The American Journal of Bioethics
closure through sustained reflections on the ethical challenges prompted by the clinical encounter, and to draw on the discussions they had during an ethics consultation to eventually moderate and manage various moral emotions and feelings of distress. Chronic, unresolved regret, guilt, and anger can be pernicious and harmful. However, there is a difference between experiencing guilt, anger, or indignation over a limited time period, and being unable to ever overcome or manage these feelings. Part of what it means to equip stakeholders to achieve closure over time is to engage in a sufficiently transparent, accessible, rich, and encouraging discussion about the moral questions, issues, and options in a case so as to allow an individual to retrospectively take up different moral vantage points and establish a constructive internal dialogue that helps to manage, contain, and move beyond the experience of various negative moral emotions and distress and achieve closure over time. Given the complexity of ethical issues and questions raised in various cases, the ethics consultant alone is unlikely to be able to adequately equip any given stakeholder or all of the stakeholders to achieve closure over time. Contrary to what Fiester suggests, effectively equipping people to address the range of moral emotions they may feel and the moral distress they might experience will require the skill set of more than just the clinical ethicist. Clergy, therapists, social workers, ombudsmen, and other hospital services are important groups of people to recruit and mobilize for the effort to equip and empower stakeholders to ultimately achieve closure on any given ethical problem(s) that were raised in a particular case. The clinical ethicist ought to be familiar with the resources at hand when encountering stakeholders with a great amount of moral distress or negative moral emotions. During the week prior to this article being written, the authors of this commentary collaborated on a number of ethics consultations in which they referred people to, or recommended they consult, social work, spiritual care,
child life, psychologists, and others to help stakeholders process their ongoing emotional and moral consternation. We felt it is part of our jobs to know about these resources and know when they are appropriate to recommend. It was not in our scope to develop a moral, emotional, or psychological counseling relationship that would be ongoing in order for closure to occur. Hopefully, our clear, compassionate, and transparent processes provided the conditions for continued work by these other professionals and the stakeholders themselves. As clinical ethicists, we can acknowledge the good of closure, but also recognize that the ethical questions and issues raised in a case will often require thought and reflection beyond the duration of an ethics consultation. Within our scope of practice is an effort to equip stakeholders to achieve closure over time. However, just as the ethical issues and moral emotions raised in a case can linger with stakeholders, they can also haunt the clinical ethicist (Ford and Dudzinski 2008). This raises the question: If the clinical ethicist is working to equip stakeholders in an ethics consultation to achieve closure in time, who is equipping the clinical ethicist to achieve closure? As a profession we should be sure that clinical ethicists are provided the same tools for the beginnings of closure as we provide the other stakeholders in these cases. &
REFERENCES Eliot, T. S. 1971. Four quartets. New York, NY: Harcourt. Original work published 1943. Fiester, A. 2015. Neglected ends: Clinical ethics consultation and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Ford, P., and D. Dudzinski, eds. 2008. Complex ethical consultations: Cases that haunt us. New York, NY: Cambridge University Press. Yoder, S. 1998. Experts in ethics? The nature of ethical expertise. Hastings Center Report 28(6): 11–17.
