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This study documents moral/ethical situations that nurses in acute care hospitals experience as described by the nurses themselves. Findings show on-going evidence of caring, connectedness, and context. Decisions made often showed a balance between perceived ideal action and realistic action. This study also demonstrates that nurses need more opportunity for ethical reflection, that employers must become more involved in ethics education, and that further study of ethical decision making is needed as professionals and clients become more diverse.     

Protection against myocardial ischemic/reperfusion injury by inhibitors of two separate pathways of Na+ entry

Critics of Kohlberg's moral theory today focus on the content of his theory and more specifically on its justice-orientated moral concept. This has led to the well-known 'justice-care debate'. The purpose of this article is to critically examine the validity of Kohlberg's moral theory for research in nursing ethics from a caring perspective (referring to the content) as well as from a cognitive-structural perspective (referring to the basic assumptions of the model). The analysis points to the usefulness and value of the cognitive-structural model to empirically study nurses' ethical behaviour; the content of Kohlberg's model, however, needs to be adapted by adding a caring perspective as well as some personal and situational variables. An adjusted version of Kohlberg's model is proposed and discussed.     

Biomedical ethics and the biomedical engineer: a review

Biomedical engineering is responsible for many of the dramatic advances in modern medicine. This has resulted in improved medical care and better quality of life for patients. However, biomedical technology has also contributed to new ethical dilemmas and has challenged some of our moral values. Bioengineers often lack adequate training in facing these moral and ethical problems. These include conflicts of interest, allocation of scarce resources, research misconduct, animal experimentation, and clinical trials for new medical devices. This paper is a compilation of our previous published papers on these topics, and it summarizes many complex ethical issues that a bioengineer may face during his or her research career or professional practice. The need for ethics training in the education of a bioengineering student is emphasized. We also advocate the adoption of a code of ethics for bioengineers.     

Caring for the older patient, Part I: The relationship of theory to practice

This is the first article of a four-part series on gerontology and its applications to the care of elderly patients in nuclear medicine. The series includes discussions about the theories of aging, approaches to meeting the special needs of the elderly and ethical dilemmas in caring for the elderly. It also reviews anatomical and physiological changes associated with aging and the role of nuclear medicine studies in caring for the elderly. Upon completion of this article, the reader should be able to: (a) describe the aging U.S. population by citing demographic data; (b) identify the theories of aging and distinguish their major characteristics; (c) differentiate a gerontologic approach from a geriatric approach in caring for the elderly; and (d) recognize factors important to the delivery of effective care for the elderly.     

The patient-physician covenant: an affirmation of Asklepios

Medicine is, at its center, a moral enterprise grounded in a covenant of trust. This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. Today, this covenant of trust is significantly threatened. From within, there is growing legitimation of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the physician-patient relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer helper, and advocate for the sick and for the health of all. By its traditions and very nature, medicine is a special kind of human activity--one that cannot be pursued effectively without the virtues of humility, honesty, intellectual integrity, compassion, and effacement of excessive self-interest. These traits mark physicians as members of a moral community dedicated to something other than its own self-interest. Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gateclosers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient's well-being places the patient at risk by treatment that may compromise quality of or access to medical care. We believe the medical profession must reaffirm the primacy of its obligation to the patient through national, state, and local professional societies; our academic, research, and hospital organizations; and especially through personal behavior. As advocates for the promotion of health and support of the sick, we are called upon to discuss, defend, and promulgate medical care by every ethical means available. Only by caring and advocating for the patient can the integrity of our profession be affirmed. Thus we honor our covenant of trust with patients.     

The role of advanced practice nurses in surgical services

Many of the changes in health care delivery systems have had detrimental effects on nurses; however, some of these same changes are providing opportunities for acute care advanced practice nurses. Advanced practice nurses ensure continuity of care, manage use of resources, and coordinate patient services, which often results in cost savings. This article describes how advanced practice nurses in the department of surgery at Memorial Health Care, Worcester, Mass, are caring for surgical patients with acute and chronic conditions.     

The importance of 2,3-dimercaptopropinol (British anti-lewisite, BAL) in the trypanocidal activity of topical melarsoprol

The author agrees with the critiques of moral theory offered by such writers as Bernard Williams and Alasdair MacIntyre, and uses ideas from Heidegger and Levinas to argue that caring is an ontological structure of human existence which takes two forms: caring about on self (which he calls our "self-project") and caring-about-others. This dual form of caring is expressed on four Aristotelian levels of human living which the author describes and illustrates with reference to the phenomenon of pain. It is concluded from this analysis that traditional notions of morality as imposing obligations should give way to an understanding of ethics as the social forms given to our caring for ourselves and for others. A number of implications for ethical theory are sketched out with the conclusion that virtue theory should be preferred and that the model could be worked out more fully to show that virtue theory can be internalist, particularist, pluralist, personalist and objectivist.     

