Background: Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients’ rights, and nurses’ duties. Objectives: This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed. Research design: In this descriptive–comparative study, data were collected using three questionnaires based on Iranian nurses’ ethical codes (...) with a focus on clinical care. The reliability of the questionnaire was verified by test–retest method (r = 0.9). The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software (v 15). Participants and research context: In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014. Ethical considerations: This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents. Findings: According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes as satisfactory. The mean scores (standard deviation) of the level of adherence to ethical codes were 38.44 (6.91) in the patients, 41.08 (4.82) in the nurses, and 37.83 (6.98) in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups (p = 0.001). Discussion: Nurses’ adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard. Conclusion: Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance. (shrink)

Background Discrimination in health care is an international challenge and a serious obstacle to justice and equality in health. Research objective The purpose of this study was to design a grounded theory of discrimination in health care based on the experiences and perceptions of Iranian healthcare providers and patients. Research design This qualitative study was conducted using by the grounded theory method. Participants and research context Data were collected through semi-structured interviews with 18 healthcare providers including 11 nurses, two physicians, (...) two nurse’s assistants, and three patients in two general hospitals in Tehran, Iran. Participants were selected through purposeful sampling and analyzed simultaneously using the Corbin and Strauss (2015) approach. Ethical considerations The study was approved by the Research Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Ethics code: IR.USWR.REC.1398.023). Also, after explaining the objectives of the study, all the participants completed and signed the written consent form. Findings The “culture of discrimination” was the study’s core category, reflecting the nature of discrimination in health care. The theory of “culture of discrimination in health care” is the result of five main categories: “individual social stimuli,” “culture of discrimination,” “unintentional discrimination,” “conflict with discrimination,” and “dissatisfaction with discriminatory behavior.” These categories cover the underlying factors, strategies, and outcomes of the discrimination process in health care. Discussion The results of the study showed that nurses and other health care providers experience unintentional discrimination. Unintentional discrimination refers to discriminatory behaviors and practices of health care providers. Conclusion The theory of culture of discrimination in health care can be used as a practical guide to describe and understand the role of health care providers, especially nurses. Further studies with a quantitative approach to applying this theory in medical settings are recommended. (shrink)

A new Turkish Penal Code came into effect on 1 June 2005. Article 280 concerns health care workers’ failure to report a crime. This article removes the responsibility from health care workers to maintain confidentiality, but also removes patients’ right to confidentiality. It provides for up to one year of imprisonment for a health care worker who, while on duty, finds an indication that a crime might have been committed by a patient and who does not inform the responsible (...) authorities about it. This forces the health care worker to divulge the patient’s confidential information. A patient who thinks he or she may be accused of a crime may therefore not seek medical help, which is the universal right of every person. The article is therefore contrary to medical ethics, oaths taken by physicians and nurses, and the understanding of patient confidentiality. (shrink)

This contribution deals with the issue of the professional autonomy ofthe medical doctor. Worldwide, the physician's autonomy is guaranteedand limited, first of all, by Codes of Medical Ethics. InItaly, the latest version of the national Code of MedicalEthics (Code 1998) was published in 1998 by the Federation ofprovincial Medical Associations (FnomCeO). The Code 1998acknowledges the physician's autonomy regarding the scheduling, thechoice and application of diagnostic and therapeutic means, within theprinciples of professional responsibility. This responsibility has tomake reference (...) to the following fundamental ethical principles:(1) the protection of human life; (2) the protection of thephysical and psychological health of the human being; (3) therelief from pain; (4) the respect for the freedom and the dignityof the human person, without discrimination; (5) an up-to-datescientific qualification (Art. 5). The authors underline that autonomyis an anthropological – and consequently ethical –characteristic of the human person. Different positions on autonomy inbioethics (individualistic, evolutionistic, utilitarian andpersonalistic models) are explained. The relation between theprofessional autonomy of the physician and the autonomy of the patientand of colleagues is discussed. In fact, the medical doctor isobliged: (1) to respect the fundamental rights of the person,first of all his/her life; (2) to ensure the continuity of thecare, even if he can only relieve the patient's suffering; (3) tomaintain, except under certain circumstances, professional secrecy andconfidentiality regarding patients and their medical records. Moreover,the physician cannot deny the patient correct and appropriateinformation. He/she should not perform any diagnostic or therapeuticactivity without the informed consent of the patient and the medicaldoctor must give up medical treatment in case of documented refusal ofthe individual. Furthermore, the medical doctor has the right to raiseconscientious objections if he/she is requested to perform medicalactions that are contrary to his/her conscience or medical opinion,unless this attitude would seriously and immediately harm the patient.Regarding the relationships with colleagues, the physician is obliged tosolidarity, mutual respect, and care of sick colleagues. Finally, theauthors discuss the Italian legislation affecting the physician'sprofessional autonomy: (1) the SSN health care Acts; (2) theso-called Charter for Public Health Care Services; (3) the Acts onprivacy; (4) Good Clinical Practice. (shrink)

