analyses were performed. Of 383 completed surveys, most physicians believed that APOL1 testing can help AA LDs make more informed donation decisions (87%), and the addition of APOL1 testing offers better clinical information about AA LD's eligibility for donation than existing evaluation approaches (74%). Among respondents who evaluate LDs (n = 345), 63% would definitely or probably begin or continue using APOL1 testing in the next year, however, few use APOL1 testing routinely (4%) or on a case-by-case basis (14%). Most did not know the right clinical scenario to order APOL1 testing (59%), but would use educational materials to counsel AA LDs about APOL1 testing (97%). Although physicians were highly supportive of APOL1 genetic testing for AA LDs, few physicians use APOL1 testing. As more physicians intend to use APOL1 testing, an ethical framework and clinical decision support are needed presently to assist clinicians in clarifying the proper indication of APOL1 genetic testing.