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In this article I argue for an interpretive approach to bioethics with critically ill children. I begin by highlighting the dominant Anglo-American bioethical framework that defines standards forethicalcare in critically ill children and then outline a critique of this framework. Drawing predominantly on the ideas of Charles Taylor, Michael Walzer and Richard Zaner, I call for a reconception of bioethics and propose an interpretive ‘thick’ framework that is centred on culture and context. Finally, I illustrate this (...) interpretive approach through a comparative study of two cases in pediatric intensivecare: the narratives of Marc and Larry. These case studies reveal thatethical dilemmas in pediatric criticalcare can be traced to relational tensions over respect, trust and power rooted in the disparity of moral horizons among the persons involved. (shrink)

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Recent years have witnessed the publication of numerous articles that draw a critical alignment between ethics and caring. In essence, this theme suggests that caring is a moral pursuit centred on the beneficent attention of one person shown to another. Yet, if such language is to have real poignancy, it must be geared towards an inclusive agenda that meets the needs of all within the community. Research evidence suggests that this is not always the case, especially in terms of the (...)care offered to members of minority ethnic groups. This article will focus on the findings of a qualitative research study that explored the expectations and perceived experiences of nursingcare among members of the Pakistani community in Bradford, West Yorkshire, UK. The findings suggest that nurses should develop a more informed narrative that readily reflects the needs of the Pakistani community. (shrink)

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Historically associated with military service, conscientious objection has become a significant phenomenon in healthcare. Mark Wicclair offers a comprehensiveethical analysis of conscientious objection in three representative healthcare professions: medicine, nursing and pharmacy. He critically examines two extreme positions: the 'incompatibility thesis', that it is contrary to the professional obligations of practitioners to refuse provision of any service within the scope of their professional competence; and 'conscience absolutism', that they should be exempted from performing any (...) action contrary to their conscience. He argues for a compromise approach that accommodates conscience-based refusals within the limits of specifiedethical constraints. He also explores conscientious objection by students in each of the three professions, discusses conscience protection legislation and conscience-based refusals by pharmacies and hospitals, and analyzes several cases. His book is a valuable resource for scholars, professionals, trainees, students, and anyone interested in this increasingly important aspect of healthcare. (shrink)

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Developingethical standards for clinical use of large-scale genome and exome sequencing has proven challenging, in part due to the inevitability of incidental or secondary findings. Policy of the American College of Medical Genetics and Genomics has evolved but remains problematic. In 2013, ACMG issued policy recommending mandatory analysis of 56 extra genes whenever sequencing was ordered for any indication, in order to ascertain positive findings in pathogenic and actionable genes. Widespread objection yielded a 2014 amendment allowing patients to (...) opt-out from analysis of the extra genes. In 2015, ACMG published the amended policy, providing that patients could opt out of the full set of extra genes, but not a subset. In 2016, ACMG enlarged the set and indicated planned expansion of the roster of extra genes to include pharmacogenetic findings. ACMG policy does not protect the respect for patient choice that prevails in other domains of clinical medicine, where informed consent allows patients to opt in to desired testing. By creating an expanding domain of genomic testing that will be routinely conducted unless patients reject the entire set of extra tests, ACMG creates an exceptional domain clinical practice that is not supported by ethics or science. (shrink)

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The growing proportion of elderly people in society, together with recent advances in robotics, makes the use of robots in eldercare increasingly likely. We outline developments in the areas of robot applications for assisting the elderly and their carers, for monitoring their health and safety, and for providing them with companionship. Despite the possible benefits, we raise and discuss six mainethical concerns associated with: (1) the potential reduction in the amount of human contact; (2) an increase (...) in the feelings of objectification and loss of control; (3) a loss of privacy; (4) a loss of personal liberty; (5) deception and infantilisation; (6) the circumstances in which elderly people should be allowed to control robots. We conclude by balancing thecare benefits against theethical costs. If introduced with foresight and careful guidelines, robots and robotic technology could improve the lives of the elderly, reducing their dependence, and creating more opportunities for social interaction. (shrink)

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Rethinking Feminist Ethics bridges the gap between women theorists disenchanted with aspects of traditional theories that insist upon the need for someethical principles. The book raises the question of whether the female conception of ethics based oncare, trust and empathy can provide a realistic alternative to the male ethics based on duty and rule bound conception of ethics developed from Kant, Mill and Rawls. Koehn concludes that it cannot, showing how problems for respect of the individual (...) arise also in female ethics because it privileges the caregiver over the cared for. Drawing on Socrates' Crito , she shows how an ethic of dialogue can instill a critical respect for the view of the other and theethical principles absent from the female ethic. (shrink)

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The COVID-19 pandemic has had a devastating impact oncare homes in the United Kingdom, particularly for those residents living with dementia. The impetus for this article comes from a recent review conducted by the authors. That review, a qualitative media analysis of news and academic articles published during the first few months of the outbreak, identifiedethicalcare as a key theme warranting further investigation within the context of the crisis. To exploreethicalcare (...) further, a set of salientethical values for deliveringcare tocare home residents living with dementia during the pandemic was derived from a synthesis of relevantethical standards, codes and philosophical approaches. Theethical values identified were caring, non-maleficence, beneficence, procedural justice, dignity in death and dying, well-being, safety, and personhood. Using theseethical values as a framework, alongside examples from contemporaneous media and academic sources, this article discusses the delivery ofethicalcare tocare home residents with dementia within the context of COVID-19. The analysis identifies positive examples ofethical values displayed bycare home staff,care sector organisations, healthcare professionals and third sector advocacy organisations. However, concerns relating to the death rates, dignity, safety, well-being and personhood – of residents and staff – are also evident. These shortcomings are attributable to negligent government strategy, which resulted in delayed guidance, lack of resources and Personal Protective Equipment, unclear data, and inconsistent testing. Consequently, this review demonstrates the ways in whichcare homes are underfunded, under resourced and undervalued. (shrink)

