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PubMed1994

The terminally ill--secular and Jewish ethical aspects.

Many ethical, religious, social and legal dilemmas are involved in the care of dying patients. Major changes and developments in recent years have greatly intensified these moral problems. In this article a comprehensive analysis of the relevant principles and practical approaches is offered in order to enhance the ability of health care providers to attain morally sound decisions concerning the dying patient. The relevant ethical principles include the following: value of life, quality of life, nonmaleficence, beneficence, autonomy, paternalism, justice, and the physician's integrity. In practical terms, there are three major categories: the patient, the treatment and the decision maker. A comparative analysis between secular and Jewish attitudes towards the terminally ill patient has revealed significant differences both in the fundamental underlying principles as well as in the practical solutions to the diverse and difficult ethical problems.

Attitude to Health↗
PubMed1996

Four approaches to doing ethics.

Within the field of medical ethics there is a startling amount of diversity regarding which issues and relationships are deemed relevant for ethical inquiry and analysis, what strategies are appropriate for examining and resolving ethical conflict, what should be the goals for medical ethics, even who should participate in that project. What I will try to make clear in this paper is that how we go about this process of doing medical ethics, of examining, reflecting, decisionmaking, and behaving, makes a practical difference, and not just a philosophical one, in terms of the understandings we will reach about ethical matters. Without attempting to resolve any of the conflicts within or between different conceptions of doing ethics, I will try to articulate the differences in orientation, and particularly the tone and educational emphasis, that attend four major contemporary approaches to ethical inquiry and analysis: deductivism, principlism, modern casuistry, and feminist/relationist ethics.

Beneficence↗
PubMed1996

Darren's case: narrative ethics in Perri Klass's Other Women's Children.

During the past fifteen years, the relationship between literature and medical ethics has evolved from the occasional use of stories as a substitute for the traditional case study in medical ethics to the emergence of a narrative approach to ethical analysis and decision making. Thus far, literary theory has been more important to narrative medical ethics than have works of literature themselves. Perri Klass's novel Other Women's Children deserves special scrutiny, however, because an analysis of it demonstrates ways that a narrative approach could enhance traditional philosophical and legal approaches to resolving ethical dilemmas in medicine.

Acquired Immunodeficiency Syndrome↗
PubMed1998

An anthropological exploration of contemporary bioethics: the varieties of common sense.

Patients and physicians can inhabit distinctive social worlds where they are guided by diverse understandings of moral practice. Despite the contemporary presence of multiple moral traditions, religious communities and ethnic backgrounds, two of the major methodological approaches in bioethics, casuistry and principlism, rely upon the notion of a common morality. However, the heterogeneity of ethnic, moral, and religious traditions raises questions concerning the singularity of common sense. Indeed, it might be more appropriate to consider plural traditions of moral reasoning. This poses a considerable challenge for bioethicists because the existence of plural moral traditions can lead to difficulties regarding "closure" in moral reasoning. The topics of truth-telling, informed consent, euthanasia, and brain death and organ transplantation reveal the presence of different understandings of common sense. With regard to these subjects, plural accounts of "common sense" moral reasoning exist.

Bioethical Issues↗
PubMedDate not supplied

Why "do no harm"?

Edmund Pellegrino has argued that the dramatic changes in American health care call for critical reflection on the traditional norms governing the therapeutic relationship. This paper offers such reflection on the obligation to "do no harm." Drawing on work by Beauchamp and Childress and Pellegrino and Thomasma, I argue that the libertarian model of medical ethics offered by Engelhardt cannot adequately sustain an obligation to "do no harm." Because the obligation to "do no harm" is not based simply on a negative duty of nonmaleficence but also on a positive duty of beneficence, I argue that it is best understood to derive from the fiduciary nature of the healing relationship.

Beneficence↗
PubMed1998

Autonomy, discourse, and power: a postmodern reflection on principlism and bioethics.

In recent years there has been an increasing critique of the philosophically based reasoning in bioethics which is known as principlism. This article seeks to make a postmodern contribution to this emerging debate by using notions of power and discourse to highlight the limits and superficiality of this abstract, rationalistic mode of reflection. The focus of the discussion will be on the principle of autonomy. Recent doctoral research on a hospice organization (Karuna Hospice Service) will be used to contextualize the debate to end-of life ethical dilemmas. The conclusion will be reached that the discursive richness of this organization's notion of autonomy or choice, which incorporates a holistic respect for the individual and the active creation of alternatives, can provide important insights to our understanding of autonomy in bioethics. The concern is raised that if autonomy is reified as a principle outside of the context of discourse, it may only complement the hegemonic power of biomedicine.

