Clinical Ethics最新文献

英文中文

From a phenomenology of birth towards an ethics of obstetric care 从分娩现象学到产科护理伦理学

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-06-01 DOI: 10.1177/14777509241233155

Tatjana Noemi Tömmel

The aim of this paper is to get from a phenomenology of birth towards an ethics of obstetric care: Human rights violations in obstetrics are currently a globally debated phenomenon. Research suggests that maltreatment is widespread and a global phenomenon. However, the prevalence cannot yet be clearly quantified. In view of this problem, it is necessary to take the subjective perspective of those affected seriously. Narrative and phenomenological accounts of birth experiences could help to foster the dialogue between persons giving birth and health professionals. First, I will present narrative accounts of birth experiences recorded by feminist phenomenologists. Second, I will interpret these narrative accounts within a feminist phenomenological framework in order to contribute to a phenomenology of birth, which, in a third step, shall help to develop an ethics of obstetric care. In engaging with the phenomenology of care outlined by feminist care ethicists, I will analyze the elements and conditions of good care, and draw conclusions for an ethic of obstetric and midwifery care. Drawing additionally on the theory of relational autonomy, my paper argues for a relational implementation of self-determination in childbirth. Lastly, I will discuss to what extent the ethical ideal of care has an affinity to the midwifery model of childbirth, and how the current situation of obstetrics prevents a women-centered birth culture.

本文旨在从出生现象学出发，探讨产科护理伦理：目前，产科领域侵犯人权的现象在全球范围内备受争议。研究表明，虐待是一种普遍的全球性现象。然而，其普遍程度尚无法明确量化。有鉴于此，有必要认真对待受影响者的主观观点。对分娩经历的叙述和现象学描述有助于促进分娩者与医疗专业人员之间的对话。首先，我将介绍女权主义现象学家记录的分娩经历叙事。其次，我将在女性主义现象学的框架内对这些叙述进行解释，以促进出生现象学的发展，第三步，这将有助于制定产科护理伦理。我将结合女权主义护理伦理学家提出的护理现象学，分析良好护理的要素和条件，并为产科和助产护理伦理得出结论。此外，我的论文还将借鉴关系自主理论，论证在分娩过程中通过关系实现自主。最后，我将讨论护理伦理理想在多大程度上与助产士的分娩模式具有亲和力，以及产科的现状如何阻碍了以妇女为中心的分娩文化。

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引用次数: 1

Psychiatry as a vocation: Moral injury, COVID-19, and the phenomenology of clinical practice. 精神病学是一种职业：道德伤害、COVID-19 和临床实践现象学。

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-06-01 Epub Date: 2023-11-14 DOI: 10.1177/14777509231208361

Matthew R Broome, Jamila Rodrigues, Rosa Ritunnano, Clara Humpston

In this article, we focus on a particular kind of emotional impact of the pandemic, namely the phenomenology of the experience of moral injury in healthcare professionals. Drawing on Weber's reflections in his lecture Politics as a Vocation and data from the Experiences of Social Distancing during the COVID-19 Pandemic Survey, we analyse responses from healthcare professionals which show the experiences of burnout, sense of frustration and impotence, and how these affect clinicians' emotional state. We argue that this may relate to the ethical conflicts they experience when they are forced to make clinical decisions where there are no optimal outcomes, and how in turn that impacts on their own emotional state. We then further examine the notion of 'burnout' and the phenomenology of 'moral injury'. Our argument is that these experiences of moral injury across a range of clinicians during the pandemic may be more prevalent and long-standing in psychiatry and mental health than in other areas of healthcare, where ethically difficult decisions and resource constraints are common outside times of crisis. Hence, in these clinical arenas, moral injury and the phenomenology of emotional changes may be independent of the pandemic. The insights gained during the pandemic may provide wider insights into the challenges of developing services and training the workforce to provide appropriate mental health care.

