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In the operating theater, the micro-politics of practice, such as interpersonal communications, are central to patient safety and are intimately tied with values as well as knowledge and skills. Team communication is a shared and distributed work activity. In an era of "professionalism," that must now encompass "interprofessionalism," a virtue ethics framework is often invoked to inform practice choices, with reference to phronesis or practical wisdom. However, such a framework is typically cast in individualistic terms as a character trait, rather than in terms of a distributed quality that may be constituted through intentionally collaborative practice, or is an emerging property of a complex, adaptive system. A virtue ethics approach is a necessary but not sufficient condition for a collaborative bioethics within the operating theater. There is also an ecological imperative-the patient's entry into the household (oikos) of the operating theater invokes the need for "hospitality" as a form of ethical practice.

In multiprofessional teams, the processes underlying ethical decisions in Palliative Care often become complicated and could cause many conflicts. Different interests and ethical positions often slow down the necessary decision-making. The lack of resources, lack of managerial structures and deficits in competence and education make the situation more difficult. We demonstrated in our case report that an established Palliative Liaison Service could support the creation of consensual decisions by forming multiprofessional ethic round-ups.

By means of a case report on a 44-year-old female patient, we show how, with changing personnel and places of care, decisions as well as the kind of decision-making during illness influence the quality of care. The patient was receiving immunosuppressive therapy after kidney transplantation and then suffered from a carcinomatous ovary. At first she refused postoperative chemotherapy, but then returned with a very advanced state of metastatic growth. The lack of continuity, a missing overall interdisciplinary concept of medical case, as well as the failure to document decision processes and the patient's attitude to life and suffering made it difficult for the caring team to accompany her in the last weeks of life. A possible solution to such a complex problem will be the introduction of ethical case deliberation.

Aim: The aim of this paper is to present the values and beliefs of clinicians and non-clinicians working in not-for-profit healthcare organizations, and the positive and negative outcomes of holding such values., Background: Ethical values are part of the essence of healthcare management and delivery. Although studies have identified what some of those values are, few studies have been undertaken to identify if the values and beliefs held are ethical, and what the outcomes, positive and negative, to holding such values are., Methods: This study was undertaken in 60 of the 65 acute care hospitals in the Republic of Ireland, and in eight regional health boards during 2001. The study population included all accessible professional clinician and non-clinician department heads. The sample size was 862 and the valid response rate was 42%. Research findings from questions requiring qualitative responses are presented and are part of a wider study. Responses were subjected to content analysis., Results: Eleven key values identified are excellence in care delivery, positive value system, managerial receptiveness and non-receptiveness, organizational dependability and lack of dependability, peer cohesion and lack of peer cohesion, equity in care delivery, personal contribution to the organization and personal importance. Findings also demonstrated positive and negative outcomes for the organization, patients and staff as a result of the values held., Conclusions: Findings show that healthcare clinicians and non-clinicians demonstrated a range of values in the delivery of health care, some of which have not been identified before. Should professionals now reconsider the values required in the delivery of health care? The most widely perceived values held by both groups were similar, although clinicians perceived that non-clinicians did not hold the same ethical values and beliefs as they did, and vice-versa, demonstrating a lack of trust in each other's moral and ethical value system.

External supervision of teams is increasingly part of mechanisms put in place both in public networks and community organizations to contribute in supporting professional mental health workers in developing their abilities and improving their clinical practices. It also plays a role in the analysis of ethical questions and in the prevention of deontological errors. The supervision of teams also includes its share of challenges, notably with regards to group dynamics and mechanisms to favour in order for supervision to rightly adjust to the needs and levels of participating professionals. Finally, the supervisor must also consider his own ethical responsibilities towards those supervised and towards their clients.

This article wants to be a contribution reflecting on the theme of applied ethics aiming at nourishing professional and interdisciplinary practices. The authors examine the process of ethical deliberation which has four major ends : the development of reflective and ethical competences of professionals, the elaboration by professionals, of an ethical reflective structure facilitating professional praxis, orientation and quick coordination of action ; implementation of a structure of collective deliberation useful in the orientation of difficult decisions and future actions. Finally, this process also has an objective of evaluation and appears relevant in the apprenticeship drawn from experiences of each participant.

Multidisciplinary healthcare committees meet regularly to discuss patients' candidacy for emerging functional neurosurgical procedures, such as Deep Brain Stimulation (DBS). Through debate and discussion around the surgical candidacy of particular patients, functional neurosurgery programs begin to mold practice and policy supported both by scientific evidence and clear value choices. These neurosurgical decisions have special considerations not found in non-neurologic committees. The professional time used to resolve these conflicts provides opportunities for the emergence of careful, ethical practices simultaneous with the expansion of therapy applications.