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BackgroundWith the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers’ perspectives on honouring eligible patients’ request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity. (...) MethodA critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-relatedcare.ResultsThemes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencingethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden.DiscussionTo our knowledge, this is the first study in Canada to explore healthcare providers’ perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people’s access to MAiD following loss of capacity, as they believed it would improve the patients’ comfort and minimize suffering. However, the lack of patients’ input at the time of provision and relatedethical and legal challenges may impact healthcare providers’ moral agency and reduce some patients’ access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD. (shrink)

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Knowledge needed forethicalcare must be constructed in the relationship between professional and patient who strive together to understand what meaning the disease factors have within the experience of the individual patient. Three kinds of knowledge are described. The first two, descriptive knowledge and abstract knowledge, are part of the more comprehensive and complex inherent knowledge. The reality of human experience and meaning is profoundly more complex than the scientific approach of fragmentation for purposes of dissection and (...) diagnosis. In order to develop descriptive, abstract and inherent knowledge as outlined here, three moves need to be made: the move from dominance to collaboration, the move from abstraction to context, and the move from beneficence to nurturance. (shrink)

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Undisputedly, the United States’ healthcare system is in the midst of unprecedented complexity and transformation. In 2014 alone there were well over thirty‐five million admissions to hospitals in the nation, indicating that there was an extraordinary number of very sick and frail people requiring highly skilled clinicians to manage and coordinate their complexcare across multiplecare settings. Medical advances give us the ability to send patients home more efficiently than ever before and simultaneously create (...) class='Hi'>ethical questions about the balance of benefits and burdens associated with these advances. Every day on every shift, nurses at the bedside feel an intense array ofethical issues. At the same time, administrators, policy‐makers, and regulators struggle to balance commitments to patients, families, staff members, and governing boards.Ethical responsibilities and the fiduciary, regulatory, and community service goals of healthcare institutions are not mutually exclusive; they must go hand in hand. If they do not, our healthcare system will continue to lose valued professionals to moral distress, risk breaking the public's trust, and potentially undermine patientcare. At this critical juncture in healthcare, we must look to new models, tools, and skills to confront contemporaryethical issues that impact clinical practice. The antidote to the current reality is to create a new healthcare paradigm grounded in compassion and sustained by a culture ofethical practice. (shrink)

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Research teams have used extra-uterine systems to support premature fetal lambs and to bring them to maturation in a way not previously possible. The researchers have called attention to possible implications of these systems for sustaining premature human fetuses in a similar way. Some commentators have pointed out that perfecting these systems for human fetuses might alter a standard expectation in abortion practices: that the termination of a pregnancy also entails the death of the fetus. With Biobags, it might be (...) possible, some argue, that no woman has the right to expect that outcome if the technology is able to sustain fetal lifeafteran abortion. In order to protect the expectation that the termination of a pregnancy always entails the death of the fetus, Elizabeth Romanis has argued that fetuses sustained in Biobags have a status different than otherwise ‘born’ children. In support of that view, she argues that these ‘gestatelings’ are incapable of independent life. This argument involves a misunderstanding of the gestational support involved, as well as a misapprehension of neonatology practice. Here, we argue that any human fetus sustained in a Biobag would be as ‘independent’ as any other premature infant, and just as ‘born’. Neonatologists would seem to have certain presumptive moral responsibilities toward any human fetus gestating in a Biobag. It remains a separate question whether the perfection and widespread application of Biobags for premature human beings would or should alter the expectation that ending a pregnancy also entails fetal death. (shrink)

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Background: It is stated that highethical sensitivity positively affects the quality of nursingcare. However, the relationship between nursingcare quality andethical sensitivity has not been clearly demonstrated in researches. Aim: This study was carried out to determine the relationship between surgical nurses’care behaviors and theirethical sensitivity. Method: The sample of this cross-sectional, descriptive-correlational study consists of 308 nurses who worked at the surgical departments in four Turkish hospitals. The data (...) were collected using the “Nurse Description Form” developed by the researcher, “Caring Behaviours Inventory-24” and “Ethical Sensitivity Questionnaire.” Data were evaluated by the Mann Whitney U test, Kruskal Wallis one-way analysis of variance and Spearman correlation analysis.Ethical considerations: The study was approved by the ethics committee. Verbal and written consent was received from the nurses. Results: It was found in the study that nurses’ Caring Behaviours Inventory-24 total score median was 5.25 (4.83–5.58), nurses’ perception level of caring quality was high, median ofEthical Sensitivity Questionnaire total score was 89.00 (75.00–101.00) and nurses’ethical sensitivity was moderate. A negative significant relation was found between nurses’ Caring Behaviours Inventory-24 total score andEthical Sensitivity Questionnaire total score (r = -0.162; p = 0.009). A negative relation was also detected between nurses’ working period at the current clinic and providing benefit (r = -0.147; p = 0.012), holistic approach (r = -0.139; p = 0.018) and orientation (r = -0.175; p = 0.003) scores ofEthical Sensitivity Questionnaire sub-scales. Conclusion: Nurses’ perception levels of caring quality were high and theirethical sensitivity levels were moderate. It was found out that nurses’ethical sensitivity increased together with their perception of caring quality, and as their working period at the current clinic increased, theethical sensitivity also increased in terms of the sub-scales of providing benefit, holistic approach, and orientation. The factors that adversely affect the quality of nursingcare andethical sensitivity should be examined and attempts should be made to improve the working environment. (shrink)

