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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. "I Should've Been Able to Decide for Myself, but I Didn't Want to Be Left Alone." A Qualitative Interview Study of Clients' Ethical Challenges and Norms Regarding Decision-Making in Gender-Affirming Medical Care. JOURNAL OF HOMOSEXUALITY 2024; 71:1757-1781. [PMID: 37097132 DOI: 10.1080/00918369.2023.2201972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.
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Affiliation(s)
- Karl Gerritse
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Casper Martens
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Fijgje de Boer
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert C Molewijk
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Yu Q, Wang H, Tian Y, Wang Q, Yang L, Liu Q, Li Y. Moral courage, job-esteem, and social responsibility in disaster relief nurses. Nurs Ethics 2023; 30:1051-1067. [PMID: 37192663 DOI: 10.1177/09697330231174540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Social responsibility can motivate disaster relief nurses to devote themselves to safeguarding rights and interests of people when facing challenges that threaten public health. However, few studies focused on the relationship of moral courage, job-esteem, and social responsibility among disaster relief nurses. OBJECTIVE To explore the influence of moral courage and job-esteem on the social responsibility in disaster relief nurses and clarify the relationship model between them. METHODS A cross-sectional study was conducted among 716 disaster relief nurses from 14 hospitals in central China through an online survey, including moral courage scale, job-esteem scale, and social responsibility questionnaire. The data were analyzed by Pearson's correlation, and the mechanism of the effect of moral courage and job-esteem on social responsibility was completed. ETHICAL CONSIDERATIONS This study was approved by the Medical Ethics Committee of the Second Xiangya Hospital of Central South University (Approval Number: 2019016). RESULTS Disaster relief nurses' moral courage positively impacted social responsibility (r = 0.677, p < 0.01), and moral courage could affect social responsibility through the mediating role of job-esteem. CONCLUSION Job-esteem mediated between moral courage and social responsibility among disaster relief nurses. Nursing managers regular assessment of nurses' moral courage and interventions such as meetings and workshops can reduce moral distress, foster morally courageous behavior, enhance job-esteem, and improve social responsibility performance among disaster relief nurses.
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Affiliation(s)
- Qiang Yu
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Huaqin Wang
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yusheng Tian
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Psychiatry, National Clinical Research Center for Mental Disorders, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qin Wang
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Li Yang
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiaomei Liu
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yamin Li
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, China
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Guinaudeau J, Baier PC, Kühlmeyer K, Borzikowsky C, Terheyden L, Witt VD, Rogge A. [Changes in the routine work and moral distress in psychiatric care during the COVID-19 pandemic : A survey among physicians active in inpatient care in Germany]. DER NERVENARZT 2023; 94:827-834. [PMID: 37405400 PMCID: PMC10499671 DOI: 10.1007/s00115-023-01499-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND During the COVID-19 pandemic a number of ethical challenges have arisen in the healthcare system. A psychological response to moral challenges is termed moral distress (MD). OBJECTIVE Identification of causes of MD in inpatient psychiatric care in the context of the COVID-19 pandemic in Germany. MATERIAL AND METHODS A survey was conducted using a self-administered non-validated online questionnaire as part of a cross-sectional study, in which 26 items about the experience of MD were examined and open questions about the handling of the pandemic and its effects on everyday work were posed. Physicians who worked in inpatient psychiatric care during the COVID-19 pandemic in Germany were surveyed anonymously with a convenience sample. The data acquisition took place between 17 November 2020 and 6 May 2021. RESULTS A total of 141 participants were included. They indicated multiple pandemic-related changes in their daily work partly resulting in MD. CONCLUSION MD is a neglected potential burden of inpatient psychiatric care under pandemic conditions (and beyond), which requires further research and an adequate handling. These results include implications for decision makers in crisis teams as well as a need for support services such as clinical ethics consultation services.
