These posters will be available :

• Ab Manan M., Tan M. Baby Steps: Growing Clinical Ethics Services for Pediatrics in a Malaysian Teaching Hospital
• Applewhite M. ETHICS CONSULTATION SERVICES AND SURGEONS: HOW TO BUILD TRUST AND COLLABORATION"
• Asif M. Bridging Gaps and Enhancing Bioethics Education in Pakistan: A Capacity Building Initiative
• Berger L. Welcoming Siblings into French Pediatric intensive care units, an overview of French practices 
• Corsico P. Engagement and normativity: What is the aim of patient engagement in clinical ethics?
• Crowell P. Cultural Accommodation, Conflict, and the Challenges of Plurality: An Ethical Case Study that Exams Competing Rights in Healthcare
• Crowell P. Indigenous Power within Healthcare:  In Search of a Delicate Balance Between Pediatric Oncology and Indigenous Children
• Dallaire C. Hidden Curriculum in Medical Education: Action Research for the Development of a Participatory Reflective Tool 
• Ehlers U. The `St. Gallen Resuscitation Decision Algorithm`
• Eijkholt M. To disclose or not to disclose. What the HEC(k) between medical law and medical Ethics
• Ferrie M. Intersexes children: what role does clinical ethics play between a new law and traditional medical practices? 
• Fumie A. The Meaning of Experiences of Communicating about heredity in Early Genetic Diagnosis of Muscular Dystrophy
• Gillam L. and Court A. Parents driving too much medical treatment for their child - Responding to the ethical challenges
• Goset K. Enhancing Patient Autonomy: An Advance Care Planning/Advance Directives Initiative by a Healthcare Ethics Committee.
• Hulkower A. Vicarious Trauma and Compassion Fatigue in Clinical Ethicists: Defining the Service Director's Role
• Jacques R. Principled approach to comingled human remains 
• Knochel K. Principle-based ethical case analysis as a tool for normative conflict resolution in pediatrics
• Lacharité F. Gaucher N. and Lavoie  B. The best interests of the child and the withdrawal of life-sustaining interventions: exploring a principle open to interpretation
• Landi A. Navigating Difficult Conversations: A Pilot Training for Clinical Ethics Fellows in Palliative Communication Skills
• Landi A. Requesting permission to consult palliative care: Patient-driven instead of patient-centered
• Lavoie B. Going to court: exploring the motivations of pediatricians in situations of treatment refusal expressed by parents
• Lavoie B. Value, Bridge Builder, or Obstacle? Clinical Perceptions of Parents' Religion in Complex Pediatric Situations
• Le Bourgeois F. Parents from a Roma community refusing treatment in paediatrics, place of the principle of autonomy  
• Lin K. The Case for Independent Clinical Ethics Committees: A Novel Structural Proposal for Healthcare Ethics Consultations in Singapore
• Mann D. MD DBe HEC-C Complicit with the illicit, how physician involvement risks condoning unorthodox parental behavior.
• Masilla S. Prognostic uncertainty and Shared Care Planning: a case of a Fetus with Severe Renal Hypoplasia and Early Anhydramnios
• Menon S. Not just advisory: Clinical Ethics Committees as the approving authority for innovative salvage treatments for patients
• Mesnage V. How clinical ethics changed my outlook and made me a committed citizen
• Moazzen V. Contribution of Forensic Medicine Specialists to Clinical Ethics Consultation and Legal Advice in Iranian Hospitals
• Moreno-Molina J. Transnational Reproductive Medicine and the Role of Clinical Bioethics: The Case of Colombia
• Moreno-Molina J. Clinical Bioethics Training for Surgical and Medical Residents: The Universidad CES Experience
• Nikolakakis I. Bioethics and Bioterrorism: Past, Present, and Future
• Patten C. Ethics on Record: A Study of Clinical Documentation Practices in EHRs
• Rhodes R. Innovation in Collaborative Clinical Ethics Consultation
• Robin M. Increasing Outpatient Life-Sustaining Treatment Discussion and Documentation in a Veterans' Administration Outpatient Clinic
• Rosca A. Ethical Conflict Resolution Through Shared Decision-Making and Advance Care Planning for Incapacitated Patients
• Šteina E. The Ethical Dilemmas of Slow and Show Codes in Healthcare 
• Tareen M. Surrogate decision-making and ethical dilemmas in palliative care: balancing patient autonomy in Muslim-majority settings
• Yip E. Navigating Ethical Dilemmas of Disclosure and Role Clarity for Medical Shadowing: A focus on Hong Kong's Public Hospitals

1)    Gillam L and Johnston C. From conceptual to concrete: learning ethics in a clinical ethics committee for medical students

Abstract:

"Medical students witness and experience ethical challenges during their clinical placements.  Student Clinical Ethics Committees (SCECs) have been established in some universities globally, as an experiential learning initiative to support students to navigate and reflect on these challenges, developing skills of professional practice.  In 2024, we piloted an SCEC as an enrichment opportunity for medical students at [blinded for peer review].  

The staff involved in the project lead clinical ethics committees within hospitals, and aimed to replicate this experience for the medical students. Each meeting was an ethicist-led discussion of a de-identified case referred by an MD student, with case notes prepared by a volunteer notetaker.  The training, referral process and model of ethics deliberation used in the SCEC reflect the real-world functioning of hospital clinical ethics committees.

The student response in the pilot year has far exceeded our expectations.  In order to include all enthusiastic students, we established three parallel committees each of which met online every two months.  Students have submitted a diverse range of complex and perceptive referrals which have stimulated excellent discussions.  
The digital format strove to promote a plurality of perspectives across various clinical and geographical settings. We value this innovative learning model as a preventive form of health ethics consultation, supporting future clinicians to be better placed to respond to ethical issues, while shaping their professional and moral identities. This presentation will discuss the design and experience of the SCEC including governance, confidentiality, risk management, types of clinical ethics issues raised, and student learning outcomes.  

In our view, an SCEC is an effective way of bringing the workplace into ethics teaching, enabling development of practical ethics skills. It builds a cohort of peers interested in ethics and, we hope, will contribute to nurturing future leaders in clinical ethics in our context."

2)    Fiester A. Abdicating the Role of Mediator in US Healthcare Ethics Consultation: A Risky Choice 

Abstract:

"The amount of conflict between patients, families, and healthcare providers is so high in the United States that a recent consensus statement of five professional medical societies recommended embedding expert conflict management consultants in all high-volume US hospitals (Bosslet et al 2015).  From the earliest days of formal ethics consultation, the US bioethics organization, the "American Society for Bioethics and Humanities" (ASBH) deemed conflict resolution skills as a core competency for ethics consultants, making the institution's ethics service a natural locus for such conflict management experts.  But over the last 25 years, clinical ethics consultation in the US has morphed into a consulting specialty similar to medical subfields like nephrology or hematology, in which the primary deliverable is knowledge-based expertise and judgment. Most US ethics consultants offer recommendations, not interventions. Even among ethics consultants with the ASBH's new formal certification (HEC-c), very few ethics consultants have any training in conflict management, despite the mandate for both in the ASBH's Core Competencies, the guiding document for the field.  I will argue that this evolution (or devolution) of ethics consultation in the US may be sowing the seeds of its own demise. Over the last 10 years, US hospitals have increasingly relied on newly emerging Departments of Patient Relations to fill the void of conflict management expertise that ethics consultants could have (and, I believe, should have) filled. These new departments are typically larger and much better funded than the hospital's ethics consult service. In fact, most US hospitals have a patient relations department though many hospitals have no paid ethics consultants at all.  If this trend continues, abdicating the role of conflict resolution in ethics consultation may put clinical ethics 'out of business.'

Bosslet, GT., et al. "An Official Policy Statement: Responding to Requests for Potentially Inappropriate Treatments." 191(11),2015: 1318'30.

3)    Semler L. Mediator or Advocate? The Role of the Clinical Ethicist

Abstract:

"Mediation is an essential component of ethics consultation. The practice of mediation uses a neutral facilitator to foster engagement of all stakeholders and their respective interests and perspectives, and facilitate a resolution or consensus on an ethically justifiable course of action. However, when, if every, is it justifiable for the clinical ethicist to step outside of the bounds of their role as mediator and advocate for what they feel to be the right course of action?
The author will describe a case in which the interests of an incapacitated patient are discovered through interview of his wife and guardian. However, neither the wife nor the attending physician is willing to move forward with the ethically appropriate course of action to uphold the patient's previously expressed wishes. In cases like this, what are the clinical ethicist's responsibilities to advocate for the most ethically appropriate course of action? Clinical ethicists are consultants, and ultimately the decision-making rests with the clinical team and patient or family. However, when the patient cannot speak for themselves, and their loved ones refuse to do so, does the ethicist have an obligation to step outside the role of neutral mediator and instead advocate for the voice of the patient? At what point would the ethicist seek institutional or legal support to advocate for a specific course of action? The author will provide support and considerations for both perspectives, along with considerations for a deontological vs consequentialist approach to consultation recommendations."

4)    Reato F. Repertoire of the Competencies of the Clinical Ethics Consultant in the light of the European and Italian Qualifications Framework

Abstract:

"For the public recognition of the qualification of the Clinical Ethics Consultant (CEC) it is necessary to build the Repertoire of the Competencies by the European Qualifications Framework (2017) and the Italian Qualifications Framework (2018) criteria. Highlighting the clear connection to the EQF level 8, we identified and described learning outcomes of the identified competencies through knowledge, skills, autonomy and responsibility.

Methods/Materials:
To reach data saturation, according to the qualitative research approach, an ethnographic study was conducted according to the principles of the "At Home Ethnography", through Participant Observation and Interviews to the Double. The interviewees are asked to imagine a hypothetical replacement by a "Double" who will take their place in the execution of the work activities and to provide him with all useful indications to cover the role of the CEC best.

Results:
Taking into account also the European Competencies Frameworks Entrecomp, LifeComp, DigComp and GreenComp, were identified 11 Transversal Competencies (01. Communication and Interpersonal Relationship; 02. Coping With Emotions; 03. Problem Solving; 04. Critical Thinking; 05. Decision Making; 06. Self Awareness; 07. Leadership; 08. Team Work; 09. Time Management; 10. Governance of Digital Transformation Processes and Technological Innovation; 11. Teaching Competencies) and 6 Technical Professional Specialist and Advanced Competencies (1. Determine the nature of uncertainties or moral conflicts that require clinical ethics consultation; 2. Conduct the clinical ethics consultation process in the health area; 3. Encourage the resolution of moral uncertainties and conflicts by facilitating the construction of an ethically based solution; 4. Document planned and implemented clinical ethics advice in the health field; 5. Monitor clinical ethics consultation service; 6. Improve the quality of clinical ethics consultant service).

Discussion and Conclusions:
The Interviews to the Double and the Participant Observation allow: tracing of the tacit routines put into place and interpreted by each Professional, through the exercise of the narration of micro actions and daily practices; identifying attitudes, knowledge, skills, emotional and intentional colors of their professional actions; identifying spaces of autonomy and responsibility; learning more about the actions and reasons for the practices of fellow Clinical Ethics Consultants."

5)    Bonaccorso A. Workplace violence against midwives and midwifery students: moral dilemmas and challenges for Healthcare Ethics Consultation (HEC)

Abstract:

"Workplace violence (WPV) against healthcare professionals represents a global issue. Violence in the maternity setting has received little research attention, with midwives often assimilated into nurses. Few studies, primarily qualitative, have explored the effect violence has on midwifery students whilst clinical placement.

Methods: An online, anonymous survey was sent via email to all members of Local Midwifery Boards in Italy and to all Italian midwifery students, investigating their experiences of WPV and bullying.

Results: The findings highlight the high exposure to violence that midwives and midwifery students experience in the workplace. A total of 1059 completed questionnaires were returned by eligible participants, 687 midwives and 372 midwifery students. Forty-five percent of midwives and 27% of students reported being a victim of WPV. This was most often in the form of verbal abuse. The women's partners or other family members (65.4%), patients (21.9%), and physicians (29.1%) were identified as the main perpetrators by midwives. Midwifery students experienced bullying mostly from supervising midwives (40.2%) or other midwives (56.8%). Over half of the victims did not report and seek assistance through formal channels. Consequences of WPV included thoughts of leaving their job (27.1% of midwives) or course of study (22.5% of students) and significantly reduced gratification from caregiving.

Discussion and Conclusions: Healthcare professionals face the following moral dilemmas: providing care to patients who have attacked them, manage emotions so as not to let them to interfere with care, balance the responsibility of protecting their own integrity and safety with professional duty and with respect for dignity of the patient. HEC can offer a listening space for victims and create the conditions allowing for the reporting of facts. In this listening space, ethical consultant can help to explore and resolve these conflicts through an analysis of professional and moral values. Also, HEC can help to create corporate awareness on the topic so that adequate prevention measures are implemented. "

1)    Kühlmeyer K. Can we identify needs for clinical ethics services by screening for moral distress?

Abstract:

"Introduction: Experiencing ethical challenges in health care can be accompanied by moral distress (MoD). Studies have shown that clinical ethics support services (CESS) can be effective in mitigating MoD of health care professionals. We explore whether a screening for MoD can be used as an indirect needs assessment for interventions by CESS. 
Research Question: How can structured MoD screenings be used to assess needs for CESS?
Main body: We present results of an ongoing mixed-methods study and a reflection of its utility for CESS. We used psychometric test instruments for MoD screening at a German University Hospital: the Measure of Moral Distress for Health Care Professionals (MMD-HP) and the moral distress thermometer (MDT). The screened sample consisted of 143 nurses and doctors of six pediatric and neonatal intensive care units (PICUs/NICUs) (49% of the population). Between the professional groups, the level of MoD was comparably high and the most common causes were directly or indirectly associated with resource scarcity and a lack of communication. The staff of the PICUs reported higher levels of MoD. First results of qualitative interviews with 19 purposefully selected employees (nurses, doctors, psychologists and social workers) showed a variety of specific causes. For example, communication problems occurred because of a lack of spaces for interprofessional discussions and unstructured handovers, or resource scarcity was reinforced by changes in professional training and extensive documentation of patient data. The reasons for MoD go beyond case-based conflicts and point to causes of moral distress at structural levels. CESS and teams with high levels of MoD could develop needs-based interventions to tackle such causes together. 
Outlook: We will explore connections between the identified causes of MoD and suitable interventions based on expert interviews with clinical ethicists."

2)    Brogtrop L. Does series of moral case deliberation increase social safety and moral courage? A pilot at the Dutch Government

Abstract:

"Context. 
After a national scandal in 2021, the Netherlands created the governmental program Dialogue & Ethics, which focuses on creating a governmental culture in which ethical reflection is a standardized element. The aim is to achieve this by facilitating guided moral dialogues (consisting of various forms of Moral Case Deliberation) throughout the entire Dutch government. The goal of these dialogues is to help public officials in recognizing and addressing the ethical dimensions of their daily work. In addition, the dialogues ought to contribute to a governmental culture in which ethical questions and concerns are included in decision making processes.
Research question. 
What is the impact of the Dialogue & Ethics program, and how to measure that impact?
Method. 
This PhD project focuses on identifying the impact of the Dialogue & Ethics program. To further specify the domain of impact, four outcome parameters have been identified, namely, social safety, moral courage, moral learning, and (loyal) contradiction. 
In order to measure the impact, a mixed method study will be conducted on four different research locations that commit to conducting various forms of MCD with their team, over the course of one year. These methods consist of ethnographic fieldwork, a questionnaire that has been developed specifically for this research, interviews, and focus groups. Currently, this questionnaire is in a developmental stage, but during the ICCEC conference the questionnaire will have been finalized.
Discussion. 
Do CESS foster social safety, moral courage, moral learning and contradiction in healthcare contexts? Are there possible harms CESS can create, and, if so, how do these harms compare to a governmental context? 
What are relevant similarities and differences between conducting CESS in 'traditional' contexts versus political contexts? Can the aforementioned research parameters also be relevant for CESS?"

3)    Zlotnik Shaul R. Moral distress debriefs: An opportunity to increase “moral peace” in the health context

Abstract:

"In this post pandemic era, rates of healthcare provider burnout are being reported at crisis levels across the globe. While many health systems are making huge financial investments into strategies to prevent their most dedicated clinicians from leaving health care, expensive solutions being dangled before the desperate eyes of hospital leadership, regularly miss a key socio-politically grounded feature of burnout.
The depleting sequelae of moral uncertainty, moral distress, moral injury and even moral stress are linked to conflicts that are not surprising within social systems marked by a plurality of values. We must not become complacent, in thinking that moral compromise is solely an individual’s responsibility or in thinking that interventions such as yoga, ergonomically correct chairs or even mindfulness courses, are effectively tailored to addressing these serious contributors to healthcare provider burnout. Recent research highlights an increasingly recognized bi-directional relationship between a definition of moral distress and burnout, revealing moral distress as a cause of burnout and burnout contributing to moral distress severity.
There is an urgent need for a strategy to address moral distress and burnout: one that we argue, needs to be sensitive to the diverse socio-political contributors. This strategy also needs to be adaptable to a range of health care systems with various levels of ethics consultation support. Our ethics team with training in bioethics, nursing, medicine and worked together to develop amoral distress reflective debrief tool aimed at moving those experiencing moral distress to the “moral peace” characterized by greater clarity regarding the moral tensions at play and regarding a plan for next steps.  
Our presentation will describe (1) the bi-directional relationship between moral distress and burnout with particular attention to the impact/influence of socio-political challenges, (2) the self-administered or ethicist-led moral distress debrief tool and (3) the ongoing roll out and evaluation."

4)    Mcloughlin P. Moral Distress Across the Whole Treatment Team: Who Feels What and What Do They Want

Abstract:

"Introduction: Moral engagements are a deeply inherent and intractable component of modern healthcare practice. These challenges affect not only healthcare providers (HCPs) but also patients and their loved ones, healthcare organizations, and the wider community. When these ethical uncertainties, conflicts, and dilemmas are unable to be resolved satisfactorily moral suffering ensues. Moral distress is a particular form of moral suffering experienced because of situations in which HCPs are aware of a moral problem, assume moral responsibility for the issue, and subsequently make a moral judgment as to what they believe is the right word or action to take (or not take). Healthcare ethics consultations (HECs) are often requested when significant moral distress is at play in the team. In fact, some centres now have a separate moral distress consultation service for these types of issues. 
Purpose of research: The purpose of this research was to explore the phenomenon of moral distress, through an interdisciplinary research lens, looking at the whole multidisciplinary team caring for patients requiring long-term ventilatory support. These HCPs were drawn from the disciplines of nursing, medicine, respiratory therapy, physiotherapy, spiritual care, pharmacy, and social work. This study is unique in exploring moral distress in this population and environment.
Methodology: An interpretive phenomenological research method was employed. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) validated questionnaire was completed and in-depth interviews undertaken.
Results & Discussion: This doctoral research highlights that moral distress is not a homogeneous phenomenon of experience amongst the separate HCPs. There are significant differences in the causes, sequalae, and self reported socio-political solutions for the different team members. It is also seen that moral distress may be experienced not only by the HCPs but also by patients and families. HCPs provide personal wisdom for how we might avoid conflicts in the first place."
 

5)     Höpfer D. and Hider G. Who is to Blame? Identifying Responsibility and Accountability in HEC Conflict Resolution

Abstract:

"When healthcare ethics consults require conflict resolution, consultants often encounter parties who place blame on others. In some cases, the person who is blamed is at fault, but in many cases blame is placed for behaviors or characteristics that are irrelevant to the matter at hand. Patients are sometimes blamed for their illnesses, one medical service might blame another for a perceived fault. Fault assumes failure. The act of blaming labels the one blamed as a failure, establishing an unwillingness to communicate and creating the need for conflict resolution. Sadly, it is all too easy to adopt an attitude of blaming. Perceptions of blame play out in an emotional response to moral distress. A cognitive response can offer a different perspective that can potentially draw the emphasis away from fault-finding and re-orient to resolution.
Rather than engaging in placing blame, healthcare ethics consultants can identify actual responsibility and accountability. Responsibility is an attempt to define goals and processes amid uncertainty. Accountability is outcome-based and provides the basis for evaluation of goals and processes. Understood together, responsibility and accountability can provide insight into what happened, what are the consequences of what happened, and how to proceed.
The presenters will demonstrate a Responsibility and Accountability model. The concepts of the model draw from a multi-disciplinary approach to clarify ethical uncertainty and emotional bias. The model reflects a real-world application process that is intended for use in clinical settings. Use of the model can aid in identifying responsibility and accountability while avoiding passing blame, thereby facilitating collaborative communication and conflict resolution."

1)    Johnson L. Preventative Ethics in the Pediatric Intensive Care Unit: Implementation of a Time-Based Automated Ethics Rounding Service

Abstract:

"Background:  Empirical evidence shows that perceptions of non-beneficial treatment and questions about goals of care cause moral distress among clinicians and are a common reason for ethics consultations. These situations arise commonly in the pediatric intensive care unit (PICU), early involvement by palliative care and ethics is recommended in professional guidelines.

Aims: We sought to assess the feasibility and acceptability of using a time-based automatic consult order to the clinical ethics service to facilitate the early involvement of ethics into interdisciplinary rounds as a form of preventative ethics in a subspecialty PICU.

Methods: Using the capabilities of the electronic medical record (EMR), an ethics consultation order occurs automatically on ICU Day 5. Ethics reviews the patient's EMR and assigns a priority to the request (urgent-round in ICU within 48 hours, standard-round within 72 hours, or low-patient expected to leave ICU, follow remotely).  An ethics rounding note is placed in the EMR following rounds unless the consultant identifies the need for a full consultation. After the initial rounding encounter, ethics follows the patient until death or ICU discharge. The Armstrong Clinical Ethics Coding System is used to track the clinical ethics issues in each case.

Results/Discussion: We will present 6 months of preliminary data including demographics, reasons for ICU admission, clinical ethics issues identified and will discuss the feasibility of implementing a time-based system for the early involvement of clinical ethics into the PICU. Our anecdotal experience with ICU rounding indicates that an automatic rounding process normalizes the role of clinical ethics in the ICU setting, serves as a form of preventative ethics, is acceptable to patients and medical staff, and is not overly burdensome to the ethics service. Institutions considering a trigger-based rounding system may wish to customize their automatic triggers to suit their individual needs."

2)    Spiegel J.L. Decision-Making in the PICU: Balancing Medical Scarcity and Parental Autonomy

Abstract:

"A nine-month-old infant was admitted to the pediatric intensive care unit (PICU) with severe hypoxic ischemic encephalopathy after drowning. Despite a tenuous initial course, he was stabilized on mechanical ventilation and nasogastric tube feeds. He was not a candidate for extubation as he did not have the cough or gag reflexes required to protect his airway. His family was left with a decision: compassionate extubation with transition to comfort care or pursuit of a tracheostomy and a gastrostomy tube for long-term care.

Decision-making supports for the family included brain imaging (MRI and nuclear scans), subspecialist consults (pulmonology, neurology, physical medicine & rehabilitation, and palliative care), family meetings, medical device demonstrations, and parental support groups. Despite these measures, the child’s parents were unable to make a unified decision for over a month. They identified familial discord, religion, guilt, and medical uncertainty as hindrances to decision-making.

In pediatrics, parents/guardians have the responsibility to act in the best interest of their child. In most instances, they have a right to choose desired treatments and to provide informed consent for interventions. Physicians, however, should only provide care where the potential benefits to the child outweigh the possible harms. Fulfillment of this ethical mandate may be complicated by unforeseen harms, by the prospect of physiologic futility, and by moral distress. There are also system- and community-level justice considerations in fair allocation of ICU beds, ventilators, and diagnostic tests, all of which are limited resources. Would it be ethically justifiable to limit the time permitted for parental decision-making for a critically ill but stable child?  What biases might influence imposition of such a time limit? What supports could be added to help both parents and health care teams in the decision-making process?"

3)    Kates Rose J. Parental experiences of DM in the grey zones of neonatal intensive care: an international multi-centre mixed methodology study

Abstract:

"Background
In the neonatal intensive care unit (NICU), grey zones – situations where multiple morally acceptable decisions exist – often arise. Sharing decision-making (DM) with caregivers in these contexts is complex. Moral distress (MoD) is well-documented in clinicians, but caregiver moral experiences remain unknown.

Aims
To elucidate caregiver moral experiences of DM in NICU grey zones, particularly, to establish whether MoD and moral schism are present.

Methods
This was a mixed-methodology phenomenological study. Parents of infants who were admitted for 3 or more days between 2018-2022 and who engaged in complex conversations surrounding care plan decisions were invited to complete a survey about their experiences of DM. Bereaved families were not contacted until at least one year following their child’s death. Demographic data were collected through chart review. Descriptive statistics were used for quantitative data. Qualitative data were analysed using thematic analysis, informed by the concepts of moral distress and moral schism.

Results
71 parents (80% mothers) completed the survey. Thematic analysis generated five themes: decision burdens, internal tensions, actualising beliefs and values through DM, inauthentic shared DM, and external factors shaping DM. Overall, 89% of parents wanted to be involved in DM, though only 63% felt included in that process. DM was experienced as burdensome and grey zones elicited tensions within parents about their roles and desires. Parents valued opportunities to actualise their values in the DM process. Despite the goal of shared DM, some parents felt coerced into decisions, consistent with MoD. Extrinsic factors, such as time pressures and partner support, influenced the DM tensions.

Discussion
Facilitating shared DM is complex, reflecting the need for personalised DM and sensitivity to external and internal pressures experienced. Caregivers are subject to MoD and moral schism. A nuanced approach that considers all perspectives may help alleviate tensions and better resolve DM conflict."

4)    Teti S. NICU Complex Care Rounds: A 42-Month Interrupted Time Series Study

Abstract:

"Background
The NICU presents a uniquely challenging environment: the fragility of the patients, the typically long courses of treatment, the hopes and dreams of parents, and close-knit culture can challenge the efficacy of a reactive ethics consultation format, however responsive it may be. An approach to managing value disagreements before they escalate into conflict was needed. Ethical sensitivity and everyday ethics skills needed to be inculcated into practice and embedded in culture.

Aims
This project sought to measure the effects of supplementing existing clinical ethics consultation services with weekly ethics Complex Care Rounds (CCR) in our 106-bed NICU as part of ongoing consult service quality improvement. Any team member (with a focus on nurses) could nominate a case for CCR. Once weekly a multidisciplinary team would meet to discuss the cases with each attending physician in turn.

Methods
A pre/post time series study design was used to investigate impact of the project with the interrupt set at six months after initiation of CCR. 110 formal ethics consults occurred in the 42-month period.

Results
In the post period, the day of the patient's hospitalization on which ethics was consulted decreased from a mean of 32.8 days to 21.2 days. Average case complexity decreased from 2.4 to 2.1 on a 4-point scale. Average length of stay decreased from 73.9 days to 53.9 days. Qualitatively, we found consults involving moral distress decreased 59% while the team's willingness to question some parental choices increased 45%. 

Discussion
As 'basic' consults (help with goals of care) decreased, a broader variety of ethical questions emerged in the post period (as measured with ACECS codes), suggesting consults change, but volumes do not necessarily diminish with increased ethics support. This suggests CCR was effective in raising the capacity of frontline team members to identify ethical issues and manage internally or escalate accordingly."
 

5)    Lukich N. Proactive and Family-Centred: Changing clinical ethics consultation in NICU

Abstract:

"Healthcare organizations strive to provide patient- and family-centred care in order to improve patient experience. Clinical ethics services can support this goal by assisting staff with challenging ethical cases as well as institutions with organizational ethical concerns. Clinical ethics services can demonstrate family-centred care by being used proactively in order to reduce various forms of conflict in clinical environments. This presentation will focus on a model being implemented in a Toronto Neonatal Intensive Care Unit (NICU), where an ethicist is working with staff and families to provide more proactive support and to predict and reduce conflict. 
NICUs face multiple ethical dilemmas which can lead to contention, including the decision to resuscitate and care for premature babies as young as 22-weeks' gestation, options and decisions regarding redirection of care, defining harm and suffering for infants who cannot speak for themselves, parental disagreements, and general moral distress associated with intensive care. While some cases may require reactive support from an ethicist, many of these scenarios could be addressed proactively. This is demonstrated through various actions, such as the ethicist rounding with the nursing and leadership teams on a regular basis, providing education for parents regarding their role, rights, and responsibilities, and empowering all members of an infant's team to collaborate in decision-making. 
While these initiatives have demonstrated success in reducing conflict between staff and parents, there are still challenges that are faced as this new model continues to be implemented, such as increasing understanding of both the purpose and limits of ethics consultation, establishing trusting relationships with parents, and balancing work with the limited resources of an ethics consultation service. Despite the challenges, however, it is clear that this model can be helpful for all NICU staff, parents, and patients in reducing conflicts and ultimately achieving more effective family-centred care."

1)    Bahus M.K. Self-harmers and the right to life. Mediation and conflict resolutions on a collision course with law

Abstract:

"Non-suicidal self-harming is intentionally self-injuring oneself without the intention of dying (Clarke et al., 2019). Examples include swallowing foreign objects or taking a dangerous amount of pain medication. Individuals who self-harm often require immediate medical attention. According to Norwegian law, healthcare professionals are required to treat a patient in an emergency, even if the patient is competent and refuses treatment. This obligation is in line with the UN Convention for the Protection of Human Rights and Fundamental Freedoms, which emphasizes the right to life in article 2.
Many self-harmers refuse necessary treatment, causing healthcare professionals having to use coercion to save their lives. This use of coercion and the attention the self-harmers thus receive, sometimes result in the patients harming themselves more severely on following occasions and also more frequently. The necessary medical treatment, mandated by law, appears to perpetuate negative and health-threatening behavior. These situations also require close cooperation between emergency physicians and psychologists and hence between different departments in the hospital. These challenging situations often lead to a need to seek advice from Clinical Ethics Committees (CECs). To give adequate guidance, the committee must find a way to hold the patient accountable for his or her actions and encourage the patient to choose not to harm him- or herself, without disregarding the health personnel's duty to provide emergency care and the patient's right to life. To facilitate mediation and conflict resolution, the legal boundaries must be carefully examined without compromising the obligation to act in an emergency. How far can we go in negotiating with the patient when his/her life is at risk?"

2)    Neefjes V. Advantages and limitations of a specialist committee deciding on futility in end-of-life treatment decisions 

Abstract:

"In England & Wales both parents and clinicians can refer intractable clinician-parent conflicts to the courts for a decision. However, given the costs of litigation, court cases about withdrawing life-sustaining medical treatment for children in England & Wales are often followed by discussion how to avoid future cases. Whilst two proposals, mediation and the introduction of a harm threshold, have received broad attention, a proposal to replace the court by a specialist review committee has not been further investigated.
This study analyses the effects of a putative replacement of the courts in England & Wales by a specialist review committee using the process enacted by the futility clauses in the Texas Advance Directive Act (TADA) as a model. Briefly, under TADA life-sustaining treatment may be withdrawn when a review committee finds it is futile, and no alternative healthcare provider can be identified within a set period. 
The investigation first considered the advantages of the current court procedures above TADA, i.e. transparency, and suggests a modified procedure that would install a national specialist review committee modelled after TADA. Installing a national review committee to replace the court would reduce the number of court cases in England & Wales to only a few. However a national specialist review committee deciding on futility has further advantages for both clinicians and parents. Advantages for clinicians are more limited exposure to delivery of clinical care that may cause moral distress and less exposure to adverse press and social media content. Advantages for parents are that the process would establish them as ethical decision makers and offer the possibility of a transfer of care provided an alternative healthcare provider can be found. Given the advantages the feasibility of a replacement of the courts by a specialist review committee deserves further investigation."

3)    Smolenski J. Involuntary Treatment for Anorexia Nervosa: Medically Obligatory, or an Exercise in Futility?

Abstract:

"In this paper, I consider the case of severe treatment-refractory anorexia nervosa (AN). Given the nature of anorexia - which involves not only delusional beliefs about one's body, but also impaired cognition caused by starvation – patients with this diagnosis often adamantly resist any efforts at treatment. In some cases, extended periods of involuntary treatment can result in positive results, even remission or cure. In others, AN patients are subjected to repeated, costly treatment against their will, which they actively resist and fails.

AN can lead to intractable refusals of treatment, such that even treatment under restraint may not be enough to generate meaningful clinical improvement. Though patients may indicate that they want to live, and that they know artificial nutrition and hydration (ANH) is necessary to achieve this goal, they may nevertheless remain unable to permit its administration. They may even appear to consent to being restrained at various times, however, the level and duration of restraint necessary for potential improvement tends to be inconsistent with more general practices regarding involuntary treatment (i.e., that it should be used as briefly as possible, as infrequently as possible, and thus is generally not considered practicable for long-term interventions). Furthermore, it is not antecedently obvious that such extended involuntary treatment will even work (let alone be in the patient's overall best interest).  

As such, clinical ethicists are increasingly being consulted about the possibility that ongoing compulsory treatment for treatment-refractory AN-especially under restraint- may be medically inappropriate, and thus morally appropriate (or even obligatory) to withhold or withdraw, even over patient or family objection. This could bring anorexia nervosa into a hotly contested domain -that of a potentially medically-futile psychiatric disorder- and thus of particular relevance to this year's theme of HEC and conflict resolution, specifically between patients/families and providers."

4)    Neefjes V. Can mediation avoid litigation in conflicts about medical treatment for children?

Abstract:

"Conflicts between parents and clinicians about medical treatment for seriously ill children have been litigated in the courts of England and Wales for many years. Whilst the value of applying to the court lies in the resolution of an otherwise intractable conflict, litigation does have disadvantages such as the length of time before a conclusion is reached, the financial costs and the adverse effects of an adversarial process on the relationship between parents and clinicians. 
It is not surprising therefore that especially after highly contentious cases questions are asked how to avoid such litigation in future.
Whilst judges, clinicians, academics and parents agree that improved communication between clinicians and parents could avoid future litigation, research outlining if and to what extent better communication will avoid future litigation is lacking.
This study aimed to investigate the reasons why parents disagree with their clinicians in cases reaching the court and to estimate the number of cases in which mediation might have resolved the conflict and avoided litigation. 
Eighty-three cases regarding medical treatment decisions for children initiated either by an NHS Trust or Local Authority and reported between 1990 and 1st July 2022 were analysed.
The analysis found that the three main areas of contention are different value judgments, factual areas such as the health of the child, their quality of life or burden of treatment and relational issues, i.e. loss of trust. More than half of the cases are estimated not to have been preventable by mediation because either no conflict existed (n=13) or the parental decision was based on strongly held, mostly faith-based, views unlikely to be open for discussion (n=31). 
The study concludes that the potential of mediation to resolve clinician-parent conflicts and thus avoid litigation may be more limited than hoped for."
 

5)    Henriksen J. "Futility" Policy Revision: Addressing Power and Promoting Fairness

Abstract:

"In the United States, a powerful emphasis on individual autonomy and the patient as consumer has influenced the way clinicians offer choices to patients. More than a quarter of ethics consultation requests we receive involve conflicts where clinicians describe feeling pressure to provide, or continue to provide, requested treatments even when they believe those treatments will not help or may be harming the patient. Many U.S. healthcare institutions have developed policies to guide responses to conflicts that arise between clinicians and patients/families about interventions of disputed benefit.
In our hospital system, the Ethics Program is responsible for this policy. In undertaking a revision of the policy, we uncovered that overall, clinicians felt unsupported by the institution and so were less willing to utilize the policy process, choosing instead to acquiesce to patient/family requests for interventions that the clinicians believed to be ineffective or harmful. Additionally, we found that across the organization, the policy had been invoked for patients with marginalized identities at a rate disproportionate to the general patient populations served in our acute care settings. These findings led us to further consider the policy through the lens of power and fairness.
This presentation will frame the ethical tensions addressed in such policies in terms of expressions of power, potential for bias and justice. It will then describe practical approaches and steps we used in revising the policy. The intention was to strike a balance between supporting clinician integrity and professional judgment and honoring patient values and preferences about what goals they judge to be worth pursuing. We will encourage group discussion to learn how other healthcare systems address power imbalances in conflicts around interventions of disputed efficacy."