Bioethics↗
PubMedDate not supplied

Are nursing's 'extraordinary' moral standards realistic?

This paper discusses a hypothetical situation, taken from the author's book Nursing Ethics: a principle-based approach, in which a nurse feels pressured into working beyond his official span of duty. The nurse experiences a conflict between a number of obligations; to patients and clients, to his family and to himself. To which should he give greatest weight? Steven Edwards suggests the nurse's decision is a moral one, based on personal standards held by the nurse.

Ethics, Nursing↗
PubMed1985

Ethical problems of recording physician-patient interactions in family practice settings.

Recordings of actual physician-patient interactions are an important tool for family medicine education and research. Their use, however, poses two sets of ethical problems: one dealing with privacy and confidentiality, and another related to limitations upon informed consent in the context of ordinary medical care. Experience with audiotaping and videotaping led to engaging in a "principle-based" method of ethical reasoning in which problems generated by difficult cases were examined in light of both current rules or guidelines and four fundamental ethical principles. Through this approach specific policies were developed for voluntary, informed consent and for protection of privacy, while recognizing that each case must be judged in the light of the physician's obligation to do the best for each patient.

Confidentiality↗
PubMed1994

So many ways to think. An overview of approaches to ethical issues in geriatrics.

This article provides an overview of ways to think about ethical issues in geriatrics. Principle-based approaches include deontology, utilitarianism, virtue theory, and natural law. Case-based approaches include casuistry, care, and narrative ethics. Pragmatism and feminism are methods that mesh case-based with principle-based considerations. Each of these approaches is explained and critiqued in relation to specific cases in geriatrics. The author concludes that clinical ethical decisions are optimized by considering, but not necessarily following, all of the available approaches to ethical dilemmas.

Aged↗
PubMed1994

Casuistry in medical ethics: rehabilitated, or repeat offender?

For a number of reasons, casuistry has come into vogue in medical ethics. Despite the frequency with which it is avowed, the application of casuistry to issues in medical ethics has been given virtually no systematic defense in the ethics literature. That may be for good reason, since a close examination reveals that casuistry delivers much less than its advocates suppose, and that it shares some of the same weaknesses as the principle-based methods it would hope to supplant.

Bioethical Issues↗
PubMed1995

An analysis of some dimensions of the concept of moral sensing exemplified in psychiatric care.

There are few studies that focus on the interpersonal aspect of everyday ethical conflicts. Conceptual frameworks for research into ethical decision making in the health care system are mainly based on an ethic in which objectivity and principle-based thinking is emphasized, leaving the experience of concrete moral conflicts relatively unexplored. The aim of this paper is to analyze the dimensions of "moral sensing," a concept identified in an earlier grounded theory study of psychiatric nursing. Four dimensions of the concept of moral sensing, i.e., feeling, intuition, benevolence and genuineness, were synthesized by reviewing the works of past and contemporary philosophers. The analysis of moral sensing and its dimensions is exemplified by actual nurse-patient encounters in psychiatric nursing practice.

Decision Making↗
PubMed1998

Codes and character: the pillars of professional ethics.

Historically, the ethics of a professional were the ethics of a gentleman. The social changes in the 1960s, where citizens asked for a greater voice in all affairs that affected them gave rise to formal approaches to ethics in the health fields. Principle-based and case-based reasoning have been dominant. Neither codes nor approaches based on virtue (the character of the professional) are perfect solutions in all cases, but professions are strengthened through the development and discussion of statements about ethical conduct.

Attitude of Health Personnel↗
PubMed1995

A memo from the central office: the "Ethical and Religious Directives for Catholic Health Care Services".

In 1994, the National Conference of Catholic Bishops revised the "Ethical and Religious Directives for Catholic Health Care Services." A goal of the Directives is to maintain the moral integrity of Catholic health care institutions and to address controversies in bioethics and health care. The Directives represent a shift to an exclusively principle-based approach to moral reason. This shift threatens to undermine the very tradition that the bishops seek to protect.

Bioethical Issues↗
PubMed1995

[Qualified particularism and affiliative virtue: emphasis of a recent trend in ethics].

