Cultivating Moral Resilience

Cynda Rushton
American Journal of Nursing:
February 2017 - Volume 117 - Issue 2 - p S11–S15
doi: 10.1097/01.NAJ.0000512205.93596.00

Here is an excerpt:

To derive meaning from moral distress, one must first change the relationship with the suffering that it causes. Human beings have the potential to consciously decide what mindset they will bring to a given situation; they have the option to choose a path of mindful awareness and inquiry over one of helplessness and frustration. When people are mired in the “judger pit,” the tone of their conversation is punctuated by negativity, closed thinking, and judgment of themselves and others.40 Alternatively, when in an inquiring mindset, they are more inclined to remain positive—despite their distress—and are able to ask questions that may help reveal unknown or overlooked possibilities.

Shifting the focus from helplessness to resilience offers promising possibilities in designing interventions to help mitigate the effects of moral distress. Resilience—an umbrella concept that has been applied in diverse fields of study—can be psychological, physiologic, genetic, sociologic, organizational or communal, or moral. Although there is no unifying definition, resilience generally refers to the ability to recover from or healthfully adapt to challenges, stress, adversity, or trauma. One definition characterizes it as “the process of harnessing biological, psychosocial, structural, and cultural resources to sustain wellbeing.”

Psychological resilience, for example, “involves the creation of meaning in life, even life that is sometimes painful or absurd, and having the courage to live life fully despite its inherent pain and futility.”

The article is here.

Taking Ethics Seriously: By Setting Up Board Committees?

Dina Medland
Forbes.com
Originally published March 9, 2016

Here is an excerpt:

However, the report does not recommend that all companies should form a committee. “While the need for more detailed oversight may favor the creation of a committee, there is a risk of the board’s own responsibilities being diluted  – and of unnecessary overlap with other committees. What remains critical is that boards address the issues of ethics and values in the context of their approach to risk oversight, even when they do not have a committee”, it says.

One could argue that the creation of a committee in a boardroom is in fact a death knell to a broader discussion of the issue of company culture – which surely includes creating attitudes to corporate values, sustainability and realistic profit targets from an ethical base implicit in the business plan.

The article is here.

Why Self-Driving Cars Must Be Programmed to Kill

Emerging Technology From the arXiv
MIT Technology Review
Originally published October 22, 2015

Here is an excerpt:

One way to approach this kind of problem is to act in a way that minimizes the loss of life. By this way of thinking, killing one person is better than killing 10.

But that approach may have other consequences. If fewer people buy self-driving cars because they are programmed to sacrifice their owners, then more people are likely to die because ordinary cars are involved in so many more accidents. The result is a Catch-22 situation.

Bonnefon and co are seeking to find a way through this ethical dilemma by gauging public opinion. Their idea is that the public is much more likely to go along with a scenario that aligns with their own views.

The entire article is here.

The Gray Areas Of Assisted Suicide

By April Dembosky
Kaiser Health News
Originally published May 21, 2015

Here is an excerpt:

People don’t talk about it, but it happens. Just over 3 percent of U.S. doctors said they have written a prescription for life-ending medication, according to an anonymous survey published in the New England Journal of Medicine in 1998. Almost 5 percent of doctors reported giving a patient a lethal injection.

Other studies suggest oncologists, and doctors on the West Coast, are more likely to be asked for life-ending medication, or euthanasia, in which the doctor administers the lethal dose.

“Those practices are undercover. They are covert,” says Barbara Coombs Lee, president of Compassion & Choices, an advocacy group. “To the degree that patients are part of the decision-making, it is by winks and nods.”

Coombs Lee’s organization helped tell the story of Brittany Maynard, a 29-year-old woman who moved from California to Oregon to be able to end her life legally after she was diagnosed with a brain tumor. Now the organization is backing legislation in California to make it legal for doctors to prescribe lethal medication to terminally ill patients who request it.

The entire article is here.

Is Age a Determinant Variable in Forgoing Treatment Decisions at the End of Life?

Guest post by Sandra Martins Pereira, Roeline Pasman and Bregje Onwuteaka-Philipsen
Journal of Medical Ethics Blog
Originally posted May 14, 2015

Decisions to forgo treatment are embedded in clinical, socio-cultural, philosophical, religious, legal and ethical contexts and beliefs, and they cannot be considered as representing good or poor quality care. Particularly for older people, it is sometimes argued that treatment is aggressive, and that there may be a tendency to continue or start treatments in situations where a shift to a focus on quality of life in light of a limited life expectancy might be preferred. Others argue that an attitude of ageism might prevent older people from receiving treatments and care from which they could benefit, thus resulting in some type of harm and compromising the ethical principles of beneficence and non-maleficence.

