A 47-year-old woman with a history of anxiety disorder is admitted to the hospital for shortness of breath. On the third day of hospitalization, she asks her physician for a copy of all documents pertaining to her care. What expectation should she have for full disclosure? Are there limits on her access to her medical records and do her physician's concerns about professional privilege matter?The virtues of transparency in medicine have been well described. As proponents of transparency, we favor (...) patient access to their medical records, but we are increasingly troubled by the ease and extent of disclosure in current practice as technology advances and... (shrink)

Confidentiality of health information is increasingly relevant in the era of electronic medical records. We discuss the case of a hospitalized patient who requested a neurology consultation for an episode he described as an “LSD-like” (Lysergic acid diethylamide) flashback. The patient expressed concern that the episode was a residual effect of past drug use, but subsequently requested that his drug use not be documented. Involved in a custody battle, he feared that if his records were released to the court (...) he could lose custody of his children. Ethical concerns arose with regards to the physician’s competing obligations with a duty to record information accurately and honestly, respect patient autonomy, and maintain patient confidentiality. We discuss the decision of the team to document the patient’s drug use by arguing that the obligation to maintain confidentiality did not supersede the primary role of the medical record as a complete and accurate account, which cannot be altered at a patient’s behest. (shrink)

Health professionals communicate with each other about medication information using different forms of documentation. This article explores knowledge and power relations surrounding medication information exchanged through documentation among nurses, doctors and pharmacists. Ethnographic fieldwork was conducted in 2010 in two medical wards of a metropolitan hospital in Australia. Data collection methods included participant observations, field interviews, video‐recordings, document retrieval and video reflexive focus groups. A critical discourse analytic framework was used to guide data analysis. The written medication (...) chart was the main means of communicating medication decisions from doctors to nurses as compared to verbal communication. Nurses positioned themselves as auditors of the medication chart and scrutinised medical prescribing to maintain the discourse of patient safety. Pharmacists utilised the discourse of scientific judgement to guide their decision‐making on the necessity of verbal communication with nurses and doctors. Targeted interdisciplinary meetings involving nurses, doctors and pharmacists should be organised in ward settings to discuss the importance of having documented medication information conveyed verbally across different disciplines. Health professionals should be encouraged to proactively seek out each other to relay changes in medication regimens and treatment goals. (shrink)

Modern Western medical individualism has had a significant impact on health care in China. This essay demonstrates the ways in which such Western-style individualism has been explicitly endorsed in China’s 2010 directive: The Basic Norms of the Documentation of the Medical Record. The Norms require that the patient himself, rather than a member of his family, sign each informed consent form. This change in clinical practice indicates a shift toward medical individualism in Chinese healthcare legislation. Such (...) individualism, however, is incompatible with the character of Chinese familism that is deeply rooted in the Chinese ethical tradition. It also contradicts family-based patterns of health care in China. Moreover, the requirement for individual informed consent is incompatible with numerous medical regulations promulgated in the past two decades. This essay argues that while Chinese medical legislation should learn from relevant Western ideas, it should not simply copy such practices by importing medical individualism into Chinese health care. Chinese healthcare policy is properly based on Chinese medical familist resources. (shrink)

This paper explores how organizational members use documents to share their knowledge within and across work settings. I suggest that organizational studies of distributed knowledge sharing and information systems would greatly benefit from the linguistic analysis of communicative practices. Specifically, the paper highlights the notion of indexical centering as formulated by the linguistic anthropologist William Hanks and demonstrates its analytical power in studying documenting as a communicative practice. Drawing on a 15-month, multi-sited ethnographic study in several pediatric healthcare settings, the (...) paper focuses on how two doctors compose and use two medical histories found in two distinct medical information systems. The analysis suggests that the doctors use documents to index the temporal, spatial, and participatory dimensions of their knowledge sharing. They do so by indexing, on the one hand, the participants, times and places for their communicative practices and, on the other hand, the participants, times and places of their general care practices. The indexical analysis allows us to perceive documents, as more than mere vessels for knowledge transfer among organizational members, but as an integrated part of how people structure their work practices and situate their knowledge sharing in complex distributed organizational settings. (shrink)

The so-called Istanbul Protocol, a Manual on the Effective Investigation and Documentation of Torture and other Cruel, Inhumane or Degrading Treatment or Punishment was adopted by the United Nations soon after its completion in 1999 and since then has become an acknowledged standard for documenting cases of alleged torture and other forms of severe maltreatment. In 2009 the “Forum for medicine and human rights” at the Medical Faculty at the University Erlangen-Nuremburg has provided the first German edition of (...) this manual. The article traces back the development of the protocol taking into account the general background as well as the factual occasion of its initiation. The main ethical and legal principles of the manual are introduced as well as the projects for implementing the rules provided in the protocol that have been carried out so far. From this the urgent need for implementation of the Istanbul Protocol guidelines also in Europe and in German-speaking countries and here not exclusively but especially within asylum procedures becomes clear. (shrink)

The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing. Objective: This study examines the role of wireless, electronic, medical records and com- munications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.

Gaston Franssen’s essay touches on important medical and literary topics: the experience of patients with unexplained somatic complaints, the importance of giving their symptoms a name or diagnosis, the verbal representation of what bothers them, or the uncertainty all parties have to live with when an underlying cause of the symptoms is missing. A diagnosis or name such as chronic fatigue syndrome can be a relief for its sufferers, as is expressed by one of the patients in the article: (...) “I wept with relief at having a name for it.” Yet CFS is but a name for something that, medically speaking, has no substance except for the patients” complaints. CFS shares this lack of objective physical signs with other... (shrink)

Healthcare organizations and workers are under pressure to produce increasingly complete and accurate data for multiple data-intensive endeavors. However, little research has examined the emerging occupations arising to carry out the data work necessary to produce “improved” data sets, or the specific work activities of these emerging data occupations. We describe the work of Clinical Documentation Integrity Specialists, an emerging occupation that focuses on improving clinical documentation to produce more detailed and accurate administrative datasets crucial for evolving data-intensive (...) forms of healthcare accountability, management, and research. Using ethnographic methods, we describe the core of CDIS’ work as a translation practice in which the language, interests, and concerns of clinicians and clinical documentation are translated via real-time “nudging” and ongoing education of clinicians into the language, interests, and concerns of medical coders, structured administrative datasets, and the various stakeholders of these datasets. Further, we show how the institutional context of CDIS’ work shapes the occupational virtues that guide CDIS’ translation practice, including financial reimbursement, quality measures, clinical accuracy, and protecting clinician’s time. Despite the existence of these multiple virtues, financial reimbursement is the most prominent virtue guiding CDIS’ limited attention. Thus, overall clinical documentation is “improved” in specific, partial ways. This research provides one of the first studies of the emergent data work occupations arising in the wake of digitization and big data opportunities, and shows how local data settings shape large scale data in specific ways and thus may influence outcomes of analyses based on such data. (shrink)

