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1.  Framing the Issues: Moral Distress in Health Care 
Hec Forum  2012;24(1):1-11.
Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care.
doi:10.1007/s10730-012-9176-y
PMCID: PMC3348467  PMID: 22446885
Moral distress; Healthcare; Ethical practice; Recruitment; Retention
2.  Outcomes of Moral Case Deliberation - the development of an evaluation instrument for clinical ethics support (the Euro-MCD) 
BMC Medical Ethics  2014;15:30.
Background
Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers’ experiences and perceived importance of outcomes of Moral Case Deliberation.
Methods
A multi-item instrument for assessing outcomes of Moral Case Deliberation (MCD) was constructed through an iterative process, founded on a literature review and modified through a multistep review by ethicists and health care providers. The instrument measures perceived importance of outcomes before and after MCD, as well as experienced outcomes during MCD and in daily work. A purposeful sample of 86 European participants contributed to a Delphi panel and content validity testing. The Delphi panel (n = 13), consisting of ethicists and ethics researchers, participated in three Delphi-rounds. Health care providers (n = 73) participated in the content validity testing through ‘think-aloud’ interviews and a method using Content Validity Index.
Results
The development process resulted in the European Moral Case Deliberation Outcomes Instrument (Euro-MCD), which consists of two sections, one to be completed before a participant’s first MCD and the other after completing multiple MCDs. The instrument contains a few open-ended questions and 26 specific items with a corresponding rating/response scale representing various MCD outcomes. The items were categorised into the following six domains: Enhanced emotional support, Enhanced collaboration, Improved moral reflexivity, Improved moral attitude, Improvement on organizational level and Concrete results.
Conclusions
A tentative instrument has been developed that seems to cover main outcomes of Moral Case Deliberation. The next step will be to test the Euro-MCD in a field study.
doi:10.1186/1472-6939-15-30
PMCID: PMC4234013  PMID: 24712735
Clinical ethics; Clinical ethics support; Ethics consultation; Moral case deliberation; Ethics rounds; Health care providers; Questionnaire; Instrument development; Evaluation
3.  Expanding Disease Definitions in Guidelines and Expert Panel Ties to Industry: A Cross-sectional Study of Common Conditions in the United States 
PLoS Medicine  2013;10(8):e1001500.
Background
Financial ties between health professionals and industry may unduly influence professional judgments and some researchers have suggested that widening disease definitions may be one driver of over-diagnosis, bringing potentially unnecessary labeling and harm. We aimed to identify guidelines in which disease definitions were changed, to assess whether any proposed changes would increase the numbers of individuals considered to have the disease, whether potential harms of expanding disease definitions were investigated, and the extent of members' industry ties.
Methods and Findings
We undertook a cross-sectional study of the most recent publication between 2000 and 2013 from national and international guideline panels making decisions about definitions or diagnostic criteria for common conditions in the United States. We assessed whether proposed changes widened or narrowed disease definitions, rationales offered, mention of potential harms of those changes, and the nature and extent of disclosed ties between members and pharmaceutical or device companies.
Of 16 publications on 14 common conditions, ten proposed changes widening and one narrowing definitions. For five, impact was unclear. Widening fell into three categories: creating “pre-disease”; lowering diagnostic thresholds; and proposing earlier or different diagnostic methods. Rationales included standardising diagnostic criteria and new evidence about risks for people previously considered to not have the disease. No publication included rigorous assessment of potential harms of proposed changes.
Among 14 panels with disclosures, the average proportion of members with industry ties was 75%. Twelve were chaired by people with ties. For members with ties, the median number of companies to which they had ties was seven. Companies with ties to the highest proportions of members were active in the relevant therapeutic area. Limitations arise from reliance on only disclosed ties, and exclusion of conditions too broad to enable analysis of single panel publications.
Conclusions
For the common conditions studied, a majority of panels proposed changes to disease definitions that increased the number of individuals considered to have the disease, none reported rigorous assessment of potential harms of that widening, and most had a majority of members disclosing financial ties to pharmaceutical companies.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Health professionals generally base their diagnosis of physical and mental disorders among their patients on disease definitions and diagnostic thresholds that are drawn up by expert panels and published as statements or as part of clinical practice guidelines. These disease definitions and diagnostic thresholds are reviewed and updated in response to changes in disease detection methods, treatments, medical knowledge, and, in the case of mental illness, changes in cultural norms. Sometimes, the review process widens disease definitions and lowers diagnostic thresholds. Such changes can be beneficial. For example, they might ensure that life-threatening conditions are diagnosed early when they are still treatable. But the widening of disease definitions can also lead to over-diagnosis—the diagnosis of a condition in a healthy individual that will never cause any symptoms and won't lead to an early death. Over-diagnosis can unnecessarily label people as ill, harm healthy individuals by exposing them to treatments they do not need, and waste resources that could be used to treat or prevent “genuine” illness.
Why Was This Study Done?
