Do we need an ethical framework for hospital infection control?

Strategies for the control of the spread of infection in hospitals may lead to constraints on individual autonomy, freedom of movement, or contact with others. Codes of (ethical) practice for healthcare professionals tend to emphasise responsibilities to individual patients. Ethical frameworks for public health focus on groups of individuals (populations), the majority of whom are relatively healthy and empowered. Hospital infection control professionals must take account of both of these perspectives, sensitive to the care of infected and potentially infectious individuals, while protecting the vulnerable and relatively dependent population of hospital patients from further compromise to their health. A number of frameworks for an ethics of public health have been proposed over the last few years but there are sufficient differences in ethical considerations between collective interventions that aim to protect and promote the health of the public and interventions taken in the context of hospital infection control to justify a distinctive ethics of hospital infection control. Professional bodies may be best placed to lead the development of such a framework.     

For the good of many: an infection control perspective on ethics

The decisions made by infection control personnel affect both individuals and those in the broader patient population in a health care facility. In making the decisions required to provide an environment free of infectious risks, while maintaining the rights of individuals to attain optimal health outcomes, infection control practitioners are often confronted with ethical dilemmas.This article describes an ethical dilemma commonly faced in infection control practice, where the needs of one patient must be weighed against the needs of the patient population. A case study describing the decision to isolate an infectious patient is presented, highlighting the role that ethics plays in decisions made to control infection. A decision making framework is applied to ensure that the needs of both individuals and groups are considered. Resource considerations and the need to conform to basic microbiological and epidemiological principles are also considered. The various issues in conflict are described, analysed, resolved and rationalised. The use of a decision making framework can help to ensure that competing interests are carefully considered to produce an ethical, and optimal, decision.     

The Ground of Dialogical Bioethics

Dialogical ethics are a procedural alternative to substantive ethics such as consequentialism, deontology, principlism, casuistry, virtue ethics and care ethics. Dialogical ethics are procedural in that they do not establish goods in advance, unlike substantive ethics, but rather determine goods through a procedure enacted by the actual parties involved (although some substantive notion of justice may still be required); and they are dialogical in that the procedure is that of dialogue, involving both empathic critical discussion and negotiation. A fundamental tenet of dialogical ethics may be the use of appropriate rules of order regulating dialogue among the parties involved. Some of the central characteristics of such rules of order are that they are reciprocally regulated by dialogue, that they override other ethical considerations, and that they institute empathic critical discussion and negotiation within the ethical dialogue. Dialogical bioethics are the application of dialogical ethics to ethical problems in medicine. The approach of dialogical bioethics has proven fruitful for resolving bioethical problems such as that of medical futility, where approaches of substantive ethics have reached an impasse. There is room for further study of special challenges within dialogical bioethics, such as the incompetence of some involved parties, conflicts of interests of third parties, and the cost-effectiveness of this ethical approach.     

Ethical and legal considerations in the provision of nutritional support to the perioperative patient

Despite the extensive current literature on ethics, very few publications have specifically addressed the ethical issues surrounding the provision of nutrition to perioperative patients. Four publications are particularly relevant and highly recommended [1-4]. This review is an attempt to draw attention to those ethical issues that are relevant to the use of nutritional support in the perioperative patient and offer guidance on appropriate action by clinicians. Emphasis is on adult patients rather than children and not on the issues that surround the terminally ill patient. General principles are discussed first and then the application of these principles.     

Utilitarismus oder Kommunitarismus als Grundlage einer Public-Health-Ethik?

The goal of public health is to maximise health, and to promote the common good. These two assumptions frequently give rise to claims that public health is founded on utilitarian or communitarian ethics, respectively. In this paper, these claims are critically examined and rejected. It is neither plausible to assume utilitarian goals in public health nor to propose a utilitarian account of public health ethics. The idea of public health as health-related utilitarianism rests on a misconception of utilitarian ethics. Once this misconception is realised, the seeming appeal of public health to utilitarianism quickly fades. Communitarianism, in turn, fails to serve as a comprehensive and systematic ethical account. Some moderate appeals to more communal spirit for public health are well taken, although not exclusive communitarian. Other more extreme proposals of communitarians, e.g. to exercise public-health police power and public-health paternalism, are to be taken with great care. Thus, it is concluded that there is a need for an ethical foundation of public health different from both utilitarianism and communitarianism.     

