Patients with serious illness hospitalized in the pediatric setting can receive support from Pediatric Palliative Care (PPC) and Ethics Consultation (EC). However, empirical data on dual PPC-EC involvement in pediatrics is limited. Therefore, we characterized ethical issues, contextual features, palliative care domains, and consultation timing for inpatients with dual PPC-EC involvement. We reviewed 135 EC from 2016 to 2023 at an academic children’s hospital to identify cases with PPC involvement. PPC notes, demographics, and admission, consultation and discharge dates were extracted from the medical record. Ethical issues, contextual features, and palliative domains were deductively coded using established frameworks. Analyses used descriptive statistics and compared EC-first, PPC-first, and combined cases. Sixty-two inpatients had dual PPC-EC involvement: of these, 33 (53
The growing integration of artificial intelligence into healthcare is frequently associated with efforts to reduce uncertainty through prediction, data analysis, and computational decision support. Recent work on generative and foundation models has intensified this aspiration while also documenting new uncertainties involving model error, variable performance, opacity, bias, and the conditions of meaningful human oversight. This conceptual and normative article argues that uncertainty in medicine is a multidimensional feature of practice rather than a single informational deficit that technology can progressively eliminate. Drawing on philosophy of medicine, medical ethics, sociology of medicine, and recent AI ethics literature, the article distinguishes epistemic, ontological, moral, communicative, and systemic uncertainty. Predictive technologies may reduce selected epistemic uncertainties, but they can also redistribute uncertainty to questions of model validity, workflow integration, and responsibility. Other uncertainties arise from value conflict, human variability, communication, and the application of population-level evidence to particular patients. The analysis examines predictive analytics, clinical decision support, and generative AI, and argues that predictive performance does not by itself settle clinical or ethical judgment. Israel is used as a bounded illustrative context, not as an empirical case study or as representative of all Israeli practice. Its digital infrastructure, current AI governance initiatives, and experience of prolonged emergency conditions make visible both the utility and the limits of prediction. The article proposes five principles for responsible integration: complementarity, proportionality, accountability, fairness, and human-centred care. Its claim is not that uncertainty is intrinsically valuable or should be preserved when it can safely be reduced. Rather, ethically responsible practice requires epistemic humility, honest communication, contestability, and deliberation where uncertainty persists. The framework is offered as a philosophical proposal requiring empirical testing with clinicians, patients, and institutions.
Defining and applying ‘futility’ has proven to be a contentious endeavor within bioethics. So contentious that our vocabulary about and conceptualization of futility have shifted to the use of ‘potentially inappropriate’ or ‘non-beneficial’ treatment. A longstanding concern has been that futility determinations are in no way objective and are instead a subjective, values-based determination. Recent scholarship has highlighted the relation of the undecided nature of futility to the problem of values imposition. Specifically, Autumn Fiester has argued that futility laws and policies can become an exercise of the ‘tyranny of the majority’; the values system(s) of physicians become pitted against the values system(s) of normative minorities. In light of such critiques, I argue that futility determinations are more properly seen as an exercise of a professional objection to non-beneficence. Such a framework is distinct from conscientious objection, which generally centers an individual, as it takes into account the particular moral community(-ies) that shape understandings of futility. That is, I consider whether what is happening in futility determinations, and any subsequent disputes, is best described as a result of the medical profession’s values system(s) and the moral significance of such a system. I further consider how specific institutions may legitimately give rise to divergent, localized understandings of futility that may provide a path forward in navigating futility disputes. Overall, I argue for a reframing of futility that seeks to recognize the practice for what it is and allows for a path forward without concealed values impositions.
