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During the last two decades there has been an enormous development in treatment possibilities in the field of neonatology, particularly for (extremely) premature infants. Although there are cross-cultural differences in treatment strategy, an overview of the literature suggests that every country is confronted withmoraldilemmas in this area. These concern decisions to initiate or withhold treatment directly at birth and, later on, decisions to withdraw treatment with the possible consequence that the child will die. Given that the (...) neonate cannot express his or her own will, who will decide? And on the basis of what information, values and norms? We explored some of these issues in daily practice by interviewing a small sample ofhealthcare practitioners in a Dutch university Neonatal IntensiveCare Unit (NICU). It turned out that experiencingmoraldilemmas is part of their daily functioning. Nurses underline the suffering of the newborn, whereas physicians stress uncertainty in treatment outcome. To make the best of it, nurses focus on their caring task, whereas physicians hope that future follow-up research will lead to more predictable outcomes. As for their own offspring, part of these professionals would hesitate to bring their own extremely premature newborn to a NICU. For the most oppressing dilemma reported – terminating an already initiated treatment – we propose the concept of ‘evidence shift’ to clarify the ambiguous position of uncertainty in decision making. (shrink)

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During the last two decades there has been an enormous development in treatment possibilities in the field of neonatology, particularly for (extremely) premature infants. Although there are cross-cultural differences in treatment strategy, an overview of the literature suggests that every country is confronted withmoraldilemmas in this area. These concern decisions to initiate or withhold treatment directly at birth and, later on, decisions to withdraw treatment with the possible consequence that the child will die. Given that the (...) neonate cannot express his or her own will, who will decide? And on the basis of what information, values and norms? We explored some of these issues in daily practice by interviewing a small sample ofhealthcare practitioners in a Dutch university Neonatal IntensiveCare Unit (NICU). It turned out that experiencingmoraldilemmas is part of their daily functioning. Nurses underline the suffering of the newborn, whereas physicians stress uncertainty in treatment outcome. To make the best of it, nurses focus on their caring task, whereas physicians hope that future follow-up research will lead to more predictable outcomes. As for their own offspring, part of these professionals would hesitate to bring their own extremely premature newborn to a NICU. For the most oppressing dilemma reported – terminating an already initiated treatment – we propose the concept of ‘evidence shift’ to clarify the ambiguous position of uncertainty in decision making. (shrink)

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In this article, it is argued that an appropriate starting point for an analysis of ethical issues inhealthcare is the consideration of the role obligation ofhealthcare professionals. These obligations have customary, legal, andmoral elements. By appreciating the different kinds ofhealthcare roles and their purposes, one can begin to understand some of the role conflicts which arise in thehealthcare community. Moreover, one can see (...) that some criticisms ofhealthcare professionals are mistaken. Nonetheless, there are internal conflicts with the roles of persons engaged inhealthcare and historically some role obligations have violated fundamental universal norms. Whereas the latter inadequacy ofhealthcare role obligations can be eliminated, the former will, to at least some extent, always be with us. In short, it may be argued that some of the so-called "moraldilemmas" inhealthcare can be resolved by taking the perspective of role morality. As will be shown, this does not suggest that there are no limitations of role morality. CiteULike Connotea Del.icio.us What's this? (shrink)

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Nurses and other medical practitioners often experiencemoral distress: they feel an anguished sense of responsibility for what they take to be their ownmoral failures, even when those failures were unavoidable. However, in such cases other people do not tend to think it is right to hold them responsible. This is an interesting mismatch of reactions. It might seem that the mismatch should be remedied by assuring the practitioner that they are not responsible, but I argue that (...) this denies something important that the phenomenon ofmoral distress tells us. In fact, both the practitioners’ tendencies to hold themselves responsible and other people’s reluctance to hold the practitioners responsible get something right. The practitioners may be right that they are responsible in the sense of having failed to meet a bindingmoral requirement, even when the requirement was impossible to meet. This makesmoral distress a fitting response because it correctly represents their own action as a wrongdoing. However, others may meanwhile be right that the practitioners are not responsible in the sense of being culpable and blameworthy. To blame others, or oneself, for certain failures, including those that are unavoidable, would be unfair. My claim depends on distinguishing between the fittingness and the fairness of holding someone (including oneself) responsible formoral failure. Having drawn the distinction, I suggest thatmoral distress should be addressed in a way that both recognizes it as a fitting response and avoids the unfairness of blame. (shrink)

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Knowledge aboutmoral development and elderly persons is very limited. A hermeneutical interpretative study was conducted with healthy elderly persons (n = 20) in order to explore and describe theirmoral orientation based on the paradigms of justice (Kohlberg) andcare (Gilligan). The types ofmoral reasoning, dominance, alignment and orientation were determined. All but one participant included both types of reasoning when discussing an ethical conflict. None of the men’smoral reasoning was dominated by (...) caring, but justice dominated the reasoning of four women. The implications for ethical decision-making and future research are discussed. (shrink)

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Knowledge aboutmoral development and elderly persons is very limited. A hermeneutical interpretative study was conducted with healthy elderly persons in order to explore and describe theirmoral orientation based on the paradigms of justice andcare . The types ofmoral reasoning, dominance, alignment and orientation were determined. All but one participant included both types of reasoning when discussing an ethical conflict. None of the men’smoral reasoning was dominated by caring, but justice dominated (...) the reasoning of four women. The implications for ethical decision-making and future research are discussed. (shrink)

