Abstract The concept ethics defines health care ethics as a professional practice. Yet the meaning of “ethics” is often unclear in the theory and practice of clinical ethics. Clarity on this matter is crucial for understanding the nature of clinical ethics and for debates about the professional identity and proper role of ethicists, the sort of training and skills they should possess, and whether they have ethics expertise. This article examines two different ways the ethics of clinical ethics can be understood: Real Ethics, which consists of objective moral norms grounded in moral truth; and Conventional Ethics, which consists of conventional norms grounded in bioethical consensus. Drawing on the bioethics literature and features of professional practice, it shows that Conventional Ethics is the dominant paradigm. Then it presents a critique of Conventional Ethics, arguing that it cannot avoid the challenge of moral pluralism, it fails to address vitally important moral questions, and it is incapable of providing an essential service to the people ethicists aim to help. It ends with suggestions about how the practice of clinical ethics might overcome these problems.

Matthew Shea

HEC Forum

The Ethics of Clinical Ethics

临床伦理的伦理

Abstract Caring for children with cancer involves complex ethical challenges. Ethics Case Reflection (ECR) rounds can be offered to support teams to reflect on challenges and what should be done in patient care. A training course, for facilitators of ECR rounds, has been offered to healthcare professionals (HCPs) in childhood cancer care by a Nordic working group on ethics. During/after the course, the trainees implemented and facilitated ECR rounds in their clinical setting. The aim was to explore the trainees’ experiences of implementing ECR rounds in childhood cancer care. HCPs, who participated as trainees in the course, participated in 3 focus group interviews ( n = 22) and 27 individual interviews ( n = 17). Interview data were analysed concurrently with data collection following classic grounded theory. Positioning ethics is the core category in this study, used to resolve the main concern of doing ethics in a context where direct patient care is prioritized. Being able to take time for ethics reflections, not perceived as the key priority, was considered a luxury in the clinical setting. Strategies for positioning ethics include allying , promoting ethics reflection , scheduling ethics reflection , and identifying ethical dilemmas. These strategies can be more or less successful and vary in intensity. The prioritisation of direct patient care is not surprising, but polarisation between care and ethics needs to be questioned and ethics reflection need to be integrated in standard care. Ethical competence seems to be central in doing ethics and more knowledge on the promotion of ethical competence in practice and education is needed.

Pernilla Pergert

Bert Molewijk

Cecilia Bartholdson

Positioning Ethics When Direct Patient Care is Prioritized: Experiences from Implementing Ethics Case Reflection Rounds in Childhood Cancer Care

当优先考虑直接患者护理时的伦理定位：在儿童癌症护理中实施伦理案例反思轮班的体验

Healthcare ethics consultants in the Veterans Health Administration (VHA) document consults in an enterprise-wide web-based database entitled IEWeb, serving as a system of record for healthcare ethics documentation at 1300 VA facilities. The need arose to evolve the database from an ethics process training resource into a more streamlined documentation repository that captures essential consult elements. A VHA National Center for Ethics in Health Care (NCEHC) Improvement Team convened for three tasks: (1) Specify and prioritize IEWeb changes (occurred via six focus groups composed of "new user" and "super user" cohorts with analysis of existing documentation patterns); (2) Pilot the changes regionally (via regional communication, training, and reviews of pre-post use patterns); and (3) Measure the impact of national change implementation on user perspectives (via pre-and post-change implementation polls). Focus groups identified six implementable priority areas for ethics consult documentation improvement, including the development of a usable consult summary note for ready conversion from IEWeb fields into the electronic health record. Post-IEWeb updates showed an increased number of consults documented, a reduction in "time to consult documentation closure" by a mean of 4.5 days, and a clinically-meaningful improvement in the quality of documentation (78% of ethics questions scored "above-bar" on the validation tool pre- vs. 89% scored "above-bar" post-IEWeb changes, n = 140). According to national survey findings, the number of consultants documenting "all" consults in IEWeb increased, satisfaction increased, and perception of documentation difficulty decreased. IEWeb simplification enabled ethics consultants to re-focus their documentation completion efforts by decreasing perception of documentation burden while improving documentation frequency and quality in a clinically-meaningful way.