In recent years, evidence for widespread financial and non-financial ties between pharmaceutical companies and the health professionals involved in writing clinical practice guidelines has increased, and concern that these links may influence professional judgments has grown. As a result, a 2011 report from the US Institute of Medicine (IOM) recommended that, whenever possible, guideline developers should not have conflicts of interest, that a minority of the panel members involved in guideline development should have conflicts of interest, and that the chairs of these panels should be free of conflicts. Much less is known, however, about the ties between industry and the health professionals involved in reviewing disease definitions and whether these ties might in some way contribute to over-diagnosis. In this cross-sectional study (an investigation that takes a snapshot of a situation at a single time point), the researchers identify panels that have recently made decisions about definitions or diagnostic thresholds for conditions that are common in the US and describe the industry ties among the panel members and the changes in disease definitions proposed by the panels.
What Did the Researchers Do and Find?
The researchers identified 16 publications in which expert panels proposed changes to the disease definitions and diagnostic criteria for 14 conditions that are common in the US such as hypertension (high blood pressure) and Alzheimer disease. The proposed changes widened the disease definition for ten diseases, narrowed it for one disease, and had an unclear impact for five diseases. Reasons included in the publications for changing disease definitions included new evidence of risk for people previously considered normal (pre-hypertension) and the emergence of new biomarkers, tests, or treatments (Alzheimer disease). Only six of the panels mentioned possible harms of the proposed changes and none appeared to rigorously assess the downsides of expanding definitions. Of the 15 panels involved in the publications (one panel produced two publications), 12 included members who disclosed financial ties to multiple companies. Notably, the commonest industrial ties among these panels were to companies marketing drugs for the disease being considered by that panel. On average, 75% of panel members disclosed industry ties (range 0% to 100%) to a median of seven companies each. Moreover, similar proportions of panel members disclosed industry ties in publications released before and after the 2011 IOM report.
What Do These Findings Mean?
These findings show that, for the conditions studied, most panels considering disease definitions and diagnostic criteria proposed changes that widened disease definitions and that financial ties with pharmaceutical companies with direct interests in the therapeutic area covered by the panel were common among panel members. Because this study does not include a comparison group, these findings do not establish a causal link between industry ties and proposals to change disease definitions. Moreover, because the study concentrates on a subset of common diseases in the US setting, the generalizability of these findings is limited. Despite these and other study limitations, these findings provide new information about the ties between industry and influential medical professionals and raise questions about the current processes of disease definition. Future research, the researchers suggest, should investigate how disease definitions change over time, how much money panel members receive from industry, and how panel proposals affect the potential market of sponsors. Finally it should aim to design new processes for reviewing disease definitions that are free from potential conflicts of interest.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001500.
A PLOS Medicine Research Article by Knüppel et al. assesses the representation of ethical issues in general clinical practice guidelines on dementia care
Wikipedia has a page on medical diagnosis (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
An article on over-diagnosis by two of the study authors is available; an international conference on preventing over-diagnosis will take place this September
The 2011 US Institute of Medicine report Clinical Practice Guidelines We Can Trust is available
A PLOS Medicine Essay by Lisa Cosgrove and Sheldon Krimsky discusses the financial ties with industry of panel members involved in the preparation of the latest revision of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM), which provides standard criteria for the classification of mental disorders
doi:10.1371/journal.pmed.1001500
PMCID: PMC3742441  PMID: 23966841
4.  Neuroprediction, Violence, and the Law: Setting the Stage 
Neuroethics  2010;5(1):67-99.
In this paper, our goal is to (a) survey some of the legal contexts within which violence risk assessment already plays a prominent role, (b) explore whether developments in neuroscience could potentially be used to improve our ability to predict violence, and (c) discuss whether neuropredictive models of violence create any unique legal or moral problems above and beyond the well worn problems already associated with prediction more generally. In “Violence Risk Assessment and the Law”, we briefly examine the role currently played by predictions of violence in three high stakes legal contexts: capital sentencing (“Violence Risk Assessment and Capital Sentencing”), civil commitment hearings (“Violence Risk Assessment and Civil Commitment”), and “sexual predator” statutes (“Violence Risk Assessment and Sexual Predator Statutes”). In “Clinical vs. Actuarial Violence Risk Assessment”, we briefly examine the distinction between traditional clinical methods of predicting violence and more recently developed actuarial methods, exemplified by the Classification of Violence Risk (COVR) software created by John Monahan and colleagues as part of the MacArthur Study of Mental Disorder and Violence [1]. In “The Neural Correlates of Psychopathy”, we explore what neuroscience currently tells us about the neural correlates of violence, using the recent neuroscientific research on psychopathy as our focus. We also discuss some recent advances in both data collection (“Cutting-Edge Data Collection: Genetically Informed Neuroimaging”) and data analysis (“Cutting-Edge Data Analysis: Pattern Classification”) that we believe will play an important role when it comes to future neuroscientific research on violence. In “The Potential Promise of Neuroprediction”, we discuss whether neuroscience could potentially be used to improve our ability to predict future violence. Finally, in “The Potential Perils of Neuroprediction”, we explore some potential evidentiary (“Evidentiary Issues”), constitutional (“Constitutional Issues”), and moral (“Moral Issues”) issues that may arise in the context of the neuroprediction of violence.
doi:10.1007/s12152-010-9095-z
PMCID: PMC4114735  PMID: 25083168
Neuroscience; Prediction; Criminal law; Psychopathy; Violence risk assessment
5.  Mind Perception Is the Essence of Morality 
Psychological Inquiry  2012;23(2):101-124.