Background: Discrimination and injustice are big obstacles in nurses’ way to socialization and are among the major clinical challenges faced by nurses. Workplace discrimination is associated with such negative consequences as stress, fatigue, demoralization, loss of professional commitment, tension and conflicts at work, and resignation. A review of literature shows that not much research has been dedicated to workplace discrimination in nursing. Objective: This study aims to investigate nurses’ perception of workplace discrimination. Method: This cross-sectional study was conducted in the (...) hospitals affiliated with a university of medical sciences in the largest city in the south of Iran in 2019. The participants consisted of 597 nurses who were selected through stratified random sampling. Data were collected using a researcher-made workplace discrimination questionnaire and analyzed in SPSS v. 21. Findings: The mean of the nurses’ workplace discrimination scores was found to be 102.57 ± 14.5, which is considered as moderate. The nurses’ mean scores for the dimensions of vertical and horizontal discrimination (44.53 ± 6.8), consequences of discrimination (20.52 ± 5.55), and unfair promotion (12.38 ± 2.44) were moderate. As for the two other dimensions of workplace discrimination, namely, gender discrimination (14.41 ± 3.28) and cultural-organizational discrimination (11.88 ± 2.99), the participants’ mean scores were low. There was a significant relationship between the nurses’ workplace discrimination mean score on the one hand and their employment status (p = 0.016) and work experience (p = 0.002) on the other. However, the nurses’ workplace discrimination mean score was not found to correlate with their level of education (p = 0.65), marital status (p = 0.274), and gender (p = 0.479). Ethical consideration: This study has been approved by the ethics committee of the university. All the participants had signed the written informed consent form before participation. Conclusion: Hospital managers should take measures to reduce discrimination and establish organizational justice to raise nurses’ morale and improve the quality of their performance as caregivers. (shrink)

Machine generated contents note: CHAPTER 1 HEALTH CARE PROFESSIONALS AND HIV: The Duty To WarnI -- CHAPTER 2 EMERGENCY CARE AND HIV: Treatment Policy and -- Pracice17 -- CHAPTER 3 A REVOLUTIONARY POLICY? Mandatory Disclosure of HIV -- Serostaus29 -- CHAPTER 4 MINORS AND HEALTH CARE: The Limits of Consent and -- Confidentiality39 -- CHAPTER 5 THE RIGHTS TO REFUSE AND DEMAND MEDICAL -- TREATMENT: The Bounds ofAutonomy andFutli{y47 -- CHAPTER 6 RELIGIOUS FREEDOM AND THE RIGHT TO REFUSE (...) CARE: -- What Are The Limits?65 -- CHAPTER 7 ASSISTED REPRODUCTIVE TECHNOLOGY: The Business of -- Making Babies 89 -- CHAPTER 8 TWINS AND TRANSPLANTS: Choosing Who Lives 113 -- CHAPTER 9 FREE ABORTION SERVICES AND FETAL TISSUE RESEARCH: -- Freedom of Choice and Coercion123 -- CHAPTER 10 PROPERTY RIGHTS, BODY PARTS, AND REPRODUCTION: -- Who Owns the Human Body? - 139 -- CHAPTER 11 OUTBREAK IN AMERICA: The Policy of Public Verses Private -- Interests 153 -- APPENDIX A CONFIDENTIALITY OF HIV TEST RESULTS: California Health -- and Safety Code Sections 120975 Through 121020169 -- APPENDIX B HEALTH CARE PROFESSIONALS AND HIV: Texas Health and -- Safety Code Section 58.204 175 -- APPENDIX C TARASOFF v, THE REGENTS OF THE UNIVERSITY OF -- CALIFORNIA: Supreme Court of California177 -- APPENDIX D THE RIGHTS OF MINORS TO CONSENT TO HEALTH CARE: -- California Family Code Sections 6903 Through 6929183 -- APPENDIX E FEDERAL DRUG AND ALCOHOL ABUSE CONFIDENTIALITY -- REGULATIONS: Title 42 Code of Federal Regulations Part 2 187 -- APPENDIX F CHILD ABUSE REPORTING LAWS: Caitfornia Penal Code -- Sections 11164 Through 11166 193. (shrink)

Parsa-Parsi et al assert that the International Code of Medical Ethics (ICoME) provides a professional standard that overrides conflicting national legal norms.1 While this claim is made in the context of laws that require doctors to participate in ‘acts of torture, or other cruel, inhuman, or degrading practices and punishments’ (para10 of ICoME), the underlying premise that medical ethics supersedes law requires scrutiny. It is clear that medical ethics and law are linked inextricably, but there is unresolved (...) debate about the sequence of this interaction: should ethics shape law; or is it the converse? Important principles, notably respect for patients’ autonomy, have arisen from case law and subsequently been adopted into medical ethics. As pointed out by Beauchamp and Childress, it is only ‘since the mid-1970s (that) the primary justification advanced for requirements of informed consent has been to protect autonomous choice’ (pg.118).2 Whereas, the legal obligation to respect autonomy can be traced to the early 1900s, in the landmark US case of Schloendorff v Society of New York Hospital : ‘Every human being of adult years and sound mind has a right to determine what shall be done with his own body’.1 Moreover, the term informed consent was born in law: it was coined …. (shrink)

Background Current requirements for ethical research in Canada, specifically the standard of active or signed parental consent, can leave Indigenous children and youth with inequitable access to research opportunities or health screening. Our objective was to examine the literature to identify culturally safe research consent processes that respect the rights of Indigenous children, the rights and responsibilities of parents or caregivers, and community protocols. Methods We followed PRISMA guidelines and Arksey and O’Malley’s approach for charting and synthesizing evidence. (...) We searched MEDLINE, PsycINFO, ERIC, CINAHL, Google Scholar, Web of Science, Informit Indigenous Collection, Bibliography of Native North Americans, and Sociological Abstracts. We included peer-reviewed primary and theoretical research articles written in English from January 1, 2000, to March 31, 2022, examining Indigenous approaches for obtaining informed consent from parents, families, children, or youth. Eligible records were uploaded to Covidence for title and abstract screening. We appraised the findings using a Two-Eyed Seeing approach. These findings were inductively coded using NVivo 12 and analyzed thematically. Results We identified 2,984 records and 11 eligible studies were included after screening. Three key recommendations emerged: addressing tensions in the ethics of consent, embracing wise practices, and using relational approaches to consent. Tensions in consent concerned Research Ethics Board consent requirements that fall short of protecting Indigenous children and communities when culturally incongruent. Wise practices included allowing parents and children to consent together, land-based consenting, and involving communities in decision-making. Using relational approaches to consent embodied community engagement and relationship building while acknowledging consent for Indigenous children cannot be obtained in isolation from family and community. Conclusions Very few studies discussed obtaining child consent in Indigenous communities. While Indigenous communities are not a monolith, the literature identified a need for community-driven, decolonized consent processes prioritizing Indigenous values and protocols. Further research is needed to examine nuances of Indigenized consent processes and determine how to operationalize them, enabling culturally appropriate, equitable access to research and services for all Indigenous children. (shrink)

