American Academy of Pediatrics (AAP) and American College of Medical Genetics (ACMG) recently provided two recommendations about predictive genetic testing of children. The Clinical Sequencing Exploratory Research Consortium's Pediatrics Working Group compared these recommendations, focusing on operational and ethical issues specific to decision making for children. Content analysis of the statements addresses two issues: (1) how these recommendations characterize and analyze locus of decision making, as well as the risks and benefits of testing, and (2) whether the guidelines conflict (...) or come to different but compatible conclusions because they consider different testing scenarios. These statements differ in ethically significant ways. AAP/ACMG analyzes risks and benefits using best interests of the child and recommends that, absent ameliorative interventions available during childhood, clinicians should generally decline to order testing. Parents authorize focused tests. ACMG analyzes risks and benefits using the interests of the child and other family members and recommends that sequencing results be examined for additional variants that can lead to ameliorative interventions, regardless of age, which laboratories should report to clinicians who should contextualize the results. Parents must accept additional analysis. The ethical arguments in these statements appear to be in tension with each other. (shrink)

BackgroundClinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. (...) ObjectiveThe primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization.MethodsWe searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. ResultsForty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes.ConclusionsThis scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC. (shrink)

Any view of equipoise faces perhaps the most radical and far-reaching objections from moral foundations. These objections hold that the equipoise requirement conflates the ethics of medical research and the ethics of clinical medicine. Once this conflation is recognized, this position holds, research can be given a new foundation on the imperative to avoid exploiting research participants. This article argues that what is novel in this critique is not as successful as its proponents claim and that the ultimate success (...) of this approach actually hinges on a version of the objection from utility. Nevertheless, this criticism highlights the limited scope of applicability of the equipoise requirement. The article concludes, therefore, by describing the outlines of what the article calls an ‘integrative approach’ to clinical trials. This approach represents one way in which the normative requirements of equipoise and the non-exploitation approach might be unified under a single, broad framework. (shrink)

As Clinical Ethics Consultation (CEC) becomes more institutionalized, concerns about its legitimacy and efficacy have grown. We defend a realist orientation, according to which CEC has normative force only if its recommendations answer to stance-independent reasons, not to individual preferences and institutional policies. Public justification can and should proceed through familiar means (e.g., shared mid-level norms and transparent procedures) so that stakeholders can scrutinize the reasoning. We show how neutrality, admirable as a procedural virtue, hollows CEC when treated as (...) a master ideal, leaving hard cases to defaults and institutional inertia. In its place, we develop moral expertise as sustained, transparent reasoning that integrates the clinical picture with the profession’s content-full standards. We then construe warranted deference as rational trust in contrastive reason-tracking rather than deference to role. Our comparative thesis holds that shared norms successfully handle routine cases, but persistent disagreement and institutional pressure call for a realist grounding that secures determinate, action-guiding recommendations. On such realist understanding, CEC remains normatively accountable and oriented toward getting things right. (shrink)

Clinical ethics support 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 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. (shrink)

The principle of clinical equipoise has been variously characterized by ethicists and clinicians as fundamentally flawed, a myth, and even a moral balm. Yet, the principle continues to be treated as the de facto gold standard for conducting randomized control trials in an ethical manner. Why do we hold on to clinical equipoise, despite its shortcomings being widely known and well-advertised? This paper reviews the most important arguments criticizing clinical equipoise as well as what the most prominent (...) proposed alternatives are. In the process, it evaluates the justification for continuing to use clinical equipoise as the gold standard for randomized control trials. (shrink)

This book offers a philosophically-based, yet clinically-oriented perspective on current medical reasoning aiming at 1) identifying important forms of uncertainty permeating current clinical reasoning and practice 2) promoting the application of an abductive methodology in the health context in order to deal with those clinical uncertainties 3) bridging the gap between biomedical knowledge, clinical practice, and research and values in both clinical and philosophical literature. With a clear philosophical emphasis, the book investigates themes lying at the (...) border between several disciplines, such as medicine, nursing, logic, epistemology, and philosophy of science; but also ethics, epidemiology, and statistics. At the same time, it critically discusses and compares several professional approaches to clinical practice such as the one of medical doctors, nurses and other clinical practitioners, showing the need for developing a unified framework of reasoning, which merges methods and resources from many different clinical but also non-clinical disciplines. In particular, this book shows how to leverage nursing knowledge and practice, which has been considerably neglected so far, to further shape the interdisciplinary nature of clinical reasoning. Furthermore, a thorough philosophical investigation on the values involved in health care is provided, based on both the clinical and philosophical literature. The book concludes by proposing an integrative approach to health and disease going beyond the so-called “classical biomedical model of care”. (shrink)

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. (shrink)

