How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety.

BACKGROUND: Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. METHODS: We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. RESULTS: We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. CONCLUSION: Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout.

An unintended consequence of COVID-19 immunity passports-quasi-experimental evidence of moral hazard observed after implementing the domestic Green Pass policy during the second wave of the COVID-19 pandemic in Italy.

Objectives: Amidst the second wave of the COVID-19 pandemic, Italian policymakers mandated to exhibit evidence of vaccination or immunity (the Green Pass) as a condition to access retail premises and public offices. This study aims to offer evidence, in a quasi-experimental setting, suggesting that an unintended consequence of this policy was the emergence of moral hazard. Methods: Google visit duration data measured the time customers typically spend on retail premises or public offices. A pairwise comparison of median visit time per premise was performed at a six-week interval before and after the introduction of the Green Pass. Results: This study is the first to provide evidence of "ex-post" moral hazard associated with introducing a domestic Green Pass policy. The median visiting time on premises that required digital immunity control significantly increased after introducing the domestic Green Pass policy, contrary to other public premises where access remained free of limitations. The increase in median visit time in premises with faster customer turnaround, such as coffee shops (+49%) and fast-food restaurants (+45%), was lower than the increase observed for fine-dining restaurants (+74%) and pizzerias (+163%). No significant increase in median visit time was observed in premises where the Green Pass was not required, such as food supermarkets, retail non-food shops, post offices, banks, pharmacies, and gas stations. Conclusion: The evidence of moral hazard highlights the critical issue of unintended consequences stemming from public health policies. This discovery is pivotal for policymakers, indicating that unforeseen behavioral adjustments could offset the intended benefits despite the intent to reduce risk through measures like the Green Pass.

Sophie de Grouchy's Political Thought in the Letters on Sympathy (1798).

This article proposes a reading of Sophie de Grouchy's moral, political, and economic thought as embedded in the tradition of natural jurisprudence, adapted to the context of the French First Republic. A close reading of her French translation of Adam Smith's Theory of Moral Sentiment and her eight Letters on Sympathy confirms that there are points to be made by reading her works in the context of the language of early modern natural law. This sheds light on the important question of how to read revolutionary republicanism emanating from multiple traditions other than the neo-Roman discourse of non-domination.

Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation.

BACKGROUND: Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. METHOD: Based on experiences and research into MCD facilitators' needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. RESULTS: The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. CONCLUSIONS: This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools.

Nostalgia increases punitiveness by intensifying moral concern.

We addressed the relation between nostalgia and moral judgment or behavior. We hypothesized that nostalgia, a social emotion, increases moral concern (H1), nostalgia intensifies punitiveness against moral transgressors (H2), and that the nostalgia-punitiveness link is mediated by moral concern (H3). We conducted three cross-sectional (Studies 1, 2, 4) and one experimental (Study 3) investigations (N = 1145). The investigations, involving distinct operationalizations of the relevant constructs (nostalgia, moral concern, punitiveness) and diverse samples (U.S., Canadian, and European Prolific workers, French business school students, Dutch community members), yielded results consistent with the hypotheses. Nostalgia keeps one's moral compass in check. The findings enrich the emotions and morality literatures.

Moral foundations in autistic people and people with systemizing minds.

