Gender Dynamics in Substance Use and Treatment: A Women's Focused Approach

Gender impacts substance use initiation, substance use disorder development, engagement with treatment, and harms related to drug and alcohol use. Using the biopsychosocial model of addiction, this review provides a broad summary of barriers and facilitators to addiction services among women. It also reviews substance use among pregnant and parenting women and approaches to care. Given the increasing rates of substance use among women, there is a need to implement and scale-up gender-responsive addiction programming and pursue advocacy at the policy level that addresses the root drivers of substance use inequities among women.

The Missing Chapter: The Education of Surgery and Anesthesiology Trainees as Civic Advocates

The SARS-CoV-2 pandemic has highlighted existing systemic inequities that adversely affect a variety of communities in the United States. These inequities have a direct and adverse impact on the healthcare of our patient population. While civic engagement has not been cultivated in surgical and anesthesia training, we maintain that it is inherent to the core role of the role of a physician. This is supported by moral imperative, professional responsibility, and a legal obligation. We propose that such civic engagement and social justice activism is a neglected, but necessary aspect of physician training. We propose the implementation of a civic advocacy education agenda across department, community and national platforms. Surgical and anesthesiology residency training needs to evolve to the meet these increasing demands.

Professionally responsible advocacy for women and children first during the COVID-19 pandemic: guidance from World Association of Perinatal Medicine and International Academy of Perinatal Medicine

The goal of perinatal medicine is to provide professionally responsible clinical management of the conditions and diagnoses of pregnant, fetal, and neonatal patients. The New York Declaration of the International Academy of Perinatal Medicine, "Women and children First - or Last?" was directed toward the ethical challenges of perinatal medicine in middle-income and low-income countries. The global COVID-19 pandemic presents common ethical challenges in all countries, independent of their national wealth. In this paper the World Association of Perinatal Medicine provides ethics-based guidance for professionally responsible advocacy for women and children first during the COVID-19 pandemic. We first present an ethical framework that explains ethical reasoning, clinically relevant ethical principles and professional virtues, and decision making with pregnant patients and parents. We then apply this ethical framework to evidence-based treatment and its improvement, planned home birth, ring-fencing obstetric services, attendance of spouse or partner at birth, and the responsible management of organizational resources. Perinatal physicians should focus on the mission of perinatal medicine to put women and children first and frame-shifting when necessary to put the lives and health of the population of patients served by a hospital first.

Ethical challenges in nephrology: a call for action

The American Society of Nephrology, the European Renal Association-European Dialysis and Transplant Association and the International Society of Nephrology Joint Working Group on Ethical Issues in Nephrology have identified ten broad areas of ethical concern as priority challenges that require collaborative action. Here, we describe these challenges - equity in access to kidney failure care, avoiding futile dialysis, reducing dialysis costs, shared decision-making in kidney failure care, living donor risk evaluation and decision-making, priority setting in kidney disease prevention and care, the ethical implications of genetic kidney diseases, responsible advocacy for kidney health and management of conflicts of interest - with the aim of highlighting the need for ethical analysis of specific issues, as well as for the development of tools and training to support clinicians who treat patients with kidney disease in practising ethically and contributing to ethical policy-making.

Medical advocacy in the face of Australian immigration practices: A study of medical professionals defending the health rights of detained refugees and asylum seekers

