Some Issues in Facial Transplantation

Human facial transplantation, a form of composite tissue allotransplantation, has now become a clinical reality. We carried out the world's second partial facial transplantation in April 2006. We reviewed some issues associated with facial transplantation, especially focusing on the individual who underwent the transplant in our department. We discussed surgical indications, techniques, risks versus benefits, informed consent and psychosocial, societal and financial issues of facial transplantation. In our opinion, with the progresses in composite tissue allotransplantation, partial or full facial transplantation is becoming a timely and effective remedy for the significantly disfigured patients. However, there are a lot of problems unsolved, and as we have performed the transplant on only three individuals, no long‐term outcome data are available. Facial transplantation needs further research.     

Human ageing and the origins of religion

During the evolution of hominids, the population could besustained even with an expectation of life at birth of less than20 years. Under these circumstances very few individuals reachedold age. In these hunter-gatherer communities, altruisticbehaviour was encouraged because it increased the likelihood ofsurvival, whereas self-interest did not. An early moral codebenefited the community as a whole. As social evolutionprogressed, the chances of survival increased, and for the firsttime very elderly individuals appeared. However, the reward forsurvival to old age was merely decrepitude and death. Underthese circumstances, new incentives became a social necessity,and these took the form of a belief in an eternal afterlife. Religion then became the basis for the moral code, and itprovided an assurance of continual survival after death.     

The Development and Psychometric Evaluation of the Ethical Issues Scale

Purpose: To describe the Ethical Issues Scale (EIS), its conceptual development and psychometric evaluation, and its uses in determining how frequently nurses experience ethical issues in practice.
Design: The EIS was validated with a sample (N=2,090) of New England registered nurses (RNs) currently in practice. The sample was randomly split into two approximately equal samples. The calibration sample was used to derive the underlying components; the validation sample was used to confirm the component structure.
Methods: Psychometric analysis of the 35-item EIS included: (a) item analysis, (b) confirmatory principal components analysis (PCA), and (c) internal consistency reliability using Cronbach's alpha.
Results: Three components (end-of-life-treatment issues, patient care issues, and human rights issues) were demonstrated, confirming the original conceptually-derived structure. The calibration sample accounted for 42.4% of initially extracted common variance; the validation sample accounted for 41.5% of initially extracted common variance.
Conclusions: The three EIS subscales had satisfactory internal consistency reliability and factorial validity for use as independent scales in future studies.     

Resolving Ethical Challenges for Psychological Practice in Long-Term Care

Psychological practice in geriatric long-term care settings, which range from community-based services to skilled nursing facilities, can present ethical dilemmas. The context for practice in long-term care consists of a complicated structure of clients, services, payers, and disciplines, and as a result is extremely complex. Ethical codes and principles are useful in resolving dilemmas. In addition, familiarity with recent legal reform such as the patient self-determination movement and the guardianship reform movement, and attention to issues of race and ethnicity are important in guiding practice.     

Increasingly distant from life: problem setting in the organization of home care

Abstract The analysis undertaken in this paper explores the significance of a central finding from a recent field study of home care case management practice: a notable feature of case management work is the preparation of an orderly, ordered space where care may be offered. However, out of their encounters with an almost endless variety of situations, out of people's diverse narratives of need, case managers seem able to pick out only limited range of recognized needs to which to respond and demonstrate a series of responses themselves equally limited. Though this observation suggests a kind of efficiency that is currently highly valued within healthcare systems, it also underlines the system's inability to engage difference and variability in a meaningful way. This inability or limitation in effectively engaging difference is conceptualized here as, in some sense, a problem, and the nature of this problem is explored through the rhetorical process of problem setting. The central question becomes how might we develop and deploy an orderly and coherent system of care without essentializing people's experiences, without treating these experiences reductively, without, in a Foucaultian frame of reference, allowing what can be understood as similarity or resemblance among clients and situations to be folded back into sameness? As we encounter complexity, variability and difference in practice, how should we treat it?     

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses

Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.     

A comparison between the ethics of justice and the ethics of care

The parameters of the problem within which the principal aim of the present article will be addressed can be described as follows. When making ethical decisions there are different perspectives that health care professionals may use. This may lead to conflict and insufficient co-operation between the members of the health team. Two of these perspectives are the ethics of justice and the ethics of care. The ethics of justice constitutes an ethical perspective in terms of which ethical decisions are made on the basis of universal principles and rules, and in an impartial and verifiable manner with a view to ensuring the fair and equitable treatment of all people. The ethics of care, on the other hand, constitutes an ethical approach in terms of which involvement, harmonious relations and the needs of others play an important part in ethical decision-making in each ethical situation. To seek some sort of way of avoiding conflict and promoting a mutual understanding about ethical decisions in the health team, there is a need to examine the ethics of justice and ethics of care. In order to understand the ethics of justice and ethics of care, the purpose of this article is to compare the two ethical perspectives. It is argued that the ethics of justice and the ethics of care represent opposite poles. If the members of the health team were to use only one of these two perspectives in their ethical decision-making, certain ethical dilemmas would almost certainly remain unresolved. Both the fair and equitable treatment of all people (from the ethics of justice) and the holistic, contextual and need-centred nature of such treatment (from the ethics of care), ought therefore to be retained in the integrated application of the ethics of justice and the ethics of care.     

Do Not Resuscitate orders and older patients: findings from an ethnographic study of hospital wards for older people

BACKGROUND AND AIM: This paper reports on the findings from an ethnographic study involving three wards in two hospitals in the Northwest of England and focuses on the controversial issue of Do Not Resuscitate (DNR) orders. The study aimed to explore the way in which terminal care was provided to older patients and examined the way in which DNR orders were a socially constructed part of the practices of both nurses and doctors. METHOD: An ethnographic approach was adopted that used participant observation and semi-structured interviews with nurses and doctors. A purposive sample of 28 qualified nurses and five medical staff were interviewed. The decision-making process of DNR orders became the focus of the interview questions. FINDINGS: The findings reveal that DNR decision-making was largely socially constructed from the interactions of hospital staff. Patients were not asked their preference and were excluded from any decision-making about Cardiopulmonary Resuscitation (CPR) or DNR orders. Two major findings emerge. First, DNR orders and the non-use of CPR could be seen as a form of medical beneficence, resulting from the often described paternalistic attitudes of hospital doctors. Second, there was a clear indication that DNR orders and the non-use of CPR for certain patients was based on improving the quality of patients' lives. CONCLUSION: The study raises issues about the quality of care received by frail older patients whom the nurses felt would not survive a futile medical procedure. The conclusion considers the need for hospitals to formulate and implement CPR policies, particularly in the prevailing climate in which patients are encouraged to become active participants in their own health care.