BACKGROUND: Do autistic people share the same moral foundations as typical people? Here we built on two prominent theories in psychology, moral foundations theory and the empathizing-systemizing (E-S) theory, to observe the nature of morality in autistic people and systemizers. METHODS: In dataset 1, we measured five foundations of moral judgements (Care, Fairness, Loyalty, Authority, and Sanctity) measured by the Moral Foundations Questionnaire (MFQ) in autistic (n = 307) and typical people (n = 415) along with their scores on the Empathy Quotient (EQ) and Systemizing Quotient (SQ). In dataset 2, we measured these same five foundations along with E-S cognitive types (previously referred to as "brain types") in a large sample of typical people (N = 7595). RESULTS: Autistic people scored the same on Care (i.e., concern for others) as typical people (h1). Their affective empathy (but not their cognitive empathy) scores were positively correlated with Care. Autistic people were more likely to endorse Fairness (i.e., giving people what they are owed, and treating them with justice) over Care (h2). Their systemizing scores were positively correlated with Fairness. Autistic people or those with a systemizing cognitive profile had lower scores on binding foundations: Loyalty, Authority, and Sanctity (h3). Systemizing in typical people was positively correlated with Liberty (i.e., hypervigilance against oppression), which is a sixth moral foundation (h4). Although the majority of people in all five E-S cognitive types self-identified as liberal, with a skew towards empathizing (h5), the percentage of libertarians was highest in systemizing cognitive types (h6). E-S cognitive types accounted for 2 to 3 times more variance for Care than did sex. LIMITATIONS: Our study is limited by its reliance on self-report measures and a focus on moral judgements rather than behavior or decision-making. Further, only dataset 2 measured political identification, therefore we were unable to assess politics in autistic people. CONCLUSIONS: We conclude that some moral foundations in autistic people are similar to those in typical people (despite the difficulties in social interaction that are part of autism), and some are subtly different. These subtle differences vary depending on empathizing and systemizing cognitive types.

Pulling the lever in a hurry: the influence of impulsivity and sensitivity to reward on moral decision-making under time pressure.

BACKGROUND: Making timely moral decisions can save a life. However, literature on how moral decisions are made under time pressure reports conflicting results. Moreover, it is unclear whether and how moral choices under time pressure may be influenced by personality traits like impulsivity and sensitivity to reward and punishment. METHODS: To address these gaps, in this study we employed a moral dilemma task, manipulating decision time between participants: one group (N = 25) was subjected to time pressure (TP), with 8 s maximum time for response (including the reading time), the other (N = 28) was left free to take all the time to respond (noTP). We measured type of choice (utilitarian vs. non-utilitarian), decision times, self-reported unpleasantness and arousal during decision-making, and participants' impulsivity and BIS-BAS sensitivity. RESULTS: We found no group effect on the type of choice, suggesting that time pressure per se did not influence moral decisions. However, impulsivity affected the impact of time pressure, in that individuals with higher cognitive instability showed slower response times under no time constraint. In addition, higher sensitivity to reward predicted a higher proportion of utilitarian choices regardless of the time available for decision. CONCLUSIONS: Results are discussed within the dual-process theory of moral judgement, revealing that the impact of time pressure on moral decision-making might be more complex and multifaceted than expected, potentially interacting with a specific facet of attentional impulsivity.

WE economy: Potential of mutual aid distribution based on moral responsibility and risk vulnerability.

Reducing wealth inequality is a global challenge that requires the transformation of the economic systems that produce inequality. The economic system comprises: (1) gifts and reciprocity, (2) power and redistribution, (3) market exchange, and (4) mutual aid without reciprocal obligations. Current inequality stems from a capitalist economy consisting of (2) and (3). To sublimate (1), the human economy, to (4), the concept of a "mixbiotic society" has been proposed in the philosophical realm. In this society, free and diverse individuals mix, recognize their respective "fundamental incapability," and sublimate them into "WE" solidarity. Moreover, the economy must have a moral responsibility as a co-adventurer and consider its vulnerability to risk. This study focuses on two factors of mind perception-moral responsibility and risk vulnerability-and proposes a novel wealth distribution model between the two agents following an econophysical approach, whereas the conventional model dealt with redistribution through taxes and institutions. Three models are developed: a joint-venture model in which profit/losses are distributed based on their factors, a redistribution model in which wealth stocks are redistributed periodically based on their factors in the joint-venture model, and a "WE economy" model in which profit/losses are distributed based on the ratio of each other's factors. A simulation comparison reveals that WE economies are effective in reducing inequality, resilient in normalizing wealth distribution as advantages, and susceptible to free riders as disadvantages. However, this disadvantage can be compensated for by fostering fellowship and using joint ventures. This study presents the effectiveness of moral responsibility and risk vulnerability, complementarity between the WE economy and joint economy, and the direction of the economy in reducing inequality. Future challenges include developing an advanced model based on real economic analysis and economic psychology and promoting its fieldwork for worker coops and platform cooperatives to realize a desirable mixbiotic society.