While medical advocacy is mandated as a core professional commitment in a growing number of ethical codes and medical training programs, medical advocacy and social justice engagement are regularly subordinated to traditional clinical responsibilities. This study aims to provide insight into factors that motivate clinician engagement and perseverance with medical advocacy, so as to inform attempts by policymakers, leaders and educators to promote advocacy practices in medicine. Furthermore, this study aims to provide an analysis of the role of medical advocates in systems where patients' rights are perceived to be infringed and consider how we might best support and protect these medical advocates as a profession, by exploring the experiences and perspectives of Australian clinicians defending the health of detained asylum seekers. In this qualitative study thirty-two medical and health professionals advocating on asylum seeker health in immigration detention were interviewed. Transcripts were coded both inductively and deductively from interview question domains and thematically analysed. Findings suggested that respondents' motivations for advocacy stemmed from deeply intertwined professional and personal ethics. Overall, advocacy responses originated from the union of three integral stimuli: personal ethics, proximity and readiness. We conclude that each of these three integral factors must be addressed in any attempt to foster advocacy within the medical profession. In light of current global trends of increasingly protectionist immigration practices, promoting effective physician advocacy may become essential in ensuring patients' universal right to health.

[Choosing for euthanasia in advanced dementia; an analysis of the decisions by the Supreme Court]

For many yearsthere has been confusion in the Netherlands about the question of whether doctors are entitled to end the life of incompetent patients with advanced dementia. The euthanasia control commission, the disciplinary courts and the penal court all answered this question differently after a doctor had performed euthanasia on a 74-year-old woman with advanced dementia and an advance directive made at an earlier stage. On 21 April 2020 the Supreme Court provided clarity, at least to a certain extent. This contribution presents an analysis of the decisions made by the Supreme Court and their implications for self-chosen death in patients with advanced dementia.

Better Guidance for Surrogates

The March-April issue of the Hastings Center Report offers another in a series of articles over the last few years on the structure and the ethics of surrogate decision-making. Here, Daniel Brudney addresses how to help the surrogate deal with a treatment decision. A core insight he offers is that the structure of the surrogate's decision has been misunderstood and the misunderstanding makes the task yet harder. As usually understood, the surrogate is supposed to be guided by the question, what would the patient choose, if the patient were making the choice herself? Brudney argues that this conception is impossible, and that the surrogate's task is instead to consider the patient's best interests, as illuminated in part by the patient's expressed values and past choices. This understanding leads, he argues, to a different guiding question: what could the patient choose, given her values?

Ethical Advocacy Across the Autism Spectrum: Beyond Partial Representation

Recent debates within the autism advocacy community have raised difficult questions about who can credibly act as a representative of a particular population and what responsibilities that role entails. We attempt to answer these questions by defending a set of evaluative criteria that can be used to assess the legitimacy of advocacy organizations and other nonelectoral representatives. With these criteria in hand, we identify a form of misrepresentation common but not unique to autism advocacy, which we refer to as partial representation. Partial representation occurs when an actor claims to represent a particular group of people but appropriately engages with only a subset of that group. After highlighting symbolic and substantive harms associated with partial representation, we propose several strategies for overcoming it.

"Asset exchange"-interactions between patient groups and pharmaceutical industry: Australian qualitative study

OBJECTIVE

To understand and report on the nature of patient group interactions with the pharmaceutical industry from the perspective of patient group representatives by exploring the range of attitudes towards pharmaceutical industry sponsorship and how, why, and when interactions occur.

DESIGN

Empirical qualitative interview study informed by ethics theory.

SETTING

Australian patient groups.

PARTICIPANTS

27 participants from 23 Australian patient groups that represented diverse levels of financial engagement with the pharmaceutical industry. Groups were focused on general health consumer issues or disease specific topics, and had regional or national jurisdictions.

ANALYSIS

Analytic techniques were informed by grounded theory. Interview transcripts were coded into data driven categories. Findings were organised into new conceptual categories to describe and explain the data, and were supported by quotes.

RESULTS

A range of attitudes towards pharmaceutical industry sponsorship were identified that are presented as four different types of relationship between patient groups and the pharmaceutical industry. The dominant relationship type was of a successful business partnership, and participants described close working relationships with industry personnel. These participants acknowledged a potential for adverse industry influence, but expressed confidence in existing strategies for avoiding industry influence. Other participants described unsatisfactory or undeveloped relationships, and some participants (all from general health consumer groups) presented their groups' missions as incompatible with the pharmaceutical industry because of fundamentally opposing interests. Participants reported that interactions between their patient group and pharmaceutical companies were more common when companies had new drugs of potential interest to group members. Patient groups that accepted industry funding engaged in exchanges of "assets" with companies. Groups received money, information, and advice in exchange for providing companies with marketing, relationship building opportunities with key opinion leaders, coordinated lobbying with companies about drug access and subsidy, assisting companies with clinical trial recruitment, and enhancing company credibility.