Moral Distress and Prospects for Closure Haavi Morreim, University of Tennessee Health Science Center Autumn Fiester (2015) argues that when an ethics consult simply issues a recommendation it may leave a vacuum then filled by moral distress or moral emotion. “Assisted conversation”—a dialogue-focused approach—
can better promote closure and reduce the negative effects of conflict. Overall, this commentary argues that although Fiester is right about the benefits of mediation, she (and the
Address correspondence to Haavi Morreim, University of Tennessee Health Science Center, 910 Madison Ave., Memphis, TN 38163, USA. E-mail: [email protected]
38 ajob
January, Volume 15, Number 1, 2015
Clinical Ethics Consultation and Closure
relevant literature generally) understates the nature of genuine moral distress and thereby overestimates possibilities for closure in those particular cases. Moral distress is best understood as a clash of “bedrock” values and/or bedrock beliefs. These are the values and beliefs underlying all one’s other beliefs and values. For instance, the assertion that “life is infinitely precious regardless of quality” is a deeply-rooted, fundamental belief that is incommensurate with an equally deeply-rooted fundamental belief that “some qualities of life are worse than death.” One endorses either “life, regardless of quality” or “quality matters.” Not both. Beliefs and values at this level cannot be defended or defeated, either rationally or empirically, because they form the substrate on which all further claims are built. Since bedrock clashes are impossible in principle to resolve—or thereby to achieve “closure”—the best uses of assisted conversation are (a) to identify the many cases in which there really is no bedrock clash despite appearances to the contrary, and (b) to recognize that often such a clash need not necessarily be resolved to forge a mutually acceptable resolution to the problem at hand. Fiester invokes a familiar definition of “moral distress”: “a strong conviction about what is right to do in a particular situation without being able to take the action perceived as morally correct” (31). Physicians, nurses, even ethics consultants can experience moral distress, with consequences including regret, self-reproach, disempowerment, and burnout. Patients and families are said to experience “moral emotion.” When “‘we judge someone to have wronged someone else, perceive that a wrong has been committed against oneself, or believe we have failed someone” (31) we feel guilt, anger, resentment, perhaps indignation. (Fiester does not explain why providers have moral distress, whereas patients and families only experience moral emotion.) This commentary proposes that the relevant literature, as a whole, fails to recognize the profound underpinnings of genuine moral distress (e.g., Browning 2013; Elpern and Balk 2008; Elpern, Cover, and Kleinpell 2005; Epstein and Delgado 2009; Hamric and Blackhall 2007; Lomis, Carpenter, and Miller 2009; Morris and Dracup 2008; Papathanassoglou et al. 2012). Rather than simply a strong conviction pitted against a barrier to acting on that conviction, true moral distress is better understood as a situation in which parties hold fundamentally opposing “bedrock beliefs” and/or opposing “bedrock values.” Bedrock beliefs and values are those on which other beliefs and values ultimately rest. These “buck stops here” precepts emerge when we can no longer answer the question “so why should we agree with that?” and instead can only resort to “that’s just the way it is, darn it!” We cannot forever, into infinite regress, provide the next justification for espousing the prior tenet. At some point rationales and justifications must end. Beliefs and values at this bedrock level cannot possibly be defended or defeated, either rationally or empirically, and any attempt to prove their validity will inevitably invoke circular, question-begging reasoning—presuming as true the very thing(s) one is trying to prove.
January, Volume 15, Number 1, 2015
Thus, bedrock beliefs mainly concern metaphysics, theology, ontology, and the like. They comprise our most fundamental picture of what the world is made of, and how things run, and what will count as proof or evidence that those beliefs are true. If one believes everything is created by a deity and that every minute event is consciously engineered or permitted by that deity, then one will see one’s survival of a terrible accident as proof-positive that this deity is alive and at work in one’s own life. Those denying such an account might respond, “You got lucky because the oncoming car’s path, intersecting with your trajectory, threw you just to the left of the tree instead of directly into it; so how would that prove there’s a God??” Where Kierkegaard says “it requires a leap of faith,” an opposing side will reply “why should I leap at all, and why in that particular direction?” Bertrand Russell comes to mind: “There is no logical impossibility in the hypothesis that the world sprang into being five minutes ago, exactly as it then was, with a population that ‘remembered’ a wholly unreal past” (Russell 1921, 159–160). One cannot possibly disprove such a proposition without at certain points presuming as true the very thing one wishes to prove. Bedrock