BackgroundDelirium is highly prevalent in the general hospital patient population, characterized by acute onset, fluctuating levels of consciousness, and global impairment of cognitive functioning. Mental capacity, its assessment and subsequent consent are therefore prominent within this cohort, yet under-explored.AimThis study of patients with delirium sought to determine the processes by which consent to medical treatment was attempted, how capacity was assessed, and any subsequent actions thereafter.MethodA retrospective documentation review of patients identified as having a delirium for the twelve (...) months February 2013 to January 2014 was undertaken. Inclusion and exclusion criteria were used; demographic and descriptive data collected. A total of n=1153 patients were identified with n=310 meeting inclusion criteria.ResultA random sample of one hundred patients were subsequently reviewed. One third of patients had documentation relating to consent, while four patients had documentation relating to capacity. Median delirium duration was three days, with treatment refusal occurring in twenty-two patients and “duty of care” being used as an apparent beneficent related treatment framework in twelve patients.ConclusionsWhile impaired decision-making was indicated, the review was unable to indicate what patient characteristics flag the need for capacity assessment. Documentation relating to consent processes appeared deficient for this cohort. (shrink)

Despite the recent advances in information and communication technology that have increased our ability to store and circulate information, the task of ensuring that the right sorts of information gets to the right sorts of people remains. We argue that the many efforts underway to develop efficient means for sharing information across healthcare systems and organizations would benefit from a careful analysis of human action in healthcare organizations. This in turn requires that the management of information and knowledge within healthcare (...) organizations be combined with models of resources and processes of patient care that are based on a general ontology of social interaction. The Health Level 7 (HL7) is one of several ANSI-accredited Standards Developing Organizations operating in the healthcare arena. HL7 has advanced a widely used messaging standard that enables healthcare applications to exchange clinical and administrative data in digital form. HL7 focuses on the interface requirements of the entire healthcare system and not exclusively on the requirements of one area of healthcare such as pharmacy, medical devices, imaging or insurance transactions. This has inspired the development of a powerful abstract model of patient care called the Reference Information Model (RIM). The present paper begins with an overview of the core classes of the HL7 (Version 3) RIM and a brief discussion of its “actcentered” view of healthcare. Central to this account is what is called the life cycle of events. A clinical action may progress from defined, through planned and ordered, to executed. These modalities of an action are represented as the mood of the act. We then outline the basis of an ontology of organizations, starting from the theory of speech Acts, and apply this ontology to the HL7 RIM. Special attention is given to the sorts of preconditions that must be satisfied for the successful performance of a speech act and to the sorts of entities to which speech acts give rise (e.g. obligations, claims, commitments, etc.). Finally we draw conclusions for the efficient communication and management of medical information and knowledge within and between healthcare organizations, paying special attention to the role that medical documents play in such organizations. (shrink)

In December 2014, Physicians for Human Rights released their analysis of the summary of the Committee Report of the Central Intelligence Agency’s Detention and Interrogation Program. PHR focused on the involvement of health care professionals in the CIA torture program, concluding that the health professionals’ commissions and omissions violated the prescriptions of many fundamental bioethical documents, including international declarations of bioethics and medical research ethics. The medical doctors’ involvement evokes some thoughts concerning bioethical education. It seems that instead (...) of developing virtues through practicing morally good habits, the experience of clinical training undermines the moral ideals that medical students identified themselves with at the commencement of their medical education. The hostile response they sometimes get from their mentors when trying to question morally troubling situations may shape the habit of ‘turning a blind eye’ to unethical behaviour, since the students do not want to jeopardize their grades and future medical career. Maybe it was the development of this habit and the failure to develop the habit of moral courage instead that prevented the medical doctors participating in torture programs from defending moral ideals of their profession more effectively. (shrink)

RESUMEN El objetivo del presente estudio está dirigido a exponer particularidades éticas del trabajo anatomopatológico a la luz de la realidad histórico social. Se emplean métodos teóricos y empíricos y a partir del análisis documental se opera con referentes en los enfoques contemporáneos. El estudio de aspectos generales referidos a la moral y a la ética permitió acceder a definiciones, bases legales y evolución histórica, a la vez que se profundiza en su repercusión en el sector salud y se desarrollan (...) las peculiaridades del trabajo anatomopatológico desde sus manifestaciones en la actividad asistencial, docente e investigativa. Se concluye que los principios éticos generales de la conducta profesional y médica son aplicables al trabajo anatomopatológico en todas sus esferas; al igual que los de la bioética. ABSTRACT The objective of the present study is directed to exhibit ethical peculiarities of the anatomical-pathological work in view of the historical-social reality. Theoretical and empirical methods are used and from the documentary analysis it occurs with modality in the contemporary approaches. The study of general aspects referred to the morality and to the ethics allowed to gain access to definitions, legal bases and historical evolution, simultaneously that deepens in its aftereffect in the sector health and the peculiarities of the anatomical-pathological work develop from its declarations in the welfare, teaching and investigative activity. One concludes that the general ethical beginning of the professional and medical conduct is applicable to the anatomical-pathological work in all its spheres; as those of the bioethics. (shrink)

Corporeality, Medical Technologies and Contemporary Culture engages the confusions and contradictions in current attitudes to, and practices of, the body. On the one hand, the body is where we turn for the certainties of nature; yet, on the other, it is the locus of a desire for permanent transformation and for constant reinvention. The body is at the same time worshipped and despised: so that now it has come to constitute not just an object of desire, but an object (...) of design. Addressing practices of corporeal ascesis- such as bodybuilding and dietetics - medical technologies - such as plastic surgery, prosthetics, and pharmacological interventions - and radical anatomical modifications- such as voluntary amputations, Francisco Ortega analyses how the body has become a screen for the projection of our ideas and imaginings about ourselves; and has also been turned into an object of suspicion, fear, anxiety, insecurity and discomfort. From the disembodied ideal of the digital purity of models - in which every little piece of fat is digitally eliminated - through the disembodiment implicit in social constructivist rejections of materiality, to the various projects of virtual reality, artificial intelligence, and posthumanism, Corporeality, Medical Technologies and Contemporary Culture documents the ambiguous legacy of a western theoretical tradition that has always despised the body. (shrink)

