The moral malaises of modern pediatric medicine

Le cadre éthique dominant en médecine pédiatrique est intrinsèquement problématique, car des considérations morales importantes y restent dissimulées. Ce problème correspond bien au déplacement des malaises moraux dans la modernité énoncés par Charles Taylor. En nous référant à Taylor, nous soutenons que la médecine pédiatrique contemporaine et la bioéthique reflètent la théorie morale moderne centrée sur des procédures décisionnelles, sans considération explicite des fondements moraux de telles procédures. L'objectif de cette thèse est d'examiner les préoccupations morales de la médecine pédiatrique contemporaine grâce au cadre philosophique développé par Taylor. Le travail de Taylor a orienté cette recherche (a) méthodologiquement, car sa conception de l'herméneutique a servi de cadre d'analyse ; et (b) substantivement, car son analyse de la modernité et de la théorie morale a été une référence indispensable. La philosophie herméneutique de Taylor ainsi que son analyse de la modernité sont examinés afin de retracer les horizons de signification et les imaginaires sociaux dans lesquels la médecine pédiatrique est née et s’est attachée à des orientations morales particulières. Cette approche montre que la médecine pédiatrique apparaît 1) d’abord lorsque les intérêts économiques et militaires de l'Etat le conduisent à valoriser la santé des enfants, 2) ensuite lorsque apparaît une orientation éthique mettant l’accent sur l'enfant lui-même selon le critère du meilleur intérêt de l’enfant. Trois malaises moraux ont été identifiés dans la médecine pédiatrique moderne: (a) la convergence du droit et de l'éthique; (b) la conception des enfants comme étant incapables et dépendants ; et (c) la nature ambiguë du concept du meilleur intérêt. Nous examinons ces malaises afin de révéler les horizons de signification et les imaginaires sociaux qui leur ont donné naissance. Un cadre taylorien est également proposé afin d’enrichir la pratique bioéthique pédiatrique actuelle – la récupération et le rapprochement herméneutiques – permettant ainsi l’accordage interprétatif et la réconciliation des considérations morales dissimulées dans le cadre éthique courant. Les implications à l’égard de la recherche ainsi que la pratique et la formation en pédiatrie sont présentées.The dominant ethical framework in pediatric medicine is inherently problematic because important moral considerations are concealed. This problem is congruent with the displacement of moral malaises in modernity articulated by Charles Taylor. Drawing on Taylor’s work, I argue that contemporary pediatric medicine and bioethics are reflective of modern moral theory, which is centered on decisional procedures without explicit regard for the substantive moral grounds that such procedures should relate to. The goal of this thesis is to examine moral concerns in contemporary pediatric medicine through Taylor’s philosophical work. Taylor’s ideas oriented this examination (a) methodologically, as his conception of hermeneutics served as the analytical framework, and (b) substantively, by drawing on his analysis of modernity and moral theory. Taylor’s hermeneutical philosophy as well as his examination of modernity are reviewed to provide a philosophical framework for tracing the horizons of significance and social imaginaries within which pediatric medicine emerged and became aligned with particular moral orientations. An operational explicitation of Taylor’s hermeneutical approach was developed to examine (a) the early history of pediatric medicine as children’s health became valued in light of state and societal economic and military interests and (b) the emergence and ongoing development of the best interests standard, a more child-centered ethical orientation. Three moral malaises in modern pediatric medicine were identified: (a) the convergence of law and ethics; (b) the construal of children as incapable and dependent; and (c) the ambiguous nature of best interests. These malaises were examined to the retrieve the background horizons of significance and social imaginaries against which they were shaped. Moreover, a Taylorian framework for the practice of pediatric bioethics is proposed - hermeneutical retrieval and rapprochement - to enrich pediatric practice through interpretive attunement and reconciliation of concealed moral considerations. The implications for future research as well as pediatric practice and education are outlined

The Palliation of Dying: A Heideggerian Analysis of the “Technologization” of Death