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Background Ethics ofcare provides a framework forhealthcare professionals to manage ethicaldilemmas andmoral resilience may mitigate stress associated with the process and outcomes of ethical reasoning. This review addresses the empirical study of ethics ofcare andmoral resilience, published in thehealthcare literature, and identifies potential research gaps. Methods and procedure Arksey O’Malley's framework was adopted to conduct this scoping review. A literature search was conducted (...) across six databases: CINAHL Plus with full text, PubMed, PsycINFO, EMBASE, Scopus and MEDLINE. We collected and synthesised information on the nature of studies including study design, methods and key findings. Results While there is an abundance of literature describing the potential strengths of an ethics ofcare approach to ethical reasoning and growing interest in the role ofmoral resilience in protecting againstmoral distress, both concepts have received little empirical attention. A total of six relevant publications were selected for review. No studies explored the relationship between ethics ofcare andmoral resilience. However, studies focused upon ethics ofcare approach as a facilitator of patient-practitioner professional relationships and effective ethical decision making inhealthcare practice. Current evidence explores key characteristics consistent withmoral resilience inhealthcare professionals. Conclusion This review identified a dearth of research in ethics ofcare andmoral resilience in healthcare practice. Further empirical investigation may provide a deeper understanding of the translation of ethics ofcare andmoral resilience tohealthcare practice to facilitate workplace culture. (shrink)

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Increased work complexity and financial strain in thehealthcare sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is,moral distress. One way to support professionals in handling ethicaldilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects onmoral distress. The results show that the participants (...) were positive about the training program.Moral distress did not change significantly. This could be interpreted as competence development, with no effects onmoral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy. (shrink)

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The authors’ aim is to bring to the attention of readers the inadequacies ofcare for people in Hungary who are terminally ill. They believe that both objective and subjective factors cause these inadequacies. Most of these factors arise frommoraldilemmas that could be eased or even solved if ethics education had a much more prominent place in the nursing curriculum. Even if nurses would not become automatically better persons morally, a much wider knowledge of medical/nursing (...) ethics could significantly improve nursingcare both before and at the end of life. Although the article is also critical of the nursingcare provided, it is not its purpose to make any generalizations. The study utilized selected passages from essays written by 76 practicing nurses on their personal experience of ethicaldilemmas in their work environment, and a questionnaire administered to 250 students (registered nurses andhealthcare students) studying for a college degree. This article is written by two authors who have formed an unusal alliance: a registered nurse with 29 years’ experience of bedside nursing, but who is currently a teacher of nursing ethics at a localhealth college, and a lawyer turned bioethicist. (shrink)

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The book offers an introduction to themoral concepts and value ofhealthcare. It is written by amoral philosopher, a doctor and a nurse and contains questions, cases and exercises which are suitable for medical, nursing and all students and commentators onhealthcare.Moraldilemmas include consent, confidentiality, the giving or withholding of information, and the economics ofhealthcare. The issues of artificial reproduction, terminalcare (...) and the research and testing of drugs are addressed. (shrink)

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Increased work complexity and financial strain in thehealthcare sector have led to higher demands on staff to handle ethical issues. These demands can elicit stress reactions, that is,moral distress. One way to support professionals in handling ethicaldilemmas is education and training in ethics. This article reports on a controlled prospective study evaluating a structured education and training program in ethics concerning its effects onmoral distress. The results show that the participants (...) were positive about the training program.Moral distress did not change significantly. This could be interpreted as competence development, with no effects onmoral distress. Alternatively, the result could be attributed to shortcomings of the training program, or that it was too short, or it could be due to the evaluation instrument used. Organizational factors such as management involvement are also crucial. There is a need to design and evaluate ethics competence programs concerning their efficacy. (shrink)

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Objectives—To investigate the incidence and solution of ethicaldilemmas in a palliativecare unit.Design—Healthcare workers recorded daily alldilemmas in caring for each patient.Setting—Palliativecare unit of National Taiwan University Hospital in Taiwan.Patients—Two hundred and forty-six consecutive patients with terminal cancer during 1997-8.Main measurement—Ethicaldilemmas in the questionnaire were categorised as follows: telling the truth; place ofcare; therapeutic strategy; hydration and nutrition; blood transfusion; alternative treatment; terminal sedation; use of medication, (...) and others.Results—The type and frequency of ethicaldilemmas encountered were: place ofcare ; truth-telling ; hydration and nutrition ; therapeutic strategy , and use of medication . Ethical problems relating to the place ofcare and to therapeutic strategy were unlikely to be solved with increased hospital stay and some ethicaldilemmas remained unsolved even in the final week in hospital, including place ofcare , truth-telling and therapeutic strategy . Problems of truth-telling occurred in nearly half of patients over sixty-five-years-old. Conflicts about blood transfusion were experienced in all patients below 18-years-old, and thedilemmas concerning the place ofcare occurred most frequently with head and neck cancer patients .Conclusions—The solution of ethicaldilemmas required refocusing by medical professionals on the importance of continuing communication. Improved ethical training for professionals would contribute to solving themoraldilemmas of palliativecare. (shrink)

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This book is a collection of articles about communication and ethics in the field of medicine andhealthcare. Common to all the articles is that they are not directly based on empirical investigations. The discussions refer to research, but this is research that has already been carried out and documented in existing literature. In this sense the articles belong to what is often called applied philosophy. All the articles address communicative and ethical challenges in patient interaction on (...) the basis of assumptions in modernmoral philosophy and philosophy of language. There is a great need for literature that deals more comprehensively with the themes in this book than many introductory books do. It is particularly difficult to find suitable reading material that can be used in teaching at graduate and master levels. This book is designed to meet this need. It is suitable for use in all higher-level courses where the aim is to give students a theoretical understanding of ethicaldilemmas and communicative challenges inhealthcare. (shrink)

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The first part of this paper seeks to clarify how interpersonal relationships are generally rooted in considerations about trust, vulnerability and interpersonal dependence. However, for nurse–patient relationships, and from the point of view of justice and fair rationing, it is essential to investigate their distinctmoral nature. Hence, the second part of the paper argues that nurse–patient relationships, as a special kind of interpersonal relationship, raise particular normative issues. I will discussdilemmas facing nurses and professionalcare‐givers (...) in general who are torn between their obligations to existing patients and more general and impartial considerations regarding the distribution of nursingcare. This discussion concerning the normative claims of immediacy and mercy vs. fairness inhealthcare is a pressing issue for nursingcare. The claims that arise from particular relationships in nursingcare are typically associated with closeness to a person's vulnerabilities. The pressing issue is how considerations of mercy and protection of individual patients can be safeguarded within today's nursing andhealth‐care practices in which distributivist considerations are crucial. (shrink)

