Care-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this.
The study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project.
Two main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility.
Underlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.
Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes of the patient's family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuk's physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited.
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Prenatal screening, consisting of maternal serum screening and nuchal translucency screening, is on the verge of expansion, both by being offered to more pregnant women and by screening for more conditions. The Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists have each recently recommended that screening be extended to all pregnant women regardless of age, disease history, or risk status. This screening is commonly justified by appeal to the value of autonomy, or women's choice. In this paper, I critically examine the value of autonomy in the context of prenatal screening to determine whether it justifies the routine offer of screening and the expansion of screening services. I argue that in the vast majority of cases the option of prenatal screening does not promote or protect women's autonomy. Both a narrow conception of choice as informed consent and a broad conception of choice as relational reveal difficulties in achieving adequate standards of free informed choice. While there are reasons to worry that women's autonomy is not being protected or promoted within the limited scope of current practice, we should hesitate before normalizing it as part of standard prenatal care for all.
"Do your homework…and then hope for the best": the challenges that medical tourism poses to Canadian family physicians' support of patients' informed decision-making.
Medical tourism-the practice where patients travel internationally to privately access medical care-may limit patients' regular physicians' abilities to contribute to the informed decision-making process. We address this issue by examining ways in which Canadian family doctors' typical involvement in patients' informed decision-making is challenged when their patients engage in medical tourism.
Focus groups were held with family physicians practicing in British Columbia, Canada. After receiving ethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participate and focus groups ranged from two to six participants. Questions explored participants' perceptions of and experiences with medical tourism. A coding scheme was created using inductive and deductive codes that captured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt with informed decision-making were shared among the investigators in order to identify themes. Four themes were identified, all of which dealt with the challenges that medical tourism poses to family physicians' abilities to support medical tourists' informed decision-making. Findings relevant to each theme were contrasted against the existing medical tourism literature so as to assist in understanding their significance.
Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician's role in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient because of the regular domestic physician's reduced role in shared decision-making; 3) strains on the patient-physician relationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domestic physicians' concerns that treatments sought abroad may not be based on the best available medical evidence on treatment efficacy.
Medical tourism is creating new challenges for Canadian family physicians who now find themselves needing to carefully negotiate their roles and responsibilities in the informed decision-making process of their patients who decide to seek private treatment abroad as medical tourists. These physicians can and should be educated to enable their patients to look critically at the information available about medical tourism providers and to ask critical questions of patients deciding to access care abroad.
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Providing nursing care for patients with end-stage renal disease entails dealing with existential issues which may sometimes lead not only to ethical problems but also conflicts within the team. A previous study shows that physicians felt irresolute, torn and unconfirmed when ethical dilemmas arose.
This study, conducted in the same dialysis care unit, aimed to illuminate registered nurses' experiences of being in ethically difficult situations that give rise to a troubled conscience.
This study has a phenomenological hermeneutic approach.
Narrative interviews were carried out with 10 registered nurses working in dialysis care.
The study was approved by the Ethics Committee of the Faculty of Medicine, Umeå University.
One theme, 'Calling for a deliberative dialogue', and six sub-themes emerged: 'Dealing with patients' ambiguity', 'Responding to patients' reluctance', 'Acting against patients' will', 'Acting against one's moral convictions', 'Lacking involvement with patients and relatives' and 'Being trapped in feelings of guilt'.
In ethically difficult situations, the registered nurses tried, but failed, to open up a dialogue with the physicians about ethical concerns and their uncertainty. They felt alone, uncertain and sometimes had to act against their conscience.
In ethical dilemmas, personal and professional integrity is at stake. Mistrusting their own moral integrity may turn professionals from moral actors into victims of circumstances. To counteract such a risk, professionals and patients need to continuously deliberate on their feelings, views and experiences, in an atmosphere of togetherness and trust.
Euthanasia has been heatedly discussed in Western countries over the last years. Only a few nations have legalized euthanasia or physician assisted suicide with the Dutch at the forefront of that field. Proponents of euthanasia mostly argue for euthanasia on two grounds. Firstly, that the patient has a right to die and secondly, that there is no substantial difference between euthanasia and palliative care. In this paper I will argue against both of the above. I discuss the arguments against euthanasia which are in principle four. Firstly, it is held by many that taking a human life is wrong under all circumstances. Secondly, that it is an unjustifiable demand to ask a person to take another person's life. In relation to that argument, euthanasia is not in accordance with the basic principles of medicine and nursing as they have evolved over the years and could therefore easily disrupt the therapeutic relationship. Thirdly, as shown from Holland there is empirical evidence that euthanasia is not under good enough surveillance and therefore invites misuse. Fourthly, even though euthanasia might possibly be justifiable under certain circumstances, legalisation might well invite abuse because of the message and pressure that the option places on both patients and professionals in terminal care. My answer to the euthanasia demand is palliative care, where dialogue between the patient and doctor is central. But the dialogue cannot be effective, unless both partners are willing and able to engage in sincere and frank conversations.
Professional health care practice should be based on ethical decisions and actions. When there are competing ethical standards or principles, one must choose between two or more competing options. This study explores ethical dilemmas experienced by International Board Certified Lactation Consultants.
The investigator interviewed seven International Board Certified Lactation Consultants and analyzed the interviews using qualitative research methods.
"Staying Mother-Centred" emerged as the overall theme. It encompassed six categories that emerged as steps in managing ethical dilemmas: 1) recognizing the dilemma; 2) identifying context; 3) determining choices; 4) strategies used; 5) results and choices the mother made; and 6) follow-up. The category, "Strategies used", was further analyzed and six sub-themes emerged: building trust; diffusing situations; empowering mothers; finding balance; providing information; and setting priorities.
This study provides a framework for understanding how International Board Certified Lactation Consultants manage ethical dilemmas. Although the details of their stories changed, the essence of the experience remained quite constant with the participants making choices and acting to support the mothers. The framework could be the used for further research or to develop tools to support IBCLCs as they manage ethical dilemmas and to strengthen the profession with a firm ethics foundation.
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