Fatores clínicos do bem-estar de mulheres em parturição: perspectivas deontológicas e da bioética principialista / Clinical factors of women in labor well-being: deontological and bioethical principlism perspectives / Factores clínicos del bienestar de la mujer en trabajo de parto: perspectivas deontológicas y de la bioética principialista

Objetivo: avaliar os fatores clínicos associados ao bem-estar das mulheres durante o trabalho de parto e parto à luz da bioética principialista e da deontologia. Método: estudo transversal com abordagem quantitativa. Participaram 396 puérperas internadas em um hospital municipal do sudoeste da Bahia, e os dados foram coletados no período de janeiro a maio de 2023, após aprovação do comitê de ética em pesquisa. Os dados foram organizados no software Excel e analisados via SPSS v.25. a partir da regressão logística multinomial. Resultados: a maior parte da amostra apresentou bem-estar com assistência em saúde, mulheres que tiveram parto realizado por profissionais não médicos apresentaram mais chances de níveis de bem-estar "adequado". E mulheres que não tiveram a via de parto cesárea apresentaram aumento de chances de bem-estar. Conclusão: é necessário que os profissionais reflitam sobre suas ações, condicionando-as à humanização no parto, em observância aos princípios bioéticos.

Objective: to evaluate the clinical factors associated with women's well-being during labor and delivery in the light of bioethics principlism and deontology. Method: a cross-sectional study with a quantitative approach was conducted. It involved 396 postpartum women admitted to a municipal hospital in the southwest of Bahia. Data were collected from January to May 2023, after approval from the research ethics committee. The data were tabulated using Excel software and analyzed using SPSS v.25 through Multinomial Logistic Regression. Results: majority of the sample exhibited well-being with health care assistance. Women who underwent delivery performed by non-medical professionals showed higher chances of "adequate" levels of well-being. Additionally, women who did not undergo cesarean delivery showed increased chances of well-being. Conclusion: It is necessary for professionals to reflect on their actions, conditioning them to the humanization of childbirth, according to bioethical principles.

Objetivo: evaluar los factores clínicos asociados al bienestar de la mujer durante el trabajo de parto y parto a la luz de la bioética y la deontología principialista. Método: estudio transversal con enfoque cuantitativo. Incluyó 396 puérperas ingresadas en un hospital municipal del suroeste de Bahía. Recolección de datos de enero a mayo de 2023, con aprobación del comité de ética en investigación. Los datos se tabularon en el software Excel y se analizaron mediante SPSS v.25. utilizando regresión logística multinomial. Resultados: la mayoría de las participantes de la muestra presentó bienestar con la atención para la salud; las que tuvieron partos realizados por profesionales no médicos tenían más probabilidades de tener niveles "adecuados" de bienestar; las que no tuvieron parto por cesárea tenían mayores probabilidades de tener bienestar. Conclusión: es necesario que los profesionales reflexionen sobre sus acciones y las adecuen para humanizar el parto, respetando los principios bioéticos.

Palliative care as a Fundamental Human Right: where are we at in Italy?

Abstract: The right to live with dignity during the final stages of existence, enshrined in national and supranational Charters of Rights, represents a significant step towards humanizing medicine and is integral to the right to health. Palliative Care, rooted in health, dignity, and therapeutic self-determination, has emerged as a fundamental human right and a moral imperative within health systems. It seeks to alleviate suffering, emphasizing the holistic well-being of patients with life-limiting illnes-ses. This paper provides an analysis of the current situation of Palliative Care in Italy and examines its critical aspects, also in relation to the issues found in other European and non-European countries. In Italy, although laws have been enacted to ensure the provision of Palliative Care, its availability remains inconsistent across different regions. Financial constraints and insufficient support hinder the comprehensive dissemination of these services. Recognizing the significance of Palliative Care, the Catholic Church also endorses its implementation as a response to human suffering and an approach to end-of-life care. Efforts to strengthen Palliative Care are critical to meeting the rising demand and ensuring access to compassionate and dignified care for all individuals in need. Through legislative advancements and adequate resources, Italy can make significant strides in advancing the provision of Palliative Care.

Legal and Ethics Considerations in Capacity Evaluation for Medical Aid in Dying.