CONCLUSIONS

An understanding of the range of views patient groups have about pharmaceutical company sponsorship will be useful for groups that seek to identify and manage any ethical concerns about these relationships. Patient groups that receive pharmaceutical industry money should anticipate they might be asked for specific assets in return. Selective industry funding of groups where active product marketing opportunities exist might skew the patient group sector's activity towards pharmaceutical industry interests and allow industry to exert proxy influence over advocacy and subsequent health policy.

A Content Analysis of Patient Advocacy Organization Policies Addressing Institutional Conflicts of Interest

Introduction: Patient advocacy organizations (PAOs) provide patient education, raise public awareness, and influence health policy for a wide range of diseases. These organizations frequently receive financial support form from drug, device, and biotechnology companies. Though PAOs often develop policies to address institutional conflicts of interest arising from industry relations, little is known about the substance of these policies. Methods: We sampled all PAOs that are members of the National Health Council. Using a standardized search strategy, all policies were obtained from each organization if publicly available. We reviewed policies for content related to restrictions on corporate partnerships, disclosure of corporate funding, and governance and monitoring of corporate partnerships. Results: We found that 24 of 47 (51%) organizations had policies that addressed institutional conflict of interest. A total of 9 of those 24 (38%) policies placed any restriction on the types of corporations that the PAO would or would not partner with. While 16 of the 24 (67%) outlined some process for disclosure of the organization's corporate donors, only 5 of 24 (21%) specified a manner for disclosing the financial value of those donations. Further, 15 of the 24 (63%) policies identified the person or persons responsible for approving corporate partnerships. However, 17 (71%) failed to address or specify the person(s) responsible for ongoing review of those partnerships. Conclusion: Nearly half of the organizations studied did not have publicly available conflict of interest policies. Among those that did, few policies had a substantial level of detail or limitations to guard against conflicts of interest.

Supporting families involved in court cases about life-sustaining treatment: Working as academics, advocates and activists

This article explores the links between our roles as academics, advocates, and activists, focusing on our research on treatment decisions for patients in vegetative and minimally conscious states. We describe how our work evolved from personal experience through traditional social science research to public engagement activities and then to advocacy and activism. We reflect on the challenges we faced in navigating the relationship between our research, advocacy, and activism, and the implications of these challenges for our research ethics and methodology-giving practical examples of how we worked with research participants, wrote up case studies and developed interventions into legal debates. We also address the implications of the impact agenda-imposed by the British Research Excellence Framework- for our actions as scholar-activists. Finally, we ask how practicing at the borders of academia, advocacy, and activism can inform research-helping to contextualize, sensitize, and engage theory with practice, leading to a more robust analysis of data and its implications, and helping to ensure a dialogue between research, theory, lived experience, front-line practice, law, and public policy.

Bioethics and activism: A natural fit?

Bioethics is a practically oriented discipline that developed to address pressing ethical issues arising from developments in the life sciences. Given this inherent practical bent, some form of advocacy or activism seems inherent to the nature of bioethics. However, there are potential tensions between being a bioethics activist, and academic ideals. In academic bioethics, scholarship involves reflection, rigour and the embrace of complexity and uncertainty. These values of scholarship seem to be in tension with being an activist, which requires pragmatism, simplicity, certainty and, above all, action. In this paper I explore this apparent dichotomy, using the case example of my own involvement in international efforts to end forced organ harvesting from prisoners of conscience in China. I conclude that these tensions can be managed and that academic bioethics requires a willingness to be activist.