In this paper I am concerned to address the question of voluntary or self‐willed death from two distinct positions—a particular community's socio‐religious practice (viz. Jaina sallekhanā) and as the matter stands in law (penal code, constitution, judicial wisdom, etc.) in India—in the light of the recent move by a bench of its apex court striking down the penal code section proscribing suicide. I also wish to draw out some implications of these deliberations for the beneficence of medical (...) practice and related bio‐ethical ramifications in the Indian context. (shrink)

This code of practice for health professionals was prepared by a multi-professional group and reflects good clinical practice in encouraging dialogue about individuals' wishes concerning their future treatment. It has a broad practical approach, considers a range of advance statements, advises of dangers and benefits of making treatment decisions in advance and combines annotated code of practice with a quick pull out guide for easy reference.

The meaning of justice can be defined according to a juridical, human, theological, ethical, biomedical, or social perspective. It should guarantee the protection of life and health, personal, civil, political, economic, and religious rights, as well as non-discrimination, inclusion, protection, and access to care. In this review, we deal with three theoretical concepts that define justice in all its aspects. (1) The utilitarian theory, which justifies moral statements on the basis of the evaluation of the consequences that an action (...) produces, elaborating a pragmatic model of medical science. (2) The libertarian theory, which considers freedom as the highest political aim, thus absolutizing the rights of the individual; here, the principle of self-determination, with respect to which the principle of permission/consent is the fundamental presupposition, plays a central role in the definition of the person. (3) The iusnaturalist theory, in which man’s moral freedom is identified with the ability to act by choosing what the intellect indicates to him as good; the natural moral law that drives every conscience to do good is therefore realized in respect for the person in the fullness of his rights. In conclusion, different forms and conceptions of justice correspond to different organizations of society and different ways of addressing ethical issues in the biomedical domain. (shrink)

Background: Spiritual development is one of the most important aspects of socialization that has attracted the attention of researchers. It is needed to train nursing student and novice nurses to provide high-quality care for patients. There is ambiguity in the definition of spiritual development and its relations, especially in the eastern countries. Research objectives:: To explore the concept of spiritual development in Iranian nurses. Research design: Qualitative content analysis approach. Data were gathered from semi-structured interviews. Participants and research context: The (...) participants were 17 Iranian Muslim nurses selected using a purposeful sampling. The place of interviews was on their choice. Ethical considerations: Based on the principles of the Helsinki declaration, the focus was on preserving the participants’ autonomy, confidentiality, and anonymity. The participants were told the study purposes and trends, and their rights were emphasized; they were then asked to sign written consent forms. Formal research approval was obtained from Kerman University of Medical Sciences. Ethical approval was granted by the University Ethics Committee before the study was conducted (K/92 etc). Findings: Three themes for spiritual development were defined: obligation to religion, commitment to ethics, and commitment to law. From the results, factors such as connection to the limitless divine power, personal and society-oriented ethical codes, and commitment to the law are proposed. Discussion: There are some differences between these findings and previous study, especially in the relation of the spirituality, religion, and law. Some studies, mostly Iranian, support these findings partially. Conclusion: The results suggest that it is better to teach nursing education based on humanistic principles, ethics, and law to the new generation of nurses to improve community health and development. More studies are needed to examine the relation between these themes. (shrink)

Background: Ethics education is a basic part of midwifery education program. However, there is no evidence to show that ethics education has been able to meet the educational needs of midwifery students. Purpose: This study aimed to explore the educational needs of students for ethics in midwifery program with a focus on the course of history, ethics, and rules of midwifery. Research design and participants: The present study is qualitative descriptive content analysis research, exploring midwifery students’ needs of ethics education (...) in bachelor’s degrees. We conducted in-depth semi-structured interviews with 11 undergraduate midwifery students, seven midwives working in hospitals and health centers, and seven midwifery faculty members in Urmia University of Medical Sciences. The participants were selected using a purposeful sampling method and invited to join the study from December 2021 to June 2022. The sampling continued until data saturation. Findings: Content analysis identified four categories and associated subcategories: 1. “The client’s rights”: respecting the dignity of clients, confidentiality, the client’s right to choose and make decisions; 2. “Legal and ethical requirements of fertility”: abortion, alternative treatment for infertility, domestic violence; 3. “Communication skills”: communication with the client, communication with clients’ caregivers and communication with colleagues; and 4. “ethical principles in research”: compliance with ethical principles in the research process and ethical principles in publishing research findings. Ethical considerations: The study was approved by the Ethics Committee of Urmia University of Medical Sciences. Before filling the questionnaires, written informed consent was obtained from the participants. The participants were assured of the confidentiality of personal information. Conclusion: The educational needs of midwifery students can be met by providing theoretical and practical training on respecting the pregnant mother, communication skills, legal and ethical aspects of the reproductive period, and incorporating ethical principles in related courses. (shrink)