Restore and Rebuild (R&R): a protocol for a phase 2, randomised control trial to compare R&R as a treatment for moral injury-related mental health difficulties in UK military veterans to treatment as usual.

BACKGROUND: Exposure to potentially morally injurious events is increasingly recognised as a concern across a range of occupational groups, including UK military veterans. Moral injury-related mental health difficulties can be challenging for clinicians to treat and there is currently no validated treatment available for UK veterans. We developed Restore and Rebuild (R&R) as a treatment for UK veterans struggling with moral injury-related mental health difficulties. This trial aims to examine whether it is feasible to conduct a pilot randomised controlled trial (RCT) of R&R treatment compared with a treatment-as-usual (TAU) control group. METHODS: We will use a feasibility single-blind, single-site RCT design. The target population will be UK military veterans with moral injury-related mental health difficulties. We will recruit N=46 veteran patients who will be randomly allocated to R&R (n=23) or TAU (n=23). Patients randomised to R&R will receive the 20-session one-to-one treatment, delivered online. Veterans allocated to TAU, as there are currently no manualised treatments for moral injury-related mental health problems available, will receive the one-to-one treatment (online) typically provided to veterans who enter the mental health service for moral injury-related mental health difficulties. We will collect outcome measures of moral injury, post-traumatic stress disorder (PTSD), alcohol misuse, common mental disorders and trauma memory at pretreatment baseline (before randomisation), end of treatment, 12 weeks and 24 weeks post-treatment. The primary outcome will be the proportion of patients who screen positive for PTSD and moral injury-related distress post-treatment. ETHICS AND DISSEMINATION: This trial will establish whether R&R is feasible, well-tolerated and beneficial treatment for veterans with moral injury-related mental health difficulties. If so, the results of the trial will be widely disseminated and R&R may improve access to effective care for those who struggle following moral injury and reduce the associated negative consequences for veterans, their families and wider society. TRIAL REGISTRATION NUMBER: ISRCTN99573523.

A preliminary epistemological ″human ecology″ framework for understanding the limits of bioethics.

This article tries to set up the epistemological bases of the science of ″human ecology″. This term has started to be used as a synonymous of morality, especially in the Catholic moral social doctrine that used for the first time to justify its marriage prospectives. We look at both terms together (human plus ecology) and we propose that human ecology should be a discipline that in the first time study human behavior and population (objective) using the postulates of the science of ecology (method) and then, once a conceptual framework for social sciences disciplines such as bioethics can be settle, could be used as a way to support or not moral postulates in the name of ecology. We conclude by defining which should be the methods of knowledge acquisition, the limits and the validity of what should be considered ″Human ecology″, that is to say, the ecology of the humans.

Cardiac organoids do not warrant additional moral scrutiny.

Certain organoid subtypes are particularly sensitive. We explore whether moral intuitions about the heartbeat warrant unique moral consideration for newly advanced contracting cardiac organoids. Despite the heartbeat's moral significance in organ procurement and abortion discussions, we argue that this significance should not translate into moral implications for cardiac organoids.

Understanding psychological outcomes following exposure to potentially morally injurious events in animal care: development of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals.

AIMS: To generate a taxonomy of potentially morally injurious events (PMIE) encountered in veterinary care and develop an instrument to measure moral distress and posttraumatic growth following exposure to PMIE in the veterinary population. METHODS: Development and preliminary evaluation of the Moral Distress-Posttraumatic Growth Scale for Veterinary Professionals (MD-PTG-VP) employed data from veterinary professionals (veterinarians, veterinary nurses, veterinary technicians) from Australia and New Zealand across three phases: (1) item generation, (2) content validation, and (3) construct validation. In Phase 1 respondents (n = 46) were asked whether they had experienced any of six PMIE and to identify any PMIE not listed that they had experienced. In Phase 2 a different group of respondents (n = 11) assessed a list of 10 PMIE for relevance, clarity and appropriateness. In Phase 3 the final instrument was tested with a third group of respondents (n = 104) who also completed the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT), a measure of posttraumatic stress, and the Stress-Related Growth Scale-Short Form (SRGS-SF) a measure of perceived posttraumatic growth. Spearman's correlation coefficients were calculated between respondent scores on each of the MD-PTG-VP subscales, the SPRINT, and the SRGS-SF to assess construct validity. RESULTS: A 10-item taxonomy of PMIE encountered in veterinary care was generated in Phase 1. Items were deemed relevant, clear and appropriate by veterinary professionals in Phase 2. These were included in the developed instrument which measures frequency and impact of exposure to 10 PMIE, yielding three subscale scores (exposure frequency, moral distress, and posttraumatic growth). Assessment of construct validity by measuring correlation with SPRINT and SRGS-SF indicated satisfactory validity. CONCLUSIONS: The MD-PTG-VP provides an informative tool that can be employed to examine professionals' mental health and wellbeing following exposure to PMIE frequently encountered in animal care. Further evaluation is required to ascertain population norms and confirm score cut-offs that reflect clinical presentation. CLINICAL RELEVANCE: Once fully validated this instrument may be useful to quantify the frequency and intensity of positive and negative aspects of PMIE exposure on veterinary professionals so that accurate population comparisons can be made and changes measured over time.