When Good Women Decide to Do Nothing

Many health professions students struggle with deciding whether and when to challenge their teachers. This graphic memoir, When Good Women Do Nothing, conveys what happened one day in the life of a paramedic student called to help an incarcerated, handcuffed woman in labor who gave birth on a stretcher. The memoir documents numerous clinical and ethical disagreements and decision points throughout the paramedic team's time with this patient.

Do junior academic bioethicists have an obligation to be activists?

Activism and bioethics have enjoyed a somewhat strained relationship. In this paper, I consider activism specifically from the perspective of junior academics. I will argue that although there may be a prima facie duty for bioethicists to be activists, countervailing considerations for junior academics may mean that they, in particular, should refrain from undertaking activist activities. I will argue this on the basis of two key claims. First, I argue that activism may come at a potential cost to the academics who undertake it, and that these costs are potentially of greatest detriment to junior academics undertaking activism. Second, I argue that junior academics are likely to be less effective activists than established academics. Moreover, undertaking activism as a junior academic may prevent one from becoming an effective activist later. Finally, I will discuss the implications of this argument for activist commitments later in one's career.

On beginning with justice: Bioethics, advocacy and the rights of asylum seekers

The situation around the seeking of refuge, both in Australia and abroad, has become a core human rights issue of our time, engendering protest and activism from the public, researchers, healthcare professionals and academics. The question remains: do bioethicists have duties to advocate on behalf of such populations, and if so, why? I argue that if our work is founded upon the principle of justice, then we do have such duties, and that our research, in itself, can become a form of advocacy.

The responsibilities of the engaged bioethicist: Scholar, advocate, activist

The work of a bioethicist carries distinctive responsibilities. Alongside those of any worker, there are responsibilities associated with giving guidance to practitioners, policy makers and the public. In addition, bioethicists are professionally exposed to and required to identify situations of moral trouble, and as a result may find themselves choosing to work as advocates or activists, with responsibilities that are distinct from those generally acknowledged within academia. The requirement for bioethics to make normative judgements entails taking a stance, which means there cannot be a sharp line between 'academic' or 'objective' bioethics, and advocacy/activism, but a continuum of bioethicists' engagement and an associated continuum of responsibilities.

Activism, Bioethics and Academic Research

This article sketches a taxonomy of the activities in which bioethics academics engage, including activities that may make their own research more impactful, from little or no engagement outside academia to activism or extreme activism. This taxonomy, the first of its kind, may be useful in determining what obligations bioethics academics have in relation to activism and activities that fall short of activism.

Bioethicists to the Barricades!

In this article I begin with an anecdote as a way of exploring just exactly what activism entails. Are we talking about the kind of activism every citizen ought to engage in? Should we confine our topic to activism in health care settings? Just what is activism anyway, and how much and what kind ought bioethicists to engage in? Finally, I consider the possibility that it's perfectly permissible for bioethicists not to be activists of any kind.

Addressing Global Human Rights Violations in Rhode Island: The Brown Human Rights Asylum Clinic

The Brown Human Rights Asylum Clinic (BHRAC) is a medical student-led organization affiliated with Physicians for Human Rights that collaborates with medical and mental health clinicians, lawyers, and community organizations to provide pro bono medical affidavits to undocumented individuals seeking legal status in the United States. Affidavits can document and corroborate the physical and psychological evidence of trauma alleged by asylum seekers, leading to better legal outcomes. This article describes our innovative program, partnerships, and workflow, as well as demographics and statistics from our past seven years of operation. Since its founding in 2013, BHRAC has conducted 55 medical evaluations, the majority involving Spanish-speaking female-identifying individuals from Guatemala, El Salvador, and the Dominican Republic. Thirteen individuals have been granted legal status, one individual was denied status, and the rest of the cases are pending. BHRAC has experienced a marked increase in affidavit requests. This paper serves as a call to action for medical professionals to become involved in this work.