Mind perception entails ascribing mental capacities to other entities, whereas moral judgment entails labeling entities as good or bad or actions as right or wrong. We suggest that mind perception is the essence of moral judgment. In particular, we suggest that moral judgment is rooted in a cognitive template of two perceived minds—a moral dyad of an intentional agent and a suffering moral patient. Diverse lines of research support dyadic morality. First, perceptions of mind are linked to moral judgments: dimensions of mind perception (agency and experience) map onto moral types (agents and patients), and deficits of mind perception correspond to difficulties with moral judgment. Second, not only are moral judgments sensitive to perceived agency and experience, but all moral transgressions are fundamentally understood as agency plus experienced suffering—that is, interpersonal harm—even ostensibly harmless acts such as purity violations. Third, dyadic morality uniquely accounts for the phenomena of dyadic completion (seeing agents in response to patients, and vice versa), and moral typecasting (characterizing others as either moral agents or moral patients). Discussion also explores how mind perception can unify morality across explanatory levels, how a dyadic template of morality may be developmentally acquired, and future directions.
doi:10.1080/1047840X.2012.651387
PMCID: PMC3379786  PMID: 22754268
6.  The ethical desirability of moral bioenhancement: a review of reasons 
BMC Medical Ethics  2014;15:67.
Background
The debate on the ethical aspects of moral bioenhancement focuses on the desirability of using biomedical as opposed to traditional means to achieve moral betterment. The aim of this paper is to systematically review the ethical reasons presented in the literature for and against moral bioenhancement.
Discussion
A review was performed and resulted in the inclusion of 85 articles. We classified the arguments used in those articles in the following six clusters: (1) why we (don’t) need moral bioenhancement, (2) it will (not) be possible to reach consensus on what moral bioenhancement should involve, (3) the feasibility of moral bioenhancement and the status of current scientific research, (4) means and processes of arriving at moral improvement matter ethically, (5) arguments related to the freedom, identity and autonomy of the individual, and (6) arguments related to social/group effects and dynamics. We discuss each argument separately, and assess the debate as a whole. First, there is little discussion on what distinguishes moral bioenhancement from treatment of pathological deficiencies in morality. Furthermore, remarkably little attention has been paid so far to the safety, risks and side-effects of moral enhancement, including the risk of identity changes. Finally, many authors overestimate the scientific as well as the practical feasibility of the interventions they discuss, rendering the debate too speculative.
Summary
Based on our discussion of the arguments used in the debate on moral enhancement, and our assessment of this debate, we advocate a shift in focus. Instead of speculating about non-realistic hypothetical scenarios such as the genetic engineering of morality, or morally enhancing ‘the whole of humanity’, we call for a more focused debate on realistic options of biomedical treatment of moral pathologies and the concrete moral questions these treatments raise.
doi:10.1186/1472-6939-15-67
PMCID: PMC4274726  PMID: 25227512
Moral enhancement; ethical analysis; neuroethics
7.  Neural basis of moral verdict and moral deliberation 
Social neuroscience  2011;6(4):398-413.
How people judge something to be morally right or wrong is a fundamental question of both the sciences and the humanities. Here we aim to identify the neural processes that underlie the specific conclusion that something is morally wrong. To do this, we introduce a novel distinction between “moral deliberation,” or the weighing of moral considerations, and the formation of a “moral verdict,” or the commitment to one moral conclusion. We predict and identify hemodynamic activity in the bilateral anterior insula and basal ganglia that correlates with committing to the moral verdict “this is morally wrong” as opposed to “this is morally not wrong,” a finding that is consistent with research from economic decision-making. Using comparisons of deliberation-locked vs. verdict-locked analyses, we also demonstrate that hemodynamic activity in high-level cortical regions previously implicated in morality—including the ventromedial prefrontal cortex, posterior cingulate, and temporoparietal junction—correlates primarily with moral deliberation as opposed to moral verdicts. These findings provide new insights into what types of processes comprise the enterprise of moral judgment, and in doing so point to a framework for resolving why some clinical patients, including psychopaths, may have intact moral judgment but impaired moral behavior.
doi:10.1080/17470919.2011.559363
PMCID: PMC3176943  PMID: 21590588
Morality; Judgment; Anterior insula; Ventromedial prefrontal cortex
8.  ‘Face’ and the Embodiment of Stigma in China: The Cases of Schizophrenia and AIDS 
Social science & medicine (1982)  2008;67(3):398-408.
The majority of theoretical models have defined stigma as occurring psychologically and limit its negative effects to individual processes. This paper, via an analysis of how ‘face’ is embodied in China, deepens an articulation of how the social aspects of stigma might incorporate the moral standing of both individual and collective actors defined within a local context. We illustrate: 1) how one’s moral standing is lodged within a local social world; 2) how one’s status as a ‘moral’ community member is contingent upon upholding intrapersonal and social-transactional obligations; and 3) how loss of face and fears of moral contamination might lead to a ‘social death’.
