BACKGROUND & AIMS: OBJECTIVE:The purposes of this article are 1) to review federal and state laws relevant to confidentiality in group therapy with impaired physicians and 2) to provide empirical data concerning the actual confidentiality practices and experiences of group therapists treating chemically impaired physicians.

METHOD:In the clinical research phase, 25 state medical societies identified 45 rehabilitation centers as those to which the societies preferentially referred chemically impaired physicians. Fifty-one group leaders from 33 of these rehabilitation centers completed the survey questionnaire employed in this project.

RESULTS:Because of the risk of potentially irreversible social and professional injury, physician patients were exceedingly concerned about breaches of confidentiality. Co-members' infractions most often involved the violator sharing with close friends and family members the name and abuse history of a fellow physician. In contrast, transgressors rarely leaked information about a co-member's drug-related illegal behaviour.

CONCLUSIONS:Chemically impaired physicians would feel safer in sharing secrets in group therapy if more jurisdictions adopted legislation making co-members liable for violating confidentiality. Currently the pertinent body of law is confusing and inconsistent and provides little protection to impaired physicians who enter group therapy. The authors propose ideas for model legislation.

背景与目标： 目标 : 本文的目的是1) 审查与受损医生的团体治疗中保密相关的联邦和州法律，以及2) 提供关于治疗化学受损医生的团体治疗师的实际保密实践和经验的经验数据。
方法 : 在临床研究阶段，有25个州医学会确定了45个康复中心，这些康复中心优先推荐化学受损的医生。来自这些康复中心中的33个的51名小组负责人完成了该项目中使用的调查问卷。
结果 : 由于存在潜在的不可逆转的社会和职业伤害的风险，医生患者非常担心保密行为。共同成员的违规行为通常涉及违反者与亲密的朋友和家人分享同伴的名字和虐待史。相比之下，违法者很少泄露有关共同成员与毒品有关的非法行为的信息。
结论 : 如果更多的司法管辖区通过立法，使共同成员对违反机密性负有责任，化学受损的医生在共享集体治疗中的秘密时会感到更安全。目前，相关的法律体系令人困惑和不一致，并且对进入团体治疗的受损医生几乎没有提供保护。作者提出了示范立法的想法。

BACKGROUND & AIMS: :Previous studies have shown that intuitive moral cognition occurs at an early stage. However, inconsistent findings indicate that moral information is recognized at a relatively late stage. This study uses the recognition potential (RP) as a neural index and simultaneously measures individuals' moral preferences using the Moral Foundation Questionnaire. We aim to investigate how individual differences in moral preferences modulate the processing of morality in the pre-semantic stage and provide some insights to explain the variation in rapid information processing linked to morality. The participants performed an implicit task in which recognizable words depicting geographical names or behaviors related to moral, disgusting or neutral content alternated with background stimuli at high rates of presentation. The results showed that the early recognition of moral information manifested in the RP depended on an individual's moral concerns. Participants with a higher level of endorsement of the harm/care foundation exhibited a greater net moral effect, namely, greater mean amplitudes of the moral-neutral RP difference waves. Meanwhile, only the group that was more sensitive to the harm/care foundation showed a distinctively larger RP for the moral words than for the neutral words. Overall, these findings suggest that the early processing of moral cognition may hinge on individual differences in moral concerns about other people's suffering.

