EMPIRICAL ETHICS AS DIALOGICAL PRACTICE

In this article, we present a dialogical approach to empirical ethics, based upon hermeneutic ethics and responsive evaluation. Hermeneutic ethics regards experience as the concrete source of moral wisdom. In order to gain a good understanding of moral issues, concrete detailed experiences and perspectives need to be exchanged. Within hermeneutic ethics dialogue is seen as a vehicle for moral learning and developing normative conclusions. Dialogue stands for a specific view on moral epistemology and methodological criteria for moral inquiry. Responsive evaluation involves a structured way of setting up dialogical learning processes, by eliciting stories of participants, exchanging experiences in (homogeneous and heterogeneous) groups and drawing normative conclusions for practice. By combining these traditions we develop both a theoretical and a practical approach to empirical ethics, in which ethical issues are addressed and shaped together with stakeholders in practice. Stakeholders' experiences are not only used as a source for reflection by the ethicist; stakeholders are involved in the process of reflection and analysis, which takes place in a dialogue between participants in practice, facilitated by the ethicist. This dialogical approach to empirical ethics may give rise to questions such as: What contribution does the ethicist make? What role does ethical theory play? What is the relationship between empirical research and ethical theory in the dialogical process? In this article, these questions will be addressed by reflecting upon a project in empirical ethics that was set up in a dialogical way. The aim of this project was to develop and implement normative guidelines with and within practice, in order to improve the practice concerning coercion and compulsion in psychiatry.     

Equity Under the Knife: Justice and Evidence in Surgery

Surgery is an increasingly common and expensive mode of medical intervention. The ethical dimensions of the surgeon‐patient relationship, including respect for personal autonomy and informed consent, are much discussed; but broader equity issues have not received the same attention. This paper extends the understanding of surgical ethics by considering the nature of evidence in surgery and its relationship to a just provision of healthcare for individuals and their populations.     

Enriching Our Views on Clinical Ethics: Results of a Qualitative Study of the Moral Psychology of Healthcare Ethics Committee Members

The contribution of healthcare ethics committee (HEC) members to HECs is fundamental. However, little is known about how HEC members view clinical ethics. We report results from a qualitative study of the moral psychology of HEC members. We found that contrary to the existing Kohlberg-based studies, HEC members hold a pragmatic non-expert view of clinical ethics based mainly on respect for persons and a commitment to the patient’s good. In general, HEC members hold deflationary views regarding moral theory. Ethical principles are not abstract foundations but the expression of moral commitments to patients that pre-exist awareness of moral theory. Emotions and proximity to patient sufferance fundamentally shape the views of HEC members on clinical ethics. Further work at the intersection of clinical ethics and qualitative research could bring to the foreground lay perspectives on moral problems that may differ from bioethics expert views.     

Clinical ethics and nursing: "yes" to caring, but "no" to a female ethics of care

According to a contemporary school of thought there is a specific female approach to ethics which is based not on abstract "male" ethical principles or rules, but on "care". Nurses have taken a keen interest in these female approaches to ethics. Drawing on the views expounded by Carol Gilligan and Nel Noddings, nurses claim that a female "ethics of care" better captures their moral experiences than a traditional male "ethics of justice". This paper argues that "care" is best understood in a dispositional sense, that is, as sensitivity and responsiveness to the particularities of a situation and the needs of "concrete" others. While "care", in this sense, is necessary for ethics, it is not sufficient. Ethics needs "justice" as well as "care". If women and nurses excessively devalue principles and norms, they will be left without the theoretical tools to condemn some actions or practices, and to defend others. They will, like generations of nurses before them, be condemned to silence.     

CLINICAL ETHICS AND NURSING: "YES" TO CARING, BUT "NO" TO A FEMALE ETHICS OF CARE

According to a contemporary school of thought there is a specific female approach to ethics which is based not on abstract "male" ethical principles or rules, but on "care". Nurses have taken a keen interest in these female approaches to ethics. Drawing on the views expounded by Carol Gilligan and Nel Noddings, nurses claim that a female "ethics of care" better captures their moral experiences than a traditional male "ethics of justice". This paper argues that "care" is best understood in a dispositional sense, that is, as sensitivity and responsiveness to the particularities of a situation and the needs of "concrete" others. While "care", in this sense, is necessary for ethics, it is not sufficient. Ethics needs "justice" as well as "care". If women and nurses excessively devalue principles and norms, they will be left without the theoretical tools to condemn some actions or practices, and to defend others. They will, like generations of nurses before them, be condemned to silence.     

