Emotional Support for Health Care Professionals: A Therapeutic Role for the Hospital Ethics Committee

Hospital ethics committees (HECs) are typically charged with addressing ethical disputes, conflicts, and dilemmas that arise in the course of patient care. HECs are not widely viewed as having a therapeutic role for health care professionals who experience psychological distress or anticipatory grief in the course of discharging professional duties. A case is presented in which an ethics consultation was requested, chiefly, to secure emotional support for health care professionals who had been asked by a patient to discontinue life-sustaining treatments. As the case demonstrates, HECs may be called upon to provide emotional support and reassurance to health care professionals who willingly carry out psychologically difficult actions, even though these actions may be ethically uncontroversial. In providing this service, the HEC may not necessarily engage in its customary activity of deliberating an ethics issue and resolving a conflict but may still provide valuable assistance, as in the case presented.     

Ethical Dilemmas and Areas of Social Work Intervention in Spain

Abstract

The purpose of this study is to identify the types of ethical dilemmas that Spanish social workers face in their respective areas of intervention. The intervention areas that have been studied are health, children, immigrants, women, family, marginalized persons, ethnic minorities, young people, prisoners, elderly people, refugees and asylum seekers, schools and social and employment-related integration, mental health, disability and drug addictions. A quantitative methodology was chosen using a version of the questionnaire prepared by Eileen J. Ain in a sample of 700 Spanish social workers. The statistical analysis shows the correlation between the different areas of intervention in Social Work and the most significant ethical dilemmas that such professionals have to solve. The most pertinent ethical dilemmas are found in the healthcare sector (confidentiality, disclosure of personal information and patient autonomy). The article is an important contribution for Social Work at the national level that emphasizes the importance of the ethics of Social Work in social interventions. It is proposed to deepen the investigation of each of the areas of intervention for future research, as well as to carry out comparative studies between different countries.     

Euthanasia and the medical profession: an Australian study

Advances in medical knowledge and technology are enabling more people to live longer in modern societies. This situation has also created dilemmas for medical practitioners in treating severely or chronically ill patients where the harm caused to them by treatment appears to outweigh the benefits. After reviewing some of the major legal and ethical issues confronting medical practitioners in Australia, this paper reports findings of a survey of Australian doctors' attitudes towards euthanasia. The findings show that a significant number of doctors receive requests from either the patients or their families to hasten death through active or passive euthanasia. A large majority of them also regard some form of passive euthanasia as an acceptable medical decision concerning the end of life. Twenty per cent of general practitioners and 17 per cent of specialists surveyed have taken active steps in the past to hasten the death of a patient. This paper explores the circumstances in which doctors are prepared to perform euthanasia and concludes with a discussion of the legal, ethical and professional issues raised by the survey's findings.     

Ethical dilemmas in social research: no easy solutions

Correspondence to Bernard Gallagher, Research Fellow, Department of Social Policy and Social Work, University of Manchester, Dover St., Mancester M13 9PL. Summary Ethical dilemmas have been encountered in many areas of socialresearch and have at times been the subject of much controversy.Despite this, the problem of how to tackle ethical dilemmashas received little attention in the literature. As a result,researchers faced with these dilemmas have little knowledgeto draw upon, and groups associated with research, such as participatingagencies and ethics committees, may not fully appreciate allthe issues involved in dealing with ethical dilemmas. Theseissues are not only philosophical in nature but relate alsoto the methodological and practical implications of followingone, rather than another, ethical principle. The researchersencountered a number of ethical dilemmas in their research inchild protection. By discussing different approaches to solvingethical dilemmas, they intend to show that this is a complexproblem and one which, along with ethics in general, requiresgreater attention in the literature.     

Reporting bad results: The ethical responsibility of presenting abused women's parenting practices in a negative light

The purpose of this paper is to present and analyse the ethical dilemmas involved in presenting research findings that describe abused women's parenting practices in a negative light. The study was based on data collected by in‐depth interviews for the purpose of examining the turning point among 20 Israeli abused women who refused to live with violence and took active steps to stop it while staying with the perpetrator. Overall the analysis indicated successful survival stories but the women's parenting practices became questionable. This raised dilemmas as to how to present such findings and what are the ethical implications related to interventions with abused women.     