Evaluating decisional capacity for patients seeking medical aid in dying (MAID) raises challenging legal, logistical, and ethics questions. The existing literature on the subject has been shaped largely by early disagreements over whether effective capacity assessment for such patients is ever possible, which in turn stemmed from debates over the ethics of MAID itself. In attempting to establish meaningful criteria for assessments, many jurisdictions have sought either to apply or to adapt models of capacity evaluation designed for other forms of medical decision-making, such as the widely used "four skills" model, failing to account for the fundamental differences in kind between these other decisions and MAID. This article seeks to reexamine these questions with a focus on two logistical matters (the appropriate credentialing for the evaluator and the potential liability of the evaluator) and three clinical matters (level of understanding, clinical scrutiny and certainty, and impairment) in an effort to raise legal and ethics concerns that remain unresolved, even as MAID is permitted in an increasing number of jurisdictions.

Toward a new clinical pragmatism: method in clinical ethics consultation.

In this paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist's perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending on the demands of the specific case, and should avoid attempts to identify a 'true' methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism's emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism's relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation.

Bioethics and Neurosurgery: An Overview of Existing and Emerging Topics for the Practicing Neurosurgeon.

Neurosurgery is field with complex ethical issues. In this article, we aim to provide an overview of key and emerging ethical issues in neurosurgery with a focus on issues relevant to practicing neurosurgeons. These issues include those of informed consent, capacity, clinical trials, emerging neurotechnology, innovation, equity and justice, and emerging bioethics areas including community engagement and organizational ethics. We argue bioethics can help neurosurgeons think about and address these issues, and in turn, the field of bioethics can benefit from engagement by neurosurgeons. Several ideas for increasing engagement in bioethics are proposed.

Factors associated with Saudi physicians' utilization of clinical ethics consultation services.

Clinical Ethics Consultation (CEC) aims to resolve ethical dilemmas at the bedside. Through a structured process, CEC allows practitioners and patients to consult ethicists at times of moral conflict or uncertainty. Over the past few decades, CEC has become an invaluable part of healthcare practice. In Saudi Arabia, however, CEC services remain inexplicably underutilized. This study attempts to understand the factors associated with Saudi physicians' utilization of CEC to better meet the needs of practitioners and patients. Results indicate that although physicians routinely experience moral dilemmas, they seldom request a CEC. This is not due to unfamiliarity, lack of accessibility, or suspicion of ethical expertise. Rather, reluctance is likely due to an ingrained medical cultural stronghold that pressures practitioners to act heroically, and to resolve ethical dilemmas independently. Recommendations to improve the utilization of CEC services include wider availability, active collaborations with clinical practitioners, routine quality improvements, and managerial and national support.

The criterion of human dignity in the Quran.

In the Holy Quran, a strong emphasis has been placed on the dignity of human beings. There are two verses in the Quran that discuss the differences between humans and other creatures. In this article, we have tried to interpret these two verses using free selection of virtues and goodness as the criterion for human dignity that was obtained in our previous research. In the verse of trust, unlike other creatures, man accepts a trust that informs us about his cruelty and ignorance. However, if we consider this trust as freedom of choice, it can also imply injustice and ignorance alongside justice and wisdom for humans. In the verse of succession, angels tell God that human as vicegerent on earth leads to corruption and bloodshed. God does not deny this, but reminds the angels of the existence of pure ones. If we consider freely choosing goodness the differentiating factor between humans and other creatures the angels accurately refer to the possibility of creating corruption and bloodshed. However, they did not see the value of voluntary goodness compared to their own compulsory goodness. Therefore, by considering freely choosing goodness as the criterion for human dignity, these two verses can be easily interpreted.

What does "urgency" mean when prioritizing cancer treatment? Results from a qualitative study with German oncologists and other experts during the COVID-19 pandemic.

PURPOSE: Cancer care in Germany during the COVID-19 pandemic was affected by resource scarcity and the necessity to prioritize medical measures. This study explores ethical criteria for prioritization and their application in cancer practices from the perspective of German oncologists and other experts. METHODS: We conducted fourteen semi-structured interviews with German oncologists between February and July 2021 and fed findings of interviews and additional data on prioritizing cancer care into four structured group discussions, in January and February 2022, with 22 experts from medicine, nursing, law, ethics, health services research and health insurance. Interviews and group discussions were digitally recorded, transcribed verbatim and analyzed using qualitative content analysis. RESULTS: Narratives of the participants focus on "urgency" as most acceptable criterion for prioritization in cancer care. Patients who are considered curable and those with a high level of suffering, were given a high degree of "urgency." However, further analysis indicates that the "urgency" criterion needs to be further distinguished according to at least three different dimensions: "urgency" to (1) prevent imminent harm to life, (2) prevent future harm to life and (3) alleviate suffering. In addition, "urgency" is modulated by the "success," which can be reached by means of an intervention, and the "likelihood" of reaching that success. CONCLUSION: Our analysis indicates that while "urgency" is a well-established criterion, its operationalization in the context of oncology is challenging. We argue that combined conceptual and clinical analyses are necessary for a sound application of the "urgency" criterion to prioritization in cancer care.