背景与目标： : 以前的研究表明，直觉道德认知是在早期发生的。但是，不一致的发现表明道德信息在相对较晚的阶段得到了认可。本研究使用识别潜能 (RP) 作为神经指标，并同时使用道德基础问卷来衡量个人的道德偏好。我们旨在研究道德偏好的个体差异如何在语义前阶段调节道德的处理，并提供一些见解来解释与道德相关的快速信息处理的变化。参与者执行了一项隐含的任务，其中描述地名或与道德，令人作呕或中立内容相关的行为的可识别单词与背景刺激交替出现，呈现率高。结果表明，RP中体现的道德信息的早期识别取决于个人的道德关注。对伤害/护理基金会认可程度较高的参与者表现出更大的净道德效果，即道德中立的RP差异波的平均幅度更大。同时，只有对伤害/护理基金会更敏感的小组对道德词的RP比中性词的RP明显更大。总体而言，这些发现表明，道德认知的早期处理可能取决于对他人痛苦的道德关注的个体差异。

BACKGROUND & AIMS: BACKGROUND:Moral distress was first described by Jameton in 1984, and has been defined as distress experienced by an individual when they are unable to carry out what they believe to be the right course of action because of real or perceived constraints on that action. This complex phenomenon has been studied extensively among healthcare providers, and intensive care professionals in particular report high levels of moral distress. This distress has been associated with provider burnout and associated consequences such as job attrition, with potential impacts on patient and family care. There is a paucity of literature exploring how middle and late career healthcare providers experience and cope with moral distress. OBJECTIVES:We explore the experience of moral distress and the strategies and resources invoked to mitigate that distress in mid- and late-career healthcare providers practicing in paediatric intensive care, in order to identify ways in which the work environment can build a culture of moral resilience. RESEARCH DESIGN:An exploratory, qualitative quality improvement project utilizing focus group and semi-structured interviews with pediatric intensive care front-line providers. PARTICIPANTS:Mid-and-later career (10 + years in practice) pediatric intensive care front line providers in a tertiary pediatric hospital. RESEARCH CONTEXT:This work focuses on paediatric intensive care providers in a single critical care unit, in order to explore the site-specific perspectives of health care providers in that context with respect to moral distress coping strategies. ETHICAL CONSIDERATIONS:The study was approved by the Quality Management Office at the institution; consent was obtained from participants, and no identifying data was included in this project. FINDINGS:Participants endorsed perspective-building and described strategies for positive adaptation including; active, reflective and structured supports. Participants articulated interest in enhanced and accessible formal supports. DISCUSSION:Findings in this study resonate with the current literature in healthcare provider moral distress, and exposed ways in which the work environment could support a culture of moral resilience. Avenues are described for the management and mitigation of moral distress in this setting. CONCLUSION:This exploratory work lays the groundwork for interventions that facilitate personal growth and meaning in the midst of moral crises in critical care practice.

背景与目标：

BACKGROUND & AIMS: :A new argument has been made against moral enhancement by authors who are otherwise in favour of human enhancement. Additionally, they share the same evolutionary toolkit for analysing human traits as well as the belief that our current morality is unfit to deal with modern problems, such as climate change and nuclear proliferation. The argument is put forward by Buchanan and Powell and states that other paths to moral progress are enough to deal with these problems. Given the likely costs and risks involved with developing moral enhancement, this argument implies moral enhancement is an unpromising enterprise. After mentioning proposed solutions to such modern problems, I will argue that moral enhancement would help implement any of them. I will then detail Buchanan and Powell's new argument disfavouring moral enhancement and argue that it makes too bold assumptions about the efficacy of traditional moral progress. For instance, it overlooks how that progress was to achieve even in relatively successful cases such as the abolition of slavery. Traditional moral progress is likely to require assistance from non-traditional means in order to face new challenges.

背景与目标： : 有人提出了反对道德提升的新论点，否则他们赞成人类的提升。此外，他们共享相同的进化工具包，用于分析人类特征，并认为我们目前的道德不适合处理现代问题，例如气候变化和核扩散。布坎南和鲍威尔提出了这一论点，并指出道德进步的其他途径足以解决这些问题。考虑到发展道德增强可能带来的成本和风险，该论点暗示道德增强是一个毫无希望的企业。在提到针对此类现代问题的拟议解决方案之后，我将认为道德提升将有助于实施其中的任何一个。然后，我将详细介绍布坎南和鲍威尔的新论点，该论点不利于道德提升，并认为它对传统道德进步的功效做出了过于大胆的假设。例如，即使在废除奴隶制等相对成功的情况下，它也忽略了如何取得这一进展。传统的道德进步很可能需要非传统手段的帮助，以便面对新的挑战。