Bouthillier M.-E., Marckmann G., Metselaar S., Ritzenthaler D., Schildmann J. The role of clinical ethics consultation in requests for assisted dying

Abstract:

"Assisted dying is a legal option in an increasing number of countries around the world. Legislative frameworks usually define basic elements of legitimate practice of assisted dying. Clinical ethics consultation (CEC) services are involved in safeguarding appropriate practices in concrete cases of requests for assisted dying. However, the role of CEC in assisted dying has been discussed controversially in the literature and varies considerably around the world: While in some countries CEC services are regularly involved in requests for assisted dying, they are involved just on demand in other countries. This difference in practice as well as the question what CEC services can actually contribute in requests for assisted dying raise the question what the appropriate role of CEC in assisted dying should be and how CEC should be conducted if it is involved.

The aims of the proposed workshop are firstly to provide insights into current practices of involvement of CEC services and secondly to provide a forum to discuss the role(s) of CEC services and underlying reasons for (possibly differing) roles. Four short presentations will introduce the participants into experiences with CECS in requests for assisted dying from four different countries, thereby covering not only different legislative frameworks but also different socio-cultural backgrounds: Canada, Germany, Switzerland and The Netherlands.
Based on these presentations, further perspectives from the participants and concrete cases, we will discuss the following guiding questions in the workshop:
(1) What can or should be appropriate roles of CEC in requests for assisted dying and what limits with regard to the contribution of CECs can be identified?
(2) How can CEC be conducted to contribute effectively to ethically justified practices of assisted dying?
Overall, the workshop shall bring together experiences and expertise from different countries to develop perspectives about what CEC can contribute to ethically sound practices of assisted dying.

Chair: Jan Schildmann, MLU Halle, Germany

Panelists:
Marie-Eve Bouthillier, Université de Montréal, Canada (confirmed)
Daniela Ritzenthaler, CHUV Centre Hospitalier Universitaire Vaudois, Switzerland (confirmed)
Suzanne Metselaar, Amsterdam UMC, The Netherlands (to be confirmed)
Georg Marckmann, LMU Munich, Germany (confirmed)"

Wasson K., Molewijk A.C., Stolper M. Training and assessing ethics support trainees/staff: examining the rationale and practice of two different simulation methods

Abstract:

"Vital to ethics consultation and facilitating moral case deliberations is the ability to identify and analyze the ethical dimensions of a case and stimulate a dialogical moral inquiry into the moral reasoning of the stakeholders. Both involve specific knowledge, skills and a particular attitude, e.g. compassion, curiosity, openness to different viewpoints, respect for all parties. Yet, how do we train and assess clinical ethics support staff to do this work?

Methods for training these specific skills in clinical ethics support are limited to date, let alone the assessment of these skills. One common approach in healthcare skills training is to use simulation-based education (SBE). Based on identified competencies, relevant skills are identified and learning objectives set for the learner.  Simulation exercises allow the learner to practice in real time with trained professionals (both from ethics and health care) providing feedback.

This workshop will offer two different approaches to SBE for clinical ethics support staff.

First, the Assessing Clinical Ethics Skills (ACES) tool was developed based on national standards for clinical ethics consultation in the United States. It includes 12 key components, and this workshop will focus on three: identifying ethical issues and considerations, identifying the ethically (in)appropriate options in a case, and articulating the ethical rationales for each option. These steps are crucial to the process of moral decision making in ethics consultation. The ACES tool allows trained raters to evaluate learners and provide consistent, structured feedback either using formative or mastery pedagogy.  

Second, Moral Case Deliberation is a structured dialogue among health care professionals about their moral questions in practice. A trained and certified facilitator moderates the moral inquiry without giving advice, using one of the various MCD conversation methods. The content and the didactics of the MCD facilitator training is developed in line with the philosophy of MCD: pragmatic hermeneutics, dialogical ethics and Socratic epistemology. Central principles are: learning by doing, reflection instead of ready-made knowledge, and dialogue on dialogue. Specific self-reflection and observation forms are developed to assess the quality of the facilitator-trainees.

After briefly describing both simulation methods (part A, 25 min), including the assessment criteria, workshop participants will get the opportunity to practice these approaches in small groups (part B, 30 min). The presenters (part C, 25 min), will also scrutinize the pros and cons of each simulation and assessment method, and then explore if, and how to use them in participants own context."

Dunsford J. and Simpson C. The Aggressive SDM: Clinical Ethics Consultation at the Intersections of Safety, Vulnerabilities, and Best Interests

Abstract:

"Violence in the health care environment is now so widespread as to be commonplace. Aggression and abuse toward health care providers is a significant cause of physical and psychological injury, moral distress, and intention to leave a position (for example, Beattie et al., 2018, Havaei & MacPhee, 2021, Kiymaz & Ko, 2022, Magnavita et al., 2020). Although much care-related violence is committed by patients, all too often the perpetrator is a patient's family member or significant support person. This results in a complex, morally fraught situation, which is made even more difficult when the perpetrator is the substitute decision-maker (SDM) for an incapable patient, making it impossible to simply remove them from the situation. Although professional obligations and patient vulnerabilities compel staff to continue to provide care in these situations, they do so at considerable personal risk of trauma at the hands of the SDM.
Clinical ethics consultation is an important support in the resolution and prevention of situations where aggressive or abusive behaviour from an SDM poses safety risks to health care providers. In this interactive workshop, using the presenters' experience in clinical ethics consultation, we unpack the morally complex phenomenon of determining and acting in the best interests of a patient whose care is complicated by threat and/or actual violence from their SDM. Our analysis and recommendations are framed by Salient Vulnerability Theory, an emerging conceptual approach based on one presenter's doctoral research. This approach focuses on understanding aggression in the health care environment, and health care providers' decision-making processes around care in the context of violence. Using a case study to exemplify the phenomenon, this workshop outlines the problem of aggression from SDMs and explores the ethical conflicts that result. We examine the intersecting vulnerabilities of patient, SDM, and provider that create tensions in care settings, and demonstrate the application of a vulnerability lens for addressing the resulting conflicts. Using small-group discussions, we consider recommendations for ethics consultants in mediating a course of action that is both in the patient's best interests, and examines how, and in what ways, the involvement of the designated decision-maker may occur despite their behaviours that place others at risk. We conclude with a discussion of the moral distress experienced by providers in these situations."

Al Sinawi H., Al Mandhari Z., Khamis F. Resolving Ethical Conflicts in Multicultural Settings: A Structured Framework for Healthcare Professionals

Abstract:

"Introduction:

Advances in biology and medicine have introduced complex ethical challenges, making it difficult to define right from wrong in healthcare. To navigate these dilemmas, particularly in culturally and religiously diverse contexts, an Ethical Framework was devised by the National Bioethics Committee in Oman to serve as a moral guide for medical policy and practice, rooted in its mission of service to humanity through universal ethical principles.

The framework emphasizes five core values protection of faith, life, lineage, intellect, and property supported by principles of autonomy, beneficence, justice, and non-maleficence. In cases where ethical disputes arise, this structured framework enables decision-makers to examine explicit reasons for or against particular actions, reflecting both institutional values and ethical principles.

Methodology:

This workshop uses a case-based approach to engage healthcare professionals in culturally sensitive ethical decision-making. Aimed at doctors, nurses, and senior medical students, it provides tools to approach real-world ethical conflicts thoughtfully and collaboratively.

1. Framework Overview: Facilitators introduce the Ethical Framework, explaining its core values and principles to guide participants in aligning decisions with institutional ethics.
2. Case-Based Problem Identification: Participants identify and define ethical conflicts within case scenarios, paying attention to relevant cultural or religious dimensions.
3. Self-Reflection on Biases and Emotions: Participants acknowledge personal biases and emotional responses to promote self-awareness and better-informed decision-making.
4. Fact-Gathering and Analysis: Each group assesses relevant facts, considering diverse perspectives, institutional policies, and applicable laws to ground their decisions.
5. Exploration of Alternatives: Teams identify and assess alternative actions and outcomes, ensuring alignment with clinical goals and ethical values.
6. Ranking and Justifying Values: Groups rank and justify values, enhancing transparency and structured reasoning in ethical analysis.
7. Decision Articulation and Implementation: Participants develop an action plan, emphasizing clear communication, documentation, and thoughtful implementation.
8. Concluding Reflection: The workshop concludes with a reflection on decision-making processes, biases, and interdisciplinary collaboration.

Conclusion:

This workshop equips healthcare professionals with a structured approach to resolving ethical conflicts, fostering culturally informed, patient-centered care. By integrating the proposed Ethical Framework's values and principles, participants gain tools for ethical reasoning that respect diverse beliefs and support fair, compassionate healthcare delivery."

Speakers :

- Richard Huxtable
- Sarah Barclay
- Anna Hirsch
- Julia Palmiano Federer

Please access the full description here

1)    Ochasi A. Mandela the Ethicist: Introducing the NEMAS Transformative Mediation Framework for Clinical Ethics Consultations

Abstract:

"Ethics consultants are tasked with resolving uncertainty or conflict regarding value-laden concerns that emerge in clinical situations. As such, they assume various roles in the process, with their primary roles often being those of negotiator, mediator, or arbitrator. While acknowledging the value of these methods of conflict resolution, their inherent limitations call for a revised approach. This paper introduces the NEMAS framework (Neutrality, Empowerment, Mutual Recognition, Addressing Power Imbalances, and Shifting from Positions to Interests) for clinical ethics consultations drawn from Nelson Mandela's transformative mediation during the Burundi Civil War. In transformative mediation, the mediators empower the parties to resolve their conflict and encourage them to recognize each other's needs and interests. The complex dynamics of clinical ethics consultations often mirror the challenges in high-stakes conflict mediation in the larger society, where trust, inclusion, mutual understanding, and recognition of each other's perspectives are critical. Mandela's approach in resolving the decade-long conflict between Hutu and Tutsi factions showcases the power of impartiality and inclusivity in fostering trust and collaboration that was pivotal in brokering the Arusha Peace Accords in 2000.
This paper argues that similar dynamics emerge in clinical ethics consultations, particularly in emotionally charged cases involving ineffective (futile) treatment at the end-of-life or complex treatment decisions. As facilitators, ethicists like Mandela must ensure that all stakeholders - patients, families, and the medical team feel heard and valued. Mandela's emphasis on neutrality, empowering marginalized voices,  and addressing power imbalances aligns with the ethicist's responsibility to recognize patient autonomy while balancing clinical realities. Furthermore, Mandela's ingenious approach of shifting discussions from rigid positions to underlying interests offers a valuable tool for ethics consultations. By diffusing the tensions and guiding parties to focus on shared values such as dignity, quality of life, and compassionate care, ethicists help the parties transform their fractured relationship and agree on mutually acceptable solutions."

2)    Kreitmair K. Empathic AI meets Hegel -- The Perils of Off-Loading Clinical Ethics Consultations onto AI Agents 

Abstract:

"Generative large-language models such as GPT4 are being adopted as 'conversational agents' or 'AI agents' in clinical encounters. NVIDIA, for instance, has partnered with Hippocratic AI to develop so-called 'AI nurses' who, for less than nine dollars an hour, talk to patients about their concerns around congestive heart failure, chronic kidney disease, hospital discharge, medication, and pre-operative procedures. This material is not transmitted in a neutral, informational manner. Rather, these AI agents are instances of so-called empathic AI, programmed to mimic human personalities and conversational styles. NVIDIA's AI agents, for example, are described as 'building rapport', 'expressing empathy', and 'getting to know the patient as a person'. At some point, we might imagine, conversational agents could take over the work of clinical ethics consultants. Technically, there is no reason such 'AI agents' would not be able to scour the bioethics literature for germane insights, comb data from electronic health records and prior ethics consultations, incorporate relevant case or statutory law, and provide 'empathic' and 'compassionate' recommendations directly to patients.
I argue that the use of conversational agents in clinical ethics is highly problematic. My argument is based on the claim that essential to good clinical encounters is the Hegelian concept of recognition. Recognition is 'a process in which a subject 'takes' another subject as a subject'. It is the existential action of appreciating another entity as a normative agent. In my argument, I show that clinical encounters, including clinical ethics encounters, require this existential action to fulfil conditions such as trust, respect for autonomy, honesty, and caring, that are essential to good clinical encounters. I further describe that the capacities necessary for recognition, namely voluntariness, capacity for consciousness, and mutuality are all absent in conversational agents. Consequently, I conclude that clinical ethics consultations should never be offloaded onto AI agents."

3)    Khan J. Enhancing conflict resolution: the role of cultural competence in medical interpretation during complex patient discussions

Abstract:

"Effective communication in complex medical care often requires medical interpreters, especially in multicultural settings. Cultural competence is essential also for healthcare ethics committees (HECs) when managing conflicts that arise from miscommunication or differing cultural values between patients and healthcare providers. At our tertiary care hospital in the United Arab Emirates, interpreters and our HEC bridge cultural and linguistic gaps during sensitive discussions, such as delivering bad news and goals-of-care conversations, sometimes towards end of life. This presentation recapitulates preliminary findings for a study done at our hospital around the cultural competence and emotional intelligence of medical interpreters and how these attributes contribute to conflict resolution and ethical decision-making.

The presentation will discuss pre-liminary findings from a mixed-methods study at CCAD, involving surveys and semi-structured interviews with medical interpreters. While interpreters generally demonstrate strong communication skills, we hypothesize that gaps remain in their training, particularly around handling emotionally charged situations and intercultural tensions.

Through the lens of clinical ethics and conflict resolution, the presentation will propose strategies for improving interpreter training. These strategies emphasize enhancing cultural sensitivity, emotional intelligence, and conflict mediation skills, all of which HECs can use to prevent or resolve ethical conflicts. The study also highlights the need for continuous professional development and a supportive environment for interpreters to manage the growing complexities of multicultural healthcare.

By addressing the intersection of HEC, cultural competence, and conflict resolution, this presentation aims to contribute to a more equitable and sustainable healthcare system, aligned with the goals of clinical ethics and patient care."

4)    Filleul A. A living ethics lab in a rehabilitation hospital: Concept and initial development  

Abstract:

"Background: Rehabilitation hospitals faced a wide range of ethical issues, such as the equitable allocation of resources to meet diverse patient needs or managing the opioid crisis in chronic pain management. These situations involve value conflicts and lead to patient frustration and clinician moral distress, contributing to staff retention problems. In addition, administrators and clinicians lack the training and resources to help them make informed ethical decisions.

Aims: LEViER is an innovative living ethics lab aimed at identifying ethical issues in rehabilitation and creating practical, actionable solutions. This project takes place at the Institut de réadaptation Gingras-Lindsay-de-Montréal (IRGLM), a major rehabilitation hospital.

Theory: The project is grounded in the concept of "living ethics," a novel stance that prioritizes dialogue and collaboration. Living ethics encourages open discussions about ethical issues, focusing notably on collective and constructive problem-solving and action.

Methods: This presentation will present the overall concept of the LEVIER program and the results from phase 1, where semi-structured interviews and focus groups with rehabilitation administrators were conducted to identify and categorize the key ethical issues they face. These findings have laid the groundwork for phase 2, which is currently underway. This phase features participatory workshops where administrators, clinicians, patients, and their families collaborate to co-create practical solutions addressing real-world ethical issues and informing policy development. Looking ahead, phase 3 will pilot test these solutions at the IRGLM, with real-time feedback helping to refine and ensure their effectiveness and sustainability.

Discussion: LEViER innovates by incorporating the perspectives of all stakeholders involved in rehabilitation care, with the aim of developing more ethically sound, contextually relevant and innovative solutions. This builds from previous like-minded efforts to propose dynamic and adaptable institutional framework to enhancing staff well-being and quality of patient care through collaboration."
 

5)    Romero M. and Eggert N. Is narrative ethics a tool for resolving conflicts within health care ethics bodies?

Abstract:

"Narrative is now recognised as a tool to support carers in the face of daily challenges and to help patients cope better with their illness. In particular, it is used as a means of 'prevention and resilience against burn-out among carers' (Gateau V., 2022), as well as a 'prophylactic treatment' (Bommier C., Tudrej B. V., Hervé C., 2019).  for their suffering. For patients, recounting their experience of their illness promotes a process of 'empowerment' (Seret-Bégué D., 2020).  by giving value to their stories. More generally, narrative is useful in situations marked by upheaval, such as during the COVID-19 pandemic (Fleury C., Gateau V., 2022). But if narrative benefits carers and patients, could it also be an asset in clinical ethics consultations and ethics committees? Indeed, with its existential, hermeneutic and ethical functions (Ricoeur, P., 1990, Charon, R. 2015, Pierron, J.-P., & Chvetzoff, G.,2021), narrative could help to prevent and resolve conflicts of values within the medical teams that call on these bodies. However, how can narrative be integrated into these deliberations, where objectivity takes precedence over meeting the patient's needs? Who is responsible for telling the story, and on whose behalf? Is it possible to construct a collective narrative within these bodies to better represent the different perspectives? The aim of this contribution is to examine the interests, limits and conditions of possibility of using narrative ethics in the context of deliberation in healthcare."

1)    Eijkholt M. Including patients in ethics support! When would perceptions about harm and risk justify reasons not to include patients in HEC?

Abstract:

"In Europe, patient participation in clinical ethics interventions (hereafter PP) is a topic of controversy. Our empirical study has revealed that some of the objections to PP relate to perceptions about harm. Part of these are related to concerns about patient harm, but also to concerns about provider harm. For example, some of the objections against PP are related to decreased openness because of PP – a certain type of harm. In the USA, where PP is much more common, provider-related harms are not part of the reasons to reject PP. Concerns about potential patient harm, however, also appear as a reason to object to PP in the US. Still, PP is hardly a topic of controversy in the USA.

In our presentation, we zoom in on our empirical findings regarding harm and objections against PP in Europe and in the US. We scrutinize perceived harms for the different stakeholders on different levels. Can we specify the concerns about harm, and how they would be embraced or rejected in the different systems. What does the lack about concern about potential harm for providers mean in the USA system, and what about concern for patient harm in both systems? We ask if and what concerns about harm can be upheld in the light of the empirical and theoretical considerations that justify PP. If we deem PP desirable for reasons of procedural or epistemic justice, we ask which cases then warrant patient participation in the light of concerns about harm. We seek to go beyond arguments of cultural differences."

2)    Bryant P. Treatment over Objection in Non-Psychiatric Facilities: Toward an Ethical Standard

Abstract:

"Treating incapacitated patients over their objection can present some of the most ethically complex and morally distressing situations faced by clinicians. Balancing the professional commitment to the patient's wellbeing with the appropriate recognition of the potential harms of forcing treatment is an evaluation that feels deeply counterintuitive to healthcare professionals. The sometimes necessary use of chemical and physical restraint can transform a therapeutic intervention into an uncomfortable admixture of care, power and perceived violence. Without ethical standards for deliberation, patients may be at risk for suboptimal care or may undergo treatments that could be overly burdensome. Little is understood about how deliberations proceed for treatment over objection in non-psychiatric facilities involving non-psychiatric treatments.  In 2019 Rubin and Prager proposed a guide to ethical deliberation consisting of seven questions to consider in treatment over objection, and in 2021 Fischkoff, Prager et al. reported analysis of 35 cases that showed the statistical relationship between the seven questions and the final decision made.1,2 Replicating the Fischkoff study's analytical approach, this presentation will share results from an analysis of 153 cases, all of which occurred over a 10-year period at another, geographically different U.S tertiary hospital. In addition, results from a secondary analysis will show the relationship between the final decision and three additional variables: race, ethnicity and insurance status. The implications for disparities will be discussed. Finally, this presentation will articulate how these results serve as a step in a longer-term project of developing widely-recognized ethical standards for treatment over objection in non-psychiatric facilities."

1.    Fischkoff D, Prager K, Dastidar J, et al. Ethical Framework to Guide Decisions of Treatment Over Objection. J Am Coll Surg. 2021,233(4):508-516.e1. doi:10.1016/j.jamcollsurg.2021.07.003
2.    Rubin J, Prager KM. Guide to Considering Nonpsychiatric Medical Intervention Over Objection for the Patient Without Decisional Capacity. Mayo Clin Proc. 2018,93(7):826-829. doi:10.1016/j.mayocp.2018.04.005

3)    Aleksandrova-Yankulovska S. Ethical aspects of fertility preservation for specific patient groups and their applicability in clinical ethics consultation 

Abstract:

"Background: 
Our report presents the first results of the ethical sub-project within the BMBF-funded Interdisciplinary Junior Researchers Center for Fertility Protection (FePro-Ulm).

Aims: 
The aim of our research was the identification and ethical analysis of the ethical aspects of fertility preservation for various user groups: children and adolescents, men with cancer, women with cancer, women with endometriosis, women wishing social egg freezing, and transgender people. Our research task was to identify the specific ethical issues of fertility preservation that differentiate in various patient groups in order to reveal the potential for their application in clinical ethics consultation.

Methods:
A systematic literature search was performed in April 2024. Altogether 125 articles were identified, distributed by patient group, and further analysed from the perspective of the four principles of bioethics.

Results:
We have been able to elucidate unique ethical aspects of fertility preservation for each of the specific patient groups. These are, among others, the right to an open future and the decisional capacity of adolescents, fertility preservation as a means for cancer patients to leave a genetically related offspring, to their surviving partner, social egg freezing's effect of disturbing the intergenerational contract, the under spoken challenges of adoption and surrogacy arrangements to transgender patients as an alternative for their genetic parenthood.

Discussion:
The identified ethical aspects of fertility preservation for specific patient groups can serve as a reference point in the provision of patient-oriented fertility preservation care. Difficult cases of fertility preservation decision-making can trigger clinical ethics consultation requests. On the other side, knowledge of the group-specific ethical aspects of fertility preservation can support clinical ethics consultation for patients belonging to such a group."

1)    Schürmann J. The Big Five Revisited: An Evaluation of the Most Frequent Topics in Ethics Consultations after Ten Years of Ethics Support 

Abstract:

"Background: Based on a new database, an earlier pilot analysis of 100 clinical ethics consultations (CECs) between 2012 and 2015 at two university hospitals in Basel, Switzerland, revealed the following "big five" of most frequent topics: coercion, care management, treatment-plan evaluation, end-of-life care, and pregnancy / assisted reproduction. Ten years later, we aim to analyze the additional CECs comparing the formal and patient characteristics as well as ethical issues of CECs with the earlier findings.

Methods: Semi-structured analysis of the consultation reports and the feedback forms from 500 CECs conducted between 2012 and 2024 at the University Hospitals in Basel. Since the category system had been refined according to the Armstrong Clinical Ethics Coding System, the previous CECs were recoded.

Results: Preliminary results show that the patients discussed in the CECs were on average 44.7 years old and more often female. The most common conditions were mental illnesses, congenital or genetic diseases, and neurological diseases. Half of the patients had preserved decision-making capacity (DMC), a third lacked DMC, and the rest had fluctuating or unclear DMC. Most CECs were prospective and were most frequently requested by physicians, followed by nurses, therapists, and patients or relatives. The requesting specialty was most often psychiatry, followed by gynecology, internal medicine, surgery, and emergency and intensive care. The most frequent ethical topics were treatment decision making - including coercion, opportunity-risk-assessment, and patient behavior - reproduction, and end-of-life-care. 

Conclusions: The distribution of major ethical topics has remained similar over the years, while the topic of coercion has become less frequent, especially in somatic acute care."

2)    Bouthillier M.-E. The perceived needs for standards and certification in clinical ethics practice in Quebec: results from a web-based survey

Abstract:

"Background: In the last decades there has been an increasing interest to define the specified training, knowledge and skills for the practice of clinical ethics (CE). The introduction of standards (code of ethics, core competencies, guidelines, certification or professional college) is a way of ensuring the quality of practice in CE. Little is known about the need for standards, in particular certification, in CE in Quebec.

Objectives: (i) to map out the perceived need for standards and certification in CE in Quebec, (ii) to identify the parameters relevant to the development of efficient standards including certification, (iii) to formulate the premises of a certification process capable of meeting the needs identified.

Methods: A web-based survey was sent to three groups of stakeholders: ethicists, health administrators and healthcare workers who have used CE services. The survey ran from February to May 2023, and consisted of closed-ended questions about the need for standards and certification, relevant parameters and considerations, and open comments. Data were analyzed using descriptive statistics. Open comments were subjected to thematic analysis. 

Results: A total of 89 participants responded: (44/89, 49 %) ethicists, (23/89, 26%) health administrators and (22/89, 25%) healthcare workers. They were in favor of setting standards, prioritizing certification and practice guidelines, both with (26/89, 29%) among all the types of standards presented. Priority is given to ethicists as the people who should be responsible for developing them. The creation of a professional college would be the last step to achieve in terms of standards. Three themes favored CE standards: 1) standardizing practice, 2) quality assurance of practice and 3) professional legitimacy. And two disfavored it: 1) practice limitation and 2) bureaucracy.

Conclusion:  Stakeholders showed their openness to develop standards for CE practice in Quebec. Resistance was encountered to create a professional college."

3)    Sommerlatte S. Requests for and practice of assisted suicide in Germany. Data and possible implications for clinical ethics consultation 

Abstract:

"Background: Following the constitutional court ruling in 2020, clinical ethics consultation in Germany are increasingly confronted with requests for support related to wishes for assisted suicide by patients. This study presents data of healthcare professionals and further stakeholders about (requests for) assisted suicide in Germany and explores possible contributions as well as limits of clinical ethics consultation to resolve conflicts associated with such requests.

METHODS: Online survey among applicants for an educational session on professional standards of assisted suicide. Descriptive analysis of quantitative data, content analysis of free text comments.

Findings: 234/672 participants accessed the online survey, data of 133/234 participants were analysed. 101 data sets were excluded due to lack of sufficient data for analysis (5 or less items completed). 44 participants were female, 84 male. 25/101 participants reported no request for assisted suicide and 69/101 participants reported 1-3 requests during the last 12 months. Ten or more requests were reported by 13/101 participants. 15/101 participants reported that assisted suicide was performed, 11 respondents provided details. Time interval between first request and assisted suicide varied between four weeks and 24 months. Decisional capacity was assessed partially by one and partially by more than one person. In nine cases, physicians and in two cases each, lawyers and relatives assessed decisional capacity. Information and counselling varied regarding involved professions and content. Time between ingestion or intravenous application of a lethal substance and death ranged from five minutes to seven hours. Results of the ongoing qualitative content analysis will be presented at the conference.

Discussion: We will use the empirical findings as starting point for reflections on the planned professional guidance on information and counseling, assessment of decisional capacity  in cases of requests for assisted suicide. In addition, we will discuss the possible role of ethical case consultation in resolving conflicts associated with requests for assisted suicide."

4)    Shamsi Gooshki E. Implementation of the first centralized clinical ethics consultation and support service in Iran

Abstract:

"Context: The need for Clinical Ethics Consultation and Support Services (CECaSS) is increasing in many healthcare settings including in the Low-and-Middle-Income Countries like Iran. This paper explores the experience of providing CECaSS by Medical Ethics and History of Medicine Center (MEHMC), established in 2000 at Tehran University of Medical Sciences (TUMS), as the first centre of its kind in West Asia and the Middle East, that  currently hosts a WHO Collaborating Center and a UNESCO Chair for Bioethics. MEHMC has leadership in bioethics education and research across TUMS. Based on Iran's unique integrated health system which medical education, biomedical research and providing healthcare is provided by medical universities as TUMS that have the role of regional health authorities. MEHMC provides technical ethics support to various sections of TUMS involved in education, research and clinical service.  
Programming: Using an earlier experience, MEHMC planned a centrally organized CECaSS for 5 university hospitals (3 generals, 1 heart center, and 1 pediatrics).  One of the MEHMC faculty members (a clinical ethicist) was appointed as the members of the Hospital Ethics Committee (HEC) in each hospital and a guiding document for Case Presentation Conferences (CPCs) was developed. 
Components: The program included 1) Discussing ethical aspects of institutional policies in HECs 2) Providing CECaSS by the clinical ethicists assisted by volunteer PhD candidates 3) Holding a series of CPCs for more complicated cases and 4) one central CPC in MEHMC for discussing selected cases or common challenges. 
Time period: The face-to-face program started in 2017 and was terminated on February 2, 2020. However, in one general hospital it was continued during the pandemic using an online platform. 
Results: This paper explores the details of this program, most frequent cases and experiences of involved clinical ethicists involved in this process."
 

5)    Teti S. The Effects of Conflict in Ethics Consultation: A Matched Pairs Cohort Study

Abstract:

"Background
While conflict frequently involves value differences, the converse is not necessarily true, through HEC, value differences can be acknowledged, respected, understood, and incorporated into a cohesive, ethical care plan all parties accept. However, the resolution of conflict is multifactorial. Questions persist as to whether, and how inherent, disagreements are, comparisons between similar cases would benefit from further investigation.

Aims
This project sought to investigate whether the presence or absence of conflict across matched sets of ethics consults could be investigated empirically. Successfully controlling for ethical issues and aggregating results across many issue types would allow for the effects of conflict to be characterized and examined.

Methods
Mixed methods, including a retrospective review of ethics consults conducted from 2020 to 2024 at an academic medical center (n = 3000). Cases coded with identical ACECS code triads used >=10 times were included to yield final data set of 595 individual consults in 34 cohorts (mean consults per cohort=16.4, median=11.5). 

Results
Significant differences were found around reported presence of uncooperative behavior (53.3% in conflict cases, 3.7% in values cases), average length of stay (24.6 days in conflict cases, 20.0 days in values cases, and in-hospital mortality (21.7% in conflict cases and 38.1% in values cases). Qualitatively, the case cohorts involved refusal of treatment, clinical candidacy, extent of decision-maker authority, and withholding treatment, with refusal of treatment presenting with the widest range of permutations.

Discussion
The relationship between conflict and stalled plans of care has been posited to account for differences in length of stay, but the marked differences in mortality between the two groups bears further investigation. Patient disposition will be presented, and the presentation will address the relative rates of moral distress, professional integrity, and other qualitative considerations."

1)    Chow P.L. How to protect the benefit and maintain justice for migrant workers: the experience in a Clinical Ethics Committee in Singapore 

Abstract:

"Singapore, as a city-state, has limited manpower, as a metropolitan, receives a large number of migrant workers for economic development. Majority of them come to Singapore working as domestic helpers and construction workers. These young migrant workers may fall sick when they work in Singapore: tropical infection, injury, auto-immune disease etc. Although it is compulsory for the employer to pay for the migrant worker's medical insurance, the coverage is very limited. When medical care involve expensive investigations and treatments, who is going to cover the hospital bill? Employer, migrant worker agency or taxpayer? Can the employers request limited medical management and send the migrant workers back to their home countries?  Knowing that they come from low-income class and the healthcare system in their home countries may not be well-developed, how should the healthcare professionals in Singapore hospitals achieve patient's beneficence, avoid maleficence, protect patient's autonomy and maintain social justice in this kind of ethical dilemma?

In this oral presentation, we will present a case referral to the Clinical Ethics Committee of Changi General Hospital, Singapore. A domestic helper who required extensive investigation for possible auto-immune encephalitis. However, the employer and the domestic helper agency staff appeared in the ward suddenly requesting discharge against medical advice. We will discuss how the primary team responded to the employer and agent, the deliberation of the Clinical Ethics Committee to this dilemma and the factors of consideration by the Clinical Ethics Committee."

2)    Liv A. Health professionals’ experiences with uninsured children in Quebec: a qualitative study in pediatric settings

Abstract:

"Background: The 2021 Bill 83 (PL83) aimed to provide provincial public health insurance (RAMQ) to previously uninsured migrant children in Quebec. However, many children remain uninsured, posing ethical challenges for healthcare professionals that have yet to be thoroughly examined.

Objectives: This study sought to explore healthcare professionals' experiences with uninsured children, focusing on the practical and ethical issues arising from the lack of insurance.

Methodology: This qualitative research adopts a comprehensive paradigm focused on participants' subjectivity and includes semi-structured interviews with healthcare professionals. These participants were recruited through purposive and snowball sampling at Quebec's two largest pediatric hospitals. Interview topics included clinical experiences with uninsured children, the impact of lacking insurance, and strategies for overcoming barriers. The theoretical framework of social justice underpins this research, advocating for the right to healthcare for children without discrimination. Interviews were fully transcribed, and thematic analysis using inductive coding (NVivo) revealed key themes.

Results: Between January and October 2024, 25 participants (52% physicians, 20% nurses, and 20% social workers) were recruited. Analysis identified three themes:
1.    Organizational and systemic factors contribute to a lack of RAMQ for migrant children, leading to significant challenges, such as hospital bills and difficulties accessing primary healthcare services.
2.    Emergency departments (EDs) become the only option for parents seeking medical care for their children. EDs are not designed to address the healthcare and psychosocial needs of these marginalized populations.
3.    Participants expressed frustration, helplessness, and a sense of injustice regarding the barriers uninsured children living in Quebec face. Ethical challenges prompt professionals to find solutions to provide equitable care, such as adapting treatments to financial limitations and life circumstances.

Conclusions: Insights from healthcare professionals highlight strategies to overcome barriers. Potential systemic solutions include presumed eligibility based on residency proof, educating the healthcare workforce, and improving access to primary care."

3)    Caci M., Burnens V., Rutz R. Ensuring equity access to healthcare for uninsured patients: a multidisciplinary decision model in a university hospital

Abstract:

"Background
International mobility and medical tourism are factors leading people to travel to Switzerland to receive specialized care. Sometimes, restrictions on the follow-up treatment in the patients' home country, particularly its unavailability, present a challenge for the choice of treatment and force patients and relatives to ask for follow-up treatment in Switzerland. In consequence, the lack of insurance coverage puts patients and healthcare professionals (HP), in a challenging position, where they navigate between significant costs and ethical tensions.

Aims
Provide a harmonized approach to treatment for all uninsured patients through a multidisciplinary evaluation and guidance within an official transparent framework, aiming to reduce injustice based on financial means or administrative status.

Method
In 2007, we established a multidisciplinary case management team comprising hospital managers, ethicists, lawyers, and social workers that is working with HP, patients and relatives to determine the extent of care provided addressing all administrative issues. Taking responsibility for the decision, the hospital's reference team supports patients and HP in the decision-making process.

Results
Each year 250 to 300 patients are evaluated and solutions are found with joint health care decisions after considering clinical, ethical, financial, and any administrative issues that may arise. The expert team support professionals in complex ethical and administrative challenges, contributing to equal care access and allows HP to better fulfill their core mission. Moreover, systemic issues identified during the assessment are referred to authorities and partners allowing further developments of the health system strategy.

Discussion
Complex financial and administrative rules for uninsured patients are often neglect by health professionals because the perceived care mission and high complexity. The situation results in injustice for patients or inappropriate cost. Expert teams can support HP and patients in making innovative multidisciplinary decisions, thus contributing to fairer access to healthcare and system improvements."

4)    Lee H. Integrating Immigrants’ Cultural Traditions in Healthcare Ethics Consultation: Addressing Moral Conflicts in Prenatal Care

Abstract:

"Background:
Healthcare Ethics Consultation (HEC) addresses moral conflicts, particularly in contexts where cultural disparities in prenatal care arise for immigrant populations. Taegyo, a traditional Korean practice focused on spiritual and emotional well-being during pregnancy, presents unique ethical challenges for Korean immigrant women, especially when integrated with modern medical practices. These challenges often involve conflicts between culturally rooted beliefs and contemporary medical advice.

Aims:
This study investigates how taegyo can inform HEC models by promoting culturally sensitive ethics consultations. The primary goal is to resolve moral conflicts in prenatal care and foster equitable healthcare and social justice by bridging cultural traditions with modern medical practices.

Methods:
In-depth qualitative interviews with Korean immigrant women and healthcare providers were conducted to explore how taegyo influences prenatal experiences and shapes moral decision-making. The study identified gaps in current healthcare systems and examined how intercultural conflicts arise between taegyo and Western medical approaches.

Results:
Findings reveal that Korean immigrant women experience both a lack of culturally sensitive guidelines and moral conflicts between taegyo and modern medical practices. Healthcare providers acknowledge the need for models that integrate cultural traditions into contemporary medical care. Incorporating taegyo and other culturally specific reproductive practices into HEC enhances ethical decision-making and fosters more culturally responsive care.

Discussion:
This research suggests that innovative HEC models that integrate cultural traditions address the ethical needs of immigrant communities, promoting equitable, culturally sensitive healthcare. This approach demonstrates how culturally grounded frameworks can enhance the practical impact of HEC, offering a model for broader application in healthcare systems serving diverse populations."
 

5)    Watson J. Ethical Strategies for Improving the Use of Interpreter Services

Abstract:

"When a patient's primary language does not match that of a healthcare team, clinicians may struggle to establish clear communication with that patient. In those cases, interpreter services can be used to create a space wherein patients can receive information and are able to share their perspective. However, variation in availability and use of interpreters puts patients at risk of having their values and preferences misunderstood or left unstated.  