Background Clinical Ethics Committees are well established at healthcare institutions in resource-rich countries. However, there is limited information on established CECs in resource poor countries, especially in Africa. This study aimed to establish baseline data regarding existing formal CECs in Africa to raise awareness of and to encourage the establishment of CECs or Clinical Ethics Consultation Services on the continent. Methods A descriptive study was undertaken using an online questionnaire via SunSurveys to survey healthcare professionals and bioethicists in (...) Africa. Data were subjected to descriptive analysis and Fischer's exact test was applied to determine associations. Texts from the open-ended questions were thematically analysed. Results In total 109 participants from 37 African countries completed the survey in December 2019. A significant association was found between participants’ bioethics qualification or training and involvement in clinical ethics. All participants were familiar with Research Ethics Committees, and initially conflated RECs with CECs. When CECs were explained in detail, approximately 85.3% reported that they had no formal CECs in their institutions. The constraints to developing CECs included lack of training, limited resources, and lack of awareness of CECs. However, the majority of participants were interested in establishing CECs. Participants listed assistance required in establishing CECs including funding, resources, capacity building and collaboration with other known CECs. The results do not reflect CECs established since the onset of COVID-19 in Africa. Conclusions This study provides a first look into CECs in Africa and found very few formal CECs on the continent indicating an urgent need for the establishment of CECs or CESs in Africa. While the majority of healthcare professionals and bioethicists are aware of ethical dilemmas in healthcare, the concept of formal CECs is foreign. This study served to raise awareness of CECs. Research ethics and RECs overshadow CECs in Africa because international funders from the global north support capacity development in research ethics and establish RECs to approve the research they fund in Africa. Raising awareness via educational opportunities, research and conferences about CECs and their role in improving the quality of health care in Africa is sorely needed. (shrink)

Clinical ethics consultation service remains undeveloped in developing countries. It is recognised that its introduction poses challenges. Malaysia, a multicultural society with diverse religions, values and perceptions further complicate the introduction of formal clinical ethics consultation service. Clinicians attending a national congress workshop completed a Strengths–Weaknesses–Opportunities–Threats analysis. The aim was to gain insight into clinician’s expectations and promote initiatives leading to the introduction of clinical ethics consultation service. Clinicians agree that clinical ethics consultation service can improve (...) quality of care, reduce healthcare costs and advocate for patients and providers. The analysis highlighted constraints in sufficient critical mass of relevant expertise and restricted opportunities for training. The opportunities lie in education, curriculum development and availability of dedicated proponents. Cultural barriers, limited resources, lack of awareness, differenc... (shrink)

Xenotransplant patient selection recommendations restrict clinical trial participation to seriously ill patients for whom alternative therapies are unavailable or who will likely die while waiting for an allotransplant. Despite a scholarly consensus that this is advisable, we propose to examine this restriction. We offer three lines of criticism: (1) The risk–benefit calculation may well be unfavorable for seriously ill patients and society; (2) the guidelines conflict with criteria for equitable patient selection; and (3) the selection of seriously ill patients (...) may compromise informed consent. We conclude by highlighting how the current guidance reveals a tension between the societal values of justice and beneficence. (shrink)

This book is about the ethical issues that clinicians encounter in caring for patients. In order to practice excellent clinical care, clinicians and those studying to become clinicians must understand ethical issues such as informed consent, truth telling, confidentiality, privacy, the distinction between research and clinical care, and end-of-life care. Our audience also includes families and other persons close to patients, who may participate in decisions about their care"--Provided by publisher.

Psychiatry has witnessed a new wave of approaches to clinical phenotyping and the study of psychopathology, including the National Institute of Mental Health’s Research Domain Criteria, clinical staging, network approaches, the Hierarchical Taxonomy of Psychopathology, and the general psychopathology factor, as well as a revival of interest in phenomenological psychopathology. The question naturally emerges as to what the relationship between these new approaches is – are they mutually exclusive, competing approaches, or can they be integrated in some way (...) and used to enrich each other? In this opinion piece, we propose a possible integration between clinical staging and phenomenological psychopathology. Domains identified in phenomenological psychopathology, such as selfhood, embodiment, affectivity, etc., can be overlaid on clinical stages in order to enrich and deepen the phenotypes captured in clinical staging (‘high resolution’ clinical phenotypes). This approach may be useful both ideographically and nomothetically, in that it could complement diagnosis, enrich clinical formulation, and inform treatment of individual patients, as well as help guide aetiological, prediction, and treatment research. The overlaying of phenomenological domains on clinical stages may require that these domains are reformulated in dimensional rather than categorial terms. This integrative project requires assessment tools, some of which are already available, that are sensitive and thorough enough to pick up on the range of relevant psychopathology. The proposed approach offers opportunities for mutual enrichment: clinical staging may be enriched by introducing greater depth to phenotypes; phenomenological psychopathology may be enriched by introducing stages of severity and disorder progression to phenomenological analysis. (shrink)

Moral pluralism poses a foundational problem for secular clinical ethics: How can ethical dilemmas be resolved in a context where there is disagreement not only on particular cases, but further, on...

Can machine intelligence do clinical ethics? And if so, would applying it to actual medical cases be desirable? In a recent target article (Meier et al. 2022), we described the piloting of our advisory algorithm METHAD. Here, we reply to commentaries published in response to our project. The commentaries fall into two broad categories: concrete criticism that concerns the development of METHAD; and the more general question as to whether one should employ decision-support systems of this kind—the debate we (...) set out to ignite with our target article. (shrink)

A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an (...) increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded ‘grey zone articles’, in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients’ and caregivers’ views on ethical challenges, is presented. (shrink)

This systematic review identifies and critically evaluates instruments that have been developed to measure clinical trial informed consent comprehension in non-cognitively-impaired adults. Literature searches were carried out on Medline (Ovid), PsycInfo, CINHAL, ERIC, ScienceDirect, and Cochrane Library for English language articles published between January 1980 and September 2008. Instruments were excluded if they focused on consent onto paediatric trials, the construct under study was primarily capacity or competency, or the instrument was developed specifically for psychiatric or cognitively-impaired populations. Instruments (...) selected for review were evaluated against the following criteria: (1) method of item generation; (2) type and format of test items; (3) administration and interpretation of test results; and (4) psychometric properties. Three instruments met our defined inclusion criteria: the Deaconess Informed Consent Comprehension Test (DICCT), the Quality of Informed Consent (QuIC) questionnaire and the Brief Informed Consent Protocol (BICEP). Each instrument varied in terms of content measured. Significantly, these are the first standardized instruments developed to assess comprehension in non-cognitively-impaired adults. Yet, each instrument had its own set of limitations such as the lack of generalizability and the absence of details pertaining to how test results should be used to guide clinical decision-making. Standardized clinical trial informed consent comprehension assessments have been developed to identify gaps in research participants' understanding and ensure that respect for patient autonomy is satisfied. (shrink)

