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This article discusses an approach to translational bioethics (TB) that is concerned with the adaptation-or 'translation'-of concepts, theories and methods from bioethics to practical contexts, in order to support 'non-bioethicists', such as researchers and healthcare practitioners, in dealing with their ethical issues themselves. Specifically, it goes into the participatory development of clinical ethics support (CES) instruments that respond to the needs and wishes of healthcare practitioners and that are tailored to the specific care contexts in which they are to be used. The theoretical underpinnings of this participatory approach to TB are found in hermeneutic ethics and pragmatism. As an example, the development of CURA, a low-threshold CES instrument for healthcare professionals in palliative care, is discussed. From this example, it becomes clear that TB is a two-way street. Practice may be improved by means of CES that is effectively tailored to specific end users and care contexts. The other way around, ethical theory may be enriched by means of the insights gained from engaging with practice in developing CES in a process of co-creation. TB is also a two-way street in the sense that it requires collaboration and commitment of both bioethicists and practitioners, who engage in a process of mutual learning. However, substantial challenges remain. For instance, is there a limit to the extent to which a method of moral reasoning can be adapted in order to meet the constraints of a given healthcare setting? Who is to decide, the bioethicist or the practitioners?, (© 2023 The Authors. Bioethics published by John Wiley & Sons Ltd.)

This symposium collection of twelve narratives from individuals who experienced clinical ethics consultations provides perspectives from a group that has not been adequately explored in the bioethics literature. The authors represent a variety of stakeholders who received ethics consultations: healthcare providers and family members. This commentary will focus on three themes addressed in the different narrative accounts: the reasons for requesting an ethics consultation; the expectations of the narrators from the consultation; and the conclusions the authors drew from their experience of the ethics consultation.

This commentary reflects on twelve stories of participants in clinical ethics consultations from the perspective of family members, some of whom are ethics consultants, and healthcare professionals. Together they reveal expectations of ethics consultations and suggest descriptions of the service. Some common themes emerge, including the role of the clinical ethics consultant in navigating complex situations, assuring all stake-holder voices are heard, attending to moral distress, addressing issues that seem beyond medical practice, and being accessible. They are almost uniformly positive about the experience, with criticism primarily about lack of access to the service.

AbstractPer the OpenNotes directive of the 21st Century Cures Act implemented in 2021, patients and their legally recognized representatives must be able to access the electronic medical record in real time. This is an opportunity for clinical ethicists and other providers to reflect on their charting practices, particularly how and when they quote patients. Although using direct quotations is common because it seems to avoid misinterpretation, it may not always be appropriate. In this article, we discuss some of the risks and benefits of quoting in the context of OpenNotes and provide suggestions for how clinical ethicists can leverage their unique position to help mitigate some of these risks and promote more reflective charting practices among the teams they work with.

In pluralist societies, stakeholders in healthcare may have different experiences of and moral perspectives on health, well-being, and good care. Increasing cultural, religious, sexual, and gender diversity among both patients and healthcare professionals requires healthcare organizations to address these differences. Addressing diversity, however, comes with inherent moral challenges; for example, regarding how to deal with healthcare disparities between minoritized and majoritized patients or how to accommodate different healthcare needs and values. Diversity statements are an important strategy for healthcare organizations to define their normative ideas with respect to diversity and to establish a point of departure for concrete diversity approaches. We argue that healthcare organizations ought to develop diversity statements in a participatory and inclusive way in order to promote social justice. Furthermore, we maintain that clinical ethicists can support healthcare organizations in developing diversity statements in a more participatory way by fostering reflective dialogues through clinical ethics support. We will use a case example from our own practice to explore what such a developmental process may look like. We will critically reflect on the procedural strengths and challenges as well as on the role of the clinical ethicist in this example., (© 2023. The Author(s).)

