Moral issues in psychotherapy.

"The first moral obligation of the psychotherapist is to be competent. The more skillful he becomes, the better he fulfills his main ethical responsibility." 4 typical examples of moral issues which arise frequently in the practice of psychotherapy are specified. "One of the falsehoods with which some therapists console themselves is that their form of treatment is purely technical, so they need take no stand on moral issues… . The illusion that our art transcends morality has kept us from forthright study of the ethical and religious disciplines. We psychologists would take a dim view of any experts in philosopy and religion who might hang out a shingle to practice psychotherapy. We would deplore their lack of training in our discipline. My thesis is that scholars in religions and ethics have a right to take an equally dim view of most psychotherapists." The "meaning and contribution of psychotherapy will be enlarged as its practitioners add to their growing technical competence a broader and deeper realization of life's persistent ethical problems." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Localization of the mRNA for the angiotensin II receptor subtype 2 (AT2) in follicular granulosa cells of the rat ovary by nonradioactive in situ hybridization

Changes in medicine brought on by health care reform will increasingly pressure physicians and physicians-in-training to adopt business or trade strategies in the name of cost containment and of competition in the health care marketplace. These strategies run directly counter to the professional standards and are a potential threat to medicine's status as a profession. A challenge for this generation of students is not to let this emphasis on finances erode medicine's professionalism. Medical faculty must ensure that their students properly understand the nature of the relationships that permit medicine to enjoy the benefits of being a profession (rather than a trade) and that they learn the appropriate balance between financial and professional considerations. Faculty can and should place financial considerations in proper perspective. Students should learn the basic components of professionalism, how physicians in the past have not always met the full criteria for professionalism, how the current emphasis on cost containment could threaten medicine's status as a profession, appropriate goals for health care reform, the need to form new alliances to meet those goals, and criteria for forming appropriate alliances. Armed with this knowledge, the generation of physicians now in training can understand the delicate balance that must be maintained between financial exigencies and professional imperatives. They will then be prepared to participate in the reform process, embrace its positive aspects, and argue effectively against its negative ones.     

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.     

Where lies social responsibility?

L. Krasner's article, "Behavior Control and Social Responsibility" (see record 1963-00116-001) bypassed several points of view which might clarify some of the issues discussed, and at the same time tone down what seems to be an exaggerated claim for urgency in dealing with problems of social responsibility. In the matter of considering moral and ethical issues, it is important to proceed with calmness and careful consideration rather than to become overly excited about finding the "right" solution. Even the "psychologist-researcher" is human and when he turns his hand to such things as communicating to the lay public he may fall into the pattern of the "sensationalists and popularizers," though obviously not so crudely. First among three basic questions and answers presented by Krasner is that concerning whether or not human behavior is controllable. His answer is to the effect that there is overwhelming experimental evidence that human behavior is controllable. Such a statement seems exaggerated in the face of other evidence from both experimental and clinical impressions. Krasner states that there is a "subtle but important" difference between the "psychology of behavior control" and the science of psychology. There are several objections to some of Krasner's implications that the behavioral scientist is not or at least is less bound by an ethical and moral system. There seem to be no logical grounds for distinguishing in principle between an ethics for behavioral scientists and an ethics for behavior controllers. The atomic scientists produced a bomb as scientists employed by their government while at war. They did their job effectively. As informed private citizens they held some moral reservations as to the consequences of their scientific endeavors. The behavioral scientist and the behavior controller can also perform their professional tasks dispassionately and efficiently, but as people they might well look to the ethical and moral issues involved. They can choose to take appropriate ethical and moral action as private citizens who have the advantages of specialized knowledge. The behavioral scientist and the behavior controller are not to be compartmentalized into a patchwork of separate roles, rather they are to see themselves as integrated individuals functioning in various ways which on occasion may bring about a conflict in ethical and moral values. Then they should be enabled to resolve the conflicts for themselves on a rational basis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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.     

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.     