I argue that generic generalizations expressed in language (i.e., “generics”) are apt for good clinical reasoning. I begin by introducing what generics are in language and describe two problems in the use and interpretation of generics: Generics can license inaccurate judgements about the frequency of events or properties within a group (i.e., a problem with the “truth-aptness” of generics) and can facilitate problematic beliefs about social kinds (e.g., prejudice or essentializing). I provide an account of clinical reasoning and (...) describe some features of what I call “good” clinical reasoning. I offer examples of generics in clinical contexts and examine how the two problems with generics (i.e., of truth-aptness and social generics) can be harmful to patients and impair clinical reasoning. However, I ultimately argue that generics are important for good clinical reasoning because they track “conspicuous” features of disease processes (e.g., severe possible outcomes). Further, I argue that prejudicial generics are often irrational to believe, and social generics that are rational to believe need not lead to problematic implicatures about social kinds and can, in principle, instead facilitate meaningfully articulating societal injustices. I then argue that statistical statements, which are tempting alternatives to generics in clinical reasoning, are no better than generics for good clinical reasoning, even with respect to the two problems identified in the use of generics. (shrink)

Clinical equipoise has been proposed as an ethical principle relating uncertainty and moral leeway in clinical research. Although CE has traditionally been indicated as a necessary condition for a morally justified introduction of a new RCT, questions related to the interpretation of this principle remain woefully open. Recent proposals to rehabilitate CE have divided the bioethical community on its ethical merits. This paper presents a new argument that brings out the epistemological difficulties we encounter in justifying CE as (...) a principle to connect uncertainty and moral leeway in clinical ethics. The argument proposes, first, that the methodology of hypothetical retrospection is applicable to the RCT design and that it can accommodate uncertainty. As currently understood, however, HR should give up its reliance on the assumption of uncertainty transduction, because the latter assumes the principle of indifference, which does not accommodate uncertainty in the right way. The same principle is then seen to distort also the received interpretations of CE. (shrink)

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

Clinical guidelines are special types of plans realized by collective agents. We provide an ontological theory of such plans that is designed to support the construction of a framework in which guideline-based information systems can be employed in the management of workflow in health care organizations. The framework we propose allows us to represent in formal terms how clinical guidelines are realized through the actions of are realized through the actions of individuals organized into teams. We provide various (...) levels of implementation representing different levels of conformity on the part of health care organizations. Implementations built in conformity with our framework are marked by two dimensions of flexibility that are designed to make them more likely to be accepted by health care professionals than standard guideline-based management systems. They do justice to the fact 1) that responsibilities within a health care organization are widely shared, and 2) that health care professionals may on different occasions be non-compliant with guidelines for a variety of well justified reasons. The advantage of the framework lies in its built-in flexibility, its sensitivity to clinical context, and its ability to use inference tools based on a robust ontology. One disadvantage lies in its complicated implementation. (shrink)

This clinical ethics case examines whether healthcare providers have an obligation to inform patients about animal-derived ingredients in medications, specifically focusing on a hospitalized patient who may object to porcine-derived heparin on religious grounds. The ethics committee concluded that healthcare providers have a moral obligation to disclose this information to all patients, not just those presumed to have religious or ethical objections, to allow for informed decision-making. While acknowledging practical challenges around information delivery and increased costs of synthetic alternatives, (...) they recommended developing systematic approaches like information leaflets and staff education to address this issue. The committee emphasized there should be no moral distinction between religious and ethical objections to animal products, and that the healthcare system needs to work with faith and advocacy groups to better serve patients' needs while balancing medical necessity with personal beliefs. (shrink)

Religions often operate as comprehensive worldviews, attempting to answer the deepest existential questions that human beings can ask: Who am I? Where do I come from? Where am I going after I die? How should I live? Often ethical systems are embedded and justified within these broader narratives. Inevitably, the clinical ethics consultant will encounter and engage with religiously based ethical systems. In this issue, the authors reflect seriously and deeply on the implications of such engagement.