Veterinarians’ Emotional Reactions and Coping Strategies for Adverse Events in Spay-Neuter Surgical Practice

This study is a thematic analysis of the experiences, thoughts, and reactions of shelter and spay-neuter veterinarians as they cope with serious adverse patient events (life-threatening complications or death) related to spay-neuter. Thirty-two veterinarians responded to an electronic questionnaire containing 22 open-ended questions relating to their emotions, thoughts, experiences and actions after adverse events. Participants experienced immediate and visceral reactions to adverse events during which they described feelings of guilt, sadness, anxiety, and self-doubt, and expressed empathy for their clients and for others affected by these events. Many controlled or managed their emotional response in the immediate aftermath of the event, both in order to complete the existing surgical workload and to maintain professional bearing. Participants’ initial reactions evolved over time to reflect their long-term resilience, or to be experienced as recurrent trauma. Four factors related to coping appeared to shape this long-term outcome: Technical Learning; Perspective and Appraisal; Support and Collegiality; and Emotional Learning. Nearly every participant emphasized the importance of technical learning in order to decrease future occurrences and improve skills. Participants used a variety of frames of reference to provide perspective, and place the adverse event in a larger context. Many veterinarians described the importance of conversations with other veterinarians following adverse events, both for technical advice and psychosocial support. Through experience, some participants attained emotional learning about how to handle and support themselves through an adverse event. Some veterinarians were able to process and move past the intrusive effects of sadness, guilt and self-doubt within a day to a week, while others were deeply affected for months or even years after a severe adverse event. Several veterinarians had considered leaving the field, and a few had stopped performing surgery. Understanding how spay-neuter veterinarians cope with adverse events could be integral to supporting the health and welfare of these skilled workers and retaining them in the field, decreasing the shame and self-doubt experienced by many, and encouraging information-sharing practices that foster continuous improvements in the patient care that spay-neuter clinics and shelters provide.     

Facets of patient complaints: pain, suffering, and the importance of consideration

Patient complaints, as it has often been recognized, serve to express multiple and varied experiences and needs. A number of options for filing complaints and a variety of ways for doing so have arisen recently, among which are ethics committees, support groups, palliative care units, and complaint examination committees. Today patients have many occasions for expressing their experiences, talking about distressing incidents, and making their needs known. Three orally related experiences are examined here, both from the viewpoint of the patient and in light of their cultural meanings: pain, suffering, and the importance of consideration. These are three expectations of care providers, but also three experiences that dispose patients to rethink their individuality and their relationships with others, to take stock of their pasts, and to reflect on who they are and who they want to become. The experience of illness has thus become pivotal in the process of constructing individual identity.     

Patients' responsibilities in medical ethics

Patients have not been entirely ignored in medical ethics. There has been a shift from the general presumption that 'doctor knows best' to a heightened respect for patient autonomy. Medical ethics remains one–sided, however. It tends (incorrectly) to interpret patient autonomy as mere participation in decisions, rather than a willingness to take the consequences. In this respect, medical ethics remains largely paternalistic, requiring doctors to protect patients from the consequences of their decisions. This is reflected in a one–sided account of duties in medical ethics. Duties fall mainly on doctors and only exceptionally on patients. Medical ethics may exempt patients from obligations because they are the weaker or more vulnerable party in the doctor–patient relationship. We argue that vulnerability does not exclude obligation. We also look at others ways in which patient responsibilities flow from general ethics: for instance, from responsibilities to others and to the self, from duties of citizens, and from the responsibilities of those who solicit advice. Finally, we argue that certain duties of patients counterbalance an otherwise unfair captivity of doctors as helpers.     

The prevention and management of medical problems during office surgery

Surgeons who perform office surgery without the presence of personnel trained in anesthesia are responsible for both the surgery and the general condition of the patient. Thus the prevention and management of medical problems that may occur during the operation or in the recovery room become their concerns. Fortunately, medical problems arise infrequently. However, the anxiety of the moment may cloud important details of treatment; as a result, having a preconsidered plan is advised. This paper presents step-by-step outlines that provide safe and effective treatment plans for guiding the surgical team during the management of medical problems during office surgery.     

Pre-operative respiratory evaluation and management of patients for upper abdominal surgery.