We first draw from Chinese ethnographies that describe the process of human cultivation before one can achieve fully ‘moral’ status in society. We integrate findings from empirical studies describing how social exchange networks in China are strictly organized based on the reciprocation of favors, moral positioning, and ‘face’. We further ground these Chinese constructs within a theoretical framework of different forms of capital, and discuss the severe social consequences that loss of face entails. By utilizing the examples of schizophrenia and AIDS to illustrate how loss of moral standing and stigma are interwoven in China, we propose a model highlighting changes in moral status to describe how stigma operates. We suggest that symbolic restoration of moral status for stigmatized groups takes place as local-level stigma interventions. By analyzing the moral aspects of ‘face’, we propose that across cultures, stigma is embedded in the moral experience of participants, whereby stigma is conceived as a fundamentally moral issue: stigmatized conditions threaten what matters most for those in a local world. We further propose that stigma jeopardizes an actor’s ability to mobilize social capital to attain essential social statuses.
doi:10.1016/j.socscimed.2008.03.011
PMCID: PMC2911783  PMID: 18420325
China; AIDS; face; mental illness; discrimination; social capital; culture; stigma
9.  Aberrant neural processing of moral violations in criminal psychopaths 
Journal of abnormal psychology  2010;119(4):863-874.
A defining characteristic of psychopathy is the willingness to intentionally commit moral transgressions against others without guilt or remorse. Despite this ‘moral insensitivity’, the behavioral and neural correlates of moral decision-making in psychopathy have not been well studied. To address this issue, the authors used functional magnetic resonance imaging (fMRI) to record hemodynamic activity in 72 incarcerated male adults, stratified into psychopathic (N = 16) and nonpsychopathic (N = 16) groups based on scores from the Hare Psychopathy Checklist-Revised, while they made decisions regarding the ‘severity of moral violations’ of pictures that did or did not depict moral situations. Consistent with hypotheses, an analysis of brain activity during the evaluation of pictures depicting moral violations in psychopaths vs. nonpsychopaths showed atypical activity in several regions involved in moral decision-making. This included reduced moral/non-moral picture distinctions in the ventromedial prefrontal cortex and anterior temporal cortex in psychopaths relative to nonpsychopaths. In a separate analysis, the association between severity of moral violation ratings and brain activity across participants was compared in psychopaths versus nonpsychopaths. Results revealed a positive association between amygdala activity and severity ratings that was greater in nonpsychopaths than psychopaths, and a negative association between posterior temporal activity and severity ratings that was greater in psychopaths than nonpsychopaths. These results reveal potential neural underpinnings of moral insensitivity in psychopathy and are discussed with reference to neurobiological models of morality and psychopathy.
doi:10.1037/a0020979
PMCID: PMC3985413  PMID: 21090881
Morality; psychopathy; fMRI; medial prefrontal cortex; anterior temporal cortex; amygdala
10.  Managing misaligned paternity findings in research including sickle cell disease screening in Kenya: ‘Consulting communities’ to inform policy☆ 
Social Science & Medicine (1982)  2013;96(100):192-199.
The management of misaligned paternity findings raises important controversy worldwide. It has mainly, however, been discussed in the context of high-income countries. Genetic and genomics research, with the potential to show misaligned paternity, are becoming increasingly common in Africa. During a genomics study in Kenya, a dilemma arose over testing and sharing information on paternal sickle cell disease status. This dilemma may be paradigmatic of challenges in sharing misaligned paternity findings in many research and health care settings. Using a deliberative approach to community consultation to inform research practice, we explored residents' views on paternal testing and sharing misaligned paternity information. Between December 2009 and November 2010, 63 residents in Kilifi County were engaged in informed deliberative small group discussions, structured to support normative reflection within the groups, with purposive selection to explore diversity. Analysis was based on a modified framework analysis approach, drawing on relevant social science and bioethics literature.
The methods generated in-depth individual and group reflection on morally important issues and uncovered wide diversity in views and values. Fundamental and conflicting values emerged around the importance of family interests and openness, underpinned by disagreement on the moral implications of marital infidelity and withholding truth. Wider consideration of ethical issues emerging in these debates supports locally-held reasoning that paternal sickle cell testing should not be undertaken in this context, in contrast to views that testing should be done with or without the disclosure of misaligned paternity information. The findings highlight the importance of facilitating wider testing of family members of affected children, contingent on the development and implementation of national policies for the management of this inherited disorder. Their richness also illustrates the potential for the approach adopted in this study to strengthen community consultation.
Highlights
•Community consultation on misaligned paternity in Kenya highlights morally important diversity.•Openness and family interests are central conflicting values in debates on misaligned paternity.•In research paternal requests for sickle cell disease testing generate prohibitive moral challenges.•Informed deliberative group discussions strengthen ethical outcomes of community consultation.
doi:10.1016/j.socscimed.2013.07.028
PMCID: PMC3778404  PMID: 24034967
Kenya; Misaligned paternity; Genetic testing; Genetic and genomics research; Community consultation; Empirical ethics; Sickle cell disease; Africa
11.  The role of disease characteristics in the ethical debate on personal genome testing 
Background
Companies are currently marketing personal genome tests directly-to-consumer that provide genetic susceptibility testing for a range of multifactorial diseases simultaneously. As these tests comprise multiple risk analyses for multiple diseases, they may be difficult to evaluate. Insight into morally relevant differences between diseases will assist researchers, healthcare professionals, policy-makers and other stakeholders in the ethical evaluation of personal genome tests.