For debate: the virtuous public health physician

This paper argues that although public health physicians have shown interest in ethical dilemmas relating to specific problems within the specialty, few have addressed the central ethical dilemma in public health, namely the conflict between the rights of the individual and the responsibilities of society for all its members. The paper reviews a number of public health programmes, where different approaches have been taken to this central dilemma. It then examines a number of schools of ethics, in an attempt to resolve the problem. Of these, only virtue ethics, perhaps supported by the insights of feminism and the ethics of care, appear to help with an irreconcilable conflict. The paper then makes an attempt to apply the concept of virtue ethics in public health medicine and to answer the question, 'what would a virtuous public health physician look like?' Finally, it lists some of the consequences of such an approach.     

Reinforcing medical authority: clinical ethics consultation and the resolution of conflicts in treatment decisions

Despite substantial efforts in the past 15 years to professionalise the field of clinical ethics consultation, sociologists have not re-examined past hypotheses about the role of such services in medical decision-making and their effect on physician authority. In relation to those hypotheses, we explore two questions: (i) What kinds of issues does ethics consultation resolve? and (ii) what is the nature of the resolution afforded by these consults? We examined ethics consultation records created between 2011 and mid-2015 at a large tertiary care US hospital and found that in most cases, the problems addressed are not novel ethical dilemmas as classically conceived, but are instead disagreements between clinicians and patients or their surrogates about treatment. The resolution offered by a typical ethics consultation involves strategies to improve communication rather than the parsing of ethical obligations. In cases where disagreements persist, the proposed solution is most often based on technical clinical judgements, reinforcing the role of physician authority in patient care and the ethical decisions made about that care.     

Furthering the sceptical case against virtue ethics in nursing ethics

In a recent article in this journal I presented a sceptical argument about the current prominence of virtue ethics in nursing ethics. Daniel Putman has responded with a defence of the relevance of virtue in nursing. The present article continues this discussion by clarifying, defending, and expanding the sceptical argument. I start by emphasizing some features of the sceptical case, including assumptions about the nature of sceptical arguments, and about the character of both virtue ethics and nursing ethics. Then I respond to objections of Putman's such as that, according to virtue ethics, virtue is relevant to the whole of a human life, including one's behaviour in a professional context; and that eudaimonia should be central in explaining and motivating a nurse's decision to enter the profession. Having argued that these objections are not compelling, I go on to discuss an interesting recent attempt to reassert the role of virtue ethics in the ethics of professions, including nursing. This centres on whether role‐specific obligations – e.g. the obligations that arise for a moral agent qua lawyer or mother – can be accommodated in a virtue ethics approach. Sean Cordell has argued that the difficulty of accommodating role‐specific obligations results in an ‘institution‐shaped gap’ in virtue ethics. He suggests a way of meeting this difficulty that appeals to the ergon of institutions. I endorse the negative point that role‐specific obligations elude virtue ethics, but argue that the appeal to the ergon of institutions is unsuccessful. The upshot is further support for scepticism about the virtue ethics approach to nursing ethics. I end by gesturing to some of the advantages of a sceptical view of virtue ethics in nursing ethics.     

Virtue and austerity

Virtue ethics is often proposed as a third way in health‐care ethics, that while consequentialism and deontology focus on action guidelines, virtue focuses on character; all three aim to help agents discern morally right action although virtue seems to have least to contribute to political issues, such as austerity. I claim: (1) This is a bad way to characterize virtue ethics. The 20th century renaissance of virtue ethics was first proposed as a response to the difficulty of making sense of ‘moral rightness’ outside a religious context. For Aristotle the right action is that which is practically best; that means best for the agent in order to live a flourishing life. There are no moral considerations besides this. (2) Properly characterized, virtue ethics can contribute to discussion of austerity. A criticism of virtue ethics is that fixed characteristics seem a bad idea in ever‐changing environments; perhaps we should be generous in prosperity, selfish in austerity. Furthermore, empirical evidence suggests that people indeed do change with their environment. However, I argue that virtues concern fixed values not fixed behaviour; the values underlying virtue allow for different behaviour in different circumstances: in austerity, virtues still give the agent the best chance of flourishing. Two questions arise. (a) In austere environments might not injustice help an individual flourish by, say, obtaining material goods? No, because unjust acts undermine the type of society the agent needs for flourishing. (b) What good is virtue to those lacking the other means to flourish? The notion of degrees of flourishing shows that most people would benefit somewhat from virtue. However, in extreme circumstances virtue might harm rather than benefit the agent: such circumstances are to be avoided; virtue ethics thus has a political agenda to enable flourishing. This requires justice, a fortiori when in austerity.     