Meaghann S. Weaver

Anita J. Tarzian

Hannah N. Hester

Karinne R. Davidson

Rodney P. Dismukes

Mary Beth Foglia

An Ethics Consult Documentation Simplification Project: Summation of Participatory Processes, User Perceptions, and Subsequent Use Patterns

伦理咨询记录简化项目：参与过程总结、用户感知及后续使用模式

This study explored the perceptions of ethics among long-term care employees (N275) in order to test two hypotheses. A cohort cross-sectional survey examined employees' perceptions of an ethics environment, racial-ethnic, and position disparities (HO1; ANOVA), and, secondarily, ethics in relationship to select, research-grounded work features measured as manage disagreements, effectiveness, work satisfaction, and opinions of care, the latter including intention to remain (HO2; Pearson Correlations). Established questionnaires with robust psychometrics were employed. Response rate was 51%. Non-significant differences between sample and population on key variables supported extrapolation of results. Statistically significant differences between racial-ethnic (p < 0.03; F 2.42) and work positions (p <0.0001; F 6.24) were revealed on ethics (3.16; HO1). Statistically significant relationships (p <0.0001; r = 0.26-0.68; HO2) between ethics and employees' work features also were found, confirming both hypotheses. Perceptions of ethics based on racial-ethnic and position disparities, as well as the robust links with employee work features, offered potential avenues for decreasing disparities at work and improving the quality of long-term care. Noted further on ethics item scoring were relatively low scores indicating less involvement in, and access to, ethics discussions and decisions. In contrast, the literature review substantiated the importance of empowerment and retention, which were enhanced by employee involvement in work, notably, discussions and decisions. Thus, implications of ethics committees in long-term care sites as ways to potentially enhance employees' work and quality of care, especially work satisfaction and retention, were explored; relevant concerns raised by the Covid pandemic were, briefly, discussed.

Charlotte McDaniel

Emir Veledar

Employee Perceptions on Ethics, Racial-Ethnic and Work Disparities in Long-Term Care: Implications for Ethics Committees

长期护理中员工对伦理、种族与工作差异的看法：对伦理委员会的启示

Throughout the COVID-19 pandemic the use of the term "hero" has been widespread. This is especially common in the context of healthcare workers and it is now unremarkable to see large banners on hospital exteriors that say "heroes work here". There is more to be gleaned from the rhetoric of heroism than just awareness of public appreciation, however. Calling physicians and nurses heroes for treating sick people indicates something about the concept of medicine and medical professionals. In this essay, I will examine three aspects of the social role of medicine exposed by the language of heroism. One, if a hero is someone who goes above and the call of duty, then does that mean exposing oneself to risk of infection is no longer a duty of physicians (as it used to be)? If so, does that mean the "profession" of medicine is much like any other business? Two, physicians and nurses are not the only "heroes" this go-around. Anyone deemed essential to the US "infrastructure" is designated by the US government as having "special responsibilities" to remain at their posts for the public good, which explicitly puts physicians in the same category as sewage workers and grocery store cashiers. Three, what does it mean to belong to a profession that does (or does not) have self-sacrifice and risk-taking as part of its mission—especially a profession that rarely gets called upon to practice these obligations?

Patrick D. Hopkins

Viral Heroism: What the Rhetoric of Heroes in the COVID-19 Pandemic Tells Us About Medicine and Professional Identity

病毒英雄主义：新冠疫情中英雄修辞对医学与职业身份的启示

Responding to a major pandemic and planning for allocation of scarce resources (ASR) under crisis standards of care requires coordination and cooperation across federal, state and local governments in tandem with the larger societal infrastructure. Maryland remains one of the few states with no state-endorsed ASR plan, despite having a plan published in 2017 that was informed by public forums across the state. In this article, we review strengths and weaknesses of Maryland's response to COVID-19 and the role of the Maryland Healthcare Ethics Committee Network (MHECN) in bridging gaps in the state's response to prepare health care facilities for potential implementation of ASR plans. Identified "lessons learned" include: Deliberative Democracy Provided a Strong Foundation for Maryland's ASR Framework; Community Consensus is Informative, Not Normative; Hearing Community Voices Has Inherent Value; Lack of Transparency & Political Leadership Gaps Generate a Fragmented Response; Pandemic Politics Requires Diplomacy & Persistence; Strong Leadership is Needed to Avoid Implementing ASR … And to Plan for ASR; An Effective Pandemic Response Requires Coordination and Information-Sharing Beyond the Acute Care Hospital; and The Ability to Correct Course is Crucial: Reconsidering No-visitor Policies.