Refining research on access to gynecologic cancer care: The DIMeS framework.

BACKGROUND: Despite its importance, there is no consensus definition of access to care, and several fundamental philosophical questions about access remain unanswered. Lack of clarity impedes interventional research designed to develop and test methods of correcting barriers to access. To help remedy this problem, we propose a conceptual framework to help guide empirical research about access to gynecologic cancer care. METHODS: Relevant philosophical and empirical literature was reviewed and analyzed to highlight key elements needed to refine research on access to care. RESULTS: The DIMeS framework involves 1) choice and justification of a Definition of access to cancer care that will guide research; 2) Identification of essential gynecologic cancer care services for which access disparities are ethically unacceptable; 3) quantitative MEasurement of specific parameters that affect access to care; and 4) Selection of a target threshold on measured parameters above which access is acceptable. CONCLUSIONS: The DIMeS framework provides clarity and reproducibility for investigators seeking to develop and test interventions to improve cancer health equity. This framework should be considered for use in research on access to gynecologic cancer care.

The ethics of artificial intelligence systems in healthcare and medicine: from a local to a global perspective, and back.

Artificial intelligence systems (ai-systems) (e.g. machine learning, generative artificial intelligence), in healthcare and medicine, have been received with hopes of better care quality, more efficiency, lower care costs, etc. Simultaneously, these systems have been met with reservations regarding their impacts on stakeholders' privacy, on changing power dynamics, on systemic biases, etc. Fortunately, healthcare and medicine have been guided by a multitude of ethical principles, frameworks, or approaches, which also guide the use of ai-systems in healthcare and medicine, in one form or another. Nevertheless, in this article, I argue that most of these approaches are inspired by a local isolationist view on ai-systems, here exemplified by the principlist approach. Despite positive contributions to laying out the ethical landscape of ai-systems in healthcare and medicine, such ethics approaches are too focused on a specific local healthcare and medical setting, be it a particular care relationship, a particular care organisation, or a particular society or region. By doing so, they lose sight of the global impacts ai-systems have, especially environmental impacts and related social impacts, such as increased health risks. To meet this gap, this article presents a global approach to the ethics of ai-systems in healthcare and medicine which consists of five levels of ethical impacts and analysis: individual-relational, organisational, societal, global, and historical. As such, this global approach incorporates the local isolationist view by integrating it in a wider landscape of ethical consideration so to ensure ai-systems meet the needs of everyone everywhere.

Open optimism as an "embodied-health" ethic for the information era.

This article forms part of a series on "openness," "non-linearity," and "embodied-health" in the post-physical, informational (virtual) era of society. This is vital given that the threats posed by advances in artificial intelligence call for a holistic, embodied approach. Typically, health is separated into different categories, for example, (psycho)mental health, biological/bodily health, genetic health, environmental health, or reproductive health. However, this separation only serves to undermine health; there can be no separation of health into subgroups (psychosomatics, for example). Embodied health contains no false divisions and relies on "optimism" as the key framing value. Optimism is only achieved through the mechanism/enabling condition of openness. Openness is vital to secure the embodied health for individuals and societies. Optimism demands that persons become active participants within their own lives and are not mere blank slates, painted in the colors of physical determinism (thus a move away from nihilism-which is the annihilation of freedom/autonomy/quality). To build an account of embodied health, the following themes/aims are analyzed, built, and validated: (1) a modern re-interpretation and validation of German idealism (the crux of many legal-ethical systems) and Freud; (2) ascertaining the bounded rationality and conceptual semantics of openness (which underlies thermodynamics, psychosocial relations, individual autonomy, ethics, and as being a central constitutional governmental value for many regulatory systems); (3) the link between openness and societal/individual embodied health, freedom, and autonomy; (4) securing the role of individualism/subjectivity in constituting openness; (5) the vital role of nonlinear dynamics in securing optimism and embodied health; (6) validation of arguments using the methodological scientific value of invariance (generalization value) by drawing evidence from (i) information and computer sciences, (ii) quantum theory, and (iii) bio-genetic evolutionary evidence; and (7) a validation and promotion of the inalienable role of theoretic philosophy in constituting embodied health, and how modern society denigrates embodied health, by misconstruing and undermining theoretics. Thus, this paper provides and defends an up-to-date non-physical account of embodied health by creating a psycho-physical-biological-computational-philosophical construction. Thus, this paper also brings invaluable coherence to legal and ethical debates on points of technicality from the empirical sciences, demonstrating that each field is saying the same thing.