The “Newborn Gang” scandal, which emerged in Türkiye in 2024, exposed allegations of organized fraud, manipulation of neonatal intensive care referrals, financial exploitation of the healthcare reimbursement system, and preventable infant deaths. While previous publications have contributed important perspectives on the case, including its political, economic, and ethical dimensions, there remains a need for a more comprehensive ethical analysis integrating clinical, organizational, and health system perspectives. This study reconstructs the chronology of the case using publicly available documents, official reports, parliamentary records, academic publications, and media sources, and examines its ethical implications through a systems-oriented adaptation of the Four-Box Method. Rather than applying the framework as a bedside decision-making model, it is used as an analytical structure to evaluate ethical failures at clinical, organizational, and health system levels. The analysis demonstrates that the scandal involved profound violations of professional integrity, informed consent, patient autonomy, and the best interests of newborns, while exposing structural vulnerabilities in governance, financial incentives, regulatory oversight, and institutional accountability. The findings are further interpreted across micro, meso, and macro levels, highlighting the interaction between individual misconduct and systemic failures. The study argues that preventing similar events requires more than legal sanctions; it necessitates stronger ethical governance, organizational accountability, clinical ethics support, transparent auditing mechanisms, and healthcare policies that prioritize patient welfare over financial incentives. These lessons are relevant beyond Türkiye and contribute to broader discussions on ethics, and patient safety in contemporary healthcare systems.
The continued evolution of clinical ethics has prompted extensive discussion about the roles clinical ethicists ought to assume in practice, with the discussion focusing largely on what these professionals bring to healthcare. The emotional impact of assuming such roles is less commonly considered despite the fact that clinical ethicists frequently navigate situations of ethical complexity and conflict. We recently interviewed 34 U.S. clinical ethicists about their experiences and learned that the desire to be helpful is resulting in these professionals assuming a wide range of roles and responsibilities. Furthermore, we found that clinical ethicists are regularly emotionally impacted by their work and that they often carry an emotional burden as a result of the roles they assume in patient care. In this article, we explore this burden and discuss what it reveals about the field of clinical ethics at this pivotal point in its development.
The career of a surgeon is among the most challenging of medical specialties. Demands for exactitude, endurance, and equanimity pile an even higher burden on an already terribly complex scope of knowledge, judgement, and technical expertise. It is no wonder that, despite the marvels of modern medicine, pitfalls abound in the life of the surgical practitioner. Nature does not always abide by the scientific algorithms of evidence-based skills. Patients suffer, patients die, blame abounds, disappointment ripens, and personal merit wavers. In its wake looms anger, volatility, depression, and withdrawal. Burnout: the triad of exhaustion, depersonalization, and discouragement sneaks in. The solution? Understanding of the pressures of surgical practice, compassion for fellow surgeons, an effort to teach better life-work balance, and, most of all, forgiveness for understandable acts of omission or commission; due diligence, of course, but also a recognition of the fallibility of not only human enterprises but the fallibility of medical science in general.
Arthroscopic surgery (AS) for chronic joint pain has demonstrated limited and inconsistent long-term benefit over conservative management (CM), despite evidence of possible short-term symptomatic improvement in selected populations. Arguments supporting continued use often rely on informed consent. However, informed consent alone cannot justify an intervention without a reasonable expectation of meaningful patient benefit along with a favorable risk-benefit ratio. This paper proposes an ethical framework for evaluating when offering OAS may remain ethically justified despite limited evidence of long-term efficacy. We first identify two primary ethical considerations that should generally guide decisions regarding OAS: (1) the expectation of meaningful patient benefit, including long-term clinical improvement, prevention of greater structural harm, or other sufficiently important patient-centered outcomes, and (2) a favorable risk-benefit assessment that incorporates procedural risk as well as financial and opportunity costs. We then explore additional categories of patient-specific benefit-including temporal; psychological and identity-related; social and caregiving; and harm-reduction considerations-which, in selected cases, may constitute ethically relevant forms of benefit or avoided harm that support offering surgery even when traditional measures of long-term efficacy would otherwise not. Together, these considerations suggest that AS should not be routine but may be ethically appropriate in carefully selected cases where patient-specific factors meaningfully influence the overall risk-benefit balance.
