Clinical Ethics in Anesthesiology

How decisions are made and communication is handled are essential to ensuring a good outcome.In the case of Scardoni v Hawryluck,1 Mrs H was an 81-year-old woman with advanced Alzheimer disease, cardiovascular illness, and septic shock whose family and physician could not agree on goals for care, requiring that a legal decision be made regarding the level of care to be provided. Over time and after much discussion, the multidisciplinary team on the intensive care unit (ICU) reached a consensus that intensive care for Mrs H would not improve her condition. So it was decided that after Mrs H was stepped down to a general medical unit, should an infection or respiratory distress develop, she would not be returned to the ICU. The attending ICU physician informed the family that instead of ICU care, “the hospital would offer her palliative care: painkillers and sedatives to keep her comfortable while her afflictions took their course.”2 In this particular case, the patient’s family challenged the health care team’s recommendations and insisted that their mother be readmitted to the ICU so that aggressive life-sustaining treatment would continue.This case, although Canadian, is relevant to ICU settings throughout North America. The purpose of this discussion is not to provide an in-depth ethical analysis, but rather to use the case of Mrs H to characterize one type of health care situation that clinical ethicists could help facilitate. Medical recommendations such as those involved in the care of Mrs H are made to prevent the “revolving door” patient, who according to ICU teams will receive no medical benefit if returned to the ICU. Decisions not to readmit are euphemistically referred to by some ICU staff as the “one-way ticket out of ICU” or “celestial transfer.” Such language shared between colleagues reflects a coping strategy, a “gallows humor,” intended to manage difficult feelings like sadness, anger, grief, sympathy, or moral distress. Cases like that of Mrs H are of particular concern to critical care nursing. Research has indicated that moral distress, a significant contributing factor to burnout, is encountered by ICU nurses when the care they are providing to a patient is regarded as futile.3It is not uncommon for hospital-based clinical ethicists to receive a request for consultation when disputes regarding similar recommendations for care arise between substitute decision makers and the ICU treatment team. These cases can lead to moral distress because of commonly held opinions among team members that futile treatment is being provided. Although staff can provide many life-sustaining treatments to such a patient, ethical questions often arise during the patient’s stay in the ICU. What ought to happen when an ICU team decides that a patient should be transferred to a general medical unit to receive comfort measures only, with no readmission to the ICU? Although teams discuss the practical questions about what can be done, the ethical questions about what ought to be done are sometimes not as clear. The following discussion explores how clinical ethicists can provide valuable assistance with the kinds of ethical challenges these situations customarily present. Particular emphasis will be placed on working within a process-driven, interdisciplinary framework that maintains a communication-oriented approach to ethical decision making.Clinical ethics is a relatively new field, and the role and purpose of clinical ethicists can vary somewhat according to the particular health care setting. For the purpose of this discussion, the authors describe the knowledge, skills, and activities of clinical ethicists through their review of relevant literature as well as their own training and experiences as staff clinical ethicists at 2 acute care settings in Ontario, Canada.Greater legal clarity or legislative measures to specifically address conflicts that arise over withdrawal or withholding of treatment for terminally ill patients are required, according to at least one legal expert. Current Canadian law, according to this same scholar, leaves doctors, patients and their families in a “grey zone” as to who should have ultimate authority on such decisions.4 The daily reality in most North American ICUs is that this gray zone persists—for better or worse. Although hospitals attempt to provide guidelines for addressing conflicts such as the one involving Mrs H, it is the quality of communication and relationship within the interdisciplinary team and between the treating team and the patient’s family that has a marked influence on decision making.5–7 In most cases similar to this one, consensus about level of care is first achieved by the interdisciplinary team, and a subsequent agreement is reached between the treatment team and the patient’s substitute decision maker and family. However, when agreement cannot be reached because of irreconcilable notions pertaining to what constitutes benefit to the patient and what constitutes harm, the results can be uncertain, stressful, and most unsatisfactory for both the health professionals involved and the patient’s family. This combination of an unfortunate turn of events for the patient, sharing of bad news with family members, and the recommendation for care outside of the ICU is a juncture of decision making at which conflict can occur and ethical challenges are most apparent to members of the interdisciplinary team.8,9Much has been written about the difficulties in communication within the ICU and how this affects patient care. Considerable evidence indicates that communication between the ICU team, patients, and patients’ families can be inadequate, leading to conflict and a possible long-term effect on the patient’s family.6,8,10,11 In one study,8 46% of families who had a loved one die