Eleanor Milligan

Creative Expressive Encounters in Health Ethics Education: Teaching Ethics as Relational Engagement

Background: The growing expectation that health practitioners should be ethically attuned and responsive to the broader humanistic and moral dimensions of their practice has seen a rise in medical ethics courses in universities. Many of these courses incorporate creative expressive encounters—such as the exploration and interpretation of poetry, art, music, and literature—as a powerful vehicle for increasing understanding of the illness experience and to support a relational approach to ethics in health care practices. Description: First-year paramedic students were invited to produce their own creative composition in response to a short vignette describing the plight of a fictional “patient-other.” Our aim was twofold: first, to engage their “sympathetic imaginations” to capture a sense of illness as being not only a fracturing of bodily wellness but also, for many, a fracturing of holistic well-being, and second, to encourage an ethics of relational engagement—rather than an ethics based on the detached, intellectual mastery of moral principles and theories—within their paramedical practice. Evaluation: After some initial apprehension, students embraced this task, producing works of great insight and sensitivity to the embedded and embodied nature of “being.” Their work demonstrated deep ethical understanding of the multiple subjective and intersubjective layers of the illness experience, displaying a heightened understanding of ethics in practice as a relational engagement. Conclusion: Educationally, we found this to be an extremely powerful and successful pedagogical tool, with our students noting emotional and intellectual transformations that challenged and sensitised them to the deeper human dimensions of their practice.

Reflections on the Use of Seclusion: In an Acute Mental Health Facility

This pilot study provides a snapshot of the use of seclusion within an acute care mental health unit in Queensland, Australia. The study collected baseline data against which practice reform aimed at reducing its use could be gauged. A mixed methodology was adopted, undertaking retrospective chart reviews, collecting qualitative survey data from individual nursing staff (n = 71) and patients (n = 4), and conducting focus groups to identify factors contributing to seclusion use. The study revealed a local facility seclusion rate of 12% compared with a national average of 10%. The re-seclusion rate of 76% was significantly higher than the national average of 31%. Eighty-seven percent of seclusion episodes were longer than 4 hours, compared with a national average of 41%. In approximately one third of cases, the required documentation was incomplete. Consumers mostly perceived seclusion as punishing and nontherapeutic, in contrast to staff, who generally viewed it as appropriate and potentially therapeutic.

Autonomy versus futility? Barriers to good clinical practice in end-of-life care: A Queensland case

Findings from a Queensland coronial inquest highlight the complex clinical, ethical and legal issues that arise in end‐of‐life care when clinicians and family members disagree about a diagnosis of clinical futility. The tension between the law and best medical practice is highlighted in this case, as doctors are compelled to seek family consent to not commence a futile intervention. Good communication between doctors and families, as well as community and professional education, is essential to resolve tensions that can arise when there is disagreement about treatment at the end of life.

Marketing to register organ donors may circumvent principles of informed consent

Organ donation and transplantation are seen as indisputable medical successes that are a communal moral good. Twin themes dominate the public debate: low organ supply is creating a preventable health tragedy, and increasing supply will solve the growing problem of organ failure. Health education and marketing campaigns to boost donation rates accompany the public debate, and they typically use emotive and persuasive language (“gifts of life”; “joy from tragedy”) to assert the worth of donation and transplantation. Ultimately, their aim is to secure advance consent from potential organ donors through registries.1 Current and prospective medical decision making relies on five well established criteria: competency; disclosure of material information; optional and voluntary participation; understanding the nature, risks, and benefits; and participation without coercion. Together these criteria form the doctrine of informed consent that lends ethical legitimacy to healthcare interventions through respecting patient autonomy.2 For posthumous organ donation, consent is sought from the dead person’s substitute decision maker at the time of organ harvesting. The donor registry indicates the wishes of the dead person and so provides a form of advance consent. Increasing donor registrations through marketing campaigns …

Health, performance and conduct concerns among older doctors: A retrospective cohort study of notifications received by medical regulators in Australia:

Objectives To determine whether ‘older doctors’ (aged over 65) are at higher risk of notifications to the medical regulator than ‘younger doctors’ (aged 36–60 years) regarding their health, performance and/or conduct. Design Retrospective cohort study. Setting National dataset of 12,878 notifications lodged with medical regulators in Australia between 1 January 2011 and 31 December 2014. Participants All registered doctors in Australia aged 36–60 and >65 years during the study period. Main outcome measures Incidence rates of notifications and incidence rate ratios of notifications (older versus younger doctors). Results Older doctors had higher notification rates (90.9 compared with 66.6 per 1000 practitioner years, p < 0.001). Sex-adjusted incidence rate ratios showed that older doctors had a higher risk of notifications relating to physical illness or cognitive decline (incidence rate ratio = 15.54), inadequate record keeping (incidence rate ratio = 1.98), unlawful use or supply of medications (incidence rate ratio = 2.26), substandard certificates/reports (incidence rate ratio = 2.02), inappropriate prescribing (incidence rate ratio = 1.99), disruptive behaviours (incidence rate ratio = 1.37) and substandard treatment (incidence rate ratio = 1.24). Older doctors had lower notification rates relating to mental illness and substance misuse (incidence rate ratio = 0.58) and for performance issues relating to problems with procedures (incidence rate ratio = 0.61). Conclusions Older doctors were at higher risk for notifications relating to physical or cognitive impairment, records and reports, prescribing or supply of medicines, disruptive behaviour and treatment. They were at lower risk for notifications about mental illness or substance misuse. Incorporating knowledge of these patterns into regulatory practices, workplace adjustments and continuing education/assessment could enhance patient care.

Why Narrative Matters (But Not Exclusively) in Bioethics Education

The conversation played out in Parker’s (2012) depiction of two bioethicists/educators invites us to consider the fundamental question at the heart of their problem, which is: “What is the purpose of including ‘ethics’ in the curriculum of tertiary health care education?” Do we teach ethics because we feel that health care has become too skewed toward the scientific or economic at the expense of the humanistic? Maybe we suspect health practitioners are at risk of becoming ethically detached and in need of a morality inoculation before they join the workforce? Perhaps it is an acknowledgment that “harm” at the hands of a health carer can occur in the simplest form—a distracted look, a thoughtless comment, or a hasty dismissal—rather than simply physical harm? Maybe we believe that moral sensitivity can actually be “taught” to the adult students who come to their training with a diverse range of preexisting values, expectations, beliefs, and ethical norms? Or perhaps we see it as providing a protective framework that will help young health professionals make sense of their professional role as they face daily reminders of the fragility of life and the inevitability of death? Our responses to these questions will shape how we respond to the practical educational challenges considered by Shanachie and Norm. It is only once we are clear on why we are teaching ethics in health professional programs that we can begin to focus on what to teach and how to teach it. As Edmund Pellegrino writes: “Medicine being simultaneously the scientific and humanistic study of man cannot escape being based in an explicit or implicit philosophy of human nature” (2003, 10). When patients enter the health care system, and the care of individual professionals within, they do so (mostly) at times of uncertainty, trauma, and vulnerability. Illness is not only a physical threat to the body, it also threatens and fractures a person’s sense of identity—of who they are, how others regard them, their possible futures, and their present capabilities. It is through this veil of vulnerability and uncertainty that the ill person tries to make meaning and sense of his or her situation. And it is at this time that health practitioners most need to grasp the “human nature” part of medicine to which Pellegrino refers—for the well-being of their patient, but also for their own well-being. It is this very vulnerability—that is in many ways a shared vulnerability—that defines the human condition and commands a caring response from health professionals. When human connection is missing in health care, moral harm can be done. The role of ethics education Bioethical Inquiry (2012) 9:507–508 DOI 10.1007/s11673-012-9389-4

Rethinking Autonomy and Consent in Healthcare Ethics

In healthcare ethics, autonomy has arguably become the ‘principal principle’. As a principle that can be readily turned into a process, the giving of ‘informed consent’ by a patient has become the surrogate measure of whether medical interventions are ethically acceptable. While ‘informed consent’ processes in medical care are presumed to be robust, research confirms that most patients do not adequately understand the medical purpose, limitations or potential ethical implications of the many medical procedures to which they consent. In this chapter, we argue that the founding tenets of autonomy and informed consent which presume people to be detached autonomous individuals who act rationally from self‐interest does not authentically capture the essence of human ‘being’. Furthermore, such assumptions do not acknowledge the deeply relational and embedded reality of the human condition which inevitably shape decision making. We contend that within healthcare organisations, the current processes of operationalising informed consent predominantly serve legal and administrative needs, while unwittingly disempowering patients, and silencing key aspects of their experience of illness. Rather than rational selfinterest, we argue that vulnerability, interdependence and trust lie at the core of ethical decision making in healthcare. Re‐framing autonomy in a way that deliberately considers the unique moral frameworks, relationships, and cultures of individuals can provide a more ethically sensitive and respectful basis for decision making in healthcare. As interdependence is an integral consideration in decision making, it must be deliberately acknowledged and incorporated into healthcare practices. Embracing a narrative approach within a shared decision making framework allows the vulnerabilities, fears and aspirations of stakeholders to be heard, creating a more effective and authentic way to meet the ethical goal of respecting those who seek care.