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Affiliation(s)
- Jeanne Guinaudeau
- Zentrum für Integrative Psychiatrie, Universitätsklinikum Schleswig-Holstein, Niemannsweg 147, 24105, Kiel, Deutschland.
| | - Paul Christian Baier
- Zentrum für Integrative Psychiatrie, Universitätsklinikum Schleswig-Holstein, Niemannsweg 147, 24105, Kiel, Deutschland
| | - Katja Kühlmeyer
- Institut für Ethik, Geschichte und Theorie der Medizin, Ludwig-Maximilians-Universität München, München, Deutschland
| | - Christoph Borzikowsky
- Institut für Medizinische Informatik und Statistik, Christian-Albrechts-Universität zu Kiel, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Laura Terheyden
- Klinik für Neurologie, Nordseeklinik Helgoland, Helgoland, Deutschland
| | | | - Annette Rogge
- Klinik für Neurologie, Nordseeklinik Helgoland, Helgoland, Deutschland
- Klinik für Neurologie, Universitätsklinikum Schleswig-Holstein, Kiel, Deutschland
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van Zuylen ML, de Snoo-Trimp JC, Metselaar S, Dongelmans DA, Molewijk B. Moral distress and positive experiences of ICU staff during the COVID-19 pandemic: lessons learned. BMC Med Ethics 2023; 24:40. [PMID: 37291555 PMCID: PMC10249541 DOI: 10.1186/s12910-023-00919-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/23/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic causes moral challenges and moral distress for healthcare professionals and, due to an increased work load, reduces time and opportunities for clinical ethics support services. Nevertheless, healthcare professionals could also identify essential elements to maintain or change in the future, as moral distress and moral challenges can indicate opportunities to strengthen moral resilience of healthcare professionals and organisations. This study describes 1) the experienced moral distress, challenges and ethical climate concerning end-of-life care of Intensive Care Unit staff during the first wave of the COVID-19 pandemic and 2) their positive experiences and lessons learned, which function as directions for future forms of ethics support. METHODS A cross-sectional survey combining quantitative and qualitative elements was sent to all healthcare professionals who worked at the Intensive Care Unit of the Amsterdam UMC - Location AMC during the first wave of the COVID-19 pandemic. The survey consisted of 36 items about moral distress (concerning quality of care and emotional stress), team cooperation, ethical climate and (ways of dealing with) end-of-life decisions, and two open questions about positive experiences and suggestions for work improvement. RESULTS All 178 respondents (response rate: 25-32%) showed signs of moral distress, and experienced moral dilemmas in end-of-life decisions, whereas they experienced a relatively positive ethical climate. Nurses scored significantly higher than physicians on most items. Positive experiences were mostly related to 'team cooperation', 'team solidarity' and 'work ethic'. Lessons learned were mostly related to 'quality of care' and 'professional qualities'. CONCLUSIONS Despite the crisis, positive experiences related to ethical climate, team members and overall work ethic were reported by Intensive Care Unit staff and quality and organisation of care lessons were learned. Ethics support services can be tailored to reflect on morally challenging situations, restore moral resilience, create space for self-care and strengthen team spirit. This can improve healthcare professionals' dealing of inherent moral challenges and moral distress in order to strengthen both individual and organisational moral resilience. TRIAL REGISTRATION The trial was registered on The Netherlands Trial Register, number NL9177.
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Affiliation(s)
- Mark L. van Zuylen
- Department of Anaesthesiology, Amsterdam UMC, University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Janine C. de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
| | - Dave A. Dongelmans
- Department of Intensive Care, Amsterdam, UMC, University of Amsterdam, Meibergdreef, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, Amsterdam, 1081 HV The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Schulz I, O'Neill J, Gillam P, Gillam L. The scope of ethical dilemmas in paediatric nursing: a survey of nurses from a tertiary paediatric centre in Australia. Nurs Ethics 2023; 30:526-541. [PMID: 36877536 DOI: 10.1177/09697330231153916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND No previous study has provided evidence for the scope and frequency of ethical dilemmas for paediatric nurses. It is essential to understand this to optimise patient care and tailor ethics support for nurses. RESEARCH AIM The aim of this study was to explore the scope of nurses' ethical dilemmas in a paediatric hospital and their engagement with the hospital clinical ethics service. RESEARCH DESIGN This study used a cross-sectional survey design. PARTICIPANTS AND RESEARCH CONTEXT Paediatric nursing staff in a tertiary paediatric centre in Australia completed an online survey asking about their exposure to a range of ethical dilemmas and their knowledge of the clinical ethics service. Analysis used descriptive and inferential statistics. ETHICAL CONSIDERATIONS Ethical approval was granted from the hospital research committee. The survey was anonymous, and no identifying details of participants were collected. RESULTS Paediatric nurses experienced a wide range of ethical dilemmas frequently, both in the intensive care and general areas. Knowledge and use of the clinical ethics service was poor and the most frequent challenge for nurses in managing dilemmas was feeling powerless. CONCLUSION There is a need to recognise the moral burden of ethical dilemmas for paediatric nurses in order to foster ethical sensitivity, and to provide adequate support to improve care and mitigate nursing moral distress.