Child protection systems between professional cooperation and trustful relationships: A comparison of professional practical and ethical dilemmas in England/Wales,Germany, Portugal,and Slovenia

This paper explores practical and ethical dilemmas for professionals when securing the protection of children in the complex non‐clinical setting of individual families. It is based on a cross‐country study on cultural encounters in interventions against child physical abuse and neglect in four countries (England/Wales, Germany, Portugal, and Slovenia). Drawing on national reports of legal‐organizational frameworks and socio‐cultural backgrounds of European child protection systems, it also presents the results of a series of focus groups with professionals. Data were analysed to identify implicit and explicit discursive constructions as well as normative representations and from this deriving the key ethical issues and dilemmas. Despite a shared normative framework across Europe, intervention cultures vary across the four countries and between the different stakeholder groups. Although each child protection system faced widespread mistrust, policy approaches differ, some relying on strong and detailed guidance whereas others stress professional skill and judgement. We conclude that despite a shared commitment to the protection of children, deliberations and perceived ethical dilemmas suggest interdependency between differences in system cultures and policy approaches that inform the character of professional interventions in the four countries.     

Researching Risk in the Probation Service

This paper will draw upon research and consultancy experience across a number of projects on risk assessment and management in the Probation Service between 1993 and 1999. The projects reflect a range of sponsors and funders, from central government bodies such as the Home Office and the Scottish Office, to professional, managerial and employment bodies such as the Association of Chief Officers of Probation and the Central Council of Probation Committees, to individual Probation Service areas. The projects have required engagement with different levels of staff and different vested interests, including the professional/union bodies representing the management and officer grades respectively, in addition to central government policy makers. All the projects have had an applied policy and practice focus. The paper begins with a review of current ethical and political dilemmas in research on offender risk assessment, and then contemporary responses to ethical dilemmas are critically reviewed, followed by an outline of 'practice guidance' for researchers. The paper concludes by arguing that researchers in the social arena should be subject to the same standards of defensible decision making as their counterparts in social care practice, and that essential to such defensibility is the transparent demonstration of the 'grounds' upon which ethical decisions are made.     

Euthanasia: an introduction

It has been argued that euthanasia is one of the most pressing social concerns of our times. A review of current scientific and legal materials, however, indicates that this issue is a complex and contentious one that crosses numerous perspectives and theoretical orientations. In order to provide background for the other articles in this collection, we present a brief history of attitudes toward euthanasia. In addition, various terms that are associated with the concept of euthanasia are defined. Finally, this paper provides a framework for the articles that follow by suggesting that three central issues must be addressed in order to resolve the controversies surrounding euthanasia. These are (1) the establishment of standardized criteria of euthanasia eligibility, (2) the investigation of public attitudes regarding acceptable means for engaging in euthanasia, and (3) the evaluation of the roles of professionals who are directly involved in euthanasia decisions. We hope that the following articles will provide insight into these issues.     

Overwhelming Casualties: Medical Ethics in a Time of Terror

Codes of ethics and ethics guidelines define standards of professional conduct, and ways to prioritize or balance ethical principles when these appear to be in conflict. In 1991 an international and interdisciplinary group of scholars met at the University of Toronto to discuss these problems in a Workshop on Ethical Considerations in Scholarship and Science. A document, “The Toronto Resolution”; (TTR), was developed, providing twelve principles for incorporation into scientific and scholarly codes, with the object of ensuring that professionals in science recognize the potential consequences of their work in the broader social context. To examine the extent to which existing codes are consonant with The Toronto Resolution's 12 principles, a content analysis was conducted on the codes of 21 Ontario‐based scientific and scholarly organizations. Criteria used in the content analysis were standardized and determined to be reliable. Only a weak correspondence was found between the contents of the codes of the scientific and scholarly organizations surveyed here and the principles set out in TTR. In particular, guidelines on specific social issues such as environmental effects or conflict resolution are scarcely mentioned at all. This study encourages consideration of The Toronto Resolution by the ethics committees of scientific and scholarly associations, as codes are revised or as new interpretations of principles in the codes evolve.     