values concern our deepest precepts about what is right and wrong, what we ought and ought not to do, in the most important realms of our lives. Thus, “Every moment of life is infinitely precious, regardless of its quality” is simply incompatible with “At some point the quality of life is so poor, death becomes preferable.” The fundamental character of bedrock beliefs and values explains why we have not, and will never, “resolve” such debates as creationism or abortion. Where one person says “a woman has the right to control her own body,” the other side replies “there are two bodies, one inside the other.” Our willingness to override a Jehovah’s Witness parent’s refusal of blood for his child presupposes, at some level, that the Witness is theologically incorrect, and that the transfusion will not carry the price of eternal separation from God. These clashes are the ultimate conflict, challenging our strongest personal commitments. Because bedrock beliefs and values can be neither defended nor defeated, and because clashing bedrocks therefore cannot be reconciled, no mediative process can possibly produce closure, emotionally or intellectually, when one side “loses” while the other “wins.” It is impossible in principle. The heightened emotions, stemming both from deep conviction and from utter helplessness, cannot be mediated away. Instead, the best uses of mediation for conflict in bioethics are (1) to explore the details of the conflict and, in many cases, discern that no bedrock clash is actually afoot and (2) to forge practical resolutions that do not require reconciling bedrock clashes. Happily, these will likely constitute the substantial majority of ethics-related conflicts, and they provide a broad range of opportunities for effective, problem-solving mediation. Take a statement like “God will work a miracle if we keep treating.” On one hand, if offered as a bedrock religious conviction asserted to oppose the staff’s insistence that treatment is futile, mediation will not likely
ajob 39
The American Journal of Bioethics
achieve closure—though it might reduce emotional tension if each side feels genuinely heard and respected. On the other hand, in many instances that same statement may simply be a trump card played because “I don’t want to talk about it,” or “you doctors aren’t omnicient and I don’t believe it’s really that hopeless,” or “you’re rich and white and I don’t think you really care if this elderly black lady is dead or alive.” These cases leave broad room for exploring underlying fears, concerns, and factual beliefs, and for a collaborative problem solving that can turn discord into a set of shared goals even where not all views are harmonized. Here is where Fiester gets it right. In high-conflict situations a skilled mediative communication, in which the mediator earns the trust of everyone involved, has the opportunity to uncover what the real issue(s) is, and potentially help parties find enough common ground to address the clinical problem(s) at hand. Often an apparent clash will turn out to be a communication misfire, and even bona fide bedrock clashes need not preclude practical resolutions. As Steven Toulmin and Al Jonsen (Jonsen and Toulmin 1988) observed so many years ago, one need not always agree on basic precepts to figure out what to do in a given case. And as echoed by Bergman (2013, 13), “Consensus on outcomes does not necessarily require consensus on principles.” Here a good mediator may be able to assist people in conflict to address their solvable problems, notwithstanding their deeper divides. & REFERENCES Bergman, E. 2013. Surmounting elusive barriers: The case for bioethics mediation. Journal of Clinical Ethics 24(1): 11–24. Browning, A. M. 2013. Moral distress and psychological empowerment in critical care nurses caring for adults at end of life. American Journal of Critical Care 22(2): 143–151.
Elpern, E. H., and R. A. Balk. 2008. Trouble in the ICU: Diagnosing moral distress. Chest Physician 3(6): 8–9. Elpern, E. H., B. Covert, and R. Kleinpell. 2005. Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care 14: 523–530. Epstein, E. G., and S. Delgado. 2010. Understanding and addressing moral distress. Online Journal of Issues in Nursing, September 30. Available at: http://www.nursingworld.org/MainMenuCategories/ EthicsStandards/Courage-and-Distress/Understanding-Moral-Distress. html Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Hamric, A. B., and L. J. Blackhall. 2007. Nurse–physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35:422–429. Jonsen, A. R., and S. Toulmin. 1988. The abuse of casuistry: A history of moral reasoning. Berkeley, CA: University of California Press. Lomis, K. D., R. O. Carpenter, and B. M. Miller. 2009. Moral distress in the third year of medical school; a descriptive review of student case reflections. American Journal of Surgery 197:107–111. Morris, P. E., and K. Dracup. 2008. Time for a tool to measure moral distress? American Journal of Critical Care 17(5): 398–401. Papathanassoglou, E. D. E., M. N. K. Karanikola, M. Kalafati, et al. 2012. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. American Journal of Critical Care 21(2): e41–e52. Russell, B. 1921. Lecture IX: Memory. The analysis of mind. London, UK: George Allen & Unwin Ltd.