Respect for confidentiality is firmly established in codes of ethics and law. Medical care and the patients' trust depend on the ability of the doctors to maintain confidentiality. Without a guarantee of confidentiality, many patients would want to avoid seeking medical assistance The principle of confidentiality, however, is not absolute and may be overridden by public interests. On some occasions (birth, death, infectious disease) there is a legal obligation on the part of the doctor to disclose but only (...) to the appropriate authorities. Permissible disclosure can be granted by the patients' consent, for example, for the purpose of insurance they may wish to take out. Moreover, there are some ambivalent situations (such as criminal acts, or notification of sexual partner in case of a patient with AIDS) for which Greek law does not include relevant provisions, and the Codes of Medical Ethics do not offer clear guidelines. Therefore, the Greek doctor is called to estimate the situation and assume full responsibility for his decision. Finally, new considerations have arisen in the context of the recent advances in the field of telemedicine and electronic archiving. The paper discusses the current situation and legislation in Greece. (shrink)

Sex offenders are sometimes offered or required to undergo pharmacological interventions intended to diminish their sex drive (anti-libidinal interventions or ALIs). In this paper, we argue that much of the debate regarding the moral permissibility of ALIs has been founded on an inaccurate assumption regarding their intended purpose—namely, that ALIs are intended solely to realise medical purposes, not correctional goals. This assumption has made it plausible to assert that ALIs may only permissibly be administered to offenders with their valid (...) consent, in line with the approach taken to most other interventions with a medical aim. However, we argue that, contrary to this assumption, the state's intention in relation to at least some ALIs is, at least in part, to achieve correctional objectives. We evaluate two legal regimes for ALI provision—section 645 of the California Penal Code and the mental health regime in England and Wales. In each case, we identify the state's implicit purpose in imposing ALIs and argue that the Californian and English regimes both serve as counterexamples to the view that ALIs are intended solely for medical purposes. While the moral implications of our argument are not straightforward, it raises the question whether consent is required for permissible imposition of ALIs, and more generally, whether the moral permissibility of crime-preventing interventions using medical means should be assessed against the standards of medical ethics or against those of criminal justice ethics. (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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The 3rd Pan-African Ethics Human Rights and Medical Law (3rd EHRML) conference was held in Johannesburg on July 7, 2013, as part of the Africa Health Congress. The conference brought together bioethicists, researchers and scholars from South Africa, Zimbabwe, Kenya and Nigeria working in the field of bioethics as well as students and healthcare workers interested in learning about ethical issues confronting the African continent. The conference which ran with a theme of "Bioethical and legal perspectives in biomedical (...) research and medical practice in Africa with a focus on: Informed consent, HIV-AIDS & Tuberculosis, leadership & organizational ethics, patients and healthcare workers rights," was designed to expand the dialogue on African bioethics beyond the traditional focus on research ethics and the ethical dilemmas surrounding the conduct of biomedical research in developing countries. This introductory article highlights some of areas of focus at the conference including issues of leadership, organizational ethics and patients and healthcare workers rights in Africa. We analyze the importance of free speech, public debate of issues, argumentation and the need to introduce the teaching and learning of ethics to students in Africa in accordance with UNESCO guidelines. This article also focuses on other challenges confronting Africa today from an ethical standpoint, including the issues of poor leadership and organizational ethics which are main contributors to the problems prevalent in African countries, such as poverty, poor education and healthcare delivery systems, terrorism, social inequities, infrastructural deficits and other forms of 'structural violence' confronting vulnerable African communities. We believe that each of the eight articles included in this supplement, which have been rigorously peer-reviewed are a good example of current research on bioethics in Africa, and explore some new directions towards broadening the African bioethics agenda as we move forward to a new dawn for Africa in the 21st century. (shrink)

Background: Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision. Objectives: The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel. Methods: In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the data were (...) collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach. Ethical considerations: Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality. Findings: The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes. Conclusion: Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them. (shrink)

Carte Blanche is the alarming tale of how the right of Americans to say "no" to risky medical research is eroding at a time when we are racing to produce a vaccine and treatments for Covid-19. This medical right that we have long taken for granted was first sacrificed on the altar of military expediency in 1990 when the Department of Defense asked for and received from the FDA a waiver that permitted it to force an experimental anthrax (...) vaccine on the ranks of ground troops headed for the Persian Gulf. Since then, the military has pressed ahead to impose nonconsensual testing of the blood substitute PolyHeme in civilian urbanities, quietly enrolling more than 20,000 non-consenting subjects since 2005. Most Americans think that their right to give or withhold consent is protected by law, but the passing in 1996 of modifications to the Code of Federal Regulations, such as statute CFR 21 50.24, now permit investigators to conduct research with trauma victims without their consent or event their knowledge. More than a dozen studies since have used the 1996 loophole to recruit large numbers of subjects without their knowledge. The erosion of consent is the result of a U.S. medical-research system that has proven again and again that it cannot be trusted. (shrink)