Crisis as challenge: counselling counsellors,persons living with HIV / AIDS and survivors

Although the AIDS pandemic has catastrophic implications for all levels of South African society, it can be viewed as an opportunity to face the inevitability of human mortality with dignity rather than fear and denial and to rebuild shattered communities. This article discusses issues pertaining to counseling HIV-infected persons, the counselors themselves, and families and social groups affected by AIDS-related deaths. Counseling of HIV/AIDS patients is supportive in nature, with a focus on here-and-now issues such as unfinished business, reconciliation with family members, finding meaning in daily activities, and preserving a sense of personal control. This process can be obstructed, however, by distrust of authority figures, anger at experts who fail to cure the disease, and an internalized sense of shame and inferiority. The effectiveness of AIDS counselors depends on their ability to recognize and resolve personal conflicts triggered by HIV-positive clients, including feelings about death, helplessness, overidentification, and discomfort with sexual issues. Most South Africans will face bereavement and have to go through a mourning process for friends and relatives. Complicated and delayed grief reactions triggered by new and continuous losses can be expected. Involvement of community members in the grieving process, whether as helpers, volunteers, professionals, or recipients of service, offers South African society an opportunity for development of a new culture of compassion.     

The Experiences of Frontline Staff Working with Children Seeking Asylum

The focus of this paper is welfare professionals’ accounts of their work with children who are seeking asylum. The empirical basis is a commissioned study of children seeking asylum in Wales. As well as qualitative research with children (which is not discussed in this paper), 62 professionals took part in interviews and focus groups. This sample included staff from social services, health, housing, education, police and the voluntary sector. Research findings are presented in relation to the experience of these frontline staff. We attempt to identify some of the sites of tension and the nature of the professional dilemmas, as well as discussing the potential for the exercise of discretion to be exercised. We conclude that there is very little room for manoeuvre within the asylum system for welfare professionals, but that there is evidence of questioning and even minor challenge of current policy from frontline staff. We discuss the extent to which the professional dilemmas raised by the asylum system are of a different order from those experienced throughout social welfare work.     

Does Anything Work?

This paper reviews the results of effectiveness research in five areas of professional practice: social work, psychotherapy and counseling, corrections, psychiatric hospitalization, and education. In all these areas the research indicates that, at best, professionals are operating with little or no empirical evidence validating their efforts, since lack of effectiveness was the rule rather than the exception. In addition, a pattern of deterioration was found in which clients of professionals frequently were found to do less well than people with similar problems who received no professional services whatsoever. Some hypotheses are presented that may account for this situation, and a number of suggestions are offered for enhancing the effectiveness of professionals in all five areas. To the extent that professionals are unable or unwilling to make substantial changes in their practice, the paper concludes that such changes may be imposed from outside the professions in the form of governmentally mandated standards and regulations.     

Private Passions, the Public Good and Public Service Reform

There has been considerable recent discussion of the impact of public service reforms on the work ethics and motivations of public service workers. In this article we draw upon recent research on the ethical dilemmas facing regeneration workers in order to look more closely at the role of values in the working lives of public service professionals. Focusing on the commitment to social justice, we argue that such values find expression in two interlinked ways, as something workers have and as a process of giving value to different goods. Our research reveals that while both aspects of values are rooted in people's life experiences the second dimension is more contingent and relational. While public service reforms appear to have less impact upon workers’ pregiven values, they can and do have an impact on the way in which these values find expression in attachment to different goods. To understand the effect of such reform processes on workers’ motivations we therefore need a more complex conceptual framework than that provided by either simple public sector ethos/private sector ethos distinctions or by models of economic individualism offered by writers such as Julian Le Grand.     