in the ICU reported conflict over decisions to withdraw or withhold life-support measures. These family members also reported conflict over the manner in which staff communicated with or behaved toward them. The authors of that study8 cited family members who felt pressured by staff to “hasten their loved one’s death because they placed a burden on valued resources.” The importance of communication between treatment teams and patients and patients’ families cannot be overstated. In addressing the difficulties and deficiencies that have been identified, 2 experts concluded, “communication with caregivers is consistently identified as the most important and least achieved factor in patient/family satisfaction surveys.”12Intensive care is primarily intended to provide maximum benefit to those patients who are likely to recover from their infirmity or trauma.13 When the interdisciplinary team is not clearly communicating ethical considerations as well as the criteria they are using to determine the effectiveness or success of the treatment plan, patients’ families may develop erroneous expectations that life-sustaining interventions will continue to be offered.6 At the same time as a loved one is receiving ICU care with a grim prognosis, families are struggling to come to terms with impending loss. Family functioning or experience in coping with loss,14 unrealistic expectations regarding health outcome, within a societal context of diverse religious or cultural beliefs, can markedly influence families’ decision making about end-of-life care. Such formidable contributing factors further emphasize that effective communication strategies, as well as an appropriate level of sensitivity, ought to be used in ICUs when dealing with patients’ families.11Team communication, in particular communication between disciplines, also has proven problematic in decisions about end-of-life care in the ICU. Critical care nurses have cited difficulties in communication and decision making within interdisciplinary ICU teams. Ferrand et al15 reported that 75% of the nursing staff who participated believed that “collaboration was inadequate during decision making” despite general agreement that such team collaboration is necessary and desired. In another study,16 about one-third of the ICU nurses who participated felt “excluded by physicians from patient care decisions and felt their exclusion to be a detriment to patient care.”In terms of the burdens carried in making decisions about end-of-life care, some evidence suggests that physicians and nurses experience equal burdens. Physicians experience the burdens associated with having to make these decisions, and nurses feel the burden of having to carry out care decisions made by someone else.17 Given the shared burdens that members of the interdisciplinary team face, as well as the reported difficulties in end-of-life care decision making in the ICU, ensuring effective communication is a key feature of high-quality patient care.7 The following discussion is intended to demonstrate how clinical ethicists can be supportive of such strategies for effective communication and decision making.Medical recommendations like those pertaining to the care of patients such as Mrs H are based on best-practice standards of care and are informed by ethical principles like beneficence, nonmaleficence, and autonomy. Continued life-sustaining support in situations where benefit is in question can be regarded as futile, a concept with inherent ethical challenges. As Weijer et al18 point out, the values inherent in medical futility arguments often confuse treatment considered ineffective and treatment that will be effective but will ultimately result in a controversial outcome such as permanent unconsciousness. A team’s decision to not readmit a patient for ICU care can be an attempt to address futility based on controversial outcomes that the team may perceive as causing more harm for the patient than good. Poignantly stated, “if the welfare of the patient is the whole purpose of providing treatment and if that treatment brings needless suffering, then the whole purpose of medicine is defeated.”19 Although the concept of futility in ICU care is a subject worthy of ethical debate, it will not be the focus of this discussion. Rather, the subject of this discussion is the role of clinical ethicists in helping decision makers address ethical considerations such as futility.The results of inadequate communication, misunderstandings, or disagreements arising from divergent views about what is beneficent and the institutional realities surrounding resource allocation can be seen in the moral distress and subsequent moral residue experienced by both the patient’s family members and the health care staff involved. Moral distress occurs when a person can identify the ethically appropriate course of action, but does not feel able to carry this action forward because of barriers that may include lack of resources, legal limits, institutional obstacles, or imbalances in power, for example. Effects of moral distress on an individual can include feelings of anger, frustration, anxiety, or depression.20 Moral residue can be encountered when “deeply held beliefs, values and principles” are set aside at the expense of one’s personal sense of integrity.21 For families of patients, moral residue can manifest in lifelong memories about difficult health care experiences.The experience of moral distress and moral residue are of particular importance to critical care nursing. Some evidence indicates a relationship between an ICU care nurse’s perception of providing futile care, inadequate communication about the care plan within the interdisciplinary team, and the incidence of moral distress, emotional exhaustion, and burnout.3,16,22 Cases like that of Mrs H can present these