During the last decade, the prevalence of cancer pain and the reality of undertreatment have been well documented in both adults and children. There has been a proliferation of educational and regulatory activity setting an expectation that management of pain is a priority. At the same time, pain has come to the attention of the media, advocacy groups, industry, legislators, regulators and litigators creating an environment where this rich and multidimensional aspect of oncology care has moved beyond a clinical focus and opening up a range of opportunities for oncology professionals to participate as experts and leaders. The ethical underpinnings of the mandate to treat pain and attend to suffering compels psychosocial clinicians to advocate for the care of patients and consider participating in an informed way in the policy, legislative and political issues that flourish around the treatment of pain.

Originally presented during Ethics Rounds at the Dana-Farber Cancer Institute, this commentary on the case of a patient treated for life-threatening cancer explores the responsibilities of health care providers when addressing the patient's desire to adopt a child.

When traditional virtue ethics is applied to clinical medicine, it often claims as its goal the good of the individual patient, and focuses on the dyadic relationship between one physician and one patient. An alternative model of virtue ethics, more appropriate to the practice of emergency medicine, will be outlined by this paper. This alternative model is based on the assumption that the appropriate goal of the practice of emergency medicine is a team approach to the medical wellbeing of individual patients, constrained by the wellbeing of the patient population served by a particular emergency department. By defining boundaries and using the key virtues of justice and team loyalty, this model fits emergency practice well and gives care givers the conceptual clarity to apply this model to various conflicts both within the department and with those outside the department.

Adult living donor liver transplantation has developed as a direct result of the critical shortage of deceased donors. Recent regulations passed by New York State require transplant programs to appoint an Independent Donor Advocacy Team to evaluate, educate, and consent to all potential living liver donors. Ethical issues surround the composition of the team, who appoints them, and the role the team plays in the process. Critics of living liver donation have questioned issues surrounding motivation and the ability of donors to provide true informed consent during a time of family crisis. This article will address issues surrounding the controversies and discuss how using the team can effectively evaluate and educate potential living liver donors and improve practice to ensure safety of living donors.

Background: Improved communication with family members of critically ill patients can decrease the prolongation of dying in the intensive care unit (ICU), but few data exist to guide the conduct of this communication., Objective: Our objective was to identify missed opportunities for physicians to provide support for or information to family during family conferences., Methods: We identified ICU family conferences in four hospitals that included discussions about withdrawing life support or delivery of bad news. Fifty-one conferences were audiotaped, including 214 family members. Thirty-six physicians led the conferences and some physicians led more than one. We used qualitative methods to identify and categorize missed opportunities, defined as an occurrence when the physician had an opportunity to provide support or information to the family and did not., Main Results: Fifteen family conferences (29%) had missed opportunities identified. These fell into three categories: opportunities to listen and respond to family; opportunities to acknowledge and address emotions; and opportunities to pursue key principles of medical ethics and palliative care, including exploration of patient preferences, explanation of surrogate decision making, and affirmation of nonabandonment. The most commonly missed opportunities were those to listen and respond, but examples from other categories suggest value in being aware of these opportunities., Conclusions: Identification of missed opportunities during ICU family conferences provides suggestions for improving communication during these conferences. Future studies are needed to demonstrate whether addressing these opportunities will improve quality of care.

General principles of medical ethics are discussed in the context of care for patients with severe dementia.

Self-neglect is more common than currently recognised. This article highlights the issue of self-neglect and the accompanying ethical values and judgements associated with it. A multidisciplinary framework for managing self-neglect is also described.

Continuing care settings cater for some of the most disabled individuals. Their care can often present major ethical dilemmas; teams involved in such care require a broad range of skills. We illustrate this with a challenging case history and discuss specific dilemmas, including investigation and treatment in the absence of specific consent and advance directives. We suggest that continuing care should be recognised as a valuable component of training in geriatric medicine.

Expert opinion supports the application of broad interdisciplinary team approaches to the care of the dying patient in the intensive care unit (ICU). Current literature contains many suggestions about how core team members-physicians, nurses, and patients/family members-could systematically enhance interdisciplinary collaboration in the care of the dying patient. In the few studies of ICU interdisciplinary collaborative care of the dying patient, investigator shave demonstrated improvement in care. In addition, ethics consultants and interdisciplinary palliative care teams, working with the core team members, have improved care for the dying. Further studies are needed to document alternative interdisciplinary models for achieving improved and durable patient, family,and provider outcomes in the care of the dying ICU patient.