Moral distress among healthcare clinicians is widely acknowledged but persistently misunderstood. The dominant institutional response has been to prescribe individual-level interventions, including resilience training, mindfulness programming, and wellness initiatives, to clinicians whose distress often arises from structural conditions beyond their control. This article argues that moral distress and its severe counterpart, moral injury, often arise from organizational ethics failure, while individual psychological factors shape how that distress is experienced rather than serving as its primary cause. Drawing on Pellegrino's account of institutional fidelity to the healing relationship, professional virtue ethics, and organizational ethics theory, the article identifies five structural drivers of moral distress, demonstrates that resilience-based responses constitute a form of moral offloading that compounds institutional harm, and proposes a four-component organizational ethics infrastructure as an affirmative institutional obligation. The article further argues that healthcare organizations must develop organizational ethics capacity beyond bedside consultation to include institutional review of the structures and policies that shape clinical practice. A healthcare institution that demands ethical commitment from its clinicians without ensuring the conditions necessary for ethical practice has violated a foundational professional obligation.
Unilateral Do Not Attempt Resuscitation (UDNAR) orders remain contentious in the care of seriously ill patients. While some regard UDNAR orders as reducing non-beneficial treatment, others raise concerns around patient autonomy, potential discrimination, and the risk of relational stress between healthcare teams and families. Ethics consultation services (ECS) are often engaged when these decisions are disputed, but data on their role is limited. In this study, we conducted a retrospective analysis of ethics consultations over a 10-year period at a quaternary academic hospital to identify consultations involving UDNAR orders. We identified 58 ethics consultations (55 adult and 3 pediatric) requested in the context of UDNAR orders. There were thirty-seven (63.7
This commentary examines the methodological and practical implications of the Ethical Case Reflection sessions reported by Bennesved et al. (2025). We argue that Ethics Case Reflection offers a distinctive contribution to clinical ethics by surfacing both ethically desirable aspirations and problematic attitudes that shape everyday practice. By applying a qualitative descriptive design and conventional content analysis to the original session transcripts, we illustrate how Ethics Case Reflection functions not only as a tool for case-based deliberation but also as an ethics laboratory in which participants explore a broad spectrum of possibilities. We highlight the importance of skilled facilitation for recognizing moments of self-critical reflection, promoting specificity in recommended actions, and supporting attention to both patient-centred and organisational dimensions.
This article examines the intersection of anxiety, emotional geography, and bioethics, exploring how uncertainty shapes the experience of patients navigating medical and social landscapes. When is the good time to start worrying about one's own well-being? Who is the "good patient"? Anxiety, particularly in medical contexts, arises from the epistemic tension between known and unknown realities, challenging patients and clinicians alike to discern which concerns warrant attention. Drawing on phenomenological and bioethical perspectives-including those of Heidegger (1962), Sartre (1996), Ricoeur (1992, 2004), and Tillich (1952), as well as the phenomenology of the body developed by Leder (1990)-alongside contemporary scholarship in emotional geography and medical humanities, this paper investigates different forms of anxiety: digital, existential, and spatial, and their impact on subjective and intersubjective medical experiences. Special attention is given to the "dys-appearing" body, the disruption of embodied self-evidence in illness, the courage required to exist in the face of medical uncertainty, and the constitutive role of intersubjective environments in shaping patients' sense of well-being. Ultimately, I argue for a more compassionate, intentional engagement with anxiety that transcends mere symptom management, advocating instead for a holistic approach that accounts for the emotional, spatial, and existential constitution of patients' realities.