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Respecting the autonomy of disabled people is an importantethical issue for providers of long-termcare. In this influential book, George Agich abandons comfortable abstractions to reveal the concrete threats to personal autonomy in this setting, whereethical conflict, dilemma and tragedy are inescapable. He argues that liberal accounts of autonomy and individual rights are insufficient, and offers an account of autonomy that matches the realities of long-termcare. The book therefore offers a framework for carers (...) to develop an ethic of long-termcare within the complex environment in which many dependent and aged people find themselves. Previously published as Autonomy and Long-termCare, this revised edition, in paperback for the first time, takes account of recent work and develops the author's views of what autonomy means in the real world. It will have wide appeal among bioethicists and healthcare professionals. (shrink)

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The increasing use of pharmacotherapy raises specificethical concerns for psychologists working with vulnerable populations. Due to a shortage of trained specialists, professionals without training in mental health, such as primarycare providers, are increasingly prescribing and monitoring psychotropic medications. Vulnerable populations face additional barriers to mental health treatment and are at heightened risk when these factors intersect. Hence, these patients experience unique barriers to receiving optimal psychopharmacologicalcare and are differentially vulnerable to deleterious outcomes associated with (...) misdiagnosis and overmedication. Taken together, these factors fuel inequities in the access, quality, and utilization of mental healthcare. Psychologists working with these patients are ethically mandated to protect patients from harm and ensure equitablecare across patient populations. Specifically, psychologists must respond to the dilemma of how to effectively treat patients within these vulnerable populations who have been misdiagnosed or poorly medicated while remaining within the bounds of their competence. This article recommends pathways to address these dilemmas through education, training, research, and advocacy. (shrink)

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This paper identifies and addresses persistent gaps in the consideration ofethical practice in ‘technology for good’ development contexts. Its main contribution is to model an integrative approach using multipleethical frameworks to analyse and understand the everyday nature ofethical practice, including in professional practice among ‘technology for good’ start-ups. The paper identifies inherent paradoxes in the ‘technology for good’ sector as well asethical gaps related to (1) the sometimes-misplaced assignment of virtuousness to an (...) individual; (2) difficulties in understanding social constraints onethical action; and (3) the often unaccounted for mismatch betweenethical intentions and outcomes in everyday practice, including in professional work associated with an ‘ethical turn’ in technology. These gaps persist even in contexts where ethics are foregrounded as matters of concern. To address the gaps, the paper suggests systemic, rather than individualized, considerations ofcare and capability applied to innovation settings, in combination with considerations of virtue and consequence. This paper advocates for addressing these challenges holistically in order to generate renewed capacity for change at a systemic level. (shrink)

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Background: In end of lifecare,ethical problems often come to the fore. Little research is performed on ways or strategies for handling those problems and even less on obstacles to and possibilities of using such strategies. A previous study illuminated stroke team members’ experiences ofethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. These findings have been further explored in this study. Objective: The (...) aim of the study was to illuminate obstacles and possibilities perceived by stroke team members in using strategies for handlingethical problems when caring for patients afflicted by sudden and unexpected death caused by stroke. Research design: A qualitative method with combined deductive and inductive content analysis was utilized. Participants and research context: Data were collected through individual interviews with 15 stroke team members working in stroke units of two associated county hospitals in western Sweden.Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. Permission was also obtained from the director of each stroke unit. Findings: All the studied strategies for handling ofethical problems were found to have both obstacles and possibilities. Uncertainty is shown as a major obstacle and unanimity as a possibility in the use of the strategies. The findings also illuminate the value of the concept “the patient’s best interests” as a starting point for the carers’ethical reasoning. Conclusion: The concept “the patient’s best interests” used as a starting point forethical reasoning among the carers is not explicitly defined yet, which might make this value difficult to use both as a universal concept and as an argument for decisions. Carers therefore need to strengthen their argumentation and reflect on and use ethically grounded arguments and definedethical values like dignity in their clinical work and decisions. (shrink)

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Through a focus on one child’s extended stay in a Pediatric IntensiveCare Unit, I raise four general questions about pediatric medicine: How should physicians communicate with parents of very sick children? How should physicians involve parents of very sick children in treatment decisions? How shouldcare be coordinated when a child is being treated by different medical teams with rotating personnel? Should the guidelines for making judgments of medical futility and discontinuation of treatment differ when the patient (...) is a child rather than an adult? (shrink)

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Background Few empirical studies have been found that exploreethical challenges among persons in high public positions that are responsible for eldercare. The aim of this paper was to illuminate the meaning of being in ethically difficult situations related to eldercare as experienced by high level decision-makers. Methods A phenomenological-hermeneutic method was used to analyse the eighteen interviews conducted with political and civil servant high level decision-makers at the municipality and county council level from two (...) counties in Sweden. The participants worked at a planning and control as well as executive level and had both budget and quality of eldercare responsibilities. Results Bothethical dilemmas and the meaning of being in ethically difficult situations related to eldercare were revealed. No differences were seen between the politicians and the civil servants. Theethical dilemmas mostly concerned dealings with extensivecare needs and working with a limited budget. The dilemmas were associated with a lack of goodcare and a lack of agreement concerningcare such as vulnerable patients in inappropriatecare settings, weaknesses in medical support, dissimilar focuses between the caring systems, justness in the distribution ofcare and deficient information. Being in ethically difficult situations was challenging. Associated with them were experiences of being exposed, having to be strategic and living with feelings such as aloneness and loneliness, uncertainty, lack of confirmation, the risk of being threatened or becoming a scapegoat and difficult decision avoidance. Conclusion Our paper provides further insight into theethical dilemmas andethical challenges met by high level decision-makers', which is important since the overall responsibility for eldercare that is also ethically defensible rests with them. They have power and their decisions affect many stakeholders in eldercare. Our results can be used to stimulate discussions between high level decision-makers and healthcare professionals concerning ways of dealing withethical issues and the necessity of structures that facilitate dealing with them. Even if the high level decision-makers have learned to live with theethical challenges that confronted them, it was obvious that they were not free from feelings of uncertainty, frustration and loneliness. Vulnerability was revealed regarding themselves and others. Their feelings of failure indicated that they felt something was at stake for the older adults in eldercare and for themselves as well, in that there was the risk that important needs would go unmet. (shrink)

