Evaluation of Interventions to Address Moral Distress: A Multi-method Approach

Moral distress is a well-documented phenomenon for health care providers (HCPs). Exploring HCPs' perceptions of participation in moral distress interventions using qualitative and quantitative methods enhances understanding of intervention effectiveness. The purpose of this study was to measure and describe the impact of a two-phased intervention on participants' moral distress. Using a cross-over design, the project aimed to determine if the intervention would decrease moral distress, enhance moral agency, and improve perceptions about the work environment. We used quantitative instruments and explored participants' perceptions of the intervention using semi-structured interviews. Participants were from inpatient settings, within three major hospitals of a large, urban healthcare system in the Midwest, United States. Participants included nurses (80.6%) and other clinical care providers. Using generalized linear mixed modeling we assessed the change in each of the outcome variables over time controlling for groups. Interviews were audiotaped and professionally transcribed. The written narratives were coded into themes. The change in scores on study instruments trended in the desired direction however did not meet statistical significance. Qualitative interviews revealed that intervention effectiveness was derived from a combination of learning benefits, psychological benefits, and building community that promoted moral agency. Findings demonstrate a clear link between moral distress and moral agency and suggest that Facilitated Ethics Conversations can enhance the work environment. Findings provide insight for developing evidenced-based approaches to address moral distress of hospital nurses.

Moral Agency Development as a Community-Supported Process: An Analysis of Hospitals' Middle Management Responses to the COVID-19 Crisis

This paper investigates the process of moral agency development as a community-supported process. Based on a multimethod qualitative inquiry, including diaries, focus groups, and documentary analysis, we analyze the experiences of middle managers in two Norwegian hospitals during the first year of the COVID-19 pandemic. We find that moral agency is developed through a community-embedded value inquiry, emerging in three partially overlapping steps. The first step is marked by moral reflex, an intuitive, value-driven, pre-reflective response to a crisis situation. In the second step, the managers involved the community in value calibration, a collective-ethical sensemaking. In the third step, they took active stances to translate values into actions, with an increased awareness of values and an ability to explain and justify their actions. We label the steps, respectively: value inquiry-in-action, value inquiry-on-action and reflective enactment of value. An analysis of the process reveals two aspects critical for moral agency development: it happens through confrontation with uncertainty, and it is relational, that is, embedded in a community. While uncertainty forces an intuitive moral response, dialogical reflection in the community develops value awareness and relationships of mutual care and support.

Physician resistance to injustice: A scoping review

Throughout history, physicians have been involved in acts of resistance to systems of harm and injustice. However, resistance has seemed to have had little legitimate place in physician professionalism or in formal professional practice. As the challenges to physicians and the profession continue to mount, there is a pressing need to understand how it might be articulated and understood. To do that we need to consider past instances of physician resistance to injustice and harm. A scoping review was conducted to understand how often and in what contexts physicians have been engaged in resistance. A search of multiple bibliographic databases returned 2123 papers, which, after filtering for relevance and inclusion, left 60 articles for full-text review. Of these, 95% were from the United States, suggesting that issues of legitimacy are even more acute outside the U.S. Narrative findings were organized around four themes: professional responsibility to resist, legitimate resistance, resistance to perceived threats, and resistance as moral agency. When physicians have resisted, they have done so with a sense of moral agency albeit with different levels of altruism. They have often engaged in resistance when they felt their personal and professional interests are threatened, with particular emphasis on threats to physician autonomy. The study suggests that, within the U.S. at least, physician resistance is a matter for concern but, it has been approached with little or no guidance or grounding. Moreover, there is a longstanding tension between those who have argued that physicians have a professional responsibility to resist and those who have considered resistance to be extraneous and even harmful to their work as healers. At a time when physicians are facing an ever-growing number of practical, ethical, and moral challenges, professional acts of resistance are of critical concern within the profession.

Vulnerability, Moral responsibility, and Moral Obligations: the case of Industrial Action in the Medical and Allied Professions

The article addresses issues at the nexus of physician industrial action, moral agency, and responsibility. There are situations in which we find ourselves best placed to offer aid to those who may be in vulnerable positions, a behavior that is consistent with our everyday moral intuitions. In both our interpersonal relationships and social life, we make frequent judgments about whether to praise or blame someone for their actions when we determine that they should have acted to help a vulnerable person. While the average person is unlikely to confront these kinds of situations often, those in the medical professions, physicians especially, may confront these and similar situations regularly. Therefore, when physicians withhold their services for whatever reason in support of industrial action, it raises issues of moral responsibility to patients who may be in a vulnerable position. Using theories of moral responsibility, vulnerability, and ethics, this paper explores the moral implications of physician industrial action. We explore issues of vulnerability of patients, as well as the moral responsibility and moral agency of doctors to patients. Determining when a person is vulnerable, and when an individual becomes a moral agent, worthy of praise or blame for an act or non-action, is at the core of the framework. Notwithstanding the right of physicians to act in their self-interest, we argue that vulnerability leads to moral obligations, that physicians are moral agents, and the imperatives of their obligations to patients clear, even if limited by certain conditions. We suggest that both doctors and governments have a collective responsibility to prevent harm to patients and present the theoretical and practical implications of the paper.