Medical records are documents of tremendous social importance. They have been the subject of much medical and sociological research, in particular regarding validity, accessibility and readability. This paper uses Conversation Analysis to add an aspect to the understanding of medical records that has been missing so far, namely how medical records are produced as interactional accomplishments; specifically, how hospital staff members during meetings conversationally negotiate and reach conclusions, treatment recommendations, and other types of consequential decisions. The (...) process involves four steps: assessing patients, interpreting implications, drawing conclusions, and dictating conclusions on tape. The key finding is that participants throughout the process orient towards a need for consensus, whilst at the same time acknowledging the doctors’ interactional leading roles. This insight can enhance our understanding of medical records in hospital settings as constructed and negotiated realities. (shrink)

Hilary Putnam’s influential analysis of the ‘division of linguistic labour’ has a striking application in the area of doctor–patient interaction: patients typically think of themselves as consumers of technical medical terms in the sense that they normally defer to health professionals’ explanations of meaning. It is at the same time well documented that patients tend to think they are entitled to understand lay health terms like ‘sickness’ and ‘illness’ in ways that do not necessarily correspond to health professionals’ understanding. (...) Drawing on recent philosophical theories of concept possession, the article argues that this disparity between medical and lay vocabulary implies that it is, in an important range of cases, easier for doctors to create a communicative platform of shared concepts by using and explaining special medical expressions than by using common lay expressions. This conclusion is contrasted with the view that doctors and patients typically understand each other when they use lay vocabulary. Obviously, use of expressions like ‘sickness’ or ‘illness’ does not necessarily lead to poor communication, but it is important that doctors have an awareness of how patients interpret such terms. (shrink)

Background Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics. Objectives To explore factors influencing nursing documentation from nurses’ perspectives in the Iranian nursing context. Methods This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients’ medical files were used for data (...) collection. Ethical considerations This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent. Findings The main theme of this study was “unsafe documentation.” Two categories, “types of errors in reporting” and “reasons of errors in reporting,” and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context. Conclusion In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice. (shrink)

Paperwork plays a key role in a how institutions accommodate, refuse, or manage disabled people. This article develops modes for reading paperwork that build on each other, beginning with (a) recognizing the institutional pressures at work in shaping bureaucratic practices, then (b) considering how a person's relationship to disability influences how they might encounter these practices, and ultimately (c) noticing how the encounter between disabled/mad people and an institution might create something new, what the author calls archival excess. These methods (...) for reading are in conversation with disability studies, medical humanities, and document studies, and ultimately work toward a goal adapted from the principles of Disability Justice: recognizing the wholeness of disabled subjects in institutional archives. (shrink)

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients at risk for life-threatening heart arrhythmias, and their use is increasingly common. However, these devices also confer risk for delivery of unexpected painful shocks during the dying process, thus reducing the quality of palliative care at the end of life. This scenario can be avoided by ICD deactivation in appropriate circumstances but patients will remain unaware of this option if not informed about it. It is not known how often end-of-life implications (...) are discussed with patients prior to ICD implantation, when focus is primarily on the short-term potential complications of the device placement procedure itself. We conducted a retrospective chart review to determine how often end-of-life implications were discussed with patients as part of the informed consent process. We evaluated consent forms and related other chart documentation for 91 patients (ranging from age 60 to 89 years) undergoing first-time ICD placement at a mid-western academic medical center from 2006-2008. Only one chart documented any discussion of end-of-life implications, in a case where the issue was raised by a patient who noted that quality of life was their main focus. Consent was provided by a health care surrogate in only four of the 91 cases. In conclusion, patients giving consent for ICD implantation may be uninformed about the device's potential future impact on end-of-life care, the dying process, and the option for device deactivation. Truly informed consent requires that both short- and long-term potential implications be reviewed with patients. (shrink)

As in other societies, medical professionalism in the Peoples’ Republic of China has been rapidly evolving. One of the major events in this process was the endorsement in 2005 of the document, “Medical Professionalism in the New Millennium: A Physician Charter,” by the Chinese Medical Doctor Association (hereafter, the Charter). More recently, a national survey, the first on such a large scale, was conducted on Chinese physicians’ attitudes toward the fundamental principles and core commitments put forward in (...) the Charter. Based on empirical findings from that study and comparing them to the published results of a similar American survey, the authors offer an in-depth interpretation of significant cross-cultural differences and important transcultural commonalities. The broader historical, socio-economic, and ethical issues relating to salient Chinese cultural practices such as family consent, familism (the custom of deferring decisions to family members), and the withholding of medical information, as well as controversial topics such as not respecting patients’ autonomy, are examined. The Chinese Survey found that Chinese physicians supported the principles of the Charter in general. Here we argue that Chinese culture and traditional medical ethics are broadly compatible with the moral commitments demanded by modern medical professionalism. Methodologically and theoretically—recognizing the problems inherent in the hoary but still popular habit of dichotomizing cultures and in relativism—a transcultural approach is adopted that gives greater (due) weight to the internal moral diversity present within every culture, the common ground shared by different cultures, and the primacy of morality. Genuine crosscultural dialogue, including a constructive Chinese-American dialogue in the area of medical professionalism, is not only possible, but necessary. (shrink)

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between “medical” and “social” egg freezing —contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the “regulatory boundary-work” around the “medical”–”social” distinction in different egg freezing regulations. Based on systematic documents’ analysis we present a cross-national comparison of the way the “medical”–”social” differentiation finds expression (...) in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: the definition of MEF and its distinctiveness—highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it ; and hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between “medical” and “social” are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects. (shrink)

