In 2021, Canada revised its Medical Assistance in Dying (MAID) law, removing the "reasonably foreseeable death" requirement. Opponents of MAID voiced concerns about a "slippery slope" leading to broader access, with some arguing the line has already been crossed. I examine the arguments against expanded eligibility, particularly those presented by Tom Koch (2023). Koch's reasoning, I submit, is flawed, lacking nuance in its understanding of the slippery slope and relying on a problematic argument about healthcare access.

Don A. Merrell

HEC Forum

Medical Assistance in Dying, Slippery Slopes, and Availability of Care: A Reply to Koch

医疗协助死亡、滑坡效应与护理可及性：对Koch的回应

Florida is currently collecting data on the "costs of uncompensated care for aliens who are not lawfully present in the U.S." (Statutes of Florida, 2023). The Florida data collection law, enacted in 2023, is part of aggressive anti-immigrant legislation. Hospitals accepting Medicaid must inquire about patients' immigration status and submit de-identified reports. In August 2024, the Governor of Texas signed an Executive Order comparable to the Florida statute. Although presented as a data-collection measure, the legal requirements have far-reaching consequences. The potential adverse impacts on immigrants' health pose bioethical concerns. Immigration-related inquiries create barriers to healthcare access and advance care planning, exacerbating healthcare disparities and presenting ethical concerns. This article examines the effects on immigrants and the resulting ethical challenges, including respect for persons, beneficence, non-maleficence, and justice. The article proposes recommendations for mitigating these challenges, including community outreach, patient education, policy development, in-service education, and advocacy. While the legal requirements apply specifically to Florida and Texas, the ethical issues have nationwide relevance.

Cathy L. Purvis Lively

Creating Barriers to Healthcare and Advance Care Planning by Requiring Hospitals to Ask Patients About Their Immigration Status

要求医院询问患者移民身份以制造医疗和预立医疗计划障碍

Abstract The concept ethics defines health care ethics as a professional practice. Yet the meaning of “ethics” is often unclear in the theory and practice of clinical ethics. Clarity on this matter is crucial for understanding the nature of clinical ethics and for debates about the professional identity and proper role of ethicists, the sort of training and skills they should possess, and whether they have ethics expertise. This article examines two different ways the ethics of clinical ethics can be understood: Real Ethics, which consists of objective moral norms grounded in moral truth; and Conventional Ethics, which consists of conventional norms grounded in bioethical consensus. Drawing on the bioethics literature and features of professional practice, it shows that Conventional Ethics is the dominant paradigm. Then it presents a critique of Conventional Ethics, arguing that it cannot avoid the challenge of moral pluralism, it fails to address vitally important moral questions, and it is incapable of providing an essential service to the people ethicists aim to help. It ends with suggestions about how the practice of clinical ethics might overcome these problems.

Matthew Shea

The Ethics of Clinical Ethics

临床伦理的伦理

Abstract Caring for children with cancer involves complex ethical challenges. Ethics Case Reflection (ECR) rounds can be offered to support teams to reflect on challenges and what should be done in patient care. A training course, for facilitators of ECR rounds, has been offered to healthcare professionals (HCPs) in childhood cancer care by a Nordic working group on ethics. During/after the course, the trainees implemented and facilitated ECR rounds in their clinical setting. The aim was to explore the trainees’ experiences of implementing ECR rounds in childhood cancer care. HCPs, who participated as trainees in the course, participated in 3 focus group interviews ( n = 22) and 27 individual interviews ( n = 17). Interview data were analysed concurrently with data collection following classic grounded theory. Positioning ethics is the core category in this study, used to resolve the main concern of doing ethics in a context where direct patient care is prioritized. Being able to take time for ethics reflections, not perceived as the key priority, was considered a luxury in the clinical setting. Strategies for positioning ethics include allying , promoting ethics reflection , scheduling ethics reflection , and identifying ethical dilemmas. These strategies can be more or less successful and vary in intensity. The prioritisation of direct patient care is not surprising, but polarisation between care and ethics needs to be questioned and ethics reflection need to be integrated in standard care. Ethical competence seems to be central in doing ethics and more knowledge on the promotion of ethical competence in practice and education is needed.