Machine Learning and Ethics

When new technology is introduced into healthcare, novel ethical dilemmas arise in the human-machine interface. As artificial intelligence (AI), machine learning (ML) and big data can exhaust human oversight and memory capacity, this will give rise to many of these new dilemmas.Technology has little if any ethical status but is inevitably interwoven with human activity and thus may serve to allow qualitative and quantitative disruption of human performance and interaction. We argue that personal integrity, justice of resource allocation and accountability of moral agency comprise three themes that characterize ethical dilemmas that arise with development and application of AI. These themes are important to address in parallel to further evolution of AI in health care for ethical practice of healthcare.

Technological Answerability and the Severance Problem: Staying Connected by Demanding Answers

Artificial intelligence (AI) and robotic technologies have become nearly ubiquitous. In some ways, the developments have likely helped us, but in other ways sophisticated technologies set back our interests. Among the latter sort is what has been dubbed the 'severance problem'-the idea that technologies sever our connection to the world, a connection which is necessary for us to flourish and live meaningful lives. I grant that the severance problem is a threat we should mitigate and I ask: how can we stave it off? In particular, the fact that some technologies exhibit behavior that is unclear to us seems to constitute a kind of severance. Building upon contemporary work on moral responsibility, I argue for a mechanism I refer to as 'technological answerability', namely the capacity to recognize human demands for answers and to respond accordingly. By designing select devices-such as robotic assistants and personal AI programs-for increased answerability, we see at least one way of satisfying our demands for answers and thereby retaining our connection to a world increasingly occupied by technology.

Moral zombies: why algorithms are not moral agents

In philosophy of mind, zombies are imaginary creatures that are exact physical duplicates of conscious subjects for whom there is no first-personal experience. Zombies are meant to show that physicalism-the theory that the universe is made up entirely out of physical components-is false. In this paper, I apply the zombie thought experiment to the realm of morality to assess whether moral agency is something independent from sentience. Algorithms, I argue, are a kind of functional moral zombie, such that thinking about the latter can help us better understand and regulate the former. I contend that the main reason why algorithms can be neither autonomous nor accountable is that they lack sentience. Moral zombies and algorithms are incoherent as moral agents because they lack the necessary moral understanding to be morally responsible. To understand what it means to inflict pain on someone, it is necessary to have experiential knowledge of pain. At most, for an algorithm that feels nothing, 'values' will be items on a list, possibly prioritised in a certain way according to a number that represents weightiness. But entities that do not feel cannot value, and beings that do not value cannot act for moral reasons.

First-person representations and responsible agency in AI

In this paper I investigate which of the main conditions proposed in the moral responsibility literature are the ones that spell trouble for the idea that Artificial Intelligence Systems (AISs) could ever be full-fledged responsible agents. After arguing that the standard construals of the control and epistemic conditions don't impose any in-principle barrier to AISs being responsible agents, I identify the requirement that responsible agents must be aware of their own actions as the main locus of resistance to attribute that kind of agency to AISs. This is because this type of awareness is thought to involve first-person or de se representations, which, in turn, are usually assumed to involve some form of consciousness. I clarify what this widespread assumption involves and conclude that the possibility of AISs' moral responsibility hinges on what the correct theory of de se representations ultimately turns out to be.

The Human Side of Artificial Intelligence

Artificial moral agents raise complex ethical questions both in terms of the potential decisions they may make as well as the inputs that create their cognitive architecture. There are multiple differences between human and artificial cognition which create potential barriers for artificial moral agency, at least as understood anthropocentrically and it is unclear that artificial moral agents should emulate human cognition and decision-making. It is conceptually possible for artificial moral agency to emerge that reflects alternative ethical methodologies without creating ontological challenges or existential crises for human moral agents.