BACKGROUND & AIMS: :Nature-based tourism (NBT) is vulnerable to a rapid increase in visitors because natural resources are often open access. Market failure caused by over-exploitation of natural resources is an example of social dilemmas in common-pool resource systems. Game theory, which describes people's decision making under conflicts, has been applied to the analysis of social dilemmas in NBT. However, previous studies use non-cooperative games assuming individualistic players and discuss the emergence of social dilemmas only in a limited situation. Here, we demonstrate, by developing a two-player non-cooperative game of wildlife viewing, that the traditional game-theoretic approach fails to find social dilemmas. By analysing the competition between tour operators (players) with different social value orientations (SVOs), we found that concentration of tours becomes a Pareto-inefficient Nash equilibrium (PINE) when both players are competitive. Whether the wildlife-viewing market is a Prisoner's dilemma depends on players' SVOs. Furthermore, we found that fair punishment on competitive players promotes rather than suppresses the emergence of PINE. Our results suggest that the diversity of SVOs is an essential factor in understanding social dilemmas in NBT.

背景与目标： : 自然旅游 (NBT) 容易受到游客迅速增加的影响，因为自然资源通常是开放的。过度开发自然资源引起的市场失灵是公共资源系统中社会困境的一个例子。描述人们在冲突下的决策的博弈论已被应用于NBT的社会困境分析。但是，以前的研究使用假设个人主义玩家的非合作游戏，并仅在有限的情况下讨论社会困境的出现。在这里，我们通过开发两人的野生动物观赏非合作游戏来证明，传统的博弈论方法无法找到社会困境。通过分析具有不同社会价值取向 (SVOs) 的旅游经营者 (玩家) 之间的竞争，我们发现，当两个玩家都具有竞争力时，旅游集中度就变成了帕累托效率低下的纳什均衡 (PINE)。野生动物观赏市场是否是囚徒困境，取决于玩家的SVOs。此外，我们发现对竞争对手的公平惩罚会促进而不是抑制松树的出现。我们的结果表明，svo的多样性是理解NBT社会困境的重要因素。

BACKGROUND & AIMS: :As concern for the oral health of vulnerable populations grows, dentistry continues to seek effective ways to respond. In August 2005, Dr. Donald Patthoff and Dr. Frank Catalanotto convened a national workshop at the American Dental Association headquarters on the ethics of access to oral health care. A series of papers were produced for the workshop and subsequently revised for publication. This one responds to the paper by Dr. David Chambers on moral communities and the discursive imperative for building community and consensus around issues affecting equitable access to oral health care. I explore three interrelated issues that ought to be considered when endeavoring to build moral communities: 1) the problem of power relations-a fundamental constituent within discourse that can impede constructive efforts; 2) the discursive disconnect between theoretical ethics and social constructs affecting dentistry; and 3) the bioethical principle of nonmaleficence as a priority in the desire for building moral communities. In essence, this article responds also to the call from ethicists who see a significant need for substantive interdisciplinary contributions to inform how people at different social levels react in ethically problematic situations in its broad social context.

背景与目标： : 随着对弱势人群口腔健康的关注日益增加，牙科继续寻求有效的应对方法。在2005年8月，Donald Patthoff博士和Frank Catalanotto博士在美国牙科协会总部召开了一次关于获得口腔保健道德的全国研讨会。为讲习班编写了一系列论文，随后修订以供出版。这篇文章回应了大卫·钱伯斯博士关于道德社区的论文，以及围绕影响公平获得口腔保健的问题建立社区和共识的话语必要性。我探讨了在努力建立道德社区时应该考虑的三个相互关联的问题: 1) 权力关系问题-话语中的一个基本组成部分，可以阻碍建设性的努力; 2) 影响牙科的理论伦理和社会建构之间的话语脱节; 3) 在建立道德社区的愿望中，将非恶意的生物伦理原则作为优先事项。从本质上讲，本文还回应了伦理学家的呼吁，他们认为非常需要跨学科的实质性贡献，以告知处于不同社会水平的人们在广泛的社会背景下在道德上有问题的情况下如何做出反应。