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Healthcare services today lack the resources to meet everybody's exspectations. Patients, professional workers and trade unions have legitimate but frequently conflicting claims, and so too have the different interest groups and specialties within medicine. This book provides an account of how resource allocationdilemmas appear to those confronted by them, in the hospital, onhealth boards and in the community, and it offers a critique of themoral and political arguments most commonly employed in (...) discussing them. (shrink)

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Dual loyalty issues confronthealth and welfare professionals in immigration detention centres in Australia. There are four apparent ways they deal with the ethical tensions. One group provides services as required by their employing body with little questioning ofmoraldilemmas. A second group is more overtly aware of the conflicts and works in a mildly subversive manner to provide the best possiblecare available within a harsh environment. A third group retreats by relinquishing employment in (...) the detention setting. A fourth group is activist in intent and actions. Derived from research and ethnography conducted in Australia, the article explores themoraldilemmas confronting those who are duty-bound by professional codes of ethics while also bound by loyalty to their employers and silenced by confidentiality statements. It provides particular focus on psychiatry, nursing and social work. We conclude by speculating whether a politics of compassion and acts of solidarity can forge a pathway through the ethical terrain. In doing so we draw upon human rights considerations as well as on the works of Joan Tronto and Elisabeth Porter. (shrink)

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OBJECTIVES: To determine the relationship between ethical reasoning and gender and occupation among a group of male and female nurses and doctors. DESIGN: Partialist and impartialist forms of ethical reasoning were defined and singled out as being central to the difference between what is known as the "care"moral orientation (Gilligan) and the "justice" orientation (Kohlberg). A structured questionnaire based on four hypotheticalmoraldilemmas involving combinations of (healthcare) professional, non-professional, life-threatening and non-life-threatening (...) situations, was piloted and then mailed to a randomly selected sample of doctors and nurses. SETTING: 400 doctors from Victoria, and 200 doctors and 400 nurses from New South Wales. RESULTS: 178 doctors and 122 nurses returned completed questionnaires. 115 doctors were male, 61 female; 50 nurses were male and 72 were female. It was hypothesised that there would be an association between feminine subjects and partialist reasoning and masculine subjects and impartialist reasoning. It was also hypothesised that nurses would adopt a partialist approach to reasoning and doctors an impartialist approach. No relationship between any of these variables was observed. (shrink)

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Combat deployments puthealthcare providers in ethically compromising and morally challenging situations. A sample of recently deployed nurses and physicians provided narratives that were analyzed to better appreciate individual perceptions ofmoraldilemmas that arise in combat. Specific questions to be answered by this inquiry are: 1) How do combat deployed nurses and physicians make sense of morally injurious traumatic exposures? and 2) What are the possible psychosocial consequences of these and other deployment stressors? This (...) narrative inquiry involves analysis of ten deployed military nurses’ and physicians’ aversive or traumatic experiences. Burke’s dramatist pentad is used for structural narrative analysis of stories that confirm and illuminate the impact of war zone events such as betrayal, disproportionate violence, incidents involving civilians, and within-rank violence on militaryhealthcare provider narrators. Results indicate cognitive dissonance and psychosocial sequelae related tomoral and psychological stressors faced by military medical personnel. Discussion addresses where healing efforts should be focused. (shrink)

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The focus of the study is the conflict betweencare and concern for particular patients, versus considerations that take impartial considerations of justice to be central tomoral deliberations. To examine these questions we have conducted qualitative interviews withhealth professionals in Norwegian hospitals. We found a value norm that implicitly seemed to overrule all others, the norm of ‘making a difference for the patients’. We will examine what such a statement implies, aiming to shed some light (...) overmoraldilemmas interwoven in bedside rationing. (shrink)

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Our study presents an overview of the issues that were brought forward by participants of amoral case deliberation (MCD) project in two elderlycare organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting ofcare providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within twocare institutions (residential homes and nursing (...) homes).Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on goodcare’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identifymoral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Oncecare providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’. (shrink)

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Healthcare providers (HCPs) are routinely placed into morally challenging situations that have the potential to causemoral distress. This is especially true for HCPs working in the military, whether they are on deployment outside their typical contexts of practice such as in disaster relief (e.g., Haiti and the Ebola missions in West Africa), or in more typically military settings such as peace keeping or armed conflicts (e.g., Afghanistan, Syria).Moral distress refers to “painful feelings and/or (...) psychological disequilibrium” (Nilsson, Sjöberg, Kallenberg, & Larsson, 2011, p. 50) that occur when an individual is aware of a morally appropriate action in amoral dilemma but obstruction prevents them from carrying it out, or when in a situation where they must choose between upholding equally treasured but conflictingmoral values. Similarly,moral distress can occur when faced with a ‘tragic choice’ where all available courses of action require something ofmoral significance to be given up, such as surgical triage in a mass casualty event (Hunt, Sinding, & Schwartz, 2012). In the literature,moral distress has been connected to negative psychological effects and even stress related mentalhealth issues including compassion fatigue, burnout, and post-traumatic stress disorder (Owen & Wanzer, 2014; Gustafsson, Eriksson, Strandberg, & Norberg, 2010; Litz, et al., 2009). (shrink)

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Healthcare professionals are one of a large group of individuals who are exposed to significant risks by virtue of their occupation, such as the police, mountain rescuers, fire-service. The types of risk to whichhealthcare professionals are exposed are numerous, many of which remain largely unrecognised by the public and may even be underestimated by the professionals themselves. Examples of thesehealth risks include fatigue, emotional/psychological trauma, physical injury caused by the use of (...) machinery, back injuries, possible even violent physical assault from a patient or hospital visitor. There is also a very significant risk of acquiring an illness in the course of employment, for example, physical damage caused by the prolonged use of toxic substances, and also infectious diseases which are acquired by various routes, such as air-borne infections, needle-stick injuries. Subjective risk evaluation and the notion of risk inhealthcare from the patients' perspective has been widely considered over many years, and in a number of different areas, including medical research, screening procedures, consent to surgery or other medical intervention. In this paper, however, themoraldilemmas which may arise forhealthcare professionals in relation tohealth risks are highlighted and specific questions are raised. (shrink)