Artificial Intelligence, Responsibility Attribution, and a Relational Justification of Explainability

This paper discusses the problem of responsibility attribution raised by the use of artificial intelligence (AI) technologies. It is assumed that only humans can be responsible agents; yet this alone already raises many issues, which are discussed starting from two Aristotelian conditions for responsibility. Next to the well-known problem of many hands, the issue of "many things" is identified and the temporal dimension is emphasized when it comes to the control condition. Special attention is given to the epistemic condition, which draws attention to the issues of transparency and explainability. In contrast to standard discussions, however, it is then argued that this knowledge problem regarding agents of responsibility is linked to the other side of the responsibility relation: the addressees or "patients" of responsibility, who may demand reasons for actions and decisions made by using AI. Inspired by a relational approach, responsibility as answerability thus offers an important additional, if not primary, justification for explainability based, not on agency, but on patiency.

Relegating Psychosis: Blood Work and "Routine Connection" in the Clozapine Clinic

This paper attends to the sociality available in the clozapine clinic regimen and suggests that the social dimensions of clozapine treatment may be as important as the biochemical efficacy of clozapine. The clozapine clinic is where people diagnosed with chronic schizophrenia who take the antipsychotic clozapine go for routine monitoring of clozapine side effects, particularly haematological effects. Psychopharmaceutical treatments are often criticized for being reductionistic and dehumanizing, but clozapine clinics offer increased clinical contact in the age of deinstitutionalization. The inadvertent social benefits of biomedically reductive treatments have not previously been ethnographically attended to in the clozapine-only context. Drawing on 18 months of ethnographic fieldwork with 43 clozapine clients and 16 clinical caregivers in two clozapine clinics in the United Kingdom in Australia, I argue that routine clinical attachments in the clozapine clinic can serve a therapeutic role in terms of providing opportunities for clients' health agency, social competence and accountability. This socio-therapeutic quality appeared to be available because the clinical emphasis was not on psychotic illness. It depended, however, on reliable and familiar social exchanges inside the clinic and on the predictability of clinical activity. The importance of unemotional but unfailing relationships and rhythms in the clozapine clinic context echoes cross-cultural findings about how schizophrenia is managed more productively in environments that invite more neutral and equal social exchanges.

Moral Experiences of Crisis Management in a Child Mental Health Setting: A Participatory Hermeneutic Ethnographic Study

Restraints and seclusion are routinely used in child mental health settings for conflict and crisis management, but raise significant ethical concerns. Using a participatory hermeneutic ethnographic framework, we studied conflict and crisis management in a child mental health setting offering care to children aged 6-12 years old in Quebec, Canada. The use of this framework allowed for an in-depth examination of the local imaginaries, of what is morally meaningful to the people in the setting, in addition to institutional norms, structures and practices. Data collection involved participant observation, interviews, and documentation review, with an interpretive framework for data analysis. We argue that the prevalent view of children shared by staff members as "incomplete human becomings" led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships, which impeded the implementation of more collaborative approaches staff members sought to put in place to prevent the use of control measures. Study results are discussed in light of conceptions of children as moral agents.

Issues pertaining to expert evidence and the reasoning about punishment in a neuroscience-based sentencing appeal

In this paper, we focus on, a significant Australian sentencing appeal in which, after hearing expert evidence pertaining to cognitive function, brain scans, and neuropsychological testing, the Court imposed a less severe sentence than that originally imposed. Our aim is to produce an interdisciplinary critical analysis of the decision, and we approach this by analysing the judicial comments on the evidence pertaining to the offender's mental condition, and the reasoning about punishment. We conclude that the Court's inferences about frontal lobe damage and likely dementia are contestable, and the reasoning about mitigation of punishment based on these questionable inferences could have been improved by a focus on sentencing's retributive aim.

Lawful Sinners: Reproductive Governance and Moral Agency Around Abortion in Mexico

The Catholic Hierarchy unequivocally bans abortion, defining it as a mortal sin. In Mexico City, where the Catholic Church wields considerable political and popular power, abortion was recently decriminalized in a historic vote. Of the roughly 170,000 abortions that have been carried out in Mexico City's new public sector abortion program to date, more than 60% were among self-reported Catholic women. Drawing on eighteen months of fieldwork, including interviews with 34 Catholic patients, this article examines how Catholic women in Mexico City grapple with abortion decisions that contravene Church teachings in the context of recent abortion reform. Catholic women consistently leveraged the local cultural, economic, and legal context to morally justify their abortion decisions against church condemnation. I argue that Catholic women seeking abortion resist religious injunctions on their reproductive behavior by articulating and asserting their own moral agency grounded in the contextual dimensions of their lives. My analysis informs conversations in medical anthropology on moral decision-making around reproduction and on local dynamics of resistance to reproductive governance. Moreover, my findings speak to the deficiencies of a feminist vision focused narrowly on fertility limitation, versus an expanded framework of reproductive justice that considers as well the need for conditions of income equality and structural supports to facilitate reproduction and parenting among women who desire to keep their pregnancies.