Measuring moral distress in health professionals using the MMD-HP-SPA scale.

BACKGROUND: Moral distress (MD) is the psychological damage caused when people are forced to witness or carry out actions which go against their fundamental moral values. The main objective was to evaluate the prevalence and predictive factors associated with MD among health professionals during the pandemic and to determine its causes. METHODS: A regional, observational and cross-sectional study in a sample of 566 professionals from the Public Health Service of Andalusia (68.7% female; 66.9% physicians) who completed the MMD-HP-SPA scale to determine the level of MD (0-432 points). Five dimensions were used: i) Health care; ii) Therapeutic obstinacy-futility, iii) Interpersonal relations of the Healthcare Team, iv) External pressure; v) Covering up of medical malpractice. RESULTS: The mean level of MD was 127.3 (SD=66.7; 95% CI 121.8-132.8), being higher in female (135 vs. 110.3; p<0.01), in nursing professionals (137.8 vs. 122; p<0.01) and in the community setting (136.2 vs. 118.3; p<0.001), with these variables showing statistical significance in the multiple linear regression model (p<0.001; r2=0.052). With similar results, the multiple logistic regression model showed being female was a higher risk factor (OR=2.27; 95% CI 1.5-3.4; p<0.001). 70% of the sources of MD belonged to the dimension "Health Care" and the cause "Having to attend to more patients than I can safely attend to" obtained the highest average value (Mean=9.8; SD=4.9). CONCLUSIONS: Female, nursing professionals, and those from the community setting presented a higher risk of MD. The healthcare model needs to implement an ethical approach to public health issues to alleviate MD among its professionals.

The sociocultural influences in Lawrence Kohlberg's life: a psychobiography.

Lawrence Kohlberg (1927-1987) was a moral development specialist and moral teacher. He is considered an exceptional individual due to the success he obtained from developing his Theory of Moral Development. Throughout Kohlberg's life, there was a reciprocal influence between Kohlberg's development and the sociocultural influences of his time, guiding his life story. This psychobiography used a longitudinal, single-case research design from the qualitative paradigm, utilising the descriptive-interpretive approach to explore the influences which shaped major life events in Kohlberg's life. This research design enabled the illumination of how sociocultural circumstances shaped various spheres in Kohlberg's life, such as his identity, education, career path and vocational success. This was done through using Bronfenbrenner's Bioecological Theory of Human Development Framework, by including its enmeshed, most up-to-date scientific research design, the Proximal-Person-Context-Time Model.

Reciprocity in ambiguous situations: Default psychological strategies underlying ambiguity resolution in moral decision-making.

When deciding whether to reciprocate trust, people are typically strongly influenced by how much trust their interaction partner has originally shown them. If a partner has placed a lot of trust in you, there is a strong motivation to reciprocate, and indeed this factor often outweighs pro-self considerations to maximize one's own financial payout. However, one important unanswered question in this regard is what people decide to do when this prior information is ambiguous; that is, when they do not know for sure exactly how trusting their partner has been. How then do people decide to reciprocate? This study utilizes a novel version of the Trust Game to directly address this question. Here, we develop, and validate, a computational model-based approach to quantify and categorize how participants assessed the trustworthiness of an unfamiliar partner when making reciprocity decisions. We find that participants spontaneously use their prior experience about the trustingness of game partners in general to inform their reciprocity decisions, even when they had the opportunity to strategically assume that their new, unfamiliar, partners were untrusting, and hence could have justified lower reciprocation rates.