Discussion
In this paper, we identify and discuss four disease characteristics - severity, actionability, age of onset, and the somatic/psychiatric nature of disease - and show how these lead to specific ethical issues. By way of illustration, we apply this framework to genetic susceptibility testing for three diseases: type 2 diabetes, age-related macular degeneration and clinical depression. For these three diseases, we point out the ethical issues that are relevant to the question whether it is morally justifiable to offer genetic susceptibility testing to adults or to children or minors, and on what conditions.
Summary
We conclude that the ethical evaluation of personal genome tests is challenging, for the ethical issues differ with the diseases tested for. An understanding of the ethical significance of disease characteristics will improve the ethical, legal and societal debate on personal genome testing.
doi:10.1186/1755-8794-5-4
PMCID: PMC3293088  PMID: 22260407
12.  What makes a problem an ethical problem? An empirical perspective on the nature of ethical problems in general practice 
Journal of Medical Ethics  2001;27(2):98-103.
Whilst there has been considerable debate about the fit between moral theory and moral reasoning in everyday life, the way in which moral problems are defined has rarely been questioned. This paper presents a qualitative analysis of interviews conducted with 15 general practitioners (GPs) in South Australia to argue that the way in which the bioethics literature defines an ethical dilemma captures only some of the range of lay views about the nature of ethical problems. The bioethics literature has defined ethical dilemmas in terms of conflict and choice between values, beliefs and options for action. While some of the views of some of the GPs in this study about the nature of their ethical dilemmas certainly accorded with this definition, other explanations of the ethical nature of their problems revolved around the publicity associated with the issues they were discussing, concern about their relationships with patients, and anxiety about threats to their integrity and reputation. The variety of views about what makes a problem a moral problem indicates that the moral domain is perhaps wider and richer than mainstream bioethics would generally allow.
Key Words: Empirical ethics • general practice • qualitative research
doi:10.1136/jme.27.2.98
PMCID: PMC1733368  PMID: 11314166
13.  Socio-economic factors related to moral reasoning in childhood and adolescence: the missing link between brain and behavior 
Neuroscientific and psychological research on moral development has until now developed independently, referring to distinct theoretical models, contents, and methods. In particular, the influence of socio-economic and cultural factors on morality has been broadly investigated by psychologists but as yet has not been investigated by neuroscientists. The value of bridging these two areas both theoretically and methodologically has, however, been suggested. This study aims at providing a first connection between neuroscientific and psychological literature on morality by investigating whether socio-economic dimensions, i.e., living socio-geographic/economic area, immigrant status and socio-economic status (SES), affect moral reasoning as operationalized in moral domain theory (a seminal approach in psychological studies on morality) and in Greene et al. (2001) perspective (one of the main approaches in neuroethics research). Participants were 81 primary school (M = 8.98 years; SD = 0.39), 72 middle school (M = 12.14 years; SD = 0.61), and 73 high school (M = 15.10 years; SD = 0.38) students from rural and urban areas. Participants' immigrant status (native vs. immigrant) and family SES level were recorded. Moral reasoning was assessed by means of a series of personal and impersonal dilemmas based on Greene et al. (2001) neuroimaging experiment and a series of moral and socio-conventional rule dilemmas based on the moral domain theory. Living socio-geographic/economic area, immigrant status and SES mainly affected evaluations of moral and, to a higher extent, socio-conventional dilemmas, but had no impact on judgment of personal and impersonal dilemmas. Results are mainly discussed from the angle of possible theoretical links and suggestions emerging for studies on moral reasoning in the frameworks of neuroscience and psychology.
doi:10.3389/fnhum.2012.00262
PMCID: PMC3449439  PMID: 23015787
moral reasoning; socio-economic factors; neuroscience; psychological research; moral domain theory
14.  The ABC of moral development: an attachment approach to moral judgment 
As with other cognitive faculties, the etiology of moral judgment and its connection to early development is complex. Because research is limited, the causative and contributory factors to the development of moral judgment in preverbal infants are unclear. However, evidence is emerging from studies within both infant research and moral psychology that may contribute to our understanding of the early development of moral judgments. Though its finding are preliminary, this proposed paradigm synthesizes these findings to generate an overarching, model of the process that appears to contribute to the development of moral judgment in the first year of life. I will propose that through early interactions with the caregiver, the child acquires an internal representation of a system of rules that determine how right/wrong judgments are to be construed, used, and understood. By breaking moral situations down into their defining features, the attachment model of moral judgment outlines a framework for a universal moral faculty based on a universal, innate, deep structure that appears uniformly in the structure of almost all moral judgments regardless of their content. The implications of the model for our understanding of innateness, universal morality, and the representations of moral situations are discussed.