In an adaptive clinical trial , key trial characteristics may be altered during the course of the trial according to predefined rules in response to information that accumulates within the trial itself. In addition to having distinguishing scientific features, adaptive trials also may involve ethical considerations that differ from more traditional randomized trials. Better understanding of clinical trial experts’ views about the ethical aspects of adaptive designs could assist those planning ACTs. Our aim was to elucidate the opinions (...) of clinical trial experts regarding their beliefs about ethical aspects of ACTs. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryChong Siow Ann, Associate ProfessorDr. G appears to experiencing symptoms of schizophrenia, which is arguably the most severe mental disorder and which afflicts about one in a hundred people. This is a psychotic disorder that causes disturbances and distortions in thinking, including neurocognitive impairments, perception and behaviour. There is no cure for this often devastating disorder. Current antipsychotic medications can alleviate some of the symptoms but it (...) often comes at a price as these antipsychotics have burdensome side effects.A feature of this disorder is anosognosia, which is a lack of awareness or “insight” that an illness is present. This lack of insight presents a particular challenge because these individuals would, as in the case of Dr. G, refuse needed treatment as they do not perceive that they are ill. This is not necessarily an all-or-none phenomenon but is rather more complex and multidimensional; there might be an unawareness or recognition on behalf of the patient that they are suffering from a mental illness, the failure to appreciate the necessity of treatment; and/or the inability to recognise and define the psychotic symptoms like unusual thoughts and hallucinations as signs of illness1 and in many instances, all three are present. It is also by no means uncommon. Studies have found that between 60% and 80% of people with schizophrenia lack awareness of their illness to varying degrees.2This phenomenon remains an enigma. Some regard it as a form of psychological defence against the harsh reality of a psychotic illness — awareness of having a chronic and devastating illness might lead to demoralisation, hopelessness and suicide.3 Recent research, however, [End Page 250] indicates that this psychological denial plays a small part, if any, and instead has found an association with certain neuropsychological and neurocognitive deficits,4 as well as functional and structural brain abnormalities in the frontal lobe of the brain.5The prevailing clinical view thus is that this is an intrinsic and organic aspect of the schizophrenic illness which has nothing to do with wilfulness but rather the incapacity to perceive the presence of the illness. Edwin Fuller Torrey, an eminent psychiatrist and executive director of the Stanley Medical Research Foundation, calls anosognosia the “single largest reason why individuals with schizophrenia and bipolar disorder do not take their medications”, and he has remarked that “to keep talking about civil liberty is illogical. Patients are anything but free when they’re at the beck and call of their own delusions”.6It is also this view that it is a product of a brain disorder that some — particularly patients — find unacceptable. At one level, it does not take into context the person’s own experiences, and at a deeper level it calls into question the conception of the self with its capacity to exercise judgements and the autonomy to make decisions.This is a perennial ethical issue in psychiatry when people with severe mental illnesses refuse treatment. This becomes a Catch-22 situation where part of the illness that needs treatment is also preventing any treatment to be given: implicit in the principle of informed consent for treatment is that the person should be aware of the nature and course of their illness and acknowledge the need for treatment. While there are laws for involuntary commitment, the bar is usually high in that there must be a clear and present risk of harm to the person or others. Alan Stone, a professor of law and psychiatry at Harvard University proposed a possible justification for involuntary treatment based on his “thank-you theory” which assumes that patients will become well and subsequently agree that the intervention was in their best interests but research suggests that only half of these patients would admit so.7One suggested mechanism is the use of advance directives — psychiatry’s version of the living will in which people can specify what sort of medical care they would like should they become mentally unwell and unable to exercise appropriate judgement. An intrinsic part of this might include a “Ulysses contract” — just as Ulysess instructed his crew to lash him to the mast of the his ship so that he could... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentarySim Kang, Associate ProfessorRegarding the question of whether to disclose the incidental finding or not to the 72-year-old subject, one needs to consider several issues pertaining to the elderly subject, investigator team, informed consent process, illness under examination and wider societal and cultural context. First, in terms of the subject, would keeping the incidental finding secret in the context of the informed consent be respectful of the (...) wishes of the subject? One needs to bear in mind that consent was taken with the understanding that assessments will not be further shared with the subject as the assessments were done in the research study to generate new data and were not part of clinical evaluation or treatment. In one sense, autonomy of the subject in agreeing and consenting to the study investigations must be respected and the subject is comfortable that no results of the extensive assessments (blood tests and brain scans which are performed at baseline and annually for three years prospectively) will be proffered in the course of the project. At a more personal level, it may also be that the subject prefers not to know of any incidental findings even if present, which in some cases may be related to cultural notions of abnormal findings and ill health.Second, from the standpoint of the research team, would awareness of the space-occupying lesion but not informing the subject constitute a breach of ethical principles of beneficence and non maleficence? When the subject is enrolled in a research study, it is understood that the balance between research risks and benefits should have been evaluated in favour of the latter. Although more needs to be clarified to determine the clinical significance of the lesion, there is a possibility that the lesion may be malignant which would pose [End Page 289] further challenges. If the lesion is detected early, there may be a likelihood of early intervention, including surgical or non-surgical options. If the lesion of undetermined stage at present is not treated expediently and expeditiously, is there a possibility of it progressing to a stage when delayed treatment may be less effective? In this aspect, the welfare of the subject needs to be kept in mind. Even if nondisclosure is opted, is it just to allow the subject to continue in the longitudinal study if the small intracerebral lesion turns out to be malignant or that treatment may be rendered less effective over time?Third, with regard to the informed consent procedure, does the patient fully appreciate the details and implications of the study including not sharing laboratory or neuroimaging evaluations? For the process of informed consent to be meaningful, there are three elements that need to be present, namely adequate and appropriate disclosure of details about the study, demonstration of understanding of the information presented, as well as voluntariness in participation. Pertaining to adequate disclosure, was there appropriate disclosure and discussion of some of the key aspects of the study, including prospective nature lasting three years, repeated measurements and no sharing of details of assessments? The subject needs to have an appreciation of the impact of the information beyond intellectual comprehension. Was he or she cognisant of the number of visits over the entire course of the study as well as the amount of time involved for each visit? What was the response of the subject when it was made known that additional information obtained from the study evaluations will not be revealed or disclosed?Factors that may influence the understanding in this case include older age with possible easier fatigability and shorter attention span, severity of illness with related level of cognitive impairment, educational level, and familiarity with research procedures, all of which are unclear in this case at this point. With respect to voluntariness, was there any undue coercion or influence that may compromise the respect for autonomy of the research subject? It is noteworthy that the team has painstakingly committed to retake the consent before each follow up (thrice over three years) and that the subject can withdraw from the participation in the study at any point in time. Were there factors that may affect the willingness of the subject... (shrink)

