Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios.

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

Ethical and Equity Guidance for Transplant Programs Considering Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) for Procurement of Hearts.

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.

Organizational Ethics in Healthcare: A National Survey.

Organizational ethics-defined as the alignment of an institution's practices with its mission, vision, and values-is a growing field in health care not well characterized in empirical literature. To capture the scope and context of organizational ethics work in United States healthcare institutions, we conducted a nationwide convenience survey of ethicists regarding the scope of organizational ethics work, common challenges faced, and the organizational context in which this work is done. In this article, we report substantial variability in the structure of organizational ethics programs and the settings in which it is conducted. Notable findings included disagreement about the activities that comprise organizational ethics and a lack of common metrics used to assess organizational ethics activities. A frequently cited barrier to full engagement in these activities was poor institution-wide understanding about the role and function of organizational ethics resources. These data suggest a tension in the trajectory of organizational ethics' professionalization: while some variability is appropriate to the field's relative youth, inadequate attention to definitions of organizational ethics practice and metrics for success can impede discussions about appropriate institutional support, leadership context, and training for practitioners.

What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases.

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is "stuck" in the hospital and the ethics consultant is called to help get the patient "unstuck." These encounters, which we call "complex discharges," are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

Clima ético egoísta y el teletrabajo en el sector eléctrico colombiano. El papel moderador del liderazgo ético

El sector eléctrico colombiano ha impulsado políticas organizacionales fundamentadas en la inclusión y el bienestar de la sociedad en general, que pretenden trasladarse al teletrabajo a través de un estilo de liderazgo ético. Sin embargo, el egoísmo -que se caracteriza por maximizar el interés propio como base de razonamiento moral-, es un factor subyacente que puede deteriorar cualquier iniciativa que busque un equilibrio institucional justo e íntegro, mediante un clima ético donde las decisiones descuiden las necesidades colectivas. Por consiguiente, el objetivo de esta investigación es determinar la relación entre un clima laboral egoísta y el teletrabajo, a través del rol moderador de liderazgo ético. El estudio aplicó un diseño cuantitativo, transversal y correlacional explicativo. La muestra fue de 448 empleados evaluados por una encuesta en línea. Se encontró que el clima ético egoísta (X) y el liderazgo ético (W) se asocian significativamente con el teletrabajo (Y). Sin embargo, cuando el liderazgo ético regula la relación entre las variables independiente y dependiente (6X - Y/W), se hace visible que a mayor percepción de una dirección ética más débil se torna el efecto del clima egoísta sobre el teletrabajo hasta desaparecer. En conclusión, el sector eléctrico colombiano, por su enfoque en la responsabilidad social y erradicación de conductas deshonestas mediante un liderazgo ético, no es compatible con un clima laboral egoísta. De hecho, el impulsar una cultura de trabajo, a través del interés propio, neutraliza todo el esfuerzo ético propuesto por el sector eléctrico colombiano en los últimos siete años, puesto que su finalidad ha sido propender por iniciativas sociales e inclusivas.

The Colombian electricity sector promotes organizational policies based on the inclusion and well-being of society in general, which also intend to transfer to teleworking through an ethical leadership style. However, the selfishness that is characterized by maximizing self-interest as the basis of moral reasoning is an underlying factor that can deteriorate any initiative that seeks a fair and comprehensive institutional balance through an ethical climate where decisions neglect collective needs. Therefore, the objective of this research is to determine the relationship between a selfish climate and teleworking through the moderating role of ethical leadership. The study applies a quantitative, cross-sectional, explanatory correlational design. The sample is 448 employees who are evaluated with an online survey. The selfish ethical climate (X) and ethical leadership (W) are significantly associated with telecommuting (Y). However, when ethical leadership regulates the relationship between the independent and dependent variables (6X - Y/W) it becomes visible that the greater the perception of a weaker ethical leadership, the effect of the selfish climate on telework becomes until it disappears. The Colombian electricity sector, due to its focus on social responsibility and on eradicating dishonest conduct through ethical leadership, is not compatible with a selfish climate. In fact, promoting only individual interests in virtual work environments would nullify all the ethical effort proposed by the sector in question in the last seven years. Since its purpose has been to promote social and inclusive initiatives.

Betraying, Earning, or Justifying Trust in Health Organizations.