Norton Elson

Howard Gwon

Diane E. Hoffmann

Adam M. Kelmenson

Ahmed Khan

Joanne F. Kraus

Casmir C. Onyegwara

Gail Povar

Fatima Sheikh

Getting Real: The Maryland Healthcare Ethics Committee Network’s COVID-19 Working Group Debriefs Lessons Learned

真实面对：马里兰医疗伦理委员会网络COVID-19工作组反思经验教训

The Covid-19 pandemic has presented major challenges to society, exposing preexisting ethical weaknesses in the modern social fabric’s ability to respond. Distrust in government and a lessened authority of science to determine facts have both been exacerbated by the polarization and disinformation enhanced by social media. These have impaired society’s willingness to comply with and persevere with social distancing, which has been the most powerful initial response to mitigate the pandemic. These preexisting weaknesses also threaten the future acceptance of vaccination and contact tracing, two other tools needed to combat epidemics. Medical ethicists might best help in this situation by promoting truth-telling, encouraging the rational adjudication of facts, providing transparent decision-making and advocating the virtue of cooperation to maximize the common good. Those interventions should be aimed at the social level. The same elements of emphasizing cooperation and beneficence also apply to the design of triage protocols for when resources are overwhelmed. A life-stages approach increases beneficence and reduces harms. Triage should be kept as simple and straightforward as reasonably possible to avoid unwieldly application during a pandemic.

Kevin Powell

Christopher Meyers

Guidance for Medical Ethicists to Enhance Social Cooperation to Mitigate the Pandemic

医学伦理学家增强社会合作以缓解疫情的指导

Organ transplantation from living related donors in Bangladesh first began in October 1982, and became commonplace in 1988. Cornea transplantation from posthumous donors began in 1984 and living related liver and bone marrow donor transplantation began in 2010 and 2014 respectively. The Human Organ Transplantation Act officially came into effect in Bangladesh on 13th April 1999, allowing organ donation from both brain-dead and related living donors for transplantation. Before the legislation, religious leaders issued fatwa, or religious rulings, in favor of organ transplantation. The Act was amended by the Parliament on 8th January, 2018 with the changes coming into effect shortly afterwards on 28th January. However, aside from a few posthumous corneal donations, transplantation of vital organs, such as the kidney, liver, heart, pancreas, and other body parts or organs from deceased donors, has remained absent in Bangladesh. The major question addressed in this article is why the transplantation of vital organs from deceased donors is absent in Bangladesh. In addition to the collection of secondary documents, interviews were conducted with senior transplant physicians, patients and their relatives, and the public, to learn about posthumous organ donation for transplantation. Interviews were also conducted with a medical student and two grief counselors to understand the process of counseling the families and obtaining consent to obtain posthumous cornea donations from brain-dead patients. An interview was conducted with a professional anatomist to understand the processes behind body donation for the purposes of medical study and research. Their narrative reveals that transplant physicians may be reticent to declare brain death as the stipulations of the 1999 act were unclear and vague. This study finds that Bangladeshis have strong family ties and experience anxiety around permitting separating body parts of dead relatives for organ donation for transplantation, or donating the dead body for medical study and research purposes. Posthumous organ donation for transplantation is commonly viewed as a wrong deed from a religious point of view. Religious scholars who have been consulted by the government have approved posthumous organ donation for transplantation on the grounds of necessity to save lives even though violating the human body is generally forbidden in Islam. An assessment of the dynamics of biomedicine, religion and culture leads to the conclusion that barriers to posthumous organ donation for transplantation that are perceived to be religious may actually stem from cultural attitudes. The interplay of faith, belief, religion, social norms, rituals and wider cultural attitudes with biomedicine and posthumous organ donation and transplantation is very complex. Although overcoming the barriers to organ donation for transplantation is challenging, initiation of transplantation of vital organs from deceased donors is necessary within Bangladesh. This will ensure improved healthcare outcomes, prevent poor people from being coerced into selling their organs to rich recipients, and protect the solidarity and progeny of Bangladeshi families.

