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A central task for clinical ethics consultants and committees (CEC) is providing analysis of, and advice on, prospective or retrospective clinical cases. However, several kinds of biases may threaten the integrity, relevance or quality of the CEC's deliberation. Bias should be identified and, if possible, reduced or counteracted. This paper provides a systematic classification of kinds of bias that may be present in a CEC's case deliberation. Six kinds of bias are discussed, with examples, as to their significance and risk factors. Possible remedies are suggested. The potential for bias is greater when the case deliberation is performed by an individual ethics consultant than when an entire clinical ethics committee is involved., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: The use of coercion in nursing homes is common as well as challenging, but was not regulated by law until 2009. Two key conditions are that the patient must be without mental competence and that the coercive measures are in the patient's best interest. Inspection reports have revealed insufficient application of the law, and this is of concern to patients as well as healthcare staff. With the aid of a qualitative study, we wished to identify the challenges encountered and the experiences gained by doctors and other nursing-home personnel from the new provisions regarding the use of coercion., Material and Method: A total of 65 nursing-home employees were interviewed in focus groups. The interview guide included questions on, for example, when coercion is being used and how the new chapter of the Act is being applied. In the qualitative analysis, the content of the statements was categorised and condensed., Results: All focus-group interviews described coercion as frequently occurring, but also that few formal decisions are being made. Involvement of the doctors and inter-disciplinary cooperation were assessed as crucial for ensuring appropriate application of the new regulations, in addition to time, staffing and competence. The participants were uncertain as to how the new regulations should be applied, and regarded the requirements for a formal decision as unrealistic. Some of the coercive measures described are illegal. The absence of legal authority in cases where coercion is regarded as the lesser evil was described as challenging., Interpretation: The new legal basis for the use of coercion is likely to raise awareness of the issue, but has a large potential for erroneous interpretation and causing reluctance to make formal decisions. In some areas, the law is out of step with the realities in nursing homes and the employees' values.

Ethics support in primary health care has been sparser than in hospitals, the need for ethics support is probably no less. We have, however, limited knowledge about how to develop ethics support that responds to primary health-care workers' needs. In this article, we present a survey with a mixture of closed- and open-ended questions concerning: How frequent and how distressed various types of ethical challenges make the primary health-care workers feel, how important they think it is to deal with these challenges better and what kind of ethics support they want. Five primary health-care institutions participated. Ethical challenges seem to be prominent and common. Most frequently, the participants experienced ethical challenges related to scarce resources and lack of knowledge and skills. Furthermore, ethical challenges related to communication and decision making were common. The participants welcomed ethics support responding to their challenges and being integrated in their daily practices.

Background: All health enterprises in Norway today have at least one clinical ethics committee (CEC). One of the aims is to give advice and to counsel the hospital staff on ethical issues. As part of the quality assurance of this work, we wanted to find out if clinicians have benefited from these committees in individual cases., Material and Methodology: The local committees were requested to distribute a questionnaire to all clinicians who had submitted a case to the committee during the previous 18 months. The survey was anonymous. Out of the 86 questionnaires that were distributed, 43 (50%) were returned to the Centre for Medical Ethics., Results: The majority of clinicians had a number of reasons for contacting the committee. The most usual reason was the desire to have a broad consultation on a case (70%), which was regarded as useful. The most common issue discussed was limiting the treatment of a seriously ill patient (56%), the will/wishes of the next-of-kin (40%) and patient autonomy (37%). The committee gave advice in 50% of the cases. Thirty-eight percent of the consultations resulted in practical consequences, including the discontinuation of treatment in six cases., Interpretation: Because of the low response percentage, the results must be interpreted with caution. The work of the committees is generally evaluated as useful, and the consultations can have practical consequences. However, it is challenging to make this work better known among clinicians and to conduct quality assurance.

Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. One important task for these committees is clinical ethics consultations. This qualitative study explores significant barriers confronting the ethics committees in providing such consultation services. The interviews with the committees indicate that there is a substantial need for clinical ethics support services and, in general, the committee members expressed a great deal of enthusiasm for the committee work. They also reported, however, that tendencies to evade moral disagreement, conflict, and 'outsiders' are common in the hospitals. Sometimes even the committees comply with some of these tendencies. The committees agree that there is a need to improve their routines and procedures, clarify the committees' profile and field of responsibility, to make the committees well-known, to secure adequate operating conditions, and to develop organizational integration and support. Various strategies to meet these challenges on a local, regional or national level are also explored in this paper.

Empathy is generally regarded as important and positive. However, descriptions of empathy are often inadequate and deceptive. Furthermore, there is a widespread lack of critical attention to such deficiencies. This critical review of the medical discourse of empathy shows that tendencies to evade and misrepresent the understanding subject are common. The understanding subject's contributions to the empathic process are often neglected or described as something that can and should be avoided or controlled. Furthermore, the intrinsic and closely interwoven relationship between medical understanding and empathy is generally not explored. Instead of challenging objectivistic and instrumental ideals, the medical discourse of empathy tends to accommodate to inadequate ideals of objectivity and instrumentalism. Thus, important aspects of physician's rationality, understanding, and morality are neglected and important opportunities for reflection, dialogue, and critique are forfeited. Both the critical and constructive parts of this paper are heavily inspired by philosophical hermeneutic insights, e.g. that physician's empathy is always historically situated and part of a moral commitment. At the end of this paper, an alternative description of empathy - i.e. appropriate understanding of another human being - is outlined to facilitate the inclusion of hermeneutic insights and accentuate the inherent relationship between empathy and morality.

Clinical ethics committees have existed in Norway since 1996. By now all hospital trusts have one. An evaluation of these committees' work was started in 2004. This paper presents results from an interview study of eight clinicians who evaluated six committees' deliberations on 10 clinical cases. The study indicates that the clinicians found the clinical ethics consultations useful and worth while doing. However, a systematic approach to case consultations is vital. Procedures and mandate of the committees should be known to clinicians in advance to ensure that they know what to expect. Equally important is bringing all relevant facts, medical as well as psychosocial, into the discussion. A written report from the deliberation is also important for the committees to be taken seriously by the clinicians. This study indicates that the clinicians want to be included in the deliberation, and not only in the preparation or follow-up. Obstacles for referring a case to the committee are the medical culture's conflict aversion and its anxiety of being judged by outsiders. The committees were described as a court by some of the clinicians. This is a challenge for the committees in their attempt to balance support and critique in their consultation services.

Background: In the wake of medical progress an important ethical discussion has arisen about when to withhold and when to withdraw life-sustaining treatment., Material and Methods: Literature on withholding and withdrawing life-sustaining treatment was assembled and analyzed, and common norms were compared with Norwegian legal regulations., Results: Withholding or withdrawing life-sustaining treatment is not unusual when the treatment is regarded as futile. As opposed to euthanasia, limiting treatment is under certain circumstances legal. Core values--such as respect for the value of human life, the duty to save lives, equality, respect for patient autonomy, dignified death and professional integrity--may be given diverging emphases and interpretations. In many cases, the patient's capacity to consent is reduced, and it can be challenging to determine what is in the patient's best interest and when the treatment is futile. Good decision making processes and communication at the end of life is demanding, but may reduce and prevent many difficulties., Interpretation: Norwegian healthcare legislation provides relatively little and to some extent unclear guidance on withholding and withdrawing life-sustaining treatment. National guidelines have not been developed. More attention could be paid to systematic approaches and dialogue with patients, relatives and all healthcare professionals about these issues.