When values-based challenges in medical interpretation arise, clinical ethicists are often asked to support teams, patients, and families in promoting patients' interests, but there is little available guidance on how ethicists can be helpful. For example, the use of family members or friends as interpreters raises concerns about the adequacy of information conveyed by the treating team. On this same line, the use of technology by patients and families, such as cell phone applications, risks achieving mere translation rather than robust interpretation, potentially missing critical cultural connotations and norms of communication that would be understood by fluent and culturally knowledgeable speakers. 

In this presentation, we review current US guidelines for the use of interpreter services as well as the professional ethical responsibilities of medical interpreters. We then highlight ethical challenges in patient care unaddressed by those guidelines and responsibilities. We conclude with strategies for how ethics consultants can improve the use of interpreter services, during both policy development and review and as part of real-time care discussions. Ultimately, we aim to discuss pathways to better promote patients' nuanced values and preferences through the use of interpreter services."

Fiester A. Introductory Skills Workshop in Mediation: Learning the Techniques of Conflict Management for Clinical Ethics Consultations

Abstract:

"A recent study of healthcare ethics consultation found that 59% of consults involve conflict (Fox et al 2022), yet few ethics consultants receive any formal training in conflict management.  Professional mediators have long possessed a unique skill set needed to facilitate difficult conversations between individuals in emotionally laden situations, generate solutions that meet the needs of all parties, and resolve conflicts that seem intractable.  This skill set is increasingly being recognized as invaluable to the work of clinical ethics consultants as they navigate conflicts between and among patients, families, surrogates, and providers.  Moreover, given that communication breakdown frequently lies at the root of many clinical ethics conflicts, the mediator's skills in effective communication are essential for uncovering the concerns, values, and perspectives of the parties in the conflict. This hands-on workshop will introduce the central concepts and skills needed for the management and prevention of contentious ethics conflicts. Through interactive, presentations and partner exercises, participants will learn core mediation concepts and techniques including positions vs. interests, problem-diagnosis, de-escalation, BATNA, reframing anger, thematic restatement and the ladder of inference.  The workshop leader is a highly experienced mediator who has over 15 years of experience teaching conflict management to clinical ethicists, nurses, and physicians.

Fox E et al. Ethics Consultation in U.S. Hospitals: New Findings about Consultation Practices. AJOB Empir Bioeth. 2022 Jan-Mar,13(1):1-9."

Semler L. Moral Distress: Managing Conflict Within Ourselves and with Others

Abstract:

"Moral distress, or the distress that arises from knowing the right thing to do but being unable to pursue that course of action, is not only increasingly prevalent in healthcare, but also an unavoidable side effect of providing patient care in a complex care environment. Moral distress is especially common when a values conflict arises during patient care. Unaddressed, moral distress can lead to a host of negative outcomes such as burnout, impact on physical and emotional impact, and even leaving the healthcare profession. Despite a growing body of literature describing and defining moral distress, few studies have been done that provide a practical approach to addressing and reducing moral distress. This author has developed and implemented an interactive moral distress workshop that was shown to decrease moral distress and increase ethical confidence (reference omitted for blinded peer review).

In this workshop, participants will have the opportunity to participate in a 90-minute seminar that allows them to:
1) describe moral distress and how it differs from other types of distress,
2) use a toolkit to identify and address the ethical issues that cause moral distress,
3) engage in conflict resolution strategies, and
4) learn techniques to strengthen moral resilience."

Payot A., Orr Gaucher N., Dallaire C. Time to Establish Brave Spaces for Clinical Ethics Consultations? Reflection Based on a Framework Implemented in Medical Education

Abstract:

"Context: Institutions are committed to protecting academic freedom and ensuring the freedom of expression for all stakeholders, both in research and teaching, especially in the context of significant cultural diversity. Many educators feel uncomfortable and at times fearful speaking about complex topics in public, where their opinions can be openly criticized and publicised, particularly with social media. In parallel, many learners are uncomfortable and hesitant to voice their opinions in the context of institutional hierarchy. It has thus become challenging to discuss complex, nuanced topics, educators and learners may prefer to remain silent rather than engage in debate, despite the importance of such discussions in addressing complex situations. The Clinical Ethics Bureau (Faculty of Medicine, University of Montreal) sought to restore educational spaces that allow for discussions on complex issues and respect for differing viewpoints. Inspired by the Brave space literature, novel tools were developed and deployed at the Faculty of Medicine to create a model of safe and authentic learning environment that encourages open and respectful exchanges.

Workshop Goal:
This workshop will present these novel tools and explore their use in clinical ethics consultations to facilitate debates and the exchange of ideas. Clinical ethics consultations often raise complex, nuanced ethical issues, that can at times be controversial or delicate. Consultations need to provide spaces that are safe while allowing to discuss and reflect on these complex issues, in which all stakeholders can express diverse viewpoints without fear of judgment or stigmatization.

Workshop Outline:
Brief theoretical presentation on the concept of brave space leading to the model of safe and authentic environment, followed by collective reflection on the importance such notions for clinical ethics consultations. 10 minutes.
Interactive plenary exploration of the different positions of stakeholders in clinical ethics consultations: 15 minutes
Ethicists and ethics professionals
Healthcare professionals
Patients, families, and loved ones

Interactive plenary exploration of participants' practices concerning the creation of safe and authentic environments for clinical ethics consultations. 15 minutes.

Presentation of the creative process underlying the development of our novel tools and their use at the Faculty of Medicine at the University of Montreal. 10 minutes.

Group discussions on the practical implementation of these tools, their advantages, disadvantages, facilitators, barriers, and challenges in clinical ethics consultations. 20 minutes.

Plenary feedback session to share reflections from group discussions. 15 minutes.

Conclusion and key messages. 5 minutes."

Mukherjee D. Guidry-Grimes L., Berlinger N. Bowen L. Toward Anti-Ableism in Clinical Ethics: Getting Beyond Admiring the Problem

Abstract:

"People with disabilities are overrepresented as patients in healthcare settings and underrepresented as colleagues. Clinical ethics consultants (CECs) are well-positioned to intervene in inequities and biases in patient care and healthcare systems, including those reflecting structural ableism. However, CECs may lack the skills to recognize and respond to ableism encountered in practice. Those who do respond often encounter institutional and interpersonal resistance. This panel will identify common manifestations of ableism in the context of clinical ethics and offer strategies for intervening and making constructive contributions. The panelists are experienced in different facets of clinical ethics work, including consulting, drafting ethical guidelines, policy development, and education. They reflect diverse disciplinary backgrounds, geographic regions, and career stages to offer practical discussions of what has worked (and what hasn't) when challenging ableism in clinical encounters, policymaking, clinician education, and the culture of clinical ethics itself.

The first panelist, a clinical/community psychologist and CEC who has worked on three continents, will explore the dignity of risk and how decisions about who gets to take risks, how risk is defined, and how cognitive biases of the clinical ethicist can impact clinical ethics consultation. The second panelist, a philosopher who has worked as a clinical ethicist in several institutional settings and US regions, will suggest strategies for interrogating clinical conversations and hospital policies that are susceptible to ableist biases. The third panelist, a bioethics and health humanities scholar who works on population aging and end-of-life care, will discuss how cultural narratives of disability and dementia intersect and diverge, and how clinical ethicists can play a role in reframing entrenched dementia narratives within clinical practice. The fourth panelist, a CEC trained in literature and health humanities, will discuss opportunities and barriers for responding to manifestations of ableism that involve complex multi-institutional and intersectional dimensions, inviting CECs to consider their roles in addressing structural ableism.  

The panelists will introduce several clinical cases and policy discussions drawn from their professional experiences, inviting interactive participation throughout. Presentations will be limited to 15 minutes each, leaving 30 minutes for audience members to share and discuss their own experiences and strategies."

Speakers :

- Kristina Würth
- Nancy Berlinger
- Rainer Tan

Please access the full description here

These posters will be available :

• Ali Shah B. Clinicians' Experiences of Obtaining Informed Consent for Research and Treatment: A nested qualitative study from Pakistan
• Al-Maamari A. Navigating Ethical Challenges in Digital Healthcare: Strategies for Responsible Implementation
• Andric V. Ethical concerns surrounding direct-to-patient release of genetic test results in the clinical setting: a scoping review
• Anvar S. Empowered Conversations: Ethical Considerations in Addressing Online Health Misinformation
• Badaiki W. DECLUTTERING THE ETHICS CLOSET: THE IMPACT OF ELECTRONIC HEALTH RECORD SYSTEMS IN CLINICAL ETHICS DOCUMENTATION AND PRACTICE. 
• Bailey M. Lack of Equitable Universal Healthcare Coverage for Federally Incarcerated Individuals in Canada
• Bailey M. Navigating Ethical Considerations Concerning the Care of Uninsured Patients in Canada  
• Bartlett V. Through the Looking Glass: Where Emerging Issues in AI Meet Experience and Insights from Clinical Ethics Consultation 
• Bishop J. Digital Moral Twins, Moral Identity, and Moral Decision
• Boutillier B. PRENATAL WORKSHOP AND SUPPORT GROUP FOR PARENTS OF CHILDREN WHO WILL COME TO THE NICU 
• Chan Z. Ethical Challenges of Robot-Assisted Vascular Surgery: Insights and Implications for the UK
• Chua E. Feeling Strangled: Balancing Best Interests and Public Health in a Breathless and Belligerent Patient
• Cotognini C. and Ruggiero R. How can a health care organization improve patient care while remaining sustainable and effective?
• Cutillo Z. Promoting Positive Childhood Screen Time Usage in the Age of Technology: Ethically Preserving Contemporary Youth Health
• Dzi K. An Umbrella review on the Ageism Older adults face while seeking healthcare services.
• Eves M.  Clinical Ethics Consultation on a Continuum: An Examination of a Coaching approach 
• Fecci A. Ethical Considerations in Research Studies with Transgender and Gender-Diverse Populations
• Furfari K. Colorado's Physician Proxy Law: Lessons in Surrogate Decision-Making and Patient Advocacy
• Hamrouni N. Gendered medical colonialism in Quebec. Bringing the land back in the cultural safety approach to healthcare services 
• Healy E. An Ethical Dilemma: Blood Product Transfusions in Situations of Physiological Futility
• Heistruevers L. From being seen to being heard and understood: Addressing structural vulnerability in the hospital setting
• Huang D. Barriers to Reproductive Autonomy for LGBTQ+ Individual in China
• Hulkower A. Minimizing Bias in Chart Notes through Templates Built for Readily Accessible Health Records 
• Jankowski J. Innovating to Meet Demand: Various Approaches to Personnel and Service Delivery Models in Ethics Consultation 
• Khan J. Cross-border end-of-life decision-making: Ethical considerations in repatriation and cultural sensitivity
• Khoso A. Systemic Challenges to Gender Equality and Pathways to Inclusivity: A Scoping Review and Stakeholder Group Consultation
• Lahfafa A. What factors influence families' bereavement after a death in paediatric intensive care?
• Meudec M. and Marin A. Promoting inclusion and/or combating discrimination in ethics? Conflicts of loyalty in research in Quebec
• Miljeteig I. Increasing Awareness, Skills and Knowledge in Medical Ethics using the ASK ME- tool 
• Monteverde S. Vulnerability and vulnerabilization in healthcare: what can we learn from the Coronavirus pandemic?
• Pilkington B. Realizing Environmental Justice Clinically: A Call to Ethicists
• Rajasegaran K. Disability, uncertainty and quality of life: does culture and religion matter?
• Ravindran N. Empathy Beyond Belief: Navigating Spirituality in Palliative Care Education With Sensitivity And Self-reflection
• Rossetti E. Digitally driven proceduralization of medicine: How clinical ethics can preserve the role of intuition
• Saverio Spiezia F. Ruggiero R IS IT POSSIBLE TO RESOLVE AND PREVENT CONFLICTS? THE KEY ROLE OF CLINICAL ETHICS IN DECISION-MAKING AT THE PATIENT'S BEDSIDE
• Seiler A. Ethical Dilemmas in Phase 1 Clinical Cancer Trials
• Sisti C.The Role of Research Ethics Patient Advocate(REPA) in Advancing Digital Transformation and Artificial Intelligence
• Sourdi M. The Ethical & Epistemic Implications of AI-supported HEC for Schizophrenia Patients
• Streuli J. Navigating decision-making dilemmas in Variations of Sex Development: The shared optimum approach
• Tolo A.K. Heggestad CECC's role in cases involving patients recurring self-harm and suicide attempts
• Zatulovsky Y. and McCann-Davis N. Barriers Behind Bars: A Duty Towards a Dignified Death

1)    MacGregor Brown M. and Nolan V. Using Artificial Intelligence for Proxy Decision-Making

Abstract:

"Background: The literature alludes to several studies highlighting challenges with human proxy as decision makers such as emotional burden, physician barriers, decisional conflict, accuracy, and overconfidence. However, only a small subset reported on a proxy's congruency. This study expanded on a proof-of-concept that artificial intelligence (AI) can act as a proxy decision maker with value preferences and considered its ethical implications.  

Aim: To compare the congruency of AI as a proxy decision maker with human proxies on end-of-life treatment decisions.

Methods: Utilizing LLaMa3, an AI Large Language Model as a proxy decision tool, we recruited 15 adults and their legal decision makers as dyads to complete a value and end-of-life preference surveys for a comparison analysis. We measured the participants' overall composite value scores and collected their end-of-life preferences to use in the AI congruence evaluation. Congruency percentage was taken over three clinical hypothetical scenarios and compared between the participant with either the human or AI proxy.

Results: The mean congruency percentage between the participant and human proxy was 44.4% (95% CI: 23.6-65.3), n = 12. Fifty percent of dyads had one or no matching responses across the three scenarios and 16% had perfectly matched responses. After the model's adjustment for prompt engineering and parameter fine-tuning, the congruency with AI and value inputs was 72.2% (95% CI: 67.4-77.0) with 67.0% matched responses. The model performed the same as the human proxy without value preferences with congruency of 45.3% (95% CI: 36.2-54.4).  

Discussion: The AI model had a 28% higher congruency as a proxy decision-maker for end-of-life treatment decisions after the inclusion of value preferences. This approach has a promising utility as a supplemental tool for human decision-making and can protect self-determination if values are pre-recorded in the event of decisional incapacity."

2)    Starke G. Advancing clinical ethics by developing a Patient Preference Predictor with machine learning: a proof-of-concept 

Abstract:

"Background: Knowing patient preferences is crucial for respecting patient autonomy and providing care in line with their wishes. Common challenges in ethics consultations arise when incapacitated patients' preferences are unknown and there are neither advance directives nor designated surrogates. In such situations, relatives or healthcare providers are asked to make decisions on behalf of the patient but frequently struggle to predict patients' preferences, creating ethical, emotional and clinical dilemmas. 

Aims: In line with the digital transformation of healthcare, ethicists have suggested that a patient preference predictor (PPP) trained with machine learning (ML) could provide a solution to this conundrum. So far, the debate lacks empirical support by an actual program. Here, we fill this gap by reporting the first proof-of-concept PPP, trained on a population sample of Swiss adults aged 50 and older. 

Methods: Using existing data from 1,814 participants of the Wave 8 (2019/2020) of the Survey of Health, Ageing and Retirement in Europe (SHARE), we evaluated several ML techniques to create a PPP, employing Shapley values to interpret the best-performing model-eXtreme Gradient Boosting Machine (XGBM). Reflecting different potential use scenarios, we trained three models: a simple model based on demographic data, a clinical model trained on data likely available in electronic health records, and a personalised model, incorporating more complex individual preferences. 

Results: Compared to couples in our sample, all three models outperformed partners in accurately predicting whether a patient would prefer resuscitation in cardiac or respiratory arrest. With up to 71% accuracy, our models also performed on par or better than typical estimates of surrogate predictive accuracy in the literature. 

Discussion: This study offers the first empirical demonstration of an ML-based PPP, highlighting both technical and conceptual limitations, and contributes to important ongoing debates regarding the ethical desirability of employing a PPP in clinical settings."

3)    Amasiadi N. Artificial Intelligence in Pharmacovigilance: Considerations for Clinical Ethics and Consultation

Abstract:

"The adoption of Artificial Intelligence (AI) in pharmacovigilance (the practice of monitoring and assessing the safety of medications) is transforming drug safety monitoring and adverse event detection, presenting new opportunities and challenges for clinical ethics and consultation. AI algorithms can process extensive clinical and patient-reported data, identifying potential safety issues in real-time and enabling proactive drug risk management offering significant advantages in patient safety and public health. However, integrating AI into pharmacovigilance also introduces challenges around transparency, accountability, patient privacy, and trust.
    One major ethical concern in AI-driven PV is patient privacy and data confidentiality. AI systems often require access to sensitive health data from diverse sources, including electronic health records, and wearable devices, which raises significant privacy risks. In clinical ethics, maintaining patient confidentiality is foundational, thus, ethical oversight is critical to ensuring that AI applications in PV adhere to privacy regulations and respect patient autonomy. Consultations with patients and ethical review bodies should incorporate clear communication on data usage, privacy safeguards, and the option for patients to consent or opt-out.
    Transparency and interpretability are further ethical issues central to clinical ethics and consultation. AI models are often "black boxes," making it difficult for clinicians and patients to understand how certain pharmacovigilance decisions—such as risk classifications and safety alerts—are reached. This opacity can challenge clinical consultations, as healthcare providers may lack the necessary insight into AI-derived findings to counsel patients confidently. For ethical AI deployment, developing explainable models is crucial, allowing clinicians to communicate AI-generated insights to patients accurately and responsibly.
    Last, algorithmic bias is one of the most pressing concerns, as AI models in PV can inadvertently reinforce existing health disparities by reflecting biases in their training data. Bias in adverse event predictions may lead to underreporting or overestimating risks for certain demographics, disproportionately affecting marginalized groups. In clinical ethics, it is imperative to address such biases, as they can lead to inequitable patient outcomes and erode trust in healthcare systems. Ensuring fairness and inclusivity in AI applications requires ongoing data audits, diverse datasets, and ethical oversight to detect and mitigate biases in real-world PV settings.
    In conclusion, while AI enhances pharmacovigilance by enabling more efficient and proactive drug safety measures, its ethical integration into clinical practice requires careful attention. Clinical ethics and consultation provide essential frameworks for addressing issues of privacy, transparency, bias, and autonomy, ensuring that AI in PV aligns with ethical standards and patient-centered care. Future research should emphasize ethical AI frameworks, continuous clinician training, and multidisciplinary collaboration to support the responsible use of AI in pharmacovigilance."

4)    Ruggiero R. and Consolandi M. Clinical Ethics at the Crossroads of Care and Emerging Technologies

Abstract:

"In recent years, clinical ethics consultation has made significant strides, increasingly establishing itself as an essential component of decision-making at the patient's bedside. This evolution has been driven by the growing complexity of clinical cases, in which ethical analysis plays a crucial role in addressing dilemmas that cannot be resolved by medical expertise alone. Simultaneously, the healthcare sector has been profoundly influenced by both significant cultural changes and techno-scientific innovation, particularly the development and application of emerging technologies and artificial intelligence. Cutting-edge technologies have revolutionized diagnostics, treatment options, and patient management, offering both opportunities and challenges, while also raising new ethical dilemmas.
The primary ethical concerns include issues surrounding AI-driven medical decision-making, which raises questions of accountability, the impact of technology on patient autonomy, data privacy and security risks, the depersonalization of care, and the risk of bias and fairness in AI systems. Additionally, there are challenges in ensuring informed consent when AI is involved in clinical decisions.
By analyzing these new ethical dilemmas, we provide evidence that healthcare professionals who utilize clinical ethics consultation in the context of new technologies uphold the centrality of the patient, respecting their humanity and dignity, as well as the care and assistance they require. We emphasize that the thoughtful integration of clinical ethics and technology can lead to more innovative and effective healthcare practices, addressing the central question of ethics: how to act in the best interests of both the patient and the healthcare professional. The future of clinical ethics stands at a pivotal juncture, where the rapid advancements in technology raise important concerns: how to improve care and offer cutting-edge medical assistance without compromising human dignity."
 

5)    Kalogeropoulou C. Navigating responsibility in the age of artificial intelligence (AI): Ethical challenges for healthcare ethics consultation (HEC)

Abstract:

"In a world undergoing rapid transformation, we are increasingly shaped by information, evolving into interconnected entities, or "inforgs" (Floridi, 2010). This shift, largely driven by emerging technologies like artificial intelligence (AI), places the concept of responsibility under heightened scrutiny, especially within healthcare ethics. As AI becomes integrated into healthcare systems, healthcare ethics consultation (HEC) faces new ethical responsibilities, raising complex socio-political questions around bias and decision-making. This presentation explores how HEC can navigate these challenges, addressing and potentially redefining traditional roles of responsibility in the healthcare landscape. First, we will explore how AI reshapes responsibility by introducing both innovative tools and ethical dilemmas. Although AI systems aim to support clinicians, they often present quasi-objective claims that conceal biases and ethical implications (O'Neil, 2017). By examining these biases, we will question AI's role in healthcare ethics and challenge the neutrality often associated with algorithmic decision-making, emphasizing the need for HEC professionals to discern the socio-political underpinnings of these technologies (Feenberg, 2005). Next, we will discuss the shifting dynamics in healthcare power structures that AI introduces. With clinicians increasingly relying on AI recommendations, their role evolves from sole decision-makers to mediators between technology and patient care (Danaher, 2019). Simultaneously, patients are encouraged to participate more actively in their healthcare decisions, highlighting the importance of shared responsibility and transparency. This shift challenges traditional hierarchies, calling for HEC's guidance in creating an equitable, collaborative healthcare environment (Prainsack, 2017). Finally, we will highlight the broader ethical implications of AI in healthcare, addressing how HEC can contribute to patient engagement, transparency, and the equitable distribution of responsibilities. By critically engaging with these new paradigms, HEC can offer insights that transcend healthcare and contribute to wider socio-political conversations around the ethics of digital disruption."

1)    Hirra Hassan Rafi AI in Medicine: Ethical Challenges and the Need for a New Framework for HEC-Response

Abstract:

"This work presents a further elaboration of bioethical principles of respect for autonomy, non-maleficence, beneficence, and justice to address the ethical dilemmas and challenges posed by the integration of Artificial Intelligence (AI) into medicine. In doing so we realize that a new bioethical framework is needed to tackle these new challenges. The new framework will guide Healthcare Ethics Committees (HECs) in addressing new ethical dilemmas. Autonomy, for instance, becomes more complicated with AI-driven precision medicine, where both patients and clinicians often struggle to fully understand decisions generated by opaque algorithms. Non-maleficence is insufficient in preventing harm when AI tools reduce human oversight and shift accountability away from humanity. Simply being beneficial does not justify AI's use, and the principle of beneficence should not apply to a tool that doctors cannot comprehend. AI is limited to its programmed data and design and is unable to account for a holistic approach to justice as human ethicists can.
In response this framework introduces additional bioethical principles-transparency, privacy, accountability, and humanness-that have gained increasing importance in the era of AI. Transparency stresses that AI systems should be clear and interpretable by those making decisions based on AI's output. Privacy ensures protects patients from exploitation due to AI's vast surveillance capabilities. Accountability reinforces human responsibility in AI-assisted decision-making and prevents healthcare professionals from relinquishing too much authority to AI systems. Humanness emphasizes the need for preserving core human roles in patient care and acknowledges that morality and virtue cannot be programmed into AI systems. AI has remarkable potential, yet, it is essential that human involvement, not a cold AI, remains central to patients' clinical and ethical care, as only humans possess the capacity for being moral."

2)    Van Biesen W. Taylorism and AI as partners in crime to push the care out of Health Care 

Abstract:

"Taylorism is a management style building on componentiality and interchangeability of production tools and laborers in the production process. In this approach, each process is broken down into ever smaller pieces, until each subunit reaches a level simple enough to be performed without special skills. Labor can then be performed under managerial supervision by increasingly lesser-skilled (and cheaper) staff, who thereby also become interchangeable. Taylorism has silently been introduced into health care to increase efficiency and reduce costs, exemplified by clinical pathways, tick-box medicine and super-specialization. Taylorism is problematic from the ethical perspective as: 1. It reduces the patient to an object  with a fault and the need of a technical fix, 2. it degrades the physician-patient interaction from a holistic and empathetic exchange of personal values and goals to that of an assembly line, inducing moral distress and burn-out of health care professionals, feeling they are no longer able to act in their patients' best interests.
Simultaneously, the introduction of artificial intelligence (AI) and clinical decision support systems (CDSS) into clinical practice brings ethical challenges, such as 1. threatening autonomy of both patients and clinicians, 2. risking deskilling, 3. problems of meaningful control, 4. delegitimizing concerns or (unmeasureable) values of patients leading to missed opportunities to do good. 
Taylorism in Health Care is facilitated by the advent of AI, they fortify each other. AI enhances managerial control, and stimulates tick-box medicine, whereby high skilled health care workers can be replaced by a lower skilled worker with a CDSS. The combination risks precipitating situations where only problems that can be measured and digitalized will be addressed. This risks reducing the legitimacy and visibility of non-somatic issues, such as psychological suffering, social deprivation or human experience."

3)    Schmidt K. W. How can artificial intelligence enhance ethics consultations? Benefits and risks

Abstract:

"Whether and how artificial intelligence (AI) and large language models (LLM), for example ChatGPT from OpenAI, can be integrated to aid ethical decision-making is a controversial topic. In 2023, we published a paper reporting how we had presented a complicated medical case to a fictitious physician on a night shift. She sought help from AI regarding the ethical and legal issues it involved. The language of the answer was astonishing, perceived as "emotional" and as "empathizing" with the difficult situation that the physician found herself in. Of course, the machine formulating the answer was not capable of "empathy", but those who read its answer nevertheless experienced it as such. (In a different case, the readers did not even notice that the answer had been written by AI). At first sight, the content of this "ethical consultation" also appeared convincing, until a closer look revealed it to be factually incorrect in places, as well as having an outdated legal basis. Despite these weaknesses, it was clear that LLM were well on their way to becoming useful aids, potentially able to enhance ethical consultations in the future.

Since then, we have continued to ask ethical questions of AI, not least because it is developing at break-neck speed (see GPT-4o). Answers are now no longer necessarily in written form, but can also be voiced (by computer), reinforcing their "emotional import". The (misleading) vagaries which this can entail were explored in the Sci-Fi movie "HER" (2013). This paper investigates the significance currently attributed to AI as an aid to ethics consultations, as well as the aspects requiring critical attention."

4)    Hollestelle M. An ethics framework for the transition to an operational learning healthcare system

Abstract:

"Introduction: In many areas of healthcare, learning healthcare systems are seen as promising ways to accelerate research and outcomes for patients by reusing health and research data. For example, in the case of pregnant and lactating people, for whom there is still a poor evidence base for medication safety and efficacy, a learning healthcare system presents an interesting way forward. Combining unique data sources across Europe in a learning healthcare system could help clarify how medications impact pregnancy outcomes and lactation exposures. While many projects have been launched with the aim of establishing such a system, the amount of operational learning healthcare systems remains limited. Given the investment of resources in these projects, a moral responsibility to pursue the transition toward a learning healthcare system falls on projects and their participating stakeholders. This paper provides an ethics framework for projects and other stakeholders that have taken steps towards building a learning healthcare system and are in the position to transition to an operational learning healthcare system.

Method: To articulate relevant ethical requirements, we analyzed established ethics frameworks in the fields of learning healthcare systems, data intensive health research, and transitioning or innovating health systems. The overlapping content and shared values were used to articulate overarching ethical requirements. To provide necessary context, we applied the insights from the analysis to the Innovative Medicines Initiative ConcePTION project, that aims to build a learning healthcare system for pregnant and lactating people.

Results: We identified four overlapping ethical requirements that are of significance for our ethics framework. These requirements are: 1) public benefit and favorable harm-benefit ratio, 2) equity and justice, 3) stakeholder engagement, and 4) sustainability.

Conclusion: Although tailored to the context of pregnancy and lactation, our ethics framework can provide guidance for the transition to an operational LHS across diverse healthcare domains."

5)    Annoni, M. Making it Fair: Principlism, Moral Perspectivism, and Ethics Consultation

Abstract:

"In this talk, I will address a critical yet underexplored issue within one of the foundational frameworks of medical ethics: principlism, or the 'four principles approach'. Despite the availability of various ethical models, principlism remains influential, with key components' such as balancing and specifying prima facie principles in conflicted cases' often accepted without scrutiny. I will argue that the popular form of principlism is inherently problematic, as its decision-making framework systematically favors one stakeholder: the physician. This imbalance may lead to unjust outcomes, particularly as the gap in moral perspectives between clinicians and patients widens. Factors such as divergent cultural, socioeconomic backgrounds, and personal beliefs exacerbate this risk, making principlism more susceptible to producing biased and inequitable decisions in contentious cases. To mitigate these issues, I propose adopting a more nuanced deliberative model rooted in Sissela Bok's -Test of Publicity.- This approach involves a thought experiment designed to bridge the discrepancy of perspectives between doctors and patients. By encouraging clinicians to consider whether they would be ready to defend their decisions in front of their conscience, their peers, the public, and ultimately patients themselves, the test of publicity may aid in minimizing bias and promote fairer ethical deliberations while balancing between different moral considerations. This proposed shift underscores the need for a more equitable framework that can accommodate diverse moral viewpoints, ultimately fostering fairer and less biased outcomes in healthcare ethic consultations."

1)    Surendran S. Ethical challenges around gender-affirming care decision-making among transgender minors, parents and providers

Abstract:

"Background: In Singapore, little is known about the practice of gender-affirming care (GAC) with uncertainty in care pathways and service provision, and providers and minors appear to face specific ethical challenges.

Aim: To explore the ethical challenges around decision-making in GAC experienced by transgender minors, parents and providers.
Methods and analysis: We conducted in-depth semi structured interviews with 13 transgender minors, six parents and 13 providers in Singapore from February to August 2024. Data were analysed inductively using thematic analysis.

Results: The ethical challenges emerged were organised into a three-phase temporal model: (1) coming out to parents, (2) interaction with the healthcare system, and (3) decision-making process. Minors delayed coming out to parents due to fears of negative reactions. When interacting with the healthcare system, minors and parents noted the lack of formal information on GAC from public hospitals, and care referral pathways varied, with some hospitals requiring additional psychiatric assessments, increasing wait times. Barriers also included providers refusing GAC due to religious beliefs, minors' age, or lack of parental consent. 
In the decision-making process, minors prioritised resolving the disconnect between their body and mind to live authentically, while parents prioritised protecting minors from irreversible physical changes and social discrimination. Some parents preferred alternatives or delaying decisions until their child was older. Minors with unsupportive parents either pressured them to consent or turned to unregulated sources for GAC. 
Additionally, providers had to balance minors' urgency for GAC with the need for thorough assessment. Some minors had unrealistic expectations, requiring providers to offer more realistic outcomes. Multidisciplinary team discussions were valued for navigating grey areas and ensuring accountability. Providers also acknowledged the challenges in applying international clinical guidelines due to the cultural and legal differences.

Discussion: This study highlights the complex ethical challenges in decision-making for GAC, as illustrated by the three-phase model."

2)    Eichhorn K. Voice Matters: How Gender Affirming Services Builds Agency & Autonomy

Abstract:

"Background: Communication is fluid. The cultural context, message content, and communication partners dictate the voice used by the speaker to convey intended messages and meaning. For gender diverse individuals, finding a voice and communication style that is authentic to themselves can build agency and autonomy. 

Objective:  For many transgender people, a mismatch between their voice and gender identity can lead to significant emotional distress, anxiety, depression, and even suicidal ideation. A voice that aligns with one's gender identity is a key component of self-expression and identity formation. Society often links gender identity with specific vocal characteristics (e.g., a higher-pitched voice for women). People who do not conform to these vocal norms may be subject to misgendering or social exclusion. This presentation seeks to highlight awareness to the need for access to specialized voice care in hopes of minimizing identity conflict and feelings of disempowerment.

Solutions: The lack of recognition or funding for gender-affirming voice care in public health policies reflects larger gaps in the provision of comprehensive transgender healthcare. Advocating for the inclusion of voice care in public health systems can be a part of broader efforts to push for policy reforms that ensure equitable access to gender-affirming services. In regions where transgender people face legal obstacles to healthcare, the absence of voice care as part of healthcare coverage further stigmatizes transgender people and silences them.

Implications: The socio-political impact of limited gender-affirming voice care cannot be underestimated, as it intersects with critical issues of healthcare access, mental health, social acceptance, and human rights. Addressing this gap in care can have a significant positive impact on the well-being of transgender and gender non-conforming individuals while also advancing broader goals of social justice, gender equality, and healthcare equity."

3)    Lim C. Statutory and regulatory requirements, and ethical concerns in the treatment of gender dysphoria

Abstract:

"This presentation discusses efforts by a hospital's multi-disciplinary team in developing a workflow to improve treatment for patients with gender dysphoria (GD), in response to statutory and regulatory changes.  Attention is given to ethical principles guiding the workflow development, health inequality, and ethical concerns.
Prior to 2018, a psychiatrist's assessment of a person as suffering from GD sufficed for the person to obtain a change in legal sex status on the national identity registration in Singapore.  A regulatory amendment that year mandated that a person diagnosed with GD must be assessed by certain medical specialists to have undergone sex reassignment surgery (SRS) to effect the sex status change.  The Healthcare Services Act (2020) enactment requires approval from the hospital's clinical ethics committee before a doctor can perform SRS.  Thus, GD patients experience two statutory/regulatory hurdles: CEC approval prior to SRS, and mandated SRS for sex status change.
However, treatment affordability limits patients' access to SRS because such surgeries are not accorded government subsidies even though subsidies are provided for hormonal therapy, psychiatry and therapy services.  This policy incoherence delays cash-strapped GD patients in obtaining SRS and its concomitant legal status change, and for some, a delay for heterosexual marriage.  SRS is medically justified for treating GD, a denial for subsidies reflects policy inconsistency that contributes to healthcare inequality for GD patients.
Ethical concerns also arise from the following: the absence of a gender care clinic in this hospital reduces coordinated care for patients, lack of specialty training among psychologists and social workers affects competent care for GD patients, and hospital admission practice does not provide adequate safeguard for GD patients' privacy and confidentiality.  Plans and steps for mitigating ethical concerns to promote distributive justice, social justice and ethically responsible treatment for GD persons are advocated."

4)    Guidry-Grimes L. Role of Clinical Ethicists in the Shifting Legal Landscape for Gender Affirming Care

Abstract:

"Healthcare systems in numerous countries continue to grapple with the politicization of gender affirming care (GAC) and the substantial shifts in the GAC legal landscape. These shifts have led to restrictions and uncertainty regarding the provision of GAC to adults and children, providers' ability to continue to follow best practices, insurance coverage, and institutional sustainability of GAC. The politicization of GAC is one part of numerous anti-transgender efforts, heightening the distress that adults and children alike face in schools, sports, bathrooms, and elsewhere. In this political climate, questions arise as to how best to support gender nonconforming patients, their families, and GAC teams. Clinical ethicists have a role in this collaborative process, given the ethical implications of threats to GAC, such as healthcare access barriers, inability to refer patients to essential services, severed therapeutic relationships, misinformation, harms to patients, threats to caregiver safety, and lost public trust.  

We describe ways in which clinical ethicists can make impactful contributions, both proactively and reactively, in the shifting legal landscape for GAC. Our suggestions are based on our experiences as clinical ethicists in states in the U.S. that have proposed or passed laws that limit GAC. Our recommendations span across bedside consultation, institutional decision-making, and public-facing comments or testimony for broader advocacy. These recommendations for clinical ethics involvement may also aid in signaling to institutional leadership appropriate situations for enlisting clinical ethics support. We share our reflections on what efforts were well-received, such as supporting ongoing communication across teams and moral distress reflective debriefs. We discuss concerns clinical ethicists may have in taking on this role, including personal political proclivities, hesitance related to advocacy work, lack of deep knowledge of GAC, and not having established relationships with GAC teams."

1)    Campbell L. Do clinical ethics services have a role in promoting social justice?