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BackgroundEthicalcare provided by nurses to earthquake victims is one of the main subjects in nursing profession. Objectives Given the information gap in this field, the present study is an attempt to explore the nurses’ experience ofethicalcare provided to victims of an earthquake. Research design and method A hermeneutic phenomenological study was performed. The participants were 16 nurses involved in providingcare to the injured in Kermanshah earthquake, Iran. They were selected using (...) purposeful sampling, and in-depth and semi-structured interviews were carried out. The transcribed interviews were analyzed based on the hermeneutic approach using the analysis method proposed by Diekelmann et al.Ethical considerations The study was approved by the Research Council and Ethics Committee of Urmia University of Medical Sciences, Iran. Findings Data analyses revealed four themes and 10 sub-themes that illustrated nurses’ experience ofethicalcare during earthquake. The themes were (1) Respecting humanistic values (sacrifice, stepping beyond task description, and voluntary work), (2) Commitment to ethics (honesty, confidentiality, and trustworthiness), (3) Respecting dignity of victims (respecting cultural values, maintaining privacy, having humanistic perspective, and effective communication), and (4) Spiritual support (helping patients to do religious rituals Psychological support). Conclusion The results showed the nurses’ experience with providingcare to earthquake victims. The findings underlined ethics andethical values in providing nursingcare during disasters. It is suggested that special courses on the importance of nursing ethics in critical situations be incorporated into nursing curriculums and in-service educations. (shrink)

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In a recent article,1Riisfeldt attempts to show that the principle of double effect (PDE) is unsound as anethical principle and problematic in its application to palliative opioid and sedative use in end-of-lifecare. Specifically, he claims that (1) routine, non-lethal opioid and sedative administration may be “intrinsically bad” by PDE’s standards, (2) continuous deep palliative sedation (or “terminal sedation”) should be treated as a bad effect akin to death for purposes of PDE, (3) PDE cannot coherently be (...) applied in cases where death “indirectly” furthers an agent’s intended end of pain relief via medically appropriate palliativecare, and (4) application of PDE requires sacrificing common beliefs about the sanctity of human life. I respond by showing that Riisfeldt’s understanding of PDE is seriously mistaken: he misattributes Kantian and Millian reasoning to the principle and conflates acts’ intrinsic properties with their effects. Further, a corrected understanding of PDE can address Riisfeldt’s case-specific objections. (shrink)

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This study presents a qualitative description of situations at work that staff members perceive as giving rise toethical issues. All staff members working with patients across seven wards were given the opportunity to freely describeethical considerations in anethical diary over the course of one week. One hundred and five staff members kept a diary. The diaries were analysed with qualitative content analysis where four dominant themes emerged: goodcare, order and clarity, loyalty, and (...) inadequacy. These results contain statements in which patients are respected and listened to, as well as statements that express a desire for relatively strict, routine-basedcare. Relatively few statements were of a reflective or discussing nature which highlights the need for clinicalethical support. There is a need of a visible and supportive leadership which encouragesethical reflection. Reflections on real cases could provide an opportunity to challenge existing practices and thereby promoteethical awareness. (shrink)

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This article offers a novel account of a key concept in Hannah Arendt’s political thought: amor mundi. In political theory’sethical turn, theorists have increasingly turned to amor mundi as a source ofethical guidance and inspiration for politics. However, in doing so, they have elided Arendt’s distinct understanding ofcare. This article recovers Arendt’s understanding of amor mundi ascare for the world by reconstructing the central concerns of her dissertation, Der Liebesbegriff bei Augustin, and (...) tracing them to the “Crisis” essays of Between Past and Future. It shows that amor mundi emerges in the dissertation as part of a question: if love is our fundamental orientation toward the world, how can we love the world without instrumentalizing it? The two “Crisis” essays provide the following answer: if love is to avoid—and perhaps militate against—the instrumentalization of the world, it must take the form ofcare. Following this analysis, this article contends that the contribution of amor mundi to theethical turn is best understood, not as the ethos needed to guide action in the political realm, but as a key pre- or nonpolitical ethos needed to conserve the world where politics takes place—and thus the very possibility of politics. (shrink)

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Background: How wellethical concerns are handled in healthcare is influenced by theethical climate of the workplace, which in this study is described as workplace factors that contribute to healthcare professionals’ ability to identify and deal withethical issues in order to provide the patient with ethically goodcare. Objectives: The overall aim of the study was to describe perceptions of the paediatric hospitalethical climate among healthcare professionals who treat/care for children with (...) cancer. Research design: Data were collected using the HospitalEthical Climate Survey developed by Olsson as a separate section in a questionnaire. Descriptive statistics were used to analyse perceptions of theethical climate. Participants and research context: Physicians, nurses and nurse-aides (n = 89) from three paediatric units participated in this study: haematology/oncology, chronic diseases and neurology.Ethical considerations: The study was approved by the regionalethical review board. Findings: Different perceptions of theethical climate were rated as positive or negative/neutral. Nurses’ ratings were less positive than physicians on all items. One-third of the participants perceived that they were able to practice ethically goodcare as they believed it should be practised. Discussion: Differences in professional roles, involving more or less power and influence, might explain why physicians and nurses rated items differently. A positive perception of the possibility to practice ethically goodcare seems to be related to inter-professional trust and listening to guardians/parents. A negative/neutral perception of the possibility to practice ethically goodcare appears to be influenced by experiences ofethical conflicts as well as a lack ofethical support, for example, time for reflection and discussion. Conclusion: The two-thirds of participants who had a negative/neutral perception of the possibility to practice ethically goodcare are at risk of developing moral stress. Clinical ethics support needs to be implemented incare where important values are at stake. (shrink)