doi:10.3389/fpsyg.2014.00006
PMCID: PMC3901400  PMID: 24478739
moral judgment; moral development; mentalization; infant development; social cognition; attachment theory
15.  A four-part working bibliography of neuroethics: part 1: overview and reviews – defining and describing the field and its practices 
Background
Neuroethics entails investigations of neurocognitive mechanisms of morality and ethics; and studies and address of the ethical issues spawned by the use of neuroscience and its technologies to investigate cognition, emotion and actions. These two principal emphases, or what have been called “traditions” of neuroethics both mirror traditional bioethical discussions (such as debates about the safety of technological and pharmaceutical advances and ethical implications of new scientific and technological discoveries), and engage discourse about neuroscientific investigations of (proto-moral and moral) cognition, emotions and behaviors, and what such findings may mean for human beliefs and conduct - from the individual to the political levels.
Given the growth, range, and rapid maturation of the field of neuroethics we provide an iterative, four-part document that affords a repository of international papers, books, and chapters that address the field in overview, and present discussion(s) of more particular aspects and topics of neuroethics. This first installment lists reviews and overviews of the discipline, and broad summaries of basic developments and issues of the field.
Methods
To systematically survey the neuroethics literature, searches were performed by accessing 11 databases, 8 additional literature depositories, and 4 individual journal searches using indexing language for National Library of Medicine (NLM) Medical Subject Heading databases. Searches and assurance against overlapping coverage were conducted using the RefWorks citation management program.
Results
Overview, review and reflections upon the history and multicultural perspectives of neuroethics were obtained and relevant listings from international journals, books, and book chapters are provided. Part I will be followed by three installments that will address a): the neuroscience of morality and ethics, including discussions of free will, and personal autonomy; b) “second tradition neuroethics”, to include specific ethical issues in neuroscience; clinical neuroethics; and c) neuroethics education/training; neuroethics and society; neuroethics and law; neuroethics and policy; and international neuroethics.
doi:10.1186/1747-5341-9-9
PMCID: PMC4047768  PMID: 24885037
Neuroethics; Neuroscience; Neurobioethics; Bioethics; Ethics; Bibliography
16.  Advance directives for non-therapeutic dementia research: some ethical and policy considerations. 
Journal of Medical Ethics  1998;24(1):32-37.
This paper explores the use of advance directives in clinical dementia research. The focus is on advance consent to participation of demented patients in non-therapeutic research involving more than minimal risks and/or burdens. First, morally relevant differences between advance directives for treatment and care, and advance directives for dementia research are discussed. Then attention is paid to the philosophical issue of dementia and personal identity, and the implications for the moral authority of research advance directives. Thirdly, a number of practical shortcomings of advance directives for non-therapeutic dementia research are explored and attention is paid to the role of proxies. It is concluded that upon a closer look the initial attractiveness of advance directives for dementia research is lessened, and that it is doubtful whether these instruments can compensate for the lack of subject consent in case of non-therapeutic dementia research involving more than minimal risks and/or burdens for the incompetent demented subject.
PMCID: PMC1377429  PMID: 9549680
17.  Gender differences in neural mechanisms underlying moral sensitivity 
Researchers have proposed that females and males differ in the structure of their moral attitudes, such that females tend to adopt care-based moral evaluations and males tend to adopt justice-based moral evaluations. The existence of these gender differences remains a controversial issue, as behavioral studies have reported mixed findings. The current study investigated the neural correlates of moral sensitivity in females and males, to test the hypothesis that females would show increased activity in brain regions associated with care-based processing (posterior and anterior cingulate, anterior insula) relative to males when evaluating moral stimuli, and males would show increased activity in regions associated with justice-based processing (superior temporal sulcus) relative to females. Twenty-eight participants (14 females) were scanned using fMRI while viewing unpleasant pictures, half of which depicted moral violations, and rated each picture on the degree of moral violation that they judged to be present. As predicted, females showed a stronger modulatory relationship between posterior cingulate and insula activity during picture viewing and subsequent moral ratings relative to males. Males showed a stronger modulatory relationship between inferior parietal activity and moral ratings relative to females. These results are suggestive of gender differences in strategies utilized in moral appraisals.
doi:10.1093/scan/nsn026
PMCID: PMC2607058  PMID: 19015084
gender; moral sensitivity; posterior cingulate; anterior insula
18.  Ethical issues relating to the banking of umbilical cord blood in Mexico 
BMC Medical Ethics  2009;10:12.
Background
Umbilical cord banks are a central component, as umbilical cord tissue providers, in both medical treatment and scientific research with stem cells. But, whereas the creation of umbilical cord banks is seen as successful practice, it is perceived as a risky style of play by others. This article examines and discusses the ethical, medical and legal considerations that arise from the operation of umbilical cord banks in Mexico.
Discussion
A number of experts have stated that the use of umbilical cord goes beyond the mere utilization of human tissues for the purpose of treatment. This tissue is also used in research studies: genetic studies, studies to evaluate the effectiveness of new antibiotics, studies to identify new proteins, etc. Meanwhile, others claim that the law and other norms for the functioning of cord banks are not consistent and are poorly defined. Some of these critics point out that the confidentiality of donor information is handled differently in different places. The fact that private cord banks offer their services as "biological insurance" in order to obtain informed consent by promising the parents that the tissue that will be stored insures the health of their child in the future raises the issue of whether the consent is freely given or given under coercion. Another consideration that must be made in relation to privately owned cord banks has to do with the ownership of the stored umbilical cord.