The role of religion in clinical ethics consultations is contested. The religion of the ethics consultant can be an important part of the consultation process and improve the quality of a consultation. Practicing neighbor love leads to empathy, which not only can improve the quality of ethics consultations but also creates a space for religion to be part of, but not imposed on, the consultation. The practice of empathy will build trust, rapport, and an intersubjective connection that improves the quality of the consultation. (The views expressed are the author's and not representative of any institution or employer)., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Moral distress forms a major threat to the well-being of healthcare professionals, and is argued to negatively impact patient care. It is associated with emotions such as anger, frustration, guilt, and anxiety. In order to effectively deal with moral distress, the concept of moral resilience is introduced as the positive capacity of an individual to sustain or restore their integrity in response to moral adversity. Interventions are needed that foster moral resilience among healthcare professionals. Ethics consultation has been proposed as such an intervention. In this paper, we add to this proposition by discussing Moral Case Deliberation (MCD) as a specific form of clinical ethics support that promotes moral resilience. We argue that MCD in general may contribute to the moral resilience of healthcare professionals as it promotes moral agency. In addition, we focus on three specific MCD reflection methods: the Dilemma Method, the Aristotelian moral inquiry into emotions, and CURA, a method consisting of four main steps: Concentrate, Unrush, Reflect, and Act. In practice, all three methods are used by nurse ethicists or by nurses who received training to facilitate reflection sessions with these methods. We maintain that these methods also have specific elements that promote moral resilience. However, the Dilemma Method fosters dealing well with tragedy, the latter two promote moral resilience by including attention to emotions as part of the reflection process. We will end with discussing the importance of future empirical research on the impact of MCD on moral resilience, and of comparing MCD with other interventions that seek to mitigate moral distress and promote moral resilience., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

AbstractThis article presents a model for doing clinical ethics consultations. It describes four phases of a consultation: investigation, assessment, action, and review. The consultant must identify the problem and determine whether it is a nonmoral problem (e.g., lack of information) or a moral problem involving uncertainty or conflict. The consultant must be able to identify the types of moral arguments that are used by participants to the situation. A simplified taxonomy of moral arguments is presented. The consultant must then assess the arguments for their cogency and identify where they align and where they conflict. The action phase of the consultation involves finding ways for the arguments to be presented and hopefully reconciled. The normative limitations to the role of the consultant are described.

AbstractDifferent methods are available in clinical ethics consultation. In our experience as ethics consultants, certain individual methods have proven insufficient, and so we use a combination of methods. Based on these considerations, we first critically analyze the pros and cons of two well-known methods in the working field of clinical ethics, namely Beauchamp and Childress's four-principle approach and Jonsen, Siegler, and Winslade's four-box method. We then present the circle method, which we have used and refined during several clinical ethics consultations in the hospital setting.

Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases ("Moral Distress Reflective Debriefs"). We discuss how the debriefing literature and other clinical ethics activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V. part of Springer Nature.)

The national standards for clinical ethics consultation set forth by the American Society for Bioethics and Humanities (ASBH) endorse an "ethics facilitation" approach, which characterizes the role of the ethicist as one skilled at facilitating consensus within the range of ethically acceptable options. To determine the range of ethically acceptable options, ASBH recommends the standard model of decision-making (informed consent, advance directives, surrogates, best interests), which is grounded in the values of autonomy, beneficence, nonmaleficence, and justice. H. Tristram Engelhardt Jr. has sharply criticized the standard model for presuming contentful moral claims in circumscribing the range of ethically acceptable options, which, he argues, cannot be rationally justified in a pluralistic context. Engelhardt's solution is a secular clinical ethics based on a contentless principle of permission. The first part of this article lays out Engelhardt's negative claim, that reason cannot establish contentful moral claims, and his positive claim, that secular clinical ethics ought to be based on a contentless principle of permission. The second part critiques these negative and positive claims. The purpose of this paper is to defend secular clinical ethics expertise-defined as the ability of ethicists to offer justified moral recommendations grounded in consensus positions endorsed by the American Society for Bioethics and Humanities-from the radical critiques of Engelhardt, who argues that no moral or metaphysical claims, and hence no bioethical consensus, can be rationally justified. Engelhardt's critiques have caused some to worry that secular clinical ethics is in a state of theoretical crisis; this article concludes that Engelhardt's view is an unstable basis for that worry., (© 2022. The Author(s), under exclusive licence to Springer Nature B.V.)