kinds of challenges to nurses providing care at the bedside. The discussion also highlights how clinical ethicists can assist interdisciplinary teams in addressing ethical challenges that can lead to moral distress.Finally, the ethical climate within our health care settings is shaped by the organizational values inherent in hospital policies, approaches to handling conflict, allocation of human and material resources, the daily-lived experience of staff providing care, and those to whom care is provided.23,24 Economic constraints, resource allocation difficulties, and staffing shortages contribute to the moral climate of health settings, the moral distress of staff, and burnout among health care providers.25,26In cases such as that of Mrs H, the ethical challenges are not just about treatment requests considered inadvisable but also about scarce resources like ventilator-equipped beds in ICU settings. In the minds of some families, the need for an ICU bed is the primary reason that palliative measures are now being recommended. When conflict surrounds decisions about level of care, it is the bedside ICU nurse who fields the questions, concerns, and emotions expressed by patients’ families.It is through such challenging decision making, in which no agreement is reached, that the moral climate is regrettably defined for all persons with a stake in the decision. However oppressive these disagreements feel to both health care professionals and patients’ family members, most often the disagreements, ironically, do not result from a lack of good intentions on either side of the debate. Rather, these circumstances reflect the complex ethical challenges that are inherent in contemporary health care settings. Clinical ethicists can be an important resource to health care teams, patients, and patients’ families in addressing these difficult challenges.Clinical ethicists who provide consultative services may be requested by the ICU team when conflicts such as the one surrounding the planning of Mrs H’s level of care arise. What are the characteristics, skills, and knowledge that make clinical ethicists a useful resource in helping to address conflict over decisions about level of care for stable but critically ill ICU patients?Clinical ethicists come from a diverse background of training: clinical and academic experiences that include but are not limited to medicine, nursing, social work, theology, philosophy, and anthropology. Most clinical ethicists have advanced academic degrees and/or training in clinical ethics. Despite this diversity in background, clinical ethicists engage in common functions: consultative services, research, education and the development of policies pertaining to patient care and organizational ethics.27–29Clinical ethicists are trained to view ethical problems within an interdisciplinary health care environment whose primary commitment should always be to provide the best patient care possible. Patient care and goals for care are best understood through the wishes, beliefs, and values of the patient and the patient’s family. The approach taken by clinical ethicists in providing consultation is to model interdisciplinary collaboration and effective communication with patients and their families, with the objective of enhancing ethical decision making.28–30In effect, clinical ethicists in cases such as the one involving Mrs H act as facilitators of communication and decision making about goals for care, while directing attention to the ethical considerations underlying such decisions. Generally, clinical ethicists can help clarify differences in the way ethical considerations such as sanctity or quality of life are valued on the basis of religious, personal, or cultural values. Some evidence suggests that ethics consultation generally has been useful in preventing or resolving conflicts, and in reducing the incidence of prolonged controversial treatment.31,32 Current trends in the training and education of clinical ethicists have emphasized skills, knowledge, and expertise better suited to provide ethics support in real time as dilemmas and conflict around decisions related to patient care unfold.28What is particularly important about the approach used by most clinical ethicists is the emphasis placed on fair and just processes for decisions of such importance and consequence in an ICU environment.In cases such as the one involving Mrs H, it is not just what decision ought to be made that is of interest to clinical ethicists, but if and why a particular decision is ethically defensible. If so, to whom is it ethically defensible? How ought discussions and conflicts be managed? These questions raise ethical concerns about justice, fairness, and a reasoned approach to decisions of such consequence. Ethical consideration must also be given to the moral climate, how people feel treated, and the concerns and opinions of key persons with a stake in the decision making, with overarching consideration given to trust in the process used to make such important decisions. Therefore clinical ethicists are as concerned with procedural fairness as they are with outcome when assisting with ethically challenging situations in health care settings.Principal aspects of procedural fairness are as follows: that the process for decision making be as transparent as possible to all involved; that concerns of key persons with a stake in the decision making be considered; that the reasons or rationale behind decisions can be understood and defended; that people responsible for decisions be held accountable; and that in the event disagreement occurs, decisions can be reviewed, taking into account the concerns of those who disagree.33 Process-driven approaches to decision making or to resolving conflict used by clinical ethicists are dependent on using frameworks to guide