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Doctor'sDilemmas, a fascinating study of themoraldilemmas confrontinghealth professionals and patients alike, examines areas ofhealthcare where ethical conflicts often arise. Gorovitz illuminates these conflicts by clearly explaining and applying a broad range of philosophical concepts. He lays the groundwork for informed ethical decision-making and provides the general reader with a lucid overview of the complexities of medical practice. Written in accessible, conversational style and making extensive use of anecdotes, examples, (...) and references to literature, Doctor'sDilemmas offers profound insights into medical ethics for all those involved with thehealth professions--be they doctors, nurses, administrators, or patients. (shrink)

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Healthcare professionals often facemoraldilemmas. Not dealing constructively withmoraldilemmas can causemoral distress and can negatively affect the quality ofcare. Little research has been documented with methodologies meant to support professionals incare for the homeless in dealing with theirdilemmas.Moral case deliberation is a method for systematic reflection onmoraldilemmas and is increasingly being used as ethics support for professionals (...) in varioushealth-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution forcare for the homeless to deal with theirmoraldilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutchcare institution for the homeless participated in MCD three times. Professionals incare for the homeless value MCD positively. They report that MCD helped them to identify themoral dilemma/question, and that they learned from other people’s perspectives while reflecting and deliberating on the values at stake in the dilemma ormoral question. They became aware of themoral dimension ofmoraldilemmas, of related norms and values, of other perspectives, and learned to formulate amoral standpoint. Some experienced the influence of MCD in the way they dealt withmoraldilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal withmoraldilemmas in the future. Most of them were in favour of further implementation of MCD in their organization. (shrink)

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Healthcare professionals often facemoraldilemmas. Not dealing constructively withmoraldilemmas can causemoral distress and can negatively affect the quality ofcare. Little research has been documented with methodologies meant to support professionals incare for the homeless in dealing with theirdilemmas.Moral case deliberation is a method for systematic reflection onmoraldilemmas and is increasingly being used as ethics support for professionals (...) in varioushealth-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution forcare for the homeless to deal with theirmoraldilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutchcare institution for the homeless participated in MCD three times. Professionals incare for the homeless value MCD positively. They report that MCD helped them to identify themoral dilemma/question, and that they learned from other people’s perspectives while reflecting and deliberating on the values at stake in the dilemma ormoral question. They became aware of themoral dimension ofmoraldilemmas, of related norms and values, of other perspectives, and learned to formulate amoral standpoint. Some experienced the influence of MCD in the way they dealt withmoraldilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal withmoraldilemmas in the future. Most of them were in favour of further implementation of MCD in their organization. (shrink)

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Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing ofhealthcare is universal and inevitable, taking place in poor and affluent countries, in publicly funded and privatehealthcare systems. Someone must budget for as well as dispensehealthcare whilst aging populations severely stretch the availability of resources. The Ethics ofHealthCare (...) Rationing is a clear and much-needed introduction to this increasingly important topic, considering and assessing the major ethical problems anddilemmas about the allocation, scarcity and rationing ofhealthcare. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value ofhealth? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking abouthealthcare rationing? Does rationinghealthcare unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for theirhealth? Why does the debate on responsibility forhealth lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics,health economics, publichealth, medicine, nursing and social work. (shrink)

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BackgroundEthiopia’s 2005 abortion law improved access to legal abortion. In this study we examine the experiences of abortion providers with the revised abortion law, including how they view and resolve perceivedmoral challenges.MethodsThirty healthcare professionals involved in abortion provisions in Addis Ababa were interviewed. Transcripts were analyzed using systematic text condensation, a qualitative analysis framework.ResultsMost participants considered the 2005 abortion law a clear improvement—yet it does not solve all problems and has led to newdilemmas. As a main (...) finding, the law appears to have opened a large space for professionals’ individual interpretation and discretion concerning whether criteria for abortion are met or not. Regarding abortion for fetal abnormalities, participants support the woman’s authority in deciding whether to choose abortion or not, although several saw these decisions asmoraldilemmas. All thought that abortion was a justified choice when a diagnosis of fetal abnormality had been made.ConclusionEthiopian practitioners experiencemoraldilemmas in connection with abortion. The law places significant authority, burden and responsibility on each practitioner. (shrink)

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This case study illustrates thedilemmas facing multinational companies in meeting social challenges in Sub-Saharan Africa. It also discusses the purpose, responsibilities and limitations of business involvement in social development. From a business standpoint, social challenges in developing countries differ greatly from those in nations where governments or markets effectively provide for the population’shealth needs. The case illustrates what led a multinational to set up a corporate foundation and focuses on three strategic and operationaldilemmas it (...) ran up against. The case discussion shows that the ethical issues intertwined with thesedilemmas are best understood using a variety of ethical approaches. We also show that Ethics ofCare are just as relevant to analysing corporate social responsibility and corporate philanthropy as the Deontological and Utilitarianism theories commonly used in business ethics. (shrink)

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Dilemma discussions have been proven to be one of the most effective methods to enhance students’moral reasoning in ethics education. Dilemma discussions are increasingly arranged online, but research on the topic has remained sparse, especially in the context of continuing professional education. The aim of the present paper was to develop a method of dilemma discussions for professional ethics. The method was based on asynchronous discussions in small groups.Health and socialcare students raised work-related (...) class='Hi'>dilemmas from their experiences and discussed them in terms of professional values, ethical guidelines and theories. Participants in this quasi-experimental study were 87 first-term graduate students at a Finnish university of applied sciences.Health and socialcare students in two consecutive ethics courses constituted two experiment groups, whereashealth and socialcare students and business students in other programmes served as control groups. Students filled in a Defining Issues Test (DIT2) at the beginning of their studies and three months apart. Statically significant increase inmoral reasoning was evidenced for experiment group 2, when discussion groups were purportedly composed to maximise differences in initial levels ofmoral reasoning. Findings suggest that online dilemma discussions can advance students’moral reasoning development, especially when students’ exposure to higher-level arguments is ensured through complementary means, such as instructions, examples and plenary discussions. Online real-life dilemma discussions may also serve other important goals of ethics education, especially acquiring ethical concepts, and they can promote other components of ethical decision making: ethical sensitivity and motivation, and acquisition of implementation skills. (shrink)