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Affiliation(s)
- Ingrid Schulz
- The Victorian Paediatric Palliative Care Program, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Jenny O'Neill
- The Department of Nursing Research, The Royal Children's Hospital, Melbourne, VIC, Australia; Melbourne School of Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; The Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Peter Gillam
- Department of Psychology, The University of Melbourne, Melbourne, VIC, Australia
| | - Lynn Gillam
- The Children's Bioethics Centre, The Royal Children's Hospital, Melbourne, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia
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Jakobsen L, Olsen RM, Brinchmann BS, Devik SA. Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences. SAGE Open Nurs 2023; 9:23779608221150725. [PMID: 36654853 PMCID: PMC9841835 DOI: 10.1177/23779608221150725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/17/2022] [Accepted: 12/26/2022] [Indexed: 01/15/2023] Open
Abstract
Introduction Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses. Objective To investigate how digital ethical reflection can support ethics work among nurses working in long-term care. Methods A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA). Results During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager. Conclusions Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.
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Affiliation(s)
- Lena Jakobsen
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway,Lena Jakobsen, Faculty of Nursing and Health Sciences, Nord University, PO Box 1490, 8049 Bodø, Norway.
| | - Rose Mari Olsen
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
| | - Berit Støre Brinchmann
- Faculty of Nursing and Health Sciences, Nord University, Norway and Nordland Regional University, Bodø, Norway
| | - Siri Andreassen Devik
- Centre for Care Research Mid-Norway, Faculty of Nursing and Health Sciences, Nord University, Namsos, Norway
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Heidenreich K, Svantesson M, Karlsson M, Bremer A. Exploring what is reasonable: uncovering moral reasoning of vascular surgeons in daily practice. BMC Med Ethics 2023; 24:1. [PMID: 36624427 PMCID: PMC9827683 DOI: 10.1186/s12910-022-00881-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/29/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Vascular surgery offers a range of treatments to relieve pain and ulcerations, and to prevent sudden death by rupture of blood vessels. The surgical procedures involve risk of injury and harm, which increases with age and frailty leading to complex decision-making processes that raise ethical questions. However, how vascular surgeons negotiate these questions is scarcely studied. The aim was therefore to explore vascular surgeons' moral reasoning of what ought to be done for the patient. METHODS Qualitative, semi-structured interviews were conducted with 19 vascular surgeons working at three Swedish university hospitals. Data were analysed according to systematic text condensation. RESULTS The surgeons' moral reasoning about what ought to be done comprised a quest to relieve suffering and avoid harm by exploring what is reasonable to do for the patient. Exploring reasonableness included to shift one´s perspective from the vessels to the whole person, to balance patient's conflicting needs and to place responsibility for right decision on one´s shoulders. The shift from blood vessels to the whole person implied gaining holistic knowledge in pondering of what is best, struggling with one´s authority for surgery through dialogue, and building relationship for mutual security. To balance patient's conflicting needs implied weighing the patient's independence and a sense of being whole against ease of suffering, respecting the patient's will against protecting life and well-being, and weighing longer life against protecting the present well-being. Finally, to place responsibility on one´s shoulders was conveyed as an urge to remind oneself of the risk of complications, withholding one's power of proficiency, and managing time during the illness course. CONCLUSIONS This study contributes to uncovering how moral reasoning is embodied in the vascular surgeons' everyday clinical discourse as a tangible part of their patient care. The results underpin the significance of moral considerations in the assemblage of medical knowledge and technical skills to further understand vascular surgeons' clinical practice. The clinical application of these results is the need of forums with sufficient possibilities for articulating these important moral considerations in everyday care.
