Paternalism in the neonatal intensive care unit

Two factors are discussed which have important implications for the issue of paternalism in the neonatal intensive care unit (NICU): the physician's role as advocate for the patient; and the range of typical responses of parents who learn that their neonate has a serious illness. These factors are pertinent to the task of identifying those actions which are paternalistic, as well as to the question of whether paternalism is justified. It is argued that certain behavior by physicians which is often thought to be paternalistic is not in fact so. Furthermore, an argument in defense of paternalism which has largely been overlooked is presented. Examples are given to illustrate how paternalism actually arises in the NICU, and it is argued that paternalism is justified in some cases.     

Ethical dilemmas in pharmacy practice

The purpose of this study was to document the responses of pharmacy students and pharmacists to various ethical dilemmas. The responses of the first professional year students, third professional year students and pharmacists were evaluated and compared. In most instances, responses indicated a high priority for patient/client welfare. Pharmacists and students reportedly act with regard to the dignity of life, individual freedom, and an inner sense of right.     

Ethical dilemmas in forensic evaluations

Ethical issues emerging from forensic assessments are addressed from clinical and research perspectives. The relevance of agency, forensic identification, and attitudes toward defendants are explored within the framework of ethical practice. Finally, the ethical role of mental health professionals in the courtroom, the scope and basis of their testimony, and the rendering of conclusory opinions are discussed within a psycholegal context.     

Ethical care for infants with conditions not curable with intensive care

Offering intensive care 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 such care, 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 intensive care, 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.     

Premature twins on a neonatal intensive care unit

This paper presents observations of boy and girl twins on a neonatal intensive care unit, following them through from 10 days old to return home. The observer hypothesizes about the experience of the twins as they progress, based on detailed notes of their actions. The preoccupations of the parents are incorporated, as are reactions and interventions of staff. The place and possible functions of such observation by a child psychotherapist attached to such a unit are elaborated in the concluding section.     

Ethical dilemmas in context: Some preliminary questions

I have tried to build on O'Neill's thought-provoking paper by examining two influences that shape and define ethical dilemmas in the community: our personal agendas and the broader context. The first influence is the way in which our personal and professional values shape our agendas for community work. The way these agendas frame the choices for action are a force to be recognized separate from the question of who constitutes our community constituency. Our values may push us into proactive roles and we must face the way our actions make personal/political statements. The broader context of the community situation and the ways in which resource limitations frame the ethical question also need to be actively recognized. Otherwise there is a danger of making the psychologist the victim by posing the ethical dilemma as a question of how they alone should find a solution. The nature of our personal agenda must be clear before we ask “responsible to whom?” The broader context must be considered before we ask “responsible for what?”     

Ethical dilemmas in the treatment of adolescent gang members

Therapists treating adolescent gang members face unique ethical dilemmas. These dilemmas arise from clinical issues that inevitably emerge in the treatment of this population. Clinical issues related to the adolescent gang member having great difficulty trusting, having experienced and observed much violence, and usually having participated in criminal activities are central to the treatment process. In this article I discuss the ethical problems that subsequently emerge: maintaining confidentiality, discharging one's duty to warn or protect, and imposing one's personal values. Suggestions for future research are offered.     

Preterm outcomes research: a critical component of neonatal intensive care

While early preterm outcome studies described the lives of preterm survivors to justify the efforts required to save them, subsequent studies demonstrated their increased incidence of cerebral palsy, mental retardation, sensory impairments, minor neuromotor dysfunction, language delays, visual-perceptual disorders, learning disability and behavior problems compared to fullterm controls. Because infants born at the lower limit of viability require the most resources and have the highest incidence of neurodevelopmental disability, there is concern that resources have gone primarily to neonatal intensive care and are not available for meeting the followup, health, educational and emotional needs of these fragile infants and their families. Despite many methodological concerns, preterm outcome studies have provided insight into risk factors for and causes of CNS injury in preterm infants. Nevertheless, it remains difficult to predict neurodevelopmental outcome for individual preterm infants. Perinatal and neonatal risk factors are inadequate proxies for neurodevelopmental disability. Recent randomized controlled trials with one to five year neurodevelopmental followup have provided valuable information about perinatal and neonatal treatments. Recognizing adverse longterm neurodevelopmental effects of pharmacological doses of postnatal steroids is a sobering reminder of the need for longterm neurodevelopmental followup in all neonatal randomized controlled trials. Ongoing longterm preterm neurodevelopmental studies, analysis of changes in outcomes over time and among centers, and evaluation of the longterm safety, efficacy and effectiveness of many perinatal and neonatal management strategies and proposed neuroprotective agents are all necessary for further medical and technological advances in neonatal intensive care.     