The spectrum of end of life care: an argument for access to medical assistance in dying for vulnerable populations

Medical assistance in dying (MAiD) was legalized by the Supreme Court of Canada in June 2016 and became a legal, viable end of life care (EOLC) option for Canadians with irremediable illness and suffering. Much attention has been paid to the balance between physicians' willingness to provide MAiD and patients' legal right to request medically assisted death in certain circumstances. In contrast, very little attention has been paid to the challenge of making MAiD accessible to vulnerable populations. The purpose of this paper was to examine the extant literature and resources that are available on the provision of MAiD in Canada. We found that the provision of EOLC in Canada offers insufficient access to palliative and EOLC options for Canadians and that vulnerable Canadians experience disproportional barriers to accessing these already limited resources. Consequently, we argue that palliative care, hospice care and MAiD must be considered a spectrum of EOLC that is inclusive and accessible to all Canadians. We conclude by imploring Canadian healthcare professionals, policy makers and legislators to consider MAiD as a viable EOLC option for all Canadians.

Shall parent / patient wishes be fulfilled in any case? A series of 32 ethics consultations: from reproductive medicine to neonatology

BACKGROUND

Questions concerning the parent/ patient's autonomy are seen as one of the most important reasons for requesting Ethics Consultations (ECs). Respecting parent/ patient's autonomy also means respecting the patient's wishes. But those wishes may be controversial and sometimes even go beyond legal requirements. The objective of this case series of 32 ECs was to illustrate ethically challenging parent / patients' wishes during the first stages of life and how the principle of patient's autonomy was handled.

METHODS

The case series has a qualitative retrospective approach. A documentary sheet was designed de novo and information was gained from EC minutes and medical charts. The cases originate from the following specialties: reproductive medicine, obstetrics and neonatology as well as two interdisciplinary cases.

RESULTS

Through the structured EC minutes aspects of patient / parents' wishes could be identified explicitly. Overall the patient / parents' wishes were not supported in 61% of the cases. Central reasons for rejection of patient / parent wishes were mainly the protection of the best interest of the unborn / new-born child as well as the rejection of clinical approaches that were regarded as being substandard treatment.

CONCLUSION

The study shows that treatment decisions in reproductive medicine, obstetrics and neonatology raise substantial ethical questions leading to the request for ethics consultation. The systematic case series presented here gives insight into the ethical reflection carried out to support the clinicians in their decision-making and counselling. It shows that clinicians, after using ethics consultation, make deliberate decisions that do not "automatically" fulfil the treatment requests of the patients and parents (to-be).

Why Physicians Should Advocate for Undocumented Immigrants' Unimpeded Access to Prenatal Care

Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines.

Are Clinicians Obliged to Disclose Their Immigration Status to Patients?

Undocumented immigrants are part of the health care workforce, whether they are eligible to work in the United States through the Deferred Action for Childhood Arrivals (DACA) program or other visa programs or permits. This case commentary considers whether-and if so, when-a clinician should reveal her immigration status to patients. After reviewing the literature on clinician self-disclosure, this commentary discusses how sharing immigration status could benefit the patient-particularly if the clinician has an immigration status that could interrupt care-but could also draw the focus away from the patient, possibly eroding trust between patient and physician. Finally, this commentary addresses mental health burdens experienced by undocumented and "DACA-mented" trainees and considers the roles that hospitals, residency programs, and health professions schools should play to support them.

The Role of Physicians in the Allocation of Health Care: Is Some Justice Better than None?

Physicians' advocacy obligations are best understood as going beyond advocacy on behalf of individual patients, which I call the "individualistic view," to include advocacy for intelligent research-based allocation schemes that promote good outcomes and cost-effective care for all patients, which I call the "systemic view." This systemic view includes moving beyond self-interest to promote less-wasteful and more cost-conscious allocation decisions and the setting of priorities at all levels to expand health care access. It includes physician involvement in discussions with patients in the context of clinical care, involvement in the formulation and administration of benefit structures and other allocation policies, and, finally, involvement in promoting public dialogue about health care priorities. This involvement is based on a concept of a deliberative process that can result in "just enough" decisions within systems for the preservation and promotion of health care and other societal goods.