Background: Patient autonomy and informed consent is increasingly emphasized in clinical practice, professional ethics and health care legislation., Material and Methods: Literature on patient autonomy and informed consent was assembled, analyzed, and common norms compared with Norwegian legal regulations., Results: The procedure of obtaining informed consent may increase patient participation and prevent unwanted treatment and care. Such a practice is in line with the principle of patient autonomy. An act is normally considered autonomous when the following three criteria are fulfilled: Sufficient understanding, competence to consent and that the consent is given voluntarily. In clinical practice it is sometimes impossible to meet all these criteria. Furthermore, it is often demanding to tailor the information and the decision-making process to the individual patient's background and preferences. When the patient lacks competence to consent, the Norwegian health care legislation assigns an especially large responsibility to the health care personnel. Recently, health care personnel's authority to use force in such situations have been expanded., Interpretation: The increased emphasis on patient autonomy and informed consent places high demands on health care personnel's moral considerations, ability to communicate, and understanding of roles and responsibilities. Assessment of competence to consent will probably become an important challenge to Norwegian health care personnel in the near future.

Background: All somatic hospitals in Norway should have guidelines on do-not-resuscitate orders, according to a directive issued by the Norwegian Board of Health in 2002., Material and Methods: All 31 Norwegian hospital trusts were asked to send in such guidelines. 20 submitted guidelines were assessed, analysed and compared according to 19 questions., Results: The guidelines have various contents. Key aspects such as indications, definitions, participation in decision-making by patients and relatives, strategies for conflict resolution, competence to consent, and advanced directives are in many guidelines either not commented, or described in an ambiguous manner. There are minor differences between the guidelines developed before and after the legal directive was issued in 2002, but legal provisions have become more heavily emphasized., Interpretation: National guidelines should be developed to clarify key questions and contribute to more consistent practice concerning do-not-resuscitate orders.

Background: The increasing numbers of elderly in need of basic medical and nursing care challenges prioritization and quality assurance within the Norwegian health care system., Material and Methods: A questionnaire on health care to patients aged 75 years or older was sent to 2103 doctors and nurses employed in hospitals and primary community care., Results: 67% returned the questionnaire. 92% of the nurses and 79% of the doctors stated that lack of resources related to all levels of medical and nursing care for ill elderly patients cause personal strain. Personnel shortage, lack of time and lack of money were the three most frequently mentioned causes of unsatisfactory coverage of basic needs. 29% said they experience reduced quality of medical treatment weekly or daily, while 25% stated that they meet reduced quality of diagnostics just as frequently. Even more often, the respondents experienced unsatisfactory coverage of hygiene and nutrition, but social needs and exercise were the most neglected areas. Nurses and doctors employed in nursing care institutions most frequently expressed that lack of resources have serious consequences for patients aged 75 years or older., Interpretation: Basic medical care for elderly ill patients is not sufficient with respect to diagnostics and medical treatment. In particular, nursing care and meeting the individuals' psychosocial needs are not prioritised highly enough. Both doctors and nurses frequently describe shortage of time as a problem. Poorly organized medical care, including lack of coordination, seems to be a continuous problem in health care for the elderly.

Background: Clinical ethics committees have recently been established in nearly all Norwegian hospital trusts. To assess the quality and function of the committees, a national research project was initiated in 2004., Methods: A questionnaire on composition, resources, qualifications, tasks and routines was mailed to all committees. The response rate was 75% (21 out of 28)., Results: The committees are interdisciplinary and meet on average nine times per year. Only three (14%) chairs have been given dedicated time. Ten (48%) committees have separate budgets. Major tasks include getting the committee established, educating employees, deliberations (cases and more general questions), and guidelines. Main issues are withholding and withdrawing treatment, communication, patient autonomy, involuntary treatment, and priority setting. 16 committees have specific deliberation procedures. Minutes were taken in approximately half of the case deliberations. Systematic evaluation is scarce., Interpretation: During a short period the committees have increased their competence and served over 2000 hospital employees, mainly through seminars. The committees probably already contribute to quality assurance in ethical decision making. The committees want more case consultations. Important challenges are obtaining sufficient resources, making the committees better known, and establishing routines.