communication. Such frameworks for communication are not just ethically defensible; they have been shown empirically to be part of good practice standards in ICU settings.6,11,34 Lilly et al35(pS398) found that using a standardized framework for communication resulted in health care providers seeing decision making as a “process rather than as an event”—an attribute consistent with principles for ethical decision making.An example of such a framework to guide communication is described by Lautrette et al,34 who identify such attributes as timeliness, opportunities for the patient’s family to speak, use of appropriate and sensitive language, and ensuring that the setting is private and comfortable. In addition to these attributes, clinical ethicists would include discussion of the values in conflict and ethical obligations that underscore decision making.Frameworks for communication appear well supported in the literature anyway, so what makes the involvement of clinical ethicists of added benefit?Despite advances in implementing communication strategies in many settings, improvement in general is needed in managing communication, enhancing understanding, and meeting needs of ICU patients and their families.6,8,10,11 Furthermore, Sherwin36 believes that communication frameworks and hospital policies can be used coercively, to enforce a particular outcome, if those who lead these discussions or who adhere to policies are not reflecting on personal biases, institutional pressures, and ethical considerations.Clinical ethicists act as facilitators, helping to raise important ethical questions, model effective communication, and model ethical decision making by using teachable moments to heighten the awareness and understanding of the ethical considerations in each case. Within most health care settings, necessary and unavoidable imbalances in power are present between various persons who have a stake in the decision making. Clinical ethicists assist in discussing the values that underlie decisions of such importance, making these transparent to and understood by key involved parties. They model the principles of procedural fairness. Inherently challenging decisions about level of care, as in the case of Mrs H, are often met with challenging feelings and opinions, making fairness and ethical reflection more important than less to involved parties.Clinical ethicists advocate for policies and practices that reduce coercive consequences that can arise when members of the ICU treatment team, patients, or patients’ family members feel overruled or dismissed. In conducting an ethics consultation, the clinical ethicist leads discussions with the interdisciplinary team members about ethical considerations that contribute to moral distress, for example, the conflict in the way benefit and harm associated with a particular therapy or level of care are understood. In most instances, the clinical ethicist must ensure that concerns raised by members of the interdisciplinary team and concerns expressed by patients’ family members are shared and considered. This process is handled in an open and transparent manner. In creating an opportunity through the consultative process for the interdisciplinary team to address concerns, related to both areas of conflict and moral distress, clinical ethicists are also capitalizing on valuable teachable moments in which knowledge about ethics and decision making can be enhanced. As Kälvemark Sporrong et al37(p835) concluded, “Ethical competence is a key factor in preventing or reducing moral distress.”We have found that consultation on an individual case often helps treatment teams identify preventative strategies to reduce or avoid conflict and to engage in more timely discussion about ethics the next time a complex care situation arises. Such measures are necessary in creating a moral climate in which discussion about ethics in daily practice can be supported and thus reducing the effects or incidence of moral distress. The potential exists for all members of the interdisciplinary ICU team, including the most responsible physician, to be so engaged in ethical reflection and decision making on challenging cases. Clinical ethicists model skills of effective communication, ethical reflection, and decision making as well as principles of procedural fairness within the consultative process that they facilitate.We are not suggesting that effective communication, procedural fairness, ethical reflection, and decision making are deficient whenever clinical ethicists are not involved in such cases. In reality, complex and ethically challenging cases occur routinely in ICU settings, most often without the involvement of clinical ethicists. What is being proposed is that clinical ethicists should be seen as a valuable resource for addressing challenging cases in the ICU. Better understanding is needed about the role of clinical ethicists and the kinds of assistance they can provide.In most cases, the ICU team and patient’s family agree on recommendations that comfort measures be provided on a medical intermediate care unit or a palliative care unit for a stable but critically ill patient. However, as in the case of Mrs H, these decisions may be met with considerable emotion from the patient’s family and with differences of opinion about benefit and the appropriate level of care. We think that clinical ethicists can be a valuable resource when challenging cases arise. By providing consultation, clinical ethicists can model effective communication, ethical reflection, and decision making, while following principles of procedural fairness, all of which are key elements to upholding ethics in daily practice and are of particular importance when conflict occurs about level of care in the ICU.The following are practical considerations for critical care nurses:

In 1972, soon after I started the first medical intensive care unit (MICU) at the University of Chicago, a unit whose patients raised multiple, serious ethical issues, I created the new field of Clinical Medical Ethics (CME) in the Department of Medicine at the university. In my view, both in 1972 and today, CME is an intrinsic part of medicine, surgery and all medical disciplines, and is not a branch of bioethics or philosophical ethics or legal ethics or theoretical ethics. Rather, it is a central component of clinical care that must be practiced and applied by licensed clinicians in their routine, daily encounters with patients. Although bioethicists may provide theoretical insights to clinicians, bioethicists cannot practice medicine or examine patients or provide care to patients. During the past 49 years, CME has become a transformative field in medicine and surgery that aims to improve both the clinical and ethical quality of care and outcomes that clinicians provide their patients (Singer et al., BMC Med Ethics 2:1, 2001). In ordinary clinical practice, CME addresses many clinical ethical issues, including truth-telling, informed consent, confidentiality, surrogate decision-making, the risks, benefits and alternatives to surgical or medical procedures, end-of-life care, and also encourages personal, humane, compassionate, and fair interactions between doctor and patient.The goals of CME are to improve patient care and outcomes by helping physicians, surgeons and other health professionals identify and respond to clinical-ethical challenges that arise in the ordinary care of patients. As Edmund Pellegrino, Peter A. Singer and I wrote 30 years ago: “The central goal of CME is to improve the quality of patient care by identifying, analyzing and contributing to the resolution of ethical problems that arise in the routine practice of clinical medicine” (Siegler et al., J Clin Ethics 1:5–9, 1990). Similar to cardiology and oncology consultations, ethics consultations are a small component of a much larger field, just as the consultations in cardiology and oncology or CME are certainly not at the core of cardiology, oncology or Clinical Medical Ethic.This article will discuss the following five topics: the origins of the field of CME; the goals and methods of CME; the relationship between the larger field of CME and the narrower practice of ethics consultations; the contributions of the MacLean Center at the University of Chicago in developing the fields of Clinical Medical Ethics; and how CME has improved the practice of medicine and surgery (Siegler, J Clin Ethics 30:17–26, 2019).KeywordsClinical Medical EthicsMacLean Center for Clinical Medical EthicsDoctor-patient accommodationShared decision-makingTruth-tellingInformed consentConfidentialitySurrogate decision-making