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Professionals within the mentalhealth services face many ethicaldilemmas and challenging situations regarding the use of coercion. The purpose of this study was to evaluate the significance of participating in systematic ethics reflection groups focusing on ethical challenges related to coercion. In 2013 and 2014, 20 focus group interviews with 127 participants were conducted. The interviews were tape recorded and transcribed verbatim. The analysis is inspired by the concept of ‘bricolage’ which means our approach was inductive. Most (...) participants report positive experiences with participating in ethics reflection groups: A systematic and well-structured approach to discuss ethical challenges, increased consciousness of formal and informal coercion, a possibility to challenge problematic concepts, attitudes and practices, improved professional competence and confidence, greater trust within the team, more constructive disagreement and room for internal critique, less judgmental reactions and more reasoned approaches, and identification of potential for improvement and alternative courses of action. On several wards, the participation of psychiatrists and psychologists in the reflection groups was missing. The impact of the perceived lack of safety in reflection groups should not be underestimated. Sometimes the method for ethics reflection was utilised in a rigid way. Direct involvement of patients and family was missing. This focus group study indicates the potential of ethics reflection groups to create amoral space in the workplace that promotes critical, reflective and collaborativemoral deliberations. Future research, with other designs and methodologies, is needed to further investigate the impact of ethics reflection groups on improvinghealthcare practices. (shrink)

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Rambam Medical Center, the only tertiarycare center and largest hospital in northern Israel, was subjected to continuous rocket attacks in 2006. This extreme situation posed serious and unprecedented ethicaldilemmas to the hospital management. An ambiguous situation arose that required routine patientcare in a tertiary modern hospital together with implementation of emergency measures while under direct fire. The physicians responsible for hospital management at that time share some of themoraldilemmas faced, the (...) policy they chose to follow, and offer a retrospective critical reflection in this paper. The hospital’s first priority was defined as delivery of emergency surgical and medical services to the wounded from the battlefields and home front, while concomitantly providing the civilian population with all elective medical and surgical services. The need for acute medical service was even more apparent as the situation of conflict led to closure of many ambulatory clinics, while urgent or planned medicalcare such as open heart surgery and chemotherapy continued. The hospital management took actions to minimize risks to patients, staff, and visitors during the ongoing attacks. Wards were relocated to unused underground spaces and corridors. However due to the shortage of shielded spaces, not all wards and patients could be relocated to safer areas. Modern warfare will most likely continue to involve civilian populations and institutes, blurring the division between peaceful high-tech medicine and the rough battlefront. Hospitals in high war-risk areas must be prepared to function and deliver treatment while under fire or facing similar threats. (shrink)

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In lieu of an abstract, here is a brief excerpt of the content:Introduction:DevelopingHealthCare in Severely Resource-Constrained SettingsPaul Farmer and Sadath SayeedThis symposium of Narrative Inquiry in Bioethics catalogues the experiences ofhealthcare providers working in resource-poor settings, with stories written by those on the frontlines of globalhealth. Two commentaries by esteemed scholars Renee Fox and Byron and Mary-Jo Good accompany the narratives, helping situate the lived experiences of globalhealth practitioners (...) within the frameworks of sociology and medical anthropology respectively.The burgeoning interest in globalhealth among students,health science trainees, clinical practitioners, social entrepreneurs, philanthropists, and government officials is often linked with substantialmoral claims. People working in globalhealth often start with the rhetorical premise that each and every human being, regardless of economic, social, or political circumstances that lie beyond his or her control, deserves equal access to qualityhealthcare services. This is a bold position at risk of trivialization, in part because the sentiment is so commonplace among globalhealth equity activists.Despite this relatively recent global outpouring of solidarity and concern, billions of poor people still lack access to basichealth services. All too often, interventions that perpetuate existing trade practices and market economics are promoted, usually to the detriment of the poor. As our good friend and colleague Arthur Kleinman warns:The irrelevance of ethics can be seen when considering universal ethical formulations of justice and equity that do not begin with the localmoral conditions of poor people, those experiencing the systematic injustice of higher disease rates and fewerhealth-care resources because of their positioning at the bottom of local social structures of power.(1999, p.72)If we are serious about reducinghealth disparities globally, we must be prepared to mobilize resources in Africa just as we would in the United States or in Europe. If we fetishize cost-effective (read: low-cost) interventions for the poor, we must ask whether we use the same metrics in other situations. In other words, we must always strive to address the fundamental structural and social causes ofhealth inequity.We believe that globalhealth must avoid the "iron cage of rationality," to use sociologist Max Weber's words. One unanticipated consequence of the growth of globalhealth as a field is that the "audit culture"—which encourages accountability and effectiveness—can at times reinforce power differentials between donors (whether government agencies or multilateral foundations) and their intended beneficiaries. Agendas are often set not by community members but by globalhealth leaders who rarely demonstrate sustained commitments to a local community. [End Page 73]As the guest editors of this issue, we hope to recapture the soul of globalhealth work through the art of storytelling. Narratives, even when presented as raw and unrefined as many within this issue, remind us of the immense challenges—both programmatic andmoral—involved in this work. The profound scarcity of resources available tohealth providers in poor countries forces ethical questions on doctors, nurses, pharmacists, social workers, and otherhealthcare workers, who make difficult choices every day about what to do with the few resources they have. These are the ethicaldilemmas of mortal dramas at their most dire. Globalhealth work demands of its practitioners an alternate mode of audit than academic methodologies can provide. Narratives return us to the basic human commitments that led many of us to this work, and they remind us to use words like equality and justice meaningfully.The narratives that follow offer unmitigated perspectives on the working lives of globalhealth practitioners. They highlight the translation of themoral and programmatic challenges ofhealthcare delivery into real choices: for example, between a visiting surgeon's desire to treat a patient and his capacity (or really incapacity) to provide follow-upcare. They acknowledge the necessity of interdisciplinary cooperation in resource-constrained settings, as well as the difficulties in collaborating across cultures and continents. Most importantly, they make the claim that a newborn in distress in a tent in Port-au-Prince merits the same resources and attention as one in Boston, and that his or her death merits the same indignation. They demonstrate the radical solidarity inherent in the... (shrink)

