The theorisation of 'best interests' in bioethical accounts of decision-making

Can the courts be viewed as an appropriate vehicle to settle clinical unease?

This paper is an exploration of the state of 'clinical unease' experienced by clinicians in contexts where professional judgement-grounded in clinical knowledge, critical reflection and a sound grasp of the law-indicates that there is more than one ethically defensible way to proceed. The question posed is whether the courts can be viewed as an appropriate vehicle to settle clinical unease by providing a ruling that clarifies the legal and ethical issues arising in the case, even in situations where there is no dispute between the patient (or her proxies) and the healthcare team.The concept of 'clinical unease' is framed with reference to the broader experience of clinical decision-making, and distinguished from other widely discussed phenomena in the healthcare literature like moral distress and conscientious objection. A number of reported cases are briefly examined where the courts were invited to rule in circumstances of apparent 'unease'. The respective responsibilities of clinicians and courts are discussed: in particular, their capability and readiness to respond to matters of ethical concern.Four imagined clinical scenarios are outlined where a clinical team might welcome a court adjudication, under current rules. Consideration is given to the likelihood of such cases being heard, and to whether there may be better remedies than the courts. There are final reflections on what clinicians may actually wish for in seeking court involvement, and on whether a willingness to engage with the experience of clinical unease may lead to greater sensitivity towards the value perspectives of others.

"She was finally mine": the moral experience of families in the context of trisomy 13 and 18- a scoping review with thematic analysis

INTRODUCTION

The value of a short life characterized by disability has been hotly debated in the literature on fetal and neonatal outcomes.

METHODS

We conducted a scoping review to summarize the available empirical literature on the experiences of families in the context of trisomy 13 and 18 (T13/18) with subsequent thematic analysis of the 17 included articles.

FINDINGS

Themes constructed include (1) Pride as Resistance, (2) Negotiating Normalcy and (3) The Significance of Time.

INTERPRETATION

Our thematic analysis was guided by the moral experience framework conceived by Hunt and Carnevale (2011) in association with the VOICE (Views On Interdisciplinary Childhood Ethics) collaborative research group.

RELEVANCE

This article will be of interest and value to healthcare professionals and bioethicists who support families navigating the medically and ethically complex landscape of T13/18.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review

BACKGROUND

The expressions of a "wish to hasten death" or "wish to die" raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the "wish to hasten death/die" based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and how the meanings behind the "wish to hasten death/die" relate to and are interpreted in light of ethical principles in palliative care.

METHODS

We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare's framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330.

RESULTS

Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the "wish to hasten death" and/or "wish to die" were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the "wish to hasten death". Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles.

CONCLUSIONS

This meta-ethnographic review shows a reduced number of qualitative studies on the "wish to hasten death" and/or "wish to die" explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed.

An Overview of Ethical Issues Raised by Medicolegal Challenges to Death by Neurologic Criteria in the United Kingdom and a Comparison to Management of These Challenges in the USA

Although medicolegal challenges to the use of neurologic criteria to declare death in the USA have been well-described, the management of court cases in the United Kingdom about objections to the use of neurologic criteria to declare death has not been explored in the bioethics or medical literature. This article (1) reviews conceptual, medical and legal differences between death by neurologic criteria (DNC) in the United Kingdom and the rest of the world to contextualize medicolegal challenges to DNC; (2) summarizes highly publicized legal cases related to DNC in the United Kingdom, including the nuanced 2022 case of Archie Battersbee, who was transiently considered dead by neurologic criteria, but ultimately determined to be in a vegetative state/unresponsive-wakeful state; and (3) provides an overview of ethical issues raised by medicolegal challenges to DNC in the United Kingdom and a comparison to the management of these challenges in the USA.