BACKGROUND & AIMS: :An integrated and collaborative team provides the best clinical care of patients and families during end-of-life moments. Behavioral Health Clinicians (BHCs) bring a skill set for facilitating team interactions, attending to group process, as well as making space for the patient or family voice in the care, often with more time available for these roles. Through a case scenario, this article explores the relevant existing codes of ethics and professional conduct for professionals practicing in integrated care settings as they pertain to end-of-life transitions and care. Most notably, potential ethical issues pertaining to patient autonomy, scope of practice, confidentiality, multiple relationships, and record keeping all come to play during end-of-life care when practicing in an integrated primary care setting. Gaps in the existing codes are discussed and recommendations for providing ethically informed patient- and family-centered end-of-life care are suggested.

背景与目标： : 一个集成和协作的团队在临终时刻为患者和家人提供最佳的临床护理。行为健康临床医生 (BHCs) 带来了一套技能来促进团队互动，参与小组过程，以及为患者或家人在护理中的声音腾出空间，通常有更多的时间来担任这些角色。通过案例，本文探讨了在综合护理环境中执业的专业人员的相关现有道德和专业行为守则，因为它们与临终过渡和护理有关。最值得注意的是，与患者自主权，执业范围，保密性，多重关系和记录保存有关的潜在道德问题在综合初级保健环境中执业时都会发挥作用。讨论了现有法规中的空白，并提出了提供以道德为基础的以患者和家庭为中心的临终关怀的建议。

BACKGROUND & AIMS: :Tomasello provides compelling evidence that children understand that people are morally obligated toward members of their social group. We call for expanding the scope of inquiry to encompass the full developmental trajectory of humans' understanding of the relation between moral obligation, sociality, and stancetaking in interaction. We suggest that humans display a lifelong preoccupation with the sociality of moral obligation.

背景与目标： : Tomasello提供了令人信服的证据，表明儿童了解人们在道德上对其社会群体的成员负有义务。我们呼吁扩大调查范围，以涵盖人类对道德义务，社会性和相互作用之间关系的理解的完整发展轨迹。我们建议人类终生关注道德义务的社会性。

BACKGROUND & AIMS: :Tomasello argues that humans' sense of moral obligation emerges early in development, relies on a shared "we," and serves as the foundation of cooperation. This perspective complements our theoretical view of the human self as information agent. The shared "we" promotes not only proximal cooperative goals but also distal ones via the construction of shared understanding - it promotes culture.

背景与目标： : Tomasello认为，人类的道德责任感在发展的早期就出现了，依赖于共同的 “我们”，并成为合作的基础。这种观点补充了我们关于人类自我作为信息代理的理论观点。共享的 “我们” 不仅通过构建共享的理解来促进近端合作目标，而且促进远端合作目标-它促进文化。

BACKGROUND & AIMS: :This article discusses the most common diagnostic dilemmas when trying to distinguish between tumor and sports injury or other trauma. Bone tumors frequently occur in the same young active patients who experience sports injuries. If the pain persists longer than expected, imaging studies should be obtained to prevent a delay in diagnosis or an inappropriate arthroscopy. A history of spontaneous fracture or a fracture after minor trauma should raise suspicion for underlying lesion as the cause. Occasionally necrosis and/or hemorrhage within a soft tissue sarcoma is so extensive that only a small cuff of viable tumor tissue is present.