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Our study presents an overview of the issues that were brought forward by participants of amoral case deliberation (MCD) project in two elderlycare organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting ofcare providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within twocare institutions (residential homes and nursing (...) homes).Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on goodcare’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identifymoral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Oncecare providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’. (shrink)

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Moral distress inhealthcare has been identified as a growing concern and a focus of research in nursing andhealthcare for almost three decades. Researchers and theorists have argued thatmoral distress has both short and long-term consequences.Moral distress has implications for satisfaction, recruitment and retention ofhealthcare providers and implications for the delivery of safe and competent quality patientcare. In over a decade of research (...) on ethical practice, registered nurses and otherhealthcare practitioners have repeatedly identifiedmoral distress as a concern and called for action. However, research and action onmoral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings ofmoral distress. To further examine these issues and foster action onmoral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium onMoral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action onmoral distress inhealthcare. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction tomoral distress; make explicit some of the challenges associated with theoretical and conceptual constructions ofmoral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action onmoral distress inhealthcare practice. The following three papers were written by key international experts onmoral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefinemoral distress, and outline directions for an agenda for action onmoral distress inhealthcare. (shrink)

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An outstanding feature of the study of nursing ethics is that it raises questions concerningmoral virtue, conscience, consistency and character. A considerable section of the literature is devoted to ideas of how best to teach ethics tohealth professionals. It has been shown that when faced with ethicaldilemmas nurses tended to rely on intuition and instinct to resolve them, with little systematic analysis to help the process. Nurses who have been in practice for a number (...) of years may experience particular difficulties in resolving ethicaldilemmas, for although they may be able easily to identify ethical problems they may feel powerless to behave appropriately through lack of theoretical background and/or confidence in participating in informed debate. An educational programme was designed to meet the needs of mature registered nurses who were undertaking a post-qualification part-time honours degree in nursing studies. A variety of teaching methods were employed in teaching the nurses. These included discussion, student-led seminars, structured debate and role play. A session which dealt with sudden death and organ donation is described in some detail. Because the topic involved communication between professionals and patients and/or relatives and was linked with ethics, role play was used to explore the dynamics in these areas. The participants were invited to act out the situation as they felt it might occur. Role play highlighted the stress and shock attached to such an experience. Before working through the dynamics of a situation the nurses were conscious of being part of decision-making 'in the cold' and 'in isolation'. As a result of the experiential learning they felt more able to reflect analytically and to participate in discussions in an informed and articulate way. (shrink)

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This article seeks to show one way in whichmoral philosophy, considered by the authors to be essential to the nursing and midwifery curricula, can be presented to achieve an optimal learning experience for nurses and midwives. It demonstrates that what might be considered a standard approach, that is, one that begins with ethical principles concerned with rights and duties and then often follows a linear pattern of teaching, may be in danger of promoting a focus on standardized outcomes. (...) Such use of philosophy could therefore actually detract from the process ofcare.Moral philosophy underpinninghealthcare ethics is commonly misperceived as a method of problem solving when there is an obvious dilemma regarding appropriatecare and/or treatment. However, it is readily recognized that key principles within philosophy, for example, deontology and utilitarianism, despite their approach to a standard or criterion of right action, are both deficient in terms of providing ready-made right decisions. This is because their main virtue is to expose the difficulty rather than to solve the problem. Given these difficulties, any subsequent principles such as respect, beneficence, nonmaleficence and justice, incur the same deficiencies a fortiori. It can be argued that the complexity of the environment in which nurses and midwives now practice requires them to develop a capability that begins with the philosophical construction of an issue. This can subsequently enable a recognition of the essential nature of their own involvement as a nurse or midwife. By so doing, nurses and midwives can then bring issues into a nursing or midwifery paradigm and ensure that this perspective informs debate. Ultimately the focus is on the process by whichcare decisions are made. The intent therefore, is not simply for nurses or midwives to learnmoral philosophy or to copy what is considered by others to be right action, but to recognize that a number of right actions are possible and, in so doing, develop their ability either to choose or influence a final action through a valid process. This article proposes and demonstrates by case example that what is often considered as a chance effect for nurses and midwives learningmoral philosophy should be seen as the main effect and intended outcome. (shrink)

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The question of corporatemoral responsibility – of whether it makes sense to hold an organisation corporately morally responsible for its actions,rather than holding responsible the individuals who contributed to that action – has been debated over a number of years in the business ethics literature. However, it has had little attention in the world ofhealthcare ethics.Healthcare in the United Kingdom(UK) is becoming an increasingly corporate responsibility, so the issue is increasingly (...) relevant in thehealthcare context, and it is worth considering whether the specific nature ofhealthcare raises special questions around corporatemoral responsibility. For instance, corporate responsibility has usually been considered in the context of private corporations, and the organisations ofhealthcare in the UK are mainly state bodies. However, there is enough similarity in relevant respects between state organisations and private corporations, for the question of corporate responsibility to be equally applicable. Also,healthcare is characterised by professions with their own systems of ethical regulation. However, this feature does not seriously diminish the importance of the corporate responsibility issue, and the importance of the latter is enhanced by recent developments. But there is one major area of difference.Healthcare, as an activity with an intrinsicallymoral goal, differs importantly from commercial activities that are essentially amoral, in that it narrows the range of opportunities for corporate wrongdoing, and also makes such organisations more difficult to punish. (shrink)