Despite an abundance of academic conferences, clinical ethicists lacked a forum to share innovative practices with peers and to generate solutions to common challenges. Organizers of the first Clinical Ethics Un-Conference developed a working event centered on active participation and problem solving through peer learning, with the goal of improving real-world practice. Registrants included 95 individuals from 64 institutions. Attendees were surveyed immediately after the Un-Conference, and again eight months later. After eight months, 85 percent (n = 33/39) of the survey respondents reported that they found the event "highly impactful" or "somewhat impactful" to their clinical practice, and 23 attendees reported that they had implemented ideas or projects inspired by the event. Three sets of best practice guidelines and four white papers were published from the event. As the field of clinical ethics continues to advance and evolve, this working event format offers an innovative, disruptive alternative to a traditional conference format and may serve as a model for future efforts aimed at improving real-world clinical ethics practice., (Copyright 2021 The Journal of Clinical Ethics. All rights reserved.)

This paper provides a series of reflections on making the case to senior leaders for the introduction of clinical ethics support services within a UK hospital Trust at a time when clinical ethics committees are dwindling in the UK. The paper provides key considerations for those building a (business) case for clinical ethics support within hospitals by drawing upon published academic literature, and key reports from governmental and professional bodies. We also include extracts from documents relating to, and annual reports of, existing clinical ethics support within UK hospitals, as well as extracts from our own proposal submitted to the Trust Board. We aim for this paper to support other ethicists and/or health care staff contemplating introducing clinical ethics support into hospitals, to facilitate the process of making the case for clinical ethics support, and to contribute to the key debates in the literature around clinical ethics support. We conclude that there is a real need for investment in clinical ethics in the UK in order to build the evidence base required to support the wider introduction of clinical ethics support into UK hospitals. Furthermore, our perceptions of the purpose of, and perceived needs met through, clinical ethics support needs to shift to one of hospitals investing in their staff. Finally, we raise concerns over the optional nature of clinical ethics support available to practitioners within UK hospitals., (© 2020. The Author(s).)

Although clinical ethics scholarship and practice has largely avoided assuming an activist stance, the many health care crises of the last eighteen months motivated a distinct change: On listserves, in blog postings, and in published essays, activist language has permeated conversations over such issues as the impact of triage policies on persons with disabilities and of color, and how the health care system has historically failed African Americans. In this paper, I defend this turn, arguing that clinical ethicists should embrace activism-generally, and with particular emphasis on institutional, mesolevel concerns. Ethicists are often uniquely situated to understand the structural factors that regularly motivate clinical ethics cases, and they are often in a privileged position to be effective change agents. In making this case, I also stress the need not to overstep one's skills and to be acutely cognizant of the political risks associated with such work., (© 2021 The Hastings Center.)

This article describes and rejects three standard views of reason in secular clinical ethics. The first, instrumental reason view, affirms that reason may be used to draw conceptual distinctions, map moral geography, and identify invalid forms of argumentation, but prohibits recommendations because reason cannot justify any content-full moral or metaphysical commitments. The second, public reason view, affirms instrumental reason, and claims ethicists may make recommendations grounded in the moral and metaphysical commitments of bioethical consensus. The third, comprehensive reason view, also affirms instrumental reason, but encourages ethicists to make recommendations grounded in the moral and metaphysical commitments of their private worldviews. A compatibilist view of public reason is then defended, which holds that each standard view captures an important role for reason in different aspects of secular clinical ethics. The article ends by identifying three implications for enduring theoretical debates in clinical ethics.

