Moral failure, moral prudence, and character challenges in residential care during the Covid-19 pandemic

In many high-income countries, an initial response to the severe impact of Covid-19 on residential care was to shield residents from outside contacts. As the pandemic progressed, these measures have been increasingly questioned, given their detrimental impact on residents’ health and well-being and their dubious effectiveness. Many authorities have been hesitant in adapting visiting policies, often leaving nursing homes to act on their own safety and liability considerations. Against this backdrop, this article discusses the appropriateness of viewing the continuation of the practice of shielding as a moral failure. This is affirmed and specified in four dimensions: preventability of foreseeable harm, moral agency, moral character, and moral practice (in MacIntyre’s sense). Moral character is discussed in the context of prudent versus proportionate choices. As to moral practice, it will be shown that the continued practice of shielding no longer met the requirements of an (inherently moral) practice, as external goods such as security thinking and structural deficiencies prevented the pursuit of internal goods focusing on residents’ interests and welfare, which in many places has led to a loss of trust in these facilities. This specification of moral failure also allows a novel perspective on moral distress, which can be understood as the expression of the psychological impact of moral failure on moral agents. Conclusions are formulated about how pandemic events can be understood as character challenges for healthcare professionals within residential care, aimed at preserving the internal goods of residential care even under difficult circumstances, which is understood as a manifestation of moral resilience. Finally, the importance of moral and civic education of healthcare students is emphasized to facilitate students’ early identification as trusted members of a profession and a caring society, in order to reduce experiences of moral failure or improve the way to deal with it effectively

Clinical Ethics Consultation in Chronic Illness: Challenging Epistemic Injustice Through Epistemic Modesty

Leading paradigms of clinical ethics consultation closely follow a biomedical model of care. In this paper, we present a theoretical refection on the underlying biomedical model of disease, how it shaped clinical practices and patterns of ethical deliberation within these practices, and the repercussions it has on clinical ethics consultations for patients with chronic illness. We contend that this model, despite its important contribution to capturing the ethical issues of day-to-day clinical ethics deliberation, might not be sufcient for patients presenting with chronic illnesses and navigating as “lay experts” of their medical condition(s) through the health care system. Not fully considering the sources of personal knowledge and expertise may lead to epistemic injustice within an ethical deliberation logic narrowly relying on a biomedical model of disease. In caring “for” and collaboratively “with” this patient population, we answer the threat of epistemic injustice with epistemic modesty and humility. We will propose ideas about how clinical ethics could contribute to an expansion of the biomedical model of care, so that important aspects of chronic illness experience would fow into clinical-ethical decision-making

Konzeptionen von Simulationen mit Simulationspersonen für die Medizinethik-Lehre

Simulationen mit Simulationspersonen (Schauspieler*innen) gehören in der medizinischen Lehre zum Ausbildungs-Standard. In der medizinethischen Lehre ist dies bisher nicht in gleichem Umfang der Fall. Für ihren Einsatz, insbesondere in der klinischen Ethik, können gute Gründe angeführt werden, wie beispielsweise die Möglichkeit konkreter Erfahrungen als Lehrelement und die situationsspezifische Verbindung von Wissen, Können und Haltungen in einem Lernprozess. Die Konzeption von Simulationen mit Simulationspersonen in der medizinethischen Lehre ist jedoch voraussetzungsreich. Es müssen die mehrdimensionalen Lernziele und die Anforderungen an die medizinethische Lehre berücksichtigt werden. Der Beitrag möchte anhand eines konkreten Beispiels einen Überblick über die Entwicklung und Konzeption von Drehbüchern bzw. Rollen-Skripten für Simulationen mit Simulationspersonen für die Lehre in der klinischen Ethik als wichtigem Teilbereich der Medizinethik geben. Dabei wird auf die besonderen Voraussetzungen und Spezifika dieser Simulationen eingegangen. Abschließend wird kritisch diskutiert, welchen Stellenwert das Training von kommunikativen Fertigkeiten in der medizinethischen Theorie und klinisch-ethischen Praxis haben kann und soll. Der Beitrag schließt mit der Überlegung, ob nicht auch in der Fortbildung von klinischen Ethiker*innen Simulationspersonen zum Einsatz kommen sollten. Background: Although simulation-based learning using simulated patients (actors) is a standard part of training in medical school, it is not yet used to the same extent in the teaching of medical ethics. There are good reasons to use simulation-based teaching, especially in clinical ethics, to gain practical experience through the situation-specific combination of knowledge, skills, and attitudes in the learning process. However, there are certain prerequisites regarding the design of simulations with actors in medical ethics education. Topics: Using a concrete example, this article aims to provide an overview of the development and conception of simulation and role scripts for simulations with actors to teach clinical ethics, which is an important subfield of medical ethics. The special requirements and specifics of these simulations are addressed. Conclusion: Although there are some limitations with regard to integrating simulations into clinical ethics, simulation-based training of knowledge, skills, and attitudes can and should play a role in medical–ethical theory and clinical–ethical practice, not only for medical and nursing students but also in the further training of clinical ethicists