Power Hierarchy and Epistemic Injustice in Clinical Ethics Consultation Anita Ho, National University of Singapore and University of British Columbia Dave Unger, Providence Health Care, Vancouver, Canada In recent years, there has been an increasing emphasis on person-centered care and shared decision making. These promote fostering partnerships with patients and their families, and ensuring that their values and preferences play a prominent role in treatment decision making. With this backdrop, Fiester’s (2015) suggestion of exploring all
stakeholders’ perspectives as part of a dialogue-focused clinical ethics consultation (CEC) has much to offer. Fiester argues that mediated (facilitated) conversations with all stakeholders is superior to a recommendation-focused CEC approach because it can promote reframing relevant statements and renegotiating options, help to prevent
Address correspondence Anita Ho, National University of Singapore, Singapore; University of British Columbia, Vancouver, Canada. E-mail: [email protected]
40 ajob
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
closure through sustained reflections on the ethical challenges prompted by the clinical encounter, and to draw on the discussions they had during an ethics consultation to eventually moderate and manage various moral emotions and feelings of distress. Chronic, unresolved regret, guilt, and anger can be pernicious and harmful. However, there is a difference between experiencing guilt, anger, or indignation over a limited time period, and being unable to ever overcome or manage these feelings. Part of what it means to equip stakeholders to achieve closure over time is to engage in a sufficiently transparent, accessible, rich, and encouraging discussion about the moral questions, issues, and options in a case so as to allow an individual to retrospectively take up different moral vantage points and establish a constructive internal dialogue that helps to manage, contain, and move beyond the experience of various negative moral emotions and distress and achieve closure over time. Given the complexity of ethical issues and questions raised in various cases, the ethics consultant alone is unlikely to be able to adequately equip any given stakeholder or all of the stakeholders to achieve closure over time. Contrary to what Fiester suggests, effectively equipping people to address the range of moral emotions they may feel and the moral distress they might experience will require the skill set of more than just the clinical ethicist. Clergy, therapists, social workers, ombudsmen, and other hospital services are important groups of people to recruit and mobilize for the effort to equip and empower stakeholders to ultimately achieve closure on any given ethical problem(s) that were raised in a particular case. The clinical ethicist ought to be familiar with the resources at hand when encountering stakeholders with a great amount of moral distress or negative moral emotions. During the week prior to this article being written, the authors of this commentary collaborated on a number of ethics consultations in which they referred people to, or recommended they consult, social work, spiritual care,
child life, psychologists, and others to help stakeholders process their ongoing emotional and moral consternation. We felt it is part of our jobs to know about these resources and know when they are appropriate to recommend. It was not in our scope to develop a moral, emotional, or psychological counseling relationship that would be ongoing in order for closure to occur. Hopefully, our clear, compassionate, and transparent processes provided the conditions for continued work by these other professionals and the stakeholders themselves. As clinical ethicists, we can acknowledge the good of closure, but also recognize that the ethical questions and issues raised in a case will often require thought and reflection beyond the duration of an ethics consultation. Within our scope of practice is an effort to equip stakeholders to achieve closure over time. However, just as the ethical issues and moral emotions raised in a case can linger with stakeholders, they can also haunt the clinical ethicist (Ford and Dudzinski 2008). This raises the question: If the clinical ethicist is working to equip stakeholders in an ethics consultation to achieve closure in time, who is equipping the clinical ethicist to achieve closure? As a profession we should be sure that clinical ethicists are provided the same tools for the beginnings of closure as we provide the other stakeholders in these cases. &
REFERENCES Eliot, T. S. 1971. Four quartets. New York, NY: Harcourt. Original work published 1943. Fiester, A. 2015. Neglected ends: Clinical ethics consultation and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Ford, P., and D. Dudzinski, eds. 2008. Complex ethical consultations: Cases that haunt us. New York, NY: Cambridge University Press. Yoder, S. 1998. Experts in ethics? The nature of ethical expertise. Hastings Center Report 28(6): 11–17.
Moral Distress and Prospects for Closure Haavi Morreim, University of Tennessee Health Science Center Autumn Fiester (2015) argues that when an ethics consult simply issues a recommendation it may leave a vacuum then filled by moral distress or moral emotion. “Assisted conversation”—a dialogue-focused approach—
can better promote closure and reduce the negative effects of conflict. Overall, this commentary argues that although Fiester is right about the benefits of mediation, she (and the
Address correspondence to Haavi Morreim, University of Tennessee Health Science Center, 910 Madison Ave., Memphis, TN 38163, USA. E-mail: [email protected]