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Background: The exploration of theethical climate in thecare settings for older people is highlighted in the literature, and it has been associated with various aspects of clinical practice and nurses’ jobs. However,ethical climate is seldom studied in the older peoplecare context. Valid, reliable, feasible measures are needed for the measurement ofethical climate. Objectives: This study aimed to test the reliability, validity, and sensitivity of the HospitalEthical Climate Survey in (...) healthcare settings for older people. Design: A non-experimental cross-sectional study design was employed, and a survey using questionnaires, including the HospitalEthical Climate Survey was used for data collection. Data were analyzed using descriptive statistics, inferential statistics, and multivariable methods. Participants and research context: Survey data were collected from a sample of nurses working in thecare settings for older people in Finland (N = 1513, n = 874, response rate = 58%) in 2011.Ethical considerations: This study was conducted according to good scientific inquiry guidelines, andethical approval was obtained from the university ethics committee. Results: The mean score for the HospitalEthical Climate Survey total was 3.85 (standard deviation = 0.56). Cronbach’s alpha was 0.92. Principal component analysis provided evidence for factorial validity. LISREL provided evidence for construct validity based on goodness-of-fit statistics. Pearson’s correlations of 0.68–0.90 were found between the sub-scales and the HospitalEthical Climate Survey. Discussion: The HospitalEthical Climate Survey was found able to reveal discrimination acrosscare settings and proved to be a valid and reliable tool for measuringethical climate incare settings for older people and sensitive enough to reveal variations across various clinical settings. Conclusion: The Finnish version of the HospitalEthical Climate Survey, used mainly in the hospital settings previously, proved to be a valid instrument to be used in thecare settings for older people. Further studies are due to analyze the factor structure and some items of the HospitalEthical Climate Survey. (shrink)

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Background The COVID-19 pandemic has forced rapid and widespread change to standards of patientcare and nursing practice, inevitably leading to unprecedented shifts in the moral conditions of nursing work. Less is known about how these challenges have affected nurses’ capacity to meet theirethical responsibilities and what has helped to sustain their efforts to continue tocare. Research objectives 1) To explore nurses’ experiences of striving to fulfill theirethical responsibilities ofcare during the (...) COVID-19 pandemic and 2) to explore what has fostered nurses’ capacity to fulfill these responsibilities. Research Design A generic qualitative approach was used incorporating concepts coming from fundamental features ofcare. Participants Twenty-four Canadian Registered Nurses from a variety of practice settings were interviewed.Ethical Considerations After receiving ethics approval, signed informed consent was obtained before participants were interviewed. Findings Four themes were identified. 1) Challenges providing goodcare in response to sudden changes in practice. 2) Tensions in juggling the responsibility to prevent COVID-19 infections with other competing moral responsibilities. 3) Supports to foster nurses’ capacity to meet their caring responsibilities. 4) The preservation of nurses’ moral identity through expressions of gratitude and health improvement. Discussion Infection control measures and priorities set in response to the pandemic made at distant population and organizational levels impacted nurses who continued to try to meet the ideals ofcare in close proximity to patients and their families. Despite the challenges that nurses encountered, thecare they received themselves enabled them to continue tocare for others. Nurses benefited most from the moral communities they had with their colleagues and occasionally nurse leaders, especially when they were supported in a face-to-face manner. Conclusion: Moral community can only be sustained if nurses are afforded the working conditions that make it possible for them to support each other. (shrink)

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The Institute of Medicine has called on healthcare leaders to transform their health systems into “learning healthcare systems,” capable of studying and continuously improving their practices. Learning healthcare systems commit to carrying out numerous kinds of investigations, ranging from clinical effectiveness studies to quality improvement research and implementation science. There has been progress in realizing the IOM's vision, but also many challenges. One of these challenges has been lingering uncertainty about whether the data collection (...) and monitoring central to learning healthcare systems is actually research and if so, what kind ofethical oversight it should have. This is not a new question. Yet so far, there has been no foundational analysis of the fit between the existing human subjects protection framework in use in the United States and the new kinds of data collection activities that are being, and increasingly will be, undertaken by learning healthcare systems. Two companion feature articles in this volume, by a team at Johns Hopkins, fill this void. (shrink)

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In recent years, a robust body of scholarship has emerged that examinesethical challenges facing the learning health organization model. In “Bystander Ethics and Good Samaritanism,” James Sabin and colleagues make a valuable addition to this scholarship, identifying and exploring the important question of what researchers' obligations are to patients receiving “usualcare” if “thatcare is seen as suboptimal.” The central issue that Sabin et al. faced was whether it would be acceptable for researchers to identify (...) patients with untreated atrial fibrillation but then assign them to a control group that would not receive education about the importance of oral anticoagulation. The authors present this challenge as an issue of “bystander ethics.” To avoid being “bystanders” to identified instances of suboptimalcare, the research team decided to instead identify a “delayed intervention” group for which they would not determine the members' anticoagulation status, thereby preventing them from knowing that specific patients met the criteria for oral anticoagulants but were not using them. This “workaround” approach strikes me as disingenuous. (shrink)

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Human connection is universally important, particularly in the context of serious illness and at the end of life. The presence of close family and friends has many benefits when death is close. Hospital visitation restrictions during the Coronavirus pandemic therefore warrant careful consideration to ensure equity, proportionality, and the minimization of harm. The Australian and New Zealand Society for Palliative Medicine COVID-19 Special Interest Group utilized the relevantethical and public health principles, together with the existing disease outbreak literature (...) and evolving COVID-19 knowledge, to generate a practical framework of visiting restrictions for inpatients receiving palliative and end-of-lifecare. Expert advice from an Infectious Diseases physician ensured relevance to community transmission dynamics. Three graded levels of visitor restrictions for inpatient settings are proposed, defining an appropriate level of minimum access. These depend upon the level of community transmission of COVID-19, the demand on health services, the potential COVID-19 status of the patient and visitors, and the imminence of the patient’s death. This framework represents a cohesive, considered, proportionate, and ethically robust approach to improve equity and consistency for inpatients receiving palliativecare during the COVID-19 pandemic and may serve as a template for future disease outbreaks. (shrink)

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South Africa is a major hub of HIV prevention trials, with plans for a licensure trial to start in 2015. The appropriate standards ofcare and of prevention in HIV vaccine trials are complex and debated issues andethical guidelines offer some direction. However, there has been limited empirical exploration of South African stakeholders’ perspectives onethical guidance related to prevention andcare in HIV vaccine trials.