Abstract:

"Promoting social justice involves a recognition of the need for a more equitable distribution of resources and opportunities and a commitment to identifying and redressing the structural factors which perpetuate inequity within society.  As health disparities continue to widen, healthcare organisations and healthcare workers pursuing a social justice agenda need to take action to ensure that barriers to healthcare for marginalized individuals and groups are removed or minimized.
Reducing inequity has become a central pillar of healthcare policy in many countries, although how this is to be achieved is often contested.  The purpose of this presentation is to explore the question of whether clinical ethics has a role to play within the larger project of promoting social justice, and the challenges associated with this expanded role in an increasingly complex clinical environment.  Skillful clinical ethics consultation has the potential to empower patients, families and clinicians by facilitating information exchange, scrutinizing value conflict and negotiating power asymmetries within the clinical encounter.  At its most transformative, it gives voice and agency to those who would not otherwise be heard.  However, while clinical ethics consultation can promote engagement with members of hard-to-reach populations, clinical ethicists committed to social justice need to go beyond this and become activists for change within their organisations. Well-established clinical ethics services are in a prime position to spearhead change, not only by influencing policy direction, but by working closely with hospital executives, administrators and health and social care professionals to ensure that the care provided to patients takes into account the enduring impact of systemic trauma, exclusion, poverty and discrimination on health and health behaviours, including barriers to accessing care. If clinical ethics can be used as an instrument of social justice, it may be time for it to become 'disruptive'."

2)    Tabari K. Apprenticeship in Clinical Ethics and Health Justice: Reimagining Fellowship Training for a More Equitable Future 

Abstract:

"Clinical ethics fellowships have traditionally focused on developing expertise in ethical decision-making, clinical consultation, and navigating complex patient-care scenarios. However, as health disparities continue to widen and social determinants of health increasingly influence patient outcomes, there is a pressing need for fellowship programs to address the intersection of clinical ethics and health justice. This presentation will explore how our team has designed and implemented a clinical ethics fellowship-titled the Providence Center for Health Care Ethics Fellowship in Clinical Ethics and Health Justice-aimed at integrating principles of health equity and justice into the training of future clinical ethicists. In this session, we will share the process of developing our fellowship, detailing how we structured the curriculum to ensure a comprehensive understanding the practical application of health justice in clinical settings. The session will also include reflections on the challenges we faced along the way, as well as the feedback we have received from stakeholders thus far. Finally, we will discuss how this fellowship model has the potential to influence future training programs, ensuring that clinical ethicists are equipped not only to navigate ethical complexities but to advocate for policies and practices that promote justice and equity in healthcare."

3)    Barned C. If Not Us, Then Who?  The Role of Advocacy & Activism in Healthcare Ethics Practice

Abstract:

"Background: There has been considerable debate about the acceptability of advocacy/ activism within the healthcare ethics consultant's (HECs) scope of practice. Whereas some have expressed hesitation and questioned the role advocacy/activism ought to play, others argue that ethicists are inherently activists given their role in addressing moral quandaries and striving to effect change. Aims: We sought to explore this debate from an empirical lens, i.e., to understand if/how these arguments transcend geographical borders and clinical contexts. This presentation stems from a larger qualitative project examining how HECs across various public hospitals and healthcare settings in Ontario, Canada, perceive the scope of their roles. Methods: Between May and October 2024, 40 semi-structured interviews were conducted with HECs across Ontario. Using reflexive thematic analysis, we examined the perceptions of, and challenges with advocacy and activism as part of the HECs role. Results: Amidst much diversity in how advocacy/activism is construed, our analysis revealed that concerns about job security, "cancel culture", reputational risk, and a lack of moral courage are all interconnected and possibly stem from the absence of institutional protections. Canadian HECs remain much more reserved about notions of activism than advocacy. Participants situated the permissibility of each in relation to their status as clinical or academic ethicists vs. their engagement as professionals or private citizens.  These themes are enmeshed in a prevailing belief that HECs should be accessible to all, which necessitates a commitment to neutrality in ethical discourse. Discussion: The differing perceptions of advocacy/activism highlight the need for clear delineation and operationalization of these terms within healthcare ethics practice. Given the criticisms of the field, and the urgent calls to action regarding racial equity and justice, these findings are instructive of how we might mobilize towards change in favour of the diverse populations served."

4)    Eijkholt M. Nice to have or need to have? Justifications for Healthcare Ethics Consultation (HEC) in tightening resource environments

Abstract:

"HEC services are under an increasing threat of administrative skepticism. With global financial crises and resources for health care becoming more constraint, structural support for HEC is under closer scrutiny. Voices that deem HEC as a NICE to have instead of a NEED are growing louder. At the same time, healthcare has become more complex and moral issues have far from resolved. Environmental-, financial- and digital crises are challenging healthcare providers by creating various dilemmas that affect patient care, on managerial and bed-side level.

Increased skepticism means that traditional arguments for HEC might no longer be satisfactory. Top-down accreditation norms are crumbling apart. And while the professionalization movement in the US may have contributed to making HEC more established, structural support for and professionalization of HEC is varied and still in its infancy in Europe.

HEC services have existed in the Netherlands for several decades. Yet HECs are far from integrated throughout the whole system, and its development and support is threatened by tightening resources. In the past year we have established a new academic HEC network by University Medical Hospitals to bundle forces and to establish fortified justifications for HEC. One of the network's aims is to increase recognition for structural reflective and ethically supportable health care systems in which HEC is considered an indispensable NEED.

This presentation will offer an insight into the first project of the network. In this project we investigated how scarcity, and social justice, issues are present in academic hospitals, and how the HEC services are engaged in the reflection on organizational and bed-side level. We examined what role HEC can play in dealing with those issues, and what this implies for the HEC's justifications and the network's role and mission."

5)    Ahmad, M. Moral Distress in the United Arab Emirates: Lessons learnt and Moral Resiliency strategies within both Healthcare Ethics Consultation Services and Medical and Nursing Practice

Abstract:

"Workplace violence (WPV) against healthcare professionals represents a global issue. Violence in the maternity setting has received little research attention, with midwives often assimilated into nurses. Few studies, primarily qualitative, have explored the effect violence has on midwifery students whilst clinical placement.

Methods: An online, anonymous survey was sent via email to all members of Local Midwifery Boards in Italy and to all Italian midwifery students, investigating their experiences of WPV and bullying.

Results: The findings highlight the high exposure to violence that midwives and midwifery students experience in the workplace. A total of 1059 completed questionnaires were returned by eligible participants, 687 midwives and 372 midwifery students. Forty-five percent of midwives and 27% of students reported being a victim of WPV. This was most often in the form of verbal abuse. The women's partners or other family members (65.4%), patients (21.9%), and physicians (29.1%) were identified as the main perpetrators by midwives. Midwifery students experienced bullying mostly from supervising midwives (40.2%) or other midwives (56.8%). Over half of the victims did not report and seek assistance through formal channels. Consequences of WPV included thoughts of leaving their job (27.1% of midwives) or course of study (22.5% of students) and significantly reduced gratification from caregiving.

Discussion and Conclusions: Healthcare professionals face the following moral dilemmas: providing care to patients who have attacked them, manage emotions so as not to let them to interfere with care, balance the responsibility of protecting their own integrity and safety with professional duty and with respect for dignity of the patient. HEC can offer a listening space for victims and create the conditions allowing for the reporting of facts. In this listening space, ethical consultant can help to explore and resolve these conflicts through an analysis of professional and moral values. Also, HEC can help to create corporate awareness on the topic so that adequate prevention measures are implemented."

1)    Hug K. Bodily intervention in pediatric oncofertility: Considerations from ethics and human rights perspectives

Abstract:

"When cancer treatments endanger reproductive potential of pediatric patients, fertility preservation (FP) measures depend on patient's age, gender, type of cancer, success rate or risks of the intervention. When patients are too young to assent, FP decisions rest on their legal guardians. We explore FP decision-making from ethics and human rights perspectives and employ ethical and legal argumentation to study four questions:

1.    What role, if any, hidden values should have in FP decision-making, especially when patients cannot be consulted due to their young age?  FP is considered in the light of society's understanding of what makes a life 'complete' and what an individual should be protected from. In the bigger picture of 'completeness' of life inability to have biologically related offspring can be seen as harm or as closing one specific 'path' in life.
2.    Should permissibility of bodily interventions without minors' assent depend on how certain legal and clinical possibilities to use their reproductive material are?  FP choices are made under many uncertainties, e.g.: Patients' future position about importance of having biologically related offspring is unknown. Neither is their future health status and clinical chances to use cryopreserved material. Country of residence may ban reproductive services for e.g. homosexual couples or single women, and the patient may fall within these categories. 
3.    Should the 'disease' status of involuntary infertility refer to future condition which may or may not be experienced? FP interventions operate under the assumption that the 'disease' status of involuntary infertility reaches as far as potential condition rather than a problem experienced here and now.
4.    Should children's open future be protected by the state rather than legal guardians when it comes to FP decisions? Empirical evidence suggests that parents often feel overwhelmed by cancer diagnosis and may not give FP enough consideration, in which case FP refusal could be seen as endangering child's open future."

2)    Francis U. The Clinical Ethics of Contested Illness 

Abstract:

"Contested illness-those whose ontology and causation are disputed within the medical community-present the paradox of an illness without an underlying disease or diagnosis. This paradox challenges the epistemic framing of the medical profession, which is to treat illness and disease as coterminous and in terms of a diagnosis. Accordingly, contested illness is often the site of epistemic injustice: unexplained symptomology is often presumed to be psychogenic, in which case patients with physiologic symptoms have an undue burden of proof thrust upon them, requiring relentless self-advocacy and provider shopping until the true diagnosis is uncovered. Conversely, psychiatric disorders that beget physical symptoms lack clinical credibility precisely because they are psychiatric in origin (see, e.g., Suzanne O'Sullivan 2017, 2018, 2021)-another instantiation of epistemic injustice. These practices are historically linked with the subjugation of women through their hystericization, indeed, women are disproportionately affected by contested illnesses and diagnosed, often in tandem, with conversion disorder). Contested illness thus presents the question: what does justice and ethics demand of providers when confronted with these paradoxes?

After situating the problem discussed above in its historical context, this paper argues that a three-pronged approach to clinical care is essential to the equitable treatment of persons presenting with contested illness. First, providers must-regardless of causation-treat a patient's symptomology and suffering as presumptively credible, effectuating epistemic justice by investing a patient's word with dignity. Second, providers must engage the problem of diagnosis with an investigative mindset, leaving open the possibility of rare disease or as-yet-undiscovered afflictions. Finally, and fundamentally, I argue for a diachronic narrative approach to patient care, which is essential to a holistic and humanist understanding of the semiotics of symptomology and, ideally, to establishing the causation that solves the paradox of an illness without a diagnosis."

3)    Westermair A.L. Justice in End-of-life Care for Persons with Anorexia Nervosa

Abstract:

"Background: End-of-life (EOL) care is the part of palliative care intended for persons nearing death. In anorexia nervosa (AN), providing EOL care instead of coercing life-sustaining measures is controversial.
Aims: To clearly delineate differing views and identify open questions as well as areas of possible consensus, we conducted the first-ever synthesis of the existing literature on EOL care care for persons with AN. In this presentation, we will focus on results pertaining to justice.
Methods: We searched EMBASE, PubMed, PsycInfo, and Web of Science for scientific publications on forgoing coerced life-sustaining measures and/or providing EOL care for persons with AN who refuse life-sustaining measures, typically artificial nutrition. As very little quantitative studies were identified, we qualitatively analyzed the material relating to relevant aspects such as conceptual questions and ethical reasoning.
Results: We identified 117 eligible publications from 1984 to 2023, mainly case reports and ethical analyses. Besides beneficence and non-maleficence, reasoning was based on the ethical principle of justice. Discrimination was used as grounds for rejecting proposals of diagnosis-based ethico-legal exceptionalism such as hard paternalism. Access to care was brought up by many authors, with some arguing that EOL care endangers access to care aiming at clinical remission and others countering that AN patients should have the same access to EOL care as persons with somatic illnesses. In addition, some authors argued that providing EOL care counters stigma by acknowledging that psychological suffering can be as real and painful as physical suffering.
Discussion: While the ethical debate around EOL care for persons with AN is often framed as a conflict between the ethical principles of beneficence and respect for autonomy, justice-based ethical reasoning is relevant, too, touching on discrimination, access to care, and stigma."

4)    Beaman L. R. Who is More Worthy? Reimagining Equity and Moral Responsibility in Transplant Patients with Perceived Patient Induced Diseases

Abstract:

"The increasing demand for liver transplants (LTs) has amplified the challenge of ensuring equity in the recipient selection process. In the U.S. alone, one in four patients listed for LT die on the waitlist or become too sick for surgery. The scarcity of organs raises critical questions about how selection committees determine which patients are suitable for transplantation, particularly in the context of 'perceived patient induced diseases' (PPIDs). PPIDs are conditions that arise partly from behaviors considered to be within the patient's control. This presentation explores the ethical issues in using different standards for PPIDs by comparing Alcoholic Liver Disease (ALD) and Metabolic Dysfunction-Associated Steatohepatitis (MASH).

ALD, caused by alcohol use disorder, and MASH, linked to obesity, can both be perceived as self-inflicted. These disorders carry significant stigma, shaped by sociopolitical narratives that influence not only public opinion, but how healthcare providers view and treat patients. This, in turn, affects transplant selection committees’ decisions about patient eligibility for transplantation. Yet, their evaluation standards differ from each other.

Moral perceptions of disease lead to certain patients being considered less ""worthy"" of life-saving organs due to the perceived controllability or moral dimension of their disease. Patients with chronic ALD are expected to maintain a minimum six-month period of abstinence from alcohol before being placed on a waitlist. Contrarily, patients with MASH are not widely required to lose weight or demonstrate changed behaviors prior to being considered for transplant.

By examining ALD and MASH through the lens of patient autonomy and culpability, utility, public perception, and transparency, it is evident that current disparities in the treatment of these conditions contribute to inequities in transplant. We suggest a practical approach of aligning selection criteria across PPIDs and eliminating moral judgments in candidate evaluation. Doing so can promote greater equity in transplant candidate selection."

5)    Remer D. C. Clinical Ethics in Practice: Ethical Care and Social Justice in Organ Transplantation

Abstract:

"Healthcare ethics consultants (HECs) can play a crucial role in addressing social justice issues in organ transplantation by advocating for ethical frameworks that mitigate inequities faced by marginalized populations. In the United States, racial and ethnic minorities, economically disadvantaged individuals, and other vulnerable groups have historically experienced disproportionately lower access to organ transplants due to systemic barriers such as implicitly biased allocation policies, limited healthcare access, and socio-economic disparities. These inequities perpetuate health injustices, limiting lifesaving transplant opportunities in these communities.

HECs are uniquely positioned to advocate for a model of care ethics that reframes justice in a more inclusive and equitable, albeit sometimes partial, context. Care ethics, with its emphasis on relationality and responsiveness to vulnerability, offers an alternative grounding that centers on patients' lived experiences rather than abstract principles that may inadvertently reinforce biases. By integrating a model of care ethics into their everyday practice, HECs can ensure justice is not only about equal distribution of resources but about addressing the unique needs of individuals, especially the historically marginalized.

In organ transplantation, this means advocating for policies that prioritize not just medical urgency and viability but also accounting for social determinants of health, like socio-economic status, race, and geography. Care ethics urges decision-makers to view patients as whole individuals with unique, particular features who are embedded in social contexts, not mere clinical metrics. In doing so, HECs can promote a more just and equitable transplant system that provides genuine justice for all.

Ultimately, HECs can reshape transplant ethics by grounding their approach in an ethic of care that redresses historical injustices while fostering a more inclusive, compassionate, and equitable healthcare system."

1)    Eibling A. Prevalence of refusal to provide emergency contraception to sexual assault victims in Michigan Catholic and non-Catholic hospitals

Abstract:

"Sexual assault presents a critical public health issue in the United States, affecting 17.6% of women during their lifetimes 1. Immediate medical care is essential to address the profound sequelae, including sexually transmitted infections, trauma, and unintended pregnancy. Standard care for sexual assault survivors includes pregnancy prevention through emergency contraception (EC), recommended by the American Congress of Obstetricians and Gynecologists (ACOG) 2. However, Catholic hospitals, guided by their Bishop's interpretation of the Ethical and Religious Directives (ERDs) for Catholic Healthcare Services, often restrict or prohibit EC to sexual assault victims 3. This study assesses the availability of EC in Michigan Catholic and non-Catholic emergency departments (EDs).

Utilizing a mystery-client approach, female interviewers inquired about EC provision in 94 Michigan EDs (69 non-Catholic, 25 Catholic). The findings indicate a disparity in EC availability: 49.3% of non-Catholic EDs versus 24% of Catholic EDs provided EC. Among non-Catholic EDs that declined EC, 93.8% provided valid referrals, compared to 72.2% of Catholic EDs. Notably, 72% of Catholic EDs and 46.4% of non-Catholic EDs refused to provide EC under any circumstance, including sexual assault.

The data underscore the limited access to EC in both Catholic and non-Catholic EDs, with a pronounced restriction in Catholic facilities. Additionally, those seeking EC often encounter judgment and hostility from staff, regardless of the hospital's religious affiliation. Multiple respondents hung up on the interviewer while the interviewer was still speaking. These limitations pose a substantial barrier to comprehensive care for survivors of sexual assault, exacerbating the psychological and physical consequences of assault. While this study reveals greater restrictions to EC in Catholic EDs, the findings highlight the need for policy changes to ensure consistent and compassionate care across all EDs, regardless of religious affiliation. Future research should explore why access to EC is limited and enhance EC accessibility for all sexual assault survivors."

2)    Schiff J. C., Burgart A. Ethical, Legal, and Social Justice Considerations of Mandatory/Routine Pregnancy Testing in the Emergency Department

Abstract:

"Taking a pregnancy test (PT) and learning information about one's pregnancy status (PS) is an intimate and personal activity/decision. This is especially true in the United States following Dobbs v. Jackson Women's Health Organization (2022), where the Supreme Court revoked the constitutional right to abortion granted in Roe v. Wade (1973) and returned that decision to states. This activity/decision is all the more pressing in current socio-political times following the 2024 U.S. presidential election. 

However, in emergency departments (EDs) across the U.S., patients who are female, female-presenting, women, women-presenting, and/or trans run the risk, without consent, of being administered PTs and learning their PS. Indeed, ED practitioners may routinely administer PTs regardless of whether their cases are emergent, urgent, or necessitate use of anesthesia. 

Healthcare ethics consultation (HEC) professionals should help ensure emergency department practices and policies align with what is best for patients, not only from a clinical standpoint, but also from an ethical, legal, and social justice standpoint. 

Our paper focuses on ethical, legal, and social justice considerations when evaluating whether PTs in the ED should be mandatory/routine for the relevant target female population. We argue that administering PTs in the ED, especially where no consent is obtained, is often:

- ethically unjustifiable according to principles of autonomy, beneficence, nonmaleficence, and justice,
- legally problematic (1) insofar as the results could have drastic consequences for patients depending on the state where they seek care/travel to and (2) to the extent such tests were administered without obtaining informed consent,
- dismissive of females', and often women's, accounts/testimony of their PS, if such accounts/testimony are sought out at all,
- dismissive of patients' reported sexual history and preferences, which flies in the face of LGBTQIA+ rights, and
- economically wasteful and irresponsible on account of the widespread use of pregnancy testing in the ED."

3)    Trachsel M. How to deal with the Criterion of Severe Mental Distress for Late Termination of Pregnancy?

Abstract:

"The issue of late termination of pregnancy (abortion after twelve weeks from the last menstruation) is a topic of intense debate among healthcare professionals and the public, as it involves balancing the divergent interests and needs of the pregnant person and the fetus. Some jurisdictions recognize severe mental distress as a valid criterion for allowing late termination of pregnancy. However, the unavailability of a clear definition presents challenges in clinical practice. 
A systematic literature review was performed to examine in which countries the criterion -severe mental distress- exists and how it is interpreted. In addition, we conducted a qualitative content analysis of clinical ethics consultation reports conducted in a Swiss university hospital. 
The systematic review of the literature yielded that 23 publications distributed worldwide were relevant to the question. Regarding the term -severe mental distress-, there is no uniform terminology. The indication for abortion is referred to as psychiatric, psychosocial, sociomedical, or maternal emergency. General criteria cited for risk of severe mental distress are psychiatric, psychological, embryopathic, socioeconomic, or criminological. 
The qualitative content analysis of 20 clinical ethics consultation reports revealed a range of ethical challenges that arise in clinical practice, namely how the risk of severe mental distress can be assessed, whether the termination of pregnancy is suitable to avert the distress, and whether the termination of pregnancy is proportionate. We identified several recurring criteria that require clarification to aid decision making, such as whether treatment options and alternatives have been adequately discussed and presented, whether the request is consistent and enduring, and whether there are causes of severe mental distress that could be eliminated otherwise.
For jurisdictions that allow late-term abortion based on severe mental distress, we propose a set of guiding questions to support healthcare professionals engaging in careful decision making."

4)    Du Peuty C. Justifying late terminations of pregnancy for psychosocial reasons: restoring social justice for women

Abstract:

"In France, women can terminate their pregnancy on the unique basis of a voluntary request only up to 14 weeks of pregnancy, later, and up to term, if doctors attest that their health is in serious danger or that their fetus carries a serious and incurable disease. Some medical teams consider unfavorable psychosocial conditions (precariousness, isolation, psychological distress, domestic violence) as -endangering women's health-, thus enabling late termination, whereas some others do not.

Clinical ethics consultations about medical termination on psychosocial grounds after 14 weeks of pregnancy help identify the ethical arguments. From this experience, it seems that respect for autonomy is not useful to make decisions in this context: these women's psychosocial conditions are interpreted as a sign of limited autonomy (understood as independence, self-determination or competence). The balance between beneficence and non-maleficence is no more helpful: the maleficence of giving birth to a dead baby and the fear that women will be overwhelmed by guilt and regrets neutralizes the beneficence of accepting the request and thus avoiding a (more) catastrophic situation for the woman. Rather, the principle of justice seems to be a more promising path to justify the decision about late termination of pregnancy for psychosocial reasons, and this is so for several reasons. First these requests are legal in France, thus indicating a wider social consensus. Second, such terminations promote psychological and social aspects of health, in line with the WHO's definition. Finally, arguments about reparation are prominent in these decisions: they contribute to compensate for poor medical practices (ex: undiagnosed early pregnancies by healthcare professionals), to counterbalance inequalities in accessing abortion across the country ”that contribute to the fact that women cross the 14 weeks gestation limit for voluntary access”, and to make up for inadequate or insufficient public policies on women's psychological health, domestic violence, sexual education and contraception. Thus, social justice seems a less intuitive yet more powerful argument to justify women's access to late termination of pregnancy on psychosocial grounds."
 

5)    Calderon Ramirez C.L. The quality of an online democratic deliberation on the COVID-19 triage protocols: results of a Canadian public assessment

Abstract:

"Background: During the COVID-19 pandemic, some democratic deliberations were conducted online.  A few of them aimed at presenting the new critical care triage protocols to the public. Experts have recommend gathering feedback from participants to assess their quality. However, little is known about the quality of these online processes.

Objectives:  1) To assess the quality of an online democratic deliberation (ODD) on COVID-19 triage protocols with public participants in Canada.  2) To determine, according to them, its transformative aspect.

Methods: This is a mixed methods study. On May 28th and June 4th, 2022, we conducted an ODD in Quebec and Ontario with a diversified target audience. At the end of deliberative session, we collected participants’ views on the quality of the process. Plus, participants responded to a survey to assess the quality and identify changes in their perspectives on triage protocols (close-ended questions and written comments). Transcripts and written comments of the survey were analyzed using a thematic analysis.  Quantitative data were subjected to descriptive statistical analysis. We calculated an index to determine equality of participation during the process.

Results: A total of 47 members of the public participated in the ODD (20 from Quebec, 27 from Ontario). Five themes emerged: 1) process appreciation, 2) learning experience, 3) reflecting for the common good, 4) technological, and 5) transformative aspects. Of the total, 46 (98%) participants responded to the survey. Participants considered satisfactory the quality of the ODD in terms of process, information, reasoning, and video conferencing.  Some participants reported at least one change of perspective on the criteria and ethical values contained in the protocols. Online modality was reported accessible and user-friendly.  Low polarization was found.

Conclusion: An ODD can be a promising alternative in a pandemic context, but some organizational adjustments must be considered."

Sylvestre P. Réseau d'éthique clinique international francophone (RECIF): comparisons, exchanges and collaborations

Abstract:

"Context:
Since May 2024, the Réseau d'Ethique clinique international francophone (RECIF), an axis of the international francophone bioethics network, has brought together clinical ethicists from Belgium, Canada, France and Switzerland. With clinical, organizational and normative issues specific to each context, clinical ethics consultation has developed differently in each setting. This plurality of practices, in terms of processes and cases handled, offers a rich opportunity to exchange and collaborate, to learn from each other's ways of doing things and to consolidate the network.

Workshop objective:
We propose a workshop that will bring together an international panel of French-speaking clinical ethicists from each of the Network's teams, in order to better understand how each team carries out its clinical ethics consultations. The workshop will be structured around a clinical vignette focusing on conflict resolution, to highlight differences and similarities in practice. The aim is to learn from different ways of approaching a similar question, to better understand how French-speaking clinical ethics teams work.

Methodology:
A clinical vignette will be developed by BL and PS. The vignette will be fictional but inspired by real cases observed in adult and pediatric settings, and will fit in with the Conference theme, specifically Clinical Ethics Consultation and Conflict Resolution. The vignette will be sent to a representative of each of the five clinical ethics consultations (CM at Bruxelles, RJJ at Lausanne, AP at Montréal, NF at Paris, MEB at Laval). Each team will then approach the case as they would in practice, documenting their approach precisely (Who? What? When? How?), asking questions of the authors and preparing their response and presentation for the workshop.  During the workshop, we will discuss the work of each team, highlighting key differences and similarities. The five clinical ethics teams have approved the proposed approach.

Workshop outline (90 mins):
- Introduction and review of clinical vignette - 5 minutes
- Presentation of each team's approach - 50 minutes (10 minutes per team)
- Open discussion with the audience to explore the differences and similarities between the approaches, in terms of the nature of the response and the process (e.g. people involved and in what order, information-gathering process, structure of deliberation, central concerns, decisional or non-decisional nature, means of communicating conclusions). - 30 minutes
- Conclusions - 5 minutes"

Johnston C., Moore K., Sacks B. Including the parents’/family voice in paediatric clinical ethics case consultation - considering best practice

Abstract:

"Ethics case consultations in paediatric settings do not routinely involve parents.  The Nuffield Council on Bioethics (2023) notes that parents are seldom included in clinical ethics consultations. Recent legal cases highlight this lack of patient / family participation as a significant concern.

In Australia, the National Health and Medical Research Council (2015) suggests consideration of the involvement of the family and/ or patient before offering case consultations and the Royal Australasian College of Physicians advocates that all patients, families, carers and clinicians have access to quality clinical ethics services. Neither gives specific guidelines.

Inclusion of parents within the ethics consultation processes arguably promotes fairness, transparency and reciprocity, enabling decisions made to reflect and incorporate the values of all stakeholders. There are varying approaches to inclusion of parental views in the ethics case consultation process throughout the world. Clinical ethics services in paediatric hospitals in Australia have not yet debated the pros and cons nor the practicalities of doing so.

We report on the findings of a 2023 Quality Assurance project of the Clinical Ethics Response Group (CERG) at Monash Children's Hospital.  All clinicians who attended a CERG case consultation were invited to participate in a semi-structured interview, exploring views on whether and how parents should be involved in ethics case consultations. Twelve interviews were conducted.

Overwhelmingly, participants expressed the importance of hearing the parental voice, to allow them to provide information about what option(s) for treatment they considered best for their child.  Suggestions included inviting families to attend CERG meetings in person, providing a written document, or meeting with an ethicist before the case consultation.

There were several challenges noted to all these approaches and most interviewees favoured parents not attending in person, but rather providing a written document.  Participants thought that parental involvement should be offered on a case-by-case basis, not as a default.

This workshop will engage audience members in a discussion of:

- Current approaches of the participants institutions to inclusion of the parental /family voice in ethics case consultation.
- The underlying moral reasoning for parental inclusion fact finding, procedural fairness, equity?
- Facilitated group discussion of the benefits and challenges of different practical approaches to parental involvement.
- How to best accommodate and support parents, especially those with language or other limitations to engagement.
- Would this move the standard clinical ethics process to a mediation model? 
- Would changes to routine practice impact the integrity of the process?"

Miljeteig I., Brendbekken A., Solheim H.A. “Be Wise - Prioritize!” Training and Supporting Healthcare Staff Facing Ethical Challenges Due to Resource Scarcity

Abstract:

"Background and Objectives:Resource scarcity poses major ethical challenges for healthcare providers (HCPs), who often find themselves stretched between delivering optimal patient care and adhering to efficiency demands. This challenge can lead to moral distress as HCPs both in high-, middle- and low-income countries struggle to allocate limited time and resources fairly. In Norwegian hospitals, Clinical Ethics Committees (CECs) have been mandated since 2021 to not only offer ethical guidance but also enhance staff's ethical competency, specified to also include education in relation to priority-setting of resources. Our CEC, serving around 14,000 hospital employees, has seen a marked rise in requests for training related to resource prioritization, especially following new challenges introduced by the COVID-19 pandemic. This workshop aims to: Engage participants in interactive learning methods used to train healthcare staff in addressing ethical challenges related to scarce resources. Foster dialogue and networking among attendees interested in enhancing CEC educational activities. Workshop Structure and Activities:Introduction (10 minutes): Overview of ethical challenges tied to resource scarcity and the role of CECs in training HCPs. Pedagogical Strategies (20 minutes): Presentation of teaching methods, learning outcomes, and evaluation strategies tailored to various healthcare roles, with evidence-based techniques for ethical reflection and decision-making. Interactive Role-Play (30 minutes): Participants will take on roles as HCPs navigating a realistic ethical dilemma in resource allocation, practicing ethical analysis, prioritization, and moral reasoning. Group Discussion (20 minutes): Facilitated dialogue on CECs' role in ethical education, with participants reflecting on the role-play, sharing institutional experiences, and discussing the impact of CEC training on staff competence. Conclusion and Networking (10 minutes): Wrap-up with an invitation for ongoing collaboration and networking among participants interested in advancing CEC educational programs. Target Audience: This workshop is for CEC members, healthcare educators, ethicists, and administrators focused on improving ethics training in resource-limited settings."

Speakers :

- Nikola Biller-Andorno
- Karin Jongsma
- Georg Starke

Please access the full description here

Eric Racine, Director of the Pragmatic Health Ethics Research Unit, University of Montreal 

The Living Ethics International Network is pleased to invite you to an open meeting titled "Imagining Ethics Otherwise: Orientation, Projects, and Perspectives in Living Ethics." This meeting will introduce to living ethics, highlight key ongoing projects and publications, and open the discussion on this new development.

Further information: https://livingethics.ca/

Presenters: Eric Racine, Suzanne Metselaar, Arthur Filleul, Marika Warren, Félix Pageau, and Katja Kühlmeyer

Headed by Ehsan Shamsi Gooshki 

1)    Spranzi M. Clinical ethics consultations and somatic treatment for mental health patients: from non-discrimination to de-stigmatization

Abstract:

"Mental health patients suffer from a loss of 15 years life expectancy with respect to the general population. This is due not only to internal factors like suicide or isolation, but to persistent difficulties in accessing somatic care: obstacles to preventive treatments, time constraints in the caring for 'difficult patients', sketchy follow up, difficult social life conditions compounded by a historical separation between psychiatric and somatic institutions and medical cultures. Advocates often point to discrimination, i.e. a consistently lower level of somatic care for mental health patients, as the main cause for mental health patients' medical loss of chance. While current discrimination certainly needs a sustained societal effort to redress a persistent gap in somatic health, certain life-threatening conditions where heavy medical procedures are at stake (dialysis, amputation, transplant, etc.), raise genuine ethical dilemmas that call for a more nuanced analysis. Indeed, the patient's refusal of somatic treatment and  the treatment adjustment to mental health patients' particular life conditions have to be taken into account in order to achieve real fairness. We shall draw on a few cases from our clinical ethics consultation services, in order to discuss the related notions of discrimination, fairness and stigmatization. It will be argued that unlike what a principle of non-discrimination suggests,  one should not only focus on measuring these patients' health outcomes but rather on fostering  an attitude of de-stigmatization, whereby these patients' voice is given the right weight in medical decisions concerning somatic care. These patients' rights should be understood in a broader sense than merely  guaranteeing equal access to somatic treatment,  rather, their special outlook on the world, their right to refuse or defer treatment and their preference not to undergo treatments they consider as futile, given their life situations, should be given proper consideration."

2)    Barned C. Healthcare Providers’ Experiences with Discriminatory Requests/Refusals from Patients: How Can Ethicists Help?

Abstract:

"Background Healthcare providers are increasingly exposed to acts of violence, harassment and bigotry from patients, their family members and visitors. When faced with such acts, there is an organizational tendency to rely on zero tolerance policies or refer to applicable guidance from regulatory bodies. Some organizations provide in-depth guidance through policy or algorithms that help direct staff on what to do, when, why, and who to contact. In lieu of substantive organizational policy, ethicists are sometimes called upon to help navigate instances where a patient requests/ refuses care from a provider solely based on their identity characteristics. 
Aims This presentation is part of a larger quality improvement project focused on the revision of a patient bias policy at a large Canadian academic health sciences hospital. Rooted in experiences of diverse healthcare providers, this presentation describes the forms of discrimination that oft arise in healthcare ethics consultation (HEC) on the topic, and notes the tangible ways in which organizations can better support their employees.
Method 27 semi-structured interviews were conducted with physicians, nurses, occupational therapists, physical therapists, recreational therapists, and social workers about their experiences with discrimination from patients/their family.
Results Participants relayed experiences with refusals owing to racism, sexism, homophobia, and islamophobia, the intersections of these and other forms of discrimination, and the ways in which these experiences were exacerbated by nuances in the work culture/ broader organization.  
Discussion HEC on the topic requires thorough understanding of the refusal, awareness of the organizational stance, applicable laws/policies, available supports, and institutional constraints that might impact how decisions are made and experienced by the healthcare workforce and the patients served. Where organizational responses are lacking, providers are left to blindly navigate these emotionally distressing encounters and struggle with the tensions between the duty to care and their right to a discrimination free workplace."

3)    Chollet M. Towards an anti-racist clinical ethics: rethinking diversity in the hospital setting

Abstract:

"The issue of racism in hospitals struggles to gain attention despite the existence of numerous studies documenting racial discrimination in healthcare settings. The aim is no longer to demonstrate the reality of racist discrimination, but to combat it. The diversity of patients in hospitals confronts ethicists with varied practices that can lead to misunderstandings. Ethics, like any discipline rooted in the social sciences, must engage in reflective practice in relation to discriminatory phenomena. Ethics practitioners face contemporary dilemmas, which require them to gain new insights into the systemic racism that has permeated hospital settings.
Sometimes, it is more comfortable to reduce the conflict at hand to its cultural dimension and to call on specialist bodies (transcultural consultations) if they exist. But the cultural dimension of hospital conflicts involving migrant patients is overestimated. At the same time, the concept of culture is often misunderstood, misinterpreted, and can even lead to discrimination. Based on two ethnographic studies in Swiss hospitals, our presentation will focus on analyzing the mechanisms of racism in healthcare and how the concept of culture is misused.
Our objectives are twofold. First, we seek to prompt reflection on the contribution of sociology to clinical ethics, which still struggles to address the structural and institutional causes of racism in healthcare. Second, we aim to propose concrete adaptations and recommendations for ethics professionals to help them make decisions that take current sociopolitical realities into account, thus avoiding the pitfalls of cultural essentialism toward migrant patients."

4)    Pageau F. Exploratory Research on EDI to Counter Discrimination in Hospital Settings in Canada- A study protocol and preliminary results

Abstract:

"Background: 
Discrimination not only represents a violation of the law but brings forth ethical risks for health and social services systems. We use the term 'ethical risks' defined as an action that occurs in an organization, against its politics and rules, that is problematic according to the standards in place (Begin et al., 2014). This type of risk undermines the ethical values uphold by users, staff members, the organisation, and society, as a whole. Hence, discrimination ought to be understood better, especially in the organization where it takes place. Appropriate measures should then be defined respecting Equity, Diversity and Inclusion (EDI) principles to reduce discrimination. 

Aims: 
Our project aims to answer:
- What are factors contributing to discrimination, including ethical risks?
- How to rally professional and organisational values preventing discrimination and sustaining EDI practices?