Developing a vaccine against HIV is one of the greatest challenges the scientific community faces today. Several vaccine candidates have undergone preliminary safety and immunogenicity studies in humans. Research teams are ready to test these vaccines in the field, yet the scientific community is divided as to whether efficacy trial should begin. This paper addresses the complex scientific and ethical issues raised by clinical trials. Considering the pressure to act rapidly to solve the crisis, scientists need to hold to (...) the fundamental principles that guide decisions in biomedical research: respect for persons, beneficence and justice. Because these studies need to enroll a large number of subjects, prospective vaccines will need to be tested in developing, as well as industrial countries. The international community needs to work to ensure that the populations that accept the risk of the research receive the full benefit of that research and, that the vaccine proven successful, be made accessible and affordable to people in less economically developed situation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical CommentaryRathi Mahendran, Associate ProfessorThe doctor-patient relationship has an important role in medical practice and in medical ethics.1 In modern times, the word “boundary” is used to frame the relationship. In the context of therapy, Gutheil and Simon have described it as “the edge of appropriate or professional behaviour, transgression of which involves the therapist stepping out of the clinical role”.2 Boundaries establish for medical professionals the (...) distinctions between professional and personal identity.3 In a therapeutic setting, boundaries distinguish acceptable and appropriate interactions and the parameters of professional conduct.4 Implicit in the concept of boundaries are the basic ethical principles of beneficence (doing good, acting in another person’s best interests), non-maleficence (doing no harm) and justice with respect for the individual’s needs and autonomy.The doctor-patient relationship is particularly important in psychological therapies where trust, integrity, confidentiality, a safe environment and empathy are fundamental to the therapeutic process. A person with BPD manifests emotional dysregulation with instability in interpersonal relationships, self-image, affect and impulsivity.5 This, together with identity disturbances, makes them a particularly vulnerable group with heightened reliance on their therapist.6Psychotherapy has been described as an interaction which serves to alleviate distress, change behaviour and alter the patient’s perspective of issues. This description however does not reflect the magnitude and significant power differentials in the relationship. Trust and a close bond are needed to allow issues to be addressed.7 In the process, patients’ fantasies and unmet emotional needs [End Page 191] might lead them to knowingly or unknowingly view their therapist differently and to seek a relationship. Similarly, multiple factors in the therapist (situational factors, intrapsychic and interpersonal factors) can undermine the therapeutic process.8Boundary TransgressionsThere is really no universal definition for a “therapeutic boundary” possibly because, as Simon explains, it is “a function of the nature of the patient, the treatment and the status of the therapeutic alliance”.9 Minor violations are referred to as boundary crossings which may arise because the therapist exhibits poor judgement.10 Such actions are non-exploitative and pose little risk to patients.11 Duckworth et al. describe how boundary crossings begin as “exaggerations of desirable attitudes”. Special arrangements and sessions for the patient and extending therapy sessions may be construed as desirable and arguably as effective for the therapeutic alliance.12 Yet, if not examined objectively, they become “subtle breaks in the therapeutic frame”.13Psychotherapists trained in analytic therapy hold very rigid views of doctor-patient interactions in psychological therapy. Some would argue that providing a personal telephone number for a patient in crisis situations is a permissible boundary crossing.14 Similarly, self-disclosure for modelling and on-site behaviour therapy interventions may be viewed as necessary for the therapeutic encounter.15The most commonly recognised boundary crossing, however, is self-disclosure.16 It occurs when the therapist relates a personal experience or information to the patient which is how the incident began in this case.17 It gradually progressed to an informal, friendly style of interaction, accepting a hug, thanking her for being a good friend, all of which are dissonant with the psychotherapeutic process.18In the first place, should the therapist have even offered to drive her home, notwithstanding the heavy downpour? While that offer could be viewed as helpful, the disclosure of marital problems was inappropriate and created confusion. We can only speculate upon the therapist’s behaviour. Was he trying to establish for his patient that they were both experiencing problems to gain her trust? Was he exhibiting some form of identification or did he have some unmet need for affirmation and for care and nurturance? It is difficult to rationalise the apparently thoughtless and impulsive behaviour.19The therapist was, at that point, vulnerable with marital problems and facing separation.20 Procci has highlighted that therapists who breach boundaries, “usually have serious personal problems and may have a psychiatric diagnoses”.21 Even though the relationship was non-sexual, it [End Page 192] moved beyond a boundary crossing and should be viewed as a boundary violation. While the most serious form of boundary violation is the sexual encounter... (shrink)

Nanomedicine promises unprecedented innovations for diagnosis and therapy as well as for predicting and preventing diseases. On the other hand it raises fears linked to new and unknown characteristics of nanoscale materials. Both, promises and fears, are closely linked to the realm of uncertainty. To a large extent it is currently not known which expectations could become reality and which suspected adverse events might come true. Medicine is quite familiar with decision-making under uncertainty. Rules and regulations for clinical research (...) have been developed to reduce possible harm for research participants without abandoning necessary investigations. Here we examine whether clinical research trials of nanomedicine need new regulations and conclude that the established rules should suffice. (shrink)

Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension from clinical judgment. This is (...) demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine’s epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi’s theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine. (shrink)