Despite increasing initiatives in healthcare, it often remains a challenge to effectuate patient participation. A promising space for patient participation is to be found within Moral Case Deliberation, a dialogical form of Clinical Ethics Support. However, presence of patients in these dialogues is still rare. This paper aims to provide a better understanding of moral considerations of participation of patients (and their relatives) in Moral Case Deliberation, by collecting expectations and experiences from patients, relatives, healthcare professionals and facilitators. The study is an explorative interview study in two clinical settings. Interviewees were recruited through purposeful sampling and among all relevant perspectives (i.e. patient, parent, healthcare professional and facilitator). Twelve interviewees were included; most did not yet have actual experiences with patient participation in Moral Case Deliberation. A variety of moral considerations was found. Three overarching themes were identified: 'equality', 'transparency' and 'vulnerability', connected to nine considerations: 'sharing the moral dilemma, engagement/acknowledgement of the patient and parent perspective', 'mutual understanding', 'complexities', 'risk of harm', 'self-censorship', 'safety' and 'power dynamics'. There seems to be - as of yet - no principled reason to adopt an attitude of categorial rejection nor acceptance of inclusion of patients or family in Moral Case Deliberation. This study provides a starting point for further identification of and reflection on such considerations. We think that a careful assessment of various considerations is something that should be done by those directly involved in the moral issue at hand on a case-by-case basis.
In this introduction to this special issue the central issue of professional identity is defined, and a brief commentary is provided. Each of the essays in this issue is summarized in the commentary in regard to the notion the formation of a professional identity in the education and training of clinical ethics consultants. The second part of the introduction brings some historical and critical context to the issue by way of pointing to a loss of heterogeneity among clinical consultants.
Normothermic Regional Perfusion remains an ethically controversial approach to organ procurement. In response to an organizational request, we convened a Community and Professional Task Group to provide guidance on the ethical elements of this process to inform potentially forthcoming policy and practice guidelines. In this paper, we share the mechanism of forming the Community and Professional Task Group within our broader ethics consultation system, the process of information gathering, as well as the guidance that was delivered to the organization. This includes the identification of and steps for addressing the ethical issues that continue to mark NRP as an ethically complex approach to organ procurement, including those around the Uniform Determination of Death Act, the Dead Donor Rule, and public perception of and trust in deceased organ donation.
New York State’s Family Health Care Decisions Act (FHCDA) governs health care decisions for patients who lack capacity and who did not decide in advance or appoint a health care agent. It also requires each hospital, nursing home, and hospice to establish an “Ethics Review Committee” (ERC) to perform certain advisory and dispute resolution functions and, in some instances, to approve or deny proposals to withdraw or withhold life-sustaining treatment. Although the ERC requirement has been in effect since 2010, not much is known about ERCs. This study involved sending a de-identified email survey to ethics professionals at New York State hospitals. Survey results found that hospitals have employed a variety of approaches to organize and operate their ERCs, that there is variability in the relationship between their ERC and other hospital ethics committees or services, and that there are differences in the capabilities of smaller or non-system hospitals as compared to larger or system hospitals. The study also found that many ERCs do not offer or require training for members, do not meet regularly, and do not have members who have ethics expertise. We suggest that ERCs could benefit by addressing those areas and others, and we offer some recommendations. Finally, we found that hospitals regard their ERCs as moderately successful in performing many of their key assigned functions, including end-of-life decision-making in cases where they have that authority.
This paper explores how historical bioethics milestones have shaped the professional identity of clinical ethicists, discussing both the benefits and challenges of professionalizing the role of the clinical ethicist by comparing how a “wise counselor,” an ethics consultant, and a clinical ethicist provide healthcare ethics guidance. I examine the evolution of clinical ethics as a sub-category of bioethics, tracing its origins and key milestones in its development toward professionalization. These include the American Society for Bioethics and Humanities’ (ASBH) Core Competencies for Health Care Ethics Consultation reports, ASBH’s Code of Ethics and Professional Responsibilities for Healthcare Ethics Consultants, Fox et al.’s national surveys of healthcare ethics consultation in the United States, and the emergence of the Healthcare Ethics Consultant Certification (HEC-C) program. Practicing as a clinical ethicist requires mastery of a wide scope of knowledge, skills, and attitudes reflected in each stage of the field’s development. Reflecting on this history may yield clues for how clinical ethicists position themselves for the next phase of the field’s evolution.