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Postmortem reproduction refers to normally unnatural situations that are made possible by modern medical technology. It's a definition that applies to a situation in which one parent of an offspring is dead at the time of conception of the offspring or at the time of birth of the offspring. It is a situation which raises complex and multifactorial dilemma as with most issues that concern decisions over human life; accordingly, this discussion of itsethical ramifications is not intended to (...) be exhaustive, but illustrative. (shrink)

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The use of psychosocial interventions for people with dementia is common and recommended because they focus on the underlying problem and well-being of the person. The promotion of well-being is a relevant dimension in person-centredcare, where the aim is to confirm the person’s ‘personhood’. Most literature about ethics in dementiacare instructs us on how and when to include people with dementia in our research. Little is written about theethical aspects regarding the use of psychosocial (...) interventions in dailycare. In clinical practise, several challenges arise about the use of psychosocial interventions. Those include questions about the person’s ability to participate in decision-making and how we know what is best for them. Furthermore, we must consider what kinds of psychosocial interventions are best for everybody, or if intervention causes discomfort for the person. This article emphasizes the necessity to consider theethical aspects of the implementation of psychosocial interventions while taking into consideration the persons individual needs. A particularethical challenge arises when a person with dementia is unable to express themselves verbally. Therefore, it is essential that the staff know the history and preferences of each person with dementia. Theethical aspects of psychosocial interventions for people with dementia will be discussed using Beauchamp and Childress fourethical principles: respect for autonomy, beneficence, non-maleficence and justice. The person-centred approach proposed by Kitwood’s and Brooker. (shrink)

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In his two works from the 1970s, Patočka proposes a very personal way that the spiritual crisis, which manifests itself as a techno-scientific reality of Gestell, can be overcome. Patočka argues that the only way to escape spiritual decline is through sacrifice. This study examines how theethical is represented in Patočka’s philosophy. It focuses on his two main concepts of sacrifice andcare for the soul and explores the relationship between them. Through a close reading of Plato (...) and Europe, ‘Four Seminars’, and his essay ‘The dangers of technicization’, this study reveals how Patočka proposes that theethical can be implemented within the realm of the political. Drawing a parallel between Socrates’ and Patočka’s lives and fates, this study points to the significance of ethics in political life – both in the ancient Greek polis of Socrates’ time and in communist Czechoslovakia in Patočka’s time. This approach highlights the influence that the philosophy of Socrates had on Patočka’s thinking. (shrink)

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ABSTRACTComparative effectiveness studies, referred to here as “usual-care” trials, seek to compare current medical practices for the same medical condition. Such studies are presumed to be safe and involve only minimal risks. However, that presumption may be flawed if the trial design contains “unusual”care, resulting in potential risks to subjects and inaccurately informed consent. Three case studies described here did not rely on clinical evidence to ascertain contemporaneous practice. As a result, the investigators drew inaccurate conclusions, misinformed (...) research participants, and subjects’ safety was compromised. Before approving usual-care protocols, IRBs and scientific review committees should evaluate the quality and completeness of information documenting usual-care practices. Guidance from governmental oversight agencies regarding evidence-based documentation of current clinical practice could prevent similar occurrences in future usual-care trials. Accurate information is necessary to ensure that trials comply with government regulations that require minimizing research risks to subjects and accurate informed consent documents. (shrink)

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Menschen mit Migrationshintergrund kommen im Zuge des demografischen Wandels zunehmend in ein Alter, in dem die Wahrscheinlichkeit, pflegebedürftig zu werden, steigt. Insbesondere Demenzerkrankungen in vorangeschrittenen Stadien führen zu hochgradiger Pflegebedürftigkeit, die eine ausschließlich häusliche Pflege durch Angehörige erschwert. Aktuellen Untersuchungen zufolge werden Pflegebedürftige mit Migrationshintergrund jedoch zumeist zu Hause ausschließlich durch Familienangehörige gepflegt und es werden nahezu keine ambulanten Hilfen in Anspruch genommen. Die geringe Inanspruchnahme von ambulanten und stationären Angeboten ist zurückzuführen auf unzureichende Information und die vom Pflegesystem unzureichende (...) Berücksichtigung der Pflegesituation und -bedürfnisse dieser heterogenen Bevölkerungsgruppe. Auch das Verständnis der Demenzerkrankung ist in unterschiedlichen Kulturen heterogen. So wird die Krankheit häufig nicht als solche akzeptiert, sondern die Symptome als „gewöhnliche“ Alterserscheinungen interpretiert, wodurch die Inanspruchnahme ärztlicher Versorgung erst spät erfolgt. Diese Faktoren führen im medizinischen und pflegerischen Alltag häufig zu ethischen Konflikten zwischen pflegenden Angehörigen und Professionellen, aber auch innerhalb des familiären Kontextes. Der Artikel stellt, ausgehend von zentralen Ergebnissen einer empirischen Studie, ethische Konflikte bei der Versorgung demenzerkrankter türkeistämmiger Menschen in Deutschland anhand von zwei Fallbeschreibungen dar. Die ethischen Herausforderungen an das ärztliche und pflegerische Handeln im stationären und häuslichen Setting bei demenzerkrankten Menschen mit Migrationshintergrund werden erörtert. Es wird der Frage nachgegangen, inwieweit diese Konflikte auf unterschiedlichen Ebenen „kulturalisiert“ werden und welche Implikationen sich für die Medizin- und Pflegeethik ergeben. (shrink)