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)

Dear Editor, Medical ethics is an interdisciplinary concept, which deals with ethical issues in medical sciences. Medical ethics can be defined as “Respecting principles and values in medical decisions concerning public health”.1 Dramatic changes have been made in medical ethics after development in medicine, technology, and ethical issues. Currently, the evaluation of science production is very important because it can create a scientific competition in different fields at the international level. Scientometrics can present a clear image of growth and development in different sciences. Continuous evaluation of science production in medical ethics and utilizing the results, would ultimately lead to its improvement. Many studies have shown that despite the importance of medical ethics, the results obtained through scientometric studies have not been applied in this field.2-5 Therefore, the main objective of the present study was to evaluate the status of science production in the field of medical ethics. Thomson Reuters database was searched to find any scientific product related to medical ethics published during 1990-2010. Various document types such as Articles, Editorials, Book Reviews, Proceeding papers, and Review Articles in which the subject of “medical ethics” was reflected in the title, abstract, or keywords were selected. The data were analyzed using HistCite software, version 12.03.17 (developed by Eugene Garfield at Thomson Reuters Institute, USA). The most (6.95%) and the least (0.86%) number of articles in medical ethics was published in 2009 and 1992, respectively. The average growth rate of publications during 1990-2010 was 65.98%. Total Local Citation Score (TLCS) and Total Global Citation Score (TGCS) indicated that most of the documents were related to fields other than medical ethics. This means that journals related to medical ethics had fewer numbers of articles on medical ethics in comparison with other journals. McCullough was the top producer who had written 31 (1.02%) articles in medical ethics. Totally, researchers from 82 countries had published articles related to medical ethics. The United States, England, and Germany were ranked first to third. The United States and England had produced 51.3% of all publications. An evaluation of the publications showed that they were presented in 14 different types. Most of the publications were produced in Article format with high TGCS and TLCS rates. The Editorials and Book Reviews were ranked second and third. The publications were written in 15 languages. English, German, and French were ranked first to third, respectively. A comparison between TLCS and TGCS revealed that most of the citations were related to other fields. A few citations were devoted to medical ethics which was not unexpected because of the limited number of documents (3035 documents). The general impact factor illustrated that the articles of this field had a high average citation, which indicated that there was a close relationship between the articles related to this field and the other fields. The most productive authors had a high local impact factor and according to their records, their local impact factor was higher than total local impact factor. All of the documents were published in 901 journals among which “Journal of Medical Ethics” had published 290 articles (9.55%) and it was ranked first. The existence of different journals with different scopes indicates that medical ethics is an interdisciplinary subject and the researchers of other fields are interested in this specialized field. Articles of this field have an increasing growth rate and the present study indicates greater participation of the science community in medical ethics publishing. However, the number of citations does not have a uniform growth rate. This could be due to the small size of this field and its association with other small fields. The global distribution of the papers and their language variations signify the global concerns for medical ethics. Moreover, linguistic, geographic, and publication type diversity of the published articles indicate a sustainable development in this field.

This volume provides a practical overview of the ethical issues arising in pediatric practice. The case-based approach grounds the bioethical concepts in real-life situations, covering a broad range of important and controversial topics, including informed consent, confidentiality, truthfulness and fidelity, ethical issues relating to perinatology and neonatology, end-of-life issues, new technologies, and problems of justice and public health in pediatrics. A dedicated section also addresses the topics of professionalism, including boundary issues, conflicts of interests and relationships with industry, ethical issues arising during training, and dealing with the impaired or unethical colleague. Each chapter contains a summary of the key issues covered and recommendations for approaching similar situations in other contexts. Clinical Ethics in Pediatrics: A Case-Based Textbook is an essential resource for all physicians who care for children, as well as medical educators, residents and scholars in clinical bioethics.

Medical law and ethics are frequently referred to in conjunction, and appear together in many textbooks. But do they combine to form a cohesive unit, and do they benefit each other? It may be argued that they do not, but rather suffer a symbiotic relationship, clashing rather than cooperating. This book examines this relationship, and how the law sees medical ethics. It then considers whether medical ethics functions in the way that the law thinks that it does. After providing a historical perspective that identifies medical ethics discourse as disjointed and fragmented, the book continues by examining key medico-legal case law and reports that have an inherent ethical content for clues as to how they define medical ethics and its role. It also considers how medical ethics sees the law, concluding that a misapprehension by each party as to what the other does creates a mutually harmful relationship between them.

BackgroundAs the practice of medicine inevitably raises both ethical and legal issues, it had been recommended since 1999 that medical ethics and human rights be taught at every medical school. Most Nigerian medical schools still lack a formal undergraduate medical ethics curriculum. Medical education remains largely focused on traditional medical science components, leaving the medical students to develop medical ethical decision-making skills and moral attitudes passively within institutions noted for relatively strong paternalistic traditions.In conducting a needs assessment for developing a curriculum germane to the Nigerian society, and by extension most of Sub-Saharan Africa, this study determined the views of Nigerian medical students on medical ethics education, ethical issues related to the doctor-patient relationship and the ethical/professional dilemmas they are confronted with.MethodsUsing self-administered 63-item structured questionnaires, a cross-sectional survey of the final year medical students of the University of Nigeria was conducted in July 2015.Using the Statistical Package for the Social Sciences software (SPSS Version 17), frequency counts and percentages were generated.ResultsThe sample included 100 males (71.4%) and 40 females (28.6%), with the respective mean (SD) age being 24.6(5.61) and 21.8 (6.38) years. Only 35.7% were satisfied with their medical ethics knowledge, and 97.9% indicated that medical ethics should be taught formally. Only 8.6% had never witnessed a medical teacher act unethically. The dilemmas of poor communication between physicians and patients, and the provision of sub-standard care were reported highest for being encountered ‘often’. A majority (60.7%) indicated that “a doctor should do his best always, irrespective of the patient’s wishes”. No significant difference in responses across gender was noted.ConclusionThere is a strong desire by the contemporary Nigerian medical student for medical ethics education. Their lack of exposure in medical ethics in an ethically challenging environment suggest a dire need for the development of an appropriate medical ethics curriculum for them and the provision of an ethically conducive learning environment.