Evolving Clinical Ethics: A Working UnConference, held 5 through 7 February 2020 in Houston, Texas, brought together 91 participants from a variety of institutions, many of whom are engaged in clinical ethics work. The event followed the success of the first Clinical Ethics UnConference hosted by the Cleveland Clinic Center for Bioethics in 2018, and offered an opportunity for ethicists to share both their challenges and their solutions to clinical ethics issues. In this article we explore the emerging themes of the second UnConference and identify the top 10 questions currently faced by the field. We address both unresolved issues and areas of agreement and highlight new collaborations that have been developed to work toward greater standardization in our field., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

Given the enduring debate over what constitutes quality, and therefore appropriate training, in clinical ethics consultation, it is unsurprising that there is variation in the structure and content of clinical ethics fellowship programs. However, this variation raises questions about the value of fellowship training when the ethicists that emerge from these programs might be quite different. The specifics of fellowship programs are largely internal. As such, the extent of variation and whether such variation is problematic remains unclear. In this article, we summarize lessons learned from discussions between fellows, their mentors and program directors at the 2020 Clinical Ethics UnConference, and outline some possible ways to advance the conversation about variation in fellowship programs and training. We argue for the more open sharing of training specifics in order to help break down the siloed nature of fellowship programs. Greater transparency could, firstly, allow for more robust reflection on and refinement of training practices and, secondly, allow us to better balance professionally appropriate consistency with unavoidable or desirable variation based on local norms, culture and leadership., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

There are few evidence-based interventions that have been developed that mitigate the negative effects of moral distress. Group debriefing is one approach that some clinical ethicists have adopted as a response. However, there is very little academic literature or empirical research that identifies best practices and approaches to debriefing as a response to moral distress. Our aim at the 2020 UnConference was to share our different approaches to debriefing with other clinical ethicists to identify best practices or guiding principles to enhance our respective approaches and meet the needs of healthcare professionals. In this article we share an overview of our respective approaches, reflect on our discussion with other clinical ethicists and healthcare professionals, and propose foundations to move debriefing forward as an intervention to address moral distress in the field of clinical ethics., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

We respond to commentaries on our article, "The Clinician as Clinical Ethics Consultant: An Empirical Method of Study," that appeared in the summer 2019 issue of The Journal of Clinical Ethics., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

Clinical ethics consultants often confront the most difficult clinical encounters, typically in the setting of chronically critically ill patients and surrogate decision makers. These encounters require not only analytical skills but interpersonal skills as well. In this article, I focus on an interpersonal skill absent from the American Society for Bioethics and the Humanities Task Force's Core Competencies for Healthcare Ethics Consultation. I introduce the psychoanalytic concept of transference and argue that knowledge and use of transference phenomena are sometimes indispensable for ethics consultation with surrogate decision makers. For solicitation of moral views, disclosure of relevant beliefs and values, and identification of the central ethical question-essential to assessment and analysis-cannot at times begin without recognition and working through of transference., (Copyright 2020 The Journal of Clinical Ethics. All rights reserved.)

Our aim in this article is to bring some clarity to the clinical ethics expertise debate by critiquing and replacing the taxonomy offered by the Core Competencies report. The orienting question for our taxonomy is: Can clinical ethicists offer justified, normative recommendations for active patient cases? Views that answer "no" are characterized as a "negative" view of clinical ethics expertise and are further differentiated based on (a) why they think ethicists cannot give justified normative recommendations and (b) what they think ethicists can offer, if they cannot offer recommendations. Views that answer "yes" to the orienting question are characterized as a "positive" view of clinical ethics expertise. Positive views are distinguished according to four additional questions. First (P1), how are those recommendations generated? Second (P2), what is the nature of the recommendations? Third (P3), we ask, how are the recommendations justified? And finally (P4), how are the recommendations communicated?

In an effort to create new synergies to fill gaps in evaluation of value, assessment of quality, and definition of roles in clinical ethics programs we convened a meeting entitled Innovations in Clinical Ethics: A Working Un-Conference (the Un-Conference) in August 2018. The Un-Conference was conceived to be a working event aimed at promoting cross pollination and idea generation for innovative practices in clinical ethics. The event was attended by 95 individuals from 62 institutions, representing a wide diversity of healthcare systems, who believed in the concept and brought their enthusiasm and expertise to share with others. As a product of the Un-Conference, whitepaper groups developed summaries and broad overviews of areas that need to be further addressed within our field. The whitepapers are being published in this issue of The Journal of Clinical Ethics. The first three whitepapers highlight the broad themes of demonstrating value to the institution, quality assessment, and emerging roles for clinical ethics programs and ethicists. The final whitepaper offers guidance to clinical ethicists engaged in pediatric ethics work and, in conversation with the emerging roles article, thoughtfully reflects on the role of pediatric ethicists., (Copyright 2019 The Journal of Clinical Ethics. All rights reserved.)