在本文中，我们将重点关注大流行病对情感的一种特殊影响，即医护专业人员的道德伤害体验现象学。借鉴韦伯在其演讲《政治是一种天职》中的反思以及 COVID-19 大流行期间社会疏离体验调查的数据，我们分析了医护专业人员的回复，其中显示了职业倦怠、挫败感和无能感等体验，以及这些体验如何影响临床医生的情绪状态。我们认为，这可能与他们在被迫做出没有最佳结果的临床决策时所经历的伦理冲突有关，以及这种冲突如何反过来影响他们自身的情绪状态。然后，我们进一步研究了 "职业倦怠 "的概念和 "道德伤害 "的现象学。我们的论点是，与其他医疗保健领域相比，精神科和心理健康领域的临床医生在大流行病期间的这些道德伤害经历可能更为普遍和长期，因为在危机时期之外，道德上的艰难决定和资源限制在这些领域很常见。因此，在这些临床领域，道德伤害和情绪变化的现象可能与大流行无关。在大流行病期间获得的启示可能会为发展服务和培训劳动力以提供适当的心理保健服务所面临的挑战提供更广泛的启示。

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引用次数: 0

Phenomenologies of care: Integrating patient and caregiver narratives into clinical care 护理现象学：将患者和护理人员的叙述融入临床护理中

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-05-05 DOI: 10.1177/14777509241251994

Jenny Krutzinna, Anna Gotlib

This special issue aims to spotlight the individual, lived experiences of caregivers and those receiving care–areas often overshadowed by clinical and medicalized narratives within clinical ethics. Our aim is to enrich the discourse by incorporating stories and narratives of medical care and challenge existing clinical practices by emphasizing patient and practitioner experiences. Through a blend of clinical and academic insights, this issue provides phenomenological narratives, highlighting the importance of lived experiences in understanding and improving clinical caregiving practices. The contributions, ranging from theoretical analyses to personal narratives, explore various aspects of caregiving. Each article contributes to a deeper understanding of the phenomenologies of care, advocating for a more inclusive, patient-centered approach in clinical ethics and practice.

本特刊旨在关注护理人员和接受护理者的个人生活经历--这些领域往往被临床伦理学中的临床和医学叙事所掩盖。我们的目标是通过纳入医疗护理的故事和叙事来丰富讨论，并通过强调患者和从业者的经验来挑战现有的临床实践。通过融合临床和学术见解，本期杂志提供了现象学叙事，强调了生活经验在理解和改进临床护理实践中的重要性。文章从理论分析到个人叙述，探讨了护理工作的方方面面。每篇文章都有助于加深对护理现象学的理解，倡导在临床伦理和实践中采用更具包容性、以患者为中心的方法。

引用次数: 0

Loneliness in medicine and relational ethics: A phenomenology of the physician-patient relationship 医学中的孤独感与关系伦理：医患关系现象学

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-04-09 DOI: 10.1177/14777509241246161

John Han, Benjamin W. Frush, Jay R Malone

Loneliness in medicine is a serious problem not just for patients, for whom illness is intrinsically isolating, but also for physicians in the contemporary condition of medicine. We explore this problem by investigating the ideal physician-patient relationship, whose analogy with friendship has held enduring normative appeal. Drawing from Talbot Brewer and Nir Ben-Moshe, we argue that this appeal lies in a dynamic form of companionship incompatible with static models of friendship-like physician-patient relationships: a mutual refinement of embodied virtue that draws both persons together. The ideal physician-patient relationship has a dialectical character that fosters each member's improvement of phenomenologically recognizing and embodying moral virtues. A key component of this dynamic is a commitment to the common goal of the patient's health, realized through joint interactivities and conversations over time. The physician's presence to the patient's suffering—understood best as an alienating phenomenological condition for the patient—orients and discloses possibilities for virtuous caregiving by structuring the meanings of the goals, conversations, and joint narrative constitutive of their relationship. Presence to suffering, paradoxically, is perhaps an important prerequisite for this dynamic partnership. These activities dialectically build an interpretive horizon of understanding through which moral goods and character refinement—in and for the other—may become revealed for both persons in their shared being-in-the-world. This analysis of suffering, mood, and revealing of (possible) moral goods has implications for addressing the modern problem of loneliness for patients and physicians, who are increasingly inhibited from building flourishing relationships with each other.