The Team Physician: Ethical and Legal Issues

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-

This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a “bottom-up” perspective might give healthcare personnel opportunities to think and reflect more than a “top-down” perspective. A “bottom-up” approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a “top-down” approach risks removing such moral responsibility.

Reviewed by: The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives ed. by Marcus Düwell et al. Alfred I. Tauber The Cambridge Handbook of Human Dignity: Interdisciplinary Perspectives Edited by Marcus Düwell, Jens Braarvig, Roger Brownsword, and Dietmar Mieth. Cambridge: Cambridge University Press, 2014. Pp. 629. $145 (cloth). Globalization, at least for advanced societies, has resulted in what is essentially a single medical-industrial complex developed within a highly integrated collaborative bioscience. Yet one of the key differences within that complex hinges on whether or not health care is a right. Health care in the United States is dominated by an individual-based consumer model, while most European nations and Canada have adopted a communal responsibility for clinical care. This fundamental opposition is reflected in medical ethics characteristic of each system. A so-called “new bioethics” originating in Europe has been proposed to balance the autonomy-based approach dominant in the American system with a schema based on human dignity (Beyleveld and Brownsword 2001). How such a recalibration might affect American bioethics is uncertain, but such discussions reflect the ongoing evolution of American medical ethics from its original commitments to individual autonomy to more pluralistic formulations. [End Page 560] A Moral Dichotomy? Extrapolating from case law, commentators have noted how autonomy became the lynchpin of medical ethics in the United States. In the post–World War II era, the basis of informed consent underlies the doctor-patient relationship, and in the opinion of many American bioethicists, autonomy thus trumps other ethical principles (such as beneficence, justice, and non-maleficence) (Annas 1989). When placed in the wider context of American political culture, the dominance of individual choice as a guiding politico-economic principle is reflected in the consumer model of health insurance, and that ethos also stretches beyond the commodification of health care to autonomy-based models of medical decision-making. Indeed, critics assert that medical ethics in its autonomy-oriented posture has been coopted by the very institutions ethicists once sought to criticize and transform. For example, Haliburton (2015) charges that an ironic reversal has taken hold: “The mainstreaming of bioethics has resulted in its domestication: it is at home in the institutions it would once have viewed with skepticism, and a central part of practices it would once have challenged” (3). On this view, autonomy has not only been transgressed, it actually serves heteronomy. In contrast, Europe and Canada place less credence in autonomy as a governing precept, both in the domain of health-care services (universal access is a right of citizenship) and as a governing tenet of medical practice. According to the dominant European point of view, where autonomy is compromised—as in the setting of illness—patients need to be protected, and so dignity, integrity, and vulnerability become guiding, protective values (Beyleveld and Brownsword 2001). In sum, respect for patient autonomy becomes only one of several values in the calculus of care. Communal responsibilities—conceived in terms both of individual patient care and of the larger socioeconomic context of institutional and governmental accountability—take priority (Parizeau 2000). These putative differences in moral attitudes reflect deeply held cultural standards. Medical ethics was born as a formal discipline in the late 1960s, and the initial concerns of American ethicists reflected complex social factors, all of which seemed to converge on a newly activated suspicion of authority (Jonsen 1998). In parallel with the loss of trust in government, education, and business, critics identified instances of patient abuse and unwarranted physician paternalism that demanded redress. If the ancient moral philosophy governing the doctor-patient relationship had become suspect, then a defensive posture that would assure patient rights was required. Thus a newly articulated medical ethics sought to build on an assumed beneficence, but one fortified with a new demand concerning the respect of patient autonomy in the guise of informed consent (Tauber 2005). The dominant voices advocated patient autonomy, not only because it was the most easily extrapolated from a rights-based politico-judicial culture, but also because it best captured what was missing: trust. From this cultural perspective, medical ethics is one piece of the deep moral crisis Americans continue to face. Medical ethics, and patient...