Military leaders must support health care and research to protect the health and readiness of their forces. Part of this effort entails conducting human subjects research to address current and emerging international health threats. The military is also attentive to the national security interests associated with global health, such as protection from widespread disruption due to disasters and epidemics. While military leaders’ global health research objectives relate to the military's strategic goals, including force health protection and national security, it is (...) only through longstanding partnerships with partner nations in several world regions that much of the relevant research is possible. Yet military priorities may differ starkly from those of the collaborating partner nations, raising concerns about the potential for exploitation in global health partnerships. However, in spite of differences in overall strategic priorities, a convergence of stakeholder interests allows for appropriate alignment in the choice of clinical research activities at global health sites supported by the military. These complex collaborative research arrangements depend on negotiating and navigating the selection of research goals and activities to ensure fairness and balancing of priorities among partners, thereby maintaining research infrastructure and capacity. Leaders of military institutions and partner nations must attend to the need for this sustained effort to balance priorities to ensure equity and successful maintenance of these essential relationships. (shrink)

Current clinical research lacks diversity in those that participate. This lack of diversity is concerning given its importance for successful drug development. The frequency and severity of many diseases, along with the pharmacological properties of therapies, can display significant differences based on patient diversity. A clinical trial population that is more reflective of these differences will help researchers better understand the therapeutic profile of the treatment and provide generalizable knowledge to the medical community. The advent of decentralized (...) class='Hi'>clinical trial designs is meant to help address this lack of diversity by using portable digital health technologies and virtual interactions to enhance clinical trial access and broaden participation. By leveraging these technologies, trial conduct can occur at locations other than traditional research sites. This shift in trial location may help address some of the logistical, educational, engagement, and trust barriers that have historically prevented enrollment of diverse populations. However, these types of trials still have limitations. Ethical concerns around justice, equity, and diversity will still exist with decentralized clinical trials, which could be mediated using clinical research vehicles. When utilized, this modality may enhance the scientific design and conduct of clinical trials and better follow these ethical principles. These enhancements and improved ethical direction could be accomplished through increasing community involvement, improving health literacy, supporting more diverse trial sites, creating community‐based research footholds, fostering connections with researchers, limiting technical challenges, and preventing data security issues. (shrink)

The clinical encounter between providers and patients is insufficient: most factors influencing health outcomes occur outside the clinic. Community Health Needs Assessments address this insufficiency via collaboration between hospitals and the communities they serve to address systemic sociological-economic variables impacting health outcomes. Considering this, why are Health Care Ethics Consultation services limited to the clinical setting? We can cultivate better ethics outcomes by addressing systemic sociological-economic factors that cause recurring ethics issues in the hospital. In this article, I (...) argue for the need for a Community Ethics Needs Assessment. CENA is a novel concept; thus, this article is exploratory. I argue for the necessity of a CENA and, more importantly, outline what methodology a CENA would use to both identify and address an ethics need. (shrink)

Background: International developments suggest that providing clinical ethics services to help clinicians negotiate ethical issues that arise in clinical practice is beneficial and reflects best practice in promoting high ethical standards and patient-centered care. The aim of this study was to explore the needs and experiences of clinical staff members to inform the development of future clinical ethics support. Methods: Health professionals at a large regional health service completed an online survey containing questions about the frequency (...) of ethical and legal issues encountered in clinical practice, the type of situations that gave rise to the ethical and/or legal uncertainty or concern, how clinicians currently address these issues, and what support would be welcome. Results: The survey was completed by 369 staff members, including 61% with more than 10 years in the profession and 51% in nursing/midwifery. Two-thirds (66%) indicated they often considered ethical implications of their clinical decisions, and half (49%) often considered the legal implications. More than half (58%) were often/occasionally concerned about the ethically right thing to do. Patient requests for borderline treatment (47%), staff disagreements about patient care (48%), and patients declining recommended treatment (54%) were the most frequent reasons given for ethical or legal uncertainty. Sixty-nine percent of respondents indicated that the way their department addressed ethical issues could be improved and 85% agreed that there is a need for more discussion on ethical issues. The majority (82%) of respondents had encountered ethically challenging clinical situations where additional support would have helped. Common approaches to issues were discussion with colleagues/supervisor (91.1%), discussion at handover/group forums (50.8%), and consultation with guidelines/protocols (60.9%). Conclusions: A majority of clinical staff members surveyed have encountered ethically/legally challenging cases daily for which they have often sought additional advice. This study indicates that many clinical staff members would welcome some form of additional clinical ethics support including advice and education. (shrink)

The European framework surrounding clinical trials on medicinal products for human use is going to change as demonstrated by the large debate at European institutional level. One of the major challenges is to overcome the lack of harmonisation of clinical trial procedures among countries. This aspect is gaining more and more importance, considering the increasing number of multicentre and multinational studies. In this work, the actual European rules governing the Clinical Trial Application have been analysed throughout the (...) different steps including the registration of the trial in the European database; the preparation of documents to be submitted and their contents; the preparation of documents related to the information and consent process; the submission to competent bodies. Specific issues related to paediatric research and trials involving non EU/EEA countries have been addressed as well. Results reveal that the European legislation offers a well defined set of European rules covering different aspects of a Clinical Trial Application. However, these are not suitable to meet the challenges from multicentre and multinational clinical studies. A stronger set of rules, such as is available in a composite European Regulation has been adopted and is expected to harmonise practices and enable sponsors to carry out well conducted trials. But will the new regulation overcome the existing criticisms of Directive 2001/20/EC? (shrink)

