Croatian physicians' and nurses' experience with ethical issues in clinical practice.

AIM: To assess ethical issues in everyday clinical practice among physicians and nurses of the University Hospital Rijeka, Rijeka, Croatia. SUBJECTS AND METHODS: We surveyed the entire population of internal medicine, oncology and intensive care specialists and associated nurses employed at the University Hospital Rijeka, Rijeka, Croatia (n = 532). An anonymous questionnaire was used to explore the type and frequency of ethical dilemmas, rank of their difficulty, access to and use of ethics support services, training in ethics and confidence about knowledge in ethics. Physicians (n = 113, 55% of them female) ranged in age from 27 to 61 years, and nurses (n = 251, 95% female), from 20 to 52. RESULTS: The most frequent ethical dilemmas concerned uncertain or impaired decision-making capacity (66% of physicians, 47% of nurses, p = 0.008), limitation of treatment at the end of life (60% of physicians, 31% of nurses, p<0.001) and disagreements among family members (47% of physicians, 31% of nurses, p = 0.025). The most difficult dilemmas concerned euthanasia and physician-assisted suicide (49% of physicians, 52% of nurses) and limitation of treatment at the end of life (14% of physicians, 18% of nurses). Only a minority reported ever using any kind of ethics support services (12% of physicians, 3% of nurses, p = 0.001) or being very confident about knowledge in ethics (5% of physicians, 6% of nurses). CONCLUSIONS: Similar ethical difficulties are present in the clinical practice of both physicians and nurses, with important differences in access and use of ethics support services. A need for systematic ethics educational activities was identified. Inclusion of individual ethics consultants in Croatian healthcare ethics support services is strongly advised.

Until they have faces: the ethics of facial allograft transplantation.

The ethical discussion of facial allograft transplantation (FAT) for severe facial deformity, popularly known as facial transplantation, has been one sided and sensationalistic. It is based on film and fiction rather than science and clinical experience. Based on our experience in developing the first IRB approved protocol for FAT, we critically discuss the problems with this discussion, which overlooks the plight of individuals with severe facial deformities. We discuss why FAT for facial deformity is ethically and surgically justified despite its negative portrayal in the media.

Stroke patients' preferences and values about emergency research.

BACKGROUND: In the USA, the Food and Drug Administration waiver of informed consent permits certain emergency research only if community consultation occurs. However, uncertainty exists regarding how to define the community(ies) or their representatives. OBJECTIVE: To collect data on the actual preferences and values of a group-those at risk for stroke-most directly affected by the waiver of informed consent for emergency research. DESIGN: Face to face focused interviews were conducted with 12 patients who were hospitalised with a stroke diagnosis in the previous year. The interviews were audiotaped and a transcript based method was used for their analysis. RESULTS: All 12 participants felt "that it was important that new treatments for stroke be developed", but they were initially confused about the distinction between "research for stroke" and "emergency research for stroke". However, after explanation, most (n = 10; 83%) expressed willingness to participate in the latter. In the absence of a surrogate to give informed consent in a stroke emergency situation, the majority (n = 11; 92%) said they would want the physician to "go ahead and enrol them in the trial". CONCLUSIONS: This study is the first to identify the values and concerns of individuals most directly affected by stroke emergency research. Further interviews and focus groups are needed to develop and test a validated questionnaire on the preferences and values surrounding emergency research for stroke.

Who shall be allowed to give? Living organ donors and the concept of autonomy.

UNLABELLED: Free and informed consent is generally acknowledged as the legal and ethical basis for living organ donation, but assessments of living donors are not always an easy matter. Sometimes it is necessary to involve psychosomatics or ethics consultation to evaluate a prospective donor to make certain that the requirements for a voluntary and autonomous decision are met. The paper focuses on the conceptual questions underlying this evaluation process. In order to illustrate how different views of autonomy influence the decision if a donor's offer is ethically acceptable, three cases are presented--from Germany, the United States, and India. Each case features a person with questionable decision-making capacity who offered to donate a kidney for a sibling with severe renal insufficiency. Although the normative framework is similar in the three countries, different or sometimes even contrary arguments for and against accepting the offer were brought forward. The subsequent analysis offers two explanations for the differences in argumentation and outcome in spite of the shared reference to autonomy as the guiding principle: (1) Decisions on the acceptability of a living donor cannot simply be deducted from the principle of autonomy but need to integrate contextual information; (2) understandings of the way autonomy should be contextualized have an important influence on the evaluation of individual cases. CONCLUSION: Analyzing the conceptual assumptions about autonomy and its relationship to contextual factors can help in working towards more transparent and better justified decisions in the assessment of living organ donors.

Hindsight, foresight, and having it both ways: a rejoinder to R. L. Spitzer.

Using the methods of philosophical analysis, we provide a rejoinder to R. L. Spitzer's (2001) response to our own consideration of the DSMs first published in 1994. Then as now, our major contention has been that the DSM contents and process have been insufficiently explicit in their various value commitments, choices, and decisions. Spitzer raises four major points in his commentary, concerning our claims about the "value naivete" of past DSMs, his contention that the goals of DSM-III and III-R were not "inherently" in conflict, about our allegations of the DSM architects preferring reliability over validity, and various DSM critics' failure to offer a viable alternative to the DSMs. We address each of Spitzer's main points in turn, appealing to Spitzer's own work while acknowledging his leadership role in addressing value issues in mental disorder classification.

The question of method in ethics consultation.

This paper offers an exposition of what the question of method in ethics consultation involves under two conditions: when ethics consultation is regarded as a practice and when the question of method is treated systematically. It discusses the concept of the practice and the importance of rules in constituting the actions, cognition, and perceptions of practitioners. The main body of the paper focuses on three elements of the question of method: canon, discipline, and history, which are treated heuristically to outline what the question of method in ethics consultation fully involves.

Appropriate use of DNR orders: a practical approach.

Too often, physicians, patients, and families make end-of-life care decisions despite poor physician-patient communication and misunderstanding by the patient and family about the effectiveness of cardiopulmonary resuscitation. We describe an approach to resolving conflict and reaching consensus on end-of-life care. This approach supports physician judgment to withhold futile treatment within the constraints of law and patient autonomy.

The importance of management for understanding managed care.

This paper argues that the concept of management is critically important for understanding managed care. A proper interpretation of management is needed before a positive account of the ethics of managed care can be constructed. The paper discusses three aspects of management: administrative, clinical, and resource management, and compares the central commitments of traditional medical practice with those of managed care for each of these aspects. In so doing, the distinctive conceptual features of the managed care paradigm are discussed. The paper concludes by arguing that the concept of management implicit in the managed care paradigm affords a basis for building a more adequate ethic of managed care.

Ethics expert testimony: against the skeptics.

There is great skepticism about the admittance of expert normative ethics testimony into evidence. However, a practical analysis of the way ethics testimony has been used in courts of law reveals that the skeptical position is itself based on assumptions that are controversial. We argue for an alternative way to understand such expert testimony. This alternative understanding is based on the practice of clinical ethics.

On values in recent American psychiatric classification.

The DSM-IV, like its predecessors, will be a major influence on American psychiatry. As a consequence, continuing analysis of its assumptions is essential. Review of the manuals as well as conceptually-oriented literature on DSM-III, DSM-III-R, and DSM-IV reveals that the authors of these classifications have paid little attention to the explicit and implicit value commitments made by the classifications. The response to DSM criticisms and controversy has often been to incorporate more scientific diversity into the classification, instead of careful inquiry and assessment of the principal values that drive the nosologic process. Implications for psychiatric science and future DSM classifications are discussed.