Paradigm shift, metamorphosis of medical ethics, and the rise of bioethics

Both the increasing incorporation of medical technology and new social demands (including those for health care) beginning in the 1960s have brought about significant changes in medical practice. This situation has in turn sparked a growth in the philosophical debate over problems pertaining to ethical practice. These issues no longer find answers in the Hippocratic ethical model. The authors believe that the crisis in Hippocratic ethics could be described as a period of paradigm shift in which a new set of values appears to be emerging. Beginning with the bioethics movement, the authors expound on the different ethical theories applied to medical practice and conclude that principlism is the most appropriate approach for solving the new moral dilemma imposed on clinical practice.     

QALYs and ethics: A health economist's perspective

Objectors on ethical grounds to the use of QALYs in priority-setting in public health care systems are here categorised as (1) those who reject all collective priority-setting as unethical; (2) those who accept the need for collective priority-setting but believe that it is contrary to medical ethics; (3) those who accept the need for collective priority-setting and do not believe that it is contrary to medical ethics, but reject the role of QALYs in it on other ethical grounds; and (4) those who accept the need for collective priority-setting in principle, but are unwilling to specify how it should be done in practice. It is argued that the first two groups of objectors are simply wrong, if distributive justice is a proper ethical concern in this context. The third group is of more interest, as this group appears to believe that QALYs are unethical because it is unethical to regard QALY maximisation as the sole objective of the health care system. This paper argues that QALYs are relevant to a much wider range of objectives than QALY maximisation, and that they can accommodate a wide variety of health dimensions and sources of valuation. They can also accommodate the differential weighting of benefits according to who gets them, so they do not commit their users to any particular notion of distributive justice. What they do commit their users to is the notion that the health of people is a central concept in priority-setting, and that it is desirable, for reasons of accountability, to have the bases for such priority-setting made as precise and explicit as possible. The fourth group of objectors needs to acknowledge that there is no perfect system on offer, and since priority-setting does and will proceed willy-nilly we cannot wait until there is. It would be more constructive to set up the desiderata that a priority-setting system should ideally fulfil, and then appraise all feasible alternatives (including the status quo) even-handedly by those criteria. None will be perfect, but this author predicts that QALYs would emerge from such an appraisal with a significant role to play.     

Some comments on the substituted judgement standard

On a traditional interpretation of the substituted judgement standard (SJS) a person who makes treatment decisions on behalf of a non-competent patient (e.g. concerning euthanasia) ought to decide as the patient would have decided had she been competent. I propose an alternative interpretation of SJS in which the surrogate is required to infer what the patient actually thought about these end-of-life decisions. In clarifying SJS it is also important to differentiate the patient’s consent and preference. If SJS is part of an autonomy ideal of the sort found in Kantian ethics, consent seems more important than preference. From a utilitarian perspective a preference-based reading of SJS seems natural. I argue that the justification of SJS within a utilitarian framework will boil down to the question whether a non-competent patient can be said to have any surviving preferences. If we give a virtue-ethical justification of SJS the relative importance of consent and preferences depends on which virtue one stresses—respect or care. I argue that SJS might be an independent normative method for extending the patient’s autonomy, both from a Kantian and a virtue ethical perspective.     

Towards Substantive Standardization: Ethical Rules as Ethical Presumptions

This paper argues that substantive ethical rules serve a critical ethical function, even in those cases where we should deviate from those rules. Assuming that the rules are valid provides decision-makers with the context essential to reaching a well-justified decision. Recognizing this helps to reconcile two attractive but incompatible positions regarding the evaluation of healthcare ethics consultants. The first position is that ethical rules can validly be used to evaluate the quality of consultants’ advice, ensuring conformity to standards promoted by a significant portion of medical ethicists. The second position—the message of ethical particularism—is that we should not evaluate consultants according to strict rules, since good ethical advice may deviate from even the most carefully wrought moral rules. Steering a path between these extremes, I argue that we should evaluate the quality of consultations by examining whether consultants have communicated the relevant ethical rules to participants as ethical presumptions. In communicating presumptions, a consultant provides an indispensable ingredient to ethical decision-making, while leaving open the possibility that the ethical course of action involves violating the very ethical rules that one should presume.     