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As the pressure on availablehealthcare resources grows, an increasingmoral challenge in intensivecare is to secure a fair distribution of nursingcare and medical treatment. The aim of this article is to explore how limited resources influence nursingcare and medical treatment in intensivecare, and to explore whether intensivecare unit clinicians use national prioritization criteria in clinical deliberations. The study used a qualitative approach including participant observation and (...) in-depth interviews with intensivecare unit physicians and nurses working at the bedside. Scarcity of resources regularly led to suboptimal professional standards of medical treatment and nursingcare. The clinicians experienced a rising dilemma in that very ill patients with a low likelihood of survival were given advanced and expensive treatment. The clinicians rarely referred to national priority criteria as a rationale for bedside priorities. Because prioritization was carried out implicitly, and most likely partly without the clinician's conscious awareness, central patient rights such as justice and equality could be at risk. (shrink)

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This study sought to determine cardiologists’ degrees of ethical awareness and preferred courses of action for ethicaldilemmas frequently encountered in clinical settings. For this evaluation, an online survey was created and sent to cardiologists affiliated with various academic posts in Ankara, Turkey. The survey included ten cases with various ethical considerations selected from our book, “Clinic Ethics with Cases from Cardiology.” Four possible action choices were defined for each case. Participants were asked to choose one or more of (...) these preferences. In addition, a fictional change was made in each case’s context without changing the original ethical issue, and participants were asked whether an attitude different from the first chosen one was preferred. The participation ratio was 49/185 (26%), consent ratio 47/185 (25,4%), and completion ratio 44/185 (23,7%). Nine of the ten scenario changes did not change participants’ preferred action. For most questions, action preferences were concentrated between the two options. Although legal regulations did not reduce ethicaldilemmas, they clarified physicians’ action preferences. Similarly, as an obscuremoral issue gained prominence, physicians were forced to draw clearer lines in their actions. External factors such as healthcare emergencies can change physicians’ ethical dilemma-solving attitudes. (shrink)

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The aim of this Swedish study was to develop the concept ofmoral sensitivity inhealthcare practice. This process began with an overview of relevant theories and perspectives on ethics with a focus onmoral sensitivity and related concepts, in order to generate a theoretical framework. The second step was to construct a questionnaire based on this framework by generating a list of items from the theoretical framework. Nine items were finally selected as most appropriate (...) and consistent with the research team’s understanding of the concept ofmoral sensitivity. The items were worded as assumptions related to patientcare. The questionnaire was distributed to two groups ofhealthcare personnel on two separate occasions and a total of 278 completed questionnaires were returned. A factor analysis identified three factors: sense ofmoral burden,moral strength andmoral responsibility. These seem to be conceptually interrelated yet indicate thatmoral sensitivity may involve more dimensions than simply a cognitive capacity, particularly, feelings, sentiments,moral knowledge and skills. (shrink)

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This study investigated 204 doctors' and nurses' perceived knowledge of bloodborne pathogens and their attitudes towards bloodborne pathogen-infectedhealthcare workers. A structured questionnaire examined: (1) their perceived knowledge of bloodborne pathogens; (2) their attitudes towards bloodborne pathogen-infected personnel; and (3) their opinions on limitation of employment of bloodborne pathogen-infected personnel and restrictions on performing clinical procedures. The levels of HIV-related knowledge were significantly higher than for hepatitis C and B viruses. Although the participants demonstrated more positive attitudes (...) towards hepatitis C- and B-infectedhealthcare workers, 64% recommended restricting infected personnel from performing invasive procedures. Attitudes were negatively correlated with opinions on restricting infected personnel fromhealthcare work or limiting their involvement in clinical activities. This study highlights the need to formulate a policy to cope with the professional andmoraldilemmas related to infectedhealthcare workers employed in hospitals, especially for those involved in invasive procedures. (shrink)

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In lieu of an abstract, here is a brief excerpt of the content:Morality in Flux: Medical EthicsDilemmas in the People's Republic of ChinaRen-Zong Qiu (bio)IntroductionModern China is undergoing a fundamental change from a monolithic society to a rather pluralistic one. It is a long and winding road. Marxism is facing various challenges as the influence of Western culture increases. Confucianism is still deeply entrenched in the Chinese mind but various religions, including Buddhism, Islam, and Christianity are experiencing a (...) revival. Almost fifty minorities coexist in the country in addition to the majority Han people. Tension and conflict are inevitable as diverse—and sometimes incompatible—values come to the fore at this historic juncture. Many fields, including medicine, face new challenges, and in this environment the field of bioethics is flourishing.Like many countries, China is groping with the effects of new medical technology and skyrocketinghealthcare costs. But in the context of the Chinese sociocultural environment, some unique—as well as more familiar—issues arise. None of the classic texts provide ready-made answers to thesedilemmas; we must find the answers ourselves. The only reasonable way to resolve the conflicts between opposing values is through dialogue, consultation, and negotiation among the various social and cultural groups.The bioethicaldilemmas receiving the most attention in China now relate to the two ends of life: birth and death. On one end are issues relating to reproductive technology, especially birth control and family planning; at the other end is euthanasia.Dilemmas Surrounding Reproductive TechnologyAccording to traditional Chinese belief, not having a child results from not having virtue. In fact, the most serious violation of the Confucian [End Page 16]principle of filial piety is to be without offspring. A Chinese man without a child experiences heavy psychological pressure, and the burden is especially onerous for women because infertility is always blamed on the wife. Wives who do not bear a child are stigmatized and mistreated—even abused—in families that stick to traditional values.In China today, this widely held belief is colliding with another reality: an apparent increase in infertility among newly-married couples. The rate may be about 5 percent. These couples turn to doctors for help.Artificial insemination by donor (AID) and by husband is now widely practiced. Eleven provinces have established sperm banks, and private doctors are performing AID for considerable fees. But procedures to address legal and ethical problems associated with the procedure have lagged behind. With the exception of a few centers in large cities, AID is undertaken without established procedures or policies relating to the selection of donors and recipients, records about those involved, or clarification of the status of the child. The legal status of the child remains unresolved.The status of the child within the community is also unresolved as traditional values clash with the application of modern technology to childbearing. The case of "The Child Who Did Not Belong" (see box), illustrates how an AID child is not accepted by the family that embraces traditional values because he is not the husband's biological child.In vitro fertilization (IVF) is another alternative. Two IVF centers are in operation, one in Beijing and the other in Changsha, and both have succeeded in producing live births. This technology has received considerable media attention and is generally accepted even among those with traditional views.But much of this medical technology is not widely accessible—especially in rural areas—and so some infertile couples resort to surrogate motherhood to ensure an heir. An infertile couple enters into a contract with a woman who has intercourse with the husband in order to bear a child for the couple. This practice is called "borrowing a wife." In some villages, the "borrowed wife" receives as much as 10,000 yuan (five times a professor's monthly salary or about $250) for a girl and double that for a boy.But the more common and thorny problems involved with the beginning of life relate to birth control, family planning, and the "one couple, one child" policy that the Chinese government instituted to curb overpopulation. The goal of that policy is to prevent China's population from exceeding 1.2 billion in the year 2000... (shrink)

