Hec Forum最新文献

Medical futility laws protect surrogate decision makers by constraining clinicians and hospitals. Professor Fiester shows that clinicians and surrogate decision makers often have different value systems. Clinicians espouse the "Best Interest Values" (BIV) system, while surrogates often espouse the "Life-Continuation Values" (LCV) system. Professor Fiester argues that there is no way to adjudicate between the BIV and LCV value systems. They are incommensurable and irreconcilable. Surrogates are not "wrong" about the patient's best interest. They just measure it differently. Consequently, because clinicians have no superior ethical claim to determine the patient's best interest, they should not impose their value-laden notion onto surrogates. I question whether clinicians are as powerful as Professor Fiester suggests. In fact, laws in many U.S. states materially constrain clinicians and hospitals, requiring them to do precisely what the LCV surrogate wants. Therefore, in these jurisdictions, clinicians are already forced to undertake the "constructive engagement" that Professor Fiester calls for. In these states, the BIV does not subjugate the LCV. Rather, the LCV likely subjugates the BIV.

In this commentary, I argue that while the value-systems of healthcare providers and surrogate decision-makers might appear to be incommensurable, they share enough common ground over high-level principles that meaningful engagement between the two groups is possible. This engagement can happen through incompletely theorized agreements that allow discussants to focus on shared values while adhering to competing value-systems. Nonetheless, I argue that the privileging of both healthcare providers and their best interest value system within healthcare creates a continued and unjustified subordination of surrogate decision-makers that threatens to undermine the possibility of meaningful engagement between the two groups. As a solution, I suggest that end-of-life policies be structured in ways that emphasize common ground between healthcare providers and surrogate decision-makers while allowing the dissent of surrogate decision-makers to be a genuinely viable option whenever possible.

In the piece, "Surrogate Wars: The 'Best Interest Values' Hierarchy & End-of-Life Conflicts with Surrogate Decision-Makers," I argue that incommensurable value systems between healthcare providers (HCPs) and surrogate decision-makers (SDMs) lie at the root of many intractable end-of-life treatment disputes. I argue that the most prevalent value system of HCPs might be understood as a "Best Interest Values" (BIV) hierarchy and that this value system is irreconcilable with the set of "Life-Continuation Values" (LCV) held by a sizable minority of families in the United States. I believe that HCPs facing seemingly intractable conflict with SDMs would be aided by understanding their BIV values framework as just one of many cogent values systems in the context of US ethical pluralism. Five preeminent bioethicists provide insightful commentaries on my essay, offering pointed critiques, raising important challenges, and gesturing towards extensions and refinements of my argument. In this essay, I respond to those thoughtful and well-argued commentaries.

In paediatric oncology, ethical dilemmas often arise and includes different perspectives about what is perceived as ethically right care for the child. Ethics Case Reflection (ECR) rounds, a form of Clinical Ethics Support (CES), offer a structured, dialogical approach to facilitate ethical reflection. A Nordic working group on ethics in pediatric oncology offers a training program for healthcare professionals to become facilitators for ECR rounds. The aim of this study was to explore experiences of these facilitator trainees when facilitating ECR rounds in Nordic paediatric oncology. Using classic grounded theory methodology, data were collected through three focus groups with 22 Nordic facilitator trainees and 27 individual interviews with 17 facilitator trainees from Sweden. Carrying the facilitator responsibility is the core category in this study, used to resolve the main concern of delivering a meaningful experience of ethics support and enabling ethically good care for the child. To carry the facilitator responsibility and handle associated challenges, the condition of achieved facilitator confidence and the strategies of allying and undertaking the facilitator role is important. ECR facilitator trainees take their role seriously as they are carrying the facilitator responsibility to deliver a meaningful experience of CES and enable ethically good care for the child. We conclude that this perceived burden of responsibility should be better addressed during future facilitator trainings, emphasising the use of various strategies to decrease this burden and share the responsibility for the ECR together with the ECR participants. Training also needs to strengthen ethical competence to achieve facilitator confidence of the trainees. Further research is needed on what kind of core ethical competencies facilitators of ECR rounds needs.

The extent to which clinical ethics consultations should be neutral with respect to religion is the subject of ongoing debate. One important position says that clinical ethics consultants ought to appeal to the secular bioethical consensus that is available to everyone inasmuch as possible, and that they can do so without the subsequent need to defend an underlying moral theory. This view has been criticized because it is doubtful that such a consensus exists. Abram Brummett argues for a more nuanced approach where clinical ethicists must appeal to the bioethical consensus in clinical settings, but that the consensus and underlying moral principles can be debated in academic contexts (2020). Furthermore, he suggests that the consensus need not avoid making at least some moral, epistemological, and metaphysical commitments, though not to the level of embracing a full-fledged comprehensive worldview. I argue that Brummett's approach fails because it does not successfully avoid the implications of the lack of a secular bioethical consensus. Any defense of such a consensus is only possible at a superficial level where there may be agreement on which moral concepts to use, even though deep disagreement remains about their nature and application. While Brummett's approach is more honest than some secular alternatives because it does not seek to avoid making any judgments about underlying commitments, it is ultimately uninformative in failing to address the fact of pluralism. To conclude, I suggest that even if I am mistaken and there really is a secular bioethical consensus, Brummett's view implies that the consensus can never be legitimately challenged in clinical settings.