Ethical dilemmas in personality assessment courses: using the classroom for in vivo training.

In this article, we argue that the student's first lessons in ethical decision making in personality assessment are in those assessment courses that have a practice component. In these courses, the student has an opportunity to experience in vivo how ethical problems are identified, addressed, and resolved. The faculty member's demonstration of a process wherein the ethical principles activated are highlighted and explored, will enable students to internalize a model for addressing future dilemmas. Four particular ethical situations are considered: (a) the students' procurement of personal experience with personality testing, (b) the identification of assessment participants, (c) the development of informed consent procedures for assessment participants, and (d) classroom presentations. This discussion does not provide concrete solutions to ethical problems but offers a consideration of the relevant ethical principles that any adequate solution must encompass.     

Ethical dilemmas of Turkish counsellors: a critical incidents study

Ethical dilemmas from a national purposive sample of Turkish counsellors (N = 172) were collected using critical incidents technique. Content analysis was performed with open coding guided by the classification of American Counseling Association code of ethics. Incidents regarding confidentiality and privacy (56.4%), with 37.1% involving incidents of reporting child sex abuse, had the highest percentage of prevalence. Dilemmas involving conflicts with school principals ranked second (16.3%), while incidents regarding dual relationships and boundaries (14%) ranked third. Implications for the development of a research-based and culturally sensitive code of counselling ethics in Turkey are discussed, and recommendations for future research are provided.     

The case of Peter: reflections on applied ethics in a neonatal intensive care unit

The case of Peter is reflected upon in order to highlight some of the moral theorising that could be brought to bear in the process of providing palliative care for sick neonates. The situation will be discussed using the theoretical lenses of deontological and virtue ethics. Nursing practice is considered as engaged moral reasoning where the nurse brings his/her beliefs, knowledge and experience into the situation and engages in reflexivity to provide appropriate ongoing patient care. The care should be provided in culturally sensitive manner and tailored to the needs of the newborn and their family. Nurses should initiate early consultations with colleagues, medical staff and families to address concerns about patient well-being in order to enhance the well-being of patients and families and to improve the work environment making it more conducive to care.     

Research as therapy, therapy as research: Ethical dilemmas in new-paradigm research

Ethical dilemmas are raised by changes in research paradigms which encourage the development of a relationship between researcher and participant. In such contexts it becomes increasingly difficult to tell the difference between a therapeutic relationship and a research interview. The rapid development of research within the therapeutic world of counselling and clinical psychology poses further ethical issues relating to the use of clients as participants in research studies. It is concluded that there must be an increased awareness of these issues and a need to accept responsibility for relationships with both participants and clients.     

Ethical issues in the application of medical technology to paediatric intensive care: two views of the newborn

Recent advances in medical technology have led to a marked improvement in the chances of survival of sick or preterm infants, thereby stimulating renewed ethical debate on the status of the newborn. Two contradictory attitudes to the medical care of preterm or congenitally malformed newborn infants can be discerned in our pluralistic society. The two attitudes have their historical roots in the classical Graeco-Roman and Judaeo-Christian ethical traditions respectively. The former views newborn infants as of potential value only whereas the latter emphasises the intrinsic worth and dignity of the individual made in God's image. Recent secular philosophical reflection has provided a rationale for infanticide of the sick or abnormal newborn. A Christian approach to the care of the newborn prohibits intentional killing yet may encompass the withdrawal of treatment that is inappropriate or unduly burdensome. Medical care should be based upon respect for the value of the individual, protection of the defenceless from abuse or exploitation, and wise stewardship of limited health-care resources.