Ethics of caring and the institutional ethics committee

Institutional ethics committees (lECs) in health care facilities now create moral policy, provide moral education, and consult with physicians and other health care workers. After sketching reasons for the development of IECs, this paper first examines the predominant moral standards it is often assumed lECs are now using, these standards being neo-Kantian principles of justice and utilitarian principles of the greatest good. Then, it is argued that a feminine ethics of care, as posited by Carol Gilligan and Nel Noddings, is an unacknowledged basis for /EC discussions and decisions. Further, it is suggested that feminine ethics of care can and should provide underlying theoretical tools and standards for lECs.     

TWENTY YEARS OF RESEARCH ON ROLE-MOTIVATION THEORY OF MANAGERIAL EFFECTIVENESS

Research related to the various hypotheses of managerial role-motivation theory is reviewed. In general this research supports the theory, although there are numerous areas that require further investigation. A total of 21 studies have been conducted to test the theory's validity and all have yielded significant results; 5 of these studies are predictive. Similar studies conducted outside the theoretical domain have uniformly failed to produce significant findings. Research carried out to evaluate the effectiveness of managerial role motivation training has indicated positive effects in 16 of 17 instances, and the construct validity of the primary measure used to operationalize the theory's variables, the Miner Sentence Completion Scale, has been established in relation to a number of other instruments. Relationships to other theories of motivation and leadership are considered, suggestions for future research are presented, and certain proposals for theoretical extensions are set forth.     

卫生保健政策与医学伦理学

卫生保健政策是卫生资源、价值目标和伦理原则三者的结合。医学伦理学是卫生政策的重要基础。当代卫生事业的特点,卫生保健服务面临的挑战以及医学伦理主体与客体的变化,决定了医学伦理学在当代卫生保健政策中的特殊意义。在医学面临全民保健的阶段,一个科学的符合人民健康利益的卫生保健政策是不言而喻的。摆脱当前卫生政策面临的困难,要求必须在医学伦理学方面作出正确的选择。     

Moral responsibility and respect for autonomy: meeting the communitarian challenge.

The principle of respect for autonomy has come under increasing attack both within health care ethics, specifically, and as part of the more general communitarian challenge to predominantly liberal values. This paper will demonstrate the importance of respect for autonomy for the social practice of assigning moral responsibility and for the development of moral responsibility as a virtue. Guided by this virtue, the responsible exercise of autonomy may provide a much-needed connection between the individual and the community.     

Organizational ethics in Catholic health care: honoring stewardship and the work environment.

Organizational ethics refers to the integration of values into decision making, policies, and behavior throughout the multi-disciplinary environment of a health care organization. Based upon Catholic social ethics, stewardship is at the heart of organizational ethics in health care in this sense: stewardship provides the hermeneutic filter that enables basic ethical principles to be realized practically, within the context of the Catholic theology of work, to concerns in health care. This general argument can shed light on the specific topic of non-executive compensation programs as an illustration of organizational ethics in health care.     

A Code of Ethics for Health Care Ethics Consultants: Journey to the Present and Implications for the Field

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.     

深化卫生事业改革应关注卫生经济伦理学研究

卫生经济伦理学是应用伦理学的一个分支,相对于经济学和卫生经济学的发展,卫生经济伦理学的建立和发展滞后,导致卫生经济体制改革的经济效果与社会效果的一定程度的偏离。卫生经济伦理学的理论前提是社会结构变迁要求各个相对独立社会领域的规则整合,其研究任务是为社会经济主体的行为提供一个规范性的评判,实现社会的和谐发展。     

Diagnosis by Documentary: Professional Responsibilities in Informal Encounters

Most work addressing clinical workers' professional responsibilities concerns the norms of conduct within established professional–patient relationships, but such responsibilities may extend beyond the clinical context. We explore health workers' professional responsibilities in such “informal” encounters through the example of a doctor witnessing the misdiagnosis and mistreatment of a serious long-term condition in a television documentary, arguing that neither internalist approaches to professional responsibility (such as virtue ethics or care ethics) nor externalist ones (such as the “social contract” model) provide sufficiently clear guidance in such situations. We propose that a mix of both approaches, emphasizing the noncomplacency and practical wisdom of virtue ethics, but grounding the normative authority of virtue in an external source, is able to engage with the health worker's responsibilities in such situations to the individual, the health care system, and the population at large.     

Fulfilling institutional responsibilities in health care: organizational ethics and the role of mission discernment

In this paper we highlight the emergence of organizational ethics issues in health care as an important outcome of the changing structure of health care delivery. We emphasize three core themes related to business ethics and health care ethics: integrity, responsibility, and choice. These themes are brought together in a discussion of the process of Mission Discernment as it has been developed and implemented within an integrated health care system. Through this discussion we highlight how processes of institutional reflection, such as Mission Discernment, can help health care organizations, as well as corporations, make critical choices in turbulent environments that further the core mission and values and fulfill institutional responsibilities to a broad range of stakeholders.     

Health Care Ethics Consultation: 'Training in Virtue'

In philosophy, intelligence is less important than character, or so Wittgenstein once argued. In this paper, in a similar vein, I suggest that in health care ethics consultation character is of preeminent importance. I suggest that the activity of ethics consultation can be understood as "training in virtue," and what distinguishes the good health care ethics consultant from his/her average colleague are differences in traits of character. The underlying assumption is that one's use of knowledge and abilities are ultimately a function of who one is and how one perceives and confronts situations of moral uncertainty and conflict. In discussing the original case presented by Mark Bliton, I focus on the virtues of wisdom, justice, courage, compassion and humility.     