Genetic Enhancement, Human Rights, and Regioglobal Bioethics.

This article examines the cross-cultural bioethical concerns stemming from the potential use of CRISPR-Cas9 for genetic enhancement projects. It emphasizes the need to differentiate between basic and non-basic human rights when considering genetic enhancement, as recent international declarations lack this distinction. Basic rights possess a universal nature and are applicable across cultures, while non-basic rights are culturally specific and should be determined within respective regions. To illustrate this, the study explores the acceptance or rejection of non-basic rights related to genetic enhancement in two distinct cultural categories: Type-A and Type-B cultures. Type-A cultures predominantly adhere to a liberal moral framework, while Type-B cultures are rooted in Confucian morality. Additionally, the article argues for two basic rights in genetic enhancement: the right to be free from bodily harm and the right to be free from deception. These rights differ from non-basic rights and should be universally upheld in all cultures. By analyzing a hypothetical case and drawing parallels with the He Jiankui incident, the article investigates the violation of these two basic rights in each scenario, regardless of cultural context. Consequently, both cases should be unequivocally rejected in both Type-A and Type-B cultures.

Black bodies in phenomenological bioethics: cultural othering, 'Corporeal Uncanny' and ethical quandaries of black nurses in Take My Hand and Small Great Things.

The aims of the present article are twofold. First, it attempts to theorise the thematic and ontological intersection between phenomenological and black bioethics and proposes 'Ontic-Black Bioethics', a neologism to evince how the corporeal misconceptions (such as race construct, bodily othering and colourism) become the cultural impediment for black women healthcare professionals. The article draws specific insights from the philosophical anthropology of race, ranging from Richard Polt to Sarah Ahmed, to understand the epistemic structures of scientific racism. Second, it investigates how the racial attitudes of white healthcare professionals and supremacist patients towards black nurses can be potential triggers of cultural othering, corporeal burden and ethical quandaries by closely reading Take My Hand by Dolen Perkins-Valdez (2022) and Small Great Things by Jodi Picoult (2016). For this, the article relies on the theoretical frameworks of cultural phenomenology and somatic attention postulated by Thomas Csordas, Philipa Rothfield and other theoreticians of varying importance. While the corporeality of black nurses is replete with the images of biological misconception and racial-cultural constructs, the epistemic perspectives and literary representations underscoring their bodily and experiential agony have been scarcely examined through the lenses of bioethics. Thus, the article construes the corporeality of black nurses as the confluence of biological and cultural discourses under phenomenological bioethics.

[Do not resuscitate orders and limitation of therapeutic effort: Ethical challenges in healthcare teams in Chile]. / Orden de no reanimar y limitación del esfuerzo terapéutico: desafíos éticos en equipos sanitarios en Chile.

The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.

El propósito de este trabajo es profundizar en los aspectos éticos que experimenta el equipo de salud cuando reciben la indicación de limitar el esfuerzo terapéutico o la orden de no reanimar. Desde un paradigma interpretativo, cualitativo y con un enfoque de análisis de contenido, se realizó un proceso basado en tres fases: preanálisis en el que se identificaron las categorías, la proyección del análisis y el análisis inductivo. Durante 2023, se realizaron entrevistas en el entorno clínico de un hospital de alta complejidad en Chile a 56 miembros de equipos de salud de unidades críticas y urgencias, de las que emergieron cuatro categorías: a) riesgo de vulnerar los derechos de los pacientes al utilizar la orden de no reanimar, y limitación del esfuerzo terapéutico; b) brecha en la interpretación del marco legal que aborda la atención y cuidado de pacientes al final de la vida, o con enfermedades terminales por parte del equipo de salud; c) conflictos éticos de la atención al final de la vida; y d) el cuidado eficiente o el cuidado holístico en pacientes con enfermedad terminal. Existen brechas importantes en la formación en bioética y aspectos del buen morir en los equipos de salud que se enfrentan a la orden de limitar el esfuerzo terapéutico y no reanimar. Se sugiere capacitar al personal, y trabajar una guía de consenso para abordar los aspectos éticos del buen morir.

The current status and challenges of bioethics education in undergraduate medical education in Karachi, Pakistan.

