Eudaimonia and well-being : Questioning the moral authority of advance directives in dementia

This paper revisits Ronald Dworkin’s influential position that a person’s advance directive for future health care and medical treatment retains its moral authority beyond the onset of dementia, even when respecting this authority involves foreshortening the life of someone who is happy and content and who no longer remembers or identifies with instructions included within the advance directive. The analysis distils a eudaimonist perspective from Dworkin’s argument and traces variations of this perspective in further arguments for the moral authority of advance directives by other authors. It then critiques a feature of the eudaimonist perspectives within these arguments—namely, the position that dementia has a retroactive negative impact on what a person has previously valued—and challenges the commonly held assumption underlying them that a person’s life and well-being have relatively low value beyond the onset of dementia. Although advance directives have moral authority as a means of guiding one’s future health care, accounts that dismiss the value of the lives and well-being of people living with dementia should be questioned to the extent that such accounts are used to support the moral authority of advance directives stipulating measures to foreshorten individuals’ lives

Dependence and a Kantian conception of dignity as a value

Kantian moral concepts concerning respect for human dignity have played a central role in articulating ethical guidelines for medical practice and research, and for articulating some central positions within bioethical debates more generally. The most common of these Kantian moral concepts is the obligation to respect the dignity of patients and of human research subjects as autonomous, self-determining individuals. This article describes Kant’s conceptual distinction between dignity and autonomy as values, and draws on the work of several contemporary Kantian philosophers who employ the distinction to make sense of some common moral intuitions, feelings, and norms. Drawing on this work, the article argues that the conceptual distinction between dignity and autonomy as values is indispensable in the context of considering our obligations to those who are dependent and vulnerable

Preparing students for an international career : the case for contextualizing and integrating ethics education

A key aim of IFAC (International Federation of Accountants)'s International Education Standard 4 (IES4) is to raise the ethical awareness of candidates preparing for careers as accounting professionals. This paper reports the results of a survey of undergraduate accounting students at an Australian university, and develops an approach for the implementation of IES4 in business schools with culturally diverse student populations. The survey asks students at different stages of their programs about the contribution of tertiary education to their ethical ideas, drawing conclusions based on their culture, year of study, career intentions, age and gender. It then suggests ways of teaching ethics that value and integrate students' diverse experiences and cultural backgrounds, as well as their existing knowledge. Such initiatives could expand the horizons of students from all cultural backgrounds by increasing their cultural sensitivity and awareness of ethics as an issue of relevance to their professional careers.12 page(s

Engaging staff in curriculum change : reflections from an accounting ethics initiative

This paper identifies the challenges associated with engaging staff in curriculum change, using the context of systematic inclusion of ethics in the accounting curriculum of a major Australian metropolitan university, and offers some suggestions as to how these challenges might be overcome. We characterize the inclusion of ethics in the accounting curriculum as ‘pluri-disciplinary’ following the typology of Davies and Devlin (2007) and draw on 22 interviews with accounting academics to examine curriculum change in a pluri-disciplinary context. We find that key staff concerns are the impact on broader accounting discourse, assignment of teaching responsibilities, curriculum content, and identification of who is ultimately responsible for the curriculum change. The responses indicate that staff would like to be equipped to confidently deliver ethics content and to have material relevant to a technically-focused student cohort. One means of achieving this might be to involve ethics experts in developing and delivering foundational material early in the curriculum and having accounting staff teach applications of this material in the latter stages. Our observations might also be of interest to those seeking to embed other ‘soft’ skills (such as communication, critical thinking and sustainability) within a technical curriculum.7 page(s

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31â127 anaesthetic procedures in 30â874 children with a mean age of 6·35 years (SD 4·50) were included. The incidence of perioperative severe critical events was 5·2% (95% CI 5·0â5·5) with an incidence of respiratory critical events of 3·1% (2·9â3·3). Cardiovascular instability occurred in 1·9% (1·7â2·1), with an immediate poor outcome in 5·4% (3·7â7·5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10â000. This was independent of type of anaesthesia. Age (relative risk 0·88, 95% CI 0·86â0·90; p<0·0001), medical history, and physical condition (1·60, 1·40â1·82; p<0·0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0·99, 0·981â0·997; p<0·0048 for respiratory critical events, and 0·98, 0·97â0·99; p=0·0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia. Funding European Society of Anaesthesiology

Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe

Background Little is known about the incidence of severe critical events in children undergoing general anaesthesia in Europe. We aimed to identify the incidence, nature, and outcome of severe critical events in children undergoing anaesthesia, and the associated potential risk factors. Methods The APRICOT study was a prospective observational multicentre cohort study of children from birth to 15 years of age undergoing elective or urgent anaesthesia for diagnostic or surgical procedures. Children were eligible for inclusion during a 2-week period determined prospectively by each centre. There were 261 participating centres across 33 European countries. The primary endpoint was the occurence of perioperative severe critical events requiring immediate intervention. A severe critical event was defined as the occurrence of respiratory, cardiac, allergic, or neurological complications requiring immediate intervention and that led (or could have led) to major disability or death. This study is registered with ClinicalTrials.gov, number NCT01878760. Findings Between April 1, 2014, and Jan 31, 2015, 31 127 anaesthetic procedures in 30 874 children with a mean age of 6.35 years (SD 4.50) were included. The incidence of perioperative severe critical events was 5.2% (95% CI 5.0-5.5) with an incidence of respiratory critical events of 3.1% (2.9-3.3). Cardiovascular instability occurred in 1.9% (1.7-2.1), with an immediate poor outcome in 5.4% (3.7-7.5) of these cases. The all-cause 30-day in-hospital mortality rate was 10 in 10 000. This was independent of type of anaesthesia. Age (relative risk 0.88, 95% CI 0.86-0.90; p<0.0001), medical history, and physical condition (1.60, 1.40-1.82; p<0.0001) were the major risk factors for a serious critical event. Multivariate analysis revealed evidence for the beneficial effect of years of experience of the most senior anaesthesia team member (0.99, 0.981-0.997; p<0.0048 for respiratory critical events, and 0.98, 0.97-0.99; p=0.0039 for cardiovascular critical events), rather than the type of health institution or providers. Interpretation This study highlights a relatively high rate of severe critical events during the anaesthesia management of children for surgical or diagnostic procedures in Europe, and a large variability in the practice of paediatric anaesthesia. These findings are substantial enough to warrant attention from national, regional, and specialist societies to target education of anaesthesiologists and their teams and implement strategies for quality improvement in paediatric anaesthesia