背景与目标： : 本文讨论了试图区分肿瘤和运动损伤或其他创伤时最常见的诊断难题。骨肿瘤经常发生在经历运动损伤的年轻活跃患者中。如果疼痛持续时间超过预期，应进行影像学检查以防止诊断延迟或关节镜检查不当。自发性骨折或轻微创伤后的骨折史应引起怀疑潜在病变是原因。有时，软组织肉瘤内的坏死和/或出血非常广泛，以至于只有一小部分存活的肿瘤组织存在。

BACKGROUND & AIMS: INTRODUCTION:Migraine is characterised as episodes of headache plus a variety of accompanying symptoms. Its pharmacological control remains unsatisfactory for some patients. The use of placebo in drug clinical trials on migraine commonly leads to numerous ethical uncertainties. METHODS:The purpose of this paper is to illustrate how the deliberation method helps in analysing the issues and finding solutions to selected ethical problems. Ethical decisions that try to solve conflicts arising from placebo use in clinical trials may be adopted using the moral deliberation method. Thus, the conflict is systematically assessed by identifying the following: Relevant facts; Values in conflict; Duties, or in other words, possible courses of action. Moral duty is following the optimal course of action. To identify this, it is recommended to state extreme courses of action, then intermediate courses of action, and then to proceed to the optimal course(s) of action. RESULTS AND CONCLUSIONS:In this paper, the application of this method is shown in several conflicting situations arising in two placebo-controlled clinical trials with drugs under development for the prophylaxis and acute treatment of migraine.

背景与目标：

BACKGROUND & AIMS: :This paper discusses a case vignette that captures an ethically challenging situation in qualitative research. The study was about families who had experienced a life-saving bone marrow transplantation between siblings, who were children at the time of transplantation. A difficult situation emerged during a joint family interview that took place a few years after the transplantation. Parents, donor and the recipient were present, both still children. The difficulties included a confrontation of the 10-year old donor child with accusations and pejorative statements from the other family members and his sidelining from the conversation. The interviewers have been acutely aware that their presence in this situation in this moment was an intrusion into family dynamics. The paper argues, on the basis of the vignette, that professional norms of qualitative research need to be reconsidered. Specifically, it is argued that interviewers are obligated to take an engaged moral stance, by taking a position in an exchange of moral arguments.

背景与目标： : 本文讨论了一个案例插图，该插图捕捉了定性研究中道德上具有挑战性的情况。该研究是关于在兄弟姐妹之间经历过挽救生命的骨髓移植的家庭，这些兄弟姐妹在移植时是孩子。移植后几年，在一次家庭联合采访中出现了困难的情况。父母、捐赠者和接受者都在场，都是孩子。困难包括与其他家庭成员的指控和贬义陈述对10岁的捐助者儿童的对抗，以及他在谈话中的旁白。面试官敏锐地意识到，他们在这种情况下的出现是对家庭动态的入侵。本文认为，在插图的基础上，需要重新考虑定性研究的专业规范。具体来说，有人认为，采访者有义务通过交换道德论点来采取积极的道德立场。

BACKGROUND & AIMS: :Incapacitated adult patients are commonly divided into two groups for purposes of decision making; those with a surrogate and those without. Respectively, these groups are often referred to as represented and unrepresented, and the relative ethics of decision making between them raises two particular issues. The first issue involves the differential application of the best interests standard between groups. Second is the prevailing notion that representedness and unrepresentedness are categorical phenomena, though it is more aptly understood as a multidimensional and continuous variable based on relational moral authority. This paper examines the nature of representedness as it relates to ethical norms of surrogate decision making.