BACKGROUND: The importance of including bioethics in the medical curricula has been recognized globally. Certain countries including Pakistan continue to lag behind although some developments have occurred recently. OBJECTIVES: The research aimed to provide a snapshot of bioethics education in undergraduate medical colleges in Karachi, Pakistan. The secondary objectives included identifying factors promoting or inhibiting integration of bioethics into the curriculum. METHODS: A two-pronged strategy was used to collect data including a website review of medical colleges, in existence for more than ten years, recognized by the Pakistan Medical and Dental Council (PMDC), the regulating body for undergraduate medical education in Pakistan. The other arm employed in-depth interviews with medical educationists in colleges fulfilling inclusion criteria. Data from the website was analyzed and presented as frequencies. Qualitative data was analyzed using content analysis method which involved coding of transcripts, multiple readings and arriving at subthemes and themes iteratively. RESULTS: Thirteen medical colleges were included for the website review, of which four were from public sector. Three medical colleges used the word "ethics" in their vision and mission statement and four had provided a detailed curriculum for ethics on their website. Thematic framework included four broad themes: 1) Need for Bioethics Education, 2) Current Status of Bioethics Education 3) Challenges in integration of bioethics in medical curriculum and 4) Recommendations for integration of bioethics in the Curriculum. Participants were in agreement that bioethics was important in development of future physicians. Participants identified various challenges, foremost being shortage of trained faculty, lack of institutional buy-in and overcrowded curriculum. CONCLUSION: The study identified sporadic inclusion of bioethics in undergraduate medical curricula, left to the discretion of individual institutions. Since Karachi is a cosmopolitan city, the findings may reasonably reflect the situation in other parts of the country. While bioethics is recognized as an important field, it will continue to remain an orphan subject in the curricula unless the regulatory and accreditation bodies make it compulsory for institutions to include ethics in their curricula.

Challenges and Suggestions of Ethical Review on Clinical Research Involving Brain-Computer Interfaces.

Brain-computer interface (BCI) technology is rapidly advancing in medical research and application. As an emerging biomedical engineering technology, it has garnered significant attention in the clinical research of brain disease diagnosis and treatment, neurological rehabilitation, and mental health. However, BCI also raises several challenges and ethical concerns in clinical research. In this article, the authors investigate and discuss three aspects of BCI in medicine and healthcare: the state of international ethical governance, multidimensional ethical challenges pertaining to BCI in clinical research, and suggestive concerns for ethical review. Despite the great potential of frontier BCI research and development in the field of medical care, the ethical challenges induced by itself and the complexities of clinical research and brain function have put forward new special fields for ethics in BCI. To ensure "responsible innovation" in BCI research in healthcare and medicine, the creation of an ethical global governance framework and system, along with special guidelines for cutting-edge BCI research in medicine, is suggested.

Translational Bioethical Decision-Making: Human Brain Organoids as a Case Study.

In an earlier essay, I advocated that translational bioethics uses the public's values, determined through social science, in its analysis of translational science technologies. It may be unclear what those values might be, and whether such a translational ethics would necessarily conclude that cutting edge technologies should not be developed. In this essay, I show the public's values relevant to human brain organoids and argue that a translational bioethics analysis using these values would support continued organoid research.

The hunger strike in prison: bioethical and medico-legal insights arising from a recent opinion of the Italian national bioethics committee.

This contribution addresses some bioethical and medico-legal issues of the opinion formulated by the Italian National Bioethics Committee (CNB) in response to the dilemma between the State's duty to protect the life and health of the prisoner entrusted to its care and the prisoner's right to exercise his freedom of expression. The prisoner hunger strike is a form of protest frequently encountered in prison and it is a form of communication but also a language used by the prisoner in order to provoke changes in the prison condition. There are no rules in the prison regulations, nor in the laws governing the legal status of prisoners, that allow the conscious will of the capable and informed subject to be opposed and forced nutrition to be carried out. However, this can in no manner make therapeutic abandonment legitimate: the medical doctor should promote every action to support the patient. In the recent opinion formulated by the CNB it was remarked how self-determination is a central concept in human rights and refers to an individual's ability to make autonomous and free decisions about his or her life and body.

Troubling Trends in Health Misinformation Related to Gender-Affirming Care.

Amidst the misinformation climate about trans people and their health care that dominates policy and social discourse, autonomy-based rationales for gender-affirming care for trans and nonbinary youth are being called into question. In this commentary, which responds to "What Is the Aim of Pediatric 'Gender-Affirming' Care?," by Moti Gorin, we contextualize the virulent ideas circulating in misinformation campaigns that have become weaponized for unprecedented legal interference into standard health care. We conclude that the current legal justifications for upending gender-affirming care gloss over how this health care field meets conventional evidentiary standards and aligns protocols with most other fields of medicine. Refusal to offer gender-affirming care is more harmful than centralizing trans and nonbinary people's health autonomy.

Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape.

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.