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Background: This study assesses how pediatric assent is conceptualized and justified within the therapeutic context. Pediatric ethicists generally agree that children should participate in medical care decisions in developmentally appropriate ways. Much attention has been paid to pediatric assent for research participation, but ambiguities persist in how assent is conceptualized and operationalized in the therapeutic context where countervailing considerations such as the child's best interest and parental permission must also be weighed. Methods: Searches were conducted in 11 databases including PubMed, Embase, Cochrane Library, and Web of Science. Articles published between 2010 and 2020 were screened in COVIDENCE for meeting each of four criteria: (1) focusing on pediatric assent, (2) focusing on clinical care, (3) including normative claims, and (4) containing substantive statements about the meaning of pediatric assent. Full texts were abstracted for (1) operational definitions of assent, (2) discussion of the temporal nature of assent, (3) description of the concept of "understanding," and (4) ethical justifications for soliciting assent. These excerpts were coded and code patterns formed themes presented in the results. Results: The final analytic data set contained 29 articles. Analysis yielded three key themes. First, valid assent varies by treatment, population (e.g., younger versus older), and geographic/cultural context. Second, assent represents two distinct longitudinal processes: One involves eliciting preferences over a disease course or care episode; the other focuses on children's developmental maturation. Third, ethical justifications for assent draw variously on instrumental and intrinsic reasons, but often remain ambiguous. Conclusions: There is widespread agreement that assent is morally valuable, but there remain substantial ambiguities or disagreements about its meaning, process, and ethical justification. [ABSTRACT FROM AUTHOR]

The article examines coverage error in the "Views in Bioethics Survey," highlighting how mismatches between the sampling frame and target population can affect survey validity. Topics discussed include the definitions and impacts of coverage error, the specific under-coverage issues in the Pierson et al. study, and the consequences of these errors for generalizability.

This article reports results of a survey about employment and compensation models for clinical ethics consultants working in the United States and discusses the relevance of these results for the professionalization of clinical ethics. This project uses self-reported data from healthcare ethics consultants to estimate compensation across different employment models. The average full-time annualized salary of respondents with a clinical doctorate is $188,310.08 (SD=$88,556.67), $146,134.85 (SD=$55,485.63) for those with a non-clinical doctorate, and $113,625.00 (SD=$35,872.96) for those with a masters as their highest degree. Pay differences across degree level and type were statistically significant (F = 3.43; p <.05). In a multivariate model, there is an average increase of $2,707.84 for every additional year of experience, controlling for having a clinical doctorate (ß=0.454; p <.01). Our results also show high variability in the backgrounds and experiences of healthcare ethics consultants and a wide variety of employment models. The significant variation in employment and compensation models is likely to pose a challenge for the professionalization of healthcare ethics consultation. [ABSTRACT FROM AUTHOR]

AbstractTo address the current lack of knowledge about clinical ethics fellowship programs (CEFPs), we surveyed all 36 programs in the U.S. and Canada. The number of CEFPs has grown exponentially over the last 40 years and far exceeds previous estimates. Commonalities among CEFPs include: 88.8% require an advanced degree or rarely accept applicants without one; 91.7% of programs do not restrict applicants to a specific background such as medicine or philosophy; and 88.9% of programs compensate fellows. CEFPs vary widely on numbers of fellows trained in the last 3 years (1–111), numbers of consultations performed by each fellow (0–450), and salaries paid ($0-$95,000). Less than half of programs meet CEFP standards established by ABPD. Nonpaying programs and larger programs tend to have lower admission standards and lower expectations for fellows. We hope these data will help inform CEFP standards that promote quality and consistency without stifling desirable diversity and innovation. [ABSTRACT FROM AUTHOR]