Methods:
This exploratory research is based on a mixed-methods approach, combining qualitative and quantitative methods in two stages. First, focus groups and individual interviews will be conducted, which will feed into a survey to understand participants' perspective on EDI and discrimination, near Quebec City, Canada. They are members of the organization as well as with users and relatives (informal care givers or concerned significant others). Our survey and interview main themes will be: 
- the ideal of inclusion in health and social services,
- risk factors leading to discrimination from an individual, sectoral and organizational perspective,
- strategies to reduce discrimination and value EDI principles.
For each theme, we will also discuss the relation between professional and organizational values.

Results: 
We will present preliminary results that will have emerge from the focus-group and individual interviews.

Discussion: 
Our presentation will highlight the elements identified by the participants as ethical risk factors as well as the mitigation measures allowing EDI approach to progress in a hospital."
 

5)    Dahlke J. Measuring the intersection of structural discrimination, non-compliance, and implicit attitudes in health care

Abstract:

"This presentation explores preliminary research on how the widespread use of terms like "non-compliance" and "non-adherence" may reflect broader factors beyond individual patient characteristics, including structural racism, discrimination, and healthcare professionals' (HCPs) implicit biases. If true, the routine use of these terms in healthcare, in the United States or elsewhere, may be inappropriate, and alternative perspectives and behaviors should be considered.

There are four arguments to support the theory described above. First is the historical context of structural racism and discrimination (SRD) in healthcare in the United States. SRD contributes to current health disparities and outcomes among Black, indigenous, people of color (BIPOC). Concerning this specific research question, only Black patients are considered, with the full recognition that people representing all historically and structurally marginalized populations are worthy of their consideration and research.

The second argument is to describe the role that implicit bias plays in HCPs' characterizations of their patients. Implicit attitudes and biases by HCPs can perpetuate pre-existing SRD in healthcare and can impact Black patients by producing or exacerbating health outcome disparities. The third argument conceptually and operationally describes the role that non-compliance plays in these encounters, including a research summary that indicates significantly disparate prevalence in characterizing Black patients as non-compliant when compared to Non-Hispanic White counterparts. 

Finally, the fourth argument is synthesizing the first three, with the goals to (1) establish a functional relationship between them and (2) propose initial solutions to address the underlying culture around non-compliance. By studying the intersection of SRD, implicit bias, and non-compliance, alternative practices, e.g. resetting cultural norms or policy changes, can be explored that may contribute to the overall reduction of related health outcome disparities."

1)    Frase B. Alone, Vulnerable, and Silent: Navigating Ethical Decision-Making for the Unrepresented Patient

Abstract:

"Hospitalized patients who lack decision-making capacity without an advance directive or legally-authorized surrogate represent an extremely vulnerable population referred to as 'unrepresented patients.' Unable to advocate for themselves and without trusted partners, clinicians and institutions have an ethical responsibility to prudently weigh treatment decisions for these patients while mitigating bias and discrimination. In the United States, limited state statutes exist that specify decision-making processes for unrepresented patients. Such laws demonstrate significant variability.

This session will outline how our institution established a process to review the clinical needs of unrepresented patients through the creation of an unrepresented patient board (UPB). This procedure involves conducting advanced decision-making capacity assessments while taking into account the patient’s dynamic capacity in relation to the complexity of the clinical decision. Additionally, it engages unit social workers, clinical ethicists, and law enforcement to ensure advance directives or appropriate surrogates do not exist. These efforts are performed to confirm the unrepresented status of the patient.

A case-based review will highlight common challenges faced by the ethics consult service in the care of unrepresented patients including guardianship, care of incarcerated patients, and end-of-life decision-making. The membership criteria for the UPB will be reviewed including requirements for interdisciplinary clinicians, allied health professionals, spiritual care providers, legal consultants, volunteer community members, and equity, inclusion, and diversity leaders. Specific operational considerations for assembling the UPB and reviewing clinical decisions will be outlined. This includes mechanisms for timely activation of the UPB, efficient processes for reviewing clinical information with the care team, facilitation techniques for effective UPB deliberation, exploration of any evidence of prior patient advance care planning for substituted judgment, and how to proceed when consensus-based decisions are not reached in UPB deliberation.

This session will promote discussion regarding social justice and equity in the care of unrepresented patients while mitigating discrimination."

2)    Regel E. Mental Health and Vulnerability: Navigating Cognitive and Socio-Political Challenges in Health Ethics Consultations 

Abstract:

"Cognitive vulnerability in patients with mental health issues and trauma presents unique challenges within health ethics consultations (HEC).  Information processing, decision-making, and self-advocacy limitations require a tailored ethical approach during HEC. This presentation will explore how vulnerability theory, with a particular focus on cognitive vulnerability, can enhance ethical analysis while addressing the socio-political factors that often compound these vulnerabilities and affect clinical outcomes.

The vulnerability approach recognizes cognitive vulnerability as an increased risk to autonomy and justice, exacerbated by such factors as psychological trauma, mental illness, and fluctuating decision-making capacity. It expands the ethical lens to include personal vulnerabilities and socio-political determinants, such as systemic discrimination, healthcare inequalities, and resource scarcity, all of which exacerbate these vulnerabilities.

In the acute care setting, the vulnerability approach supports a framework of -relational autonomy,- which recognizes that autonomy is dynamically shaped by cognitive capacity, mental health, and the patient's social context.  HEC conducted with the lens of vulnerability can adopt strategies incorporating cognitive and relationship needs, employing clear communication enhanced by trauma-sensitive language and a collaborative decision-making process to facilitate the patient's understanding and informed consent while respecting their dignity and personhood.  When cognitive vulnerabilities impact decision-making, HEC can adopt empowering strategies that prioritize patient well-being while striving to maintain the patient's agency.  This includes simplified information delivery, frequent check-ins, and trauma-sensitive communication that respects the patient's processing abilities and personal history.

The vulnerability approach also highlights the social-political dimensions, underscoring how system issues, such as inadequate mental health resources, policy-driven barriers, and social stigma, do shape clinical ethics.  Patients with mental health issues often face structural inequalities that limit access to care and support, thus intensifying cognitive and emotional vulnerabilities.  Addressing these broader forces in ethics consultations will encourage clinicians to advocate for policies that alleviate these burdens, promoting justice alongside patient-centered care.

The vulnerability approach offers an enriched ethical consultation framework by integrating cognitive and social-political considerations.  This approach will help clinicians not only navigate the moral dilemmas arising from cognitive complexities and systemic limitations faced by patients with mental health issues and a history of psychosocial trauma but also ensure that HEC is both compassionate and contextually responsive to the unique needs and circumstances of this patient population."

3)    Moisi L. Medical decision-making in critically ill geriatric patients: are we moving from ageism to ableism?

Abstract:

"Across the globe, media, legislators, healthcare professionals (HCPs), and healthcare organizations are increasingly concerned with gender-affirming care (GAC). More specifically, there is purported concern that patients may regret their decision of pursuing GAC. Regret is consequently framed as an outcome that patients ought to be protected from, resulting in undue challenges for patients trying to access GAC-specific interventions. These access-limiting measures constitute medical gatekeeping. Although justified at times, medical gatekeeping can risk unjustified paternalism and barriers to care.  

In this presentation, we first outline the ethical contours of medical gatekeeping and its relation to regret risk in GAC. We analyze the concept of regret and its role in moral deliberation, demonstrating that concerns about potential regret can be disproportionately weighted in the context of GAC and based on mistaken assumptions. We also show how the language of regret can at times act to both protect patients from undue harm, as well as overprotect patients already vulnerable to bias and undertreatment in a way that perpetuates injustice and disempowerment. We thus recommend caution when making judgements about the potential for regret in medical decision-making. Second, we discuss the practical and ethical implications for organizations and legislatures in preemptively limiting access to GAC on the basis of regret mitigation. Third, we examine the role of clinical ethicists in navigating these concerns and include strategies for responding to consults, developing embedded roles, contributing to practice guidelines, delivering education, and mitigating moral distress.  

We conclude that (1) not every potential for regret can or should be avoided, (2) it is not within the purview of HCPs nor legislators to eliminate patients' potential for experiencing regret, and (3) shared decision-making can address the potential for regret without unjust medical gatekeeping. The presenter/s will invite attendees to share experiences and practices and their own organizations."

4)    Malbois E. A wolf is in sheeps’ clothing: How Protecting the Dignity of People with Dementia Can Mask Ableism

Abstract:

"Certain therapeutic approaches with people with dementia, such as the use of dolls or certain social robots that look like animals or children's toys, have been criticized for being humiliating and infantilizing, and therefore a threat to the dignity of their users. In this paper I argue that this argument is problematic because it is ableist. I begin by showing that dolls and robots can only be seen as a threat to the dignity of their users with dementia if dignity is understood as dignity of identity. This sense of dignity is connected to the identity of the person as grounded on their autonomy, integrity and social relations. These values are often central to our sense of identity and of worthiness and are associated with respect (for ourselves or from others). As a result, the degradation of these values is perceived as a loss of worthiness and can be seen as humiliating. Hence, when people with (advanced) dementia interact with dolls or certain robots as if they were babies or animals, their loss of autonomy and integrity becomes very apparent, which is seen as humiliating and a threat to their dignity of identity. However, this view implies that the loss of cognitive abilities is a deterioration and a loss of value and is, therefore, ableist. It is offensive and discriminatory towards people with dementia and people with intellectual disabilities. Therefore, this dignity-based argument against the use of robots should be rejected. I then discuss how clinical ethics committees should approach consultations on this issue, given that the ableist stance behind such requests is mostly unconscious but very pervasive. Indeed, because this argument is closely tied to issues of respect and humiliation, it often cannot simply be disregarded on the grounds that it is ableist."
 

5)    Olson E. Freak Show: How Monsterization, Isolation, and the Lure of Neurotypicalism Oppress Disabled Adults with Cerebral Palsy

Abstract:

"This paper critically examines representations of deviation in human morphology within the tonal contexts of both cultural history and disability ethics, with a particular emphasis on the challenges of young adults with cerebral palsy as they transition from pediatric to adult health care systems. I suggest that the traditional model of care between pediatrics and adult medicine is fragmented and often does not match the multi-faceted needs of disabled pediatric patients as they age. Through careful reconsideration of the legacy of disability within what is arguably and historically its most stigmatized form “the freak show“ as well as within modern clinical care practices, I emphasize the transitional care gap as one of many major societal manifestations of monsterization. I propose a three-pronged approach, broadly centered on availability, exposure, and standardization of transitional programs, as a potential solution for closing the identified gap in neurological disability care. Finally, I call for a reexamination of the use of the pejorative 'freak' in contemporary discussions of disability, suggesting that the embodiment of physical traits which are traditionally associated with a lack of health may not always clinically indicate that an individual with a disability is unhealthy, instead, impacts to physical and cognitive prowess are often only socially assumed. When these assumptions of disability-based ineptitude are made in socio-political environments by individuals in positions of power, lapses in clinical care often result. Such lapses in care can be more dangerous and damaging than the physiological harm of disability itself — especially in instances where sustained care is critical to the management of disability through the lifespan."

1)    Johnson R.M. Ethical Framework for Offering Fetal Interventions in Fetuses with Concurrent Genetic Diagnosis

Abstract:

"Fetal interventions are transitioning from research to clinical care globally. However, there is a lack of ethical guidance for including fetuses with chromosomal abnormalities. The authors analyze the ethical framework for expanding fetal surgery criteria by examining a paradigmatic case offering prenatal repair for fetuses diagnosed with neural tube defect (NTD) and Down Syndrome. We conclude it is ethically permissible to offer prenatal NTD repair in cases with concurrent genetic diagnoses.

Utilizing the concept that the fetus can be a patient, research shows prenatal repair for NTD is clinically beneficial to the neonate while balancing the risks acceptable to the fetal and pregnant patient. Examining the balance of beneficence and non-maleficence to the maternal-fetal dyad and future neonate, we conclude that performing prenatal repair should not confer additional risks to the pregnant patient or fetus without a concurrent lethal anomaly. Based on the principle of autonomy, provided the pregnant patient is presented with comprehensive information to make an informed decision, she has the autonomy to decide to undergo prenatal repair if she deems it in the best interest of herself and her fetus. Finally, based on the principle of justice, we find there is no morally compelling justification for excluding fetuses with Down syndrome.

Though our ethical analysis is not intended to be limited by geography, restricted access to the full spectrum of reproductive healthcare, including abortion in many states (and approximately 40% of the global population capable of pregnancy), provides an even more compelling argument in support of our conclusion, as laws restrict pregnant patients in these areas from accessing all medically appropriate options. Considering this, the authors argue it is ethically obligatory to offer prenatal repair in fetuses with NTD and Down Syndrome. This ethical framework can be expanded through casuistry analysis to address other concurrent genetic diagnoses."

2)    Ayoub S. The lived experience of families of children with 22q11 deletion syndrome of the disclosure of the diagnosis

Abstract:

"Introduction: The 22q11 deletion syndrome (22q11DS) is a prevalent genetic microdeletion disorder, presenting a wide range of symptoms that can affect nearly any body system. Identified frequently in childhood, this syndrome requires ongoing, intensive care, most often provided by the affected child's parents or primary caregivers. Diagnosis, whether lived positively or negatively, is an important turn point for these families, and can shape their lives significantly.

Aims: This study investigates the fundamental aspects of the lived experience of families of children with 22q11DS during the diagnosis period.

Methods: This interview study was a component of a broader mixed-methods research project aimed at enhancing the psychosocial well-being of individuals with 22q11DS and their families. The qualitative segment focused on insights from purposively selected families caring for children with 22q11DS. Semi-structured interviews were transcribed and analyzed using an inductive thematic approach.

Results: Interviews with 36 families from diverse backgrounds and with children of various ages. The diagnosis was mainly delivered after birth, but a few families received it prenatally. Three major themes were identified regarding the genetic diagnosis: circumstances, reaction, and impact of the disclosure of the diagnosis.

Discussion: An ethical disclosure requires an informed consent and a good understanding of the implications of genetic results for the future, including privacy considerations and the need to test other family members. The respect of parental and child autonomy is important to support parents' rights to informed decision-making while ensuring they understand implications for their child's health. Balancing between honesty and compassion supports parents in receiving simple information on potential health impact without overwhelming them. Clinical ethics can guide disclosing a 22q11DS diagnosis by emphasizing transparency, compassion, and clarity."

3)    Kondrat A. The Fallacy of Consensus: Reallocating Power in Ethics Consultation 

Abstract:

"The push to professionalize the field of clinical ethics has grown rapidly in the United States. Examples include ASBH's HEC-C certification, the ongoing effort to update ASBH's Core Competencies, and the Clinical Ethics Consultation Benchmarking Collaborative.

One prevalent argument given for these efforts is that demonstrating some level of homogeneity in the field "insofar as a shared taxonomy of ethical issues and standardized responses to them is possible“ is the best means for ensuring quality in clinical ethics practice. The reasoning is that this sort of conformity is in the best interest of those requesting help from ethics consultants because it assures them of a standard of competence that, once met, empowers primary clinical stakeholders to make the best decision given the options.

I argue that such standardization, however, leads to the opposite effect: it disempowers stakeholders and cedes that power to the clinical ethics consultant. In forcing stakeholders to adapt to the language and concepts of -professional(ized) ethics,- such standardization turns the power in and of discourse into a tool of those who created the language and concepts- the field and practitioners of clinical ethics.

Stakeholders request ethics consultation in language reflective of their own understanding and experience of the concerns they face. Responding to their understanding and experience with taxonomies or principles that turn the request into a standard 'ethics' question that can be answered via professional consensus statements or algorithms thus does little, if anything, to help ethics consultants respond responsively to requesters' actual experience. Instead of leaning into this push for conformity, clinical ethics consultants must cede our power back to stakeholders by abandoning our specialized language and resisting standardized responses. Indeed, this should be a core component “and competency“ of clinical ethics consultation if we are to truly be responsible to those requesting our help."

4)    Faye P.J. Is spirituality in medical education a step towards holistic care or an unwanted avenue for preaching? A systematic review

Abstract:

"Background: Spirituality, or the core values and beliefs that make us human, is the very foundation of personhood. Unsurprisingly, it is influenced by one's upbringing, religion and socio-cultural contexts. Spirituality is similarly central to clinical decision-making, shaping patients' and healthcare providers' priorities, life goals, and perceptions of what makes a good life and death. Therefore, medical education has recently spotlighted spirituality, with some schools and residencies incorporating it into their curriculum.

However, ethical concerns in encompassing spirituality into clinical care include: a) the potential of physicians' personal spiritual beliefs compromising patient care and autonomy, b) the need to respect patients' alternative spiritual beliefs and c) how much should physicians' and patients' spiritual beliefs influence clinical decision-making. Recognition of these issues can guide spirituality curricula design for medical students. Hence, a systematic scoping review of the ethics of spirituality education in medical schools is proposed.

Method: Krishna's systematic evidence-based approach (SEBA) was utilised. Search strings were applied to Pubmed, Embase, ERIC and Scopus databases for relevant articles published on the ethics of spirituality education in medical schools from 1 January 2000 to 10 June 2024. 

Results: Reviewing the included articles identified several key domains: a) ethical arguments for and against teaching spirituality,  b) the common stance on teaching spirituality, and c) how spirituality should be taught.

Conclusion: Our findings accentuate the necessity of educating students on spirituality to counter the purely biomedical model of care and more comprehensively acknowledge the socio-cultural context of patient health. Despite the ethical challenges, it prepares future clinicians to engage with patients' values, beliefs, and existential concerns, which are often pivotal in intricate ethical decision-making scenarios, including end-of-life care, resource allocation, and informed consent. Nevertheless, further critical evaluation is needed to ensure neutrality and respect for the appropriate boundaries between physicians' personal beliefs and professional responsibilities."
 

5)    Gariti A. Normothermic Regional Perfusion in Pediatric Donors - Recommended Guidelines for its Ethical Implementation 

Abstract:

"The scarcity of transplantable organs relative to demand has led to the exploration of novel techniques, such as normothermic regional perfusion (NRP), to enhance organ viability. While NRP offers promise to increase the quality and quantity of transplantable organs, its implementation raises significant ethical concerns regarding the Dead Donor Rule, consent/authorization, and physician participation. These concerns are further magnified in pediatric organ donation given children's  increased vulnerability and lack the decision-making authority. While these ethical challenges are widely acknowledged, numerous institutions have begun implementing NRP. This presentation explores the ethical challenges of NRP in pediatric patients and proposes ethical guidelines for institutions considering  implementing NRP. Emphasis is placed on informed consent, respecting parental and cultural values, and the role of conscientious objection with the aim of fostering transparency and trust in the organ procurement process. We propose a set of guidelines institutions pursuing NRP should follow to support the ethical implementation of NRP in pediatric patients. We include a checklist institutions can incorporate into their consent process to ensure all families and patients receive the same, ethically important information."

1)    Chobany M. Equity and Access in Healthcare Ethics: Who Gets a Voice in Clinical Consultations?

Abstract:

"Introduction:
In clinical ethics consultations (CEC), ensuring that all patients can voice their preferences and concerns is essential to upholding equity and patient-centered care. However, individuals with severe psychiatric conditions face significant barriers to meaningful participation, impacting their autonomy and decision-making rights. This presentation examines how HEC professionals can address these disparities by advocating for the inclusion of psychiatric patients in consultations and ensuring equitable access to decision-making processes.

Methods:
This non-empirical study is conducted through a literature review of bioethics, autonomy, and decision-making capacity, with a focus on psychiatric care. The analysis identifies systemic and interpersonal barriers to psychiatric patients' participation in clinical consultations, examining sources of stigma, structural biases, and best practices for inclusive ethics consultations. Strategies are evaluated for how CEC professionals can support and advocate for equitable care practices. 

Results: The literature review reveals key barriers faced by psychiatric patients, including stigma, assumptions about capacity, and a lack of decision-support resources. Findings suggest that HEC professionals can address these challenges through approaches such as supported decision-making models, culturally competent consultations, and the inclusion of patient advocates and caregivers. Each of these strategies can facilitate a more inclusive consultation process and enhance patient autonomy.

Discussion: Addressing inequities in clinical ethics consultations for psychiatric patients is critical to advancing social justice in healthcare. CEC professionals are uniquely positioned to promote fair access and equitable voice in decision-making, thus ensuring ethical integrity in patient care. By implementing patient-centered strategies, CEC can reduce barriers that psychiatric patients face, promoting autonomy and respect. This presentation argues that fostering inclusivity within clinical ethics ultimately contributes to a more just and responsive healthcare system for all."

2)    Izquierdo Martinez L-C. Key components in the professional ethics of sign language interpreters in healthcare contexts: A qualitative study 

Abstract:

"Sign language interpreters play a crucial role in bridging communication between Deaf and hearing individuals in healthcare, ensuring access to essential health information. Despite international frameworks for ethical standards, many Low and Middle-Income Countries, including Colombia, lack proper certification and training for medical interpreters. This paper identified professional ethics core components of medical sign language interpreters. Through qualitative exploration via semi-structured interviews with Colombian sign language interpreters, we identified key themes (confidentiality, privacy, professionalism, business practices, and professional development). Our analysis of the data from 17 participants shows the need for codes of conduct and establishement of professional codes of ethics for sign language interpreters working in a health context. The proposed framework addresses the challenges within the professional ethics of sign language interpreters in healthcare. These findings offer unique insights into the ethical experiences of Colombian sign language interpreters. This framework can be a valuable reference for interpreters facing ethical dilemmas. The clarity of ethical considerations is crucial for overcoming barriers to healthcare for the deaf population. The identified ethical issues underscore the necessity of education, training, and the establishment of codes of ethics and legislation for sign language interpreters."

3)    Santini A. Family on the Frontier: Hospital sanctuary for potential proxies of unauthorized immigrants receiving end-of-life care

Abstract:

"Language barriers, limited health system knowledge, and lack of familial support can all contribute to increased vulnerability and limited autonomy for unauthorized immigrants receiving end-of-life care. This presentation proposes that establishing sanctuary for healthcare proxy candidates of unauthorized immigrants who are nearing the end of their lives would address these concerns. Defining and defending the role of family and healthcare proxys in end-of-life care for unauthorized immigrants allows for protection of their autonomy, a respect for cultural pluralism, and enables otherwise unavailable access to religious and cultural practices that respect core patient beliefs. While citizens may also experience some of these concerns, the unique combination of legal and practical factors that unauthorized immigrants experience requires special protection. This presentation advocates for protection of proxy candidates already located in the United States regardless of citizenship status and not to bring in additional persons from other countries. The presentation begins by establishing ethical standards for end-of-life care based in the Universal Declaration on Bioethics and Human Rights. Next, it identifies treatment timeliness and heightened incidence of incapacitation as particular concerns raised in end-of-life care which require a healthcare proxy. Following this, the presentation analyzes hospital proxy access policies and identifies the legal, economic, and cultural factors that prevent unauthorized immigrants from receiving the same care. Finally, the presentation will validate the solution through the lenses of consequentialism, care ethics, and hospital organizational constraints to distinguish the solution as a practical possibility. The presentation will analyze a combination of qualitative and quantitative data from sources based in human rights, legal precedent, and clinical studies. Ultimately, establishing hospital sanctuary for proxy candidates of unauthorized patients will benefit providers and patients on a global scale."

4)    Agnaou J. Health Care in Prison: Toward a New Definition of Autonomy?

Abstract:

"Background:
The law of January 18, 1994, concerning public health and social protection, marked a turning point in the healthcare provision for incarcerated individuals in France, notably through its reform of the prison healthcare system. Aimed at improving their access to healthcare and implementing a public health policy in prisons, this law enabled the transfer of healthcare responsibility from the prison administration to the public hospital service. For nearly thirty years, two administrations with different functions, cultures and goals have coexisted and worked together within places of confinement to ensure equal access to healthcare for incarcerated individuals.

Aims:
This doctoral research explores the specificities of healthcare in prison from the perspectives of social epidemiology, moral and political philosophy, and the philosophy of care. Through fieldwork as a “nurse-researcher” - issues surrounding this status can also be discussed - it allows a reflection on the nature of care in prison, focusing on its implementation, access, challenges, and limitations. It critically examines the concept of autonomy, as theorized by Beauchamp and Childress, in the context of the constraints and deprivation of liberty inherent to prison life.

Method:
The research combines different qualitative data from fieldwork conducted in the health units of several remand centers in France. It explores the bio-psycho-social approach of health and life trajectories of incarcerated patients, their experiences of imprisonment, and their perspectives on reintegration. This field philosophy commitment involves immersion in the prison environment through direct observation, informal exchanges, and semi-structured interviews with incarcerated patients, healthcare professionals, and prison staff.

Results and Discussion:
This presentation will share initial findings from the field, particularly on how the concept of autonomy can be redefined in the prison context, challenging the traditional framework proposed by Beauchamp and Childress, and widely employed in ethical and clinical discussions in France."
 

5)    Johnston C. & Ko D. Ethics support addressing clinicians’ questions about futility and use of finite resources for vulnerable “non-compliant” patients

Abstract:

"Patients with complex medical and psychosocial challenges often struggle to follow clinical recommendations, leaving clinicians questioning whether the right course of action is to pursue treatments when engagement is low, or progress limited.

We use as a starting point for discussion two deidentified clinical cases referred to our clinical ethics response group. Firstly, a patient with complex mental health issues requiring frequent endoscopies following the ingestion of dangerous items. The other a young refugee unable to attend dialysis regularly due to work obligations.

Vulnerability through factors such as mental ill health, childhood trauma and challenging social conditions may cause patients to repeatedly fail the expectations of healthcare providers, sometimes fuelling feelings of hopelessness and prompting clinicians to wonder - why are we bothering?

In discussions with the treating team, the clinical ethics response group explored how to balance patient care with resource limitations and sustainable service delivery. Key questions arose: Does patient vulnerability justify ongoing treatment that seems ineffective? Do certain vulnerabilities inadvertently lead to clinician bias in determining futility?

We will discuss how our hospital's ethics service and committee assisted clinicians to see a way to a resolution, of sorts, by highlighting the limits of agency in vulnerable patients, exploring the meaning and scope of futile treatment, and prompting a better understanding of the patient's medical, social and personal goals."

1)    Streuli J.C. Navigating decision-making dilemmas in Variations of Sex Development: The shared optimum approach

Abstract:

"In many countries, children are not legally entitled to give valid consent for medical decisions, so parents usually act as surrogate decision-makers, acting in their best interests. However, there is a growing emphasis in medical guidelines on involving children in decisions about their own health. This trend toward inclusion was sparked by the United Nations Convention on the Rights of the Child (1989) which recognizes children as social agents rather than passive recipients of adult protection.
The debate on child involvement and consent to treatment has been particularly prominent in the health care management of intersex persons or individuals born with variations in sex characteristics (VSC). Regardless of the focus on patient involvement and individualization of care, medical practices in VSC continue to be parent- rather than patient-centered. This may explain why despite growing skepticism about early surgical interventions, there is no general moratorium on sex assignment surgery. Indeed, the 2006 Consensus Statement on the Management of Intersex Disorders did not rule out cosmetic surgery on the basis that it could reduce parental distress and improve bonding.
Research shows that parents find it often difficult defer surgery because they fear that it might impede their children from leading a 'normal' life. At the same time, studies highlight that intersex people who have experienced nonconsensual surgery during childhood may develop mistrust in medical providers and delay emergency and preventive healthcare visits. Healthcare professionals find it often challenging to navigate between the (future) child's and parental needs.
The present presentation aims to present the shared optimum approach (SOA), a combination of best interests and shared decision-making, as a method to tackle decision-making dilemmas with parents and affected individuals over time. SOA is a process that focuses on family values and clinical facts while using a clearly and transparently defined threshold of harm."

2)    Pannekoek J. But What If - ? Interrogating the Role of Regret in Gatekeeping Gender-Affirming Care

Abstract:

"Across the globe, media, legislators, healthcare professionals (HCPs), and healthcare organizations are increasingly concerned with gender-affirming care (GAC). More specifically, there is purported concern that patients may regret their decision of pursuing GAC. Regret is consequently framed as an outcome that patients ought to be protected from, resulting in undue challenges for patients trying to access GAC-specific interventions. These access-limiting measures constitute medical gatekeeping. Although justified at times, medical gatekeeping can risk unjustified paternalism and barriers to care.  

In this presentation, we first outline the ethical contours of medical gatekeeping and its relation to regret risk in GAC. We analyze the concept of regret and its role in moral deliberation, demonstrating that concerns about potential regret can be disproportionately weighted in the context of GAC and based on mistaken assumptions. We also show how the language of regret can at times act to both protect patients from undue harm, as well as overprotect patients already vulnerable to bias and undertreatment in a way that perpetuates injustice and disempowerment. We thus recommend caution when making judgements about the potential for regret in medical decision-making. Second, we discuss the practical and ethical implications for organizations and legislatures in preemptively limiting access to GAC on the basis of regret mitigation. Third, we examine the role of clinical ethicists in navigating these concerns and include strategies for responding to consults, developing embedded roles, contributing to practice guidelines, delivering education, and mitigating moral distress.  

We conclude that (1) not every potential for regret can or should be avoided, (2) it is not within the purview of HCPs nor legislators to eliminate patients' potential for experiencing regret, and (3) shared decision-making can address the potential for regret without unjust medical gatekeeping. The presenter/s will invite attendees to share experiences and practices and their own organizations."

3)    Rivoire I. Trans identity and access to care: difference as a determinant of trust and trustworthiness in health care and clinical practice

Abstract:

"In the medical literature, transgender people are mainly considered through the prism of medical transitions. As a result, there is little data on their trust in medicine or their access to primary care. Yet transgender people can have the same health problems as cisgender people. It is therefore important to understand whether transgender people do, or do not, trust professionals and access primary care.
The aim of this study is to understand the expectations and needs of transgender people in the context of medical consultations unrelated to medical transitions and the obstacles encountered when accessing primary care, as well as to provide an initial overview of their access to primary care.
For this exploratory study, we conducted six focus groups lasting between 1.5 and 2 hours, with 21 transgender people in Geneva. Four main themes were explored: general, positive, and negative experiences, as well as the strategies used by participants.
Our findings reveal that transgender people often avoid primary care due to a perceived lack of training and knowledge on trans-identity issues among health professionals. This leads to participants feeling compelled to educate doctors on these issues during consultations, which often results in negative experiences marked by discomfort, fear, or anger. Our study also reveals that participants have particularly low expectations of health professionals, mainly just wanting access to care. Participants mentioned various strategies, most of them community-based, to improve their access to care when needed.
This exploratory study focused on the canton of Geneva, but similar studies are needed on national and international levels. Loss of trust despite low expectations is particularly concerning.  It would also be useful to include healthcare professionals' perspectives in a broader study. Furthermore, comparing the experiences of transgender people with those of individuals facing other forms of identity-related discrimination could provide additional insights."

4)    Hamrouni N. Gendered medical colonialism in contemporary Quebec. Bringing the land back in the cultural safety approach to healthcare services

Abstract:

"On the 28th of September 2020, Joyce Echaquan, a 37-year-old Atikamekw woman, died at the Joliette's hospital under the dehumanizing, misogynistic and racist insults of the nursing staff. The public outrage that followed gave rise to the community-based movement Justice for Joyce and put pressure on the Quebec government to set up a public inquest. In the months following Joyce's premature passing, several analyses of the problem have emerged, which can be roughly classified into two main bodies of literature. On the one hand, works based on an equity approach to justice addressed the issues at stake in terms of racial discrimination and unequal access to equitable healthcare. On the other hand, Echaquan's experience of injustice was presented in epistemic terms: because of prejudices pertaining to her social identity, the patient was accorded a diminished level of credibility when she testified about her acute pain, and eventually died from it.

In this talk, we argue that by entirely eschewing the land question at the heart of the imperative of decolonization, these approaches paint an incomplete and misleading picture of the injustice at stake here. Indeed, they fail to adequately capture the gendered dimensions of colonial violence experienced by the indigenous mother of seven children. And they omit contextualizing this death sentence within the broader historical landscape of the colonial project. An Indigenous feminist approach, as framed by scholars and activists such as Ellen Gabriel (2024), Suzy Basile (2023, 2017) and Andrea Smith (2004)  is the most appropriate to reveal the systemic treatment of Indigenous women's bodies as disposable (Butler, 2006, Razak 2020, Smith, 2004), a key aspect of the ongoing extractivist project. The bodies of Indigenous women, which bear and nurture future generations, and symbolically represent the relentless Indigenous presence on the territory, are the first targets of this lethal violence. In light of this analysis and building on the writings of indigenous scholars such as Kim Anderson, Ellen Gabriel, Leanne Simpson and Suzy Basile, we suggest that bringing the land back into the cultural safety approach currently being developed in Quebec will not only require making access to the Quebec healthcare system more equitable for Indigenous people, but also demand supporting the development of a self-determined healthcare network by and for Indigenous people within their own communities."
 

5)    Steininger J., Löffelmann F., Ihrig F. “Flipped Examination Room” - Ascriptions of Vulnerability Between Trans Patients and Their Healthcare Providers 

Abstract:

"Background: The history of pathologisation has left many traces in trans healthcare contexts, especially barriers to receiving healthcare. These can be explained with theories of biopower -the disciplining of non-normative bodies, which often results in breached boundaries and repudiation of agency. Aims: Our study connects to -applied transgender studies-, which centre aims to improve material conditions of trans, inter* and nonbinary (tin*) people's lives. In this exploratory phase of an ongoing research project, we investigated current practices and underlying beliefs about 'trans-sensitive healthcare' in Austria. We focus specifically on ascriptions of vulnerability as modes to gain back or hinder agency in healthcare contexts. Methods: Embedded in frameworks of Institutional Ethnography and Community-Based Participatory Research, we analysed recordings from one tin* Community Team discussion and one training session for healthcare providers (HCPs) with Charmaz' Grounded Theory. Results: By depicting tin* patients as vulnerable and themselves as the needed supporters, some HCPs practice benevolent 'pathologisation', a term we coined in combination of our findings and previous research on trans healthcare. Yet, negotiations of intimacy and responsibility as well as power imbalances can render both parties vulnerable. HCPs' own vulnerability frequently stems from knowledge gaps and expectations concerning expertise, responsibility and authority.  Discussion: We argue that a caring and transparent approach to the contextual vulnerabilities in interactions between tin* patients and HPCs is paramount. The notion of caring encounters, where being uncertain is not a flaw but a mere fact of human existence, is a transformative perspective. For a future-oriented, ethical and sensitive approach to healthcare for marginalised, especially tin* people, a 'compassionate gaze' is crucial. This can not only equalize power im_balances but improve health outcomes. One can conclude that tin* people do not require 'special treatment', they require adequate treatment, e.g. medical assessments which are appropriately thorough but not intrusive."

Agich G., Dawson A., Van Delden H., Matur R., Miljeteig I., Moodley K., Reis A., Shasi-Gooshki E. Interactive Deliberation on WHO’s Clinical Ethics Guidance: A Critical Examination of Draft Content and Key Recommendations

Abstract:

"Over the past decade, clinical ethics has gained increasing prominence within the field of health ethics, especially from a global perspective. The COVID-19 pandemic, in particular, brought a range of clinical ethics challenges into sharp focus, from bedside rationing to the use of unproven therapies. While professional organisations have done a lot in this domain, the World Health Organization (WHO) has occasionally addressed specific clinical ethics concerns, but there remains a lack of comprehensive, general WHO guidance on clinical ethics. Given WHO's role in global health, the organization is well-positioned to advise and recommend member states on improving healthcare delivery and health systems through specific guidance. The upcoming WHO ""Clinical Ethics Guidance"" is intended to play this vital role at the global level.

This guidance has been developed to support and provide broad recommendations, with a particular emphasis on governance in clinical ethics to a diverse range of stakeholders, especially member states and health policymakers.  Governance is crucial for shaping systems that ensure ethical standards in clinical settings and encounters at the point of healthcare delivery. Accordingly, governance is central to this document, which addresses governance at institutional, national, and international levels. While clinical ethics encompasses many specific issues, this document focuses on key global ethical challenges and their governance and implementation.
The guidance is organized into several sections. The first provides a historical background and context for clinical ethics. The second addresses key issues in clinical ethics education. The third explores clinical ethics support services, including ethics committees and consultations. The fourth focuses on policy development for ethical healthcare practices at national and institutional levels. The fifth discusses international coordination and governance. The final section offers practical recommendations for stakeholders, particularly Ministries of Health, to enhance governance and implement ethical standards in clinical settings. It is developed by an international working group (WG) comprised of experts from all WHO regions and observer organisations which was established at the end of 2023, under the supervision of a WHO internal steering committee.