Ethics education in nursing—structural characteristics and didactical implications of nursing education

Die Pflegeausbildung weist die Besonderheit auf, dass die berufliche Bildung an unterschiedlichen Lernorten erfolgt. Die jeweils beteiligten Lernorte (Lernort Theorie, Lernort Praxis, zunehmend erweitert durch den dritten Lernort, das Skillslab) beeinflussen und fördern die Entwicklung der Ethikkompetenzen der angehenden Pflegfachpersonen – lernortspezifisch als auch lernortübergreifend – in unterschiedlicher Weise. Diese besonderen strukturellen Gegebenheiten des Lehrens und Lernens wirken sich sowohl auf die Ausgestaltung der Ethikbildung als auch auf die Förderung der Ethikkompetenzentwicklung im Ausbildungsverlauf aus. Die Ausführungen leitet die folgende Frage: Welche spezifischen pädagogischen und didaktischen Anforderungen, aber auch welche bildungsrelevanten Rahmungen ergeben sich angesichts der unterschiedlichen Lernorte für die Ethikbildung und die Ethikkompetenzentwicklung zukünftiger Pflegefachpersonen? Der Beitrag unterstreicht die Relevanz einer systematischen, methodisch reflektierten und lernortabgestimmten Ethikbildung im Bereich der Pflegeausbildung wie auch die Relevanz der bewussten Einbindung ethischer Reflexionsräume in die Prozesse der Ethikkompetenzentwicklung an den jeweiligen Lernorten. Die Besonderheiten der Ethikbildung erschließen sich hierbei aus den pflegeberuflichen Anforderungen an das professionelle Pflegehandeln und aus den Erfahrungen der Lernenden an den unterschiedlichen Lernorten im Verlauf der Pflegeausbildung.Background: A special characteristic of nursing education is that professional teaching takes place in various locations. The learning locations involved (such as learning in theory, learning in clinical practice, or learning in third facilities, which are becoming increasingly popular, such as the skills lab) have an impact on and promote the development of ethical competences among prospective nursing professionals in various ways. Furthermore, it has become evident that the structural conditions that are specific to teaching and learning in nursing education programs shape the organization of ethics education and the promotion of ethical competence development among nurse trainees over the course of their education. Objectives: The aim of this article is to discuss the following key question: What are the specific pedagogical and didactical requirements and educational frameworks that arise in view of the various learning locations in nursing education in order to facilitate ethics education and ethical competence development among prospective nursing professionals? Discussion: This article emphasises the importance of a systematic, methodically reflected and learning-location-coordinated approach to ethics education in the field of nursing education. Moreover, it highlights the relevance of the conscious promotion of settings for ethical reflection within the process of ethical competence development in the different locations of learning. The unique quality of ethics education in nursing emerges from the professional requirements that are characteristic to nursing care and the individual experiences of trainees at the various locations of learning throughout their nursing education progra

