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

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

La concettualizzazione dell'assistenza infermieristica nella letteratura italiana: un'analisi integrativa a supporto dello sviluppo di una teoria

Introduction: Nursing theories are essential for orienting nursing practice. To date, three models for nursing practice have been developed in Italy. In addition, significant epistemological reflections have been published, sparking a rich professional debate regarding the theoretical foundations of nursing in Italy. However, conceptual models from other countries are often still used, despite many difficulties associated with applying them in practice. In order to investigate and redress this ‘theoretical gap’ and related implications for intervention, three scoping reviews of the Italian nursing literature were conducted to examine three categories of nursing knowledge: (a) nursing practice in Italy; (b) the basic nursing concepts of person, health, environment and nursing; and (c) regulatory/normative statements regarding what nursing practice should be in Italy. Objective: The purpose of this investigation was to identify how nursing is conceptualized in the Italian literature through an integrative narrative analysis of three scoping reviews. Methods: The Scoping Review according to the recommendations published by Arksey and O'Malley and subsequently implemented by Levac et al. has been selected as the optimal methodology for mapping nursing knowledge. At the end of the reviews carried out to answer the three research questions, the researchers integrated the results by conducting a coding of the results. Results: The narrative synthesis highlighted a systemic conception of persons in their social context, ‘incorporated’ within relational systems. Persons are imagined as active agents with self-determination toward promoting their own health. Health, derived from levels of equilibrium between multiple systemic components and based on the person's holistic view, is a fundamental right and a collective social interest. Maintaining or promoting a person’s health requires careful consideration of all these constitutive and integral elements. The nursing process is implemented through technical acts as well as relational and caring skills. Professional autonomy, influenced by clinical and organizational contexts, is expressed in collaboration with other professionals who contribute to the healthcare process. The results of this integrative narrative analysis suggest the need for a holistic vision of persons, with an active role in their health management, indissociable from the system of relationships in which this is contextualized, within which nurses are embedded. Conclusion: In light of the results of our investigation, the promotion of a conceptualization of nursing based on the centrality of the person-social relational system and on the active role of persons that nurses work with, this could guide approaches used in nursing education and administration. This could help enhance care provided by nurses and persons' participation in decisions regarding their own health. Keywords: nursing theory, nursing discipline, review, metaparadigm Introduzione: Le teorie infermieristiche costituiscono un riferimento imprescindibile per la prassi infermieristica. In Italia sono stati elaborati e proposti tre modelli professionali italiani. Oltre ad essi, il dibattito professionale si è arricchito anche di significative riflessioni di tipo epistemologico. Tuttavia, ancora oggi risultano essere spesso adottati modelli concettuali provenienti da altri Paesi con la difficoltà del loro utilizzo nella prassi infermieristica. Allo scopo di studiare e approfondire “questo divario teorico” e le possibili linee di intervento sono state realizzate tre revisioni della produzione scientifica infermieristica italiana su tre categorie di conoscenze infermieristiche: la pratica infermieristica in Italia, i concetti fondanti di persona, salute, ambiente e assistenza e tutte le dichiarazioni normative riguardo a cosa dovrebbe essere in Italia la pratica infermieristica. Obiettivo: Lo scopo di questo studio è la produzione di una sintesi narrativa che identifica la concezione di infermieristica nella letteratura italiana attraverso un’analisi integrativa di scoping reviews. Metodi: La Scoping Review secondo le raccomandazioni pubblicate da Arksey and O’Malley e successivamente implementate da Levac et al. è stata selezionata come la metodologia ottimale per eseguire la mappatura delle conoscenze infermieristiche. Al termine delle revisioni realizzate per rispondere alle tre domande di ricerca, i ricercatori hanno integrato i risultati conducendo una codifica dei risultati. Risultati: La sintesi narrativa ha evidenziato una concezione sistemica di base riguardante le persone nel loro contesto sociale, “incorporate” nei sistemi di relazioni. La persona è identificata come agente attivo nell'autoderminazione della salute. La salute derivante da livelli di equilibrio tra più componenti sistemiche e basata sulla visione olistica della persona è un bene fondamentale e un interesse sociale collettivo. Mantenere o promuovere la salute della persona richiede un'attenta considerazione di tutti quelli elementi che ne sono parte costituiva e integrante. La processualità dell'assistenza è messa in atto attraverso atti di natura tecnica e attraverso competenze relazionali e di caring. L'autonomia professionale, influenzata dai contesti clinici e organizzativi si esprime anche nella collaborazione con gli altri professionisti che contribuiscono alla realizzazione del processo di cura. I risultati di questa analisi integrativa suggeriscono la necessità di una visione olistica della persona, del suo ruolo attivo nella gestione della salute e della sua inscindibilità dal sistema di relazioni in cui questa è contestualizzata e del quale l’infermiere entra a far parte. Conclusione: Alla luce dei risultati del nostro studio, la promozione di una concezione di assistenza infermieristica basata sulla centralità dell’intero sistema persona-relazioni sociali e sul ruolo attivo della persona assistita potrebbero orientare sia i processi formativi sia le amministrazioni infermieristiche così da consentire e valorizzare la presa in carico globale da parte dei professionisti infermieri e la partecipazione della persona alla presa di decisioni riguardanti la propria salute