医学中的孤独感不仅是病人面临的一个严重问题，因为疾病本质上会使病人感到孤独，而且也是当代医学中医生面临的一个严重问题。我们通过研究理想的医患关系来探讨这一问题，这种关系与友谊的类比具有持久的规范性吸引力。借鉴塔尔博特-布鲁尔（Talbot Brewer）和尼尔-本-莫舍（Nir Ben-Moshe）的观点，我们认为这种吸引力在于一种动态的陪伴形式，它与静态的类似友谊的医患关系模式不相容：一种体现美德的相互提炼，将两个人吸引到一起。理想的医患关系具有辩证的特点，能够促进每个成员提高对道德美德的现象学认识和体现。这种动态关系的一个关键组成部分是对患者健康这一共同目标的承诺，通过长期的共同互动和对话来实现。医生对病人痛苦的存在--最好理解为病人异化的现象学条件--通过构建目标、对话和共同叙事的意义，构成了他们之间的关系，从而引发并揭示了良性护理的可能性。自相矛盾的是，对痛苦的存在也许是这种动态合作关系的一个重要前提。这些活动辩证地建立了一种解释性的理解视界，通过这种视界，双方在共同的世界存在中，都能看到对方的道德品质和人格完善。这种对痛苦、情绪和揭示（可能的）道德物品的分析，对于解决现代病人和医生的孤独问题具有重要意义，因为他们越来越无法与对方建立蓬勃发展的关系。

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引用次数: 0

Gross negligence manslaughter of intern doctors – scapegoating or justified? 实习医生严重过失杀人--替罪羊还是正当理由？

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-02-25 DOI: 10.1177/14777509241234778

Wing Hin Kason Lin

Criminalizing unintentional mistakes in medicine as the offence of gross negligence manslaughter has always been a contentious issue. The threshold of prosecution is not well-defined, and even less clear when faced with a situation in which an intern doctor is held liable. This commentary attempts to review the current legal position of holding an intern doctor liable for gross negligence medical manslaughter.

以重大过失过失杀人罪将医疗中的非故意过失定为刑事犯罪一直是一个有争议的问题。起诉的门槛并没有明确界定，在实习医生被追究责任的情况下就更不明确了。本评注试图回顾当前追究实习医生重大过失过失杀人罪的法律地位。

引用次数: 0

Breaking down organ donation borders: Revisiting “opt out” residency requirements in the UK 打破器官捐赠的边界：重新审视英国的 "选择退出 "居住要求

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-02-20 DOI: 10.1177/14777509241231501

J. Parsons

All four UK nations have, in recent years, introduced “opt out” organ donation systems. Whilst these systems are largely similar, they operate independently. A key feature of each policy is a residency requirement, stipulating that opt out may only apply where the deceased had been ordinarily resident in that nation for at least 12 months. A resident of Scotland who dies in England, for example, would not fall under opt out. Public awareness is the underlying reasoning for such stipulations. A residency requirement was appropriate when Wales was the only UK nation with an opt out system, but, I suggest, the continued imposition of intra-UK borders on organ donation is unjustified now that all four nations operate the same policy. Further, it has the potential to limit organ donation. There is a need for all four systems to be amended to allow for UK-wide applicability, such that providing the deceased was ordinarily resident in the UK, they can fall under opt out in any of the four nations. I argue that such an amendment is ethically justified – continuing to satisfy the public awareness criterion – and practically straightforward. In doing so, I emphasise that my proposed amendment should extend only to the four UK nations, stopping short of the Crown Dependencies even though they also operate opt out systems for organ donation.

近年来，英国所有四个国家都引入了 "选择退出 "器官捐献系统。虽然这些制度大体相似，但各自独立运作。每项政策的一个主要特征是居住地要求，规定只有在死者通常居住在该国至少 12 个月的情况下，才能适用 "选择放弃 "制度。例如，在英格兰去世的苏格兰居民就不属于选择退出的范围。公众意识是做出此类规定的根本原因。当威尔士是英国唯一一个实行选择退出制度的国家时，居住地要求是合适的，但我认为，现在所有四个国家都实行同样的政策，继续对器官捐献施加英国内部边界是不合理的。此外，它还有可能限制器官捐献。有必要对所有四个系统进行修订，使其适用于整个英国，这样只要死者通常居住在英国，他们就可以在四个国家中的任何一个国家选择退出。我认为这样的修订在伦理上是合理的--继续满足公众意识标准--在实践上也是简单易行的。同時，我強調我建議的修訂應只擴展至英國㆕個國家，而不包括英國屬土，儘管它們也實施器官捐贈的選擇不捐贈制度。