38 ajob
January, Volume 15, Number 1, 2015
Clinical Ethics Consultation and Closure
relevant literature generally) understates the nature of genuine moral distress and thereby overestimates possibilities for closure in those particular cases. Moral distress is best understood as a clash of “bedrock” values and/or bedrock beliefs. These are the values and beliefs underlying all one’s other beliefs and values. For instance, the assertion that “life is infinitely precious regardless of quality” is a deeply-rooted, fundamental belief that is incommensurate with an equally deeply-rooted fundamental belief that “some qualities of life are worse than death.” One endorses either “life, regardless of quality” or “quality matters.” Not both. Beliefs and values at this level cannot be defended or defeated, either rationally or empirically, because they form the substrate on which all further claims are built. Since bedrock clashes are impossible in principle to resolve—or thereby to achieve “closure”—the best uses of assisted conversation are (a) to identify the many cases in which there really is no bedrock clash despite appearances to the contrary, and (b) to recognize that often such a clash need not necessarily be resolved to forge a mutually acceptable resolution to the problem at hand. Fiester invokes a familiar definition of “moral distress”: “a strong conviction about what is right to do in a particular situation without being able to take the action perceived as morally correct” (31). Physicians, nurses, even ethics consultants can experience moral distress, with consequences including regret, self-reproach, disempowerment, and burnout. Patients and families are said to experience “moral emotion.” When “‘we judge someone to have wronged someone else, perceive that a wrong has been committed against oneself, or believe we have failed someone” (31) we feel guilt, anger, resentment, perhaps indignation. (Fiester does not explain why providers have moral distress, whereas patients and families only experience moral emotion.) This commentary proposes that the relevant literature, as a whole, fails to recognize the profound underpinnings of genuine moral distress (e.g., Browning 2013; Elpern and Balk 2008; Elpern, Cover, and Kleinpell 2005; Epstein and Delgado 2009; Hamric and Blackhall 2007; Lomis, Carpenter, and Miller 2009; Morris and Dracup 2008; Papathanassoglou et al. 2012). Rather than simply a strong conviction pitted against a barrier to acting on that conviction, true moral distress is better understood as a situation in which parties hold fundamentally opposing “bedrock beliefs” and/or opposing “bedrock values.” Bedrock beliefs and values are those on which other beliefs and values ultimately rest. These “buck stops here” precepts emerge when we can no longer answer the question “so why should we agree with that?” and instead can only resort to “that’s just the way it is, darn it!” We cannot forever, into infinite regress, provide the next justification for espousing the prior tenet. At some point rationales and justifications must end. Beliefs and values at this bedrock level cannot possibly be defended or defeated, either rationally or empirically, and any attempt to prove their validity will inevitably invoke circular, question-begging reasoning—presuming as true the very thing(s) one is trying to prove.
January, Volume 15, Number 1, 2015
Thus, bedrock beliefs mainly concern metaphysics, theology, ontology, and the like. They comprise our most fundamental picture of what the world is made of, and how things run, and what will count as proof or evidence that those beliefs are true. If one believes everything is created by a deity and that every minute event is consciously engineered or permitted by that deity, then one will see one’s survival of a terrible accident as proof-positive that this deity is alive and at work in one’s own life. Those denying such an account might respond, “You got lucky because the oncoming car’s path, intersecting with your trajectory, threw you just to the left of the tree instead of directly into it; so how would that prove there’s a God??” Where Kierkegaard says “it requires a leap of faith,” an opposing side will reply “why should I leap at all, and why in that particular direction?” Bertrand Russell comes to mind: “There is no logical impossibility in the hypothesis that the world sprang into being five minutes ago, exactly as it then was, with a population that ‘remembered’ a wholly unreal past” (Russell 1921, 159–160). One cannot possibly disprove such a proposition without at certain points presuming as true the very thing one wishes to prove. Bedrock values concern our deepest precepts about what is right and wrong, what we ought and ought not to do, in the most important realms of our lives. Thus, “Every moment of life is infinitely precious, regardless of its quality” is simply incompatible with “At some point the quality of life is so poor, death becomes preferable.” The fundamental character of bedrock beliefs and values explains why we have not, and will never, “resolve” such debates as creationism or abortion. Where one person says “a woman has the right to control her own body,” the other side replies “there are two bodies, one inside the other.” Our willingness to override a Jehovah’s Witness parent’s refusal of blood for his child presupposes, at some level, that the Witness is theologically incorrect, and that the transfusion will not carry the price of eternal separation from God. These clashes are the ultimate conflict, challenging our strongest personal commitments. Because bedrock beliefs