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Background: Transgender healthcare is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association of Transgender Health (WPATH) Standards ofCare (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion ofethical considerations in providingcare. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in theethical aspects (...) of clinical support for gender diverse and transgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on generalethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter in transgender healthcare, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the fourethical principles as applied to transgender healthcare. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access tocare. Some of theethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, for transgender and nonbinary people, particularly youth, seeking medicalcare. Discussion: We highlight the interplay betweenethical principles and clinical practice, underscoring the need forethical guidance in addressing the diverse challenges faced by healthcare providers and patients in transgender healthcare. We advocate for continuous refinement ofethical thinking to ensure that transgender healthcare is not only medically effective but also ethically sound. (shrink)

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Offering intensivecare to neonates who have conditions that carry extremely poor prognoses is a source of great contention amongst neonatologists. The concept of best interests is commonly used as a rationale for refusing suchcare, despite the fact that parents of these infants often have a different view of what best interests means. This article takes up the question of what best interests should incorporate for infants with lethal conditions not curable with intensivecare, and how (...) and who should decide which treatment options should be implemented. Based on our recommendation that parents be apprised of the basis upon which physicians are evaluating treatment options, we offer a framework that allows all relevant parties to approach the issue of what is appropriate treatment from a similar place. We maintain that this approach will increase transparency, dialogue, understanding, and trust, which, in turn, may result in greater consensus. (shrink)

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The decision-making environment in intensivecare units (ICUs) is influenced by the transformation of intensivecare medicine, the staffing situation and the increasing importance of patient autonomy. Normative implications of time in intensivecare, which affect all three areas, have so far barely been considered. The study explores patterns of decision making concerning the continuation, withdrawal and withholding of therapies in intensivecare. A triangulation of qualitative data collection methods was chosen. Data were collected through non-participant (...) observation on a surgical ICU at an academic medical centre followed by semi-structured interviews with nurses and physicians. The transcribed interviews and observation notes were coded and analysed using qualitative content analysis according to Mayring. Three themes related to time emerged regarding the escalation or de-escalation of therapies: influence of time on prognosis, time as a scarce resource and timing in regards to decision making. The study also reveals the ambivalence of time as a norm for decision making. The challenge of dealing with time-related efforts in ICUcare results from the tension between the need to wait to optimise patientcare, which must be balanced against the significant time pressure which is characteristic of the ICU setting. (shrink)

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The study presented in this article is based on field observations over one year on a criticalcare unit in Norway. Data were analysed according to Glaser’s grounded theory and generated a theory of hidden and emerging drama in the context of ambiguity while the nurses routinized the handling of complex technology. To the untrained eye the unit presented a picture of calm competence, while under the surface one finds hidden drama full of difficult interacting clinical andethical (...) problems. The nurses identified sixethical dilemmas: (1) end of life issues; (2) whether there should be an age limit for coronary surgery; (3) distributing limited resources; (4) resource allocation in terms of better staffing; (5) situations in which is it more harmful than beneficial to continue treatment; and (6) transferring patients to other facilities. The six problems overlap and have clinical as well asethical components, but it was theethical dimensions that the nurses identified and discussed. The significance for nursing is the importance of well-educated and well-qualified nurses and how they find viable solutions to complexethical and clinical problems. (shrink)

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It is rare to find honest accounts of the difficulties and dilemmas encountered when conducting sensitive research with vulnerable research populations. This account explores some of theethical issues raised by a qualitative interview study with lesbians and gay men about their experiences of nursingcare. There is tension between the moral duty to conduct research with vulnerable and stigmatized groups in order to improvecare, and the inevitable lack of resources that go with such a venture. (...) This increases the risk of harm during the process of research. The risk of harm to both the researchers and the researched is explored and the need for a support structure for both groups is raised. There is a pressing need to develop further understanding about the ways in which the dissemination of research can potentially harm already vulnerable research populations. (shrink)

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BackgroundPsychiatric staff members have the power to decide the options that frame encounters with patients. Intentional as well as unintentional framing can have a crucial impact on patients’ opportunities to be heard and participate in the process. We identified three dominantethical perspectives in the normative medical ethics literature concerning how doctors and other staff members should frame interactions in relation to patients; paternalism, autonomy and reciprocity. The aim of this study was to describe and analyse statements describing real (...) work situations andethical reflections made by staff members in relation to three central perspectives in medical ethics; paternalism, autonomy and reciprocity.MethodsAll staff members involved with patients in seven adult psychiatric and six child and adolescent psychiatric clinics were given the opportunity to freely describeethical considerations in their work by keeping anethical diary over the course of one week and 173 persons handed in their diaries. Qualitative theory-guided content analysis was used to provide a description of staff encounters with patients and in what way these encounters were consistent with, or contrary to, the three perspectives.ResultsThe majority of the statements could be attributed to the perspective of paternalism and several to autonomy. Only a few statements could be attributed to reciprocity, most of which concerned staff members acting contrary to the perspective. The result is presented as three perspectives containing eight values.•Paternalism; 1) promoting and restoring the health of the patient, 2) providing goodcare and 3) assuming responsibility.•Autonomy; 1) respecting the patient’s right to self-determination and information, 2) respecting the patient’s integrity and 3) protecting human rights.•Reciprocity; 1) involving patients in the planning and implementation of theircare and 2) building trust between staff and patients.ConclusionsPaternalism clearly appeared to be the dominant perspective among the participants, but there was also awareness of patients’ right to autonomy. Despite a normative trend towards reciprocity in psychiatry throughout the Western world, identifying it proved difficult in this study. This should be borne in mind by clinics when considering the need forethical education, training and supervision. (shrink)