At the workshop, on behalf of the WHO WG (https://www.who.int/groups/working-group-on-developing-who-guidance-on-clinical-ethics), the team leading the guidance development will present the latest content and gather feedback from participants. The most recent version of the guidance will be shared in advance to allow participants ample time for review and meaningful deliberation."

Tilburt J. et al. Situating Ethics Consultation and Overtreatment in Socio-Political Context: Reconciling Power, Plurality, and Principles

Abstract:

"Ethics consultants commonly encounter situations in which utilization of healthcare resources may or may not fit a patient's preferences and may or may not conform to specific notions of distributive justice. This year's conference theme is predicated on to possibility that good clinical ethics must consider broader socio-political issues, and HEC professionals maycontribute an interesting view to these socio-political debates. But how, and with what vocabulary, and on what basis of expertise?

In this session we will use the thorny issues raised by over- (and sometimes under-) treatment of the frail elderly as an illustrative conversational touchpoint under the conference subtheme (2) HEC and social justice, examining in particular how inter- and intra-societal pluralism, professional power, and differential application of ethical principles get navigated in the United States and the Netherland.

Caring for frail elderly patients requires sound conversational engagement and discernment. Yet, as our case studies will illustrate, too often contemporary healthcare proceeds with a kind of clinical inertia until conflict arises. Then, in a panic, someone calls an ethics consultant. Our multi-disciplinary group of social scientists, theologian, clinicians, and ethics consultants, has been thinking, discussing, and writing together on the challenges of over- and under-treatment in the frail elderly. As we have come to learn, clinical teams face similar challenges in North America and Western Europes notwithstanding quite divergent socio-political contexts.

In this 60-minute interactive session we will discuss with participants 2 case studies, one from North America, one from Western Europe, touching on common clinical situations in which an HEC might face important broader (and contested) socio-political forces influencing over- or under- treatment. We will draw upon the expertise of our multi-disciplinary panel to discuss their moral intuitions about specific cases, assess to what extent the four principles offer an adequate frame for addressing the ethical concerns raised, and what, if any, is the role of the ethics consultant in attending to, addressing (or at least naming) justice-related concerns in particular cases and how to reconcile those concerns with specific patient-centered (beneficence/non-maleficence) concerns in the work of healthcare ethics consultation. "

Tardif C., Staltari C., Lemieux G. A Workshop on Interdisciplinary Collaboration and Partnership with Indigenous Patients during Clinical Ethics Consultations 

Abstract:

"The tragic death of Joyce Echaquan has highlighted the inequities and injustices suffered by Indigenous peoples in Quebec and Canada, triggering a cry of alarm throughout the Quebec health network and prompting a questioning of care practices. As a teaching hospital and referral centre for the RUISSS McGill territory, the McGill University Health Centre (MUHC) provides specialized services to the populations of the North, including 14,000 Inuit in Nunavik and 18,000 inhabitants in the Cree Lands of James Bay. These populations, often forced to travel to Montreal for specialized care not available locally, face many challenges, revealing profound systemic deficits in health care delivery. Although Indigenous people in the North account for 3000 admissions, 20,000 ambulatory visits and 2,500 emergency department visits annually at the MUHC, our understanding of their care experience remains limited.

The deeply rooted discrimination faced by these patient groups can render clinical ethics dilemmas and consultation processes particularly sensitive and complex. Hence, there is a growing need for a systematic, adapted and culturally safe ethics approach to clinical cases involving Indigenous patients.

Through recent clinical ethics consultations at the MUHC, we developed a pragmatic, collaborative method for cases involving Indigenous patients. At its core, this innovative method incorporates people-centered care and cultural safety approaches. It involves an active collaboration between clinical ethicists, the patient engagement quality team, indigenous allies, clinical champions and stakeholders. This collaboration aims to build a trustful, respectful relationship characterized by a keen interest in understanding the lived experience. This helps address questions surrounding social justice more adequately and avoid further contributing to trauma and discrimination of these patient groups. Throughout this process, humility and compassion are prioritized over the quick resolution of the perceived dilemma. To our knowledge, no other similar method has been reported in the field of clinical ethics.

In this workshop, we first introduce the clinical ethics, patient engagement quality and cultural safety services at the MUHC. We then delve into unique challenges and questions that can arise in clinical ethics consultations involving Indigenous patients. In response, we propose a novel, pragmatic approach to these consultations. Next, we engage the participants in a case study where they can learn to apply this method in practice. We co-construct ways in which this method can be adapted and incorporated into the participants' own practices. Finally, we explore future avenues for solidifying and expanding the application of this method to other clinical contexts."

Speakers :

- Cristina Richie
- Andrew Hantel

Please access the full description here

These posters will be available :

• Aebischer G. When you say “conflict of interest”, do you mean “corruption”?
• Anderson D. HEC for Healthcare Buildings: Bioethics Peer Review 
• Baker C. Show Me the Money: Comparing Industry Payments to Physicians and Advanced Practice Clinicians Across Specialties in the USA
• Billstein E. Ethics support staff’s perceptions of patient and parent participation in clinical ethics support services in childhood cancer car
• Blanc S. “Not at home”: insights from case studies on setting preferences in assisted suicide
• Burgess T. South African researchers’ experiences of ethical challenges during COVID-19 and lessons learned for future pandemics
• Buturovic Ponikvar J. The case of organ donation after euthanasia
• de Janon-Quevedo L. Ambivalence While Training Communication of Bad News May Suggest Academic Burnout Among Medical Students 
• Eikamp L.R. Moral Measuring: Thinking or Feeling you know how to measure somethingEves M. Lawst in the Silence: When Lack of Legal Clarity Harms Patients
• Furfari K. Beyond Hierarchies: Rethinking Surrogate Decision-Making with Colorado’s Inclusive Approach
• Giuseppe Staffa A.M. The creation of an Ethical Space within an Italian Territorial Social Health Agency to encourage community welfare
• Hahlweg P. Aid in dying requests: longitudinal processes on diverse levels
• Hassanein M. Navigating Challenges: The Interplay of Identity and Environment in Clinical Ethics Fellowships
• Hassanein M. Provider Preferences and Protected Characteristics: Navigating Requests in a Pediatric Setting
• Horsburgh C. Filling the Gap: Does Clinical Ethics Immersion Continue to Serve the Field? 
• Jaswaney R. Still Good Enough? Considering Disposition Planning for Patients with Eating Disorders and Medical Complexity
• Kennedy A. Proposed Legislation on Physician Assisted Dying in the UK Compared to the International Standards
• Tan M. Quo Vadis? Reforming Practices on Determining Mental Capacity and Identifying Surrogate Decision-Makers in Malaysia
• Kumwenda Mtande T. Exploring the Potential of Moral Community and Moral Dialogues at Bwaila Family Health Unit in Lilongwe, Malawi
• Larocque A. Balancing Risk: Clinicians’ Perceptions and Breast Cancer Screening Recommendation in Quebec
• Moreno-Molina J. Euthanasia in Colombia: Expanding Legal Boundaries and the Role of Clinical Ethics Consultation
• Orfali K. COMPARING THE DECISIONAL ROLE OF SURROGATES FOR INCAPACITATED PATIENTS IN THE US AND MANY EUROPEAN COUNTRIES: WHY SUCH DIFFERENCE
• Pannekoek J. Community and Healthcare Professional Input on the Topic of Normothermic Regional 
• Paulsen W. Midwifery ethics  – more diverse as supposed to be. Do we need a broader approach?
• Pegoraro R. Clinical Ethics Committee’s Deliberation on a Complex Cystic Fibrosis: the Issue of Pregnancy
• Pichardo A. Preventing Financial Toxicity in Healthcare: Organizational & Ethical obligations
• Placencia F.X.  A Cultural Engagement Program for Islamic Parents of Premature Children Eligible for Donor Breast Milk
• Propper R. My Patient Was Dying, And I Did Not Tell Her: Exceptions to Truth-Telling in Pediatric Critical Care
• Pullman D. MAiD (m§edical assistance in dying) in Canada and the Death of Dignity
• Raimondi C. Ethical, Legal and Social Issues in Diagnosis and Prevention of Childhood Melanoma
• Rey Leong J. Shaping the Future of Healthcare Ethics: Insights on Professional Identity and Multidisciplinary Professional Socialisation
• Siddiqui S. ‘Anesthesiologists’ Duty of Care and Questions of Conscience
• Smith A. Newsome Paging Externist: Utilizing Clinical Ethicists in Patient-Engaged Care Planning to Improve Clinical Outcomes Post-Discharge 
• Spriggs K. Lessons from the Holocaust: Patient Advocacy in Nursing Education
• Toader  E. PATIENT WELFARE IN PALLIATIVE CARE: INTEGRATING MEDICAL, MORAL, AND SPIRITUAL DIMENSIONS
• Yan Y. Evidence-Based on End-of-life Decision-making in China for Severe Brain Injury 
• Yeo M. and Gillam L. Dying to be Thin: Confronting ethical questions when young people do not respond to treatment for Anorexia Nervosa

1)    Brendbekken A. Conceptualising costs: prescribing clinicians’ perceptions of opportunity cost in the case of high-cost cystic fibrosis treatment

Abstract:

"Background: Resource scarcity necessitates priority-setting at the macro-level between groups of patients in publicly funded healthcare systems. When clinicians at the micro-level provide treatment to one patient, less resources are available elsewhere in the healthcare system. Following the advent of high-cost therapeutics for rare diseases, pharmaceutical budgets are increasing across the world. In 2022, elexacaftor/tezacaftor/ivacaftor (Kaftrio) was reimbursed in Norway for patients with cystic fibrosis through an undisclosed price agreement. The treatment is life-long, and it was publicly contested before implementation due to its exceptional high cost and expected significant effect.

Aim: We aim to understand how clinicians conceptualize the cost of Kaftrio and its impact on availability of other healthcare services across their department and hospital. Kaftrio prescription in Norway provides a clear case for considering cost conceptualizations, as the indication was explicit, and the treatment's list price well-known.

Methods: We conducted 18 in-depth interviews with clinicians and hospital department leaders working with cystic fibrosis and analysed data using reflexive thematic analysis.

Results: The opportunity cost of prescribing Kaftrio is unclear to clinicians. Uncertainty about the undisclosed pharmaceutical price and to what level in the hospital budget the cost is allocated provide unclear incentives for rationing treatment. Clinicians justify providing treatment by double-counting costs and benefits which are already accounted for at the macro-level.

Discussion: This study adds to the scarce evidence on the interplay between macro-level decision-making and its micro-level clinical operationalization. A lack of transparency obscures incentives for clinicians to ration treatment. Macro-micro level misunderstandings of costs and benefits risks skewing allocation in unintended ways.
Conclusion: A better understanding of real-life healthcare rationing behavior at the micro-level and its interactions with intended directives from the macro level of priority-setting is needed to ensure coherent policy operationalization across levels of healthcare."

2)    Brummett A. Principled Conscientious Provision

Abstract:

"U.S. law grants expansive protections for conscientious objection, while the issue of conscientious provision enjoys no legal protection.  For example, a clinician who conscientiously objects to providing a prescription for birth control in a secular hospital is legally protected, but a clinician who wishes to conscientiously provide a prescription for birth control for the purpose of contraception in a Catholic hospital is not. 
There are three ways to respond to this conscience asymmetry. One is to offer a moral justification for the conscience asymmetry. Another is to argue for conscience symmetry, in general, which could be accomplished either by creating legal protections for all conscientious provisions or by removing protections for all conscientious objections. This talk explores a third option-legal protection for only some forms of conscientious provision in Catholic hospitals. 
We develop our defense of limited conscientious provision rights by rejecting the current -referral asymmetry.- The referral asymmetry refers to the fact that clinicians at secular hospitals are legally protected when they refuse to refer patients for treatments permitted at their hospital, while clinicians at Catholic hospitals are not legally protected if they provide referrals for treatments (e.g., contraception, sterilization) that are prohibited at their hospital. 
Our argument advances in three parts.  First, we argue that conscientious refusal to refer and conscientious provision of referral should have equal legal protection. Second, we propose that referral-related conscience rights should be expanded to cover the conscientious provision of referrals. Finally, we explore the implications of expanding referral conscience rights by identifying a key principle 'the principle of comparably trivial institutional burdens' that can be used to justify legal protections for some additional forms of conscientious provision (e.g., writing prescriptions for medication abortion) without grounding legal rights for all forms of conscientious provision (e.g., providing surgical abortions)."

3)    Warren M. Conscientious Provision of Legal Healthcare Services When An Organization Objects

Abstract:

"Conscientious objection policies, common throughout North America and Europe, offer healthcare providers protection from sanctions when they are asked to provide legal healthcare services that fall within their scope of practice and the provider refuses to offer those services for conscience-based reasons.

Imagine a healthcare organization that decides to stop distributing safe injection supplies for patients who choose to inject substances.  The organization states that this is due to fundamental organizational values about how substance use disorder is treated.  Now imagine a physician with training in treatment of substance use disorder who has admitting privileges within that organization.  This physician decides to continue distributing safe injection supplies.  When threatened with loss of privileges, the physician invokes protection from sanction based on conscientious provision, stating that the provision of supplies was based in conscientious beliefs about treatment of substance use disorder and professionalism.

In this presentation, I describe the structure of conscientious objection and outline paradigmatic instances when conscientious objection is invoked, including termination of pregnancy, assisted reproduction, medical assistance in dying, and gender-affirming care.  I argue that conscientious provision is symmetrical to conscientious objection and demonstrate that this symmetry holds across all these types of care.  This symmetry grounds a claim that conscientious provision warrants protection from punishment.

I then address the reliance of the symmetry argument on the claim that organizations can have conscientious beliefs. I argue that symmetry is sufficient but not necessary to ground protections for conscientious provision, patients' claims to legal healthcare services and providers' interests in professional integrity are also sufficient.

Finally, I briefly identify and address other objections, including concerns that conscientious provision could justify the provision of discredited or unproven interventions, and emphasize that the target of both conscientious objection and provision is legal, clinically indicated care that is desired by the patient."

4)    Brandeland M. Ethics, Globalization and Medical Travel: A Proposal for Best Ethical Practice Standards in the Care of International Patients

Abstract:

"Background
Healthcare tourism has grown significantly in the last two decades. For many patients, coming to the U.S. for medical care is a final recourse for complex and serious illness. Currently, no best ethical practice standards exist in the care of international patients.

Objective
Our objective is to propose best ethical practice standards in the care of international patients which may guide further preventive ethics work in this area.

Methods
We completed a retrospective chart review of ethics consultations on international patients over 19-year period (2006-2024). Results were reviewed by faculty in Clinical Ethics and our International Office. For each reason for ethics consultation, we analyzed contributing factors. Using this information, we created a proposal for best ethical practice standards.

Results
We identified 49 ethics consultations requested on international patients. The most common reasons for consultation were goals of care / ‘futility’ (31%), patient autonomy (29%) and allocation of resources / distributive justice (12%). Spiritual or cultural considerations were a significant aspect of the reason for consultation in 71% of cases. Five areas of best ethical practice standards for the care of international patients are proposed. (1) Clinical Care, including standardizing the patient intake process and setting clear expectations for treatments before travel, (2) Medical Records, including ensuring accurate and timely transfer of medical records (3) Language and Culture, including ensuring adequate interpreter services and patient coordinators and educating staff in cultural humility (4) Spiritual Care, including ensuring diverse spiritual care staff and support for religious practices, and (5) Financial, including review of expected costs and payment source(s) prior to travel.

Conclusion
Ethical dilemmas arise in the care of international patients due to differences in culture, religion, expectations for medical care, and healthcare financing. We propose best ethical practice standards that may guide future preventive ethics work for international patients."
 

5)    Greer M.L.J., Schiff J. C. Should clinical ethicists “put a pin in it”? The ethics of wearing social justice pins and signs of support on hospital badges

Abstract:

"Badge identification (ID) cards and lanyards provide a unique opportunity for healthcare professionals (HCPs), including clinical ethicists (CEs), to wear pins, clips, and/or stickers to outwardly signal support for social justice causes (SJCs). These social justice signs (SJSs) can be affirming for patients, particularly those from historically marginalized groups (e.g. queer people, black people, women, and individuals with disabilities), who are vulnerable to social determinants of health and whose care can be compromised by HCPs with biases/prejudices.

However, SJSs of support may be off-putting to, or even alienate, patients whose socio-political views conflict with views typically associated with some SJCs. One might wonder whether physicians' obligations to treat their patients with non-judgmental regard (i.e., deliver uncompromised care to the homophobe, racist, misogynist, and ableist) implies an obligation for physicians not to wear SJSs. Furthermore, physicians and HCPs in general may wear SJSs merely to -virtue-signal,- potentially taking attention away from patients.

Clinical ethicists comprise a special subset of HCPs with unique responsibilities and duties. It is foundational to healthcare ethics consultation (HEC) that CEs ought to demonstrate appropriate ethical concern for all patients, including the homophobe, racist, misogynist, and ableist. 
Therein lies the question: should CEs in patient-facing roles wear SJSs in support of SJCs? Our ethical analysis focuses on sexual orientation and gender identity in particular. We connect the history of discrimination against queer people to their health outcomes and experiences as patients. We offer arguments for and against CEs wearing SJSs to signal support for SJCs related to sexual orientation and gender identity. We consider, for example: what is in the best interest of patients, care-needs of pediatric patients, CEs wider geographical/socio-political/legal context, relevant hospital policies, the promotion of an inclusive professional environment, and the protection of queer and queer-questioning CEs."

1)    Watson J. Ethics Consultation When Cultures Collide: Setting Expectations for Clinicians and Patients   

Abstract:

"A concern expressed at previous international clinical ethics conferences is that Western bioethics implies a normative mandate to adapt unequivocally the values, cultures, and approaches of a patient's current medical context to the patient's care regardless of the patient's cultural background. In the US, Canada, the UK, and Europe, this would entail prioritizing individualism, patient autonomy, and medical beneficence, even when caring for patients who identify with cultures that value different priorities. 

However, a foundational element of Western bioethics includes facilitating a process that elicits patient preferences and values and ensuring their interests are adequately represented in health care conversations. When patients have social, cultural, or religious backgrounds that are unfamiliar to care teams or that come into conflict with ethical commitments or standards of care as defined in the care team's social and clinical context, the role of the clinical ethics consultant is to assist with amplifying patient values to ensure that they are given appropriate consideration in that patient's care while also helping patients and families appreciate the responsibilities of health care teams that are informed by legal and policy constraints.  

In this presentation, we explore three cases where a patient's cultural or religious commitments present challenges to Western standards of medical care and the role of clinical ethicists in navigating these challenges. We highlight how we, as Western-trained bioethicists, can invoke aspects of our tradition to help preserve rather than minimize a plurality of values within the constraints of medical feasibility, while acknowledging the constraints imposed by law and policy. We conclude that the ethical dangers to pluralism lie less in an oversimplified conception of Western bioethics and more in lack of training for clinical ethicists in how to facilitate rich discussions of patients' values and preferences."

2)    Paré-Tremblay A. Patient partnership: an instrument for regaining citizenship

Abstract:

"Context: The experience of severe chronic illness, followed by the imposition of a 'disabled' status, constitutes barriers to civic participation and triggers processes of disqualification and disaffiliation. This marginalization process fundamentally challenges patients' sense of belonging in the civic space. Driven by the rise of health democracy, the patient partnership model advocates for the full integration of patient engagement within the system. While patient engagement and empowerment in healthcare is a dynamic and rapidly expanding field of research, knowledge on patients' perspectives regarding these new roles at micro, meso, and macro levels remains underdeveloped.

Objectives: Through the narratives of chronic patient-users who became partners, this research seeks to give a voice to the actors of this partnership, allowing them to reveal if and how this clinical and organizational process impacted their care and life trajectories. This project investigates the ways in which access to patient-partner status enables these same patients to mobilize new adaptive processes to cope with their chronic diagnoses.

Methods: An interpretive qualitative design was used to address the study objectives. In-depth semi-structured interviews, inspired by Bertaux's (1997) life-story method, were conducted with nine participants (n=9) who had taken on the role of 'patient partner'.

Analysis: The life stories (n=9) were then analyzed using phenomenological interpretive analysis (IPA), in an idiographic approach.

Results: After initially enduring the multiple disruptions imposed by illness on their life trajectories, the interviewed PPs expressed wanting to regain their status as active, participating citizens within society - a society they see driven by a culture of urgency, transactions and demands. The participants reported perceiving their role as patient partners as offering the possibility to address this essential reconquest by providing them with a renewed sense of usefulness and confidence, while also allowing them to build community and navigate the healthcare system more effectively.

Conclusion: Partnership presents itself to patient partners as a means of accepting and integrating the diagnostic event into their life story. This 'negotiation of reality' thus appears to lay the foundation for reclaiming their self-esteem and their place as 'full' citizens. They report engaging as patient partners in the hope of alleviating the social suffering induced by illness and envisioning a more inclusive citizenship to which they could, in turn, belong."

3)    Court S. Patient Participation in Clinical Ethics Support Services: an Impossible Debate

Abstract:

"Clinical ethics support services (CESS) can assist clinicians with the resolution of moral problems that arise in healthcare. CESS discussions do not typically involve patients as participants, a matter which has recently begun to be questioned.

There exists considerable variation within the category of CESS. These services can be, for instance, clinical ethics committees, individual ethics consultants or small group gatherings focused on moral reflection.

While some of the differences between these services are practical, differences can also be identified that are more fundamental, for instance, in the content and practical aims of the discussions that tend to occur within these services. Some ethics services may be, for instance, particularly geared towards conflict resolution, while others may be aimed more at personal reflection. These differences seem to arise out of the diverse contexts in which these ethics services exist, not only the hospital contexts, but the different social contexts more broadly.

So far, academic debate about patient participation has been localised to the context of specific forms of CESS or it has been with regard to CESS discussions as a whole. I examine three 'case studies' of different clinical ethics support services, drawing attention in particular to the different practical aims of their discussions. I then show that these aims have different implications for patient participation.

In doing so, I demonstrate that patient participation cannot be considered separately from different specific approaches to clinical ethics support, or in isolation from the contexts in which these services are embedded. Thus, it is a mistake to consider patient participation with regard to CESS discussions as a whole."

4)    Billstein I. Ethics support staff’s perceptions of patient and parent participation in clinical ethics support services in childhood cancer care

Abstract:

"Background: There is a growing notion for patient and parent participation (PPP) in Clinical Ethics Support (CES). However, participation is increasing slowly due to complexity of execution. Therefore, we need further understanding of how to create forums and models of CES where patients and parents can participate and reflect and share their perspectives on ethical dilemmas.

Aim: The aim was to explore PPP in CES in childhood cancer care by gaining deeper understanding of ethics support staff's perceptions of the feasibility and moral appropriateness of PPP in CES. 

Methods: Ethics support staff (N=26) experienced in providing CES in Nordic childhood cancer care/paediatrics, were invited to focus group interviews (N=6). Data was analysed with qualitative content analysis. 

Results: Most participants were healthcare professionals without former experience of PPP in CES. Participants perceived that PPP in CES could deepen understanding and trust, catalyse conflicts and create dilemmas of decision-making participation. The expressed benefits of PPP in CES were overshadowed by a fear of causing participant harm. Strategies to avoid the risk of causing harm were expressed on organizational (challenge the ambiguity of ethics and CES, preparation and debriefing, create a safe environment), relational (balance care relationship, protect child-parent relationship) and individual (assess child participation, assess parent participation, assess exposure of healthcare professional) levels. 

Discussion: The appropriateness of PPP in CES depends on the situation. In cases where it can be considered, adaptation of the CES model on a case-by-case basis is important, with the starting point of applying the strategies to reduce the risk of causing harm. This study contributes to increased understanding of practical and moral challenges and benefits of PPP in CES which can be helpful when considering models to foster PPP in CES in childhood cancer care as well as other paediatric settings."

5)    Paré-Tremblay A. Patient Partnership: A Pathway to Reclaiming Civic Belonging

Abstract:

"Context: The experience of severe chronic illness, constitutes barriers to civic participation and triggers processes of disqualification and disaffiliation. This marginalization process fundamentally challenges patients' sense of belonging in the civic space. Driven by the rise of health democracy, the patient partnership model advocates for the full integration of patient engagement within the healthcare system. While patient engagement and empowerment in healthcare represent a dynamic and rapidly expanding field of research, knowledge on patients' perspectives regarding these new roles at micro, meso, and macro levels remains underdeveloped.

Objectives: This research seeks to give a voice to the main actors of this partnership, allowing them to reveal if and how this clinical and organizational process impacted their care and life trajectories. This project investigates the ways in which access to patient-partner status enables patients to mobilize new adaptive processes to cope with their chronic diagnoses.

Methods: An interpretive qualitative design was used to address the study objectives. In-depth semi-structured interviews, inspired by Bertaux's (1997) life-story method, were conducted with nine participants (n=9) who had taken on the role of 'patient partner'.

Analysis: The life stories (n=9) were then analyzed using phenomenological interpretive analysis (IPA), in an idiographic approach.

Results: Having initially endured the multiple disruptions imposed by illness, the interviewed PPs expressed a desire to reclaim their status as active, participating citizens within society. The participants reported perceiving their role as patient partners as an opportunity to respond to this essential reclaiming, providing them with a renewed sense of usefulness and confidence, as well as enabling them to build community and navigate the healthcare system more effectively.

Conclusion: Partnership serves as a 'negotiation of reality' for patient partners, and thus, appears to lay the foundation for reclaiming their self-esteem and their place as 'full' citizens. They report engaging as patient partners in the hope of alleviating the social suffering induced by illness and envisioning a more inclusive citizenship to which they could, in turn, belong."

1)    Perron C. Towards a better understanding of medical assistance in dying in Quebec, Canada: The mandate of the CIRAMM

Abstract:

"Since 2015, medical assistance in dying (MAiD) has been available in Quebec for people who meet the criteria of the Act respecting end-of-life care. Quebecer's growing use of MAiD places the province in first place worldwide for deaths by MAiD, ahead of all countries where it is practiced. Our team, the Interdisciplinary Research Consortium on Medical Assistance in Dying (CIRAMM), was mandated by the Ministry of Health and Social Services of Quebec to study the factors behind this increase. The factors analyzed are divided into four themes: (1) legislative comparisons, (2) societal factors, (3) personal characteristics, (4) organization of health care and services. 
The aims are to identify the legal, societal, individual and organizational factors that facilitate or limit the recourse of MAiD.
The project comprises four cross-thematical methods (systematic review, semi-structured interviews with key informants, population-based survey and focus groups with healthcare professionals, deployed in six jurisdictions (Belgium, California, Canada, Oregon, Netherlands, Switzerland)). Specific methods will also be used for each themes: (1) realist synthesis and comparative legal analyses, (2) media synthesis and community forum, (3) individual interviews, triadic case studies and file studies, (4) literature review and system mapping.
The results should provide a comprehensive understanding of the factors influencing the use of MAiD in Quebec, whether related to practices, laws, societal or personal characteristics, or the organization of care and services. Several knowledge mobilization strategies are deployed to reach different audiences: thematic information kits, briefing notes for decision-makers, policy notes for managers, practice guides for healthcare providers and infographics for the general population.
By shedding light on the factors influencing the administration of MAiD, we provide valuable insights to policymakers and healthcare providers. The implications of our results extend beyond Quebec, they offer insights to other jurisdictions either with established MAiD legislation or considering similar measures."

2)    Marcoux I. Which factors influence the evolution of the use of medical assistance in dying? A scoping review 

Abstract:

"Background: Medical assistance in dying (MAiD) is now legal in over 25 jurisdictions in 12 countries, and the numbers of requests and administrations are increasing at different rates. A few hypotheses have been suggested [1] or studied [2] in order to explain this phenomenon, but there is still no systematic assessment of the types and extent of existing evidence. As MAiD is a practice fundamentally rooted in clinical ethics, it is important to better understand the factors that influence its use while considering its evolution over time.
Objective: To identify factors, including socio-political ones, associated with the use of MAiD (requests or administrations) in jurisdictions where this practice is legal.
Methods: A scoping review is undertaken following the recommendations of the Joanna Briggs Institute. Nine electronic databases (i.e. MEDLINE, CINAHL, EMBASE, Web of Science) and grey literature are searched. To be included, the documents must examine factors associated with MAiD (requests or administration), focus on jurisdictions where the practice has been legal for at least 5 years, and be available online. Selection and extraction are carried out by two independent reviewers using Covidence software.
Expected results: The results will enable us to determine which factors, including political and legal ones, social and cultural norms, care organization and individual characteristics are associated with MAiD and its evolution over time. We will also assess these results according to the level of existing evidence. 
Discussion: Knowing the individual characteristics, organizational and socio-political factors associated with requests for and administration of MAiD while considering their evolution over time, can help practitioners and policy-makers assess complex end-of-life care situations and services in their settings and jurisdictions."

3)    Galmiche O. From Polarization to Reconciliation: the Role of Clinical Ethics in Redefining Medical Integrity in the Assisted Dying Debate

Abstract:

"In France, the medically assisted dying debate is at a turning point. An opinion of the National Ethics Council in 2022 has opened the way to a possibility of changing the law to allow a form of aid in dying. It was followed by various political and public debates, including a Citizen's Convention and a Parliamentary Report on the current law regarding end-of-life. Their conclusions acknowledged both the need for more respect for patients' autonomy and situations of suffering that do not find resolution in the current healthcare offer, as have other countries with legislations on assisted dying before them. However, a significant disagreement arose regarding whether assisted dying should be considered part of healthcare, which have sparked debates about the definition of medical integrity - a question that remains unresolved to this day. A comparison of how stakeholders use and discuss the argument of medical integrity both in the sociopolitical debate and in clinical ethics settings can help in addressing new elements on this challenge.
In the French sociopolitical debate, based on an analysis of opinion columns in the press, the perception of medical integrity is very polarized. Opposite definitions are used against each other, those defending medically assisted dying considering it is compatible with one definition, and those against it affirming the opposite.
In clinical ethics settings, based on a review of 7 years of clinical ethics consultations about assisted dying requests and preliminary results from a qualitative research protocol, there is no presupposed definition of medical integrity. Its contours are rather questioned in each situation by professionals, as well as patients and proxies.
This reflection aims for a better understanding of the way clinical ethics can modify the use of this concept, notably by including patients and proxies' perspectives on what is a physician's role in assisted dying."

4)    Favron-Godbout C. Medical assistance in dying in the context of mental disorders: Co-development of a reflection and discussion guide  

Abstract:

"Background: Medical assistance in dying where a mental disorder is the sole underlying medical condition (MAiD-MD) is permitted in several countries and is legally scheduled to become available in Canada as of 2027. This option raises lively debate and concerns internationally, as well as the need to be prepared to deal with delicate situations related to MAiD-MD.

Aim: To engage various stakeholders in the co-development of a support tool addressing concerns about MAiD-MD.

Methods: Participatory action research project in four phases: 1) Literature reviews, 2) Series of 9 focus-groups with people living with mental disorders, relatives and healthcare professionals, 3) Community consultation with 10 groups of key-informants, 4) Preliminary assessment of the support tool. An advisory committee mobilizing academic, clinical and experiential expertise guided the project.

Results: The presentation will report on focus-groups results supporting the co-development process. Numerous concerns were shared: 1) issues currently experienced (e.g., lack of resources, challenging care experiences), 2) needs to be addressed (e.g., to specify the guidelines and procedures that will guide MAiD-MD provision, to inform, prepare and support stakeholders), 3) complexity to be considered (e.g., particularities related to mental disorders, potential obstacles to MAiD-MD, consequences of rejected requests), 4) other sensitive questions (e.g., how to broach the subject of MAiD-MD, involve loved ones, reconcile divergent perspectives). Ideas for support were also explored, including: 1) offering better aid in living with mental disorders, 2) having prior preparation, 3) offering support, and 4) opening dialogue to ease discomfort.

Discussion: The need to prepare various stakeholders to live through complex situations and to open dialogue with respect, benevolence and humility guided the development of the support tool: a reflection and discussion guide. This guide was refined during subsequent phases of the project, and the co-development process was experienced by many involved as empowering."

5)    Morrison K. Should health care ethicists provide administrative support/leadership of hospital Medical Assistance in Dying programs?

Abstract:

"Since MAiD was decriminalized in Canada (2016), hospitals have developed local processes to respond to new or existing requests from patients. Health care ethicists have played a significant role in this development, engaging in activities such as MAiD case coordination, policy development, and education. Some hospital MAiD programs report to the administrative director of ethics, and in other cases the MAiD navigator reports to a health care ethicist. While this has resulted a high degree of ethics integration into MAiD care (with some ethicists being effectively embedded in hospital MAiD programs), it has also called into question whether these activities are within the appropriate role and scope of a health care ethicist. This raises concerns, among other things, about the role clarity of health care ethicists when doing MAiD related work, the impact of MAiD on ethicist workload, and the effect of routine ethicist involvement on public perception of MAiD.

Eight years on, the purpose of this paper is to evaluate the role that health care ethicists have had in administration of Canadian hospital MAiD programs. The paper begins by reviewing the involvement of health care ethicists in hospital MAiD services from 2016-present. The paper then analyzes the question of whether health care ethicists should provide administrative support/leadership of hospital MAiD programs by considering the following key questions:

1) Are these activities aligned with what health care ethicists do? 
2) What are the benefits and risks? 
3) How do alternative models of administrative support/oversight compare? 
4) Are there more effective ways for MAiD programs to engage hospital ethics resources?

Based on this reflection and analysis, the authors will make recommendations to enhance the quality of both ethics and MAiD programs."

1)    Homami S. Navigating Clinical Ethics Dilemmas: A New Framework for Decision-Making 

Abstract:

"Background: Although situations with ethical dilemmas are usually frequent in clinical experiences and several models and frameworks have been introduced to address them systematically, cultural diversity and rapid technological and socioeconomic changes in the current era have caused a continuous need to review and update these decision-making tools for health care ethics training and consultations. 

Aim: The present study was conducted in Iran to develop a framework for dealing with clinical ethics dilemmas, focusing on post-intervention actions. 
Methods: In first phase, we reviewed the existing models and frameworks for dealing with clinical ethics dilemmas. Accordingly based on findings and with the consensus of the research team, a draft for the new proposed framework was prepared. The following steps included testing the draft framework on several common dilemmas of clinical ethics and some real cases in the Iranian context, evaluating its face validity by clinicians and content validity by ethicists, and finally, assessing the level of accuracy and transparency by expert reviewers.

Results: The framework includes nine stages that start with the "Identification of the moral challenge" and "Clarification of the relevant contextual factors", it continues with the "Moral judgment" stage,"Reflection & deliberation," "Moral action," "Follow-up the decision," "Dissemination of the learned lessons," and proposing some "Modifications," and then ends with some "Empowerment actions." Some stages include several steps that need to be followed in order to resolve clinical ethics dilemmas.

Discussion & conclusion: The development process of the current new proposed framework has some innovative aspects, such as its focus on post-intervention actions, comprehensiveness, and methodological validation. Thus, it can potentially be applicable for training and empowering healthcare professionals in clinical ethics dilemmas."

2)    Farid S. The Need for Healthcare Ethics Consultation in Bangladesh: Addressing Moral Uncertainty and Value Conflicts in a Healthcare System

Abstract:

"Background
Bangladesh's healthcare system faces significant ethical challenges, particularly in cases of end-of-life care, reproductive health, and resource allocation. The absence of formal Healthcare Ethics Consultation (HEC) structures often leaves healthcare professionals without proper guidance in navigating complex moral dilemmas, leading to inconsistent and sometimes inequitable decision-making.

Aims
This paper aims to explore how the lack of HEC impacts decision-making and conflict resolution in Bangladeshi hospitals, with a focus on ethically sensitive cases. It also outlines the potential benefits of introducing HEC structures to enhance ethical support and improve patient outcomes.

Methods
A qualitative analysis was conducted on case studies involving ethical dilemmas in Bangladeshi hospitals, including end-of-life care, reproductive health, and resource distribution. Interviews with healthcare professionals provided insight into how these cases are currently managed and the ethical challenges they face in the absence of HEC.

Results
Findings reveal that healthcare professionals often struggle with moral uncertainty and conflicting values, particularly when balancing patient autonomy with family or cultural expectations. The lack of formal HEC results in ad hoc decision-making processes, which vary between institutions and professionals, leading to potential inequities and unresolved ethical conflicts.