and values can be neither defended nor defeated, and because clashing bedrocks therefore cannot be reconciled, no mediative process can possibly produce closure, emotionally or intellectually, when one side “loses” while the other “wins.” It is impossible in principle. The heightened emotions, stemming both from deep conviction and from utter helplessness, cannot be mediated away. Instead, the best uses of mediation for conflict in bioethics are (1) to explore the details of the conflict and, in many cases, discern that no bedrock clash is actually afoot and (2) to forge practical resolutions that do not require reconciling bedrock clashes. Happily, these will likely constitute the substantial majority of ethics-related conflicts, and they provide a broad range of opportunities for effective, problem-solving mediation. Take a statement like “God will work a miracle if we keep treating.” On one hand, if offered as a bedrock religious conviction asserted to oppose the staff’s insistence that treatment is futile, mediation will not likely
ajob 39
The American Journal of Bioethics
achieve closure—though it might reduce emotional tension if each side feels genuinely heard and respected. On the other hand, in many instances that same statement may simply be a trump card played because “I don’t want to talk about it,” or “you doctors aren’t omnicient and I don’t believe it’s really that hopeless,” or “you’re rich and white and I don’t think you really care if this elderly black lady is dead or alive.” These cases leave broad room for exploring underlying fears, concerns, and factual beliefs, and for a collaborative problem solving that can turn discord into a set of shared goals even where not all views are harmonized. Here is where Fiester gets it right. In high-conflict situations a skilled mediative communication, in which the mediator earns the trust of everyone involved, has the opportunity to uncover what the real issue(s) is, and potentially help parties find enough common ground to address the clinical problem(s) at hand. Often an apparent clash will turn out to be a communication misfire, and even bona fide bedrock clashes need not preclude practical resolutions. As Steven Toulmin and Al Jonsen (Jonsen and Toulmin 1988) observed so many years ago, one need not always agree on basic precepts to figure out what to do in a given case. And as echoed by Bergman (2013, 13), “Consensus on outcomes does not necessarily require consensus on principles.” Here a good mediator may be able to assist people in conflict to address their solvable problems, notwithstanding their deeper divides. & REFERENCES Bergman, E. 2013. Surmounting elusive barriers: The case for bioethics mediation. Journal of Clinical Ethics 24(1): 11–24. Browning, A. M. 2013. Moral distress and psychological empowerment in critical care nurses caring for adults at end of life. American Journal of Critical Care 22(2): 143–151.
Elpern, E. H., and R. A. Balk. 2008. Trouble in the ICU: Diagnosing moral distress. Chest Physician 3(6): 8–9. Elpern, E. H., B. Covert, and R. Kleinpell. 2005. Moral distress of staff nurses in a medical intensive care unit. American Journal of Critical Care 14: 523–530. Epstein, E. G., and S. Delgado. 2010. Understanding and addressing moral distress. Online Journal of Issues in Nursing, September 30. Available at: http://www.nursingworld.org/MainMenuCategories/ EthicsStandards/Courage-and-Distress/Understanding-Moral-Distress. html Fiester, A. 2015. Neglected ends: Clinical ethics consutlaiton and the prospects for closure. American Journal of Bioethics 15(1): 29–36. Hamric, A. B., and L. J. Blackhall. 2007. Nurse–physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. Critical Care Medicine 35:422–429. Jonsen, A. R., and S. Toulmin. 1988. The abuse of casuistry: A history of moral reasoning. Berkeley, CA: University of California Press. Lomis, K. D., R. O. Carpenter, and B. M. Miller. 2009. Moral distress in the third year of medical school; a descriptive review of student case reflections. American Journal of Surgery 197:107–111. Morris, P. E., and K. Dracup. 2008. Time for a tool to measure moral distress? American Journal of Critical Care 17(5): 398–401. Papathanassoglou, E. D. E., M. N. K. Karanikola, M. Kalafati, et al. 2012. Professional autonomy, collaboration with physicians, and moral distress among European intensive care nurses. American Journal of Critical Care 21(2): e41–e52. Russell, B. 1921. Lecture IX: Memory. The analysis of mind. London, UK: George Allen & Unwin Ltd.
Power Hierarchy and Epistemic Injustice in Clinical Ethics Consultation Anita Ho, National University of Singapore and University of British Columbia Dave Unger, Providence Health Care, Vancouver, Canada In recent years, there has been an increasing emphasis on person-centered care and shared decision making. These promote fostering partnerships with patients and their families, and ensuring that their values and preferences play a prominent role in treatment decision making. With this backdrop, Fiester’s (2015) suggestion of exploring all
stakeholders’ perspectives as part of a dialogue-focused clinical ethics consultation (CEC) has much to offer. Fiester argues that mediated (facilitated) conversations with all stakeholders is superior to a recommendation-focused CEC approach because it can promote reframing relevant statements and renegotiating options, help to prevent
Address correspondence Anita Ho, National University of Singapore, Singapore; University of British Columbia, Vancouver, Canada. E-mail: [email protected]
40 ajob
January, Volume 15, Number 1, 2015
Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
