AbstractDoes the principle of nonmaleficence in medicine need updating? And if so, what should such an updating look like? This article engages with these questions by critically discussing the relation-centered view of nonmaleficence presented by Christopher Crenner and Skylar Bird. It contends that an adequate account of the principle must do two things: It must establish the integrity of the principle as one that is distinct from the more general principle of beneficence, and it must show it to have sufficient content to warrant its inclusion as a fundamental principle in clinical medical ethics. The proposal to focus on relational harms in the medical relationship is a good one, but such a proposal must be integrated into a more comprehensive account of the principle of nonmaleficence. This more comprehensive account relates relational harms to medical professionalism and derives the content of the principle of nonmaleficence from the standards of acceptable medical practice. After clarifying this more comprehensive view of medical nonmaleficence, the article concludes by responding to an important autonomy-based objection to it. This response raises large and difficult questions about the nature and point of medical practice in modern societies.
AbstractThis article argues that the ethical principle of nonmaleficence, to "do no harm," has become conceptually thin. Harm in medical settings is ubiquitous and typically in balance with beneficent intent, making nonmaleficence subsidiary to beneficence. Other independent applications of nonmaleficence have lost some of their original force. We propose to expand the conventional concept of nonmaleficence to add the obligation and the goal to avoid harm to the medical relationship. We offer scenarios demonstrating how connecting nonmaleficence to the ethics of care and relational autonomy helps to address key weaknesses in conventional principlism. We pose these relational obligations in prohibitory form because optimal clinical relationships remain context dependent, varying by setting and condition. In addition, this reframing of nonmaleficence foregrounds the risk of relational harm posed by an increasingly fragmented and compartmentalized medical realm that still relies heavily on trust, open communication, and confidentiality between clinicians and patients.
AbstractWhether and how patients should participate in clinical ethics discussions is an important contemporary debate. Murdoch recently reported clinicians' and ethics service members' views from England and the United States on patient participation in ethics consultation. In response to the call for further understanding, we report parents' and clinicians' experiences of active parental and child involvement in ethics case reviews (ECRs), including the then-novel use of videoconference ECRs during the pandemic in a UK tertiary children's hospital. Between January 2018 and May 2023, parents attended 59 of 85 hospital ECRs and provided positive anecdotal feedback. To better understand their perspectives, we interviewed three families (two couples and one single parent) and four clinicians involved in ECRs, conducted via videoconference because of pandemic restrictions, between March and December 2020. All reviews concerned proposals for innovative COVID-19 therapies. Reflexive thematic analysis identified six themes: (1) parental presence at ECRs is essential; (2) preparation is vital; (3) ECRs support complex decision-making; (4) videoconferencing worked well, although choice of format is important; (5) ECRs offer wider benefits; (6) the ECR process was generally smooth but could still be improved. Although this evaluation focused on videoconference ECRs during the pandemic, the findings remain relevant to current debates. Unlike Murdoch, we found that both parents and clinicians highly valued ECR and supported active participation by parents and, where possible, children and young people. However, we agree that clear guidance is needed to support patients' involvement in ethics processes, including preparation and support that promote inclusive, effective reviews.
AbstractObjective: To explore parents' understanding of clinical ethics consults, what might influence their openness to an ethics consult in the future, and what they define as medical ethics. STUDY DESIGN:Electronic survey of parents of children with complex medical conditions. Questions were adapted from a study of adult patients' and family members' experiences of ethical concerns in the healthcare setting. Respondents were also invited to participate in subsequent interviews. RESULTS:We surveyed 218 parents and interviewed 28. Most respondents (63%) were not familiar with ethics consults and did not know how to request one (88%). For those reporting interest in a future ethics consult, knowing more about how ethics consults could help (71%) and a doctor's recommendation (58%) would most influence their interest. Hesitancy in speaking with an ethics consultant most often stemmed from worry that their child/family would not be understood (77%). Parents defined "medical ethics" as relating to serious medical conditions (67%), communication with the medical team (61%), and goals of care (57%). Interviews demonstrated generally consistent themes with the survey. CONCLUSIONS:Pediatric ethics consultation is not a commonly recognized or utilized resource for families facing medical complexity and ethical challenges. More needs to be understood about how best to meet patient and family needs via ethics consults.
AbstractOrganizational ethics (OE) in healthcare has gained prominence, particularly during the COVID-19 pandemic. This article provides detailed guidance for establishing OE services and conducting OE consultations, drawing on examples from Seattle Children's Hospital. We define OE, compare it with clinical ethics, and describe consultation processes and procedures. Examples illustrate OE's role in guiding institutional decisions, promoting equity, and managing resource constraints. We conclude with recommendations for OE program development and integration.