Informed consent is one of the foundational ethical and legal requirements of research with human subjects. The Nuremberg Code, the Helsinki Declaration, the Belmont Report, the Common Rule and many other laws and codes require that research subjects make a voluntary, informed choice to participate in research.12345 Informed consent is based on the moral principle of respect for autonomy, which holds that rational individuals have a right to make decisions and take actions that reflect their values and preferences. 6 Whereas (...) most guidelines and codes also require that informed consent be properly documented, informed consent is much more than signing a piece of paper: It is a continuous process of communication between the investigator and the research subject. 7 Because the body of knowledge impacting a study frequently changes, subjects should receive information from investigators after they have enrolled in a study, such as significant new findings that may affect their decision to participate in research or clinically useful tests results. 8910 In large studies, some investigators use newsletters to update subjects on the progress of research and other developments.11Most of the ongoing communications between investigators and subjects involve little more than information sharing, without revisiting the decision to participate in research or signing any additional documents. Sometimes, however, it may be necessary for subjects to reaffirm their decision to participate, to re-consent, or to sign or re-sign a document. 8 Re-consent can be defined as an action in which a subject makes the decision to participate in research once again. Re-consent is different from reaffirming a commitment to participate in a study, because in re-consent one actually reconsiders the information necessary to make decision, whereas in reaffirmation one simply expresses …. (shrink)

Euthanasia and assisted dying are illegal in India according to Sections 306 and 309 of the Indian Penal Code, and Article 21 of the Constitution of India. There have been a number of cases where the Indian High Courts and Indian Supreme Court issued differing verdicts concerning the right to life and the right to die. Nevertheless, on 7 March 2011, a paradigm shift happened as a result of the Indian Supreme Court's judgment on involuntary (...) passive euthanasia in the case of Aruna Shanbaug. In its judgment, the Supreme Court requested the government to prepare a law on euthanasia. Accordingly, the 241st Report of the Law Commission of India proposed a bill to permit passive euthanasia. In May 2016 the Ministry of Health and Family Welfare issued the draft bill for public comment in order to create an informed decision. The Indian people are divided on the issue of euthanasia. The majority of the scientific community welcome it, while some religious groups oppose it. Hindus, in general, express both supporting and opposing views on euthanasia, whereas, Christians and Muslims have hardened their opposition against it. The Supreme Court judgment and the Report of the Law Commission pave the way for the development of new policies pertaining to passive euthanasia by the central government of India. Once such legislation is passed, passive euthanasia may, and probably will, have an enormous impact on the cultural, political, public and medical spheres of India in the near future. (shrink)

Paragraph 12 of the revised International Code of Medical Ethics (ICoME) states that ‘the physician should strive to practise medicine in ways that are environmentally sustainable with a view to minimising environmental health risks to current and future generations.’1 This emphasis on environmental sustainability is in line with popular discourse as well growing scholarly attention in medical ethics for healthcare’s contribution to climate change. Recent research analyses, for instance, the ‘greening’ of informed consent and related bioethical principles.2 3 (...) It is unclear what the duty of practising sustainable healthcare means at the level of doctor–patient interaction. Parsa-Parsi et al flag the potential conflict in the ICoME’s provisions if ‘the actions of physicians are influenced by environmental considerations to the detriment of patients’ (p. 2), noting that the ICoME does not provide a handhold to improve understanding of such tensions. The code ‘does not go into extensive detail, does not include comprehensive explanations nor any rules or guidance on how to reconcile its principles when they conflict’ (p. 4). For Parsa-Parsi et al, not codes, but textbooks have a crucial role to play in resolving this conflict. It is rife that professional codes can lead to internal inconsistencies and …. (shrink)

The practice of covertly administering medications to patients without their consent is often discussed in the framework of legal questions around the right of patients to consent and refuse medical treatment. However, this practice also raises significant questions surrounding the professional duties and obligations of health care professionals as it relates to the decision-making process of whether to engage in the covert administration of medications. In this paper, I present an overview of the origin of those duties and obligations, (...) and discuss how those duties and obligations when seen from different perspectives may either justify or prohibit the practice. Further, I discuss whether the duties and obligations of health care professionals as they are currently framed are suited to address the complexities of this issue both from the health care professional and patient perspectives. This analysis is conducted in the context of duties and obligations that arise from not only legal framework but also from the ethical requirements from professional codes of ethics. (shrink)

In _Pharmaceutical Freedom_ Professor Flanigan argues we ought to grant people self-medication rights for the same reasons we respect people’s right to give (or refuse to give) informed consent to treatment. Despite being the most comprehensive argument in favour of self-medication written to date, Flanigan’s _Pharmaceutical Freedom_ leaves a number of questions unanswered, making it unclear how the safe-guards Flanigan incorporates to protect people from harming themselves would work in practice. In this paper, I extend Professor Flanigan’s account (...) by discussing a hypothetical case to illustrate how these safe-guards could work together to protect people from harms caused by their own ignorance or incompetence. (shrink)

This chapter provides a brief introductory history of biomedical practitioners’ efforts at self-regulation though oaths, codes, and statements of ethical principle, tracing them from ancient oaths through the nineteenth-century transition to codes of medical ethics. The more recent foundation for modern biomedical ethics was laid in post-World-War II oaths and codes written in the aftermath of the Holocaust, and later modified in response to animal rights and patients’ rights movements that promoted principles and practices enforced by (...) semi-self-regulatory acronym-laden ethics committees— HECs, IACUCs, IRBs/REBs/RECs. The last section of this chapter discusses the modern origins of self-regulatory ethical principles for benchside biomedicine and biomedical publications. (shrink)

The “Universal Declaration of Human Rights” and the “Geneva Declaration” by the World Medical Association, both in 1948, were preceded by the foundation of the United Nations in New York (1945), the World Medical Association in London (1946) and the World Health Organization in Geneva (1948). After the end of World War II the community of nations strove to achieve and sustain their primary goals of peace and security, as well as their basic premise, namely the health (...) of human beings. All these associations were well aware of the crimes by medicine, in particular by the accused Nazi physicians at the Nuremberg Doctors Trial (1946/47, sentence: August 1947). During the first conference of the World Medical Association (September 1947) issues of medical ethics played a major role: and a new document was drafted concerning the values of the medical profession. After the catastrophe of the War and the criminal activities of scientists, the late 1940s saw increased scrutiny paid to fundamental questions of human rights and medical ethics, which are still highly relevant for today’s medicine and morality. The article focuses on the development of medical ethics and human rights reflected in the statement of important persons, codes and institutions in the field. (shrink)