Pernilla Pergert

Bert Molewijk

Cecilia Bartholdson

Positioning Ethics When Direct Patient Care is Prioritized: Experiences from Implementing Ethics Case Reflection Rounds in Childhood Cancer Care

当优先考虑直接患者护理时的伦理定位：在儿童癌症护理中实施伦理案例反思轮班的体验

Healthcare ethics consultants in the Veterans Health Administration (VHA) document consults in an enterprise-wide web-based database entitled IEWeb, serving as a system of record for healthcare ethics documentation at 1300 VA facilities. The need arose to evolve the database from an ethics process training resource into a more streamlined documentation repository that captures essential consult elements. A VHA National Center for Ethics in Health Care (NCEHC) Improvement Team convened for three tasks: (1) Specify and prioritize IEWeb changes (occurred via six focus groups composed of "new user" and "super user" cohorts with analysis of existing documentation patterns); (2) Pilot the changes regionally (via regional communication, training, and reviews of pre-post use patterns); and (3) Measure the impact of national change implementation on user perspectives (via pre-and post-change implementation polls). Focus groups identified six implementable priority areas for ethics consult documentation improvement, including the development of a usable consult summary note for ready conversion from IEWeb fields into the electronic health record. Post-IEWeb updates showed an increased number of consults documented, a reduction in "time to consult documentation closure" by a mean of 4.5 days, and a clinically-meaningful improvement in the quality of documentation (78% of ethics questions scored "above-bar" on the validation tool pre- vs. 89% scored "above-bar" post-IEWeb changes, n = 140). According to national survey findings, the number of consultants documenting "all" consults in IEWeb increased, satisfaction increased, and perception of documentation difficulty decreased. IEWeb simplification enabled ethics consultants to re-focus their documentation completion efforts by decreasing perception of documentation burden while improving documentation frequency and quality in a clinically-meaningful way.

Meaghann S. Weaver

Anita J. Tarzian

Hannah N. Hester

Karinne R. Davidson

Rodney P. Dismukes

Mary Beth Foglia

An Ethics Consult Documentation Simplification Project: Summation of Participatory Processes, User Perceptions, and Subsequent Use Patterns

伦理咨询记录简化项目：参与过程总结、用户感知及后续使用模式

Sharoon Shahzad

Rehana Sajid

Joel Fakhar

Ayesha Saleem Khan

Nizar Ali

Ahtisham Younas

Survey of Moral Distress and Self-Awareness among Health Care Professionals

医护人员道德困扰与自我意识调查

Abstract The possibility of editing the genomes of human embryos has generated significant discussion and interest as a matter of science and ethics. While it holds significant promise to prevent or treat disease, research on and potential clinical applications of human embryo editing also raise ethical, regulatory, and safety concerns. This systematic review included 223 publications to identify the ethical arguments, reasons, and concerns that have been offered for and against the editing of human embryos using CRISPR-Cas9 technology. We identified six major themes: risk/harm; potential benefit; oversight; informed consent; justice, equity, and other social considerations; and eugenics. We explore these themes and provide an overview and analysis of the critical points in the current literature.

Lindsay Wiley

Mattison Cheek

Emily LaFar

Xiaolu Ma

Justin Sekowski

Nikki Tanguturi

Ana Iltis

The Ethics of Human Embryo Editing via CRISPR-Cas9 Technology: A Systematic Review of Ethical Arguments, Reasons, and Concerns

CRISPR-Cas9技术下人类胚胎编辑的伦理问题：伦理论据、理由和担忧的系统综述

George E. Freigeh

Hannah Fagen

Janice Firn

Review of Outpatient Pediatric Ethics Consults at an Academic Medical Center

学术医学中心门诊儿科伦理咨询回顾

Abstract Moral distress reflects often recurrent problems within a healthcare environment that impact the quality and safety of patient care. Examples include inadequate staffing, lack of necessary resources, and poor interprofessional teamwork. Recognizing and acting on these issues demonstrates a collaborative and organizational commitment to improve. Moral distress consultation is a health system-wide intervention gaining momentum in the United States. Moral distress consultants assist healthcare providers in identifying and strategizing possible solutions to the patient, team, and systemic barriers behind moral distress. Moral distress consultants offer unique perspectives on the goals, successes, areas for improvement, and sustainability of moral distress consultation. Their ideas can help shape this intervention’s continued growth and improvement. This qualitative descriptive study features 10 semi-structured interviews with moral distress consultants at two institutions with longstanding, active moral distress consultation services. Themes from consultant transcripts included consultant training, understanding the purpose of moral distress consultation, interfacing with leadership teams, defining success, and improving visibility and sustainability of the service. These findings describe the beginnings of a framework that organizations can use to either start or strengthen moral distress consultation services, as well as the first steps in developing an evaluation tool to monitor their utility and quality.