Health care and public health programs increasingly rely on, and often even require, organizational action, which is facilitated, if not dependent on, trust. Case examples in this essay highlight trust, trustworthiness, and distrust in public and private organizations, providing insights into how trust in health-related organizations can be betrayed, earned, and justified and into the consequences of organizational trust and trustworthiness for the health of individuals and communities. These examples demonstrate the need for holistic assessments of trust in clinicians and trust in organizations and for organizations, public health, and the medical profession to address questions concerning their own trustworthiness. Normative and empirical assessments of trust and trustworthiness that capture the experiences of those treated within the walls of a health care organization, as well as the care of those outside, will contribute to more trustworthy systems of care.

The ethical void: a critical analysis of commissioned expert reports on Swedish healthcare governance.

PURPOSE: The purpose of this paper is to contribute knowledge on ethical issues and reasoning in expert reports concerning healthcare governance, commissioned by the Swedish healthcare system. DESIGN/METHODOLOGY/APPROACH: An in-depth analysis of ethical issues and reasoning in 36 commissioned expert reports was performed. Twenty-seven interviews with commissioners and producers of the reports were also carried out and analysed. FINDINGS: Some ethical issues were identified in the reports. But ethical reasoning was rarely evident. The meaning of ethical concepts could be devalued and changed over time and thereby deviate from statutory ethical goals and values. Several ethical issues of great concern for the Swedish public healthcare were also absent. PRACTICAL IMPLICATIONS: The commissioner of expert reports needs to ensure that comprehensive ethical considerations and ethical analysis are integrated in the expert reports. ORIGINALITY/VALUE: Based on an extensive data material this paper reveals an ethical void in expert reports on healthcare governance. By avoiding ethical issues there is a risk that the expert reports could bring about reforms and control models that have ethically undesirable consequences for people and society.

Perspectives on the role of the nurse ethicist.

This paper offers four contrasting perspectives on the role of the nurse ethicist from authors based in different areas of world, with different professional backgrounds and at different career stages. Each author raises questions about how to understand the role of the nurse ethicist. The first author reflects upon their career, the scope and purpose of their work, ultimately arguing that the distinction between 'nurse ethicist' and 'clinical ethicist' is largely irrelevant. The second author describes the impact and value that a nurse in an ethics role plays, highlighting the 'tacit knowledge' and 'lived experience' they bring to clinical ethics consultation. However, the second author also warns that the 'nurse ethicist' must be cautious in their approach to avoid being viewed as a resource only for nurses. The third author questions the introduction of additional professional distinctions such as 'nurse ethicist' on the basis that distinctions threaten the creation of egalitarian healthcare systems, while also acknowledging that clinical ethicists ought not strive for objective attachment in their work. In direct contrast, the final author suggests that the nurse ethicist can play a pivotal role in highlighting and addressing ethical challenges that are specific to nurses. These four short pieces raise questions and point to concepts that will be expanded upon and debated throughout this special issue of Nursing Ethics.

Organizational Ethics Indicators in Iranian Hospital: An Importance-Performance Analysis.

Background: Organizational ethics focuses on the importance of how organizations behave when faced with specific situations and decisions. This study aims to identify and prioritize organizational ethics indicators in Imam Khomeini Hospital Complex (IKHC) in Iran. Materials and Methods: This was a mixed-method research project. To recognize hospital ethics indicators, 18 semistructured interviews were conducted and 38 indicators were identified through thematic analysis. In the next stage, a quantitative approach was adopted to use the importance-performance matrix for data analysis. This part was a descriptive survey with a statistical population consisting of nurses, medical, clinical, and administrative staff. The questionnaire was distributed using the random sampling method, and a total of 349 samples were collected. Results: Based on the interviews and open coding, 73 themes were identified for organizational ethics indicators and classified into two main groups: "ethics drivers in hospital" and "personal ethics." After measuring content validity, 35 indicators of organizational ethics in IKHC were examined in terms of importance and performance. The results showed that nine indicators had high importance and poor performance, 11 had high importance and performance, nine had low importance and performance, and finally six indicators had low importance and high performance, and according to these findings, practical suggestions were put forward. Conclusions: Based on the identified indices and by applying importance-performance analysis, it is recommended to continually assess the status of ethics in hospitals and offer strategies for improving organizational ethics.

Visitor restrictions in hospitals during infectious disease outbreaks: An ethical approach to policy development and requests for exemptions.

In this paper, we explore the ethics of restricting visitation to hospitals during an infectious disease outbreak. We aim to answer three questions: What are the features of an ethically justified hospital visitor restriction policy? Should policies include scope for case-by-case exemptions? How should decisions about exemptions be made? Based on a critical interpretive review of the existing ethical literature on visitor restrictions, we argue that an ethically justified hospital visitor restriction policy has the following features: proportionality, comprehensiveness, harm mitigation, exemptions for specific patient populations, visitation decisions made separately from a patient's treating clinicians, transparency, and consistency in application. We also argue that an ethical policy ought to include scope for case-by-case exemptions for individual patients. We propose a process for ethical decision-making that provides a shared language and structure to decrease the risks and burdens of decision-making when clinicians or managers are considering requests for exemptions.