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引用次数: 0

The need for Hispanic cultural competency in drug abuse treatment training programs: An empirical and ethical evaluation of US universities 在药物滥用治疗培训项目中培养西班牙裔文化能力的必要性：对美国大学的实证和伦理评估

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2024-01-09 DOI: 10.1177/14777509231220531

Veronica Fish

Ethical clinical practice requires cultural competency. In the United States, Hispanics report stronger attitudinal barriers to drug abuse treatment than any other racial/ethnic group. Hispanics report feeling that drug abuse treatment providers do not understand their unique cultural needs and are unfamiliar with their experiences of discrimination and immigration. Using this case study to explore broader ethical and policy issues, this study investigates the extent to which US universities train counselors to address the culturally specific needs of Hispanic patients and how this is reflected in practice in Los Angeles County. Based on a content analysis of the required courses, syllabi, and course descriptions at 30 universities related to culture/race/racism/ethnicity/diversity at the undergraduate and graduate levels on the addiction therapist track, and thematic analysis of eight in-depth interviews with counselors working in outpatient rehabilitation centers in Los Angeles, I argue that cultural competency education for drug abuse counselors is too surface level and infrequent to adequately prepare students for a career in addiction counseling for Hispanic clients. Significant changes must be made to how cultural diversity is valued and prioritized in the field of psychology to provide better care for Hispanic people with a substance use disorder and fulfill the moral obligation to eliminate this health disparity. Although this study focuses on counselors in Los Angeles, these findings are relevant for professionals and healthcare systems across the United States and beyond who seek to provide equitable and effective care for Hispanic patients.

合乎道德的临床实践需要文化胜任能力。在美国，与其他种族/族裔群体相比，西班牙裔人在接受药物滥用治疗时遇到的态度障碍更大。西班牙裔报告称，他们认为药物滥用治疗提供者不了解他们独特的文化需求，也不熟悉他们遭受歧视和移民的经历。本研究利用这一案例研究来探讨更广泛的伦理和政策问题，调查美国大学在多大程度上培训心理咨询师来满足拉美裔病人的特定文化需求，以及这在洛杉矶县的实践中是如何体现的。根据对 30 所大学的必修课程、教学大纲和课程描述进行的内容分析，以及对在洛杉矶门诊康复中心工作的心理咨询师进行的八次深入访谈进行的主题分析，我认为针对药物滥用心理咨询师的文化能力教育过于表面化，而且缺乏经常性，不足以让学生为从事针对拉美裔客户的成瘾咨询工作做好充分准备。必须对心理学领域重视和优先考虑文化多样性的方式做出重大改变，以便为患有药物使用障碍的拉美裔患者提供更好的治疗，并履行消除这种健康差异的道德义务。虽然这项研究的重点是洛杉矶的心理咨询师，但这些发现对于美国及其他地区的专业人士和医疗保健系统都有借鉴意义，因为他们都希望为拉美裔患者提供公平有效的治疗。

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引用次数: 0

No means no: A case study on respecting patient autonomy 不行就是不行关于尊重病人自主权的案例研究

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-12-19 DOI: 10.1177/14777509231218205

David John Doukas, Nathan Stout

This case study examines the circumstance of a patient who has clearly articulated non-treatment preferences and who then later becomes incapacitated. The patient's wife as well as a consulting physician both expressed a preference for full treatment at the time of this incapacity. The analysis of this circumstance is pertinent given misinformed beliefs by health care providers that once a patient is incapacitated, the family is free to override prior values and preferences. The analysis discusses the autonomy, beneficence, and virtue-based considerations as to why a formerly capacitated patient who has not recanted his non-treatment preferences should be obeyed.

