Background: Studies show that healthcare professionals often experience ethical difficulties in their relations with patients, relatives, and other professionals and in relation to organisational issues, and these can sometimes be difficult to handle. Failing to act or to relate in accordance with one’s values for what is good and right might cause a troubled conscience that is connected to feelings of guilt and ill-being. Ethical issues related to the care of patients with end-stage renal disease have been described, but no studies in this context have been found that explore registered nurses’ (RNs’) and physicians’ experiences of being in ethically difficult situations that give rise to a troubled conscience. The importance of communicating ethical issues in order to understand and handle ethically difficult care situations has been emphasized. Various forms of clinical ethics support (CES) have been described and evaluated, but studies on the communication processes and the organisation of CES interventions are sparse and no study describing a CES intervention based on Habermas’ theory of communicative action has been found. Aim: The overall aim was to increase our understanding about being in ethically difficult care situations and about how communication concerning ethical issues in healthcare can be promoted. More specifically, the aim of studies I and II was to illuminate experiences of being in ethically difficult situations giving rise to a troubled conscience among RNs and physicians, while studies III and IV aimed to describe the communication of value conflicts (III) and the organisation and performance of a CES intervention (IV). Methods: In studies I and II narrative interviews with ten RNs (I) and five physicians (II), were performed in a dialysis care context. The interviews were analysed using a phenomenological hermeneutic approach. In studies III and IV, eight audio- and video-recorded and two audio-recorded sessions of the CES intervention, were conducted and sorted by the data tool Transana and analysed in accordance with a qualitative content analysis (III) and a qualitative concept- and data-driven content analysis (IV). Results: The RNs’ narratives (I) resulted in the theme ‘Calling for a deliberative dialogue’. Their narratives expressed feelings of uncertainty, solitude, abandonment, and guilt in complex and ambiguous ethically difficult situations. The narratives concerned the value conflict between preserving life by all means and preserving life with dignity. The physicians’ narratives (II) resulted in the themes ‘Feeling trapped in irresolution’ and ‘Being torn by conflicting demands’. Their narratives expressed feelings of uncertainty, solitude, abandonment and guilt related to the obligation to make crucial decisions and in situations when their ideals and the reality iii clashed. The analysis of the communication of value conflicts during the CES intervention inspired by Habermas’ theory of communicative action (study III) revealed a process of five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, revelation of the value conflict, enhancing realistic expectations of the patients and relatives, and seeing opportunities to change the situation instead of obstacles. The CES intervention (study IV) was organised as a framework with a given structure and an openness for variations to facilitate communicative action. Three courses of actions to reach a communicative agreement were identified and concerned the approach to achieve a permissive communication, opening up for extended views, and enhancing mutual understanding (IV). Conclusion: The results show that both RNs and physicians expressed feelings of uncertainty abandonment and loneliness in similar ethically difficult situations but from different points of view. They struggled with the same value conflicts and feelings, but they did not share their struggles with each other. The lack of communication and confirmation led to distrust and increased feelings of uncertainty. The CES intervention, inspired by Habermas’ theory of communicative action, offered the possibility of dealing with experiences of ethically difficult care situations. In the permissive atmosphere, the professionals helped each other to balance their ambiguity, frustrations, and powerlessness and came to an agreement about how to handle the value conflicts and how to act. The findings from this CES intervention constitute a step towards a CES method that is clearly described so that leaders can be educated and extended intervention studies with different kinds of data can be conducted in order to further develop knowledge about how to promote an inter-professional dialogue about ethical difficulties.

Thesis advisor: James Keenan / Environmental conservation is a pressing issue for modern humans. Health care systems and the consumption of medical goods should therefore be assessed in light of environmental sustainability. While the primary focus of environmental bioethics has been hospitals and health care facilities, ethicists must also address the offerings of the medical industry going forward. My dissertation proposes four principles to assess the environmental sustainability of current and future medical developments, techniques, and procedures. The four principles of green bioethics are: 1. General allocation of resources should precede special interest access: distributive justice 2. Current human needs over current human wants: environmental conservation 3. Simplicity before complexity: reducing dependence on medical intervention 4. The common good should drive health care instead of financial profit: ethical economics. The four principles of green bioethics will move environmental bioethics into the 21st century in a responsible and sustainable manner. / Thesis (PhD) — Boston College, 2016. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Theology.