In the contemporary healthcare sector, organizations frequently function within networks. This has implications for the ethics consultation services they offer. The issue at hand concerns the integration of these services into the network, with the objective of ensuring their role as an integral component of the intricate healthcare delivery system. In practice, the hub-and-spoke model is employed for this purpose and is thoroughly discussed in the relevant literature. The present article examines the organizational ethical aspects of this model. The hub-and-spoke model has been demonstrated to be a framework that must be contextualized in relation to ethics consultation. A thorough examination of the model’s implications, both advantageous and disadvantageous, is conducted. The article elucidates which elements of an organizational culture can facilitate it. When understood in this manner, the hub-and-spoke model is not merely an administrative form of organization, but rather an opportunity to develop the healthcare organization in terms of organizational ethics.
In contexts where children face imminent death despite ongoing medical care, a significant ethical question arises: should they be informed of their approaching death? Although international guidelines now advocate for honest and developmentally appropriate communication, parents and clinicians are sometimes still inclined to withhold this information. Such non-disclosure may be viewed as an exercise of therapeutic privilege, potentially justified by the Best Interest Standard, the prevailing framework for proxy decision-making in pediatrics. Yet it remains contested whether concealing end-of-life information truly aligns with a child’s best interests, as evidence suggests that withholding information may not always serve the child’s overall well-being. This paper critically examines the legitimacy of non-disclosure in pediatric end-of-life care. It explores whether non-disclosure can be inherently beneficial and whether children possess an intrinsic interest in knowing about their imminent death. Moving beyond the dichotomy of disclosure versus non-disclosure, the paper proposes a nuanced, interest-based evaluative framework, where truth is treated not as an absolute value but as a means to promote the child’s overall well-being.
Clinical ethics committees support ethical decision-making in healthcare. In the DACH region (Germany, Austria, Switzerland), their adoption is growing, but factors shaping implementation and daily functioning remain underexplored. Development has been uneven, and little is known about what drives it. This qualitative study examined influences on committee adoption, implementation, and routine practice. Semi structured expert interviews were conducted with committee representatives and researchers, then analysed using thematic qualitative text analysis in MAXQDA, identifying six key themes. The adoption is driven by bottom-up and top-down initiatives, external pioneers, societal debates, certification demands, and resources. Efficient implementation relied on leadership, protected time and funding, committee member role clarity, and visibility through early activities. Everyday functioning depended on member motivation, clinician acceptance, staffing, training, networking, and regulatory and cultural factors. Evaluation of their activities was frequently emphasized but often constrained by limited resources. Legal and regulatory requirements were also debated: mandates could promote establishment but risk tokenism, making softer mechanisms preferable. Future directions emphasized professionalization, billing options, care integration, organizational models, and systematic evaluation. Sustainable, high-quality committee functioning requires coordinated action across policy and institutional levels, alongside clinician engagement and evaluation capacity. These empirically grounded insights provide practical strategies for managers and policymakers to strengthen clinical ethics infrastructure in the DACH context.
Culturally informed care requires integrating patients’ cultural, religious, and personal values into clinical decision making. Yet many health systems lack the structural supports necessary to ensure that these values are elicited, documented, and operationalized consistently. Systemic barriers—including reliance on assumptions, insufficient documentation mechanisms, and opaque pharmaceutical labeling—undermine informed consent and trust. An ethics consultation involving the retrospective discovery of both a medication’s porcine origin and a patient’s Muslim religious identity illustrates how institutional gaps create avoidable ethical uncertainty. Because values had not been previously discussed with the patient, clinicians were unsure whether disclosure would respect autonomy or reinforce stereotypes. This case demonstrates that demographic fields alone cannot substitute for meaningful value-elicitation processes. This paper analyzes the systemic factors that impede culturally informed care and proposes structural reforms—including enhanced transparency around medication ingredients and intentional documentation practices and tools in the electronic health record (such as a Cultural and Personal Values Alert)—to support values-aligned care. These institutional changes can reduce reliance on assumptions, strengthen informed consent, and distribute ethical responsibility across clinical systems.