Patients presenting for surgery, be it on an elective or emergency basis, do so in the hope that the anesthetic will be without risk. Yet complications which arise are not always due to anesthesia. More often, the surgical process and factors intrinsic to the patient are major determinants of outcome. Pre-operative assessment allows review of the patient and the proposed surgery, and formation of a plan of management for the pre-, intra-, and post-operative anesthetic care. This paper provides an overview of the pre-operative assessment and management of patients who are to undergo upper abdominal surgery, with the aim of minimizing their risk of post-operative pulmonary complications. In particular, factors which contribute to the development of post-operative respiratory problems are described.     

仿真手术刀在虚拟外科手术系统中的应用与研究

目的 设计了一种基于手术刀的虚拟外科手术系统,培训外科实习医生熟悉并体验外科手术的过程.方法 符合外科医生实际操作习惯设计仿真外科手术系统专用的手术刀,完成各种结构设计、三维定位跟踪、力反馈选型,设计配套软件系统,使其提供逼真的三维虚拟场景.结果 在所建立的虚拟手术台上所做的虚拟切割实验表明,该虚拟外科手术系统使操作者体验到真实做手术的感觉,完全可用于外科医生的培训当中,使得受训者获得逼真的手术教学效果.结论 利用这种仿真手术刀进行虚拟外科手术系统的解决方案,并构建了一个虚拟手术台,为训练外科实习医生熟练使用手术刀提供了一个方便快捷的途径.     

Chromosome 16 microdeletion in a patient with juvenile neuronal ceroid lipofuscinosis (Batten disease).

The gene that is involved in juvenile neuronal ceroid lipofuscinosis (JNCL), or Batten disease--CLN3--has been localized to 16p12, and the mutation shows a strong association with alleles of microsatellite markers D16S298, D16S299, and D16S288. Recently, haplotype analysis of a Batten patient from a consanguineous relationship indicated homozygosity for a D16S298 null allele. PCR analysis with different primers on DNA from the patient and his family suggests the presence of a cytogenetically undetectable deletion, which was confirmed by Southern blot analysis. The microdeletion is embedded in a region containing chromosome 16-specific repeated sequences. However, putative candidates for CLN3, members of the highly homologous sulfotransferase gene family, which are also present in this region in several copies, were not deleted in the patient. If the microdeletion in this patient is responsible for Batten disease, then we conclude that the sulfotransferase genes are probably not involved in JNCL. By use of markers and probes flanking D16S298, the maximum size of the microdeletion was determined to be approximately 29 kb. The microdeletion may affect the CLN3 gene, which is expected to be in close proximity to D16S298.     

Ethnic Elders and American Health Care—A Physician's Perspective

The aging process is a fugue composed of innumerable themes; the theme of “ethnicity” is by far one of its more dominant. Due to the increasing incidence of chronic, progressive infirmity and acute, catastrophic illness, the elderly are thrust into direct contact with the health care systems of their society. The experiences of ethnic elders in American health care situations are fraught with conflict and mutual dissatisfaction with the physician-patient relationship. Both providers and consumers of health care services harbor differing culture-bound perceptions of health, illness and the healing process; these cultural beliefs define personal and professional needs and expectations and notions of how those needs are to be met by others. Both physicians and patients can enhance their communication and their compassion for one another by acknowledgment of cultural differences and by increased willingness to interpret motives and behavior within native context.It behooves us in medicine to examine the cultural traditions underlying our own attitudes, beliefs and values about the aged in a universal sense, as well as in a culturally specific sense, that we may gain insight that will be helpful in serving elderly persons more effectively, and in solving some of the problems inherent in the aging process.     

A technique for the long term measurement of intra-compartmental pressure in the lower leg

The early diagnosis of an acute compartmental pressure syndrome is often difficult, but can be facilitated by long term, up to several days, measurement of intra-compartmental pressures. A measuring system has been developed, together with its associated surgical and operational procedures, which may be applied in a variety of situations, including an immobile patient or a patient mobilized following surgery. If the technique is adopted as soon as the patient enters hospital, or immediately postoperatively, an acute compartmental syndrome may be recognized early and measures taken to alleviate its consequences.     