Compulsory Admission in Hong Kong: Balance between Paternalism and Patient Liberty

In Hong Kong, compulsory admission is governed by the Mental Health Ordinance Section 31 (detention of a patient under observation), Section 32 (extension of period of detention for such a patient), Section 36 (detention of certified patients), and the sections in Part IV for hospital order, transfer order, and removal order. Mental health professionals adopt both legal criteria and practice criteria for compulsory admission. The present study discusses the harm principle, the patient's decision-making capacity, the multi-axial framework for compulsory admission, and the balance between paternalism and patient liberty.

School Nurse Advocacy: The Dilemma of Ethical Interpretation Versus Legal Protection

This article summarizes the facts and rulings of a recent, representative federal court decision concerning the legal claims of a school nurse who had engaged in advocacy for student safety, with particular attention to a student with insulin-dependent diabetes who committed suicide. The discussion of the court's rulings for the school nurse's various legal claims identifies the difference between ethical interpretation in terms of prevailing perceptions among school nurses and legal protection in terms of the current state of the case law specific to such advocacy.

Is there a place for CPR and sustained physiological support in brain-dead non-donors?

This article addresses whether cardiopulmonary resuscitation (CPR) and sustained physiological support should ever be permitted in individuals who are diagnosed as brain dead and who had held previously expressed moral or religious objections to the currently accepted criteria for such a determination. It contrasts how requests for care would normally be treated in cases involving a brain-dead individual with previously expressed wishes to donate and a similarly diagnosed individual with previously expressed beliefs that did not conform to a brain-based conception of death. The paper first focuses narrowly on requests for CPR and then expands its scope to address extended physiological support. It describes how refusing the brain-dead non-donor's requests for either CPR or extended support would represent enduring harm to the antemortem or previously autonomous individual by negating their beliefs and self-identity. The paper subsequently discusses potential implications of policy that would allow greater accommodations to those with conscientious objections to currently accepted brain-based death criteria, such as for cost, insurance, higher brain formulations and bedside communication. The conclusion is that granting wider latitude to personal conceptions around the definition of death, rather than forcing a contested definition on those with valid moral and religious objections, would benefit both individuals and society.

Decision-Making for an Incapacitated Pregnant Patient

Decisions about continuing or terminating a pregnancy touch on profound, individualized questions about bodily integrity, reproductive autonomy, deeply held values regarding one's capacity for parenthood, and, in the case of a high-risk pregnancy, the risks one is willing to take to have a baby. So far as possible, reproductive decisions are made between a patient, in some cases her partner, and her medical provider. However, this standard framework cannot be applied if the patient lacks decision-making capacity. In this essay, we discuss one such case that came before our clinical ethics team. We describe the challenges of respecting a patient's reproductive preferences when the patient cannot share what those preferences are, and we argue that decisions regarding reproductive health care should not be treated with exceptionalism. Rather, they should proceed under the normal processes of surrogate decision-making, including the application of substituted judgment. This approach enables us to take the patient's values into account when considering the questions implicated in reproductive health care, just as we do for other kinds of health care decisions in which a patient's deeply held values are salient.