Zu den elementaren Rechtfertigungsbedingungen der medizinischen Forschung an und mit Menschen zählt die informierte Einwilligungserklärung („informed consent“) des Probanden/Patienten. Für die Gewährleistung eines „informed consent“ sind dem potenziellen Studienteilnehmer u. a. qualitativ hochwertige schriftliche Aufklärungsmaterialien zur Verfügung zu stellen. Wir entwickelten eine Liste von Prüfpunkten, um mit ihnen die Qualität schriftlicher Aufklärungsmaterialien zu bestimmen und zu bewerten. Mithilfe eines Kriterienkataloges bestehend aus über 100 Prüfpunkten wurde die Qualität von 128 zufällig ausgewählten schriftlichen Aufklärungsmaterialien zu Forschungsvorhaben beurteilt, die der Ethikkommission der (...) Universität zu Lübeck im Jahr 2006 vorgelegt worden waren. Jeder Prüfpunkt ist einem von sechs Qualitätsbereichen zugeordnet (z. B. Lesbarkeit und Verständlichkeit, Nutzen-/Schadenpotenziale). Die untersuchten Aufklärungsmaterialien erfüllten im Durchschnitt die Hälfte der 117 abgefragten Qualitätskriterien, die Spannweite reichte dabei von 20 % bis 76 %. Der höchste Qualitätsscore wurde für den Bereich „Einwilligungserklärung“ beobachtet (64 % der Kriterien erfüllt), am schlechtesten schnitt der Bereich „Nutzen- und Schadenpotenziale“ ab (35 % der Kriterien erfüllt). Aufklärungsmaterialien zu klinischen Prüfungen von Arzneimitteln zeigten dabei eine signifikant höhere Qualität als die Aufklärungsmaterialien zu anderen Studientypen. Nur 21 der 117 analysierten Qualitätskriterien wurden in mehr als 80 % der einschlägigen Aufklärungsmaterialien umgesetzt. Die vorliegende Arbeit zeigt deutliche Defizite in der Qualität der untersuchten Aufklärungsmaterialien auf. Forscherinnen und Forscher benötigen Hilfestellung bei der Erstellung von Materialien, die eine informierte Entscheidung für oder gegen eine Studienteilnahme ermöglichen. Der von uns eingesetzte Kriterienkatalog könnte u. a. im Rahmen von Doktorandenseminaren dazu genutzt werden, den Blick für die Vielfalt der Anforderungen zu schärfen. (shrink)

This book contains a collection of treaty documents and soft law on health care rights and health ethics which are used in health law training programs. Regional documents and explanatory reports on health care rights, which are derived from international human rights law, provide a way of "unwrapping" government obligations in health care, making rights more specific, accessible, and (judicially) accountable. In addition, soft law declarations and medical ethics contribute to understanding the moral meaning of human rights in health (...) care. As such, the principles and standards provide practical guidance for States when dealing with equal access to health care services, the rights of patients, biomedical research, organ donations and transplants, genetics, and public health. The book covers the basic documents, while general comments and explanatory reports amplify the principles embodied in the human rights treaties. The authoritative interpretations clarify a 'European approach' on a State's obligations concerning health care rights and ethics. (shrink)

Healthcare facilities in receiving countries regularly encounter guest workers whose need for acute or subacute care triggers the prospect of termination of employment and repatriation. In these scenarios, country‐specific migration and employment policies and norms of medical professionalism and ethics offer some guidance, but also create tensions. It is not clear under what conditions such medical repatriation is ethically permissible.This paper analyses the application of a previously articulated criteria for the ethical medical repatriation of undocumented immigrants, to (...) the situation of documented guest workers, with focus on the context of Singapore. We examine how these standards could be adapted and applied to the provision of care for guest workers, and argue that healthcare institutions and medical professionals have a duty to intervene in employers’ decisions to repatriate guest workers for medico‐economic reasons when repatriation essentially amounts to ‘patient dumping’. Barriers and challenges in implementing the criteria, and their possible solutions will be discussed. (shrink)

This document was developed by prosecutor A. Josephus Jitta, Chief, Office of Justice, Alkmaar, The Netherlands, with assistance from physicians and is typical of the euthanasia report forms completed by medical examiners and coroners In The Netherlands.

There is a lot of conceptual engineering going on in medical research. I substantiate this claim with two examples, the medical debate about cancer classification and about obesity as a disease I also argue that the proper target of conceptual engineering in medical research are experts’ conceptions. These are explicitly written down in documents and guidelines, and they bear on research and policies. In the second part of the chapter, I propose an externalist framework in which conceptions (...) have both the explanatory power of psychological concepts and that of semantic concepts. It is likely, however, that human activities and practices distinct from medical research, and regulated by different practices and epistemic rules, call for different targets for conceptual engineering. I conclude with indicating an open agenda of problems for philosophers of medicine interested in conceptual engineering. (shrink)

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture. Mounting information from many sources, including Pentagon documents, the International Committee of the Red Cross, Amnesty International, Human Rights Watch, etc., indicate that medical personnel failed to maintain (...) medical records, conduct routine medical examinations, provide proper care of disabled and injured detainees, accurately report illnesses and injuries, and falsified medical records and death certificates. Medical personnel and medical information was also used to design and implement psychologically and physically coercive interrogations. The United States military medical system failed to protect detainee's human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism. (shrink)

The contention that medical artificial intelligence (AI) should be ‘explainable’ is widespread in contemporary philosophy and in legal and best practice documents. Yet critics argue that ‘explainability’ is not a stable concept; non-explainable AI is often more accurate; mechanisms intended to improve explainability do not improve understanding and introduce new epistemic concerns; and explainability requirements are ad hoc where human medical decision-making is often opaque. A recent ‘political response’ to these issues contends that AI used in high-stakes scenarios, (...) including medical AI, must be explainable to meet basic standards of legitimacy: People are owed reasons for decisions that impact their vital interests, and this requires explainable AI. This article demonstrates why the political response fails. Attending to systemic considerations, as its proponents desire, suggests that the political response is subject to the same criticisms as other arguments for explainable AI and presents new issues. It also suggests that decision-making about non-explainable medical AI can meet public reason standards. The most plausible version of the response amounts to a simple claim that public reason demands reasons why AI is permitted. But that does not actually support explainable AI or respond to criticisms of strong requirements for explainable medical AI. (shrink)