本案例研究探讨了一名病人的情况，这名病人明确表示了不接受治疗的意愿，但后来却丧失了行为能力。病人的妻子和一名会诊医生在病人丧失行为能力时都表示希望得到全面治疗。鉴于医疗服务提供者错误地认为，一旦病人丧失了行为能力，家属就可以随意推翻先前的价值观和偏好，因此对这种情况的分析具有相关性。该分析讨论了自主性、受益性和基于美德的考虑因素，说明为什么应该服从以前有行为能力但没有收回其非治疗偏好的病人的意见。

引用次数: 0

Roadblocks to reforming UK guidelines on medically unnecessary penile circumcision: inconsistent safeguarding of bodily integrity 改革英国医学上不必要的阴茎包皮环切术指南的障碍：对身体完整性的保护不一致

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-12-19 DOI: 10.1177/14777509231216027

Antony Lempert

Medically unnecessary penile circumcision (MUPC) performed on a non-consenting child has been the subject of increasing critical attention in recent years. This paper provides a behind-the-scenes narrative of the politics of ethical policymaking in the United Kingdom in this area including a discussion about some potential barriers to reform. After a brief overview of ethical guidance for medically unnecessary surgical procedures on children in general and on their genitalia in particular, the paper takes a closer look at three contemporary documents released by UK medical bodies and highlights the unique ethical and safeguarding contradictions in this area. The outcomes of initiatives aimed at engaging constructively with the medical bodies and encouraging wider debate are then described, along with some of the main obstacles to engagement and counter-arguments employed. MUPC is subsequently discussed in a wider societal context, highlighting why serious safeguarding concerns have been raised about what many people believe to be a harmful, preventable practice hiding ‘in plain sight’. The paper ends by calling for UK MUPC guidance to be made consistent with the body of guidance that UK doctors are expected to follow.

近年来，对未经同意的儿童实施医学上不必要的阴茎包皮环切术（MUPC）越来越受到批评界的关注。本文从幕后角度阐述了英国在这一领域的伦理决策政治，包括对一些潜在改革障碍的讨论。在简要概述了对儿童，尤其是对儿童生殖器进行医学上不必要的外科手术的伦理指导之后，本文仔细研究了英国医疗机构发布的三份当代文件，并强调了这一领域独特的伦理和保障矛盾。然后介绍了旨在与医疗机构进行建设性接触和鼓励更广泛辩论的各项举措的成果，以及在接触过程中遇到的一些主要障碍和采用的反驳论据。随后从更广泛的社会背景下讨论了 MUPC，强调了为什么许多人认为这是一种隐藏在 "众目睽睽 "之下的有害、可预防的做法，却引起了严重的安全问题。本文最后呼吁英国的 MUPC 指南应与英国医生应遵循的指南保持一致。

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引用次数: 0

Shame, health literacy and consent 羞耻感、健康知识和同意

Q1 Arts and Humanities

Clinical Ethics

Pub Date : 2023-12-12 DOI: 10.1177/14777509231218203

Barry Lyons, Luna Dolezal

This paper is particularly concerned with shame, sometimes considered the ‘master emotion’, and its possible role in affecting the consent process, specifically where that shame relates to the issue of diminished health literacy. We suggest that the absence of exploration of affective issues in general during the consent process is problematic, as emotions commonly impact upon our decision-making process. Experiencing shame in the healthcare environment can have a significant influence on choices related to health and healthcare, and may lead to discussions of possibilities and alternatives being closed off. In the case of impaired health literacy we suggest that it obstructs the narrowing of the epistemic gap between clinician and patient normally achieved through communication and information provision. Health literacy shame prevents acknowledgement of this barrier. The consequence is that it may render consent less effective than it otherwise might have been in protecting the person's autonomy. We propose that the absence of consideration of health literacy shame during the consent process diminishes the possibility of the patient exerting full control over their choices, and thus bodily integrity.

本文特别关注羞耻感（有时被认为是 "主要情绪"）及其在影响同意过程中可能发挥的作用，特别是当羞耻感与健康知识的减少有关时。我们认为，在同意过程中缺乏对一般情感问题的探讨是有问题的，因为情感通常会影响我们的决策过程。在医疗环境中经历羞耻感会对与健康和医疗相关的选择产生重大影响，并可能导致对可能性和替代方案的讨论被关闭。就健康素养受损而言，我们认为它阻碍了通常通过沟通和信息提供来缩小临床医生与患者之间的认识差距。对健康知识的羞耻阻碍了对这一障碍的认识。其后果是，在保护个人自主权方面，它可能会降低同意的有效性。我们认为，如果在同意过程中不考虑健康知识羞耻感，就会降低患者完全控制自己选择的可能性，从而影响身体完整性。

引用次数: 0

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