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. (shrink)

The current process towards formalization within evaluation research, in particular the use of pre-set standards and the focus on predefined outcomes, implies a shift of ownership from the people who are actually involved in real clinical ethics support services in a specific context to external stakeholders who increasingly gain a say in what ‘good CESS’ should look like. The question is whether this does justice to the insights and needs of those who are directly involved in actual CESS practices, (...) be it as receivers or providers. We maintain that those actually involved in concrete CESS practices should also be involved in its evaluation, not only as respondents, but also in setting the agenda of the evaluation process and in articulating the criteria by which CESS is evaluated. Therefore, we propose a participatory approach to CESS evaluation. It focuses on the concrete contexts in which CESS takes place, reflective and dialogical learning processes, and how to be democratic and inclusive. In particular, this approach to CESS evaluation is akin to realist evaluation, dialogical evaluation, and responsive evaluation. An example of a participatory approach to evaluating CESS is presented and some critical issues concerning this approach are discussed. (shrink)

Robust clinical decision-making depends on valid reasoning and sound judgment and is essential for delivering quality healthcare. It is often susceptible, however, to a clinician’s biases such as towards a patient’s age, gender, race, or socioeconomic status. Gender bias in particular has a deleterious impact, which frequently results in cognitive myopia so that a clinician is unable to make an accurate diagnosis because of a patient’s gender—especially for female patients. Virtue epistemology provides a means for confronting gender bias in (...) clinical decision-making and for correcting or even preventing its impact. The medical literature on cardiovascular and coronary heart disease is used to illustrate the role intellectual virtues can play in redressing the deleterious impact of gender bias on clinical decision-making and practice. Finally, questions are considered surrounding the pedagogy of intellectual virtues for medical students and practicing clinicians in order to provide quality care for patients, regardless of gender. (shrink)

Background The aim was to explore how the clinical ethics committees in Norway have worked and functioned within mental health care and addiction treatment services. Methods Analysis of 256 annual reports from clinical ethics committees from 2003 to 2012 and a survey to clinicians who had used a clinical ethics committee. Results Dilemmas related to coercion, confidentiality, information, and patient autonomy dominated. The committees established only for psychiatric hospitals, had received more cases from mental health and addiction (...) services than the committees also serving somatic services. Many of the case discussions involved both somatic and mental health care, complicated legal issues as well as ethical dilemmas. Mental health care professionals that have used the clinical ethics committees evaluated the clinical ethics committees deliberation as useful. Conclusion Given the many difficult ethical dilemmas in mental health care ethics work need to be strengthened. The complexity of the cases requires varied and interdisciplinary competence and training among the clinical ethics committee members. (shrink)

After a 50-page outline of the principles of clinical reasoning, over 60 actual cases are detailed that illustrate (and are keyed to) the principles, presenting case records, analysis, and references to literature. For medical students and interns, and their instructors. Annotation copyright Book Ne.

Clinical Pharmacology is a specialty with many attributes and our association with the subject has allowed us to acquire, apply and disseminate myriad aspects of research and practice. Though clinical pharmacologists are conspicuous by virtue of their small number, recent years have shown a growing need for the course. In the review below we navigate through several aspects of the subject as we encountered them from time to time. From critical appraisal of literature, to application of knowledge of (...) drugs, to clinical practice; moving on to clinical and basic research, to drug development process, to policy making - these are but a few of the many fields which constitute the scope of clinical pharmacology. The importance of the subject lies in allowing a trainee to develop a broad overview of the entire process, from drug generation to drug distribution to drug utilization, a process meant for the greater common goal of better health for all. We foresee a bright future for the subject though with a slight skepticism thrown in. In the present article, we make use of personal experiences and reference from literature to help you get a broad view of what clinical pharmacology means to us. (shrink)

Clinical research must be understood to be the foundation of scientific medicine of the clinical type. But the essence of scientific clinical medicine remains a matter of profound confusion, even in clinical academia, and so does the essence of clinical research. The confusion now revolves, principally, around ‘clinical epidemiology’. We address clinical research in the meaning of quintessentially ‘applied’ clinical research, which we take to be the foundation of the scientific knowledge base (...) of clinical medicine, of gnosis (dia‐, etio‐, pro‐) in it. More specifically, we address the essence, priorities, and status quo of this research – and argue that the requisite theory of this is not a matter of ‘clinical epidemiology’ but of theory of clinical research endogenous to clinical (rather than epidemiological) academia. (shrink)

This clinical ethics case examines whether to provide a blood transfusion to a severely injured Jehovah's Witness patient who initially agreed to the transfusion but changed her mind after speaking with a friend. The ethics committee analyzed several key issues: how to handle information from friends about a patient's religious beliefs when unconscious, the validity of advance directives, concerns about potential coercion in the patient's change of mind, and how to balance respect for religious beliefs against immediate medical needs. (...) The committee recommended that while unconscious, life-saving treatment should proceed given limited verifiable information about the patient's wishes. Once conscious, if the patient maintains a competent refusal after thorough discussion of risks and consideration of possible coercion, her decision should be respected even if it conflicts with medical recommendations. They emphasized the importance of consulting hospital Jehovah's Witness liaison services and documenting all discussions while exploring non-blood alternatives when possible. (shrink)