Purpose Engagement of healthcare professionals with patients from diverse cultural and religious backgrounds is crucial in our multicultural society, where miscommunication and errors in medical history taking can lead to incorrect treatment. In particular, Muslim patients may present unique considerations due to their specific cultural and religious beliefs, which can significantly impact treatment outcomes. This study focuses on perioperative medication therapy for patients undergoing upper and lower gastrointestinal tract and pancreatic tumor surgery, specifically examining whether Islamic beliefs were duly (...) considered in medication selection compared to a matching patient cohort. Materials and methods Data from January 2004 to July 2023 were analyzed. Muslim patients were identified using the onomastic method and matched with non-Muslim patients at a 1:3 ratio based on age, gender, and procedure. Analysis included examination of subcutaneous, oral, and intravenous medications, with attention to ingredients and compatibility with Islamic principles. Results Among 5272 patients, only 5 met the study’s inclusion criteria as Muslim patients, undergoing procedures such as anterior rectum resection, gastrectomy, and pancreatic head resection. Their religious affiliations were not documented in the admission records. According to the matched-pair analysis, consistent treatment was performed regardless of religious beliefs. All patients received subcutaneous medication, primarily enoxaparin, instead of fondaparinux, an Islam-compliant alternative. Intravenous heparin was used once for short period. Contrary to Islamic dietary restrictions and the availability of alternatives, capsules containing animal-derived gelatin and other non-compliant medications were administered orally. Conclusion This study underscores the importance of acknowledging Muslim patients’ cultural and religious backgrounds in the perioperative setting, as failure to do so may lead healthcare professionals to overlook their potential alternative medication needs, which are essential for providing tailored medical care in modern societies. Integration of diversity-related topics into medical curricula is essential for better preparing physicians for clinical practice and ensuring patient-centered care. (shrink)

The Declaration of Geneva is one of the core documents of medical ethics. A revision process was started by the World Medical Association in 2016. The WMA has also used this occasion to examine how the Declaration of Geneva is used in countries throughout the world by conducting a survey of all WMA constituent members. The findings are highly important and raise urgent questions for the World Medical Association and its National Medical Associations : The Declaration (...) of Geneva is only rarely used as an oath text despite the fact that physicians’ oaths are generally widespread. This is not consistent with the intention and claim of the Declaration of Geneva. The article then discusses three questions. Should there be one single binding oath? Which organization should be responsible for such an oath? Which oath is the most obvious candidate? In a globalized world and despite all cultural diversity, the medical profession should have one core moral basis which is binding for physicians all over the world. The most obvious candidate for an oath incorporating this moral basis is the Declaration of Geneva. (shrink)

BackgroundDecision-making in out-of-hospital cardiac arrest should ideally include clinical and ethical factors. Little is known about the extent of ethical considerations and their influence on prehospital resuscitation. We aimed to determine the transparency in medical records regarding decision-making in prehospital resuscitation with a specific focus on ethically relevant information and consideration in resuscitation providers’ documentation.MethodsThis was a Danish nationwide retrospective observational study of out-of-hospital cardiac arrests from 2016 through 2018. After an initial screening using broadly defined inclusion criteria, (...) two experienced philosophers performed a qualitative content analysis of the included medical records according to a preliminary codebook. We identified ethically relevant content in free-text fields and categorised the information according to Beauchamp and Childress’ four basic bioethical principles: autonomy, non-maleficence, beneficence, and justice. ResultsOf 16,495 medical records, we identified 759 (4.6%) with potentially relevant information; 710 records (4.3%) contained ethically relevant information, whereas 49 did not. In general, the documentation was vague and unclear. We identified four kinds of ethically relevant information: patients’ wishes and perspectives on life; relatives’ wishes and perspectives on patients’ life; healthcare professionals’ opinions and perspectives on resuscitation; and do-not-resuscitate orders. We identified some “best practice” examples that included all perspectives of decision-making. ConclusionsThere is sparse and unclear evidence on ethically relevant information in the medical records documenting resuscitation after out-of-hospital cardiac arrests. However, the “best practice” examples show that providing sufficient documentation of decision-making is, in fact, feasible. To ensure transparency surrounding prehospital decisions in cardiac arrests, we believe that it is necessary to ensure more systematic documentation of decision-making in prehospital resuscitation. (shrink)

Purpose Moral orientation can affect ethical decision-making. Very few studies have focused on whether medical education can change the moral orientation of the students. The purpose of the present study was to document the types of moral orientation exhibited by medical students, and to study if their moral orientation was changed after preclinical education. Methods From 2007 to 2009, the Mojac scale was used to measure the moral orientation of Taiwan medical students. The students included 271 first-year (...) and 109 third-year students. They were rated as a communitarian, dual, or libertarian group and followed for 2 years to monitor the changes in their Mojac scores. Results In both first and third-year students, the dual group after 2 years of preclinical medical education did not show any significant change. In the libertarian group, first and third-year students showed a statistically significant increase from a score of 99.4 and 101.3 to 103.0 and 105.7, respectively. In the communitarian group, first and third-year students showed a significant decline from 122.8 and 126.1 to 116.0 and 121.5, respectively. Conclusion During the preclinical medical education years, students with communitarian orientation and libertarian orientation had changed in their moral orientation to become closer to dual orientation. These findings provide valuable hints to medical educators regarding bioethics education and the selection criteria of medical students for admission. (shrink)

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it routine in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive text, it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical (...) record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided. (shrink)

We argue that while presidential candidates have the right to medical privacy, the public nature and importance of the presidency generates a moral requirement that candidates waive those rights in certain circumstances. Specifically, candidates are required to disclose information about medical conditions that are likely to seriously undermine their ability to fulfill what we call the "core functions" of the office of the presidency. This requirement exists because (1) people have the right to be governed only with their (...) consent, (2) people's consent is meaningful only when they have access to information necessary for making informed voting decisions, (3) such information is necessary for making informed voting decisions, and (4) there are no countervailing reasons sufficiently strong to override this right. We also investigate alternative mechanisms for legally encouraging or requiring disclosure. Protecting the public's right to this information is of particular importance because of the documented history of deception and secrecy regarding the health of presidents and presidential candidates. (shrink)

Background In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. Setting A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. Methods Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: (...) all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. Results Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. Conclusion Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement. (shrink)