When the need to make a decision about treatment concerns an older person at the end of life, physicians need to reflect on the following questions: In this situation, for this person, what is the best course of action? Is this person capable of assessing the situation and making a decision about it adequately herself? What are the preferences of the person? Who needs to be involved in the decision-making process? What will be the consequences of starting or withholding this treatment?

The blog post is here.

The paper is here.

The Ethics of Enhanced Interrogations and Torture: A Reappraisal of the Argument

William O'Donohuea, Cassandra Snipesa, Georgia Daltoa, Cyndy Sotoa, Alexandros Maragakisa & Sungjin Im
Ethics & Behavior
Volume 24, Issue 2, 2014

Abstract

This article critically reviews what is known about the ethical status of psychologists’ putative involvement with enhanced interrogations and torture (EITs). We examine three major normative ethical accounts (utilitarian, deontic, and virtue ethics) of EITs and conclude, contra the American Psychological Association, that reasonable arguments can be made that in certain cases the use of EITs is ethical and even, in certain circumstances, morally obligatory. We suggest that this moral question is complex as it has competing moral values involved, that is, the humane treatment of detainee competes with the ethical value/duty/virtue of protecting innocent third parties. We also suggest that there is an ethical duty to minimize harm by making only judicious and morally responsible allegations against the psychologists alleged to be involved in EITs. Finally, we make recommendations regarding completing the historical record, improvements in the professional ethics code, and the moral treatment of individuals accused in this controversy.

The entire article is here.

Response to Critics of The Moral Landscape

By Sam Harris
His Blog
January 29, 2011

Here are two excerpts:

The problem posed by public criticism is by no means limited to the question of what to do about misrepresentations of one’s work. There is simply no good forum in which to respond to reviews of any kind, no matter how substantive. To do so in a separate essay is to risk confusing readers with a litany of disconnected points or—worse—boring them to salt. And any author who rises to the defense of his own book is always in danger of looking petulant, vain, and ineffectual. There is a galling asymmetry at work here: to say anything at all in response to criticism is to risk doing one’s reputation further harm by appearing to care too much about it.

These strictures now weigh heavily on me, because I recently published a book, The Moral Landscape: How Science Can Determine Human Values, which has provoked a backlash in intellectual (and not-so-intellectual) circles. I knew this was coming, given my thesis, but this knowledge left me no better equipped to meet the cloudbursts of vitriol and confusion once they arrived. Watching the tide of opinion turn against me, it has been difficult to know what, if anything, to do about it.

(cut)

For those unfamiliar with my book, here is my argument in brief: Morality and values depend on the existence of conscious minds—and specifically on the fact that such minds can experience various forms of well-being and suffering in this universe. Conscious minds and their states are natural phenomena, of course, fully constrained by the laws of Nature (whatever these turn out to be in the end). Therefore, there must be right and wrong answers to questions of morality and values that potentially fall within the purview of science. On this view, some people and cultures will be right (to a greater or lesser degree), and some will be wrong, with respect to what they deem important in life.

The entire blog post is here.

Girls Talk: The Sexualization of Girls

By the American Psychological Association

APA's Public Interest directorate invited six middle school girls to sit down and share their thoughts about the images of girls they see all around them and how they feel about the way girls today are portrayed.




The Executive Summary of this report can be found here.

What happens to whistleblowers?

By David Nather
Politico
Originally published June 13, 2013

Edward Snowden might want to talk to a slew of recent national security leakers who learned a lesson the hard way: whistleblowing comes at a price.

Thomas Tamm, the DOJ attorney who told the New York Times about the National Security Agency’s surveillance program in 2004, struggled to stay employed for the five years he was under federal investigation.

And he was one of the lucky ones. Thomas Drake, a former National Security Agency official who helped expose a wasteful NSA surveillance program without privacy protections, is working in an Apple store.

And Matt Diaz, the Navy lawyer who secretly sent a list of Guantanamo Bay prisoners to a New York civil rights firm, was disbarred and now does non-legal work for the Bronx public defender’s office.

Snowden is still on the run, but he is expected to be extradited to the United States, eventually, and most likely charged with a crime.

If Snowden’s life turns out like other national security whistleblowers, his life will never be the same — leaving him to grapple with huge legal bills, poor job prospects, and a notoriety that will never really go away.

The entire story is here.