The modern West has vigorously sought to overcome death, or at the very least minimize the suffering that it entails. Whereas the former has been predominantly pursued through modern scientific medicine, the minimization of the adversity of death and dying has been sought through ‘death technologies’. This technologization of death is analyzed in light of Martin Heidegger’s phenomenological philosophy. The analysis begins with an outline of the fundamental tenets of Heidegger’s ‘philosophy of Being’. In turn, his philosophical framework is utilized to highlight the manner in which the technologization of dying serves to conceal the central existential questions about being and finitude that dying gives rise to. The paper concludes with a discussion of how Heidegger’s work can inspire a more authentic stance toward dying. Leo Tolstoy’s The Death of Ivan Ilych is referred to in order to illustrate Heidegger’s construal of this existential struggle toward dying. Indo-Pacific Journal of Phenomenology, Volume 5, Edition 1 April 200

Correctional nursing in Liguria, Italy: Examining the ethical challenges

IntroductionCorrectional nursing can involve significant ethical difficulties. This study examined ethical challenges encountered by correctional nurses in the Italian region of Liguria. Empirical data were analyzed in relation to relevant ethical standards. The former involved a study of 75 nurses and managers in the Ligurian correctional system, while the latter involved an analysis of the Italian Code of Ethics for Nurses and related standards for correctional practice. MethodsQuantitative and qualitative methods were used for the empirical study. Questionnaires were administered to collect data on participants’ characteristics and care settings. The Measure of Job Satisfaction (MJS) was also administered. Five focus groups were conducted. ResultsQuantitative Data: Respondents identified factors that mostly impacted on recruitment and retention. Unfavourable factors included: structural, organizational, and relational factors. Favourable factors included: nursing consultation, continuing education activities, and peer support. MJS results were equal to ‘unsatisfied’.Qualitative Data: Five themes were identified through thematic analysis of focus group data: Health needs of incarcerated persons; Negotiation of the boundaries between care and custody; Job satisfaction related to nursing in a correctional setting; Barriers to providing good care; and Security needs. Ten categories of norms were identified in the Code as areas of ethical standards relevant for the empirical data. ConclusionsOur empirical findings demonstrate that these nursing standards can be systematically compromised in correctional settings. Nurses feel compelled to provide ethically-problematic nursing services, with situations of moral distress. This research informs the development of needed policy, educational, and practice changes for nurses in correctional settings

Developing population interventions with migrant women for maternal-child health: a focused ethnography

BACKGROUND: Literature describing effective population interventions related to the pregnancy, birth, and post-birth care of international migrants, as defined by them, is scant. Hence, we sought to determine: 1) what processes are used by migrant women to respond to maternal-child health and psychosocial concerns during the early months and years after birth; 2) which of these enhance or impede their resiliency; and 3) which population interventions they suggest best respond to these concerns. METHODS: Sixteen international migrant women living in Montreal or Toronto who had been identified in a previous study as having a high psychosocial-risk profile and subsequently classified as vulnerable or resilient based on indicators of mental health were recruited. Focused ethnography including in-depth interviews and participant observations were conducted. Data were analyzed thematically and as an integrated whole. RESULTS: Migrant women drew on a wide range of coping strategies and resources to respond to maternal-child health and psychosocial concerns. Resilient and vulnerable mothers differed in their use of certain coping strategies. Social inclusion was identified as an overarching factor for enhancing resiliency by all study participants. Social processes and corresponding facilitators relating to social inclusion were identified by participants, with more social processes identified by the vulnerable group. Several interventions related to services were described which varied in type and quality; these were generally found to be effective. Participants identified several categories of interventions which they had used or would have liked to use and recommended improvements for and creation of some programs. The social determinants of health categories within which their suggestions fell included: income and social status, social support network, education, personal health practices and coping skills, healthy child development, and health services. Within each of these, the most common suggestions were related to creating supportive environments and building healthy public policy. CONCLUSIONS: A wealth of data was provided by participants on factors and processes related to the maternal-child health care of international migrants and associated population interventions. Our results offer a challenge to key stakeholders to improve existing interventions and create new ones based on the experiences and views of international migrant women themselves

Understanding the Private Worlds of Physicians, Nurses, and Parents: A Study of Life-Sustaining Treatment Decisions in Italian Paediatric Critical Care