Clinical ethics consultants face a wide range of ethical dilemmas that require broad knowledge and skills. Although there is considerable overlap with the approach to adult consultation, ethics consultants must be aware of differences when they work with infant, pediatric, and adolescent cases. This article addresses unique considerations in the pediatric setting, reviews foundational theories on parental authority, suggests practical approaches to pediatric consultation, and outlines current available resources for clinical ethics consultants who wish to deepen their skills in this area., (Copyright 2019 The Journal of Clinical Ethics. All rights reserved.)

The role of clinical ethics consultant in hospitals was created about 30 years ago. Since that time, two very different models for clinical ethics consultation, and who should perform it, have arisen: clinician ethicists and nonclinician ethicists, or bioethicists. Neither model provides everything that hospitals might need, and both include perspectives that are not ideal for hospital practice. It's time for a new model, one designed specifically to meet the needs of hospital patients, one we might call the hospital model of clinical ethics (HMCE)., (Copyright 2019 The Journal of Clinical Ethics. All rights reserved.)

In this article, we first review the development of clinical ethics in pediatrics in the United States. We report that, over the last 40 years, most children's hospitals have ethics committees but that those committees are rarely consulted. We speculate that the reasons for the paucity of ethics consults might be because ethical dilemmas are aired in other venues. The role of the ethics consultant, then, might be to shape the institutional climate and create safe spaces for the discussion of difficult and sometimes contentious issues. Finally, we report how pediatric clinical ethics has evolved differently in a number of other countries around the world., (Copyright 2019 The Journal of Clinical Ethics. All rights reserved.)

Clinical ethics support (CES) services are experiencing a phase of flourishing and of growing recognition. At the same time, however, the expectations regarding the acceptance and the integration of traditional CES services into clinical processes are not met. Ethics rounds as an additional instrument or as an alternative to traditional clinical ethics support strategies might have the potential to address both deficits. By implementing ethics rounds, we were able to better address the needs of the clinical sections and to develop a more comprehensive account of ethics quality in our hospital, which covers the level of decisions and actions, and also the level of systems and processes and aspects of ethical leadership., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: To support healthcare professionals in dealing with ethically difficult situations, Clinical Ethics Support (CES) services like Moral Case Deliberation (MCD) are increasingly implemented. To assess the impact of CES, it is important to evaluate outcomes. Despite general claims about outcomes from MCD experts and some qualitative research, there exists no conceptual analysis of outcomes yet. Therefore, the aim of this study was to systematically define and categorize MCD outcomes. An additional aim was to compare these outcomes with the outcomes in the Euro-MCD Instrument from 2014, to further validate this Instrument., Methods: The concept mapping method was used and involves qualitative and quantitative steps including brainstorming, individual structuring, computation of concept maps (by principal component analysis and cluster analysis), group interpretation and utilization. In total, 12 experienced MCD participants from a variety of professional backgrounds participated in two sessions., Results: The focus group brainstorm resulted in a list of 85 possible MCD outcomes, of which a point map and concept maps were constructed. After a thorough discussion of each cluster, final consensus was reached on the names and position of 8 clusters of MCD outcomes: 1) Organisation and Policy; 2) Team development; 3) Personal development focused on the Other Person; 4) Personal development as Professional, focused on Skills; 5) Personal development as Professional, focused on Knowledge; 6) Personal development as an Individual; 7) Perception and Connection; and 8) Concrete action., Conclusions: This study explored and categorized MCD outcomes in a concept mapping focus group. When comparing the results with the Euro-MCD Instrument, our study confirms that outcomes of MCD can be categorized in clusters referring to the organisational level, team development, personal development (both as an individual and a professional) and the concrete case-level. In developing CES evaluation tools, it is important to be explicit if an outcome refers to the individual or the team, to knowledge or skills, to the organisation or the specific case. The findings will be used in the further validation of the Euro-MCD Instrument. The current study further contributes to the field of evaluating CES in general and defining outcomes of MCD in particular.