Summary
Conflicts between moral principles and economic interests (non-moral principles) cause dilemmas in the clinical practice of umbilical cord blood storage and use especially in privately owned banks. This article presents a reflection and some of the guidelines that must be followed by umbilical cord banks in order to deal with these conflicts. This reflection is based on the fundamental notions of ethics and public health and seeks to be a contribution towards the improvement of umbilical cord banks' performance.
doi:10.1186/1472-6939-10-12
PMCID: PMC2745420  PMID: 19678958
19.  Moral Emotions and Moral Behavior 
Annual review of psychology  2007;58:345-372.
Moral emotions represent a key element of our human moral apparatus, influencing the link between moral standards and moral behavior. This chapter reviews current theory and research on moral emotions. We first focus on a triad of negatively valenced “self-conscious” emotions—shame, guilt, and embarrassment. As in previous decades, much research remains focused on shame and guilt. We review current thinking on the distinction between shame and guilt, and the relative advantages and disadvantages of these two moral emotions. Several new areas of research are highlighted: research on the domain-specific phenomenon of body shame, styles of coping with shame, psychobiological aspects of shame, the link between childhood abuse and later proneness to shame, and the phenomena of vicarious or “collective” experiences of shame and guilt. In recent years, the concept of moral emotions has been expanded to include several positive emotions—elevation, gratitude, and the sometimes morally relevant experience of pride. Finally, we discuss briefly a morally relevant emotional process—other-oriented empathy.
doi:10.1146/annurev.psych.56.091103.070145
PMCID: PMC3083636  PMID: 16953797
shame; guilt; pride; elevation; gratitude
20.  Using focus groups to understand causes for morale decline after introducing change in an IM residency program 
BMC Medical Education  2014;14:132.
Background
Although program evaluation is a core requirement of Internal Medicine residencies, little is reported in the literature regarding resident satisfaction with training. Most program evaluation consists of numerical rating scales from which it is often difficult to pinpoint exact sources of dissatisfaction.
Methods
Our goal in this work is to evaluate the utility of focus group methodology to uncover in detail the reasons for residents’ deteriorating morale in an IM residency program, as well as to solicit suggestions for correction. This study employed focus groups (FG) in a qualitative research design, in which descriptive statistics from a resident program evaluation survey served to guide an intensive focus group process. Participants were 40 of 45 2nd and 3rd year internal medicine residents enrolled in the IM residency training program. Five chief residents were trained to conduct 5 focus groups with 8 residents in each group. The focus groups examined possible issues contributing to the deterioration of morale noted in the quantitative survey.
Results
Many unexpected themes were uncovered by the FGs. Residents identified the following factors as the major contributors to deteriorating morale: 1) Pace of change 2) Process of change 3) The role of chief residents in change 4) Fear of intimidation and retaliation. Groups also suggested practical recommendations for improving the culture of the residency.
Conclusion
Introducing change in residency training is a challenging process. Respectful attention to resident frustrations and solution-focused discussions are necessary to understand and improve morale. Focus groups proved to be a useful tool in revealing the precise source of pervasive resident concerns as well as providing potential solutions. In addition, FGs methodology can be adapted in a practical manner to residency evaluation.
doi:10.1186/1472-6920-14-132
PMCID: PMC4094667  PMID: 24994046
Education medical graduate; Residency program evaluation; Focus groups; Qualitative research; Morale; Burnout
21.  From ethics of care to psychology of care: reconnecting ethics of care to contemporary moral psychology 
Frontiers in Psychology  2014;5:1135.
Moral psychology once regarded ethics of care as a promising theory. However, there is evidence to suggest that nowadays moral psychology completely ignores ethics of care’s various insights. Moreover, ethics of care’s core concepts – compassion, dependence, and the importance of early relations to moral development– are no longer considered to be relevant to the development of new theories in the field. In this paper, I will firstly discuss some of the reasons which, over recent years, have contributed to the marginalization of the role of ethics of care in moral psychology. Next, I will show that ethics of care’s most promising idea centered on the care given to an infant and the importance of that care to the development of moral thinking. In this context, I will be describing the implications of John Bowlby’s attachment theories, infant research, findings in moral psychology and neuroscience. I will argue that ethics of care needs to be radically re-thought and replaced by a psychology of care, an attachment approach to moral judgment, which would establish the centrality of the caregiver’s role in moral development. The philosophical implications of this approach to the understanding of the “rationalists” and “intuitionists” debate about the true nature of moral judgment is also discussed.
doi:10.3389/fpsyg.2014.01135
PMCID: PMC4201096  PMID: 25368588
ethics of care; attachment theory; moral development; infant research; moral psychology; mind perception
22.  Teaching ethics using small-group, problem-based learning. 
Journal of Medical Ethics  1997;23(5):315-318.