"Please amputate my child's arms"

Jeremy sustained bilateral complete brachial plexus injuries in an auto collision on an icy road a month before his third birthday. The accident rendered both upper extremities completely flail and insensate: he has no motor or sensory function of his shoulders, elbows, wrists, or digits. Jeremy does, however, have normal function of the lower extremities. Physical therapists have worked with the child for over a year with no noted improvement in arm function. Jeremy falls frequently, causing injury to his face and head, and occasionally, his arms get twisted or caught in his crib and his fingers turn blue. Jeremy's mother, who carries the main responsibility for his daily care, believes that his insensate arms are too heavy and "get in his way," causing the falls. She and Jeremy's father present to the orthopedic clinic at the children's hospital with the request of having both arms amputated. The primary orthopedic surgeon and the orthopedic team disagree with the parents that bilateral upper-extremity amputation offers any medical benefit, but Jeremy's mother tells the surgeon that, if he will not perform the surgery, her family will find a doctor who will. The surgeon, who feels ethically distressed by the parental insistence on this amputation in such a young child, requests an ethics consultation.

Response: Freedom from Pain as a Rawlsian Primary Good

In a recent article in this journal, Carl Knight and Andreas Albertsen argue that Rawlsian theories of distributive justice as applied to health and healthcare fail to accommodate both palliative care and the desirability of less painful treatments. The asserted Rawlsian focus on opportunities or capacities, as exemplified in Normal Daniels' developments of John Rawls' theory, results in a normative account of healthcare which is at best only indirectly sensitive to pain and so unable to account for the value of efforts of which the sole purpose is pain reduction. I argue that, far from undermining the Rawlsian project and its application to problems of health, what the authors' argument at most amounts to is a compelling case for the inclusion of freedom from physical pain within its index of primary goods.

Ethics and Regulation in Organ Procurement Research

This article explores the role of ethics and regulation in human research conducted by organ procurement agencies; basic ethical principles for human research are outlined. Organ procurement agencies are not required to observe federal regulations; however, voluntary adherence will ensure that procurement research is conducted according to current standards of ethical practice. Although most organ procurement research will qualify for exempt status, this determination should be made by an institutional review board. Even if studies qualify for exempt status, there is a moral presumption that informed consent should be sought, unless certain narrow conditions for waiver of consent are satisfied. Finally, when future research utilizing organ procurement records is anticipated, procurement coordinators should provide sufficiently detailed information to families about such plans to permit their advance informed consent to research activities.

Clinical Wisdom Among Proficient Nurses

This article examines clinical wisdom, which has emerged from a broader study about nurse managers' influence on proficient registered nurse turnover and retention. The purpose of the study was to increase understanding of proficient nurses' experience and clinical practice by giving voice to the nurses themselves, and to look for differences in their practice. This was a qualitative study based on semistructured interviews followed by analysis founded on Gadamerian hermeneutics. The article describes how proficient nurses experience their practice. Proficient practice constitutes clinical wisdom based on responsibility, thinking and ethical discernment, and a drive for action. The study showed that poor working conditions cause proficient nurses to regress to non-proficient performance. Further studies are recommended to allow deeper searching into the area of working conditions and their relationship to lack of nurse proficiency.

Everyday Ethical Problems in Dementia Care: A teleological Model

In this article, a teleological model for analysis of everyday ethical situations in dementia care is used to analyse and clarify perennial ethical problems in nursing home care for persons with dementia. This is done with the aim of describing how such a model could be useful in a concrete care context. The model was developed by Sandman and is based on four aspects: the goal; ethical side-constraints to what can be done to realize such a goal; structural constraints; and nurses’ ethical competency. The model contains the following main steps: identifying and describing the normative situation; identifying and describing the different possible alternatives; assessing and evaluating the different alternatives; and deciding on, implementing and evaluating the chosen alternative. Three ethically difficult situations from dementia care were used for the application of the model. The model proved useful for the analysis of nurses’ everyday ethical dilemmas and will be further explored to evaluate how well it can serve as a tool to identify and handle problems that arise in nursing care.