The man with stars inside

Public opinion polls show that a large percentage of persons in the United States currently favor the legalization of professionally assisted death. This support reflects widespread fear and confusion over the tortuously prolonged and painful process of dying countenanced by contemporary medicine. Physician-assisted suicide and euthanasia are complex moral issues. The current drive to translate them into debates about "rights" and public policy is curious: Does the energy directed toward "palliation-by-death" mean that our society is more compassionate now, or more just, than in the past? To the contrary, I believe that the movement toward assisted death reflects inadequate palliative care, poor patient-physician communication, great confusion about the right to refuse treatment, and profound inequity in U.S. health care. Legalization of assisted death diverts us from addressing these problems. Palliation-by-death will drive us farther apart, not closer together.     

Comparison of seizure related amino acid release in human epileptic hippocampus versus a chronic, kainate rat model of hippocampal epilepsy

Many ethical issues in emergency medicine involve the question of informed consent. In this article, the ethical basis for informed consent, the essential elements of a morally valid informed consent, and the inadequacy of the law as a moral guide for informed consent are discussed. The ways in which the nature of emergency medicine affects the application of moral principles are examined, and specific guidelines for assessing a patient's decision-making capacity regarding informed consent are provided.     

Ethical care at the end of life

In treating dying patients, who by virtue of their physical and emotional situation are frail and vulnerable, physicians must meet a high standard of professional, ethical care. Such a standard is based upon a philosophy of care that recognizes the patients' inherent worth as human beings and their uniqueness as individuals. The ethical and virtuous physician will practice in accordance with the principles of biomedical ethics that form the foundations of thought and treatment approaches in this area and will seek to do the best for the patient and the family. "Doing the best" includes respecting autonomy through gentle truth-telling, helping the patient and family to set treatment goals, and providing for symptom control, continuing attentive care and accompaniment throughout the course of the illness. Total care includes physical, emotional and spiritual aspects, is sensitive to cultural values and is best provided by an interdisciplinary team. Practices of symptom control in routine care and in crisis situations, as well as the cessation and non-initiation of treatment, will have as their goals the relief and comfort of the patient. The ethical physician will not act with the intention of bringing about the death of the patient, whether by ordering medication in excess of that required for symptom control, administering a lethal injection or any other means.     

Sociology in American medical education since the 1960s: the rhetoric or reform

Despite recommendations by medical reformers that medical sociology be included in the curriculum, there is currently little evidence of a far-reaching integration of sociological perspectives in American medical education. Yet, support for the relevance of sociological knowledge has since the late 1960s helped to diffuse external pressures for change in health care and medical education. As a symbol of the communitarian commitment of the medical profession, claims in favor of the incorporation of sociological perspectives have thus occasionally, and largely unintentionally, served the public relations interests of biomedicine. However, the more recent interest in medical ethics has to some degree transformed medicine's educational agenda and the definition of medical 'human values'. Whereas the rhetorical expropriation of medical sociology primarily has concerned medicine's responsibility vis-à-vis society as a whole, the new medical ethics education signifies a return to a more individualistically oriented medical morality.     

Contributions of ethics to the practice of intensive care

Intensive care, one of the greatest achievements of modern medicine, is not without its problems. In what sense could ethics contribute towards an intensive care medicine which would be humane and respectful of what it means to be sick? After having presented a phenomenology of what it means to be sick and in intensive care, the author proposes an ethical framework which could guide the decision-making of physicians specialized in the field. This framework has three levels. Level one deals with the basic values of benevolence and autonomy which are those of medicine itself. Level two deals with the implementation of these values, which bioethics sees as conflicting. Implementation is achieved by "conversation" between the physician and the patient. Finally, the physician is invited to question his or her own attitude towards the unavoidable dilemmas created by the paradoxes and contradictions of modern medicine.     

Ethics: Virtue and politics in the science and practice of psychology.