Discussion 
The introduction of HEC could provide a structured approach to addressing these ethical challenges, offering healthcare professionals support in navigating moral uncertainty and value conflicts. HEC can enhance decision-making by fostering dialogue between stakeholders, facilitating conflict resolution, and promoting ethical consistency across the healthcare system.

Conclusion
Implementing HEC in Bangladesh's healthcare system is crucial for addressing the growing ethical challenges posed by modern medicine. A formal consultation structure would not only assist in conflict resolution but also ensure that decisions align with ethical principles, improving both patient care and healthcare professionals' moral clarity."

3)    Dirksen K. Integrity & Sustainability: Exemplifying the Use of an Adapted Clinical Ethics Decision-Making Process in the Hospital Boardroom

Abstract:

"The advent of clinical ethics has proved powerful for providing increased support for ethically-challenging decision-making at the bedside and helping establish norms of practice around historically-vexing topics like the duty to informed consent and forgoing disproportionate treatment at the end-of-life. With such a great need at the bedside, many have become content with ethics staying focused on this arena: autonomy and dignity prioritized over sustainability and social responsibility, individualized dilemmas over community-based needs, personal over structural. While leaving the bedside is not the answer, adding the boardroom to an ethicist's natural habitat can help prioritize sustainable-minded goals in health care operational decision-making.

We will describe our ethics program's commitment to assisting operational health care leadership in making some of the most ethically-complex decisions they face. In our experience, the kinds of operational decisions best suited for a clinical ethicist's engagement relate to: changes in the level of quality, service, and experience of patients and the community (e.g., administering anesthesia by physician-anesthesiologists to nurse-trained anesthesia providers), considering new investments in or sunsetting existing health-related supports (e.g., terminating a health navigator program), allocating community benefit spending (e.g., which non-profit to provide a grant to), or consolidating services (e.g., closing a service line requiring that patients would need to access this care elsewhere). This is not to say that these decisions should be executively made by a clinical ethicist, but effectively ethicist-supported.

By exploring three actual situations in the last year where our program assisted operational leaders as outlined here, we will help catalyze the relatively untapped potential that clinical ethicists have in their hospitals and health systems to engage beyond the bedside and, in turn, work toward justice, decide with integrity, and promote sustainability."

4)    Hofset Larsen B. and Molewijk B. CES staff’s moral challenges related to confidentiality and transparency - needs for moral guidance when offering Ethics Support?

Abstract:

"Introduction
Clinical ethics support (CES) never takes place in an a-political context. In and outside health care institutions, CES seems to become increasingly vulnerable to, and involved in, political and (social) media sensitive domains. We will present two self-experienced morally challenging situations that we encountered as CES staff, including: conflicting values, protecting users of CES, CES staff and the integrity of CES itself, moral responsibilities, and, how we responded.

Norwegian case
Staff from the maternity ward at a Norwegian hospital asked the clinical ethics committee (CEC) for advice regarding women in labor opposing recommended interventions, raising concerns about the child's welfare. A birth right activist group member, also being a journalist, contacted the hospital claiming access to all minutes from meetings - where CEC had discussed the dilemma when the mother opposes interventions in connection with pregnancy and childbirth, obstetric violence, the legal protection of the unborn child or related issues.

Dutch case
Due to a serious incident in a Dutch hospital a patient died (not because of the illness or treatment).The head of the department asked the internal Ethics Support team for a Moral Case Deliberation to focus on the moral stress of the team members and to reflect upon various moral questions related to this tragic incident. Afterwards, the Ombudsman and the Health Inspectorate asked for the minutes from that specific MCD session, and requested an interview with the MCD facilitator.

Discussion
After comparing the facts and moral reasoning in both examples of ethics support staff's moral challenges, we will present an innovative ethics support tool specifically developed for CES staff experiencing moral challenges when offering CES in a political context (the Confidentiality Compass). During the last part of our presentation, we will engage with the audience in discussions about future needs of CES staff for related moral guidance."

5)    Jameson K. et al. Moral distress in healthcare: Supporting quality of care and staffs' moral empowerment

Abstract:

"Empirical research reveals an increasing incidence of moral distress among healthcare practitioners across all areas of the healthcare system, with significant implications for both individual well-being and system-wide functioning. From 2023-2024, Vancouver Coastal Health's (VCH) Ethics Services documented 260 consultations related to moral distress, marking a 58% increase from the previous year. Moral distress occurs when healthcare practitioners are unable to act according to their values due to internal or external constraints, leading to significant harms at both the individual and system level. Healthcare practitioners experiencing moral distress often face feelings of guilt, depression, burnout, loss of trust, self doubt, and dissatisfaction at work, which consequently, can contribute to increased staff burnout, sick leave, and staff attrition. Furthermore, moral distress can adversely affect the quality of care and patient safety. In this presentation, we describe the VCH Ethics Services' approach to facilitating moral distress debriefs and offer reflections on some micro, meso, and macro-level recommendations to help support quality improvement across the healthcare system. We introduce tools to support moral distress debriefs, including our ethical decision-making frameworks and a moral distress debrief template that holds space for shared and divergent values through discussions, reflections, and knowledge sharing. We discuss the challenges and opportunities encountered in trialing different approaches to moral distress debriefs and emphasize the importance of interprofessional partnerships in addressing the diverse causes and effects of moral distress. Finally, we explore the evolving role of Ethicists in facilitating moral distress debriefs and how our approach fosters collaborative decision making to mitigate moral distress and promote moral empowerment across healthcare environments."

1)    Fanning J.B. Understanding Treatment Over Objection in Non-Psychiatric Facilities: A Review of the Literature

Abstract:

"More is known about treatment over objection in psychiatric facilities because there is more legal accountability in the United States. But very little is understood about treatment over objection in non-psychiatric facilities involving non-psychiatric treatments. In the experience of the primary presenter who is an ethics consultant, these acts of care elicit considerable moral distress in clinicians and make stark the vulnerabilities of incapacitated patients who can nonetheless resist care verbally and/or physically. Isolated instances of practice guidelines authored by ethics consultants and health care professionals are valuable but a more comprehensive understanding of what is known about treatment over objection is needed.

The methodology, results and analysis of selected themes within a systematic literature review of treatment over objection in non-psychiatric acute care hospitals will be presented in this paper. After the inclusion and exclusion process, twenty-four articles were included: twenty one (87.5%) were case studies and three (12.5%) were descriptive studies focused on occurrence frequency. The articles were coded for recurring themes which were analyzed for conceptual relationships. Four core themes were elucidated: 1) Assessing decisional capacity 2) Recognizing patient resistance 3) Evaluating benefit / burden profile and 4) Coordinating decisional support. The complex relationship between assessing decisional capacity and recognizing patient resistance receives significant conceptual attention because intentional resistance can be ascribed in ways that confuse the status of being decisionally incapacitated. Furthermore, the process of evaluating the benefit-burden profile in light of added burdens like mechanical restraints were contingent on the available representatives to make decisions."

2)    Ahmad M. Is it ever ethical? Non-disclosure requests from family, healthcare Ethics Consultation (HEC) and Life-limiting diagnoses

Abstract:

"Is it ever ethical to honor a non-disclosure request made by family and not share pertinent diagnostic details with the patient, especially if the patient is capacitated? What if it were an oncologic diagnosis and there were still treatments that could be offered but the family still vehemently objects to patient being told? This is a common source of healthcare ethics consultation (HEC) at our tertiary-care hospital in the United Arab Emirates (U.A.E) and a frequent source of moral distress for clinical teams, both nursing and physician-led. In this presentation, we aim to address the question whether it is ever ethical to honor non-disclosure requests by family members, highlighting the challenges in bringing Western bioethical standards to bear on non-Western contexts.

The presenter/s will share an ethics consultation case that evolved at our hospital to stimulate audience discussion, aiming to highlight the conflicting values of patient autonomy and team's commitment towards non-maleficence that these requests evoke. At the razor-sharp edge between the more prevalent Western ethical norms truth-telling and first-person decision-making, and the collective sense of shared familial-decision-making prevalent in this region, the non-disclosure requests regarding end-of-life diagnoses are a true reflection of the society's norms outside of healthcare. After a description of the approach our HEC service has taken in response to these requests, discussion will focus on the associated benefits and risks/harms to all stakeholders, including inter-professional relationships, such as our palliative medicine colleagues.

Additionally, the session will review many of the social, cultural, religious and political dimensions underlying these family requests, share lessons learnt during the eight years our HEC has been handling such requests from global patients and offer unique best practices that reflect culturally sensitive medical care delivery for this Middle Eastern region, where these requests are the norm, rather than the exception."

3)    Sylvestre P. Preferences Regarding Location of Death in Children with Static or Progressive Encephalopathy: Bereaved Parents' Perspectives

Abstract:

"Background:
Children with static encephalopathy (SE) die more often in the intensive care unit (PICU) than others with complex chronic conditions, notably progressive encephalopathy (PE). Location of death (LOD) is considered essential in assessing the quality of end-of-life care. Bereaved parents' preferences regarding LOD for their children with SE/PE are unknown.

Aims:
To explore the experiences of bereaved parents of children with SE/PE and better understand their preferences regarding LOD.

Methods: 
This convergent mixed-methods study used individual semi-structured interviews and a questionnaire with bereaved parents of children with SE/PE, who died 1-6 years prior. A distribution of diagnoses (SE/PE) and LOD (home, PICU, ward, free-standing hospice) was sought through purposive sampling. LOD preferences, planning, and concordance were explored through a qualitative naturalistic inquiry. Likert scales assessed parental end-of-life experiences and preferences. Interviews were transcribed verbatim and analyzed using thematic analysis.

Results:
Between October 2023-June 2024, 21 parents participated (16 mothers). Their children had SE (n=14) or PE (n=7) and died in various LOD. All participants (100%) found it very important to be involved, informed, discuss care objectives, benefit from care coordination. Some participants (15%) reported ability to choose LOD as "Not important/not important at all". Qualitative analysis revealed three main themes: (1) varying preferences regarding LOD, shaped by complex evolving medical needs, family circumstances and available resources, (2) relative unimportance of actual LOD for these parents, compared to other considerations such as quality of end-of-life care, minimal suffering, (3) importance of integrating LOD planning within a broader holistic palliative care approach (clarifying goals of care, navigating uncertainty, providing support/resources), to work towards goal-concordant locations of care throughout the end of life.

Conclusions:
Bereaved parents of children with SE/PE had varying preferences regarding LOD. Supporting these families through a holistic palliative care approach may be more important than planning LOD per se."

4)    Racine E. A living ethics lab to tackle psychological distress in complex chronic and rare diseases

Abstract:

"Background: Ethical issues are often difficult to discuss openly in clinical settings. We report on a living ethics initiative aimed at facilitating dialogue and management of psychological distress in people living with rare or complex chronic diseases.

Methods: This study was conducted at a highly specialized interdisciplinary clinic in Montreal (Canada), following a 5-phase living lab methodology: 1) problem identification, 2) problematization, 3) ideation, 4) enactment, and 5) appreciation. Phase 1 took the form of informal pre-project consultation with patients and healthcare providers (HCPs) from this clinic. For phases 2-5, data were collected through semi-structured interviews with patients and HCPs, as well as a brief patient survey (for phase 5). Interview transcripts underwent qualitative content analysis while survey data were analyzed using descriptive statistics.

Results: Phase 1 led to the identification of the management of psychological distress as a key ethical and clinical issue for patients and HCPs. Phase 2 showed its association with several causes and consequences for both parties. Phase 3 led to identify 17 potential interventions to address patients’ psychological distress, of which 4 were prioritized based on relevance and feasibility. Phase 4 involved the co-creation and enactment of these 4 interventions: a pre-consultation form, a repertoire of patient resources, mental health awareness ads, and a webpage. Phase 5 revealed numerous positive outcomes stemming from the project and the interventions, such as: (1) active patient involvement in clinic improvements, (2) better integration of mental health into specialized care, and (3) normalization of mental health discussions.

Discussion and conclusion: By creating an ethical space where patients and HCPs could reflect on and discuss psychological distress, this living ethics lab initiative deepened the understanding of psychological distress and initiated a paradigm shift in a clinical setting. Participatory research methods hold great promise to make ethics live in clinical environments."

5)    Zachary Chan S.M. Ethical Challenges in Aesthetic Medicine: Social Media’s Influence in the UK

Abstract:

"The introduction of social media has transformed the landscape of aesthetic medicine in the UK where platforms such as Instagram heavily influence public perception on beauty standards and cosmetic procedures. The growing reliance on social media in the field creates both opportunities and ethical challenges for medical professionals. This review aims to identify the ethical issues created with the proliferation of social media use in aesthetic medicine.

A comprehensive literature search was conducted using the PubMed database to identify relevant articles on the ethical implications of social media in aesthetic medicine. The search employed the keywords -Ethics- OR -Ethical- AND -Aesthetic- OR -Social media,- covering the period from 2000 to 2024. A total of 223 articles were initially retrieved. After applying inclusion and exclusion criteria, only 220 articles were selected as they were not in English.
An independent literature search was also carried out to identify the current regulations on non-surgical cosmetic procedures in the UK. This included a review of relevant governmental, professional body, and healthcare regulatory websites.

The literature review identified multiple ethical challenges with the use of social media: risk of harm to patients by usage of language to obscure intentions, unrealistic expectations on beauty standards and aesthetic outcomes, misinformation to patients due to the non-regulation of marketing and lack of formal credential authentication by aesthetic influencers.

Whilst the use of social media brings about its own ethical issues, the influence and potential it brings in to strengthen the patient-doctor relationship via connection and education has to be acknowledged. There needs to be regulation and licensing of aesthetic businesses in the UK to prevent the misleading of patients. Establishment of a social media guideline will standardize the information shared on platforms which will reduce misinformation and unrealistic expectations."

Crites J. Revising ASBH’s Core Competencies: What the 3rd Edition might mean for Clinical Ethics in the U.S. and Beyond 

Abstract:

"The Core Competencies for Clinical Ethics Consultation, published by the American Society for Bioethics and Humanities (ASBH) is influential in the U.S. and around the globe for informing the practices of ethics consultation services and for training future professional clinical ethicists. ASBH is undertaking a 3rd¯edition of the Competencies, to be published in 2025, and the leaders of this workshop were involved in writing the 3rd edition at different stages of the process. While the document is an improvement over previous versions, especially in areas such as consultation models, we believe that its attempt to accommodate the broadest type of ethics consultant limits its influence to push the field forward and relegates discussion of competencies needed for advanced, high-volume, individual consultation to other venues. The aim of this revision is to highlight select changes and updates to clinical ethics practice in light of both socio-ethical and medical developments and evolutions of professionalization in the field of clinical ethics since the previous edition (2011).

We will begin the workshop by reviewing some of the changes and developments as available in the current public-comment draft of the 3rd edition, notably: increased recognition of ethicists in non-consultation roles, increased attention to vulnerable populations, a move away from a full committee model as viable for consultation, advancements in professionalization of the field, and the pressing need to engage in quality assessment and establish practice standards as the field grows.  We will close the presentation portion of the workshop by sharing our personal, professional perspectives, both as authors of the document as well as clinical ethicists working in the American context, specifically reflecting on implications of the 3rd edition for both formal and informal clinical ethics training and practice in the U.S.  We will then engage attendees in an interactive discussion related to the influence of Core Competencies outside of the U.S. context, utilizing a 25/10 Crowd Sourcing exercise. This format drives exchange of innovative ideas through recognition of patterns of solutions shared among attendees. The goal is to clarify how current changes might affect capacity and competency building for ethics consultants globally."

Menon S. et al. Clash of the titans: Ethical conflicts when families reject modern medicine in favour of complementary and alternative medicine

Abstract:

"Many countries have integrated complementary and alternative medicine (CAM) into their healthcare systems as part of holistic care. Data from the World Health Organisation (WHO) shows about 50% of the population in industrialised countries regularly use some form of CAM, although it is mainly limited to outpatient care and plays a complementary role to modern medicine.
Some patients however reject modern medicine completely, to the point where they may put their lives at risk. While patients have the liberty to choose their own treatments, even when others think it is not in their best interests, ethical challenges arise when patients who have not, or are unable to express treatment preferences, require modern medicine treatments to save their lives or prevent a serious deterioration in their health, and their families reject modern medicine for CAM. 
In this interactive workshop, the facilitators will use three cases to explore the ethical challenges faced by healthcare professionals and clinical ethics committees when family preferences for CAM place patients' health at risk, making it difficult to balance benefits and harms, and to advocate for the patient while respecting the family.

Case 1: Lina, a 59-year-old woman found unresponsive on a park bench, was conveyed to hospital and diagnosed with sepsis, renal and liver failure. She lacks capacity to make any medical decisions and is unlikely to regain capacity soon. Her son, who is a Traditional Chinese Medicine (TCM) practitioner, arrived at the hospital shortly after her admission. While the doctors were preparing to intubate Lina and commence dialysis, her son informs them that Lina will only receive TCM and seeks her discharge from hospital, even when informed this may result in her suffering from preventable harm. 

Case 2: Kai is a 4-year-old boy, diagnosed with standard risk childhood leukaemia, which has a good prognosis with conventional chemotherapy. His parents believe that fresh air and unprocessed foods will treat his cancer. The medical team recommended chemotherapy, which the parents refused, even when informed of the good prognosis.

Case 3: Mia is a 14-year-old girl diagnosed with Stage 2 osteosarcoma of the left leg. She wants to recover, return to school and see her friends. Mia has read up about her condition on the internet and prefers the modern medicine options explained by the doctors. Her parents however believe those treatments would harm Mia, and prefer CAM instead, notwithstanding the medical advice."

Rhodes R. et al. Responding to Moral Complexity 

Abstract:

"Most requests for healthcare ethics consultation (HEC) involve a single clinical service.  Occasionally, they involve two different services, sometimes with conflicting concerns and views. Rarely, more than two clinical services are involved.

A recent case at our institution involved three different services, namely obstetrics, pediatrics, and psychiatry. It involved a pregnant woman in the grips of an acute psychiatric crisis who denied being pregnant and refused to cooperate with recommended fetal monitoring. It also involved her severely growth restricted fetus with an abnormal placenta at risk for stillbirth or permanent disability from prematurity at extremely low birth weight.
Thus, several of the most contested socio-political issues were central to the case resolution. The value conflicts embedded in the ethical analysis encompassed abortion, women's rights, fetal rights, rights of people with disabilities, parental rights, self-determination for people with mental illness, prejudice, and discrimination. Whereas everyone from the HEC and each participant from the several clinical services involved was committed to reaching a decision that served the interests of the patient, her inability to reliably communicate about her commitment to the pregnancy, her potential future child, or her priorities under the circumstances presented unusual challenges. 

This workshop will demonstrate our interdisciplinary, collaborative, consensus-forging HEC approach. It will involve the audience in dissecting complex ethical quandaries, navigating multiple uncertainties involved in a complicated clinical case, and piloting a HEC through the somewhat different and conflicting professional commitments of the clinicians involved.

Our Ethics Committee's co-chairs, a clinician and a philosopher, will moderate the session. They will briefly describe our collective model for HEC and invite the audience to serve as HEC team members responding to the request for guidance. The moderators will, in turn, ask our institution's clinicians from psychiatry, obstetrics, and newborn medicine each to present the situation from their clinical perspective. Audience members will pose questions for the presenting clinicians. Thus, the initial workshop segment will focus on developing understanding of the psychiatric and medical situation for the woman and the fetus.

Once there is preliminary agreement on the facts, the discussion will turn to resolving the moral dilemmas involved. The audience will be encouraged to raise ethical concerns and share thoughts about potential problems they foresee. Along the way, the moderators will interject clarifying comments and summary statements. Striving together, the overall aim of the group discussion will be to reach a consensus and formulate recommendations for moving forward. "

Bartlett V. et al. You Don’t Know How it Feels: A Reflective Practice Workshop for Healthcare Ethics Consultants

Abstract:

"Ethics consultants' personal experiences of doing ethics consultation are largely absent from professional literature or academic discussions.

This strange absence limits the possibilities of having such experiences probed, interrogated, or expanded upon through self-reflection and others' critical engagement, which then can limit ethics consultants' professional development, building what may become challenges for sustainable practice for individuals and as a field. This absence also gives some weight to the decades-old criticism that consultants are non-combatants with no real understanding of the experiences that patients, families, and clinicians undergo in ethics consultations. The charge of you don't know how it feels can diminish ethics consultant's effectiveness in complex clinical encounters, conversely, an ethics consultant sharing their personal values or commitments in a consultation encounter, or focusing on their experience as consultants in publications and presentations, is often seen as transgressing professional boundaries, expectations, and decorum with Too Much Information

Since there are few examples of and fewer opportunities for consultants to practice such uncomfortable and often unwelcome work, this workshop offers both and an opportunity to reflect individually and collectively on how academic forms and professional norms constrain practice but are not definitively limiting, i.e., one can break out of those constraints, with a deliberate choice to risk and expose oneself while at the same time limiting the extent of doing so.

Presenter one begins the workshop with an historical review of the collective professional avoidance of describing and expressing personal experiences with ethics consultation, within academic and clinical constraints. Presenter two explores the shadow stories in clinical ethics work, reflecting on tales that we don't tell, or can't tell, despite their deep influence on our professional experiences and practices.  The workshop then offers two examples of self-reflective and creative expression of clinical ethics work. Presenter three shares poetry voicing the unspeakable in consultants' experiences. Presenter four performs a monologue representing the internal voices we hear at times in clinical encounters. Between each segment, workshop participants engage in active pauses, with invited prompts from presenters, for individual reflection and their own creative response (with creative materials provided) about what the pieces raise, identify, or put into question about their own experiences and practice as clinical ethics consultants.

The workshop concludes with group reflections on the practices, challenges, and opportunities of such reflective work for ethics consultants, and an invitation for participants to share their reflections and creations from the workshop."

Martisella M. et al. Disagreements regarding gender-affirming care: How can clinical ethicists contribute?

Abstract:

"Title: Disagreements regarding gender-affirming care: How can clinical ethicists contribute?

Background: An increasing number of youths identify as gender diverse. Such individuals may turn to healthcare professionals (HPs) for gender-affirming care (GAC). While the literature on the topic of GAC has proliferated, it is not without controversy. HPs who encounter gender diverse youth in their practice may face various ethical challenges that pertain to the initiation of GAC. Good medical practice requires that HPs be attuned to the ethical dimensions of care, the medical indications that justify treatment initiation and the legal frameworks governing informed consent. In the context of pediatric GAC, clinical ethicists may struggle to define their specific role and the potential consequences related to their involvement. How can they navigate the tension between gatekeeping practices and ethics rubber stamping in a context where numerous ethical questions may arise?

Aim and methods: Using a fictitious clinical vignette that pertains to the ethical acceptability of initiating GAC, we propose a workshop that will highlight the ethical subtleties and challenges CEs faced throughout a consultation process. Facilitators will be intentional about creating a safe and encouraging environment for participation which aims to provide clarity with respect to finding a balance between the clinical, ethical, and legal imperatives surrounding GAC.

Implications for practice: Requests for pediatric GAC are increasing worldwide and given the ethical issues surrounding this practice and their resulting controversies, CEs may see an increase in consultation requests surrounding this topic. Therefore, it is necessary that CEs feel adequately prepared to address the ethical challenges that arise in this context in a manner that does not harm the various stakeholders involved. Adequate preparation begins with an open and honest dialogue regarding the complexities associated with GAC. By creating a safe environment for such dialogue in this workshop, we hope to contribute to CEs reflective practice in the realm of GAC."

Speakers :

- Mark Aulisio
- Stella Reiter-Theil
- Laura Guidry-Grimes

Please access the full description here

1)    Lemyre S. Toward a better understanding of the use of Medical Assistance in Dying: a qualitative study with international key informants

Abstract:

"Background: The use of Medical Assistance in Dying (MAiD) - euthanasia and assisted suicide - varies significantly across jurisdictions with such legislation. It ranges from 0.3% of all deaths in California (2023) to 7.3% in Quebec, Canada (2023-2024). Various hypotheses are proposed to understand why some jurisdictions have higher rates than others, relating to patient age, religiosity, education, socio-demographic characteristics, public awareness, eligibility criteria, number of MAiD practitioners per capita, institutional support and method used (injection vs self-administration). Few empirical studies have been published on the factors behind the increase in MAiD rates in certain countries. To assess the moral implications of MAiD operationalisation, we need to understand the factors contributing to its prevalence.

Objectives: To better understand the factors associated with the use of MAiD in jurisdictions where the practice has existed for at least five years.

Methods: This qualitative study uses semi-structured interviews with 50 key informants (KI) from Canada, Belgium, California (US), The Netherlands, Switzerland and Victoria (Australia) selected through purposive sampling. KI are members of a regulatory organization for MAiD or experts actively involved in MAiD. The interview guide addresses all possible factors related to the use of MAiD and has been pretested. We perform descriptive thematic analysis and make comparisons between jurisdictions.

Results: Results revealed that factors influencing the use of MAiD can be divided in four themes: 1) laws and policies on MAiD, 2) the impact of the organization of care and services, 3) individual characteristics of people who make MAiD requests, and 4) social dimensions that influence the use of MAiD.

Discussion: By shedding light on the factors influencing the use of MAiD, we can provide valuable insights to policymakers and healthcare providers for a more responsible delivery of MAiD. This study offers an international comparison between jurisdictions with established MAiD legislation."

2)    Lukich N., Oliver S. An integrative and innovative model for MAiD equity: The Ottawa-Champlain Region Experience

Abstract:

"Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Since then, health care organizations have implemented MAiD procedures to address increasing volumes of requests. However, some institutions have not historically had adequate resources, preventing them from offering MAiD services. While faith-based organizations have the legal ability to conscientiously object to providing MAiD services, secular ones do not. This has raised questions regarding health equity and accessibility in a publicly-funded health care system, particularly from patients requesting MAiD who cannot be transferred to another hospital or home due to fragility. 
Our presentation reflects upon the use of ethics consultations in conjunction with support from a regional MAiD program and Advanced Practice Nursing (APN) to assist organizations in implementing MAiD services to meet the needs of their community. This includes robust ethics consultation and education to provide accurate and up-to-date information, to survey available resources and willing assessors and providers, to support and address fear and moral distress internally and within a small community, and establishing a set of procedures to meet legislative requirements and standards of care. 
Using this integrative and innovative model, combining the clinical experience of an Advanced Practice Nurse and the ethics expertise of an ethicist, ensured that patients and families were able to exercise their autonomous right to a legal health care service in an equitable manner, and hospital staff had any questions or moral distress addressed. Laying this foundation enabled the organization to implement ongoing education and support while maintaining a positive reputation within their local community of being a compassionate and patient-centred care provider."

3)    Beaudin A. To better understand refusals of medical assistance in dying: a relational ethical approach

Abstract:

"Mediation is an essential component of ethics consultation. The practice of mediation uses a neutral facilitator to foster engagement of all stakeholders and their respective interests and perspectives, and facilitate a resolution or consensus on an ethically justifiable course of action. However, when, if every, is it justifiable for the clinical ethicist to step outside of the bounds of their role as mediator and advocate for what they feel to be the right course of action?
The author will describe a case in which the interests of an incapacitated patient are discovered through interview of his wife and guardian. However, neither the wife nor the attending physician is willing to move forward with the ethically appropriate course of action to uphold the patient's previously expressed wishes. In cases like this, what are the clinical ethicist's responsibilities to advocate for the most ethically appropriate course of action? Clinical ethicists are consultants, and ultimately the decision-making rests with the clinical team and patient or family. However, when the patient cannot speak for themselves, and their loved ones refuse to do so, does the ethicist have an obligation to step outside the role of neutral mediator and instead advocate for the voice of the patient? At what point would the ethicist seek institutional or legal support to advocate for a specific course of action? The author will provide support and considerations for both perspectives, along with considerations for a deontological vs consequentialist approach to consultation recommendations."

4)    Marckmann G., Hirsch A. Beneficence-based ethical obligations in assisted dying

Abstract:

"Assisted dying usually is ethically justified by respect for the person's autonomy. However, there are also beneficence-based obligations towards persons requesting assisted dying. What beneficence requires from persons assisting in dying is far less obvious and less discussed. We will therefore explore in our contribution what role obligations of beneficence can or should play in responding to requests for assisted dying, also within ethics consultation.
After a brief philosophical analysis of the concept of well-being, we will assess whether beneficence-based obligations can be used as 'gatekeeping' criteria for assisted dying. Some countries and states restrict access to assisted dying to unbearable suffering and/or treatment resistant, incurable or terminal illness. We will argue that these beneficence-based criteria are neither suitable nor justified to determine ethically legitimate assisted dying. Gate-keeping can only be justified by the protection of autonomous decisions.
Nevertheless, beneficence-based obligations can play an important role in responding to requests for assisted dying. First, they require to offer appropriate psychosocial support and medical (esp. palliative) care. Professional standards of care therefore should not only include safeguards for autonomous decision-making, but also provisions of appropriate care and support for the requesting person and her families. Second, beneficence-based arguments can have an instrumental value for promoting the requesting person's autonomy. Within a shared decision-making process, they can provide an important input into the joint deliberation about the available options. Third, beneficence-based obligations can help the person who has been asked for assistance in their individual decision about whether they shall follow the request. 
As a conclusion, persons responding to requests for assisted dying should have specific expertise in evaluating and balancing beneficence-based obligations. Focusing more on the beneficence-based obligations ("appropriate help for the person's need") may improve the care for the requesting persons and their families and strengthen their autonomy."

5)    Hahlweg P. Psycho-oncologists’ role in requests for assisted suicide - a qualitative interview study on current state and future directions

Abstract:

"Background: Assisted suicide (AS) is a socio-political challenge. In Germany, AS is legal, but new legislation is pending. Previous legislation drafts provided for the involvement of various professional groups, including psychosocial professions such as psycho-oncologists. Psycho-oncologists have a lot of experience in dealing with seriously ill people, end-of-life decisions, and possibly the topic of AS. Their work is intertwined with ethical considerations. However, there is a lack of studies on the role of psycho-oncologists in AS, especially for Germany.

Aim: The aim was to ask psycho-oncologists about their tasks and needs in AS inquiries in order to identify possible forms of participation.

Methods: We conducted a cross-sectional, qualitative interview study with psycho-oncologists in Germany. Inclusion criteria were a current clinical activity as a psycho-oncologist and having talked about AS in at least one conversation with a patient. The invitation to participate was sent by email to the study team's network and via social media channels. Interested parties responded on their own initiative (convenience sample). The interviews were analyzed qualitatively using pragmatic thematic content analysis.

Results: A total of N=12 interviews were conducted. Results suggest that the psycho-oncologists surveyed would mainly like to take on the role of open discussion partners, both currently and in the future. Whether psycho-oncologists should assess decision-making capacity and voluntariness was controversial among participants. The vast majority rejected participation in realizing the AS. They were against having to take on mandatory roles. For AS work, the participants would need, among other things, a clear legal and institutional framework and specific training opportunities.

Discussion: This study provides initial insights into the (potential) areas of responsibility and needs of psycho-oncologists in AS requests. It can serve as a basis for follow-up studies, e.g., with clinical ethicists as the target population. Suitable structures and training opportunities should be developed."

1)    Shakhsheer B. Framing Bias in Clinical Ethics Consultation

Abstract:

"Background: Clinical ethics consultation may be susceptible to framing bias. Framing bias may occur when the party requesting consultation perceives and frames the ethical question in a way that influences the consultation team, including their analysis and ultimate recommendations. Framing bias is problematic because it may result in ethically unjustified or sub-optimal recommendations and has not been extensively investigated within the context of clinical ethical consultation. 

Aims: We sought to evaluate if the party asking for the clinical ethics consultation affects how the consultation service perceives the ethical question and if framing bias is introduced into the consultation process.

Methods: Recent (1-year) graduates and current fellows of a clinical ethics training program were administered two surveys one week apart. Each survey included brief descriptions of several ethics consultation cases, the surveys were identical except for information on who initiated the consult. In the first survey, the cases were presented such that the consultation was requested by patients or their families. In the second survey, the cases were presented such that the consultation was requested by a party other than the patient/family.  We assessed the two surveys for concordance in which bioethical ethical principles were involved, and which were perceived as the primary and secondary most influential. Difference in difference analysis were used to test for concordance.

Results: 14 respondents completed part one, 11 respondents completed part two. For each case, there were statistically significant differences in the ethical principles perceived to be involved by the ethics consultants, as well as the principles that were ranked as primarily and secondarily involved in the case.

Discussion: These data indicate that framing is a potential source of bias within clinical ethics consultation. Consultants should guard against this by evaluating the ethical question outside of the person or entity calling for consultation."

2)    Brendbekken A. The multiple roles of a clinical ethical committee: how do ethics education for staff impact ethical consultation requests?

Abstract:

"Background: In Norwegian specialist healthcare, Clinical Ethics Committees (CEC) have been mandatory by law in hospitals since 2021, supported by a new national directive. The mandate has two main goals: to enhance health professionals' ethical awareness and competence, and to provide advisory support for ethical challenges in patient treatment and care. This study investigates whether training in case identification, ethical analysis, and structured problem-solving could reduce the need for CEC consultations by empowering staff to address ethical issues independently. Alternatively, increased awareness and knowledge may lead to greater utilization of CEC services, possibly influencing the volume and nature of requests.

Aim: This study aims to understand whether trends in requests to the CEC change following the introduction of the CEC's educational activities.

Method: Written records from CEC case consultations over the past 12 years at Haukeland University Hospital were analyzed using descriptive statistics. We examined the type of ethical challenges presented and the nature and extent of CEC consultations. We compared CEC consultation statistics with educational activities provided by CEC in the departments requesting these consultations.

Results: Ninety cases were analyzed in relation to the CECs educational activities. In several departments, CEC-led training sessions resulted in an increased number of consultation requests, particularly in departments with limited previous contact with the CEC. Conversely, CEC consultations often generated requests for further educational activities, including teaching sessions, reflection group facilitation, supervision of groups and leaders, and involvement in guideline development. A general trend emerged showing fewer requests for CEC consultation and an increase in request for support in building ethics competence among staff.

Discussion: It is essential for CECs to fulfill both their educational and advisory functions within hospitals. By doing so, they enhance staff's ethical capabilities and confidence, contributing to ethically robust healthcare services."

3)    Stout N. Beyond Moral Distress: Understanding Moral Regret in Clinical Ethics Consultation

Abstract:

"In the clinical ethics literature, much has been written in an effort to conceptualize moral distress and to understand its impact on healthcare providers. However, I contend that the moral distress framework does not adequately characterize the experiences of clinical ethicists when dealing with hard cases. Typically, moral distress is thought to occur when an individual knows the right thing to do but is prevented from acting on this knowledge due to institutional or other external constraints on their decision-making. However, clinical ethicists are much less likely than other participants in patient care to actually encounter these constraints. Often, the clinical ethicist has no institutional or systemic barrier that prevents them from making the recommendations that they believe to be most ethically justifiable, and, so, standard accounts of moral distress often don't apply. Nevertheless, the clinical ethicist is often left with feelings of regret, or sometimes guilt, as a result of their involvement in hard cases, and these feelings can take a personal and professional toll on the ethicist. It is well documented that moral distress contributes to burnout among clinicians, but no data exists on the experience of regret among ethicists or on its long term impact on the ethics consultant. I argue that, if left unaddressed, difficult moral emotions like regret stand to have detrimental effects for the practice of clinical ethics consultation in much the same way that moral distress impacts other healthcare practitioners. I maintain that in order to prevent this, more work needs to be done to understand the negative moral emotions involved in clinical ethics consultation and their impact on the ethicist and the sustainability of his or her practice, and I propose potential pathways for addressing these issues."

4)    Levasseur M.C. All caregivers: a case study in implementing a new code of ethics at CHU Sainte-Justine

Abstract:

"Background: In the wake of scandals in the public service network, Quebec's government is recommending the development of codes of ethics in each health institution. These codes of ethics apply to all hospital staff and aim to disseminate the rights of users and the values of the organization, in terms of patient care and processes. Despite limited evidence of their impact on care and services, healthcare organizations invest considerable time and resources in creating them.

Aim: This study examines the influence of the implementation of a code of ethics built via a participative process on the care experiences of patients, family members, and staff (all professions combined).

Methods: Based on a case study, this qualitative research is conducted in the pediatric department of a specialized health care institution in Quebec, Canada, which has developed and implemented a new code of ethics since 2018.  Recruitment is based on a convenience sample of participants from different professional categories, hospitalized patients and their relatives. Interviews are conducted and transcribed verbatim. Initial inductive coding is conducted and reviewed by two members of the research team (NVivo). Thematic analysis are identified according to the categories explored in the interviews and derived from the narrative analysis.