The Role of Medical Professionals Related to Hunger Strikes at Guantanamo

Obama to Seek Closing Amid Hunger Strikes at Guantanamo

By Charlie Savage
The New York Times
Originally published April 30, 2013

Here is a piece of the article:

Last week, the president of the American Medical Association, Dr. Jeremy A. Lazarus, wrote a letter to Defense Secretary Chuck Hagel saying that any doctor who participated in forcing a prisoner to eat against his will was violating “core ethical values of the medical profession.”

“Every competent patient has the right to refuse medical intervention, including life-sustaining interventions,” Dr. Lazarus wrote.

He also noted that the A.M.A. endorses the World Medical Association’s Tokyo Declaration, a 1975 statement forbidding doctors to use their medical knowledge to facilitate torture. It says that if a prisoner makes “an unimpaired and rational judgment” to refuse nourishment, “he or she shall not be fed artificially.”

The military’s policy, however, is that it can and should preserve the life of a detainee by forcing him to eat if necessary.

“In the case of a hunger strike, attempted suicide or other attempted serious self-harm, medical treatment or intervention may be directed without the consent of the detainee to prevent death or serious harm,” a military policy directive says. “Such action must be based on a medical determination that immediate treatment or intervention is necessary to prevent death or serious harm and, in addition, must be approved by the commanding officer of the detention facility or other designated senior officer responsible for detainee operations.”

On Monday, Colonel House also said that some detainees on the “enteral feeding” list were drinking the supplement.

“Just because the detainees are approved for enteral feeding does not mean they don’t eat a regular meal,” he said. “Once the detainees leave their cell and are in the presence of medical personnel, most of the detainees who are approved for tube feeding will eat or drink without the peer pressure from inside the cellblock.”

Medical ethicists and the Pentagon also clashed during the Bush administration over hunger strikes at Guantánamo.

The entire article is here.

Physicians' Top Ethical Dilemmas: Medscape 2012 Survey Results

Physicians' Top Ethical Dilemmas

Would you fight with a family that wanted to withdraw care from a viable patient? Would you follow the family's directive to continue treatment if you thought it was futile? Would you date a patient? More than 24,000 physicians told us how they feel about this and other ethical dilemmas.

The entire survey is here.

Inadequate Ethics Training Leaves Young Scientists Unprepared for "Ethical Emergencies"

By Beryl Benderly
Science Careers Blog
Originally published July 14, 2013

Difficult ethical issues can present significant challenges to graduate students and early-career scientists, but few receive adequate training and guidance in dealing with these problems, agreed a panel of experts at the Euroscience Open Forum (ESOF) 2012 in Dublin. Formal training in ethics was unknown in science before 1990, when it became a requirement in the United States, said Nicholas Steneck of the University of Michigan, who is a consultant to the Federal Office of Research Integrity. In recent years, he continued, interest has increased in other countries as well. Concepts of ethics and responsible research vary among countries and disciplines, however, the speakers agreed, and there is no uniformity in the content of training even within countries. And, although various initiatives are underway in a variety of nations, nowhere is training sufficient to the needs of young researchers, the panelists said.

The competitive pressures that young scientists face today are much more severe than in the past and can make ethical problems more acute, said Maria Leptin of the European Molecular Biology Organization (EMBO) in Germany and the Initiative for Science in Europe. Today's intense competition greatly increases incentive to produce the maximum number of publications and to have one's name on as many papers as possible.

The entire story is here.

Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing

By Jon C. Tilburt and Christine Cassel
JAMA. 2013;309(8):773-774. doi:10.1001/jama.2013.368.

The ethics of rationing health care resources has been debated for decades. Opponents of rationing are concerned that societal interests will supplant respect for individual patient choice and professional judgment. Advocates argue that injustices in the current system necessitate that physicians use resources prudently on behalf of society, even in their daily work with individual patients. The debate is important, potentially divisive, and unavoidable.

Various groups have championed the cause of medicine practiced leanly, consistent with the professional responsibility to use resources wisely. These initiatives, which champion “parsimonious medicine,” have highlighted the 20% of routine practices in US medicine that add no demonstrable value to health care but that persist in the inertia and rituals of clinical work. The specialty societies and the Choosing Wisely collaborative outline commonsense principles for avoiding unnecessary, wasteful care.

Recent calls for waste avoidance and parsimonious care are not just a clever way to help physicians ration health care.  Despite the intuitive similarity between themes in rationing and waste avoidance, the ethical rationales underlying the two differ considerably.

The entire article is here.

Vignette 22: A Duty to Report?

Dr. Tell worked with a woman for several months on issues related to depression, anxiety, and relationship issues. During one session, the patient indicated that her boyfriend has lost interest in sex and became more involved with online pornography. While discussing these issues, the patient suddenly stopped talking. Dr. Tell allowed several moments to pass before asking the patient what was happening. 