Cultivating a moral sense of nursing through model emulation

This paper reports part of a longitudinal research project, which sought to capture students' conceptualization of caring practice as they progressed to different levels of study in a nursing diploma programme in Hong Kong. Model emulation was found to be an effective means of focusing students' learning processes on the moral aspects of nursing practice. The theory of model emulation from a Chinese perspective and how it is applied to create a learning context to allow students to acquire a moral sense of nursing are discussed. The participating students are invited to be sincere enquirers in the pursuit of the good embedded in practice through introspective self-examination and dialogue. They are asked to describe and share their experience of positive and negative examples of nursing in written accounts. Van Kaam's phenomenological method was adopted to explicate the good and bad constituents of nursing from these examples, with the students assuming an active role in the explication process. The explication reveals that the students were able to articulate the good and bad practices in a variety of patient care situations.     

Power differentials, context, relationship, and emotions: feminist ethics considerations and human subjects research

As increasing attention is paid to the ethical concerns raised by human subject research, more needs to be focused on issues usually not discussed in the research ethics literature. No longer is it sufficient to talk only about the conflicting goals of clinical care and clinical research. We need to delve more deeply into how human subjects studies are performed and examine the feminist ethics issues of power differentials, context, relationships, and emotions. The source of much of our moral discomfort with clinical trials frequently is in these components of the clinical research settings that are discussed less often.     

An emerging cancer risk: organ transplantation

Advancements in surgical techniques, procurement, and immunosuppressant therapy have made organ transplantation a major treatment modality with increasing survival posttransplantation. However, this longevity has placed individuals with transplanted organs at an increased risk for developing cancer. This article examines the following pertinent issues. First, what is the prevalence of malignancies among transplant recipients? Second, are organ recipients told that they may be at risk for developing cancer? Third, is the medical community trading one lethal disease for another? And finally, are oncology nurses properly trained to handle the maintenance of a transplanted organ while caring for a person with cancer? This article looks at several ethical issues, including the ethical principle of autonomy, which examines the respect for a patient's right to choose or refuse treatment. Within this text, autonomy will be the basis for informed consent and the need for cancer risk disclosure. The ethical principle of beneficence is also examined, in regards to the health-care community trading one illness for another. The final ethical principle of nonmaleficence is considered and the need for future oncology nurses to examine their practice to determine if they are ready to care for these posttransplant cancer patients.     

Research contributions of counseling psychologists to neuropsychology

Otolaryngologists, like most physicians, tend to avoid local, state, and national politics for a variety of reasons. Although physicians and their patients are frequently affected by policies made in these political arenas, physicians tend to avoid active participation because of inexperience, lack of time, lack of knowledge about ways to influence policy development, and a general distaste for the political process. Otolaryngologists need to participate in the process to ensure that their particular perspectives and concerns are heard. However, otolaryngologists also need to look beyond their personal or specialty interests to influence the broader health care debate. Before we are specialists, we are first physicians who have a fiduciary responsibility to mankind (our patients) to improve the health care system for all Americans. We have a moral and ethical obligation to address, influence, and support health care beyond the specialty level. Health policy developed in an absence of physician input is missing the insight of expertise and experience.     

Ethical challenges in the managed practice of obstetrics and gynecology

Obstetrics and gynecology has been transformed from a fee-for-service, unmanaged system to a prepaid managed system. This change poses significant ethical challenges, which we address. We show that obstetrician-gynecologists and medical institutions are moral co-fiduciaries of female and pregnant patients, that the obstetrician-gynecologist should be economically disciplined without capitulating to managed care, and that managed care organizations have an obligation to support the medical education and research from which they benefit.     

Preserving moral integrity: a follow-up study with new graduate nurses

The purpose of this follow-up study was to describe, explain and interpret how new graduate nurses perceived their adaptation to the 'real world' of hospital nursing and what they perceived as major influences on their moral values and ethical roles in the 2 years following graduation. The method was qualitative, specifically grounded theory. The earlier study took place when informants were senior nursing students. The follow-up study began after the informants had been practising for 1 year. Research questions guiding the study were: How do new graduate nurses describe their adaptation to the 'real world' of hospital nursing? What do they describe as factors influencing their moral values and ethical roles in hospital nursing? Preserving moral integrity was the basic psycho-social process that explained how these new graduate nurses adapted to the real world of hospital nursing. Six stages of this process were identified: vulnerability; getting through the day; coping with moral distress; alienation from self; coping with lost ideals; and integration of new professional self-concept. Moral distress was a consequence of the effort to preserve moral integrity. It is the result of believing that one is not living up to one's moral convictions. Data supported that the most pervasive attributes of moral distress were self-criticism and self-blame, as informants judged their actions against their moral convictions and their standards of what a good nurse would do. Moral distress was an acute form of psychological disorientation in which informants questioned their professional knowledge, what kind of nurses they were and what kind of nurses they were becoming. Theoretical explanations of these findings are grounded in social interaction and moral psychology theories.     