Clinical recognition is not produced by nursing judgment alone. Building on Fricker's account of epistemic injustice and extending critical theories of legibility, classification, measurement, and the clinical gaze, this article advances clinical legibility as a foundational theoretical construct for nursing. Clinical legibility names the structural condition under which patient testimony, bodily signs, and nursing concern can be captured, recognized, documented, transmitted, and acted upon equitably across populations. It shifts recognition from the individual knower's mind to the (...) infrastructures that make patient reality actionable, distinguishing clinical legibility from epistemic injustice, implicit bias, structural bias, diagnostic error, and failure to rescue through its focus on the prior problem of recognizability. Three interlocking conditions structure clinical legibility: instruments that produce valid inferences across patient populations, educational repertoires adequate to diverse bodies and presentations, and documentation and escalation systems capable of preserving patient testimony and nursing concern as actionable knowledge. For nursing, clinical legibility clarifies how surveillance, documentation, advocacy, escalation, and care all depend on recognition infrastructure capable of holding patient reality. Reforming that infrastructure is not peripheral to nursing's disciplinary project; it is a condition of ethical care and a disciplinary obligation. (shrink)

Clinical exchange: one model to achieve culturally sensitive care This paper reports on a clinical exchange programme that formed part of a pre‐registration European nursing degree run by three collaborating institutions in England, Holland and Spain. The course included: common and shared learning including two summer schools; and the development of a second language before the students went on a three‐month clinical placement in one of the other base institutions’ clinical environments. The aim of the course (...) was to enable students to become culturally sensitive carers. This was achieved by developing a programme based on transcultural nursing principles in theory and practice. Data were gathered by interview, focus groups, and questionnaires from 79 exchange students, fostering the strategies of illuminative evaluation. The paper examines: how the aims of the course were met; the factors that inhibited the attainment of certain goals; and how the acquisition of a second language influenced the students’ learning about nursing. A model is presented to illustrate the process of transformative learning from the exchange experience. (shrink)

Much of the literature on clinical ethical conflict has been specific to a specialty area or a particular patient group, as well as to a single profession. This study identifies themes of hospital nurses’ and physicians’ clinical ethical conflicts that cut across the spectrum of clinical specialty areas, and compares the themes identified by nurses with those identified by physicians. We interviewed 34 clinical nurses, 10 nurse managers and 31 physicians working at four different Canadian hospitals (...) as part of a larger study on clinical ethics committees and nurses’ and physicians’ use of these committees. We describe nine themes of clinical ethical conflict that were common to both hospital nurses and physicians, and three themes that were specific to physicians. Following this, we suggest reasons for differences in nurses’ and physicians’ ethical conflicts and discuss implications for practice and research. (shrink)

BackgroundClinical ethics case consultations (CECCs) provide a structured approach in situations of ethical uncertainty or conflicts. There have been increasing calls in recent years to assess the quality of CECCs by means of empirical research. This study provides detailed data of a descriptive quantitative and qualitative evaluation of a CECC service in a department of cardiology and intensive care at a German university hospital.MethodsSemi-structured document analysis of CECCs was conducted in the period of November 1, 2018, to May 31, 2020. (...) All documents were analysed by two researchers independently.ResultsTwenty-four CECCs were requested within the study period, of which most (n = 22; 92%) had been initiated by physicians of the department. The patients were an average of 79 years old (R: 43–96), and 14 (58%) patients were female. The median length of stay prior to request was 12.5 days (R: 1–65 days). The most frequent diagnoses (several diagnoses possible) were cardiology-related (n = 29), followed by sepsis (n = 11) and cancer (n = 6). Twenty patients lacked decisional capacity. The main reason for a CECC request was uncertainty about the balancing of potential benefit and harm related to the medically indicated treatment (n = 18). Further reasons included differing views regarding the best individual treatment option between health professionals and patients (n = 3) or between different team members (n = 3). Consensus between participants could be reached in 18 (75%) consultations. The implementation of a disease specific treatment intervention was recommended in five cases. Palliative care and limitation of further disease specific interventions was recommended in 12 cases.ConclusionsTo the best of our knowledge, this is the first in-depth evaluation of a CECC service set up for an academic department of cardiology and intensive medical care. Patient characteristics and the issues deliberated during CECC provide a starting point for the development and testing of more tailored clinical ethics support services and research on CECC outcomes. (shrink)

This case commentary explores whether and when it is justifiable NOT to direct injured or ill host nation patients to international coalition military hospitals that are better equipped than host nation hospitals to meet patients' health needs in order to ensure sufficient patients for success in clinical partnering. The case discusses Medical Rules of Eligibility as a policy to determine the destination of patients who present for medical care to international military medical services. It also discusses the ethical challenges (...) for international military healthcare workers when working as clinical partners to support capability‐building in host national medical facilities. This can be particularly difficult if it involves shared care of patients rather than didactic training. Finally, the case discusses the ethical dimensions of news reporting within medical facilities, especially if this is part of the military effort to share information about the military campaign. The case highlights ethical aspects of higher‐level military policy that impact clinical care and the importance of considering if external review of such policies is needed to ensure alignment with legal and professional ethical obligations. (shrink)

In After God: Morality and Bioethics in a Secular Age, H. Tristram Engelhardt, Jr. explores the broad implications for moral reasoning once a culture has lost a God’s-eye perspective. In this paper, I focus on the implications of Engelhardt’s views for clinical ethics consultation. I begin by examining the question of whether clinical ethics consultants should advocate a particular viewpoint and/or process during consultations or adopt a neutral stance. I then examine the implications of Engelhardt’s views for this (...) question. Finally, I discuss some of Engelhardt’s foundational ontological, metaphysical, meta-ethical, and epistemological commitments and how these commitments connect to his views on clinical ethics consultation. (shrink)