This study's aim was to describe: (a) How life-sustaining treatment (LST) decisions are made for critically ill children in Italy; and (b) How these decisional processes are experienced by physicians, nurses and parents. Focus groups with 16 physicians and 26 nurses, and individual interviews with 9 parents were conducted. Findings uncovered the 'private worlds' of paediatric intensive care unit (PICU) physicians, nurses and parents; they all suffer tremendously and privately. Physicians struggle with the weight of responsibility and solitude in making LST decisions. Nurses struggle with feelings of exclusion from decisions regarding patients and families that they care for. Physicians and nurses are distressed by legal barriers to LST withdrawal. Parents struggle with their dependence on physicians and nurses to provide care for their child and strive to understand what is happening to their child. Features of helpful and unhelpful communication with parents are highlighted, which should be considered in educational and practice changes

The Point of View of Undergraduate Health Students on Interprofessional Collaboration: A Thematic Analysis

Interprofessional education (IPE) is essential to prepare future professionals for interprofessional collaboration (IPC). Learning together is essential for students because it is a way to understand the roles of other colleagues, improve their skills, knowledge, competencies, and attitudes to collaborate with the interprofessional teams. To explore how undergraduate students who attend IPE courses define IPC, a qualitative study using semistructured interviews followed by a thematic analysis was performed. Four main themes were identifed: IPC as a resource, requirements for IPC, emotions linked to IPC, and tutor\u2019s role to facilitate students\u2019 perception of IPC. Students considered IPE important to build IPC, where clinical placement tutors play a key role. The most important findings of the present study include the students\u2019 considerations about the importance of IPE when building their IPC definition and the key role played by the tutor during the placement in building IPC in clinical practic

Ethical challenges for children undergoing surgery: Evaluation of graduate nursing students' learning

Background Multiple barriers can impede the holistic care of children and their meaningful involvement in their healthcare in the context of surgery. These include lack of clinician knowledge of the ethical concerns impacting children and scarce educational resources. Our team created an open-access training module (https://childsxethics.net) to enhance clinicians’ understanding of ethical challenges for children undergoing surgery.  Objective To evaluate the level of Bloom’s Taxonomy cognitive, affective, and psychomotor learning reached by graduate nursing students after completing the module.  Methods A qualitative descriptive study was conducted. Data sources comprised of participants’ course assignments. Data were analysed inductively and deductively using Bloom’s Taxonomy and the Childhood Ethics Framework. Results Nineteen participants wrote online reflections and peer responses. Two subgroups completed group assignments. The module and associated class assignments successfully promoted high levels of cognitive and affective learning of ethical challenges impacting children undergoing surgery. The type of assignment influenced participants’ level of learning and achievement of learning objectives. Cognitive and affective learning processes were enhanced when integrating reflections and fostering dialogue/interaction among peer learners.  Implications Study findings will be used to improve the module. Future iterations will include collaborations with international clinicians to enhance the global relevance of the module contents, which will be evaluated with other clinicians/trainees. Providing educational resources for clinicians on ethical challenges in children’s surgery will help facilitate the recognition of children as active moral agents and improve their surgical experiences by promoting holistic patient care

Análise normativa sobre a voz da criança na legislação brasileira de proteção à infância

Objetivo: Identificar e analisar, no discurso normativo de proteção à infância no Brasil, marcas das vozes da criança na tomada de decisão sobre seus cuidados em saúde.Método: Análise normativa da legislação de proteção à infância no Brasil (1988-2012), operacionalizada pela análise de conteúdo de nove textos, no ano de 2015.Resultados: A legislação destaca a voz da criança no processo decisório, tanto na pesquisa como nos cuidados em saúde. O reconhecimento do direito a dignidade e liberdade, informação e proteção depende do julgamento do adulto sobre a capacidade de discernimento da criança e se a situação a isenta de danos para si mesma.Conclusões: O discurso normativo de proteção à infância confere voz à criança, mas com restrição e sob a tutela do adulto.Palavras-chave: Criança. Defesa da criança e do adolescente. Participação do paciente. Tomada de decisões