Objective: Health Care Ethics Committees (HEC) are new ways of implementing clinical ethics in hospitals and nursing homes. In the US all health care institutions must provide some structure to handle ethical conflicts in everyday patients' care. However, in Germany only a minority of hospitals, often members of the Protestant or Catholic Hospital Associations, have founded HEC. No studies exist in regard to the situation at German university hospitals., Methods: In November 2002 we posted a questionnaire with 13 items to all medical directors (M) and directors of nursing (N) of the 36 German university hospitals., Results: The response rate was 82 %. Limitation of treatment, informed consent and the conflict between beneficience and autonomy are the most relevant ethical issues in everyday practice. N estimated the need for additional support of their staff in ethical issues higher than M. Improvement of interdisciplinary teamwork, further education in ethics and ethical guidelines have been identified in order to improve ethical professional performance. However, N mentioned the lack of time and the low priority of ethics more often than M as problems in implementing theses measures. Five German university hospitals are planning to establish a HEC and two hospitals want to employ a clinical ethicist., Conclusion: Our data show a high need for information about HEC in German university hospitals. The tasks, working methods and chances for further development of HEC are neither known nor used in the majority of German university hospitals.

This article presents partial results from a study aimed at recognizing the work of members of a public health team who regularly perform tubal ligations. Empirical data were obtained through interviews and observation of routine activities by nine team members. The principal analytical categories were health work concepts. The team was basically characterized as hierarchical, but the specific decision on surgical sterilization tended to become more horizontal, with a tendency towards a multidisciplinary approach. This situation tends to involve the ethical dimension, with a shift from scientific and biomedical knowledge to the social sciences and humanities. On the other hand, and in a contradictory way, in the actual decision to perform surgical sterilization, technical criteria are supported by biomedical knowledge, and comprehensive knowledge is relegated to a secondary role.

Evidence based medicine is rightly at the core of current medicine. If patients and society put trust in medical professional competency, and on the basis of that competency delegate all kinds of responsibilities to the medical profession, medical professionals had better make sure their competency is state of the art medical science. What goes for the ethics of clinical trials goes for the ethics of medicine as a whole: anything that is scientifically doubtful is, other things being equal, ethically unacceptable. This particularly applies to so called orphaned fields of medicine, those areas where medical research is weak and diverse, where financial incentives are lacking, and where the evidence regarding the aetiology and treatment of disease is much less clear than in laboratory and hospital based medicine. Examples of such orphaned fields are physiotherapy, psychotherapy, medical psychology, and occupational health, which investigate complex syndromes such as RSI, whiplash, chronic low back pain, and chronic fatigue syndrome. It appears that the primary ethical problem in this context is the lack of attention to the orphaned fields. Although we agree that this issue deserves more attention as a matter of potential injustice, we want to argue that, in order to do justice to the interplay of heterogeneous factors that is so typical of the orphaned fields, other ethical models than justice are required. We propose the coordination model as a window through which to view the important ethical issues which relate to the communication and interaction of scientists, health care workers, and patients.

Background: Providing the individual with the correct information about their diagnosis can help maximize the patient's autonomy, however empirical evidence identifies inconsistencies in the practice of diagnosis disclosure in dementia. Within health care, ethical problems arise frequently and these present a challenge for health care professionals. This challenge can also give rise to conflict when professionals are torn between respecting autonomy, doing good and avoiding paternalism., Aim: The aim of this paper is to highlight the need for interprofessional collaboration when faced with ethical dilemmas such as diagnosis disclosure in the care of adults with dementia. The use of a dialogue and supplementary notes are used to explore crucial ethical points raised by health care professionals., Relevance to Clinical Practice: The increasing rate of dementia and the need for patients to have access to timely and appropriate information about their diagnosis has prompted much debate about disclosing the diagnosis with the individual who has dementia. This paper may also be useful for educational purposes when used as a framework for discussion/debate in student nurse education., Conclusion: Ethical theories are of benefit in assisting the members of the multidisciplinary team to reach a morally defensible decision. Making ethical decisions in practice can cause the nurse concern. While there is no complete set of 'rules' that can provide an answer to each ethical dilemma, it is of immense value to nurses working within the multidisciplinary team to possess a sound knowledge of ethical positions in order to analyse the many complex situations that nurses encounter. The pivotal role of the health care professional is to work in collaboration and engage in sharing the diagnosis with the patient. It is hoped that this paper will stimulate and encourage further debate and study regarding the individual with dementia and diagnosis disclosure. Recommendations for practice, education, policy and research will also be highlighted.