Expected Results: From November 2024 to February 2025, 60 patients/families and staff will take part in semi-structured interviews (20-45 minutes). We assess the impact of the code of ethics on care and services from the perspective of patients, families, and employees. The presented results will guide healthcare institutions wishing to implement code of ethics as well as to measure its influence on stakeholders.

Discussion: This study shed light on the influence of the implementation of a new code of ethics grounded on the values of patients, families and staff on the care experience."

5)    Gaucher N. Normativity and creativity in clinical and organisational ethics: what are ethicists' opinions?

Abstract:

"Background: Tensions between normativity and creativity are highlighted by specific situations in healthcare, such as innovation in medicine. However, little is known regarding how creativity is utilised by ethicists in clinical and organisational ethics.

Objectives: The objectives of our study were to: 1) describe the meaning of creativity in clinical and organisational ethics practice in Quebec, Canada, 2) develop and assess a reflexive tool to think through the role of creativity in ethics practice.

Methods: The interdisciplinary study team developed a reflective tool based on existing literature, such as Bassot's integrated reflective cycle, and experiences as ethicists. During their annual symposium in October 2023, all members of the Regroupement de éthiciens du réseau du Québec were invited to participate in a reflective workshop. They participated in small group discussions on: "according to you, what is the role of creativity in the practice of clinical and organisational ethics?" Following discussions, interested participants completed anonymous self-administered web-based surveys (LimeSurvey). Surveys consisted in: 1) a reflective tool questioning the role of creativity in a specific ethics case experienced by each participant, 2) demographic data, 3) appreciation of the tool.

Results: Forty-one participants completed the survey. Most were less than 10 years in practice (80%), worked in urban settings (68%) and had advanced degrees (36% master's, 28% doctorate). Creativity was understood as: 1) professional competency - to respond to uncertainty, reestablish communication between parties, and create proximity, 2) method - deliberative, pragmatic and applied, proactive, reflexive, 3) reflective space - a safe and open space, both outside norms but coexisting within them. The tool's strengths included: stimulated reflection, identify positives of creativity, ease of use.

Conclusions: Creativity is an important part of clinical and organisational ethics, at many different levels. A reflexive tool can help identify creativity in practice."

1)    Fleck. AI, Algorithmic (In)Justice, and the Ethics Consultant: Quo Vadis? 

Abstract:

"It would be naïve to think that AI would not invade the ethics consultation process.  CAR T-cell therapy has front-end costs of $475,000 for patients with various advanced hematologic cancers.  We know that 70% of these patients will gain 1-4 extra years of life from this therapy.  However, the other 30% will fail to gain an extra year of life. 
With the goal of providing a more cost-effective and just allocation of those limited health care resources, an emerging version of AI, using multiple biomarkers, will be able to predict with 90% confidence who is in the 30% group. Imagine a private insurance company, or the NHS in the UK, is considering use of this AI protocol for purposes of saving money or re-allocation to higher priority health needs.  Is such a choice just and/or congruent with a commitment to solidarity?
They, and their physician advisors, are seeking guidance from you as an ethics consultant.  As an ethics consultant, what will your advice be to the insurance company, or the NHS, and to the physicians on this advisory committee?  Should you be functioning as a patient advocate or as a prudent steward of social resources?  Is it irresponsible for the ethics consultant to leave the matter to executives, bureaucrats, economists, and other self-interested stakeholders?  I will critically assess potential responses that might be offered by an ethics consultant.  Spoiler alert: No easy answers will be offered.  Physicians are seeking insight, not indifference.  Patients need fair, affordable, effective treatment. Consequently, I will argue that timorous neutrality by an ethics consultant would not be a virtue.  Likewise, retreat to the bedside would be cowardly, i.e., allowing each physician to apply the AI protocol as they saw fit, thereby risking bedside algorithmic injustice."

2)    Fiester A. Abdicating the Role of Mediator in US Healthcare Ethics Consultation: A Risky Choice 

Abstract:

"The amount of conflict between patients, families, and healthcare providers is so high in the United States that a recent consensus statement of five professional medical societies recommended embedding expert conflict management consultants in all high-volume US hospitals (Bosslet et al 2015).  From the earliest days of formal ethics consultation, the US bioethics organization, the "American Society for Bioethics and Humanities" (ASBH) deemed conflict resolution skills as a core competency for ethics consultants, making the institution's ethics service a natural locus for such conflict management experts.  But over the last 25 years, clinical ethics consultation in the US has morphed into a consulting specialty similar to medical subfields like nephrology or hematology, in which the primary deliverable is knowledge-based expertise and judgment. Most US ethics consultants offer recommendations, not interventions. Even among ethics consultants with the ASBH's new formal certification (HEC-c), very few ethics consultants have any training in conflict management, despite the mandate for both in the ASBH's Core Competencies, the guiding document for the field.  I will argue that this evolution (or devolution) of ethics consultation in the US may be sowing the seeds of its own demise. Over the last 10 years, US hospitals have increasingly relied on newly emerging Departments of Patient Relations to fill the void of conflict management expertise that ethics consultants could have (and, I believe, should have) filled. These new departments are typically larger and much better funded than the hospital's ethics consult service. In fact, most US hospitals have a patient relations department though many hospitals have no paid ethics consultants at all.  If this trend continues, abdicating the role of conflict resolution in ethics consultation may put clinical ethics "out of business."

Bosslet, GT., et al. "An Official Policy Statement: Responding to Requests for Potentially Inappropriate Treatments." 191(11),2015: 1318-30.

3)    Mollar E. et al. The Role of Research Ethics Patient Advocate (REPA) in Advancing Digital Transformation and Artificial Intelligence

Abstract:

"Objectives: Digital platforms can significantly contribute to establishing standards in bioethics and support leveraging the benefits of artificial intelligence (AI) in the healthcare sector. We seek to identify key areas where AI can be useful in identifying blind spots in complex medical cases where ethical considerations are significant in decision-making. The review and acceptance of digital AI platforms and examination and approval of criteria used in AI algorithms will have more desirable outcomes in terms of equity and inclusion of a broad spectrum of the population when reviewed by a panel that includes a trained Health Ethics Consultant  (HEC) acting in the role of Research Ethics Patient Advocate (REPA) to ensure that ethical considerations are included in the selection of AI models.

Methods: The research employs a mixed-methods approach, combining qualitative and quantitative analyses. Surveys and interviews with healthcare professionals, AI developers, and HEC stakeholders are conducted to gather insights on current AI applications and the effectiveness of digital platforms. Reviewing existing AI implementations in healthcare settings requires feedback from end users to improve the tool and if the selection of research subjects reflects the relevant target population.

Results: Preliminary findings indicate that digital platforms significantly enhance the capabilities of AI in healthcare by providing robust data management and facilitating real-time analytics. The study highlights the need for better policies in evaluating AI platforms and for REPAs to be included in assessing an AI algorithm or platform.  Beyond diagnostic accuracy, personalized treatment plans, and operational efficiency, the impact on the ethical approach is critical. More strides are needed to create ethical digital tools for successful outcomes. Our organization's process management and collaboration tool for ethics and medical research protocol management, BioEthx, is a baseline for digital transformation applied to ethical patient care.

Conclusion: Best uses of AI in healthcare require digital platforms and algorithms that have demonstrated models inclusive of cultural and racial differences and have transparency through the review of a panel of experts that includes HEC's involvement in the role of REPA.  AI technologies for determining treatment alternatives must balance best outcome rating versus risk and consider social determinants of health and patient's cultural and spiritual dispositions."

1)    Kelecevic J. Doing the right thing wherever our clients are: a scoping review of clinical ethics support for community service providers

Abstract:

"In Canada, dedicated health care ethicists are mostly employed by large academic hospitals, and will sometimes contract to support smaller community hospitals. Yet the conditions giving rise to ethical issues in hospital do not disappear at discharge. Further, the locus and range of home and community service delivery make the ethical issues inherently different from those encountered in an acute care environment (1). An example is that the ethics of decisions to live at risk is impacted by heightened socio-economic and geographic disparities, as well as heightened communication challenges based in cultural/religious diversity. There is an opportunity to explore how ethics capacity is built among community agencies, including education, and networks of collaboration among care providers.

The purpose of this scoping review is to understand the current literature on ethics support for community and social service agencies. This may include organizations that vary widely in size and focus of operation such as mental health and addictions, acquired brain injury, home care, and assisted living. This scoping review follows a 5-step approach outlined by Arksey and O'Malley (2), searching 3 databases (Medline, Scopus, and Web of Science). The scoping review will generate key findings, and yield recommendations for health care ethicists and ethics champions looking to implement an appropriate model of community ethics support."

(1) Boulanger R, Ibarra K, Wagner F. A Road Map to Building Ethics Capacity in Home and Community Care. Healthcare Quarterly. 2014, 17(1)
(2) Arksey H, O'Malley L. Scoping Studies: Towards a Methodological Framework. International Journal of Social Research Methodology. 2005, 8(1), 19-32

2)    Hall G. Bearing Witness as an Ethical Act

Abstract:

"Challenging global and local socio-political conditions including economic hardship, political uncertainty, natural disasters and cost of living pressures impact clinical care with greater demand for scarce resources, bed-count pressures, equitable distribution of costly treatment, and discharge planning. The healthcare professional increasingly feels the pinch of escalating demands coupled with rising levels of patient aggression, often leading to moral distress and burnout. When navigating ethically complex clinical situations in such trying times, standard ways of resolving challenges sometimes don't work and it can feel like there is no ethical way forward.In such instances, it is easy to overlook the substantial moral value derived from simply bearing witness to the patient's experience. This is done, often subconsciously, by healthcare professionals who walk with a patient and their families through the uncertainty, grief, doubt, and emotion of their experience. Bearing witness is active listening and not turning away from the pain and suffering of the situation. It can feel uncomfortable or inadequate for the bearer, but carries discreet moral weight and value as a unique and valuable aspect of patient care. This presentation explores the neglected ethical concept of 'bearing witness' as a powerful aspect of caring for patients and their families. It draws from established conceptual foundations in the indigenous truth-telling context and Holocaust legacy, and maps how the idea finds shape in the nursing literature. I demonstrate that there is moral value and concrete utility for both the patient and family, and the healthcare professional, in finding meaning in the space and quiet of true presence."

3)    Bartlett V.L. From Fading Myths to Conspiracy Theories: Can Ethicists Bridge Ideals of Physician-Servants and Realities of Corporate Medicine?

Abstract:

"This paper will identify frictions at the intersection where mythologies of physician roles and responsibilities meet physician realities in corporate healthcare systems and become conspiracy theories that undermine physician responsibility and disrupt sustainable practice. The paper will also explore how Healthcare Ethics Consultants might respond to the concerns that emerge from these myths and theories to open space for understanding and resistance.

Part one lays out the historical roots of physician's service role, with its expectations and obligations to patients, and identifies contemporary factors that erode or become barriers to physician practice such that service seems like an idealistic myth.

Part two identifies the challenges and distress physicians experience regarding their diminishing sense of profession and care within the role, and the drive to avoid responsibility that not supported, though still expected. This section will explore the trend of viewing the myth of services as conspiracy for manipulation, with and physicians pivoting to corporate medicine (venture capitalist medical groups, contracted hospitalist services) that seems more 'honest.'

Part three explores places where healthcare ethics consultants can support sustainable professional practices: identifying the disconnects between such professional myths and conspiracies, and clinicians' embrace of corporate models, introducing alternate myths/sources of meaning and sustenance in practice to counter conspiracy theories about physician manipulation, normalizing recurrent and ongoing elements of these frictions within histories of professional practice.  

The paper will conclude with invitation to consider spaces and opportunities for discussion and ongoing forms of resistance to conspiracy theories in clinical and educational settings, and in public-facing discussion of healthcare roles and expectations."

4)    Fanning J. B. Resisting Force Through Conditional Thinking

Abstract:

"Skeptics of clinical ethics consultation claim that the ethicist is merely an institutional rationalizer, a sophisticated mouthpiece for the powerful perspectives focused on the legal, political, financial and personal liabilities of contested care. Indeed, since navigating and negotiating perspectives is central to the work of ethics consultation, clinical ethicists are susceptible to the undue influence of authoritative perspectives [clinicians, patients, surrogates, administrators] whose force can undermine ethically justifiable care. A temptation to resist is to counter force with force, cashed out in strategies like "Tell the team, -Ethics thinks X-" or documenting that -Ethics recommends-. Through four selected case vignettes demonstrating different forms of perspectival power, this presentation argues that we should avoid such strategies. Rather, we should make explicit and endorse conditional thinking as a key to leveraging the authority of and responsibility to shared ethical content over against the sheer pragmatic force of statements made by powerful stakeholders. Recollecting the philosophical distinction between pragmatic force and semantic content, Robert Brandom articulates the important function of conditional thinking: "embedding a declarative descriptive sentence as an unasserted component in a compound asserted sentence strips off the pragmatic force its free-standing, unembedded occurrence would otherwise have had." Conditional thinking might appear to be a mere matter of theoretical precision but it is actually the practical lever that allows ethical content to be the fulcrum that can move power-laden situations toward ethically justified care."

5)    Khamis F. Role of Clinical Ethics in Addressing Equity for MSM Requiring HIV Pre-Exposure Prophylaxis (PrEP) in Non-Western Cultures

Abstract:

"Establishing a clinic for pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) in non-Western cultures presents significant challenges due to religion, social stigma, legal restrictions, and healthcare inequities.

This initiative addresses the urgent need for HIV prevention services that navigate cultural norms inhibiting discussions about sexual health.The clinic is designed to provide a safe and inclusive environment where MSM can access PrEP services without fear of discrimination. A multidisciplinary team trained in cultural competency fosters trust and confidentiality while addressing stigma and supporting sexual autonomy - essential elements for effective healthcare delivery to vulnerable populations.

The presentation will highlight clinical scenarios illustrating ethical complexities from the perspective of an HIV physician who is also a practicing Muslim. It will explore real-world examples of ethical conflicts encountered when providing PrEP to MSM, such as when clients engage in condomless sex with multiple partners, which may clash with the personal values of healthcare providers. Ethical principles like beneficence guide providers to prioritize client health by offering PrEP as an effective preventive measure. Non-maleficence addresses risks like "prevention optimism," where perceived protection from PrEP may encourage higher-risk behaviors. Autonomy is respected by ensuring clients receive comprehensive information about PrEP's benefits and limitations, empowering them to make informed health choices. Justice emphasizes the clinic's commitment to equitable healthcare access, regardless of sexual orientation or lifestyle.

Our advocacy extends beyond the clinic through our roles in the Oman National Bioethics Committee, promoting awareness of PrEP's importance in reducing HIV transmission. We engage religious leaders and legislators to reduce stigma and enhance understanding of MSM healthcare needs, ultimately striving for equitable and culturally sensitive healthcare services to effectively combat HIV transmission."

1)    Zlotnik Shaul R. Plurality & Power in Paediatric Ethics: A Bioethics Service's 40+ Years of Adapting to Socio-Political Realities

Abstract:

"Meeting the ethics needs of a dynamic tertiary paediatric hospital requires a bioethics service that responds not only to clinical physiologically-grounded dilemmas but also to the socio-political forces shaping hospital activities. This presentation will explore the evolution of our paediatric bioethics service from the 1980s to the present, drawing on insights from a historical inquiry. We will examine how our department, through its four core pillars of activity adapted to emerging challenges and opportunities, enhancing ethical decision-making and fostering a culture of ethical awareness throughout the institution.

1. Consultation: Ethical tensions often arise from the socio-political context of young people as rights holders, balancing their best interests with emerging autonomy. Over time, our consultation model has evolved from an ethics committee to a more dynamic approach, involving individual bioethicists, Clinical Bioethics Associates, and a Bioethics Advisory Committee.

2. Education: Our department has continually innovated educational approaches to address socio-political issues, including targeted in-services, monthly Bioethics Grand Rounds, and an annual Bioethics Week. Other initiatives include Bioethics-Morbidity and Mortality Rounds, fellowships, electives, and selectives, ensuring wide-ranging, hospital-wide engagement with ethical issues.

3. Policy: Today, our department plays a key role in developing frameworks, guidelines, and policies to address emerging ethical challenges, such as post-pandemic surgical prioritization and the ethical integration of new technologies. Our historical inquiry sheds light on how the department has embedded itself within the hospital's bureaucratic structures, shaping access to and influence over institutional decision-making.

4. Research: Research and scholarship in our bioethics department has historically, and presently engaged with (sometimes controversial) dialogues beyond the hospital walls on socio-political issues. These engagements, on topics like healthcare funding priorities for children, the responsibilities of the clinician-scientist, and the impact of moral distress on clinician burnout continue to be opportunities for demonstrating the value of ethics expertise."

2)    Finder S. Grounding Clinical Ethics Practice in the Clinical as an Inherently Responsive Means for Responding to the Socio-Political

Abstract:

"Clinical contexts are shaped by a variety of features that, when carefully examined, provide the ethical texture of such contexts.  Most prominent among these are four complex and interrelated features: (a) the multiplicity of embedded and mostly unarticulated values that intimately influence (b) specific and dynamic relationships among individuals (who are mostly strangers to one another) and the roles they fulfill in the pursuit of offering (and providing) care to those suffering from disease, injury, or syndrome, care that itself must account for the (c) inherent uncertainties due to a variety of ongoing change whereby (d) what counts as 'best' is necessarily interpretive.  Accordingly, when providing clinical ethics support or consultation, focus must be directed towards how these features reflect and shape what is seen as most worthwhile for those making decisions about how best to proceed.

In this light, as Bliton and Finder wrote 25 years ago the main activity of clinical ethics work, as a kind of "clinical" practice, may be characterized as the "conducting of conversations" which aim "to identify by speech, and through oneself as an example, what is most worthwhile" so that those who face decisions not only may make choices consummate with their beliefs and commitments but do so in the face of having to live in the aftermath of their choosing.  

On the face of it, this understanding of clinical ethics work does not appear to be concerned with socio-political considerations (social justice, sustainability, AI in healthcare, etc.).  Through use of a clinical example, this paper will explore how this conception of clinical ethics work is, however, inherently a socio-political sensitive form of engagement insofar as macro-level considerations are constantly (and practically) instantiated in the micro-level context of any clinical encounter.  Thus, clinical ethics work, as "clinical" must be responsive to these."

3)    Kekesi-Lafrance K et al. An Advanced State of Irreversible Decline in Capabilities: How Politics Impact Patient Care

Abstract:

"In 2021, the Canadian Criminal Code was amended to allow access to medical assistance in dying (MAiD) for a person whose death is not reasonably foreseeable. In the summer of 2023, Quebec followed by amending the Act Respecting End-of-Life Care to allow MAiD for people who are not at the end of life.

One of the eligibility criteria for patients who are not at the end of life is that they must be 'in an advanced state of irreversible decline in capability'. This criterion seems to bear the load previously born by being at the end of life. Despite its weight, this ambiguous criterion becomes virtually impossible to apply in some of the more complex cases. When is a condition 'advanced'? What standard should be used to assess an 'advanced state'?

We identify three different standards used in practice: (1) an objective standard relative to the typical trajectory of the illness, (2) an objective standard relative to the person and their prior capacities, (3) a subjective standard that relies on the individual's own assessment of whether their state of decline is advanced. We use fibromyalgia, a condition for which there is no objective physiological marker and known to disproportionately impact women, to discuss how power affects the application of ambiguous criteria, leaving patients and providers in a state of moral uncertainty. We look at how sexist dismissal of women's pain can negatively affect access to MAiD and reliance on ambiguous criteria heightens this risk. Through a pluralistic lens, we describe the ambiguities of applying these standards and the differences in how these standards are assessed in Quebec and the rest of Canada."

4)    Bahmani F. The role of Socio-political issues in the development and function of Hospital Ethics Committees in Iran

Abstract:

"In Iran, Hospital Ethics Committees (HECs) emerged in 1997 through the implementation of newly introduced requirements for hospitals by the Ministry of Health and Medical Education (MoHME) and developed through two phases.  In the first phase, these committees were involved more in the implementation of cultural and religious values, than in clinical ethics in today's sense. However, after a while, as the first version of the Charter of Patients' Rights was approved in 2002, these committees started to change their point of focus to patients' rights gradually.

The rise of the second phase of clinical ethics occurred when medical universities started to offer some post-graduate degree-based programs in medical ethics in 2008, which informed academic scholarship in the field of medical ethics in Iran. At this stage, the policymakers came to the conclusion that HECs function more effectively by the creation of central regulations and support. Hence, the MoHME established the National Clinical Ethics Committee (NCEC) in 2018, after the successful experience of the establishment of the National Research Ethics Committee and subordinate committees in universities. The NCEC soon drafted the 'Guidelines for the establishment, classification and description of duties of clinical ethics committees' and required regional health authorities to form 'regional clinical ethics committees' with the task of monitoring and guiding the HECs toward implementing medical ethics standards in the affiliated hospitals.

The guidelines for clinical ethics committees brought some innovations in the field of clinical ethics to tackle the socio-political challenges faced by the HECs, leading them to function more as 'organizational ethics committees' than 'clinical ethics committees'. We will discuss the role of these socio-political issues in the development and function of HECs in Iran and argue the main issues these committees have to tackle in order to effectively address healthcare ethics needs."
 

5)    Hendriks M. Navigating Coercion in Medicine: Medical-ethical Guidelines and the Role of Patient Autonomy 

Abstract:
 
"In clinical ethics, coercive measures those performed against a patient's wishes or resistance go along with complex ethical and legal conflicts. While respect for patient autonomy is a fundamental ethical principle, situations arise in which a patient's refusal conflicts with medical indications, such as in emergencies like acute agitation or postoperative delirium when decisional capacity is temporarily impaired. This workshop will explore the ethical tensions between respect for patient autonomy and the perceived need for coercive medical measures.
Developments in ethics, legislation, medical practice and societal values necessitate a revision of the Swiss Academy of Medical Sciences (SAMS) medical-ethical guidelines on coercive measures. The revision aims to address concerns raised by healthcare professionals (HCPs) and public inquiries, requiring a nuanced, interdisciplinary approach and to facilitate decision-making. Central to the revision is also the impact of the UN Convention on the Rights of Persons with Disabilities (CRPD), ratified by Switzerland in 2014. The CRPD Committee advocates for a radical shift from "substitution" (e.g., guardianship) to "assistance," i.e., supported decision making, raising significant ethical and practical questions about a zero-coercion framework.
Through interactive panel discussions, participants will engage with these issues, exploring how updated medical-ethical guidelines can support HCPs in navigating conflicts between legal obligations, patient rights, and clinical realities. Particular attention will be given to the socio-political pressures influencing these debates, including the impact of international human rights law and national policy reforms.
The workshop will be moderated by an interdisciplinary team of ethicists and HCPs involved in the ongoing revision of the SAMS guidelines, ensuring that participants reflect on the theoretical and practical medical-ethical issues of coercive measures faced by HCPs."

1)    Racine E. Understanding what clinical ethics cases are: Review and perspectives from a Canadian collaborative on clinical ethics methods

Abstract:

"Background: Clinical ethics involves understanding concrete moral situations and supporting meaningful discussion to identify appropriate responses. However, concepts and methods to describe cases vary between authors and clinical ethics consultation methods. We undertook (1) a review of contrasting models of consultation methods in the literature and (2) embarked on a critical and interpretive analysis of these methods by involving a large group of Canadian clinical ethicists.

Method: Non-exhaustive literature review to identify a range of influential ideas on how to describe clinical ethics cases (e.g., with respect to terminology and definitions) and the methods recommended to understand these (e.g., grasping of medical facts, grasping context). Through participatory co-author group discussions, we explored the strengths and limitations of existing models and practices to offer a critical interpretive analysis (inspired by McDougall's method). 

Results: We identified nine families of clinical ethics consultation methods, which vary considerably with respect to the basic description of cases (e.g., dilemmas, cases, stories, morally problematic situations) and the use of moral principles in understanding cases. Recommended practices also vary greatly, especially regarding medical fact (e.g., as being 'facts' or as being 'interpretations') and the descriptions of the processes of understanding situations (e.g., as being linear or as being cyclical and iterative). Recommended practices also vary according to their methodological accounts of contexts, social and power dynamics, and emotions (e.g., as being constitutive or not of cases).

Discussion and conclusion: We identify and discuss five issues with respect to clinical ethics consultation methods: (1) restrictive terminology, (2) gaps between theory and practice, (3) oversight of context, (4) cursory treatment of power dynamics and trust, and (5) a limited awareness of the positionality of ethicists and interested parties. This research paves the way for further steps of co-research and co-creation to develop advanced practices."

2)    Finley-Roy V. Title: Medically assisted dying practices: What role for clinical ethicists?

Abstract:

"Background: Euthanasia and physician-assisted suicide are two forms of medically assisted dying (AD) practices that have been legalized in several jurisdictions throughout the world over the last two decades. Because of this increased trend, more individuals now have access to a self-chosen death. Despite its legalization and the diversity of frameworks governing AD, it remains morally taxing, fraught with ethical challenges. However, there is a dearth of literature regarding the specific roles clinical ethicists (CEs) may have in AD practices. 

Aim: We sought to address this literature gap by:

1) Gathering healthcare professionals' (HPs) and CEs perspectives on how CEs may contribute 
2) Identifying how CEs may have been involved thus far
3) Identifying promising practices and pitfalls related to their involvement

Methods: An exploratory qualitative study using focus groups, purposive and snowball sampling. Four online focus groups were held. Groups comprised of 1) HPs involved AD and 2) CEs from Quebec and Switzerland. Data was analyzed using thematic analysis.

Results: A total of 11 HPs participated which included: physicians (n=5), a social worker (n=1), a neuropsychologist (n=1) and nurses (n=4). A total of 10 CEs participated. Five major themes were identified: 1) Previous/Current involvement in AD, 2) Specific Roles for CEs, 3) CEs competencies that are deemed useful in AD provision, 4) Operationalization of CEs involvement 5) Obstacles/Pitfalls associated to CEs' involvement in AD.

Discussion: By highlighting the specific roles identified in our study and linking such roles with the competencies that are deemed necessary for CEs involved in AD, we will discuss questions and issues that pertain to the legitimacy of including CEs in AD. Promising practices and potential pitfalls related to their involvement will also be presented, considering the variability of AD practices around the world."

3)    Blanc S. Advance directives and public support for assisted suicide in a population-based sample of older adults

Abstract:

"Clinical ethicists are often confronted with new societal developments and changing attitudes regarding the end of life. As evidenced by rising rates of advance directives (ADs) and memberships in right-to-die organizations, there is a growing public support for both ADs and assisted suicide (AS) in Switzerland. This study investigates the association between the completion of ADs and attitudes toward AS among older adults in Switzerland, evaluating whether older adults might be inclined to engage in ADs and, at the same time, support AS.

Data from 1,523 participants aged 58 years and older were collected through the Swiss component of the representative Survey on Health, Ageing, and Retirement in Europe (SHARE) for 2019/2020. Participants were asked if they had completed ADs. Behavior toward AS was assessed using three key questions: support for AS, consideration of it, and membership in a right-to-die association. Probit regression models analyzed the associations, considering various social, health, and regional characteristics.

Overall, 42% of the sample had completed ADs. Additionally, 81% supported legal access to AS, 63% considered asking for it, and 9% were members of a right-to-die association. Among members of a right-to-die a, 89% had completed an ADs. Respondents who had completed ADs were more likely to support AS (p<0.001), consider it (p<0.001), and be members of a right-to-die organization (p<0.001).

Conclusions:
The study reveals an association between completing ADs and supporting behavior toward AS among older adults in Switzerland. When engaging in Advance Care Planning (ACP), older adults may seek clarification on assisted suicide practices. Clinicians should prepare to engage in informed discussions, ensuring that patients are well-informed about end-of-life available options. Future developments in end-of-life care planning and healthcare ethic consultations should consider incorporating these discussions and adapted documentation of both ADs and AS together."

4)    Reato F. Repertoire of the Competencies of the Clinical Ethics Consultant in the light of the European and Italian Qualifications Framework

Abstract:

"Background/aims:
For the public recognition of the qualification of the Clinical Ethics Consultant (CEC) it is necessary to build the Repertoire of the Competencies by the European Qualifications Framework (2008, 2017) and the Italian Qualifications Framework (2012, 2016, 2018) criteria. Highlighting the clear connection to the EQF level 8, we identified and described learning outcomes of the identified competencies through knowledge, skills, autonomy and responsibility. 

Methods/Materials:
To reach data saturation, according to the qualitative research approach, an ethnographic study was conducted according to the principles of the "At Home Ethnography", through Participant Observation and Interviews to the Double (Alvesson, 2009, Nicolini, 2009). The interviewees are asked to imagine a hypothetical replacement by a "Double" who will take their place in the execution of the work activities and to provide him with all useful indications to cover the role of the CEC best. 

Results:
Taking into account also the European Skills Frameworks Entrecomp, LifeComp and DigComp, was identified 11 Transversal Competencies (01. Communication and Interpersonal Relationship, 02. Coping With Emotions, 03. Problem Solving, 04. Critical Thinking, 05. Decision Making, 06. Self Awareness, 07. Leadership, 08. Team Work, 09. Time Management, 10. Governance of Digital Transformation Processes and Technological Innovation, 11. Teaching Competencies) and 6 Technical Professional Specialist Competencies (1. Determine the nature of uncertainties or moral conflicts that require clinical ethics consultation, 2. Conduct the clinical ethics consultation process in the health area, 3. Encourage the resolution of moral uncertainties and conflicts by facilitating the construction of an ethically based solution, 4. Document planned and implemented clinical ethics advice in the health field, 5. Monitor clinical ethics consultation service, 6. Improve the quality of clinical ethics consultant service). 

Discussion and Conclusions:
The Double Instructions and the Participant Observation allow: tracing of the tacit routines put into place and interpreted by each Professional, through the exercise of the narration of micro-actions and daily practices, identifying attitudes, knowledge, skills, emotional and intentional colors of their professional actions, identifying spaces of autonomy and responsibility, learning more about the actions and reasons for the practices of fellow Clinical Ethics Consultants."

Brandeland M. et al. Globalization, Medical Travel and Clinical Ethics: Exploring Preventive Ethics Solutions in the Care of International Patients

Abstract:

"Background  

Healthcare tourism has grown significantly in recent years. For many patients, seeking medical care abroad represents a last resort for complex and serious illness. Clinicians caring for international patients encounter a variety of ethical dilemmas. Preventive ethics is a discipline that emphasizes prevention of ethical conflicts through critical reflection on individual and institutional factors.  

Objectives  

We propose three objectives for this workshop. First, participants will gain insight into common reasons for ethics consultations requested for international patients in the United States. Second, participants will explore proposed best ethical practice standards in the care of international patients. Third, participants will create preventive ethics solutions for the care of international patients in their own countries.  

Methods  

The workshop will consist of three parts each focusing on one of the above objectives.  

Part 1: First, we will review background information on healthcare tourism and a recent study from our institution summarizing ethics consultations on international patients over 19-year period (2006-2024). Then, we will divide participants into small groups of 3-4 people to discuss sample case vignettes and share their own experiences working with international patients.  

Part 2: First, we will present our proposed best ethical practice standards in the care of international patients. We suggest five primary areas of best ethical practice standards including (1) Clinical Care (2) Medical Records (3) Language and Culture (4) Spiritual Care (5) Financial. After presenting these, we will divide participants into small groups of 3-4 to discuss these standards.  

Part 3: First, we will provide a brief overview of preventive ethics to the large group. Then, we will divide participants into small groups of 3-4 people and encourage them to propose preventive ethics solutions for the care of international patients in their own countries. We will close the workshop by coming together for a large group discussion. We will provide participants with a list of references for further learning.  

Conclusion  

Ethical dilemmas arise in the care of international patients due to differences in culture, religion, expectations for medical care, clinical practice norms and healthcare financing. This workshop will provide participants with the opportunity to explore common ethical challenges in the care of international patients, review proposed best ethical practice standards and engage in discussion to develop preventive ethics solutions for the care of international patients in their own countries."

Abdool R., Fernandes V. Developing an Ethical Framework to Guide Decisions related to Preferential Treatment in Healthcare Organizations

Abstract:

"Case Scenario: A manager's VP asks them to move a patient, whose family has made a large donation to the hospital, to a private room, this would require displacing a patient who is actively dying. The family is also requesting additional tests that are not medically indicated.

Background: Every day in healthcare organizations, individuals at all levels, from the point of care to the boardroom, encounter situations related to requests/offers of preferential treatment (e.g., VIP jumping the queue in the emergency department, hiring family/friends) in which power and politics are at play. When faced with such situations, there is limited guidance on how an individual ought to respond and people may experience pressure to act in ways that are inconsistent with their own personal and professional values. Ethical issues include those related to fairness and equitable access to care and resources. A need for guidelines has been identified (Rockwell et al., 2022).

Part 1 - Discussion: The workshop will begin with a facilitated discussion of ethical issues related to preferential treatment in healthcare organizations.

Part 2 - Small Group: Participants will be divided into small groups to review three frequently encountered paradigmatic cases where power and politics are at play. Participants will discuss how they would approach such an ethics consultation and identify key ethical principles that should be considered.

Part 3 - Prioritization Exercise: Using coloured stickers, each participant will identify what they believe are the three most important ethical principles that should be considered when addressing decisions about preferential treatment. This prioritized list of principles will be used to inform the development of an ethical framework to guide decision-making related to preferential treatment in healthcare organizations.

References: Rockwell, H., et al. (2022). "VIP Patients in Interventional Radiology: Do Some Patients Deserve 'Better' Care?" Seminars in Interventional Radiology, 39(04):454-458."

Hotz S. et al. Childrens’ rights in healthcare: How can participation in pediatric and child- and adolescent psychiatric practice succeed?

Abstract:

"The right to participation of children in healthcare is defined and anchored by a legal framework on various levels. However, current practice doesn't fully comply with these requirements in Switzerland. Barriers include legal, policy-based, and healthcare aspects. Our workshop aims to present and discuss the participation of children and adolescents in healthcare, looking at very dioerent diagnoses and settings (acute, chronic, light/heavy mental health diseases).
We will discuss from a multi-professional perspective, individual, institutional and regional factors to participation and discuss capacities and constraints that facilitate or hinder the participation of children and adolescents in healthcare.

In the first part of our workshop, we will exchange about the current state of child participation in health care from legal/policy, institutional and individual perspectives. To that end, a multidisciplinary approach using pediatrics, child and adolescent psychiatry,
health ethics and law, public health and sociology will be used. (30 min.)

The second part of the workshop will be organized as a group discussion exploring how the participation of children in our health care system looks like (e.g. for specific acute or chronic, physical, or psychological problems) and how changes towards a more inclusive
child healthcare can be made (30 min.)

To conclude, an integrative discussion will take place (30 min.)"

Memon R. et al. Co-developing a Casebook on Clinical Ethics in Pakistan: Local Stakeholder Engagement and Regional Collaboration

Abstract:

"In low- and middle-income countries (LMICs) such as Pakistan, there is little or no integration of bioethics into clinical training. In Pakistan, healthcare professionals have had few opportunities to learn how to recognize and manage ethical challenges arising in everyday practice. This workshop describes an ongoing process to engage healthcare professionals in different regions of Pakistan in the development of a clinical ethics casebook, modelled on a successful approach used in another Asian nation. By creating a structured, culturally relevant resource for bioethics education, this initiative has the potential to enhance professional development for healthcare workers in Pakistan and beyond, empowering them to make informed, ethically sound decisions, while fostering a culture of mentorship, reflection, and ethical inquiry in clinical practice.

Panellist 1, is a British Pakistani bioethicist who has PhD in bioethics from University College London (UCL) and is an Alumni Interdisciplinary Centre of Bioethics, Yale University. She will describe project aims, including how our team is learning from and adapting an approach developed by and for Singapore’s multi-ethnic society. In this approach, stakeholder meetings to identify ethical challenges arising in practice build interest and engagement and ensure that the work reflects real-world practice and ethical uncertainties. The challenges identified via stakeholder meetings become the basis of casebook materials that can support clinical teaching and learning in Pakistan.

Panellist 2 is a Pakistani who has recently completed her certification in bioethics summer program from the Interdisciplinary Centre of Bioethics, Yale University. She will describe the first stage of our project, including barriers and opportunities encountered and findings from our initial stakeholder discussion.
Interactive discussions with participants will enable sharing of information and resources to support similar initiatives in LMICs."