Finding a Place for the Commonplace: Hurricane Katrina, Communities, and Preservation Law

The aftermath of Hurricane Katrina drew attention to commonplace landscape markers that create for a community a sense of place— that connection between people and places crucial to a sense of corporate and individual identity and heritage. There is a legal context for sense of place within extant federal preservation legislation. Nevertheless, many such markers with special meanings for residents have been overlooked in federal documentation, the cornerstone of which is the National Register of Historic Places. Grassroots efforts and national media coverage have helped forge a niche for sense of place within the recovery plans and policy emerging in the affected region. However, it is unclear whether this will carry over into practice. In terms of long-term policy shifts, remedying the shortcomings highlighted by Katrina may require changes to the National Historic Preservation Act and its associated guidelines and regulations, or it may entail a new approach altogether.     

A sequence of 'factishes': the media-metaphorical knowledge dynamics structuring the German press coverage of the human genome

This article deals with the cultural framing of the near sequencing of the human genome and its impact on the media coverage in Germany. It investigates in particular the way in which the weekly journal Die Zeit and the daily newspaper Frankfurter Rundschau reported this media event and its aftermath between June 2000 and June 2001. Both newspapers are quality papers that played an essential role in framing the human genome debate--alongside the Frankfurter Allgemeine Zeitung--which became the most prominent genomic forum. The decoding of the human genome prompted a huge controversy concerning the ethics of human engineering, research on stem cells and Preimplantation Genetic Diagnosis. The main aim of this article is to show how this controversy was structured by metaphor. The media coverage of the genome generated DNA-factishes--a neologism designating the ambivalence of something as fact (fait) and as a fetish (fetiche)--that mostly propagated images of a new DNA-scienticism or biological determinism. Mediated by cultural experiences, the human genome became a highly artificial and social construct of a 'NatureCulture'.     

The oral examination: awesome or awful?

Medical and surgical specialty boards are constantly striving to insure that those seeking certification in their specialty are adequately trained and sufficiently evaluated to guarantee the highest quality of patient care. One traditional component of the evaluation process, the oral examination, has been discontinued by some specialty boards but is still retained by most. A review of the history of the oral examination, combined with personal experiences of the author, suggests that this particular rite of passage may have outlived its usefulness in all but a few areas of medical specialization. Addressing the most pressing problems of patient mismanagement in the most visible area of practice, the hospital environment, requires that major emphasis be on the improvement of hospital practices rather than on doctors' qualifications. Only in this way can we ensure patient safety and restore patients' confidence in the care they receive and in the doctors responsible for administering it.     

Assessment of the ethical review process in Sudan

The ethical review process is an important component of contemporary health research worldwide. Sudan started an ethical review process rather late in comparison with other countries. In this study, we evaluate the structure and functions of existing ethics review committees. We also explore the knowledge and attitudes of Sudanese researchers toward the ethical review process and their experience with existing ethics review committees. There are four ethics review committees in the country; these committees have no institutional regulations to govern their functions. Furthermore, Sudan also lacks national guidelines. Ethical reviews are carried out primarily for studies seeking international funding and are almost always governed by the funding agencies' requirements. Nearly half of respondents (46.3%) knew about the existence of research ethics committees in Sudan. Researchers reported a variety of experiences with the ethical review process; most of them were unable to define 'ethics committee'.     

Responsibility after the apparent end: 'following-up' in clinical ethics consultation

Clinical ethics literature typically presents ethics consultations as having clear beginnings and clear ends. Experience in actual clinical ethics practice, however, reflects a different characterization, particularly when the moral experiences of ethics consultants are included in the discussion. In response, this article emphasizes listening and learning about moral experience as core activities associated with clinical ethics consultation. This focus reveals that responsibility in actual clinical ethics practice is generated within the moral scope of an ethics consultant's activities as she or he encounters the unique and specific features that emerge from interactions with a specific patient, or family, or practitioner within a given situation and over time. A long-form narrative about an ethics consultant's interactions is interwoven with a more didactic discussion to highlight the theme of responsibility and to probe questions that arise regarding follow-up within the practice of clinical ethics consultation.     

Clinical Anaerobic Infections

Clinical anaerobic infections are often associated with and in proximity to the mucous membranes where they are predominantly normal human flora. This wide variety of infections can be associated with significant morbidity and mortality, especially when clinically unrecognized or ineffective antimicrobial therapy is selected or inadequate surgical therapy is utilized. These diverse infections may be located anywhere in the body but are usually associated with the mucous membranes of the oral cavity, respiratory tract, gastrointestinal tract, female genitourinary tract and the fecal stream. Abscess formation and foul odor to a discharge or wound, and the presence of necrotic tissue are clinical clues of anaerobic infections.