The massive growth in global health research in past decades has posed many challenges for its effective ethical oversight, not least of which is how best to provide effective protection of research participants. The extent of the HIV epidemic in sub-Saharan Africa in particular makes research into prevention technologies for HIV, including HIV vaccine research, a global priority. However, the need for vaccine research must be considered in conjunction with the individual's right to informed consent, which is based on the (...) principle of respect for autonomy. One of the primary human rights violations likely to occur in the context of HIV vaccine research is that potential research participants may not fully understand what participation in research studies entails. People who elect to enrol in HIV vaccine trials are required to understand both the potential negative effects of participation (eg, discrimination) as well as complex scientific concepts such as randomisation and prophylaxis in order to be ethically enrolled. In this study, two vignettes are presented to illustrate two core issues in conducting phase III HIV vaccine trials in low-income countries—namely, (1) from the perspective of participants, the extent to which understanding is a prerequisite for consenting to participate in a trial, and (2) from the perspective of trial investigators, whether it is appropriate to persuade eligible people to enrol in a trial, even though their initial reaction is to decline to participate. These vignettes are used to analyse these issues through the prisms of research ethics and human rights in order to identify helpful synergies. It is argued that the human rights perspective provides a helpful lens on ethical issues. (shrink)

Increasing attention is being paid to the potential of anti-retroviral treatment for HIV prevention. The possibility of eliminating HIV from a population through a universal test and treat intervention, where all people within a population are tested for HIV and all positive people immediately initiated on ART, as part of a wider prevention intervention, was first proposed in 2009. Several clinical trials testing this idea are now in inception phase. An intervention which relies on universally testing the entire population for (...) HIV will pose challenges to human rights, including obtaining genuine consent to testing and treatment. It also requires a context in which people can live free from fear of stigma, discrimination and violence, and can access services they require. These challenges are distinct from the field of medical ethics which has traditionally governed clinical trials and focuses primarily on patient researcher relationship. This paper sets out the potential impact of a population wide treatment as prevention intervention on human rights. It identifies five human right principles of particular relevance: participation, accountability, the right to health, non-discrimination and equality, and consent and confidentiality. The paper proposes that explicit attention to human rights can strengthen a treatment as prevention intervention, contribute to mediating likely health systems challenges and offer insights on how to reach all sections of the population. (shrink)

Informed consent forms have been useful in clinical practice and they constitute a part of the shared decision making in the informed consent process. They provide information to patients about clinical procedures and techniques. They also act as a remainder of the information discussed after the medical interview. Sometimes these documents are not readable to everybody. Belgian law specifies that all information that patients receive has to be proportionate verbally, but written information is also handled. The present research (...) analyzes the readability of the Flemish informed consent forms located in the webs of all General Hospitals using a simple random sample of 75 informed consent forms. By using the Douma tool, which bases its analysis in the length of words and sentences, the readability mean of the sample was 46, level “Difficult”. The 59% of them had a difficult level. The 11% were normal. It is a fact, then, that the 59% of the informed consent forms evaluated in this study are not suitable for everybody in Flanders, especially those people with low literacy. There were some researches made in other countries that agreed with these results. Written clinical information was poorly written so the informed consent forms were not working helping patients to recall information nor helping patients to become a part in the shared decision making about their health. The use of readability formulas represented a simple way to discriminate those informed consent forms that had normal readability scores from those that should be adapted. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 14.4 (2004) 411-425 [Access article in PDF] Vulnerability, Vulnerable Populations, and Policy Mary C. Ruof "Special justification is required for inviting vulnerable individuals to serve as research subjects and, if they are selected, the means of protecting their rights and welfare must be strictly applied."Guideline 13: Research Involving Vulnerable Persons International Ethical Guidelines for Biomedical Research Involving Human Subjects Council for International Organizations (...) of Medical Sciences (CIOMS) and World Health Organization (WHO) Geneva, Switzerland, 2002 Within medical research and healthcare certain groups are afforded special protections and services because of their designation as vulnerable. The vulnerable require special justification to participate in human subject research in order to eliminate potential human rights abuses. The Nuremberg Code of 1947 was written in response to the extreme human subject abuses that occurred under the Nazi regime, and, although the intent of the 1947 Code was to protect human rights, rigid voluntary consent requirements deprived some individuals of the right to participate in clinical trials. Recent human research guidelines, such as the CIOMS/WHO guidelines referenced above and the guidelines referenced in Section V of this Scope Note, attempt to balance both protection from abuse in research and access to new, experimental treatments for the vulnerable.Although various protective guidelines stipulate special protections for vulnerable populations, the concept of vulnerability and consequently the criteria designating vulnerable populations remain vague. Precisely who are the vulnerable? The word "vulnerability" stems from the Latin vulnerare, "to wound." (Oxford Encyclopedic English Dictionary 1995). In clinical research, the term [End Page 411] vulnerable generally is applied to individuals who are unable to give informed consent or who are susceptible to coercion. The Common Rule (45 CFR 46, Subpart A) includes as vulnerable research subjects: children, prisoners, pregnant women, and persons who are handicapped, mentally disabled, economically disadvantaged, or educationally disadvantaged. Although the Common Rule specifies certain vulnerable categories, the guidelines were not intended to be exclusive, leaving open the interpretation of vulnerability.In medical research and health policy, vulnerability is an abstract concept that has concrete effects both for those labeled vulnerable and for those not. Clinical researchers, healthcare workers, ethical reviewers, and policymakers must be able to identify vulnerable subjects to establish how healthcare resources will be allocated and who will qualify for special protections and socialized benefits. Attempts to quantify vulnerability in clear, measurable ways have met little if any consensus. As Alexander Morawa (II, 2003, p. 150) states, "There is no single approach to definition of vulnerability. In fact, there is no purposeful categorisation at all."Difficulties in defining vulnerability have prompted discourse surrounding its utility as a qualifying factor in the allocation of health resources and its appropriateness as a guiding principle in bioethics. Some of the authors cited in this Scope Note argue against the labeling and categorization of vulnerable individuals and populations. "Labeling individuals as 'vulnerable' risks viewing vulnerable individuals as 'others' worthy of pity, a view rarely appreciated" (III, Danis and Patrick 2002, p. 320). The categories of vulnerable groups listed under the Common Rule have been the source of controversy, "for example, many find the suggestion that pregnant women are vulnerable to be quite sexist" (IV, DeBruin 2001, p. 7). Instead of creating categories of vulnerable populations, would it not be better to derive an account of just treatment from a just social policy at large that encompasses human vulnerabilities (II, Brock 2002, p. 283).For some of the authors listed here, the concept of vulnerability is essential to bioethics. Robert Goodin (I, 1985, p. 107) writes that the vulnerability of other human beings is the source of our special responsibilities to them. In contrast to the four American principles of biomedical ethics—autonomy, nonmaleficence, beneficence, and justice—the four principles of European bioethics and biolaw include vulnerability along with autonomy, dignity, and integrity. According to, Jacob Dahl Rendtorff and Peter Kemp (I, 2000, p. 274) "the principle of vulnerability is ontologically prior to the other [European] principles, it expresses better than all of the other ethical principles... the finitude of the human condition."Some of the... (shrink)