Vanessa Amos

Phyllis Whitehead

Beth Epstein

Moral Distress Consultation Services: Insights from Consultants

道德困境咨询服务：咨询师见解

Abstract The Canadian approach to assisted dying, Medical Assistance in Dying (MAiD), as of early 2024, is assessed for its ability to protect patients from criminal healthcare serial killing (HSK) to evaluate the strength of its safeguards. MAiD occurs through euthanasia or self-administered assisted suicide (EAS) and is legal or considered in many countries and jurisdictions. Clinicians involved in HSK typically target patients with the same clinical features as MAiD-eligible patients. They may draw on similar rationales, e.g., to end perceived patient suffering and provide pleasure for the clinician. HSK can remain undetected or unconfirmed for considerable periods owing to a lack of staff background checks, poor surveillance and oversight, and a failure by authorities to act on concerns from colleagues, patients, or witnesses. The Canadian MAiD system, effectively euthanasia-based, has similar features with added opportunities for killing afforded by clinicians’ exemption from criminal culpability for homicide and assisted suicide offences amid broad patient eligibility criteria. An assessment of the Canadian model offers insights for enhancing safeguards and detecting abuses in there and other jurisdictions with or considering legal EAS. Short of an unlikely recriminalization of EAS, better clinical safeguarding measures, standards, vetting and training of those involved in MAiD, and a radical restructuring of its oversight and delivery can help mitigate the possibility of abuses in a system mandated to accommodate homicidal clinicians.

Christopher Lyon

Canada’s Medical Assistance in Dying System can Enable Healthcare Serial Killing

加拿大医疗协助死亡系统可能助长医疗连环杀人

HEC 论坛是一份经过同行评审的国际刊物，收录了执业医师、护士、社会工作者、风险管理人员、律师、伦理学家和其他 HEC 委员会成员感兴趣的原创贡献。欢迎来自任何相关来源的投稿，但应编写文本以供 HEC 成员和非专业读者欣赏。 HEC 论坛发表论文、研究论文，并包含以下部分： 关于实质性生物伦理/健康法问题的论文 程序或运营委员会问题的分析 文件交流 专题文章 国际视角 MT./ST.匿名：案例和机构政策 点/对位论证 案例审查、分析和决议 主席的“难点”部分 关键注释 卫生法警报 网络新闻 致编辑的信

HEC Forum is a peer-reviewed international journal that publishes original contributions of interest to practitioners such as physicians, nurses, social workers, risk managers, lawyers, ethicists, and other members of HEC committees. We welcome submissions from any relevant source, provided that the text is written in a manner accessible to HEC members and non-specialist readers. HEC Forum publishes papers, research articles, and includes the following sections: papers on substantive bioethics/health law issues, analyses of procedural or operational committee matters, document exchanges, thematic articles, international perspectives, anonymous discussions of cases and institutional policies, point/counterpoint arguments, case reviews, analyses and resolutions, the Chair's 

HEC Forum 是一本经过同行评审的国际期刊，专注于执业医师、护士、社会工作者、风险管理人员、律师、伦理学家及其他 HEC 委员会成员感兴趣的原创研究。我们欢迎来自任何相关领域的投稿，文章应以 HEC 成员和非专业读者能够理解的方式撰写。HEC Forum 发表各种类型的论文和研究，包括：关于重要生物伦理和健康法律问题的论文、程序或运营委员会问题的分析、文件交流、专题文章、国际视角、案例和机构政策的匿名讨论、对立论证、案例审查、分析和决议、主席的“难点”部分、关键注释、卫生法律警报、网络新闻及致编辑的信件。

Journals	HEC Forum
ISSN	0956-2737, 1572-8498
h-index	28
Journal Impact	1.39
Quartiles(Global)	ETHICS(Q3)
Quartiles(China)	哲学(4区)哲学伦理学(4区)