AbstractTo succeed, an accreditation process for clinical ethics fellowship programs (CEFPs) would need support from CEFP directors. To assess CEFP directors’ opinions, we surveyed all 36 CEFP directors in the United States and Canada, achieving a 100% response rate. We found that support for accreditation is strong, with 30.6% strongly supportive, 44.4% supportive, 22.2% neutral, 2.8% opposed, and 0% strongly opposed. Most directors (77.8%) would be likely to apply for accreditation within the next five years regardless of the availability of government funding; even more (86.1%) would apply if government funding became available for accredited programs. Most directors thought that lack of a national accreditation process (75.0%), lack of agreed-upon standards (90.0%), and lack of funding for CEFPs (91.7%) were at least moderate problems for the field. When directors were asked what they thought was the greatest challenge or barrier to developing an accreditation process, many mentioned the diversity of programs and the challenge of achieving consensus on accreditation standards. Directors offered a variety of suggestions for how to overcome or manage challenges or barriers, including collecting data on existing programs, mirroring standards established for other health professions, and setting clear expectations on the need for compromise. When directors were asked how they expected that accreditation and government funding would affect their own programs, the field of clinical ethics, and patient care, directors mostly had very positive expectations; no director expected negative effects in any of these areas. Overall, this study provides evidence that developing an accreditation process for CEFPs would be both possible and desirable. Our findings have immediate practical implications for the field and will inform efforts that are already underway to establish an accreditation process for CEFPs. [ABSTRACT FROM AUTHOR]

A commentary on the 2024 article "Affect, Values and Problems Assessing Decision-Making Capacity," by J. Hawkins is presented. Topics covered include how Hawkins' modifications to criteria for decision-making capacity (DMC) focuses attention in the wrong place, the good reasons not to treat patients over their objections even when they lack DMC and how coercive treatment is often more involved and troubling that it may first appear to be.

The article focuses on the ethical challenges faced by clinicians when dealing with patients lacking decision-making capacity but expressing strong treatment preferences, questioning traditional bioethical views that only patients with decision-making capacity are authorized to make decisions about their care. It authors argue for a nuanced understanding of decision-making capacity, proposing that patients who may lack certain cognitive capacities for consent can still possess.

Purpose: To gain a deeper understanding of healthcare workers experiences during COVID- 19 using an anonymous, web-based, audio narrative platform. Methods: Data were collected from healthcare workers in the midwestern United States using a web-enabled audio diary approach. Participant recordings were analysed using a narrative coding and conceptualization process derived from grounded theory coding techniques. Results: Fifteen healthcare workers, in direct patient care or non-patient care roles, submitted 18 audio narratives. Two paradoxical themes emerged: 1) A paradox of distress and meaningfulness, where a harsh work environment resulted in psychological distress while simultaneously resulting in new rewarding experiences, sense of purpose and positive outlooks. 2) A paradox of social isolation and connection, where despite extreme isolation, healthcare workers formed intense and meaningful interpersonal connections with patients and colleagues in new ways. Conclusions: A web-enabled audio diary approach provided an opportunity for healthcare workers to reflect deeper on their experiences without investigator influence, which led to some unique findings. Paradoxically, amid social isolation and extreme distress, a sense of value, meaning and rewarding human connections emerged. These findings suggest that interventions addressing healthcare worker burnout and distress might be enhanced by leveraging naturally occurring positive experiences as much as mitigating negative ones. [ABSTRACT FROM AUTHOR]

Abstract Some physicians refuse to perform life-sustaining interventions, such as tracheostomy, on patients who are very likely to remain permanently unconscious. To explain their refusal, these clinicians often invoke the language of “futility”, but this can be inaccurate and can mask problematic forms of clinical power. This paper explores whether such refusals should instead be framed as conscientious objections. We contend that the refusal to provide interventions for patients very likely to remain permanently unconscious meets widely recognized ethical standards for the exercise of conscience. We conclude that conscientious objection to tracheostomy and other life-sustaining interventions on such patients can be ethical because it does not necessarily constitute a form of invidious discrimination. Furthermore, when a physician frames their refusal as conscientious objection, it makes transparent the value-laden nature of their objection and can better facilitate patient access to the requested treatment. [ABSTRACT FROM AUTHOR]

According to a standard account of patient decision-making capacity (DMC), patients can provide ethically valid consent or refusal only if they are able to understand and appreciate their medical condition and can comparatively evaluate all offered treatment options. We argue instead that some patient refusals can be capacitated, and therefore ethically authoritative, without meeting the strict criteria of this standard account—what we call comparative DMC. We describe how patients may possess burdens-based DMC for refusal if they have an overriding objection to at least one burden associated with each treatment option or goals-based DMC for refusal if they have an overriding goal that is inconsistent with treatment. The overridingness of a patient's objections to burdens, or of their commitment to a goal, can justify the moral authority of their refusal, even when a patient lacks some of the cognitive capacities that standard accounts of DMC involve. [ABSTRACT FROM AUTHOR]