The impact of volunteer service on moral education performance and mental health of college students.

BACKGROUND: Moral education in colleges and universities is an important part of the talent training system, including moral education curriculum, moral education practice, mental health education. Volunteer service is a public welfare act in which volunteers volunteer their time, knowledge, property, technology, with the ultimate goal of helping others and serving the society without personal compensation. As an innovative form of moral education practice in colleges and universities, college students' voluntary service is of great significance in promoting the reform and innovation of moral education, enhancing the affinity, appeal and influence of moral education, and building a positive psychology for college students. SUBJECTS AND METHODS: As an effective carrier of moral education practice in colleges and universities, voluntary service is helpful to enhance the effectiveness of moral education practice and construct the positive psychology of college students. This project is based on the actual situation of college students participating in volunteer services, and collected the volunteer services of 4545 college students in Zhejiang Province. Through model construction and data modeling, the correlation between college students' participation in volunteer service and their moral education performance and mental health was analyzed, and the basic path and guarantee measures to promote the role of volunteer service in moral education and positive psychological construction were deeply explored. RESULTS: From the correlation analysis of students' voluntary service participation, moral education performance and voluntary service motivation, students' attributes are determined according to their voluntary service participation, so as to predict their moral education performance and mental health level. CONCLUSION: College students' voluntary service is partially positively related to their moral education performance and mental health. In order to improve students' moral education performance and mental health, we can optimize the participation frequency, participation duration, participation ways and type structure of voluntary service, constantly increase the participation frequency of voluntary service, increase the duration of voluntary service, broaden the participation ways of voluntary activities, and enrich the types of voluntary service activities.

What keeps you up at night? Moral distress in nurse leaders in the USA, Germany, Austria and Switzerland.

PURPOSE: Nurse leaders are challenged by ethical issues in today's complex health-care settings. The purpose of this study was to describe and analyze key elements of moral distress identified by nurse leaders from health-care systems in the USA, Germany, Austria and Switzerland. The aim was to develop an understanding of distressing ethical issues nurse leaders face in the USA and three German-speaking European countries. DESIGN/METHODOLOGY/APPROACH: This descriptive cross-sectional study surveyed a convenience sample of nurse leaders in the USA, Germany, Austria and Switzerland. The voluntary, anonymous survey also included qualitative questions and was distributed using the Qualtrics® platform. A thematic analysis of the qualitative data in each country was carried out and a comparative analysis identified similarities and differences between the groups of nurse leaders comparing the US data to that from three German-speaking European countries. FINDINGS: The survey was completed by 316 nurse leaders: Germany, Austria, and Switzerland (n = 225) and the USA (n = 91). Similar themes identified as causing all nurse leaders moral distress included a lack of individual and organizational integrity, hierarchical and interprofessional issues, lack of nursing professionalism, patient care/patient safety concerns, finances negatively impacting care and issues around social justice. Within these six themes, there were also differences between the USA and the three German-speaking European countries. ORIGINALITY/VALUE: Understanding the experiences associated with distressing ethical situations can allow nurse leaders and organizations to focus on solutions and develop resilience to reduce moral distress in the USA and three German-speaking European countries.

[Relationship between Moral Concerns and Problem-Solving Behaviors for Outpatient Nurses Working in Palliative Care Accredited Educational Facilities].

The purpose of this study was to examine the moral concerns and problem-solving behavior for outpatient nurses in palliative cancer care. The target of this study was 284 outpatient nurses(22.9%)out of 1,241 respondents. As a result, it was concluded that outpatient nurses providing palliative cancer care have higher ethical concerns than nurses working in acute care hospitals. In addition, the more moral concerns there were, the more nurses manage their care according to patient's individual circumstances. In the future, it is necessary to provide education on the moral concerns of outpatient nurses and the problem-solving behavior for nurses so that patients in the final stages of life and their families can spend a better time.