This paper explores the implications for medical ethics of ethic of care. It characterizes the ethic of care in terms of two principal commitments, to qualified particularism and to the challenge to the centrality of affiliative virtue. Both of these commitments pose a much standard work in medical ethics characterizing moral judgment and responses as essentially impartial, principled and dispassionate. A care-oriented medical ethics will, it is suggested, call on us to focus on those virtues needed to sustain community and enhance effective communication and interpersonal understanding within the practices of health care. It stresses healing rather than curing as the objective of medical and nursing care; and it emphasizes the importance of trust in clinical relationship. As a methodological approach, the ethic of care highlights the limitations of principle-based approaches in guiding moral judgment and response, asserting the value of institutional narratives as guides to moral practice.

Bioethics↗
PubMed1993

Emotions, care and particularity.

The main intention of this article is to illuminate the normative foundation of caring in nursing. I will focus on the debate between an ethics of care and an ethics of universal principles which has evolved both in nursing ethics and moral philosophy during the last decade. In spite of what a number of people have claimed, I shall argue that a care-based ethics is compatible with judgment based on universal, impartial principles. However, an ethics of care articulates other important aspects of morality and moral behavior than the justificational ones that are central to prevailing impartialist ethics. The paper explains why and how moral perception, sensitivity and emotional capacities are important for a modern professional nursing ethics. It focuses on capacities and preconditions for principle-based reflection and action by arguing that moral perception and certain emotional qualities are prerequisites for moral judgment and action. Achieving perceptual awareness and emotional sensitivity in understanding the situation and its particulars are genuine moral tasks in nursing. These qualities are essential in discovering the morally salient features of the situation. This perspective on an ethics of care also recognizes an important place to central positions in traditional nursing ethics, where developing personal qualities and altruistic capabilities have always been a fundamental normative claim.

Emotions↗
PubMed1998

Self-perception and value system as possible predictors of stress.

This study was directed towards personality-related, value system and sociodemographic variables of nursing students in a situation of change, using a longitudinal perspective to measure their improvement in principle-based moral judgement (Kohlberg; Rest) as possible predictors of stress. Three subgroups of students were included from the commencement of the first three-year academic nursing programme in 1993. The students came from the colleges of health at Jönköping, Växjö and Kristianstad in the south of Sweden. A principal component factor analysis (varimax) was performed using data obtained from the students in the spring of 1994 (n = 122) and in the spring of 1996 (n = 112). There were 23 variables, of which two were sociodemographic, eight represented self-image, six were self-values, six were interpersonal values, and one was principle-based moral judgement. The analysis of data from students in the first year of a three-year programme demonstrated eight factors that explained 68.8% of the variance. The most important factors were: (1) ascendant decisive disorderly sociability and nonpractical mindedness (18.1% of the variance); (2) original vigour person-related trust (13.3%) of the variance); (3) orderly nonvigour achievement (8.9% of the variance) and (4) independent leadership (7.9% of the variance). (The term 'ascendancy' refers to self-confidence, and 'vigour' denotes responding well to challenges and coping with stress.) The analysis in 1996 demonstrated nine factors, of which the most important were: (1) ascendant original sociability with decisive nonconformist leadership (18.2% of the variance); (2) cautious person-related responsibility (12.6% of the variance); (3) orderly nonvariety achievement (8.4% of the variance); and (4) nonsupportive benevolent conformity (7.2% of the variance). A comparison of the two most prominent factors in 1994 and 1996 showed the process of change to be stronger for 18.2% and weaker for 30% of the variance. Principle-based moral judgement was measured in March 1994 and in May 1996, using the Swedish version of the Defining Issues Test and Index P. The result was that Index P for the students at Jönköping changed significantly (paired samples t-test) between 1994 and 1996 (p = 0.028), but that for the Växjö and Kristianstad students did not. The mean of Index P was 44.3% at Växjö, which was greater than the international average for college students (42.3%) it differed significantly in the spring of 1996 (independent samples t-test), but not in 1994, from the students at Jönköping (p = 0.032) and Kristianstad (p = 0.025). Index P was very heterogeneous for the group of students at Växjö, with the result that the paired samples t-test reached a value close to significance only. The conclusion of this study was that, if self-perception and value system are predictors of stress, only one-third of the students had improved their ability to cope with stress at the end of the programme. This article contains the author's application to the teaching process of reflecting on the structure of expectations in professional ethical relationships.

Adult↗