Discusses the thesis that the discipline of psychology needs to re-discover and reclaim virtue and moral values as its base for ethical behavior, thinking, and being. Psychology has a short history in formalizing codes of ethics and codes of conduct. Current and historical events, and concepts and values, including those based on philosophy and religion, have influenced the development of psychology's scientific and professional codes. The ethical behavior of psychologists may be inspired by values, regulated by rules, determined by external pressures, or any combination of these. Emerging issues and challenges in today's changing and turbulent society require an incorporation of moral principles in finding acceptable strategies to achieve acceptable goals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The relative effectiveness of setting goals as a chance for dealing with complex decision processes in medicine

Beyond specialist aspects, decision making in medicine must also take ethical and economic considerations into account. Decisions according to the rational principle are orientated towards premisses with goals as a crucial part of them. Upon close examination, medical as well as ethical and economic premisses turn out to be uncertain, offering room for interpretation and procedural considerations. Simple algorithms of problem solution fail in complex decision situations especially if contradictory goals have to be considered and if a high potential of conflict exists. In complex problems, therefore, it is suggested to employ a three-step programme that consists of limiting the conflict by making the goals more precise and of handling the conflict by balancing different goals as first measures. As third step one could image a solution of the conflict by means of an evolution of different goals basing on the very uncertainty or relativity of goals.     

Risk factors and clinical outcomes between fungal and bacterial keratitis: a comparative study

OBJECTIVE: Thirty years ago, cardiopulmonary resuscitation (CPR) was primarily developed for otherwise healthy individuals who experienced sudden cardiac arrest. Today, CPR is widely viewed as an emergency procedure that can be attempted on any person who undergoes a cessation of cardiorespiratory function. Therefore, the appropriateness of CPR has been questioned as a matter of the outcome, the patient's preferences, and the cost. The objective of this article is to analyse ethical issues in prehospital resuscitation. ARGUMENTS: CPR is bound by moral considerations that surround the use of any medical treatment. According to Beauchamp and Childress, the hierarchy of justification in biomedical ethics consists of ethical theories, principles, rules, and particular judgements and actions. The decision to start CPR is based on the medical judgement that a person is suffering from circulatory arrest. The decision is justified by the moral rule that the victim of a cardiac arrest has the right to survive and to receive CPR. Moral rules are more specific to contexts and are based on ethical principles. The principle of beneficence means the provision of benefits for the promotion of welfare. Talking about beneficence in resuscitation means once again reporting stories of success, as many victims of pre- and in-hospital sudden death have been saved in the past. Nevertheless, resuscitative efforts still remain unsuccessful in the majority of cases, involving the principle of nonmaleficence. There is potential harm in CPR. Survivors may recover cardiac function, but sustain severe hypoxic brain damage, at worst surviving without awakening for months or years. In particular, post-traumatic CPR is associated with an extremely poor outcome, leading to the issue of futility. However, futility should be defined in a strict fashion, as there might be an individual chance of survival. The principle of respect for autonomy means the right of a patient to accept or reject medical treatment, which continues in emergency conditions and after the patient has lost consciousness. The time frame in CPR requires medical decision-making within seconds, and CPR is usually initiated without the patient's involvement. If the patient's wish's can be ascertained later on, life-sustaining therapies might be withdrawn at the time. Terminally ill but still competent patients should be encouraged to write a no-CPR document, which does not deny patients relief from severe symptoms, but might facilitate withholding resuscitative efforts at the scene. The principle of justice affects priorities in the allocation of health care resources. The decision made for a particular patient might delay or prevent emergency treatment in other patients who could receive greater benefit. CONCLUSIONS: The standard of care remains the prompt initiation of CPR. However, ethical principles such as beneficence, nonmaleficence, autonomy, and justice have to be applied in the unique setting of emergency medicine. Physicians have to consider the therapeutic efficacy of CPR, the potential risks, and the patient's preferences.     

A radical rupture in the paradigm of modern medicine: conflicts of interest, fiduciary obligations, and the scientific ideal

Conflicts of interest serve as a cipher for a radical rupture in the Flexnerian paradigm of medicine, and they can only be addressed if we recognize that health care is now practiced by institutions, not just individual physicians. By showing how "appropriate utilization of services" or "that which is medically indicated" is a function of socioeconomic factors related to institutional responsibilities, I point toward an administrative and organizational ethic as a needed component for addressing conflicts of interest. The argument is developed by reviewing three important books. First, I consider Mark Rodwin's attempt to configure the economic structures of medicine so that classical fiduciary and scientific ideals can be fostered. Second, I consider E. Haavi Morreim's attempt to modify the classical ideals in order to account for new economic realities. Finally, by considering essays in a recent volume on conflicts of interest edited by Spece, Shimm, and Buchanan, I argue for a constructive dialectic between the approaches of Rodwin and Morreim. In order to properly address conflicts of interest, there must be a radical reassessment of medicine that accounts for the interrelation between scientific, ethical, and economic concerns. Until institutions come into view and professional ethics is developed to account for their role, legitimate interests and obligations of diverse parties cannot be harmonized.     