Abram Brummett and Christopher Ostertag offer critiques of my argument that clinical ethics consultants have expertise but are not "ethics experts" (Brummett and Ostertag 2018). My argument begins within our less-than-ideal world and asks what a justification of a clinical ethics consultation recommendation might look like under those conditions. It is a challenge to what could be called an "inflationary" position on ethics expertise that requires agreement on or rational proof of metaethical facts about the values at stake in clinical ethics consultation. Brummett and Ostertag critique three distinct steps in the argument. Two of those I have a brief answer for, and an assessment of the third demonstrates that Brummett and Ostertag do not consider the premise upon which I based my account. Instead, they assert a counter-premise without argument, which at best results in a stalemate between our two accounts. However, the reasons supporting my premise still seem to me to be stronger, so I am in the end unconvinced by their critiques.

"Clinical ethics consultants" have been practicing in the United States for about 50 years. Most of the earliest consultants-the "pioneers"-were "outsiders" when they first appeared at patients' bedsides and in the clinic. However, if they were outsiders initially, they acclimated to the clinical setting and became "insiders" very quickly. Moreover, there was some tension between traditional academics and those doing applied ethics about whether there was sufficient "critical distance" for appropriate reflection about the complex medical ethics dilemmas of the day if one were involved in the decision making. Again, the pioneers deflected concerns by identifying and instituting safeguards to assure professional objectivity in clinical ethics consultation services. One might suggest that in moving inside and establishing normative practices, the pioneer clinical ethics consultants anticipated adoption of their routines and professionalization of the field.

Objective: We sought to understand ethics and education needs of emergency nurses and physicians in paediatric and adult emergency departments (EDs) in order to build ethics capacity and provide a foundation for the development of an ethics education programme., Methods: This was a prospective cross-sectional survey of all staff nurses and physicians in three tertiary care EDs. The survey tool, called Clinical Ethics Needs Assessment Survey, was pilot tested on a similar target audience for question content and clarity., Results: Of the 123 participants surveyed, 72% and 84% of nurses and physicians fully/somewhat agreed with an overall positive ethical climate, respectively. 69% of participants reported encountering daily or weekly ethical challenges. Participants expressed the greatest need for additional support to address moral distress (16%), conflict management with patients or families (16%) and resource issues (15%). Of the 23 reported occurrences of moral distress, 61% were associated with paediatric mental health cases. When asked how the ethics consultation service could be used in the ED, providing education to teams (42%) was the most desired method., Conclusions: Nurses report a greater need for ethics education and resources compared with their physician colleagues. Ethical challenges in paediatric EDs are more prevalent than adult EDs and nurses voice specific moral distress that are different than adult EDs. These results highlight the need for a suitable educational strategy, which can be developed in collaboration with the leadership of each ED and team of hospital ethicists., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Clinical ethics, as a sub-discipline of bioethics, is subject to growing professionalization in North America, Europe and elsewhere. Since the goal of clinical ethics is the identification, analysis and resolution of ethical dilemmas and conflicts in health care settings, specific competencies for practitioners and criteria to evaluate them are strongly needed. Regarding clinical ethics consultation (CEC) many efforts have been made by American clinical ethicists and scholars to delineate the core knowledge and skills to perform it, to settle specific professional responsibilities and tasks and to identify the fundamental training and quality requirements that candidates and actual professionals should satisfy in order to serve as ethics consultants. Starting from the analysis of two meaningful international experiences, the one American and the other German, the paper discusses the process of certification of the clinical ethics consultant and encourages its implementation in the Italian context trying to outline a model which is suited to it.