PHOTO ID 121339257© Designer491| Dreamstime.com ABSTRACT When physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be apparent conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters future physicians’ commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. We use an ethical dilemma that was presented to a group of third-year medical students to examine how ethics education might (...) be causing them to give undue deference to autonomy, thereby undermining their commitment to beneficence. INTRODUCTION The right of patients to choose which treatments they prefer is rooted in today’s social mores and taught as a principle of medical ethics as respect for autonomy. Yet, when physicians use their clinical knowledge and skills to advance the well-being of their patients, there may be a conflict between patient autonomy and physician beneficence. We are skeptical that today’s medical ethics education adequately fosters a commitment to beneficence, which is both rationally defensible and fundamentally consistent with patient autonomy. I. An Ethical Dilemma The impetus for this paper arose when students who were completing their third clinical year discussed a real-life ethical dilemma. A middle-aged man developed a pulmonary hemorrhage while on blood thinners for a recently placed coronary stent. The bleeding was felt to be reversible, but the patient needed immediate intubation or he would die. The cardiologist was told that the patient previously expressed to other physicians that he never wanted to be intubated. However, the cardiologist made the decision to intubate the patient anyway, and the patient eventually recovered.[1] Students were asked if they believed that the cardiologist had acted ethically. Their overwhelming response was, “No, the patient should have been allowed to die.” We looked into how students applied ethical reasoning to conclude that this outcome was ethically preferred. To explore how the third-year clinical experience might have formed the students’ judgment, we presented the same case to students who were just beginning their third year. Their responses were essentially uniform in recommending intubation. While there is likely more than one reasonable view in this case, we agree with the physician and the younger medical students that intubation was the ethically appropriate decision and will present an argument for it. But first, we explain the reasoning behind the more advanced medical students’ decision to choose patient autonomy at the expense of beneficence. II. Medical Ethics Education and the Priority of Autonomy Beauchamp and Childress’s Principles of Biomedical Ethics, first published in 1979 and now in its 8th edition, is a significant part of the formal ethics education in medical school.[2] Students learn an ethical decision-making approach based on respect for four ethical principles: autonomy, beneficence, nonmaleficence, and justice. While Beauchamp and Childress officially afford no prima facie superiority to any principle, the importance of respect for patient autonomy has increased through the editions of their book. For example, early editions of their book opposed the legalization of physician-assisted death compared to recent editions that defended it.[3] As another example, Beauchamp and Childress make paternalism harder to justify by adding an autonomy-protecting condition to the list of conditions for acceptable paternalism.[4] Authority, they contend, need not conflict with autonomy—provided the authority is autonomously chosen.[5] “The main requirement,” they write, “is to respect a particular patient’s or subject’s autonomous choices, whatever they may be.[6] In the principlism of Beauchamp and Childress, autonomy now seems to have a kind of default priority.[7] However, the bioethics discourse has strong counternarratives, noting some movement to elevate the role of beneficence and to respect the input of stakeholders, including the family and the healthcare team. Ethics education achieves particular relevance in the third clinical year when students become embedded in the care of patients and learn from what has been called the informal curriculum. They observe how attending physicians approach day-to-day ethical problems at the patient’s bedside. In this context, students observe the importance of informed consent for serious treatments or invasive procedures, a practice that highlights the principle of patient autonomy. In both the formal and informal curriculum, medical students observe how, in the words of Paul Wolpe, “patient autonomy has become the central and most powerful principle in ethical decision-making in American medicine.”[8] In short, students appear to learn a deference for patient autonomy. This curricular shift in favor of autonomy coincides with legal developments that protect patients’ rights and decision-making with respect to their healthcare choices. The priority of autonomy in medicine benefits patients by reflecting their choices and, in some cases, their fundamental liberty. III. The Practice of Medicine and the Commitment to Beneficence There are many critiques of the dominant place that autonomy has in biomedical ethics,[9] especially considering that autonomy seems to be biased toward individualistic, Western, and somewhat American culture-driven values.[10] In addition, many bioethical dilemmas are cast as a conflict between autonomy and beneficence. Our point is that medical students bring to their study of medicine a commitment to beneficence that seems to be suppressed by practical ethics education. We think this commitment is rationally defensible and should be nurtured. It is striking that young medical students have a pre-reflective commitment to beneficence at all. For, as we mentioned, it is not just medicine but Western culture generally that prioritizes autonomy in settling ethical dilemmas. In wanting to act for the good of others (rather than simply agreeing to what others want), physicians are already swimming somewhat against the cultural tide.[11] However, doing so makes sense, given the nature of medicine and the profession of healing. When prospective medical students are asked why they wish to become physicians, the usual answer is some variation on caring for the sick and preventing disease. It is unlikely that a reason to become a physician is to respect a patient’s autonomy. It would be easy to dismiss medical students’ commitment to beneficence as a mere intuition and contrary to a more reasoned and deliberative approach. Beauchamp and Childress seem to minimize the value of physician intuition, stating that justifications for certain procedures are “…supported by good reasons. They need not rest merely in intuition or feeling.”[12] Henry Richardson writes that “situational or perceptive intuition…leaves the reasons for decision unarticulated.”[13] We think this is a crude and rather thin way of understanding intuition. Some bioethicists have defended intuition as essential to the practice of medicine and not something opposed to reason.[14] In the case we describe, we believe the ethical justifications s for the patient’s intubation are fundamentally sound: the patient did not have a “do not intubate” order written in the chart, the emergency intubation had not been foreseen, so the patient did not have the opportunity to consent to or reject intubation; the patient had consented to the treatment for his cardiac disease so his consent for intubation could have been assumed;[15] and the consequences of respecting his autonomy did not justify allowing him to die.