Postgraduate education in medical ethics in Japan

The objective of this paper was to investigate what kind of postgraduate education in medical ethics medical residents in Japan receive and what they want for ethical education and guidelines. Sixteen teaching hospitals that provide a general internal medicine residency programme in Japan were used (145 medical residents working at the departments of general internal medicine). A total of 114 residents participated in our survey, yielding a response rate of 79%. Of these, 28% received education in medical ethics more than once a month; 24% were offered it only when ethical problems were involved in actual patient care; and 18% answered that opportunities were very rare and sporadic. A full 30% had received no education in medical ethics at all. Many residents (71%) learned medical ethics from individual supervising doctors. A majority of the residents had been taught about informed consent (79%) and doctor–patient relationships (54%); 46% had learned about the appropriateness of truth telling and of ethical decisions regarding withholding and withdrawing a life-sustaining treatment, respectively. A total of 85 residents (75%) wanted to have more comprehensive education in medical ethics, 13% could not decide, and 12% did not want it. Many (66%) thought that both doctors and ethical philosophers should jointly teach medical ethics in postgraduate residency programmes. The results suggest that many residents desire more comprehensive and interdisciplinary education in medical ethics and educators in Japan should aim to develop education programmes to meet these desires.     

Patient rights and healthcare-associated infection

The Universal Declaration of Human Rights was adopted by the United Nations in 1948, and since that time, human rights have become widely recognized and legally enforceable in many countries. Patient rights are now included in healthcare constitutions, such as that of the English National Health Service, and in professional codes of practice. Patient rights have a number of implications for the control of healthcare-associated infections (HCAI), including: (1) justification for infection control over and above economic benefit; (2) focus and emphasis on the individual patient experience; (3) identification of some of the actions taken to control infection as breaches of rights; (4) bridging professional, infection control and public health ethics; (5) a requirement to specify the conditions under which rights can be breached; and (6) grounds for those seeking compensation for HCAI. Assuring patient rights has the potential to improve the patient experience, and in so doing, improve public confidence in healthcare provision and providers.     

Scepticism about the virtue ethics approach to nursing ethics

Nursing ethics centres on how nurses ought to respond to the moral situations that arise in their professional contexts. Nursing ethicists invoke normative approaches from moral philosophy. Specifically, it is increasingly common for nursing ethicists to apply virtue ethics to moral problems encountered by nurses. The point of this article is to argue for scepticism about this approach. First, the research question is motivated by showing that requirements on nurses such as to be kind, do not suffice to establish virtue ethics in nursing because normative rivals (such as utilitarians) can say as much; and the teleology distinctive of virtue ethics does not transpose to a professional context, such as nursing. Next, scepticism is argued for by responding to various attempts to secure a role for virtue ethics in nursing. The upshot is that virtue ethics is best left where it belongs – in personal moral life, not professional ethics – and nursing ethics is best done by taking other approaches.     

What Ethical Issues Really Arise in Practice at an Academic Medical Center? A Quantitative and Qualitative Analysis of Clinical Ethics Consultations from 2008 to 2013

As the field of clinical ethics consultation sets standards and moves forward with the Quality Attestation process, questions should be raised about what ethical issues really do arise in practice. There is limited data on the type and number of ethics consultations conducted across different settings. At Loyola University Medical Center, we conducted a retrospective review of our ethics consultations from 2008 through 2013. One hundred fifty-six cases met the eligibility criteria. We analyzed demographic data on these patients and conducted a content analysis of the ethics consultation write-ups coding both the frequency of ethical issues and most significant, or key, ethical issue per case. Patients for whom ethics consultation was requested were typically male (55.8 %), white (57.1 %), between 50 and 69 years old (38.5 %), of non-Hispanic origin (85.9 %), and of Roman Catholic faith (43.6 %). Nearly half (47.4 %) were in the intensive care unit and 44.2 % died in the hospital. The most frequent broad ethical categories were decision-making (93.6 %), goals of care/treatment (80.8 %), and end-of-life (73.1 %). More specifically, capacity (57.1 %), patient’s wishes/autonomy (54.5 %), and surrogate decision maker (51.3 %) were the most frequent particular ethical issues. The most common key ethical issues were withdrawing/withholding treatment (12.8 %), patient wishes/autonomy (12.2 %), and capacity (11.5 %). Our findings provide additional data to inform the training of clinical ethics consultants regarding the ethical issues that arise in practice. A wider research agenda should be formed to collect and compare data across institutions to improve education and training in our field.