For fifteen years no national ethics committee has matched the quality and value of the work of the U.S. President's Commission. Its analyses and guidance remain some of the most useful in bioethics. The need to continue to produce such work is widely recognized. In Europe various countries have set up various types of committee, but none has yet had the same impact. The closest is probably the French national committee, which has produced nearly forty guidance notes (Avis) in the last decade. Within France they have had a considerable impact and, in some cases, have led to changes in the law. But any wider influence that the committee might have is prevented by the French language law, which requires that all official documents only be published in French. There are other national committees--in Denmark and Italy, for instance. The Danish Council of Ethics has taken the need for public consultation very seriously and reaches a large portion of the Danish population, particularly school children. But the council's analyses of ethical dilemmas have not so far attracted much attention outside the country. Those of the Italian committee have had even less influence, probably because the government appointed so many committee members to represent every possible sectarian interest that the committee cannot function. The need for a committee in the United Kingdom--indeed for two committees, one for medical ethics generally, and one for medical research ethics--has long been recognized. The creation of either has, however, been effectively stymied by the medical officers at the Department of Health who advise ministers. For some curious reason--perhaps because they think it helps to keep discussion of medical ethics centered within the medical profession--they have ensured for two decades that British governments do the least possible about medical ethics dilemmas. Research ethics committees (the U.K. equivalent of IRBs), for instance, struggle to function because the Department of Health refuses to mandate any support for them, either funding or training. On average they review eighty research proposals each year, yet some have to do so without any budget. Other bioethics issues are dealt with in an ad hoc fashion, as late in the day as possible. Bob Edwards, the driving force behind the development of in vitro fertilization, asked for consideration of the law and ethics of assisted reproduction as early as 1969. Yet the Human Fertilization and Embryology Act only came into force in 1990, twelve years after the first test tube baby was born. This September afforded another splendid example of last-minute ad hockery. …

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain.

One hundred and one students at different levels of their medical education were surveyed as to their views about inclusion of medical ethics in their curriculum. The results showed that 88% of the students feel that medical ethics has a place in their curriculum, and 84% rated medical ethics to be of High to Critical Importance to good medical care. They tended to read infrequently about medical ethics, which they would like integrated at all levels of the curriculum, particularly the clinical years. The more senior students were less sensitive to ethical issues. The students mentioned only dramatic issues in their accounts of encounters with cases involving ethical issues. It is felt that a wide gap is left in the education of these students if medical ethics is not included in a positive way in their curriculum.

INTRODUCTION Ethics support services for hospital clinicians have become increasingly common globally but not as yet in New Zealand. However, an initiative to change this is gathering momentum. Its slogan 'Clinical ethics is everyone's business' indicates that the aim is to encompass all of health care, not just the hospital sector. General Practitioners (GPs) deal with ethical issues on a daily basis. These issues are often quite different from ethical issues in hospitals. To make future ethics support relevant for primary care, local GPs were interviewed to find out how they might envisage ethics support services that could be useful to them. METHODS A focus group interview with six GPs and semi-structured individual interviews with three GPs were conducted. Questions included how they made decisions on ethical issues at present, what they perceived as obstacles to ethical reflection and decision-making, and what support might be helpful. FINDINGS Three areas of ethics support were considered potentially useful: Formal ethics education during GP training, access to an ethicist for assistance with analysing an ethical issue, and professional guidance with structured ethics conversations in peer groups. CONCLUSION The complex nature of general practice requires GPs to be well educated and supported for handling ethical issues. The findings from this study could serve as input to the development of ethics support services. KEYWORDS General practice; primary care; ethics; support; education.