Environmental ethics beyond conferences: A response to the WCB bioethics in Qatar.

Rieke van der Graaf, Karin Jongsma, Martine de Vries, Suzanne van de Vathorst, and Ineke Bolt have done well to voice ethical concerns over the decision of the IAB to host the next WCB in Qatar. Conferences should be more sustainable. Yet, attention to the carbon impact of conferences-and, perhaps, any country that a person might travel to for business or pleasure-are only one small part of environmentally responsible citizenship, especially for those trained in ethics and committed to health. Both bioethics as a discipline and bioethicists as individuals need to interrogate their environmental choices. To this end, some ecological choices are more obvious targets of ethical scrutiny-diet and travel-while others appear sacrosanct, like reproduction and even healthcare use. This underscores the importance of making sustainable and ethical organizational choices, such as where to hold a conference, without absolving environmental accountability in other ethical calculations. Many organizations in academic and clinical medicine need to make drastic alterations in their practices and policies to effectively mitigate carbon. While the burden is not only on bioethics alone, the expectation that it should be remains.

Situational vulnerability within mental healthcare - a qualitative analysis of ethical challenges during the COVID-19 pandemic.

BACKGROUND: Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability. METHODS: We present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability. RESULTS: Difficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics. CONCLUSIONS: Applying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability.

Perceptions on the role of research integrity officers in French medical schools.

Researchers, organizations, and governments are trying to foster research integrity. In France, the law recently permitted the appointment of research integrity officers (RIOs) in each university, to promote research integrity and handle misconducts. Since we assumed that having adequate bodies to deal with research integrity could foster research integrity, we wanted to understand how this might work more concretely. We interviewed 11 newly appointed RIOs in medical schools about how they perceive their role and cope with their responsibilities. We analyzed data following the Paillé and Muchielli's thematic analysis approach. The RIOs report a strong and interesting appropriation of concepts of research integrity, which allows them to warrant their role. Although they report that they did not seek their appointment, they show a real desire to cope with their responsibilities. They are willing to build a role which is currently poorly defined. They assert their legitimacy through their position and experience. They identify themselves with a preventive and corrective role, in an altruistic way. They emphasize their independent and collective role, congruent with other actors. The RIOs intend to be enablers of a responsible conduct of research. These results are encouraging about the potential impact of RIOs to foster research integrity.

Demand and Supply: Association between Pediatric Ethics Consultation Volume and Protected Time for Ethics Work.

BACKGROUND: Despite national increase in pediatric ethics consultation volume over the past decade, protected time and resources for healthcare ethics consultancy work has lagged. METHODS: Correlation study investigating potential associations between ethics consult volume reported by recent national survey of consultants at children's hospitals and five programmatic domains. RESULTS: 104 children's hospitals in 45 states plus Washington DC were included. There was not a statistically significant association between pediatric ethics consult volume and hospital size, rurality of patient population, or number of consultants. Academically-affiliated children's hospitals had fewer ethics consults compared to nonacademically affiliated. Association was found between full-time equivalent (FTE) hours and number of ethics consults (p < 0.0001). Spearman rank correlation between ethics consult volume and FTE was 0.5. CONCLUSIONS: While the results of this study should be interpreted with caution, investment in protected time for ethics consultancy work may translate into increased volume of pediatric ethics consults.

MAiD to Last: Creating a Care Ecology for Sustainable Medical Assistance in Dying Services.

This paper depicts a case study of an organizational strategy for the promotion of ethical practice when introducing a new, high-risk, ethically-charged medical practice like Medical Assistance in Dying (MAiD). We describe the development of an interprofessional program that enables the delivery of high-quality, whole-person MAiD care that is values-based and sustainable. A "care ecology" strategy recognizes the interconnected web of relationships and structures necessary to support a quality experience of MAiD for patients, families, and clinicians. This program exemplifies a care ecology approach that addresses common barriers to entry to MAiD practice, and also meets the needs of a variety of stakeholders through the creation of patient and family resources, team supports, standards of practice, professional development opportunities, organizational infrastructure, and community partnerships. We also describe how a thriving care ecology evolves to remain resilient, and to enable integration as the needs of the organization, team and program change over time. The design and development of this program may be adapted to other jurisdictions and organizations where MAiD is introduced, or where new patient populations become eligible for MAiD. This care ecology model may also be applicable to the creation of sustainable programs that provide other morally controversial or novel clinical services.