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Suitable for courses in Medical Ethics, Bioethics,Moral Issues in Medicine/HealthCare, or as a supplement for courses in ContemporaryMoral Issues. Appropriate for use in nursing, pre-med, and public administration programs as well as in philosophy departments.

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Among the myriad longstanding political, socioeconomic, andmoral debates focused on the fair distribution ofhealth-care resources within the United States, those addressing intergenerational justice tend to produce the most heat and, often, the least amount of light. The familiar narratives tend to be binary ones of opposing generational stakeholders. While a great number of proposed solutions focus on reconfiguring rationing priorities, this paper will instead shift the discourse to intergenerational interdependence, suggesting that these conflict-bornmoral (...)dilemmas are in important ways false. The alternative view of intergenerational relations defended here is grounded in an interdependent, rather an oppositional, model of human relationships. I argue that this interdependence can best be realized through a deliberate movement toward intergenerational narrative understandings, as well as through physical proximities. I conclude by considering several ongoing intergenerational projects directed at just such a goal. (shrink)

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Suffering is an unavoidable reality inhealthcare. Not only are patients and families suffering but also the clinicians whocare for them. Commonly the suffering experienced by clinicians ismoral in nature, reflecting the increasing complexity ofhealthcare, their roles within it, and the expanding range of available interventions.Moral suffering is the anguish experienced in response to various forms ofmoral adversity includingmoral harms, wrongs or failures, or (...) unrelievedmoral stress. Confrontingmoral adversity challenges clinicians' integrity: the inner harmony that arises when their essential values and commitments are aligned with their choices and actions. The most studied response tomoral adversity ismoral distress. The sources and sequelae ofmoral distress, one type ofmoral suffering, have been documented among clinicians across specialties. Recent interest has expanded to include a more corrosive form ofmoral suffering,moral injury.Moral resilience, the capacity to restore or sustain integrity in response tomoral adversity, offers a path designing individual and system solutions to addressmoral suffering. It encompasses capacities aimed at developing self- regulation and self-awareness, buoyancy,moral efficacy, self-stewardship and ultimately personal and relational integrity.Moral resilience has been shown to be a protective resource that reduces the detrimental impact ofmoral suffering. Clinicians and healthcare organizations must work together to transformmoral suffering by cultivating the individual capacities formoral resilience and designing a new architecture to support ethical practice. Used worldwide for scalable and sustainable change, the Conscious Full Spectrum Response, offers a method to solve problems to support integrity, shift patterns that underminemoral resilience and ethical practice, and source the inner potential of clinicians and leaders to produce meaningful and sustainable results that benefit all. (shrink)

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Background: Nurses exposed to communityhealth nursing commonly encounter situations that can be morally distressing. However, most research onmoral distress has focused on acutecare settings and very little research has exploredmoral distress in a communityhealth nursing setting especially among nursing students. Aim: To explore themoral distress experiences encountered by undergraduate baccalaureate nursing students in communityhealth nursing. Research design: A descriptive qualitative design was employed to explore the community (...)health nursing experiences of the nursing students that led them to havemoral distress. Participants and research context: The study included 14 senior nursing students who had their course in CommunityHealth Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year. Ethical considerations: Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants. Findings: Nursing students are vulnerable and likely to experiencemoral distress when faced with ethicaldilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which includedmoral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community. Conclusion: This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the “real world,” where the ideals they have will be constantly challenged and tested. (shrink)

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American adults currently enjoy a widely accepted and legally well-settled right to refusehealthcare, including life sustaining treatment. Joel Feinberg provides amoral foundation for this right in liberal political theory. Feinberg's theory grounds the right to refuse in a broad right to self-determination, and it implements the right through a variable conception of voluntariness. This theory provides a plausible account that comports with the widely accepted right to refuse, commonsense, and ordinary practice. -/- Allen Buchanan (...) and Dan Brock contend, however, that Feinberg's priority for the right to self-determination is inconsistent with his variable scale of voluntariness. Although Feinberg presents his theory as one that grants categorical priority to self-determination over individual well-being, Buchanan and Brock argue that Feinberg's variable scale of voluntariness involves a balancing of self-determination and well-being. This balancing approach, which Buchanan and Brock endorse, seems to undermine the competent patient's right to refusecare because it allows concern for the patient's well-being to override that person's right to self-determination in some circumstances. Taken together, these arguments seem to suggest that we must give up either the competent patient's right to refuse treatment or the intuitively sensible variable scale. -/- In this paper, I argue that one can reconcile a categorical priority for self-determination with legal rules that incorporate a variable scale of competence. This integration requires careful examination of the practical and expressive functions of legal rules as well as of the manner in which these rules embodymoral priorities. This analysis pursues specific and general projects. Specifically, it addresses themoral foundations of the legal right to refuse treatment, identifying a substantive difference between the balancing approach and the priority for self-determination that characterizes Feinberg's liberalism. Generally, it examines the types of priorities embodied by legal rules as practical decision guides and as expressions of the conventional morality represented by the law. This general project extends beyond the right to refuse treatment to the analysis of the manner in which legal rules express and applymoral priorities. (shrink)

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