Dream/Hope/Love/Create/Act (and back) is a collaborative arts-based research project on the experiences that support workers have with enacting support, care and education practices in the disability support and education field. Five support workers were interviewed using arts-based and collaborative methods. Conversations focused on the disciplining power that policies, systems and structures have over the support practices provided to young people labeled with an intellectual disability. Questions were formulated on support worker experiences with enacting care, behaviour support, and curriculum. The following four issues were central to the inquiry: child development and the pressure for language acquisition; issues of consent in everyday practice and clinical spaces; the creation and enactment of behaviour plans; and disability labels and the diagnosis process. The in-depth, unstructured arts-based individual and group conversations were collaboratively designed with research participants, and topics of care, support and professional ethics were intentionally politicized. Conversations took place during the creation of poetry, painting and collage to grapple with practitioners’ own power in shaping the worlds of young people. By way of experimenting with diffractive approaches to analysis, assemblages of poetry, art and theory were created as thresholds for entry into the larger thesis assemblage. Transcripts and art were analyzed while thinking with various theoretical threads from critical disability studies, feminism, queer theory, critical race theory and social justice, with the purpose of blurring and resisting harmful and normative support practices. This study shows that support workers are honouring the bodies and communications of resistance of the young people with disabilities they support. This study also shows support workers as deeply self-reflexive as they engage in critical practices in resistance to ableism. Dream/Hope/Love/Create/Act (and back) has implications for informing research, training and education that grow support work practices to become increasingly consensual and designed with and for young people with a variety of disability labels. / Graduate

<p>The intimate connection between autonomy and decision-making in applied health care, especially in various kinds of consent and refusal has taken center stage in medical ethics since the Salgo decision in 1957. Prior to that time, the physician’s supposedly moral duty to provide appropriate medical care typically surpassed the legal obligation to respect patient’s autonomy. The Salgo decision concluded that physicians have a legal duty to provide facts necessary for the patient to make an informed decision. "The doctor knows best" long ago was replaced with "The doctor proposes; the patient disposes." There is no legal obligation for the patient’s choice to be palatable to anyone, other than that patient himself/herself. Although Beauchamp and Childress justified the obligation to solicit decisions from patients and potential research subjects by the principle of respect for autonomy, they however, acknowledged that the principle’s precise demands remain unsettled and open to interpretations and specification. This thesis addresses a current debate in the bioethical community on the four-principle approach. Using Tom Beauchamp and James Childress as case study, to discuss mainly the principle of respect for autonomy, I go on to explain their central arguments concerning this principle in relation to decision making in health care ethics. Rather than focus on their respective weaknesses, which many theorist and health care professionals do, I emphasis instead on the contribution the principle of respect for autonomy can make in the process of ethical decision making in health care situation.</p>

In recent years, sentimentalist care ethics has been developed and defended as a normative ethical theory alongside and in opposition to Kantian liberalism. Carol Gilligan introduced the idea of a woman’s moral perspective that emphasizes maintaining relationships and responding to need, and saw it as a different way of framing moral issues. Care ethics is no longer associated only with women, and it is presented as a theory for both men and women that has its own distinctive accounts of ethical notions like justice and autonomy. These accounts have developed from analyses of injustice towards women and uncaring attitudes that they face in patriarchal societies, but ironically, care ethics has failed to discuss women’s anger at their own mistreatment, and their inability to deal with that anger. This notable lacuna in the care ethics literature is of philosophical importance because analyzing the phenomenon of women’s anger uncovers epistemic issues that have not been addressed. I discuss these epistemic issues in order to strengthen care ethics from within and extend it into other areas of ethics. My goal is to make care ethics a real contender among normative ethical theories and a truly feminist ethic.

The intimate connection between autonomy and decision-making in applied health care, especially in various kinds of consent and refusal has taken center stage in medical ethics since the Salgo decision in 1957. Prior to that time, the physician’s supposedly moral duty to provide appropriate medical care typically surpassed the legal obligation to respect patient’s autonomy. The Salgo decision concluded that physicians have a legal duty to provide facts necessary for the patient to make an informed decision. "The doctor knows best" long ago was replaced with "The doctor proposes; the patient disposes." There is no legal obligation for the patient’s choice to be palatable to anyone, other than that patient himself/herself. Although Beauchamp and Childress justified the obligation to solicit decisions from patients and potential research subjects by the principle of respect for autonomy, they however, acknowledged that the principle’s precise demands remain unsettled and open to interpretations and specification. This thesis addresses a current debate in the bioethical community on the four-principle approach. Using Tom Beauchamp and James Childress as case study, to discuss mainly the principle of respect for autonomy, I go on to explain their central arguments concerning this principle in relation to decision making in health care ethics. Rather than focus on their respective weaknesses, which many theorist and health care professionals do, I emphasis instead on the contribution the principle of respect for autonomy can make in the process of ethical decision making in health care situation.

Thesis (Ph. D.)--University of Washington, 1992. / Vita. Includes bibliographical references (leaves [157]-166).

Proefschrift Radboud Universiteit Nijmegen.