Do Health Care Organizations Have Legitimate Responsibilities beyond the Delivery of Health Care? Insights from Citizenship Theory.

Many health care organizations made public commitments to become antiracist in the wake of George Floyd's murder. These actions raise questions about the appropriateness of health care's engagement in racial justice and social justice movements generally. We argue that health care organizations can be usefully thought of as having two roles: a functional role to care for the sick and a meta-role as an organizational citizen. Fulfilling the role of citizen may require participating in the pursuit of social justice, including efforts to achieve racial equity. The demands of these two roles will need to be balanced, but the role of organizational citizen has been largely ignored and merits serious attention.

Access Isn't Enough: Evaluating the Quality of a Hospital Medical Assistance in Dying Program.

Following an initial study of the needs of healthcare providers (HCP) regarding the introduction of Medical Assistance in Dying (MAiD), and the subsequent development of an assisted dying program, this study sought to determine the efficacy and impact of MAiD services following the first two years of implementation. The first of three aims of this research was to understand if the needs, concerns and hopes of stakeholders related to patient requests for MAiD were addressed appropriately. Assessing how HCPs and families perceived the quality of MAiD services, and determining if the program successfully accommodated the diverse needs and perspectives of HCPs, rounded out this quality evaluation. This research implemented a mixed-methods design incorporative of an online survey with Likert scale and open-ended questions, as well as focus groups and interviews with staff and physicians, and interviews with MAiD-involved family members. There were 356 online surveys, as well as 39 participants in six focus groups with HCP, as well as fourteen interviews with MAiD-involved family members. Participants indicated that high-quality MAiD care could only be provided with enabling resources such as policies and guidelines to ensure safe, evidence-based, standardized care, as well as a specialized, trained MAiD team. Both focus group and survey data from HCPs suggest the infrastructure developed by the hospital was effective in delivering high-quality MAiD care that supports the diverse needs of various stakeholders. This study may serve as a model for evaluating the impact and quality of services when novel and ethically-contentious clinical practices are introduced to healthcare organizations.

Getting Beyond Pros and Cons: Results of a Stakeholder Needs Assessment on Physician Assisted Dying in the Hospital Setting.

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015-16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study's qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization.

Implementation of Medical Assistance in Dying as Organizational Ethics Challenge: A Method of Engagement for Building Trust, Keeping Peace and Transforming Practice.

This paper focuses on the ethics of how to approach the introduction of MAiD as an organizational ethics challenge, a focus that diverges from the traditional focus in healthcare ethics on the ethics of why MAiD is right or wrong. It describes a method co-designed and implemented by ethics and medical leadership at a tertiary hospital to develop a values-based, grassroots response to the decriminalization of assisted dying in Canada. This organizational ethics engagement method embodied core tenants that drew inspiration from a variety of sources, including poetic ones. These tenants are: make the problem bigger; focus on values; cultivate open moral spaces; and trust emergence. The paper describes how these tenants were put into practice in order to create a rigorous and sustainable MAiD program that delivers high-quality care to patients and families while honoring the moral diversity of the hospital workforce. One of the goals in sharing this method is to provide a roadmap for healthcare organizations in Canada and other jurisdictions around the world that are facing the challenge of responding to patient requests for MAiD following the decriminalization of this care option.

The Role of Social Responsibility and Ethics in Employees' Wellbeing.

Social responsibility (SR) is a concept or practice by which organizations take into account the interest of society by taking responsibility for the impact of their activities on all stakeholders. The SR of organizations implies ethical behavior concerning all stakeholders and a company's commitment to the sustainable economic development of society. Organizational ethics is a set of written and unwritten codes of principles and values that govern decisions and actions within an organization. Ethics has a rather internal perspective, while social responsibility has a rather external perspective. This study examines the impact of social responsibility and organizational ethics on employees' wellbeing. To perform the empirical analysis, we conducted a survey among 423 employees from Romanian organizations. Using the structural equation modeling, we analyzed the relationships between social responsibility, organizational ethics, and employees' wellbeing, emphasizing the positive impact of ethical and responsible behavior of the organization on the employees' wellbeing. The organization's employees play a dual role: firstly, they are all internal stakeholders, and secondly, they are constituents of an external stakeholder essential for the organization-the community. The results show a significant positive influence of social responsibility and organizational ethics on employees' wellbeing as a result of a responsible and ethical behavior in relation to the organizational stakeholders.