[16] While it is possible to have more than one reasonable view on this case, we think the case for beneficence is strong and certainly should not be dismissed out of hand. We do not deny that if a patient makes a clearly documented, well-informed decision to forgo intubation that this decision ought to be respected by the physician (even if the physician disagrees with the patient’s decision). But, in this situation, as in many others in the practice of medicine, the patient’s real wishes and preferences are not well-articulated in advance. There are many cases where a physician acts based on what she believes the patient, or the surrogate, would want, sometimes in situations that do not allow much time for reflection. An example might be resuscitation of a newborn at the borderline of viability. In their ethics education, beneficence would mean acting first to save a life. If the patient or surrogate makes an informed decision to the contrary, a beneficent physician respects that autonomous decision. In the case presented, the patient expressed gratitude to the cardiologist when extubated. But what if he had expressed anger at the physician for violating his autonomy? There are those who could argue that not only was intubation ethically wrong but that the cardiologist put himself in legal jeopardy by his actions (especially if there had been a written refusal applicable to the specific situation). In the example we use, we point out that the cardiologist may not have escaped a lawsuit if the patient had died without intubation. His family, when hearing the circumstances, may have sued for failure to act and dereliction of the cardiologist’s duty to save him. Beyond a potential legal challenge for either action or inaction, there is an overriding ethical question the cardiologist had to address: what course would be most satisfying to his conscience? Would he rather allow a patient to die for fear of recrimination, or act to save his life, regardless of the personal consequences? In the absence of real knowledge about the patient’s considered wishes, it is most reasonable to err on the side of promoting patient well-being. A physician’s commitment to beneficence is not necessarily a way of undermining a patient’s autonomy. In acting for the patient's good, physicians are also acting on what it is reasonable to believe a patient (or most patients, perhaps) would want, which is obviously connected to what a patient does want. Pellegrino and Thomasma argue that beneficence includes respect for a patient’s autonomy since “the best interests of the patient are intimately linked with their preferences.”[17] Instead of conceptualizing ethical dilemmas in medicine as conflicts between autonomy and beneficence, it is possible that medical schools could teach students that truly practicing beneficence is a way of valuing patient autonomy, especially when the patient’s wishes are not specific to the situation and are not clearly expressed. CONCLUSION It is important for students and practicing physicians to understand the principle of respect for patient autonomy in a pluralistic society that demands personal self-determination. However, the role of the physician as a beneficent healer should not be diminished by this respect for autonomy. Respecting a patient’s autonomy is grounded in and manifested by physician beneficence.[18] That is, seeking what is good for the patient can only be good if it respects their personhood and dignity. We propose that a commitment to beneficence, incipient in young medical students, should be developed over time with their other clinical reasoning skills. Such a commitment need not be sacrificed on the altar of patient autonomy. Beneficence needs greater relative moral weight with students as they proceed in their ethics education. - [1] S. Jauhar, “When Doctors Need to Lie,” New York Times, February 22, 2014, https://www.nytimes.com/2014/02/23/opinion/sunday/when-doctors-need-to-lie.html. [2] T. L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019). [3] Louise A. Mitchell, “Major Changes in Principles of Biomedical Ethics,” The National Catholic Bioethics Quarterly 14, no. 3 (2014): 459–75, https://doi.org/10.5840/ncbq20141438. [4] Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 8th ed. (New York, NY: Oxford University Press, 2019), 238. [5] Beauchamp and Childress, 103. [6] Beauchamp and Childress, p. 108. [7] For other accounts that prioritize autonomy, see e.g. Allen E. Buchanan and Dan W. Brock, Deciding for Others: The Ethics of Surrogate Decision Making (Cambridge University Press, 1989), 38–39; R Gillon, “Ethics Needs Principles—Four Can Encompass the Rest—and Respect for Autonomy Should Be ‘First among Equals,’” Journal of Medical Ethics 29, no. 5 (October 2003): 307–12, https://doi.org/10.1136/jme.29.5.307. For examples of critiques of these accounts, see footnote 9. [8] P. R. Wolpe, “The Triumph of Autonomy in American Bioethics: A Sociological View,” in Bioethics and Society: Constructing the Ethical Enterprise, p. 43. [9] V. A. Entwistle et al., “Supporting Patient Autonomy: The Importance of Clinician-Patient Relationships,” Journal of General Internal Medicine 25, no. 7 (July 2010): 741–45; C. Foster, Choosing Life, Choosing Death: The Tyranny of Autonomy in Medical Ethics and Law, 1st ed. (Oxford ; Hart Publishing, 2009); O. O’Neill, Autonomy and Trust in Bioethics, The Gifford Lectures, University of Edinburgh 2001 (Cambridge, UK: Cambridge University Press, 2002). [10] P. Marshall and B. Koenig, “Accounting for Culture in a Globalized Bioethics,” The Journal of Law, Medicine & Ethics: A Journal of the American Society of Law, Medicine & Ethics 32, no. 2 (2004): 252–66; R. Fan, “Self-Determination vs. Family-Determination: Two Incommensurable Principles of Autonomy,” Bioethics 11, no. 3–4 (1997): 309–22. [11] Arguments stressing the importance of beneficence, as ours does here, certainly approach paternalistic arguments. We set aside the complex issue of paternalism for purposes of this paper and simply note that the principle of beneficence as such does not say anything specifically about acting against the patient’s will. In the case study that focuses this paper, we do not believe the patient’s will or wishes were clearly indicated. [12] Beauchamp and Childress, Principles of Biomedical Ethics, p. 20, see note 2 above. [13] H. S. Richardson, “Specifying, Balancing, and Interpreting Bioethical Principles,” The Journal of Medicine and Philosophy: A Forum for Bioethics and Philosophy of Medicine 25, no. 3 (January 1, 2000): 285–307, p. 287. [14] H. D. Braude, Intuition in Medicine a Philosophical Defense of Clinical Reasoning (Chicago ; University of Chicago Press, 2012). [15] R. Kukla, “Conscientious Autonomy: Displacing Decisions in Health Care,” The Hastings Center Report 35, no. 2 (2005): 34–44. [16] M. Schermer, The Different Faces of Autonomy: Patient Autonomy in Ethical Theory and Hospital Practice, vol. 13, Library of Ethics and Applied Philosophy (Dordrecht: Springer Netherlands, 2002). [17] E. D. Pellegrino and D. C. Thomasma, For the Patient’s Good - the Restoration of Beneficence in Health Care (New York, NY: Oxford University Press, 1988), p. 29. [18] Pellegrino and Thomasma, For the Patient’s Good. 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Most regulations and guidelines require that potential research participants be told a great deal of information during the consent process. Many of these documents, and most of the scholars who consider the consent process, assume that all this information must be disclosed because it must all be understood. However, a wide range of studies surveying apparently competent participants in clinical trials around the world show that many do not understand key aspects of what they have been told. The standard view (...) of the conditions for valid consent therefore implies that these people have failed to give valid consent to research participation. In this paper we argue that the standard view is false. The primary function of the requirement that researchers disclose information about a study is the avoidance of illegitimate control over someone’s consent decision, which is a form of fraud.We derive the content and manner of appropriate disclosure by analysing the ways in which the manipulation of information can invalidate consent. Our analysis shows that the informational requirements for valid consent are conceptually distinct and thus unlikely to have identical contents. This implies that consent can be valid when not everything that ought to be disclosed by the person asking for consent is understood by the person who proffers it. (shrink)