Ethics is the emphasis of our first-year Introduction to Clinical Medicine-1 course. Introduction to Clinical Medicine-1 uses problem-based learning to involve groups of seven to nine students and two facilitators in realistic clinical cases. The cases emphasize ethics, but also include human behaviour, basic science, clinical medicine, and prevention learning issues. Three cases use written vignettes, while the other three cases feature standardized patients. Groups meet twice for each case. In session one, students read the case introduction, obtain data from the written case or standardized patient, identify the case's ethical problems, formulate learning issues, discuss ways to resolve the moral conflicts, and assign research responsibilities. In session two, students discuss their assigned learning issues and specify and justify clinical actions to address the case's ethical dilemmas. Following three cases, groups write an essay discussing what they learned and describing how they would approach and resolve the case's learning issues.
PMCID: PMC1377372  PMID: 9358353
23.  Moral judgment reloaded: a moral dilemma validation study 
We propose a revised set of moral dilemmas for studies on moral judgment. We selected a total of 46 moral dilemmas available in the literature and fine-tuned them in terms of four conceptual factors (Personal Force, Benefit Recipient, Evitability, and Intention) and methodological aspects of the dilemma formulation (word count, expression style, question formats) that have been shown to influence moral judgment. Second, we obtained normative codings of arousal and valence for each dilemma showing that emotional arousal in response to moral dilemmas depends crucially on the factors Personal Force, Benefit Recipient, and Intentionality. Third, we validated the dilemma set confirming that people's moral judgment is sensitive to all four conceptual factors, and to their interactions. Results are discussed in the context of this field of research, outlining also the relevance of our RT effects for the Dual Process account of moral judgment. Finally, we suggest tentative theoretical avenues for future testing, particularly stressing the importance of the factor Intentionality in moral judgment. Additionally, due to the importance of cross-cultural studies in the quest for universals in human moral cognition, we provide the new set dilemmas in six languages (English, French, German, Spanish, Catalan, and Danish). The norming values provided here refer to the Spanish dilemma set.
doi:10.3389/fpsyg.2014.00607
PMCID: PMC4077230  PMID: 25071621
moral dilemmas; moral judgment; decision making; cross cultural; DPHMJ
24.  Preimplantation genetic diagnosis for mitochondrial DNA disorders: ethical guidance for clinical practice 
European Journal of Human Genetics  2009;17(12):1550-1559.
Although morally acceptable in theory, preimplantation genetic diagnosis (PGD) for mitochondrial DNA (mtDNA) disorders raises several ethical questions in clinical practice. This paper discusses the major conditions for good clinical practice. Our starting point is that PGD for mtDNA mutations should as far as possible be embedded in a scientific research protocol. For every clinical application of PGD for mtDNA disorders, it is not only important to avoid a ‘high risk of serious harm' to the future child, but also to consider to what extent it would be possible, desirable and proportional to try to reduce the health risks and minimize harm. The first issue we discuss is oocyte sampling, which may point out whether PGD is feasible for a specific couple. The second issue is whether one blastomere represents the genetic composition of the embryo as a whole – and how this could (or should) be investigated. The third issue regards the cutoff points below which embryos are considered to be eligible for transfer. We scrutinize how to determine these cutoff points and how to use these cutoff points in clinical practice – for example, when parents ask to take more or less risks. The fourth issue regards the number of cycles that can (or should) justifiably be carried out to find the best possible embryo. Fifth, we discuss whether follow-up studies should be conducted, particularly the genetic testing of children born after IVF/PGD. Finally, we offer the main information that is required to obtain a truly informed consent.
doi:10.1038/ejhg.2009.88
PMCID: PMC2987024  PMID: 19471315
ethics; PGD; mitochondrial DNA; genetic testing minors
25.  Neural foundations to moral reasoning and antisocial behavior 
A common feature of the antisocial, rule-breaking behavior that is central to criminal, violent and psychopathic individuals is the failure to follow moral guidelines. This review summarizes key findings from brain imaging research on both antisocial behavior and moral reasoning, and integrates these findings into a neural moral model of antisocial behavior. Key areas found to be functionally or structurally impaired in antisocial populations include dorsal and ventral regions of the prefrontal cortex (PFC), amygdala, hippocampus, angular gyrus, anterior cingulate and temporal cortex. Regions most commonly activated in moral judgment tasks consist of the polar/medial and ventral PFC, amygdala, angular gyrus and posterior cingulate. It is hypothesized that the rule-breaking behavior common to antisocial, violent and psychopathic individuals is in part due to impairments in some of the structures (dorsal and ventral PFC, amygdala and angular gyrus) subserving moral cognition and emotion. Impairments to the emotional component that comprises the feeling of what is moral is viewed as the primary deficit in antisocials, although some disruption to the cognitive and cognitive-emotional components of morality (particularly self-referential thinking and emotion regulation) cannot be ruled out. While this neurobiological predisposition is likely only one of several biosocial processes involved in the etiology of antisocial behavior, it raises significant moral issues for the legal system and neuroethics.
doi:10.1093/scan/nsl033
PMCID: PMC2555414  PMID: 18985107
antisocial; psychopathy; moral; prefrontal; temporal

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