Described as one of the two fathers of medical law, Professor Peter Skegg has been a leading figure in the study of law and medicine. Over a 46 year academic career at the University of Auckland, University of Oxford, and the University of Otago, Professor Skegg has helped develop the field of medical law into a burgeoning academic discipline and has provided intellectual guardianship for the practice of law and medicine. This collection brings together contemporaries, colleagues, and former (...) students of Professor Skegg to celebrate his enduring contribution to the study of medical law. This edited collection contains twelve essays written by a range of internationally recognised medical lawyers. The topics cover the regulation of medical practitioners, consent, rights in bodily material, euthanasia, compensation and ethical approval for medical research, treatment orders for mental health conditions, and surrogacy laws. Whilst some of the essays return to territory that has been initially surveyed by Peter s research and analysis, others touch upon some wider medical law topics, illustrating Peter s lasting contribution to medical law as well as mapping out some of the new frontiers for the discipline of medical law. Academics, students and practitioners, from a range of jurisdictions, who are interested in how the law governs the provision of healthcare will benefit reading the various essays contained here. In addition, anyone who has had the good fortune of working with, or learning from, Professor Skegg will also enjoy the opportunity to return to the field of study that he founded. (shrink)

Rapid Ethical Assessment is an approach used to design context tailored consent process for voluntary participation of participants in research including human subjects. There is, however, limited evidence on the design of ethical assessment in studies targeting cancer patients in Ethiopia. REA was conducted to explore factors that influence the informed consent process among female cancer patients recruited for longitudinal research from Addis Ababa Population-based Cancer Registry. Qualitative study employing rapid ethnographic approach was conducted from May–July, 2017, at the Tikur (...) Anbessa Specialized Referral Hospital. In-depth and key informants’ interviews were conducted among purposively selected 16 participants. Regular de-briefings among the study team helped to identify emerging themes and ensure saturation. Interviews and debriefings were tape recorded in Amharic, and transcribed and translated to English. Coding of the transcripts was facilitated by use of NVivo software. Thematic analysis was employed to respond to the initial questions and interpret findings. Perceived barriers to voluntary study participation included lack of reporting back study results of previous studies, the decision making status of women, hopelessness or fatigue in the patients, shyness of the women, data collectors approach to the patient, and patient’s time constraints. Most of the patients preferred oral over written consent and face-to-face interview over telephone interview. Provision of detail information about the study, using short and understandable tool, competent, compassionate and respectful enumerators of the same gender were suggested to assure participation. Due to the perceived severity, the use of the term “cancer” was associated with fear and anxiety. Alternatively, uses of phrases like “breast or cervical illness/disease” were suggested during patient interviews. Voluntary participation is not straight forward but affected by different factors. Using competent, compassionate and respectful enumerators, short and precise questioning tools to limit the time of the interview could improve voluntary participation. Moreover, careful consideration of the patients and families concept of the disease such as wording and information has to be taken into account. This assessment helped in improving the consent process of the ongoing project on breast and cervical cancer patients. (shrink)