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Affiliation(s)
- Kaja Heidenreich
- grid.15895.300000 0001 0738 8966Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, S-Huset, 2nd Floor, 70182 Örebro, Sweden
| | - Mia Svantesson
- grid.15895.300000 0001 0738 8966Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, S-Huset, 2nd Floor, 70182 Örebro, Sweden
| | - Marit Karlsson
- grid.5640.70000 0001 2162 9922Department of Health, Medicine and Caring Sciences, Linköping University, 58183 Linköping, Sweden
| | - Anders Bremer
- grid.8148.50000 0001 2174 3522Faculty of Health and Life Sciences, Linnaeus University, 35195 Växjö, Sweden
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Wilhelmy S, Müller R, Gross D. Identifying the scope of ethical challenges caused by the Ebola epidemic 2014-2016 in West Africa: a qualitative study. Philos Ethics Humanit Med 2022; 17:16. [PMID: 36575529 PMCID: PMC9794467 DOI: 10.1186/s13010-022-00128-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 12/01/2022] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND The West African Ebola virus epidemic from 2014 to 2016 is unprecedented in its scale, surpassing all previous and subsequent Ebola outbreaks since 1976. This epidemic provoked a humanitarian emergency that extended to different spheres of life, making visible ethical challenges in addition to medical, economic, and social ones. The present article aims to identify and differentiate the scope of ethical issues associated with the Ebola epidemic. METHODS An online media analysis was performed on articles published from March 2014 to September 2015 in ten preselected academic journals (scientific press) and two online newspapers (lay press). Two methodological approaches were combined: a systematic literature search and a qualitative content analysis. An additional keyword search was conducted on the PubMed database for the period after the end of the Ebola epidemic (2016-2020) to obtain an overview of research dealing with medical ethics due to the epidemic and to compare these results with the identified ethical challenges. RESULTS A total of 389 articles dealing with the subject fields "Ebola epidemic" and "ethics" were researched. For qualitative content analysis, the time span with the highest article density was selected and a total of 64 articles were included (15 scientific articles, 49 popular articles). Five core ethical challenges of the Ebola epidemic emerged: 1. Responsibility and Accountability, 2. Spillover Effects, 3. Research and Development, 4. Health Communication, and 5. Resource Allocation. Articles in academic journals were dominated by the discussion of normative aspects in the area of "research and development", while newspaper articles focused on aspects of "responsibility and accountability". CONCLUSION An ethical discussion of the Ebola epidemic requires an examination of as many of the ethical dimensions involved as possible. The presented investigation of the two types of media with regard to the Ebola epidemic offers this possibility of a more comprehensive insight into this diversity as a basis for ethical discussions.
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Affiliation(s)
- Saskia Wilhelmy
- Institute for History, Theory and Ethics of Medicine, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074 Aachen, Germany
| | - Regina Müller
- Institute of Philosophy, University of Bremen, Enrique-Schmidt-Str. 7, 28359 Bremen, Germany
| | - Dominik Gross
- Institute for History, Theory and Ethics of Medicine, Medical Faculty, RWTH Aachen University, Wendlingweg 2, 52074 Aachen, Germany
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals' ethical challenges and norms regarding decision-making in gender-affirming medical care. BMC Med Ethics 2022; 23:139. [PMID: 36575401 PMCID: PMC9793857 DOI: 10.1186/s12910-022-00880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands. METHODS In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents' explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged. RESULTS Respondents' ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC's guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI. CONCLUSIONS This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.