Despite the existence of codified ethical standards in healthcare, their consistent application in clinical decision-making remains underexplored. This study quantitatively evaluates the knowledge, attitudes and practices of Moroccan healthcare professionals regarding medical ethics. Guided by a positivist epistemology and a hypothetico-deductive methodology, a validated questionnaire was administered to 200 practitioners from diverse medical backgrounds. Descriptive statistics revealed that 96% of respondents report disclosing medical errors, yet only 50% had formal exposure to medical ethics, and 51.5% were familiar with the national code of ethics. Correlation analysis indicated weak but positive associations between ethical training and disclosure practices (r ≈ 0.07). Multiple linear regression demonstrated that variables such as knowledge of ethics (β = 0.111) and training (β = 0.022) had modest, non-significant effects on ethical conduct (R² = 1.05%). Attitudinal factors, such as acceptance of placebo use (β = - 0.121, p = 0.094), showed marginal influence, while respect for patient autonomy and additional training did not significantly predict behavior. Sociodemographic variables (age, experience, rank) also lacked predictive power, though the main model constant (β ≈ 1.0, p < 0.001) suggests a generally strong ethical baseline. These findings show the importance of targeted ethics education and institutional reinforcement to strengthen ethical clinical behavior and promote transparency within the Moroccan healthcare system.

The case of Aruna Shanbaug, a young nurse rendered permanently unconscious following a violent assault in 1973, stands as a defining moment in India's medico-legal and ethical history. Over four decades of institutional care without legal guardianship, reassessment, or advance directive brought to light the systemic gaps in forensic investigation, sexual violence prosecution, and end-of-life jurisprudence. This essay undertakes a critical analysis of the forensic failures surrounding the assault, the narrow legal definitions that denied justice, and the prolonged absence of ethical oversight in Shanbaug's custodial management. It further explores the Supreme Court's 2011 judgment on passive euthanasia, which - though denying the specific plea - laid the groundwork for constitutional recognition of the right to die with dignity. By drawing comparisons with international cases such as Terri Schiavo (USA) and Tony Bland (UK), the essay situates the Indian experience within a global discourse on bioethics, autonomy, and medical futility. It also charts the post-2011 evolution of Indian medico-legal frameworks, including the recognition of advance directives, reforms in sexual violence law, and the institutionalization of ethical review in clinical practice. Through this multidisciplinary reappraisal, the essay argues that the Shanbaug case was both a consequence of systemic inaction and a catalyst for enduring reform in law, medicine, and ethics in India.

Healthcare Ethics Consultants (HECs) can serve as a resource for facilitating values-based conversations for responsible integration of AI technologies that benefit patients, providers, and healthcare organizations. First, the paper describes the different types of AI and its uses in healthcare. Second, it considers the role of HECs and why facilitating conversations around the responsible use and implementation of AI better frames the ethical content for AI healthcare. Third, the paper explores the ethical knowledge necessary to think through responsible use of AI. Finally, it identifies how ethics can be embedded into the process of adopting AI in healthcare from its development to its implementation in the organization and in the need for continual research on its use. The skills necessary for HECs can be utilized in a way to better improve values-based decision-making and evaluation for AI in healthcare.

Clinical Ethics Support (CES) includes various forms of systematic support to deal with ethical challenges in healthcare and case-based CES (C-CES) is used for CES in particular cases. The aim was to describe and normatively discuss organizational and methodological aspects of C-CES used in Swedish healthcare. A mixed-methods approach was used. A descriptive survey was answered regarding eight organizations on hospital, regional and national level, with large variations in the number of conducted C-CES activities. Data were compiled and frequencies calculated. Based on the survey results, normative questions were formulated. Six participants, with expertise of C-CES, participated in a normative group discussion. Field notes and transcribed data were analysed qualitatively. The top ranked goal of C-CES was "Supporting decision making". Mainly prospective cases were used and C-CES was carried out as un-planned and pre-planned sessions. The normative results showed the importance of avoiding making C-CES unattractive to clinicians, for instance by keeping the time frame. The professional backgrounds of C-CES leaders varied greatly and arguments were provided for the facilitating role and that C-CES leaders ought not facilitate where they have been clinically engaged. Identified challenges included variations in uptake of C-CES activities that do not mirror the ethical challenges of the context. The unfair uptake of C-CES can be compared with the uptake in Norway where there are legal requirements for CES. In this study patients and families were not reported to request or attend C-CES. Thus, further research and interventions are needed to ensure their representation in Swedish C-CES.