Medical Ethics Research Between Theory and Practice

The main object of criticism of present-day medical ethics is the standard view of the relationship between theory and practice. Medical ethics is more than the application of moral theories and principles, and health care is more than the domain of application of moral theories. Moral theories and principles are necessarily abstract, and therefore fail to take account of the sometimes idiosyncratic reality of clinical work and the actual experiences of practitioners. Suggestions to remedy the illnesses of contemporary medical ethics focus on re-establishing the connection between the internal and external morality of medicine. This article discusses the question how to develop a theoretical perspective on medical ethical issues that connects philosophical reflection with the everyday realities of medical practice. Four steps in a comprehensive approach of medical ethics research are distinguished: (1) examine health care contexts in order to obtain a better understanding of the internal morality of these practices; this requires empirical research; (2) analyze and interpret the external morality governing health care practices; sociological study of prevalent values, norms, and attitudes concerning medical-ethical issues is required; (3) creation of new theoretical perspectives on health care practices; Jensen's theory of healthcare practices will be useful here; (4) develop a new conception of bioethics that illuminates and clarifies the complex interaction between the internal and external morality of health care practices. Hermeneutical ethics can be helpful for integrating the experiences disclosed in the empirical ethical studies, as well as utilizing the insights gained from describing the value-contexts of health care practices. For a critical and normative perspective, hermeneutical ethics has to examine and explain the moral experiences uncovered, in order to understand what they tell us.     

Health Care Chaplains and their Role on Institutional Ethics Committees: An Australia Study

This paper presents the results of the largest Australian pastoral study concerning the perceptions of health care chaplains about their involvement on hospital research ethics committees (also known in some contexts as institutional ethics committees). Survey results from over 300 Australian health care chaplains indicated that nearly 90% of chaplains believed there was merit in chaplains serving on hospital research ethics committees, yet only a minority (22.7%) had ever participated on such committees. Data from in-depth interviews is also presented exploring the reasons for the lack of participation and the varying opinions regarding the role, appropriateness, and value of chaplains on ethics committees. Some implications of this study with respect to chaplaincy, hospital research ethics committees, health care institutions, ecclesiastical institutions, and government responsibilities are discussed.     

Building a practically useful theory of goal setting and task motivation. A 35-year odyssey

The authors summarize 35 years of empirical research on goal-setting theory. They describe the core findings of the theory, the mechanisms by which goals operate, moderators of goal effects, the relation of goals and satisfaction, and the role of goals as mediators of incentives. The external validity and practical significance of goal-setting theory are explained, and new directions in goal-setting research are discussed. The relationships of goal setting to other theories are described as are the theory's limitations.     

医生执业特点引发的心理变化对医患关系的影响

近年来医患关系紧张成了一个社会热点问题.医生在执业过程中,可能受到一些内在心理因素的影响.通过对医生的执业特点及其引发的心理变化进行分析,包括工作压力、职业倦怠、风险、收入、伦理、信心等,试图寻找引起医患关系紧张的医生内在思想问题.通过这些问题的解决以期达到改善医患关系,增进卫生事业发展的目的.     

The clinical ethicist at the bedside

In this paper we attempt to show how the goal of resolving moral problems in a patient's care can best be achieved by working at the bedside. We present and discuss three cases to illustrate the art and science of clinical ethics consultation. The sine qua non of the clinical ethics consultant is that he or she goes to the patient's bedside to obtain specific clinical and ethical information. Unlike ethics committees, which often depend on secondhand information from a physician or nurse, clinical ethics consultants personally speak with and examine patients and review their laboratory data and medical records. The skills of the clinical ethics consultant include the ability to delineate and resolve ethical problems in a particular patient's case and to teach other health professionals to build their own frameworks for clinical ethical decision making. When the clinical situation requires it, clinical ethics consultants can and should assist primary physicians with case management.     

Behavioral Health Consultation and Primary Care: Lessons Learned

This article provides an overview of 20 years of professional experiences with developing and implementing a model for integrating behavioral health services into primary care. The Primary Care Behavioral Health (PCBH) model is designed to provide immediate access to behavioral care for a large number of primary care patients by positioning a behavioral health consultant in the exam room area to function as a core member of the primary care team. In an initial era of discovery, the authors were directly involved in developing and testing a variety of new approaches to providing behavioral health services in general medicine. In a second era focused on feasibility, the authors worked with Kaiser Permanente, the United States Air Force and Navy, the Veteran’s Administration, and the Bureau of Primary Care to system test this innovative model of integrated care. Now in an era devoted to dissemination, the authors review the various roles formal research, system level quality improvement initiatives and stakeholder analysis play in promoting integrated care. The authors also describe current efforts to (1) create a tool that helps systems develop integration targets and (2) use the PCBH model as a platform for teaching medical residents and behavioral health providers to work together in a redesigned primary care team model.     

论公共卫生决策的伦理模式

公共卫生决策的伦理问题是公共卫生伦理研究的一个核心问题。近年来我国公共卫生领域出现了大量严重的伦理问题,其主要根源在于公共卫生决策的伦理缺失。强调指出公共卫生伦理决策应当树立科学健康观,并以此为基础,从转变政府职能、强化公共卫生信息系统和加大政府投入等方面详细论述了公共卫生伦理决策的一种新模式。     

Threats to Moral Identity: Testing the Effects of Incentives and Consequences of One's Actions on Moral Cleansing

Individuals engage in moral cleansing, a compensatory process to reaffirm one's moral identity, when one's moral self-concept is threatened. However, too much moral cleansing can license individuals to engage in future unethical acts. This study examined the effects of incentives and consequences of one's actions on cheating behavior and moral cleansing. Results found that incentives and consequences interacted such that unethical thoughts were especially threatening, resulting in more moral cleansing, when large incentives to cheat were present and cheating explicitly harmed others. Implications are discussed in terms of ethics training, using incentives as motivators, and the depersonalized norms of science.