The client indicated that she was hesitant to speak about the issue for fear of a breach of confidentiality. Dr. Tell reminded her about confidentiality and the laws in Pennsylvania that would override it. The client continued to struggle. She eventually blurted out that, during a heated discussion, her boyfriend indicated that looking at online pornography was not as bad as what his uncle did. She went on to detail how her boyfriend described how his uncle was involved in collecting and distributing child pornography but remained faithful to his aunt. The client's boyfriend expressed that she should never discuss this with anyone. The client asked if she could just give Dr. Tell the information about the uncle so that she could report it to the authorities and leave her out of the situation. The client is feeling very helpless and vulnerable about this bind. 

Dr. Tell explained that the alleged perpetrator was several times removed from their sessions and she did not believe that she had the obligation to report it. The client then asked if she could invite her boyfriend to the next session so that they could all discuss the information and the best way to handle the situation. 
 

Dr. Tell focused the client on her dilemma as well as the relationship issues with her boyfriend. Dr. Tell agreed to contact someone to discuss whether Dr. Tell had to report this information to the police or Child Protective Services. And, Dr. Tell agreed to determine whether or not reporting this information would put her client’s confidentiality at risk. She also agreed to think about the need to bring in the boyfriend, because inviting him to therapy will not necessarily help the situation.

  

Dr. Tell contacts you with the above scenario.
 

1. How would you feel if you were Dr. Tell?
 

2. How would you feel if you were the consultant?

3. Is Dr. Tell a mandated reporter in this situation?

4. As a mandated reporter, would Dr. Tell report place her client's confidentiality be at risk?
 

5. If Dr. Tell is not a mandated reporter, should Dr. Tell bring in the boyfriend gather more facts so that Dr. Tell can report the alleged crime?
 

6. Is the goal of therapy to help the client manage the situation or is the responsibility now on the psychologist to gather more information about the possible crimes committed with children?
 

7. Can the client contact Child Protective Services anonymously in this case?

8. Can the psychologist contact Child Protective Services anonymously, provided that the client supply the name and address of the uncle?

9.What should the psychologist do?

Is Lab Safety An Ethical Issue?

By Jane Robbins
Inside Higher Ed
Originally published October 24, 2012


This week’s post is in response to an issue raised via the confidential post box.  The questioner wondered, as one of two principle questions, whether laboratory safety fell into the category of an ethical issue.

The short answer is yes. Safety is, in fact, often referred to, in organizational terms, as a “terminal value”; most airlines, for example, would say that safety is their primary terminal value: something closely tied to their mission-critical goal of getting people and cargo entrusted to them from point A to point B. Such terminal values translate into rules of conduct that become a matter of duty in practical, everyday terms:  for airlines, all the safety checks to the plane, pilots’ autonomy in the cockpit to abort, the security procedures, the flight attendant demonstrations and cross-checks, and so on. Without safety and a record of safety, there would be no business, no ability to fulfill the mission. So operationally it is sometimes said that such procedures are instrumental to supporting the terminal value -- indeed, to the very raison d’être of an organization.

In supporting mission in a particular way, safety, in theory and practice, is normative at its core. Lab safety, like airline safety, can be thought of in the stakeholder terms that airline safety procedures reflect. Beyond excellence at, say, flying or a conducting a particular type of research, there is recognition that the very act or process of flying or running a lab affects others.  So here we see how much relational context (internal to external); rights and obligations; and consequences enter into thinking about what is an ethical issue or not. Each lab might analyze their stakeholders differently, but at a minimum they likely include funders; scientists, technicians, students, administrators, custodians, and other lab workers; and the potential users of the lab’s outputs, such as patients, industrial firms, or consumers.

The entire blog post is here.

Dilemma 18: Co-authorship with a Former Patient

Dr. Jordan is a psychologist who typically works with a wide variety of patients.  At the end of the day, he listens to voicemail messages to learn that a former patient is reaching out to him for a request. 

Prior to returning the call, Dr. Jordan reviews the patient’s chart.  The patient had been in treatment for about 10 months on a weekly basis.  The treatment notes indicate that she dropped out of therapy about one year ago.  She stopped therapy because her insurance changed and Dr. Jordan was not an in-network provider.  The therapy focused on depression and anxiety related to work-related issues, interpersonal limitations, and relationship difficulties.  Some of the sessions focused on a sexually abusive relationship between a basketball coach and the patient when she was age 13 to 16.    