Playing,Sitting Out,and Observing the Game: An Investigation of Faculty Members’ Perspectives on Political Behavior in Ethical Decision Making

Ethical dilemmas are inherently ambiguous, complex, and ill-defined. Additionally, these dilemmas involve multiple stakeholders. These characteristics may induce political behavior as a resolution tactic. Thus, the goal of the present effort was to investigate perspectives on politics among researchers in an ethical decision-making context. A qualitative analysis of interviews with university faculty members revealed that faculty members’ perspectives on political behavior in an ethical decision-making context fall into a number of categories, including positive, negative, and realistic views of political activity. The implications of these varying perspectives on ethical decision making are discussed.     

The Ethical Challenges of Socially Responsible Science

Social responsibility is an essential part of the responsible conduct of research that presents difficult ethical questions for scientists. Recognizing one’s social responsibilities as a scientist is an important first step toward exercising social responsibility, but it is only the beginning, since scientists may confront difficult value questions when deciding how to act responsibly. Ethical dilemmas related to socially responsible science fall into at least three basic categories: 1) dilemmas related to problem selection, 2) dilemmas related to publication and data sharing, and 3) dilemmas related to engaging society. In responding to these dilemmas, scientists must decide how to balance their social responsibilities against other professional commitments and how to avoid compromising their objectivity. In this article, we will examine the philosophical and ethical basis of social responsibility in science, discuss some of the ethical dilemmas related to exercising social responsibility, and make five recommendations to help scientists deal with these issues.     

Accountability in research using persons with mental illness

Although medical research involving the use of persons with mental illness is critically important, in order for the research to be ethical and legal there are certain considerations and restrictions which should be immediately readdressed in order to insure that the welfare of these vulnerable research subjects is protected, and their best interests are assured. A brief historical examination of medical research codes, guidelines, recommendations and Federal Regulations reveals the various considerations and restrictions on informed consent and accountability applicable to the use of persons with mental illness in medical research. Several concerns are raised about how these considerations and restrictions have been interpreted, and specific recommendations are offered to improve them immediately by means of representation from consumers and/or their families, and organizations, e.g., NAMI members.     

Resolving Beecher's Paradox: Getting beyond IRB reform

Protection of persons participating as research subjects is an essential element of ethical research conduct. There is growing concern that the existing system of institutional review boards (IRBs) and informed consent may not be adequate and is in need of reform. When science and medicine are “merged”; in clinical research, confusion of roles and conflicts of interests arise in relationships between patient‐subjects and physician‐investigators. IRBs have always had a primary role in protection of research participants. Their efforts to protect research subjects may make it more difficult for investigators to conduct research. This tension has lead to the development of an adversarial relationship between IRBs and investigators. Investigators and IRBs are also subject to external pressures that could impact efforts to protect research subjects. Efforts are underway to address these concerns. IRB reform, while needed, is not likely to be sufficient. Adoption of a new paradigm in which IRBs, investigators and research sponsors collectively accept protection of research subjects as their primary and shared responsibility may provide a more effective and efficient model that will be better able to deal with difficult ethical and social issues in clinical research.     

Researcher Perceptions of Ethical Guidelines and Codes of Conduct

Ethical codes of conduct exist in almost every profession. Field-specific codes of conduct have been around for decades, each articulating specific ethical and professional guidelines. However, there has been little empirical research on researchers’ perceptions of these codes of conduct. In the present study, we interviewed faculty members in six research disciplines and identified five themes bearing on the circumstances under which they use ethical guidelines and the underlying reasons for not adhering to such guidelines. We then identify problems with the manner in which codes of conduct in academia are constructed and offer solutions for overcoming these problems.     

Qualitative Approaches to the Study of Thriving: What Can Be Learned?

Using the data from two ongoing studies of resilience and thriving, one of gay men growing up in heterosexist environments, the other of women living with AIDS, we review how qualitative approaches have enabled researchers to grapple with conceptual, methodological, and ethical dilemmas related to the study of resilience and thriving. We discuss the implications our values as researchers have on determining who is thriving; the powerful social, cultural, and political contexts that must be considered when investigating the effects of and resistance to adversity; and the implications of conceptualizing thriving as a process. Finally, we consider the opportunities opened up by qualitative analysis and suggest some avenues for future research.