Informal coercion during childbirth: risk factors and prevalence estimates from a nationwide survey of women in Switzerland

Background: In many countries, the increase in facility births is accompanied by a high rate of obstetric interventions. Lower birthrates or elevated risk factors such as women’s higher age at childbirth and an increased need for control and security cannot entirely explain this rise in obstetric interventions. Another possible factor is that women are coerced to agree to interventions, but the prevalence of coercive interventions in Switzerland is unknown. Methods: In a nationwide cross-sectional online survey, we assessed the prevalence of informal coercion during childbirth, women’s satisfaction with childbirth, and the prevalence of women at risk of postpartum depression. Women aged 18 years or older who had given birth in Switzerland within the previous 12 months were recruited online through Facebook ads or through various offline channels. We used multivariable logistic regression to estimate the risk ratios associated with multiple individual and contextual factors. Results: In total, 6054 women completed the questionnaire (a dropout rate of 16.2%). An estimated 26.7% of women experienced some form of informal coercion during childbirth. As compared to vaginal delivery, cesarean section (CS) and instrumental vaginal birth were associated with an increased risk of informal coercion (planned CS risk ratio [RR]: 1.52, 95% confidence interval [1.18,1.96]; unplanned CS RR: 1.92 [1.61,2.28]; emergency CS RR: 2.10 [1.71,2.58]; instrumental vaginal birth RR: 2.17 [1.85,2.55]). Additionally, migrant women (RR: 1.45 [1.26,1.66]) and women for whom a self-determined vaginal birth was more important (RR: 1.15 [1.06,1.24]) more often reported informal coercion. Emergency cesarean section (RR: 1.32 [1.08,1.62]), being transferred to hospital (RR: 1.33 [1.11, 1.60]), and experiencing informal coercion (RR: 1.35 [1.19,1.54]) were all associated with a higher risk of postpartum depression. Finally, women who had a non-instrumental vaginal birth reported higher satisfaction with childbirth while women who experienced informal coercion reported lower satisfaction. Conclusions: One in four women experience informal coercion during childbirth, and this experience is associated with a higher risk of postpartum depression and lower satisfaction with childbirth. To prevent traumatic after- effects, health care professionals should make every effort to prevent informal coercion and to ensure sensitive aftercare for all new mothers

‘We felt like part of a production system’: A qualitative study on women’s experiences of mistreatment during childbirth in Switzerland

Introduction Mistreatment during childbirth is an issue of global magnitude that not only violates fundamental human rights but also seriously impacts women’s well-being. The purpose of this study was to gain a better understanding of the phenomenon by exploring the individual experiences of women who reported mistreatment during childbirth in Switzerland. Materials and methods This project used a mixed methods approach to investigate women’s experiences of mistreatment during childbirth in general and informal coercion specifically: The present qualitative study expands on the findings from a nationwide online survey on childbirth experience. It combines inductive with theoretical thematic analysis to study the 7,753 comments women wrote in the survey and the subsequent interviews with 11 women who reported being mistreated during childbirth. Results The women described a wide range of experiences of mistreatment during childbirth in both the survey comments and the interviews. Out of all survey participants who wrote at least one comment (n = 3,547), 28% described one or more experiences of mistreatment. Six of the seven types of mistreatment listed in Bohren and colleagues’ typology of mistreatment during childbirth were found, the most frequent of which were ineffective communication and lack of informed consent. Five additional themes were identified in the interviews: Informal coercion, risk factors for mistreatment, consequences of mistreatment, examples of good care, and what’s needed to improve maternity care. Conclusion The findings from this study show that experiences of mistreatment are a reality in Swiss maternity care and give insight into women’s individual experiences as well as how these affect them during and after childbirth. This study emphasises the need to respect women’s autonomy in order to prevent mistreatment and empower women to actively participate in decisions. Both individual and systemic efforts are required to prevent mistreatment and guarantee respectful, dignified, and high-quality maternity care for all