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Affiliation(s)
- Karl Gerritse
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Casper Martens
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Marijke A. Bremmer
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Baudewijntje P. C. Kreukels
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Medical Psychology, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Fijgje de Boer
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Bert C. Molewijk
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
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Tawse J, Demou E. Qualitative study to explore UK medical students' and junior doctors' experiences of occupational stress and mental health during the COVID-19 pandemic. BMJ Open 2022; 12:e065639. [PMID: 36523252 PMCID: PMC9748513 DOI: 10.1136/bmjopen-2022-065639] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This qualitative study aimed to explore the occupational experiences of medical students and junior doctors working during the COVID-19 pandemic. In particular, the research sought to identify factors which mediated work stress, barriers to disclosing mental health problems and levels of support medical students and junior doctors received during the pandemic. DESIGN This study was a form of thematic analysis and adopted an inductive, 'bottom-up' approach, in which coded categories were derived from rich, descriptive data. SETTING Semistructured interviews were conducted online with UK-based medical students and junior doctors. Interviews were recorded, and analysis was done by coding salient quotes into themes. PARTICIPANTS The final sample consisted of seven junior doctors and eight medical students, during the summer of 2021. RESULTS High levels of occupational stress were identified, which were exacerbated by COVID-19. A number of organisational difficulties associated with the pandemic compounded participants' experiences of work stress. Participants recognised progress towards promoting and managing mental health within the profession but may still be reluctant to access support services. Barriers to disclosure included fear of stigmatisation, concerns about adding to colleagues' workloads, lack of clarity about career implications and mistrust of occupational health services. CONCLUSIONS While attitudes towards mental health have improved, medical students and junior doctors may avoid seeking help. Given the immense pressures faced by health services, it is imperative that extra measures are implemented to minimise work-stress, encourage help-seeking behaviours and promote supportive work cultures.
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Affiliation(s)
- James Tawse
- University of Glasgow College of Social Sciences, Glasgow, UK
- Staff Advice and Liaison Service, Alder Hey Children's Hospital, Liverpool, UK
| | - Evangelia Demou
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow College of Medical Veterinary and Life Sciences, Glasgow, UK
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Hofstad T, Husum TL, Rugkåsa J, Hofmann BM. Geographical variation in compulsory hospitalisation - ethical challenges. BMC Health Serv Res 2022; 22:1507. [PMID: 36496384 PMCID: PMC9737766 DOI: 10.1186/s12913-022-08798-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 11/07/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Compulsory hospitalisation in mental health care restricts patients' liberty and is experienced as harmful by many. Such hospitalisations continue to be used due to their assumed benefit, despite limited scientific evidence. Observed geographical variation in compulsory hospitalisation raises concern that rates are higher and lower than necessary in some areas. METHODS/DISCUSSION We present a specific normative ethical analysis of how geographical variation in compulsory hospitalisation challenges four core principles of health care ethics. We then consider the theoretical possibility of a "right", or appropriate, level of compulsory hospitalisation, as a general norm for assessing the moral divergence, i.e., too little, or too much. Finally, we discuss implications of our analysis and how they can inform the future direction of mental health services.
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Affiliation(s)
- Tore Hofstad
- grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Tonje Lossius Husum
- grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway ,grid.412414.60000 0000 9151 4445Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Jorun Rugkåsa
- grid.411279.80000 0000 9637 455XHealth Services Research Unit, Akershus University Hospital, Lørenskog, Norway ,grid.463530.70000 0004 7417 509XCentre for Care Research, University of South-Eastern Norway, Porsgrunn, Norway
| | - Bjørn Morten Hofmann
- grid.5510.10000 0004 1936 8921Centre for Medical Ethics, University of Oslo, Oslo, Norway ,grid.5947.f0000 0001 1516 2393Department of Health Sciences, Norwegian University of Science and Technology, Gjøvik, Norway
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Müller R, Klemmt M, Ehni HJ, Henking T, Kuhnmünch A, Preiser C, Koch R, Ranisch R. Ethical, legal, and social aspects of symptom checker applications: a scoping review. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:737-755. [PMID: 36181620 PMCID: PMC9613552 DOI: 10.1007/s11019-022-10114-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 09/03/2022] [Indexed: 06/16/2023]
Abstract
Symptom Checker Applications (SCA) are mobile applications often designed for the end-user to assist with symptom assessment and self-triage. SCA are meant to provide the user with easily accessible information about their own health conditions. However, SCA raise questions regarding ethical, legal, and social aspects (ELSA), for example, regarding fair access to this new technology. The aim of this scoping review is to identify the ELSA of SCA in the scientific literature. A scoping review was conducted to identify the ELSA of SCA. Ten databases (e.g., Web of Science and PubMed) were used. Studies on SCA that address ELSA, written in English or German, were included in the review. The ELSA of SCA were extracted and synthesized using qualitative content analysis. A total of 25,061 references were identified, of which 39 were included in the analysis. The identified aspects were allotted to three main categories: (1) Technology; (2) Individual Level; and (3) Healthcare system. The results show that there are controversial debates in the literature on the ethical and social challenges of SCA usage. Furthermore, the debates are characterised by a lack of a specific legal perspective and empirical data. The review provides an overview on the spectrum of ELSA regarding SCA. It offers guidance to stakeholders in the healthcare system, for example, patients, healthcare professionals, and insurance providers and could be used in future empirical research to investigate the perspectives of those affected, such as users.
