Development Role And Methodologies

Formal efforts to address clinical ethics first developed in the United States and Canada, though similar efforts are clearly underway in western and central Europe and Japan. Indeed, interest in clinical ethics has spread to many areas of the world, including parts of Central and South America, eastern Europe, and parts of Africa. Though variously defined, clinical ethics involves the identification, analysis, and resolution of value conflicts or uncertainties that arise in the provision of healthcare in clinical settings (Fletcher and Boyle; Jonsen, Siegler, and Winslade). Clinical ethics activities include examination or formulation of relevant policies, ethics education, and ethics consultation to healthcare professionals, patients, families, surrogates, or organizations. Unlike some solely academic domains of the broader field of bioethics, clinical ethics must take into account the actual context in which clinical ethical issues arise because it aims to make contributions to clinical practice and to policy governing clinical practice. This context includes complex psychosocial, medical, legal, cultural, and political dimensions that have implications both for the types of ethical issues that arise and how those issues may be resolved (Aulisio, Arnold, and Youngner, 2000, 2003; May).

Traditionally, clinical ethics discussions tended to focus on issues related to informed consent, confidentiality and privacy, decision capacity or competence, decision making involving minors, resource allocation, and end-of-life care. Though these issues remain central to clinical ethics, the mid-1990s through early 2000s saw a growing recognition of the important relationship between clinical, organizational, and business ethics (Schyve et al.), along with the development of a number of new areas of concern, including physician-assisted suicide (Battin, Rhodes, and Silvers), palliative care (Barnard et al.), medical mistakes (Rubin and Zoloth; Institute ofMedicine), ethics and genetics (Juengst), and even bioterrorism (Gostin).

The typical mechanism for addressing issues in clinical ethics in most healthcare institutions is an ethics committee. Ethics committees are present in most hospital settings in the United States and Canada, and increasingly in other settings, such as long-term care, as well. In some clinical settings, most often academic medical centers, ethics committees are part of a much larger clinical ethics program. Such programs are commonly staffed by full-time ethicists who are responsible for ethics education, service, and research.

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