Who Should Decide How Machines Make Morally Laden Decisions?

Who should decide how a machine will decide what to do when it is driving a car, performing a medical procedure, or, more generally, when it is facing any kind of morally laden decision? More and more, machines are making complex decisions with a considerable level of autonomy. We should be much more preoccupied by this problem than we currently are. After a series of preliminary remarks, this paper will go over four possible answers to the question raised above. First, we may claim that it is the maker of a machine that gets to decide how it will behave in morally laden scenarios. Second, we may claim that the users of a machine should decide. Third, that decision may have to be made collectively or, fourth, by other machines built for this special purpose. The paper argues that each of these approaches suffers from its own shortcomings, and it concludes by showing, among other things, which approaches should be emphasized for different types of machines, situations, and/or morally laden decisions.

Distributed Cognition and Distributed Morality: Agency, Artifacts and Systems

There are various philosophical approaches and theories describing the intimate relation people have to artifacts. In this paper, I explore the relation between two such theories, namely distributed cognition and distributed morality theory. I point out a number of similarities and differences in these views regarding the ontological status they attribute to artifacts and the larger systems they are part of. Having evaluated and compared these views, I continue by focussing on the way cognitive artifacts are used in moral practice. I specifically conceptualise how such artifacts (a) scaffold and extend moral reasoning and decision-making processes, (b) have a certain moral status which is contingent on their cognitive status, and (c) whether responsibility can be attributed to distributed systems. This paper is primarily written for those interested in the intersection of cognitive and moral theory as it relates to artifacts, but also for those independently interested in philosophical debates in extended and distributed cognition and ethics of (cognitive) technology.

"But You Would Be the Best Mother": Unwomen, Counterstories, and the Motherhood Mandate

This paper addresses and challenges the pronatalist marginalization and oppression of voluntarily childless women in the Global North. These conditions call for philosophical analyses and for sociopolitical responses that would make possible the necessary moral spaces for resistance. Focusing on the relatively privileged subgroups of women who are the targets of pronatalist campaigns, the paper explores the reasons behind their choices, the nature and methods of Western pronatalism, and distinguishes three specific sources of some of the more lasting, and stigmatizing attacks: popular culture, law and policy, and medicine itself. I then argue that because they are construed by motherhood-essentializing, and increasingly popular, pronatalist narratives as, among other things, "failed" or "selfish," voluntarily childless women are subsequently burdened with damaged identities that can leave them personally othered and uniquely liminal in ways that are destructive to moral agency. Finally, I conclude with a challenge to the pronatalist master narratives by suggesting the possibility of counter narratives to the voluntarily childless woman's liminality that might serve as the ground of moral and political solidarity among differently situated women, regardless of their motherhood status.

Free choice in residential care for older people - A philosophical reflection

OBJECTIVE

Free choice in elderly care services is a debated issue. Using the theoretical support of philosophers of free will, this paper explores free choice in relocation to residential care. The three dominant perspectives within this field of philosophy, libertarianism, determinism and compatibilism, are applied from the perspective of the older individual to the process of moving.

METHOD

Empirical data were collected through qualitative interviews with 13 older individuals who had recently moved into residential care.

RESULTS

These individuals had made the choice to move following either a health emergency or incremental health problems. In a deterministic perspective they had no alternative to moving, which was the inevitable solution to their various personal problems. A network of people important to them assisted in the move, making the choice possible. However, post-move the interviewees' perspective had changed to a libertarian or compatibilist interpretation, whereby although the circumstances had conferred little freedom regarding the move.

CONCLUSIONS

The interviewees reported a high degree of self-determination in the process. It appeared that in order to restore self-respect and personal agency, the older individuals had transformed their restricted choice into a choice made of free will or freer will.

Self-realization and cultural narratives about later life

In late modern circumstances, aging individuals are confronted with the task of creating a meaningful individual life trajectory. However, these personal narratives are situated in the context of broader cultural narratives. It is argued that current cultural narratives about aging are often stereotyping and demeaning, being based on either a decline ideology or an age-defying ideology. This complicates the ascription of meaning to later life. We argue that narrative gerontology could profit from integrating a more cultural critical stance in its investigations. Dominant cultural narratives need to be challenged by viable counter narratives aimed at repairing and strengthening the moral agency of aging individuals. We discuss the criteria such counter narratives have to answer to and consider how the moral discourse on self-realization can provide an ideological foundation for meaning-generating cultural counter narratives on aging.