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Affiliation(s)
- Regina Müller
- Institute of Ethics and History of Medicine, University of Tübingen, Gartenstraße 47, 72074 Tübingen, Germany
| | - Malte Klemmt
- Institute of Applied Social Sciences, University of Applied Sciences Würzburg-Schweinfurt, Münzstraße 12, 97070 Würzburg, Germany
| | - Hans-Jörg Ehni
- Institute of Ethics and History of Medicine, University of Tübingen, Gartenstraße 47, 72074 Tübingen, Germany
| | - Tanja Henking
- Institute of Applied Social Sciences, University of Applied Sciences Würzburg-Schweinfurt, Münzstraße 12, 97070 Würzburg, Germany
| | - Angelina Kuhnmünch
- Institute of Ethics and History of Medicine, University of Tübingen, Gartenstraße 47, 72074 Tübingen, Germany
| | - Christine Preiser
- Institute of Occupational and Social Medicine and Health Services Research, University Hospital Tübingen, Wilhelmstraße 27, 72074 Tübingen, Germany
| | - Roland Koch
- Institute for General Practice and Interprofessional Care, University Medicine Tübingen, Osianderstraße 5, 72076 Tübingen, Germany
| | - Robert Ranisch
- Faculty of Health Sciences Brandenburg, University of Potsdam, Karl-Liebknecht-Str. 24-25, House 16, 14476 Potsdam, Golm, Germany
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Dittborn M, Micolich C, Rojas D, Salas SP. Ethical Challenges Experienced by Healthcare Workers Delivering Clinical Care during Health Emergencies and Disasters: A Rapid Review of Qualitative Studies and Thematic Synthesis. AJOB Empir Bioeth 2022; 13:179-195. [PMID: 35467462 PMCID: PMC9881594 DOI: 10.1080/23294515.2022.2063996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background: The COVID-19 pandemic has posed several ethical challenges worldwide. Understanding care providers' experiences during health emergencies is key to develop comprehensive ethical guidelines for emergency and disaster circumstances.Objectives: To identify and synthetize available empirical data on ethical challenges experienced by health care workers (HCWs) providing direct patient care in health emergencies and disaster scenarios that occurred prior to COVID-19, considering there might be a significant body of evidence yet to be reported on the current pandemic.Methods: A rapid review of qualitative studies and thematic synthesis was conducted. Medline and Embase were searched from inception to December 2020 using "public health emergency" and "ethical challenges" related keywords. Empirical studies examining ethical challenges experienced by frontline HCWs during health emergencies or disasters were included. We considered that ethical challenges were present when participants and/or authors were uncertain regarding how one should behave, or when different values or ethical principles are compromised when making decisions.Outcome: After deduplication 10,160 titles/abstracts and 224 full texts were screened. Twenty-two articles were included, which were conducted in 15 countries and explored eight health emergency or disaster events. Overall, a total of 452 HCWs participants were included. Data were organized into five major themes with subthemes: HCWs' vulnerability, Duty to care, Quality of care, Management of healthcare system, and Sociocultural factors.Conclusion: HCWs experienced a great variety of clinical ethical challenges in health emergencies and disaster scenarios. Core themes identified provide evidence-base to inform the development of more comprehensive and supportive ethical guidelines and training programmes for future events, that are grounded on actual experiences of those providing care during emergency and disasters.
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Affiliation(s)
- Mariana Dittborn
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, UK;,Center for Bioethics, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Constanza Micolich
- Palliative Care Unit, Mauricio Heyermann Hospital of Angol, Angol, Chile
| | | | - Sofía P. Salas
- Center for Bioethics, Faculty of Medicine, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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