DSM-IV Cluster A personality disorder diagnoses among young adults with a 2-7-8 MMPI profile

The Ethical Principles exhort psychologists "to encourage ethical behavior by students, supervisees, employees, and colleagues, as appropriate" (American Psychological Association, 1992, p. 1599). In spite of a clear directive to attempt resolution of unethical conduct by colleagues, research indicates that satisfactory resolution or actual reporting of misconduct is infrequent. This paper will address some of the forces that discourage psychologists from dealing responsibly and appropriately with professional misconduct by colleagues. The goals of this paper are to promote understanding of factors that interfere with the effective resolution of ethical misconduct, to identify possible signs of reluctance to address misconduct, and to propose strategies to combat those forces that keep us in silent collusion with colleagues who engage in unethical practices. A flowchart of steps for addressing possible misconduct by a colleague is provided, and educational, organizational, and professional considerations are discussed.     

The nature and limits of violence

I take advantage of a point made by H. J. Gert, in "Rights and Rights Violators: A New Approach to the Nature of Rights" (The Journal of Philosophy 1990; 87 (12): 688-694) to provide the following definition of violence. "Violence is an intentional or knowing attempt by a moral agent to directly cause harm, i.e., death, pain, disability, loss of freedom or pleasure, to someone who is protected by morality without the consent of that person." I show how this definition applies to violence in hospitals and discuss some of the ethical problems created by violent patients.     

Comparison of the high-tech service delivery experiences of hospice and non-hospice home health providers

This study examined the degree to which national samples of hospice and non-hospice home health care agencies (N = 154) present different organizational profiles and grapple with different patient capacity issues when delivering technology-enhanced services to incapacitated elderly. Hospice agencies employ more part-time staff, make more in-home visits, see more high-tech patients, and provide a wider range of high-tech services than non-hospice providers. Factor analysis of index data confirms that hospice staff have more experience (p < .05) addressing the legal/ethical dimensions of care. Specifically, hospices deal with "right to die" issues more often (p < .05), but not with "delegation of authority" and "patient rights" issues. More agencies of both types have policies for handling decisions about life-sustaining treatment than for dealing with patients having questionable decision-making capacity. Needed agency policies for dealing with limited patient decision-making capacity in hospice and non-hospice home care agencies are reviewed.     

Psychotherapy or massage parlor technology? Comments on the Zeiss, Rosen, and Zeiss treatment procedure.

Argues that there are numerous ethical, moral, philosophical, and social psychological issues involved in modern sex therapy. Psychologists have accorded sex therapy a warm reception into the field, but present ethical guidelines are insufficient to protect clients from psychological damage in the form of massive intrusions on privacy and reoriented moral and religious values. Further, the more explicit procedures seem to carry a message to society that "anything goes." The procedure employed by A. M. Zeiss et al (see record 1978-01520-001) is used as a reference point for discussing these issues. (22 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Advance directives and advocacy in end-of-life decisions

This article examines the issue of advocacy for all adults in end-of-life decisions to help enhance the role of health care providers as partners in decision making. The ethical issues of death and dying are of particular concern for the elderly. Conflicts may prevent providers and nurses from creating a good dying experience for patients and family. Among the many issues associated with end-of-life decision making are futility, autonomy, and quality of life, a "good death," advance directives, family distress, and the culture of medicine. To overcome related barriers, involved health care providers can promote advocacy by offering choices in end-of-life care and providing an environment of listening and communication. Initiating and maintaining dialogue on this difficult subject will provide better care to patients and families.