Dr. Jordan returns the phone call.  After the initial greetings, the former patient indicates that she has finally started to write down more thoughts, memories, and recollections about her abusive experiences.  She stated that Dr. Jordan recommended that she write down her memories.  She recalled that he agreed that it could make a good book.  She stated she wanted to include some education around sexual abuse and tell her story in a healthy, therapeutic manner.

When attempting to clarify the request, the former patient is not asking to return to therapy, but to have Dr. Jordan become the co-author or a consultant for the book.  Dr. Jordan thanked her for the compliment and indicated that he needed to think about the request.  He promised to call her back within a week.

Dr. Jordan calls you on the phone for an ethics consultation.

What are the ethical issues involved in this case?

What are some possible suggestions for Dr. Jordan?

If you were Dr. Jordan, how would you feel about this request?

Considering Death Row for Organs

By Brandi Grissom

The New York Times

Originally published September 8, 2012

Before Gov. John Kitzhaber of Oregon established a moratorium on his state’s death penalty last year, Christian Longo, a death row inmate, started a campaign to allow the condemned to donate their organs.

Mr. Longo argued that a new execution protocol that many states — including Texas — have adopted leaves inmates’ organs viable for transplantation.

“While I can potentially help in saving one life with a kidney donation now, one preplanned execution can additionally save from 6 to 10 more lives,” Mr. Longo wrote in a plea that Oregon officials denied.

No state allows death row inmates to donate their organs. Although Texas recently abandoned a three-drug cocktail in favor of a single-drug method for execution, the Texas Department of Criminal Justice said it did not intend to change its policy. 

There are 11,000 Texans on the organ transplant waiting list.

The entire story is here.

To Evaluate or Not To Evaluate

Dr. Joey Bishop has been conducting pre-ordination evaluations for a religious institution for many years. The purpose of these psychological evaluations is to identify individuals who have gross psychopathology, strong personality disorders, or other characteristics that would make them incapable of performing their religious duties adequately. Dr. Bishop developed a strong relationship with this institution and they have been quite satisfied with his work.

One day, Dr. Bishop receives a phone call from his contact at the institution.  The contact is now requesting that Dr. Bishop begin to screen individuals for "homosexual tendencies" because, according to the doctrines of the denomination, such individuals are not eligible to become clergy.

Dr. Bishop feels uneasy about this situation, as “homosexuality” has not been considered a mental illness since the 1970s.  Simultaneously, the religious institution is adamant about this requirement. 

Dr. Bishop calls you for a consult about this situation.

What are the ethical issues involved in this scenario?

If you were the psychologist, what would be your emotion response to this situation?

What are some potential responses that you could offer Dr. Bishop?

Massachusetts Debates ‘Death With Dignity’

By Paula Span
The New Old Age Blog: Caring and Coping
The New York Times
Originally published May 29, 2012

Consider this an update. Last fall, when I talked with some of the 350 volunteers circulating petitions, they sounded confident about collecting 70,000 certified signatures by the end of the year. They more than succeeded, which meant the state legislature had until May 1 to act. It didn’t — to no one’s surprise — so volunteers for the organization backing the referendum, Dignity 2012, have headed back out with their clipboards.

If they can gather another 11,000 signatures by July 2, the public will decide whether the state’s physicians can lawfully prescribe medications with which terminally ill patients can end their lives. (You can read the exact language here.)

Oregon enacted essentially the same law allowing self-administration of lethal drugs in 1997, and Washington in 2009. Though their adversaries often used “slippery slope” arguments, the number of residents who have taken advantage of the laws remains quite small. After meeting all the requirements and undergoing the mandated waiting periods, 114 people received lethal prescriptions last year in Oregon and 103 in Washington. In both states, about a third of those who qualified ultimately decided not to use the drugs.
But the controversy was intense in those states, with contentious public debate and expensive media campaigns, and it will be this round, too. In both camps, fund-raising has already begun.

“It has potent national implications,” the Rev. J. Brian Hehir, secretary for health care and social services at the Roman Catholic Archdiocese of Boston, said of the referendum. “We are talking about fundamental human values, deeply personal choices.”

The entire blog entry is here.

From an Ethics of Rationing to an Ethics of Waste Avoidance

By Howard Brody, MD, PhD
The New England Journal of Medicine
Originally published on May 24, 2012

Dr. Howard Brody

Bioethics has long approached cost containment under the heading of “allocation of scarce resources.”  Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste. This little-noticed shift has important policy implications.

 Whereas the “R word” is a proverbial third rail in politics, ethicists rush in where politicians fear to tread. The ethics of rationing begins with two considerations.  First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community.

The entire story is here.

An interview with Dr. Brody is here.

Thanks to Gary Schoener for this lead.