Participação em programa de intercâmbio internacional: contribuições da experiência de graduação-sanduíche em enfermagem

http://dx.doi.org/10.5902/217976927922Aim: to describe the experience of a Nursing Undergraduate student in an international exchange program in Canada. Methodo: The exchange happened through the awarding of a scholarship from the Brazilian government Science without Boarders Program, between the Federal University of Santa Maria/RS/Brazil and McGill University, in Montreal/Quebec/Canada. It was conducted from march to august 2012, with Graduate and Undergraduate Programs in diverse fields of child and adolescent health. Results: activities in research groups, courses, lectures and research projects focused on palliative care, bioethics and qualitative approaches in research. Final Considerations: This experience enabled academic, personal and social development, as well as the beginning of constructing a research network, contributing to exchange among researchers and the process of internationalization of Nursing.Objetivo: describir la experiencia de estudiante de grado en enfermería en el Programa de intercambio internacional en Canadá. Método: El intercambio se llevó a cabo a través de la concesión de la subvención del Programa Ciencia Sin Fronteras del gobierno brasileño, entre la Universidad Federal de Santa Maria/RS/Brasil y la Universidad McGill de Montreal/Quebec /Canadá. Se desarrolló entre marzo a agosto de 2012, junto con los Programas de Grado y Postgrado en diversos campos de la salud del niño y del adolescente. Resultados: actividades de inserción en equipo de investigación, disciplinas, cursos e pesquisas se han centrado en los cuidados paliativos, la bioética y la investigación cualitativa. Consideraciones Finales: esta experiencia ha permitido el desarrollo académico, personal y social, así como el principio de tejer una red de investigación, lo que contribuye al intercambio entre los investigadores y el proceso de internacionalización del Curso de Enfermería.http://dx.doi.org/10.5902/217976927922Objetivo: descrever a experiência de estudante de graduação de Enfermagem em Programa de intercâmbio internacional no Canadá. Método: O intercâmbio deu-se por meio de concessão de bolsa do Programa Ciência Sem Fronteiras do governo brasileiro, entre a Universidade Federal de Santa Maria/RS/Brasil e a McGill University, em Montreal/Quebec/Canadá. Foi desenvolvido no período de março a agosto de 2012, junto aos Programas de Graduação e de Pós-Graduação em diversos campos da saúde da criança e do adolescente. Resultados: atividades de inserção em grupo de pesquisa, disciplinas, cursos e projetos de pesquisa tiveram foco em cuidados paliativos, bioética e abordagem qualitativa de pesquisa. Considerações Finais: Essa vivência possibilitou o desenvolvimento acadêmico, pessoal e social bem como o início da tessitura de uma rede de pesquisa, contribuindo para o intercâmbio entre pesquisadores e o processo de internacionalização do Curso de Enfermagem

Pediatric home mechanical ventilation: A Canadian Thoracic Society clinical practice guideline executive summary

Over the last 30 to 40 years, improvements in technology, as well as changing clinical practice regarding the appropriateness of long-term ventilation in patients with “non-curable” disorders, have resulted in increasing numbers of children surviving what were previously considered fatal conditions. This has come but at the expense of requiring ongoing, long-term prolonged mechanical ventilation (both invasive and noninvasive). Although there are many publications pertaining to specific aspects of home mechanical ventilation (HMV) in children, there are few comprehensive guidelines that bring together all of the current literature. In 2011 the Canadian Thoracic Society HMV Guideline Committee published a review of the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. This current document is intended to be a companion to the 2011 guidelines, concentrating on the issues that are either unique to children on HMV (individuals under 18 years of age), or where common pediatric practice diverges significantly from that employed in adults on long-term home ventilation. As with the adult guidelines,1 this document provides a disease-specific review of illnesses associated with the necessity for long-term ventilation in children, including children with chronic lung disease, spinal muscle atrophy, muscular dystrophies, kyphoscoliosis, obesity hypoventilation syndrome, and central hypoventilation syndromes. It also covers important common themes such as airway clearance, the ethics of initiation of long-term ventilation in individuals unable to give consent, the process of transition to home and to adult centers, and the impact, both financial, as well as social, that this may have on the child\u27s families and caregivers. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information