Questionable Requirement for Consent in Observational Research in Psychiatry

Informed consent represents a cornerstone of the endeavours to make health care research ethically acceptable. Based on experience of qualitative research on power dynamics in nursing care in acute psychiatry, we show that the requirement for informed consent may be practised in formalistic ways that legitimize the researcher's activities without taking the patient's changing perception of the situation sufficiently into account. The presentation of three patient case studies illustrates a diversity of issues that the researcher must consider in each situation. We argue for the necessity of researchers to base their judgement on a complex set of competencies. Consciousness of research ethics must be combined with knowledge of the challenges involved in research methodology in qualitative research and familiarity with the therapeutic arena in which the research is being conducted. The article shows that the alternative solution is not simple but must emphasize the researcher's ability to doubt and be based on an awareness of the researcher's fallibility.

The Respectful Nurse

Respect is much referred to in professional codes, in health policy documents and in everyday conversation. What respect means and what it requires in everyday contemporary nursing practice is less than clear. Prescriptions in professional codes are insufficient, given the complexity and ambiguity of everyday nursing practice. This article explores the meaning and requirements of respect in relation to nursing practice. Fundamentally, respect is concerned with value: where ethical value or worth is present, respect is indicated. Raz has argued that the two ways of encountering value are to respect and to engage with it. The former requires acknowledgement and preservation. Respect in nursing practice necessarily requires also engagement. Respect is an active value and can be conceptualized within the context of virtue ethics as a hybrid virtue having both intellectual and ethical components. Examples from the literature are provided to illustrate situations where the respectful nurse requires these components or capabilities.

Restraint and the Question of Validity

Restraint as an intervention in the management of acute mental distress has a long history that predates the existence of psychiatry. However, it remains a source of controversy with an ongoing debate as to its role. This article critically explores what to date has seemingly been only implicit in the debate surrounding the role of restraint: how should the concept of validity be interpreted when applied to restraint as an intervention? The practice of restraint in mental health is critically examined using two post-positivist constructions of validity, the pragmatic and the psychopolitical, by means of a critical examination of the literature. The current literature provides only weak support for the pragmatic validity of restraint as an intervention and no support to date for its psychopolitical validity. Judgements regarding the validity of any intervention that is coercive must include reference to the psychopolitical dimensions of both practice and policy.

Exploring the Moral Distress of Registered Nurses

Registered nurses (RNs) employed in an urban medical center in the USA identified moral distress as a practice concern. This study describes RNs' moral distress and the frequency of morally distressing events. Data were collected using the Moral Distress Scale and an open-ended questionnaire. The instruments were distributed to direct-care-providing RNs; 100 responses were returned. Morally distressing events included: working with staffing levels perceived as `unsafe', following families' wishes for patient care even though the nurse disagreed with the plan, and continuing life support for patients owing to family wishes despite patients' poor prognoses. One high frequency distressing event was carrying out orders for unnecessary tests and treatments. Qualitative data analysis revealed that the nurses sought support and information from nurse managers, chaplaincy services and colleagues. The RNs requested further information on biomedical ethics, suggested ethics rounds, and requested a non-punitive environment surrounding the initiation of ethics committee consultations.

The `Little Extra' That Alleviates Suffering

Nursing, or caring science, is mainly concerned with developing knowledge of what constitutes ideal, good health care for patients as whole persons, and how to achieve this. The aim of this study was to find clinical empirical indications of good ethical care and to investigate the substance of ideal nursing care in praxis. A hermeneutic method was employed in this clinical study, assuming the theoretical perspective of caritative caring and ethics of the understanding of life. The data consisted of two Socratic dialogues: one with nurses and one with nursing students, and interviews with two former patients. The empirical data are first described from a phenomenological approach. Observations of caregivers offering `the little extra' were taken to confirm that patients were `being seen', not from the perspective of an ideal nursing model, but from that of interaction as a fellow human being. The study provides clinical evidence that, as an ontological response to suffering, 'symbolic acts' such as giving the `little extra' may work to bridge gaps in human interaction. The fact that `little things' have the power to preserve dignity and make patients feel they are valued offers hope. Witnessing benevolent acts also paves the way for both patients and caregivers to increase their understanding of life.