Md. Sanwar Siraj

Deceased Organ Transplantation in Bangladesh: The Dynamics of Bioethics, Religion and Culture

孟加拉国遗体器官移植：生物伦理、宗教与文化的动态

Multiple studies have been performed to identify the most common ethical dilemmas encountered by ethics consultation services. However, limited data exists comparing the content of ethics consultations requested by specific hospital specialties. It remains unclear whether the scope of ethical dilemmas prompting an ethics consultation differ between specialties and if there are types of ethics consultations that are more or less frequently called based on the specialty initiating the ethics consult. This study retrospectively assessed the incidence and content of ethics consultations called by surgical vs. non-surgical specialties between January 1, 2013 to December 31, 2018 using our RedCap Database and information collected through the EMR via our Clinical and Translational Science Center. 548 total ethics consultations were analyzed (surgical n = 135, non-surgical n = 413). Our results demonstrate that more surgical consults originated from the ICU, as opposed to lower acuity units (45.9% vs. 14.3%, p ≤ 0.001), and surgical patients were more likely to have a DNR in place (37.5% vs. 22.2%, p = 0.002). Surgical specialties were more likely to call about issues relating to withholding/withdrawing life-sustaining treatment (p ≤ 0.001), while non-surgical specialties were more likely to call about issues related to discharge planning (p = 0.001). There appear to be morally relevant differences between consults classified as the "same" that are not entirely captured by the usual ethics consultations classification system. In conclusion, this study highlights the unique ethical issues experienced by surgical vs. non-surgical specialties. Ultimately, our data can help ethics consultation services determine how best to educate various hospital specialties to approach ethical issues commonly experienced within their field.

Nicole A. Meredyth

Joseph J. Fins

Inmaculada de Melo-Martin

Ethics Consultation in Surgical Specialties

外科专科的伦理咨询

The novel coronavirus of 2019 exposed, in an undeniable way, the severity of racial inequities in America's healthcare system. As the urgency of the pandemic grew, administrators, clinicians, and ethicists became concerned with upholding the ethical principle of "most lives saved" by re-visiting crisis standards of care and triage protocols. Yet a colorblind, race-neutral approach to "most lives saved" is inherently inequitable because it reflects the normality and invisibility of 'whiteness' while simultaneously disregarding the burdens of 'Blackness'. As written, the crisis standards of care (CSC) adopted by States are racist policies because they contribute to a history that treats Black Americans are inherently less than. This paper will unpack the idealized fairness and equity pursued by CSC, while also considering the use of modified Sequential Organ Failure Assessment (mSOFA) as a measure of objective equality in the context of a healthcare system that is built on systemic racism and the potential dangers this can have on Black Americans with COVID-19.

Nneka O. Sederstrom

Jada Wiggleton-Little

Acknowledging the Burdens of ‘Blackness’

承认“黑人”的负担

HEC 论坛是一份经过同行评审的国际刊物，收录了执业医师、护士、社会工作者、风险管理人员、律师、伦理学家和其他 HEC 委员会成员感兴趣的原创贡献。欢迎来自任何相关来源的投稿，但应编写文本以供 HEC 成员和非专业读者欣赏。 HEC 论坛发表论文、研究论文，并包含以下部分： 关于实质性生物伦理/健康法问题的论文 程序或运营委员会问题的分析 文件交流 专题文章 国际视角 MT./ST.匿名：案例和机构政策 点/对位论证 案例审查、分析和决议 主席的“难点”部分 关键注释 卫生法警报 网络新闻 致编辑的信

HEC Forum is a peer-reviewed international journal that publishes original contributions of interest to practitioners such as physicians, nurses, social workers, risk managers, lawyers, ethicists, and other members of HEC committees. We welcome submissions from any relevant source, provided that the text is written in a manner accessible to HEC members and non-specialist readers. HEC Forum publishes papers, research articles, and includes the following sections: papers on substantive bioethics/health law issues, analyses of procedural or operational committee matters, document exchanges, thematic articles, international perspectives, anonymous discussions of cases and institutional policies, point/counterpoint arguments, case reviews, analyses and resolutions, the Chair's 

HEC Forum 是一本经过同行评审的国际期刊，专注于执业医师、护士、社会工作者、风险管理人员、律师、伦理学家及其他 HEC 委员会成员感兴趣的原创研究。我们欢迎来自任何相关领域的投稿，文章应以 HEC 成员和非专业读者能够理解的方式撰写。HEC Forum 发表各种类型的论文和研究，包括：关于重要生物伦理和健康法律问题的论文、程序或运营委员会问题的分析、文件交流、专题文章、国际视角、案例和机构政策的匿名讨论、对立论证、案例审查、分析和决议、主席的“难点”部分、关键注释、卫生法律警报、网络新闻及致编辑的信件。

Journals	HEC Forum
ISSN	0956-2737, 1572-8498
h-index	28
Journal Impact	1.39
Quartiles(Global)	ETHICS(Q3)
Quartiles(China)	哲学(4区)哲学伦理学(4区)