Made available in DSpace on 2014-12-17T15:12:12Z (GMT). No. of bitstreams: 1 HilanaCRS_DISSERT.pdf: 527997 bytes, checksum: 6a5d195240496a23303bcbe24bbd836c (MD5) Previous issue date: 2010-11-30 / To elucidate the important contribution of care ethics in improving human relations and social intimates, this work reveals the fragility and lack of ethics on the formation of a just society, equal, peaceful and caring. To this end, we study on the moral development of men and women, warning of the natural differences between the sexes, which change for both the way of seeing life and live it - which does not imply inferiority to some genres. From this study it is clear that the natural care is innate to humans, it provides a tendency to act for the good of all life forms and nature as a whole. But it is evident here a greater sensitivity of women to such care because they possess perception and more emotion than men, which make them more participatory and involved in relationships. This greater openness to care found in women, due in part to the strong and lasting relationship with their mothers. Thus is revealed the power that women have to positively change the direction of human relationships, providing careful with your example, protective and caring, the awakening of a new and comprehensive ethics - opens to the truth, and features especially for affections. Therefore, the care ethics arises from the life experiences of women and aims, through them, to join the men's morality in order to bring out the relevant fact of interdependence between human beings, of human fragility and the need for relationships to the fullness of life / Visando a elucidar a importante contribui??o da ?tica do cuidado no aperfei?oamento das rela??es humanas ?ntimas e sociais, este trabalho revela a fragilidade e insufici?ncia da ?tica atual para a forma??o de uma sociedade justa, igualit?ria, pac?fica e cuidadosa. Para tanto ? feito um estudo sobre o desenvolvimento moral de homens e mulheres, alertando para as naturais diferen?as de comportamento e pensamento existente entre os sexos, as quais modificam para ambos a maneira de ver a vida e de viv?-la - o que n?o implica em inferioridade para algum dos g?neros. Partindo desse estudo, fica claro que o cuidado natural ? inato ao humano, o que lhe propicia a tend?ncia de agir em favor do bem de todas as formas de vida e da natureza como um todo. Mas evidencia-se aqui uma sensibilidade maior das mulheres a esse cuidado por elas possu?rem percep??o e emotividade mais agu?adas que os homens, o que as tornam mais participativas e envolvidas em relacionamentos. Essa maior abertura ao cuidado encontrada na mulher, deve-se em parte ao forte e duradouro relacionamento com suas m?es. Assim, ? revelado o poder que as mulheres t?m em mudar positivamente a dire??o dos relacionamentos humanos, proporcionando com seu exemplo cuidadoso, protetor e sol?cito, o despertar de uma ampla e nova ?tica - com abertura para a verdade, para particularidades e principalmente para os afetos. Portanto, a ?tica do cuidado surge das experi?ncias de vida das mulheres e almeja, por meio delas, juntar-se ? moralidade masculina no intuito de trazer ? tona a relevante realidade da interdepend?ncia entre os seres, da fragilidade humana e a necessidade das rela??es afetivas para a plenitude da vida

L’objectif de ce travail est d’examiner les tensions dans la relation entre infirmier et patient à la lumière de la notion de service, dans le contexte français. Le terme même de service renvoie à modalités diverses de liens interpersonnels : don, contrat, et de subordination ou encore de sollicitude. La profession infirmière se situe au carrefour de logiques médicales et administratives au sein de l’institution hospitalière. Si le service qu’elle rend est largement reconnu par la population, le contenu même de sa prestation reste méconnu, laissant ainsi son autonomie professionnelle en perpétuel devenir.Une tensions qui accompagne l’histoire de cette profession est d’être tantôt identifiée en tant que groupe habilité à accomplir certains actes, tantôt en tant que discipline procurant un service particulier à la population, mais dont le contenu reste encore imprécis. Les enjeux et les réformes du service hospitalier ont pour objectifs une plus grande transparence, une demande de rentabilité accrues ainsi que l’évaluation de la satisfaction des destinataires. Ces objectifs s’adressent également au service infirmier et à la relation de service entre infirmier et patient. Ils rendent plus complexes et contradictoires entre elles les orientations de prise en soin du patient par l’infirmier. Nous souhaitons contribuer à la compréhension des changements que la profession infirmière est en train de vivre. Le passage d’une vision du soin comme action bienfaitrice qui trouve sa justification en lui-Même, vers le soin comme «prestation-Produit» doit expliciter son bien-Fondé et sa finalité en incluant une visée éthique. / The main topic of this research is to identify the tensions between nurses and patients from a service relation perspective, in French hospital. The concept of service contains several meanings related to interpersonal relations: unselfish donation, contractual exchange, subordinate professional position or caring relationships. The nursing profession has arrived at an important turning point in its history. While its duty and image are very popular and well considered, its actual tasks and clinical analysis as disciplinary knowledge, is still underestimated. The recent reforms in the health care system promote patient autonomy and open information from healthcare practitioners, global effective administration system and costumer satisfaction. Nursing teams are therefore subjected to contradictory injunctions that will be explored in this manuscript: acting in patient’s best interest and following medical instructions and respecting hospital regulations. This fieldwork contributes to a better understanding of nursing care problems on a daily base. This research tends to demonstrate how nursing care has to deal with problems that are similar to those of the medical profession: the importance of patient information and patient consent, clients complaints management, and satisfaction as a new objective in nursing. Nursing care has been traditionally considered as motivated by charity and altruism. As a work and a service, nursing care has to demonstrate its efficiency and its results. This involves ethical questions such as: emotional work considered as a competence or informed consent considered as a target