Background: Robust ethics consultation services cannot be sustained by all hospitals; consultative service from a high-volume center via teleconferencing is an attractive alternative. This pilot study was conceived to explore the feasibility and understand the practical implications of offering such a service., Methods: High-definition videoconferencing was used to provide real-time interaction between the rounding clinicians and a remote clinical ethicist. Data collection included: (1) evaluation of the hardware and software required for teleconferencing, and (2) comparison of ethics trigger counts between the remote and on-site ethicist during rounds., Results: Issues with audio represented the majority of technical problems. Once technical difficulties were addressed, the on-site ethicist's count of "triggers" was not statistically different from the count of the remote ethicist., Conclusion: Remote clinical ethics rounding is feasible when the equipment is optimized. Remote ethicists can identify similar numbers of "triggers" for possible ethical issues when compared to on-site ethicist numbers., (Copyright 2018 The Journal of Clinical Ethics. All rights reserved.)

Background: Although a mechanism for resolving ethical issues in patient care is required for accreditation of American hospitals, there are no formal qualifications for providing clinical ethics consultation (CEC), and there remains great variability in the composition of ethics committees and consult services. Consequently, the quality of CEC also varies depending on the qualifications of those performing CEC services and the format of CEC utilized at an institution. Our institution implemented an online CEC comment system to build upon existing practices to promote consistency and broad consensus in CEC services and enable quality assurance., Methods: This qualitative study explored the use of an online comment system in ethics consultation and its impact on consensus building and quality assurance. All adult ethics consultations recorded between January 2011 and May 2015 (n = 159) were analyzed for themes using both open and directed coding methods., Results: We found that comments broadly reflected three categories: expressions of approval/agreement (87% of consults), comments about the case (89%), and comments about the written record (72%). More than one-third of consults included responses to other comments (37%). The most common types of "comments about the case" included requests for additional information (36%), recommendations for additional services (21%), and references to formal policies/standards (28%). Comments often spanned multiple categories and themes. Comments about the written record emphasized accessibility, clarity, and specificity in ethics consultation communication., Conclusions: We find the online system allows for broad committee participation in consultations and helps improve the quality of CEC provided by allowing for substantive discussion and consensus building. Further, we find the use of an online comment system and subsequent records can serve as an educational tool for students, trainees, and ethics committee members.

Background: Little is known about what factors may contribute to the growth of a consultation service or how a practice may change or evolve across time., Methods: This study examines data collected from a busy ethics consultation service over a period of more than two decades., Results: We report a number of longitudinal findings that represent significant growth in the volume of ethics consultation requests from 19 in 1990 to 551 in 2013, as well as important changes in the patient population for which ethics help is requested. The findings include (1) a steady growth in requests from primary care providers (e.g., physicians and nurses), as well as increases in ancillary services (e.g., social workers); (2) a decrease in length of stay (days) before ethics help is requested; (3) an increase in the reasons that individuals ask for help from ethics; (4) an upsurge in consults requests from areas outside the intensive care unit (ICU); (5) a decrease in patients that died during hospitalization (e.g., live discharges); and (6) growth in the numbers of patients lacking decision-making capacity., Conclusions: We believe the increases in consult requests reflect appropriate and necessary growth because recent consultations have also been associated with consultations requiring (7) additional interventions and (8) reasonably high time intensity scores.

The daily work of the clinical ethics teacher and clinical ethics consultant falls into the routine of classifying clinical cases by ethical type and proposing ethically justified alternatives for the professionally responsible management of a specific type of case. Settling too far into this routine creates the risk of philosophical inertia, which is not good either for the clinical ethicist or for the field of clinical ethics. The antidote to this philosophical inertia and resultant blinkered vision of clinical ethics is sustained, willing exposure to philosophical provocation. The papers in this clinical ethics issue of the Journal of Medicine and Philosophy provide just such philosophical provocation related to core topics in clinical ethics: the distinction between clinical practice and clinical research; telemedicine, or medicine at a distance; illness narratives; the concept of the placebo effect; and sex reassignment., (© The Author 2017. Published by Oxford University Press, on behalf of the Journal of Medicine and Philosophy Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)