背景与目标： : 出于决策目的，无行为能力的成年患者通常分为两组; 有代理人的人和没有代理人的人。这些群体通常被称为有代表性的群体和无代表性的群体，它们之间决策的相对伦理提出了两个特殊的问题。第一个问题涉及群体之间最佳利益标准的不同应用。其次是普遍的观念，即代表性和不代表性是分类现象，尽管它被更恰当地理解为基于关系道德权威的多维和连续变量。本文研究了代表性的性质，因为它与替代决策的道德规范有关。

BACKGROUND & AIMS: :It is argued, in this paper, that moral theories should not be discussed extensively when teaching applied ethics. First, it is argued that, students are either presented with a large amount of information regarding the various subtle distinctions and the nuances of the theory and, as a result, the students simply fail to take it in or, alternatively, the students are presented with a simplified caricature of the theory, in which case the students may understand the information they are given, but what they have understood is of little or no value because it is merely a caricature of a theory. Second, there is a methodological problem with appealing to moral theories to solve particular issues in applied ethics. An analogy with science is appealed to. In physics there is a hope that we could discover a unified theory of everything. But this is, of course, a hugely ambitious project, and much harder than, for example, finding a theory of motion. If the physicist wants to understand motion, he should try to do so directly. We would think he was particularly misguided if he thought that, to answer this question, he first needed to construct a unified theory of everything.

背景与目标： : 本文认为，在教授应用伦理学时，不应广泛讨论道德理论。首先，有人认为，要么向学生提供有关该理论的各种细微差别和细微差别的大量信息，结果，学生根本无法接受，要么向学生介绍了该理论的简化漫画，在这种情况下，学生可能会理解他们所提供的信息，但是他们所理解的信息几乎没有价值，因为它只是理论的讽刺画。其次，有一个方法论问题，即诉诸道德理论来解决应用伦理学中的特定问题。与科学的类比很吸引人。在物理学中，我们希望能够发现一个统一的万物理论。但这当然是一个雄心勃勃的项目，而且比例如找到运动理论要困难得多。如果物理学家想了解运动，他应该尝试直接这样做。如果他认为，为了回答这个问题，他首先需要构建一个统一的万物理论，我们会认为他特别被误导了。

BACKGROUND & AIMS: :Based on the analysis of a French pre-exposure prophylaxis trial (Ipergay), and focusing on the communication strategies used to recruit volunteers, this article explores the figure who serves to justify the trial and who shapes the way in which populations concerned by this prevention tool are targeted. We show that this figure is that of the fallible man, a classic in moral philosophy: while aware of what is good or right for him, he is unable to put this knowledge into practice. The targeting of fallible men makes sense in the context of a resurgence of high-risk behaviors objectified in the late 1990s: qualifying gays who take risks as fallible individuals create a distance with respect to the "barebacker" who risks his life deliberately and has no intention of changing his behavior. Recognizing that certain gays are vulnerable to risk also provides justification for a preventive strategy that acknowledges the inadequacy of behavioral prevention, without giving up on prevention altogether. All in all, this analysis shows that the technological and epidemiological realism often highlighted in pre-exposure prophylaxis interventions is not without a moral dimension, attentive to individuals' contradictions and singularities, doubts and uncertainties, and to the risk of stigmatization inherent to the acknowledgement of risk-taking.

背景与目标： : 基于对法国暴露前预防试验 (Ipergay) 的分析，并着重于用于招募志愿者的沟通策略，本文探讨了为该试验辩护的人物以及谁塑造了与该预防工具有关的人群的方式。我们证明这个数字是容易犯错的人的数字，这是道德哲学的经典: 尽管意识到什么对他有利或正确，但他无法将这些知识付诸实践。在20世纪90年代末中物化的高风险行为死灰复燃的背景下，针对容易犯错的人是有意义的: 作为容易犯错的人冒险的合格同性恋者与故意冒险的 “barebacker” 保持距离。无意改变他的行为。认识到某些同性恋者容易受到风险的影响，也为预防策略提供了理由，该策略承认行为预防的不足，而又不完全放弃预防。总而言之，这项分析表明，暴露前预防干预措施中经常强调的技术和流行病学现实主义并非没有道德层面，关注个人的矛盾和奇异性，怀疑和不确定性，以及承认风险所固有的污名化风险。