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Background The nursing profession requiresethical and legal regulations to guide nurses’ performance.Ethical climate plays a part in shaping nurses’ethical practice. Therefore, ethico-legal aspects andethical climate contribute to improving nurses’ethical practice and competencies with reducing medical errors in hospital settings. Objective This study examined the effect of ethico-legal aspects andethical climate on managing safe patientcare and medical errors among nurses. Materials and methods A cross-sectional correlational study was (...) carried out on 548 nurses. Data were collected through self-administered questionnaires about nurses’ knowledge in bothethical and legal aspects,ethical practice, competencies,ethical climate and experience with medical error. Results The main sources of nurses’ knowledge ofethical and legal aspects were undergraduate lectures, job experience and colleagues. Nurses’ knowledge in bothethical and legal aspects, nurses’ethical practice and competencies were insufficient. Nurses fairly perceived theirethical climate. Also, nurses experienced medical errors about 22.6% in their units. Nurses’ knowledge ofethical and legal aspects, as well as theethical climate were positive predictors of inadequate nurses’ethical practice and competencies. Additionally, nurses’ knowledge in bothethical and legal aspects,ethical climate and practice had a negative influence on the occurrence of medical errors. Conclusion Enhancing nurses’ knowledge in bothethical and legal aspects as well asethical climate could significantly influence improving nurses’ethical practice, competencies and reducing medical errors in the study units. Therefore, planning for enhancing the nurses’ ethico-legal learning andethical climate seems to be mandatory. (shrink)

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Public collective hunger strikes take place in complex social and political contexts, require medical attention and presentethical challenges to physicians. Empirical research, theethical debate to date and existing guidelines by the World Medical Association focus almost exclusively on hunger strikes in detention. However, the public space differs substantially with regard to the conditions for the provision of healthcare and the diverse groups of healthcare providers or stakeholders involved. By reviewing empirical research on the experience (...) of health professionals with public collective hunger strikes, we identified the followingethical challenges: (1) establishment of a trustful physician–striker relationship, (2) balancing of medico‐ethical principles in medical decision‐making, (3) handling of loyalty conflicts and (4) preservation of professional independence and the risk of political instrumentalization. Some of these challenges have already been described and discussed, yet not contextualized for public collective strikes, while others are novel. The presence of voluntary physicians may offer opportunities for a trustful relationship and, hence, forethical treatment decisions. According to our findings, it requires more attention to how to realise autonomous medical decisions in the complex context of a dynamic, often unstructured and politically charged setting, whichethical norms should shape the professional role of voluntary physicians, and what is the influence of the hunger strikers' collective on individual healthcare decisions. Our article can serve as a starting point for furtherethical discussion. It can also provide the basis for the development of potential guidelines to support health professionals involved in public collective hunger strikes. (shrink)

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Medical Officers serving with their national contingents in peacekeeping operations are faced with difficultethical decisions in regard to their obligations to the local civilian population. Such populations may be under-resourced in regard to medicalcare, and vulnerable to abuse and exploitation. Though the medical officer may support the local medical services, he/she should never undermine these resources. Adopting a human rights approach and observing the requirements ofethical medicine, aids the doctor in prioritising his/her duties. At (...) times there may be conflict with one’s own military superiors. It is wise to discuss potential difficulties prior to setting out on the mission. Human rights abuses cannot be ignored. The medical officer has a duty to do his/her best to report their observations so as to prevent abuse or to bring it to an end. (shrink)

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There is unanimous agreement regarding the need to ethically conduct research for improving therapy for patients admitted to hospital with acute conditions, including in emergency obstetriccare. We present a conceptual analysis ofethical tensions inherent in the informed consent process for randomized clinical trials for emergency obstetriccare and suggest ways in which these could be mitigated. A valid consenting process, leading to an informed consent, is a cornerstone of this aspect necessary for preservation and maintenance (...) of respect for autonomy and dignity. In emergency obstetriccare research, obtaining informed consent can be problematic, leading toethical tension between different moral considerations. Potential participants may be vulnerable due to severity of disease, powerlessness or impaired decisional capacity. Time for the consent process is limited, and some interventions have a narrow therapeutic window. These factors createethical tension in allowing potentially beneficial research while avoiding potential harms and maintaining respect for dignity, human rights, justice and autonomy of the participants. Informed consent in emergency obstetriccare in low- and middle-income countries poses numerousethical challenges. Allowing research on vulnerable populations while maintaining respect for participant dignity and autonomy, protecting participants from potential harms and promoting justice underlie theethical tensions in the research in emergency obstetric and newborncare. Those involved in research conduct or oversight have a duty of fair inclusion, to avoid denying participants the right to participate and to any potential research benefits. (shrink)

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The last three articles within this section of Cambridge Quarterly have focused on organizations or disciplines outside the mainstream of bioethics that are making inroads within the field. This issue's article may be viewed as a departure, but it is not-my thesis is that despite the active presence of the clergy in the ethics field, individuals involved in pastoralcare are often thought by health professionals, as well as by a sizeable number of pastors themselves, to not be within (...) the mainstream ofethical decision-making for patients. (shrink)

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In this paper, I examine Foucault’s ideas concerning thecare of the self. What exactly is this ideal that Foucault describes in his last two books? Do these books represent a break or a continuation with the earlier writings on knowledge and power? Most important, I consider whether thecare of the self could ever be a significantethical ideal given some of the objections that have been raised against Foucault’s position. I also look at the (...) class='Hi'>care of the self as the focus of Foucault’s own views on spiritual life. I argue that Foucault’s later work offers the basis for a secular or non-theistic spirituality which is especially relevant today. (shrink)

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