Development research methodology was utilized to design an interdisciplinary ethics course for students from seven disciplines: dental hygiene, nursing, nurse anesthesia, occupational therapy, physician assistant, physical therapy, and social work. Two research questions, 'What content areas should be considered for inclusion in an interdisciplinary course in Ethics?' and 'What design framework, format, or structure would best fit the content chosen?' guided the study. An interdisciplinary faculty design team conducted a comparative analysis of each of the seven discipline's codes of ethics to find common topics of interest. Further analysis then grouped these topics into eight categories of professional responsibility. The result was a fifteen-week course with validated content relevant to all disciplines.

This paper discusses the moral relevance of accounting for various personal characteristics when prioritising between groups of patients. After a review of the results from empirical studies, we discuss the ethical reasons which might explain-and justify-the views expressed in these studies. The paper develops a general framework based upon the causes of ill health and the consequences of treatment. It then turns to the question of the extent to which a personal characteristic-and the eventual underlying ethical justification of its relevance-could have any relationships to these causes and consequences. We attempt to disentangle those characteristics that may reflect a potentially relevant justification from those which violate widely accepted principles of social justice.

The provision of patient-focused care to the elderly is often fraught with many ethical and challenging dilemmas. However, for health care professionals, these dilemmas can be magnified when the chronic disease is accompanied by dementia. Such was the case of Mrs. A. The multidisciplinary team of a 36-bed acute care unit identified the challenges they experienced while caring for a 65-year-old female with multiple medical problems: diabetes; hypertension; cardiovascular disease; end stage renal disease and dementia probably due to cardiovascular and metabolic causes. Mrs. A. was admitted to start hemodialysis treatments. Her care was complicated by frequent outbursts of verbal and physical aggression towards staff. Mrs. A. was deemed incapable with regard to personal care and property. Her son believed she required long-term placement, and control of her property was assumed by the Public Guardian and Trustee. Mrs. A. vehemently objected to this total loss of control. This paper will describe how the multidisciplinary team implemented a variety of strategies to help staff intervene more effectively in meeting the care needs of Mrs. A.

Living donation is an increasingly common option offered to patients in most transplant programs. Staff involved in the education, assessment, and care of this patient group is faced with increasingly complicated assessments both medically and psychologically. Supporting arguments for dedicated care teams for living organ donors include the large number of transplantations performed using living donors, the continued need to promote living organ donation, and the growing complexity of both medical and psychological factors in donor assessments. In addition, there is a need to implement the standards proposed by the 2000 Consensus Group, as well as to develop a body of evidence-based research related both to short- and long-term issues for this patient group. The ethical issues related to simultaneous involvement with both donors and recipients, and a need to ensure confidentiality are additional supporting arguments for the need to provide separate care providers for donors and recipients.

Background: Head and neck cancer occupies an important place in the field of oncology in France (8%). Patient management requires a wide diversity of treatment modalities and must be based on a multidisciplinary approach., Materials and Methods: This clinical ethics study was based on analysis of a national survey of current practise in public and private hospital structure. A 28-questions anonymous questionnaire was send to 164 practitioners caring for these patients from the stage of diagnosis and evaluated the modalities of dental treatments and the related ethical aspects., Results: The competence of the various practitioners in their respective fields is undeniable, but there is a lack of multidisciplinary collaboration. The absence of an oral practitioner is a serious problem and can reduce the patient's chances of cure., Discussion: The oral practitioner must participate in head and neck cancer committees at all steps of treatment in order to provide curative, preventive care and prosthetic rehabilitation, thereby contributing to improvement of the quality of life of these patients.

Aim: To examine clinical nurse supervisors' styles, in terms of models, organization, focus on supervision and theories used in supervision, as well as their perceptions of ethical dilemmas within health care., Background: The importance of clinical supervision in clinical practice has been reported. However, literature dealing with its implementation is rare., Methods: This study is a descriptive-correlational study. Data were collected by means of a questionnaire from two groups of nurse supervisors randomly selected from a university (n = 55) and a hospital (n = 31). Data were analysed using descriptive and inferential statistics., Results: The models most frequently used were 'case-oriented' and 'decision-making oriented'. The nurse supervision was reported as being organized on a one-to-one basis. The focus of supervision was on 'patient problems' and 'cooperation in team'. The theory most commonly used was the theory of reflection. The supervisors' perceptions of moral dilemmas were related to 'decision making' and actions impacting on quality of care resulting from their supervisor styles., Conclusion: By correlating the supervisors' styles and their perceptions of ethical dilemmas, we conclude that it is important to contribute to further research on supervisors' styles in order to ensure successful supervision.