Professional integrity in clinical research

In response to public concern over abuses in human medical experimentation, the dominant approach to the ethics of clinical research during the past 30 years has been regulation, particularly via institutional review board review and approval of scientific protocols and written consent forms. However, the effectiveness of regulatory mechanisms in ensuring the ethical conduct of clinical research is limited. Little attention has been devoted to the nature and role of professional integrity of physician investigators, a conscientious framework for guiding investigators in the socially important but morally complex activity of clinical research. Professional integrity is vital in forging an ethically sound relationship between investigators and patient volunteers, a relationship that differs in important ways from the patient-physician relationship in standard clinical practice. We examine critically 2 models of the moral identity of physician investigators, the investigator as clinician and the investigator as scientist; in neither of these 2 models can the physician investigator eliminate completely the moral conflicts posed by clinical research. The professional integrity of physician investigators depends on a coherent moral identity that is proper to the enterprise of clinical research. The roles of clinician and scientist must be integrated to manage conscientiously the ethical complexity, ambiguity, and tensions between the potentially competing loyalties of science and care of volunteer patients.     

The internal morality of medicine: explication and application to managed care

Some ethical issues facing contemporary medicine cannot be fully understood without addressing medicine's internal morality. Medicine as a profession is characterized by certain moral goals and morally acceptable means for achieving those goals. The list of appropriate goals and means allows some medical actions to be classified as clear violations of the internal morality, and others as borderline or controversial cases. Replies are available for common objections, including the superfluity of internal morality for ethical analysis, the argument that internal morality is merely an apology for medicine's traditional power and authority, and the claim that there is no single, "core" internal morality. The value of addressing the internal morality of medicine may be illustrated by a detailed investigation of ethical issues posed by managed care. Managed care poses some fundamental challenges for medicine's internal morality, but also calls for thoughtful reflection and reconsideration of some traditionally held moral views on patient fidelity in particular.     

Family physicians' involvement with dying patients and their families. Attitudes, difficulties, and strategies

OBJECTIVE: To determine family physicians' perceptions of the difficulty in caring for dying patients and how prepared they are to provide such care relative to strategies used with difficulties encountered, personal need for support and development, and cooperation with other caregivers. DESIGN: Exploratory. SETTING: Physicians' offices. SUBJECTS: Thirty-five randomly selected family physicians (doctors of medicine and doctors of osteopathy) representative of family physicians practicing in Franklin County, Ohio. INTERVENTIONS: None. MAJOR OUTCOME MEASURES: A semistructured interview guide corresponding to a three-dimensional theoretical model developed prior to the study was used to determine family physicians' perceptions regarding care of dying patients and their families. The three dimensions include family physicians' involvement with dying patients and their families, their personal needs and development, and their cooperation with other caregivers. RESULTS: Participants agreed that the care of dying patients and their families is an important and special component of practicing family medicine. Generally seeing themselves as adequately prepared, they still found such care difficult and desired more education and training to increase comfort of their patients and of themselves. Their perceptions regarding the care of dying patients and their families could be categorized in terms of communication as part of the care process, family issues, legal and ethical issues, coordination of care, physicians' feelings, and physicians' influence and support. CONCLUSIONS: Family physicians require formal training in death issues and need to find a way to maximize learning through personal experiences. Discussion of cases in a support group may be beneficial.     

Ethical issues and critical thinking: students' stories

Through the stories told by these students it is evident that beginning students do think critically and act ethically during their first clinical nursing course. Ethical dilemmas involving students and staff, patients, faculty, and peers depict beginning students' development of values as they evolve into professionals. The conscientiousness and caring displayed by beginning students is apparent from students' shared perspectives. It is particularly encouraging that they seemed to focus more on values and cognitive aspects of patient care than on primarily technical psychomotor skills such as taking blood pressures and giving injections. Teaching beginning students is a challenge because the educator's role is twofold: Help students build a foundation for developing ongoing critical thinking abilities and help students develop an ethical view of patient care. Further exploration of critical thinking and ethical decision making should emphasize the mutual student-educator roles in facilitating self-awareness, through conscious awareness of their beliefs, values, feelings, and multiple perspectives. Because nursing emphasizes the human element and student nurses deal with human lives, educators play a vital role in facilitating the development of beginning students as critical thinkers and as ethical nurses. The most knowledgeable and most psychologically mature faculty are needed to teach beginning nursing students. Through ongoing reflection and critical thinking, nurse educators can help beginning students to identify and develop multiple perspectives on the ethics of nursing practice.     

Nursing students' responses to ethical dilemmas in nursing practice

In literature as well as in nursing practice a growing concern about nurses' ethical competence can be observed. Based on the cognitive theory of moral development by Kohlberg, this research examined nursing students' ethical behaviour in five nursing dilemmas. Ethical behaviour refers not only to the ethical reasoning of nursing students but also to the relationship between reasoning and behaviour. Kohlberg's definition of morality was refined by adding a care perspective. The results show that the majority of students can be located in the fourth moral stage according to Kohlberg's theory, that is, the conventional level of moral development. This finding implies that students are still guided by professional rules, norms and duties, and have not (yet) succeeded in making personal ethical decisions on the basis of their own principles and acting according to such decisions.