Focusing the APA Ethics Code to Include Development: Applications to Abuse

Extant ethics codes in psychological work generally are not sufficiently developmentally oriented. Here, we examine the American Psychological Association ethics code for its developmental sensitivity, find it lacking in this regard, and make recommendations. Our approach was to place children and youth at the forefront in forming developmentally-targeted principles, meta-principles, values, and rights. To further this aim, we consulted the one ethics code in the field that is developmentally-attuned, the ethics code of the American Academy of Child and Adolescent Psychiatry. We used a revised set of ethical principles for psychological work and developed a set of meta-principles. The five APA ethics code principles are: (a) beneficence and nonmaleficence; (b) fidelity and responsibility; (c) integrity; (d) justice; and (e) respect for people's rights and dignity. The set of ethical principles taken from Young (Revising the American Psychological Association ethics code, Springer International Publishing, 2017) includes: (a) life preservation, (b) caring beneficence/nonmaleficence, (c) relational integrity, (d) respect for the dignity and rights of persons and peoples, and (e) promoting and acting from justice in society. The major meta-principles proposed here include: (a) functioning from responsibility, (b) promoting personhood, and (c) promoting participation. In addition, we added meta-principles for working from appropriate (d) theory and (e) meta-theory (Neo-Maslovian and a combined relationism-empiricism, respectively). Secondary meta-principles in the text refer to (a) systems, (b) the person as unique, (c) the vulnerabilities of people, (d) autonomy, and (e) morality.

Between Multiple Identities and Values: Professionals' Identity Conflicts in Ethically Charged Situations

This study explored identity conflict dynamics in interpersonal interactions in professionals facing ethically charged situations. Through semi-structured interviews (N = 47), we conducted a qualitative study among doctors and nurses working for the English National Healthcare Service and analyzed the data with grounded theory approaches. Our findings reveal that identity conflict is triggered by three micro processes, namely cognitive and emotional perspective taking, as well as identifying with the other. In these processes, identity conflict is signaled by emotions and recognized as a clash not only between identities and their values, but also within one identity and its multiple values. Behavioral and psychological outcomes of identity conflict involve seeking peer support, doing reflective practices and identity growth. This article contributes to identity literature by providing a multilevel approach of identity conflict dynamics able to account for both interpersonal and intrapsychic processes, deeply hold values and emotions, as well as crucial behavioral and psychological consequences.

Continuation of Hemodialysis in a Patient With Global Hypoxic Brain Injury: Ethical Considerations and Factors That May Influence Decision Making

Survivors of an out-of-hospital cardiac arrest are at a high risk of mortality and morbidity especially when there is resultant global hypoxic brain injury. In these situations, the patient's degree of neurologic recovery may be uncertain and family decision making is often difficult. Decision making may also be complicated by the age of the patient and one's underlying cultural and spiritual beliefs stressing the importance of patient- and family-centered care. In this article, this clinical case demonstrates the challenges in decision making and highlights the importance of communication among the health care team and the family to align the patient's goals, values, and preferences in light of a poor neurological prognosis.

Best interests and low thresholds: legal and ethical issues relating to needle and syringe services for under 18s in Sweden

Access for legal minors to needle and syringe programmes raises a number of practical, legal and ethical challenges that traverse clinical practice, child protection and child rights. This article addresses the current legal age restriction on access to needle and syringe programmes (NSPs) in Sweden. Based on legislation and legislative preparatory works, it traces the rationale for retaining an age restriction in the context of a policy priority to improve access for people who inject drugs. Building on threshold theory and child rights literature, the article unpacks the apparent tension between protecting the low threshold nature of service provision, child protection duties of healthcare staff, and the best interests of the child. It explores whether this tension could be alleviated through replacing a legal age restriction for all with best interests assessments for each individual, and discusses the potential ethical and practical challenges involved in such a change.

Consent for rapid genomic sequencing for critically ill children: legal and ethical issues

Although rapid genomic sequencing (RGS) is improving care for critically ill children with rare disease, it also raises important ethical questions that need to be explored as its use becomes more widespread. Two such questions relate to the degree of consent that should be required for RGS to proceed and whether it might ever be appropriate to override parents' decisions not to allow RGS to be performed in their critically ill child. To explore these questions, we first examine the legal frameworks on securing consent for genomic sequencing and how they apply to the specific context of RGS for critically ill children. We then use a tool from clinical ethics, the Zone of Parental Discretion, to explore two case studies and identify under which circumstances it might be appropriate for parental refusal of RGS to be overridden. We argue that RGS may be a context where, in addition to assessing the complexity of the test offered, it is ethically appropriate to consider an effect on patient outcomes when deciding the degree of consent required. We also suggest that there are some contexts where it may be ethically justified to perform RGS, even when it is actively against the wishes of the parents. More work is needed to examine exactly how 'time-sensitive' exceptions to current guidance on consent for genomic sequencing could be formulated and operationalised for RGS for critically ill-children.