Both the recent 'Warner' review of the UK research ethics committee (REC) system and the subsequent consultation document produced by the Central Office for Research Ethics Committees (COREC) emphasize the need to distinguish 'research' from what might be termed 'non-research'. This is to be determined through a process of filtering or 'triage', the intention being that RECs will avoid considering proposals with 'no material ethical issues'. In this paper we argue that trying to distinguish 'true' research from other projects is (...) counterproductive, misleading and potentially unethical. Our case is built around three assertions: (1) the distinction between research and non-research is imprecise; (2) both medical research and non-research can generate similar ethical issues; and (3) projects should be judged according to what they involve, not how they are labelled. (shrink)

Ancient medical and healing systems are currently attracting considerable interest. This issue includes interdisciplinary studies which focus on new perceptions of some ancient and medieval medical systems, exploring how they related to each other, and assessing their contribution to modern society. It is shown that pre-Greek medicine included some rational elements, and that Egyptian and Babylonian medical systems contributed to a tradition which led from classical antiquity through the Middle Ages and beyond. The reliability of sources of (...) evidence is considered, as well as the legacy of the ancient healing environments and disease treatments. Finally, where documentation survives, the legacy of social attitudes to health and disease is considered. Overarching principles directed policies of social medicine and healthcare in antiquity and the Middle Ages: for example, the causes and transmission routes of infectious diseases, as well as the basic principles of sterilization, were unknown, but nevertheless attempts were made to improve sanitation, provide clean water, and ensure access to trained physicians. In some cases, the need to limit the size of the population prompted the use of contraceptive measures, and surviving information also illuminates attitudes to deformity, disability and the treatment of the terminally ill. (shrink)

This book is an annotated translation of Xu Shuwei’s collection of 90 medical case records – Ninety Discussions of Cold Damage Disorders – which was the first such collection in China. The translation reveals patterns of social as well as medical history. This book provides the readers with a distinctive first hand perspective on twelfth-century medical practice, including medical aspects, such as nosology, diagnosis, treatment, and doctrinal reasoning supporting them. It also presents the social aspect of (...) medical practice, detailing the various participants in the medical encounter, their role, the power relations within the encounter, and the location where the encounter occurred. Reading the translation of Xu’s cases allows the readers high-resolution snapshots of medicine and medical practice as reflected from the case records documented by this leading twelfth-century physician. The detailed introduction to the translation contextualizes Xu’s life and medical practice in the broader changes of this transformative era. (shrink)

Reliable reconstruction of historical – cultural past, including the past related to medical culture, remains an important methodological task. However, most documents and materials traditionally used for such reconstructions are often "mythologems", influenced by official ideology. Inevitably, the historical-cultural context is replaced by the historical-clinical one. The researcher is transferred from the field of culture to the space of professional constructions that impoverish our ideas about such elusive phenomena as medical ethics, body practices, attitudes to illness and health. (...) The article substantiates the possibility of using literary texts as complementary discourses for such reconstructions. Important topics in the development of medicine can be clarified using literary reflection. (shrink)

This document is designed to give guidance on assessing researchers in bioethics/medical ethics. It is intended to assist members of selection, confirmation and promotion committees, who are required to assess those conducting bioethics research when they are not from a similar disciplinary background. It does not attempt to give guidance on the quality of bioethics research, as this is a matter for peer assessment. Rather it aims to give an indication of the type, scope and amount of research that (...) is the expected in this field. It does not cover the assessment of other activities such as teaching, policy work, clinical ethics consultation and so on, but these will be mentioned for additional context. Although it mentions the UK’s Research Excellence Framework, it is not intended to be a detailed analysis of the place of bioethics in the REF. (shrink)

In the past few years, machine learning (ML) tools have been implemented with success in the medical context. However, several practitioners have raised concerns about the lack of transparency—at the algorithmic level—of many of these tools; and solutions from the field of explainable AI (XAI) have been seen as a way to open the ‘black box’ and make the tools more trustworthy. Recently, Alex London has argued that in the medical context we do not need machine learning tools (...) to be interpretable at the algorithmic level to make them trustworthy, as long as they meet some strict empirical desiderata. In this paper, we analyse and develop London’s position. In particular, we make two claims. First, we claim that London’s solution to the problem of trust can potentially address another problem, which is how to evaluate the reliability of ML tools in medicine for regulatory purposes. Second, we claim that to deal with this problem, we need to develop London’s views by shifting the focus from the opacity of algorithmic details to the opacity of the way in which ML tools are trained and built. We claim that to regulate AI tools and evaluate their reliability, agencies need an explanation of how ML tools have been built, which requires documenting and justifying the technical choices that practitioners have made in designing such tools. This is because different algorithmic designs may lead to different outcomes, and to the realization of different purposes. However, given that technical choices underlying algorithmic design are shaped by value-laden considerations, opening the black box of the design process means also making transparent and motivating (technical and ethical) values and preferences behind such choices. Using tools from philosophy of technology and philosophy of science, we elaborate a framework showing how an explanation of the training processes of ML tools in medicine should look like. (shrink)

Codes of medical ethics (codes) are part of a longstanding tradition in which physicians publicly state their core values and commitments to patients, peers, and the public. However, codes are not static. Using the historical evolution of the Canadian Medical Association's Code of Ethics as an illustrative case, we argue that codes are living, socio-historically situated documents that comprise a mix of prescriptive and aspirational content. Reflecting their socio-historical situation, we can expect the upheaval of the COVID-19 pandemic (...) to prompt calls to revise codes. Indeed, Alex John London has argued in favour of specific modifications to the World Medical Association's International Code of Medical Ethics (which has since been revised) in light of moral and scientific failures that occurred during the COVID-19 pandemic. Responding to London, we address the more general question: should codes be modified to reflect lessons drawn from the COVID-19 pandemic or future such upheavals? We caution that codes face limitations as instruments of policy change because they are inherently interpretive and ‘multivocal’, that is, they usually underdetermine or provide more than one answer to the question, ‘What should I do now?’ Nonetheless, as both prescriptive and aspirational documents, codes also serve as tools for reflection and deliberation—collective practices that are necessary to engaging with and addressing the moral and scientific uncertainties inherent to medicine. (shrink)