Records the papers and commentaries, with an edited discussion, presented at an international consultation convened by the Council for International Organizations of Medical Sciences (CIOMS) to guide revision of the CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects. The Guidelines, first issued in 1982 and then revised in 1993, are being updated and expanded to address a number of new and especially challenging ethical issues. These include issues raised by international collaborative trials of drugs in developing countries, (...) especially expensive drugs, and the use of placebo controls in randomized clinical trials. Others arise from the complexity of research in human genetics, including stem-cell research, and in reproductive biology. Throughout, particular attention is given to the difficult questions that arose during the heated debate over trials in developing countries, of short-duration zidovudine (AZT) therapy to reduce perinatal transmission of HIV. The International Ethical Guidelines for Biomedical Research Involving Human Subjects set out a code of research ethics that is widely used by ethical review committees and other bodies responsible for reviewing and overseeing the ethical design of studies and conduct of research. The revision of the Guidelines is being coordinated by CIOMS, in collaboration with WHO. The consultation centered on seven specially commissioned papers, authored by international experts that explore some of the more difficult issues in depth. Each is followed by an invited commentary, often expressing opposing views, and a summary of the issues or conclusions that emerged during the subsequent debate. The first paper, on justice in international research, deals with the question of whether proposals for research to be conducted in a developing country should make provision for future access of the population involved to the interventions under investigation. Also considered are questions that arise when research uses populations in developing countries to investigate interventions that will be of exclusive benefit to the industrialized world. Case studies of recent drug trials and their research protocols are discussed to illustrate circumstances in which use of populations in developing countries is justified or constitutes exploitation. Ethical challenges of the randomized controlled trial are considered in the second paper, which includes a discussion on the equitable distribution of benefits and risks, the use of placebo for controls, and the obligation to ensure that the participation of controls does not compromise their medical care or endanger their health. A paper on informed consent in international health research considers how cultural factors influence communication and language in the informed-consent process and respect for privacy and confidentiality in the research. Subsequent papers address issues in genetics research and reproductive biology, including the moral status of fetuses and the use of embryos in research, and examine the contribution which international human rights instruments can make in the application of the general principles of ethics to research involving human subjects. The final paper gives an overview of capacity building and the role of communities in international biomedical research. (shrink)

The term informed consent does not have long historical roots. Until recent centuries, healthcare professionals were not held responsible for providing information to patients. The author reports a written consent from Anatolia dated almost five centuries ago. The contract was signed in 1539 in Gaziantep, Turkey (formerly known as Aintab, Ottoman Empire). The document, of course, differs from modern counterparts. It lacks details of interventions. The author believes this to be the first written consent in medical history. (...) Further investigations of court registers should be made to ascertain the earliest date of their appearance. (shrink)

Background Informed consent is often cited as the “cornerstone” of research ethics. Its intent is that participants enter research voluntarily, with an understanding of what their participation entails. Despite agreement on the necessity to obtain informed consent in research, opinions vary on the threshold of disclosure necessary and the best method to obtain consent. We aimed to investigate Australian researchers’ views on, and their experiences with, obtaining informed consent. Methods Semi-structured interviews were conducted with 23 researchers from NSW institutions, working (...) in various fields of research. Interviews were analysed and coded to identify themes. Results Researchers reported that consent involved information disclosure, understanding and a voluntary decision. They emphasised the variability of consent interactions, which were dependent on potential participants’ abilities and interests, study complexity and context. All researchers reported providing written information to potential participants, yet questioned the readability and utility of this information. The majority reported using signed consent forms to ‘operationalise’ consent and reported little awareness of, and lack of support in implementing more dynamic informed consent procedures, such as verbal informed consent, that was fit for the purposes of their studies. Views on Human Research Ethics Committees varied. Some reported inconsistent, arduous inputs on the information form and consent process. Others expressed reliance on HRECs for guidance, viewing them as institutional safeguards. Conclusions This study highlights the importance of transparent relationships, both between researchers and participants, and between researchers and HRECs. Where the relationship with study participants was reported as more robust, researchers felt that they were better able to ensure participants made better, more informed decisions. Where the relationship with HRECs was reported as more robust, researchers were more likely to view them as institutional safeguards, rather than as bureaucratic hindrances. Conscientious and mindful researchers are paramount to ensuring the procedure accommodates individual requirements. This study advocates that when designing ethical informed consent practices, researchers should be integrated as autonomous players with a positive input on the process, rather than, in the worst case, predatory recruiters to be curtailed by information forms and oversight. (shrink)

Drawing from a wide range of primary historical and sociological sources, this book presents medical ethics in China from a Chinese-Western comparative perspective, and in doing so it provides a fascinating exploration of cultural differences and commonalities exhibited by China and the West in medicine and medical ethics. The book focuses on a number of key issues in medical ethics including: attitudes towards foetuses; disclosure of information by medical professionals; informed consent; professional medical ethics; and (...) human rights. This careful examination not only provides insights into Chinese viewpoints, but also sheds light on the appropriate methods for comparative culture and ethical research. Through its analysis, Jing-Bao Nie seeks to put forward a theory of "transcultural bioethics", an ethical paradigm which upholds the primacy of morality whilst resisting cultural stereotypes, and appreciating the internal plurality, richness, dynamism and openness of medical ethics in any culture. Medical Ethics in China will be of particular interest to students and academics in the fields of Medical Law, Bioethics and Medical Ethics as well as Chinese/Asian Studies and Comparative (Chinese-Western) Cultural Studies. (shrink)

Twelve contributors discuss critical issues affecting medical ethics. Topics include: the normative principles of medical ethics, concepts of health and disease, the physician-patient relationship, human experimentation, informed consent, genetics, ethical issues in organ transplantation, and moral.

There is a global shortage of nurses that affects healthcare delivery, which will be exacerbated with the increasing demand for healthcare professionals by the aging population. The growing shortage requires an ethical exploration on the issue of nurse migration. In this article, we discuss how migration respects the autonomy of nurses, increases cultural diversity, and leads to improved patient satisfaction and health outcomes. We also discuss the potential for negative impacts on public health infrastructures, lack of respect for cultural diversity, (...) and ethical concerns related to autonomy and justice, including coercion and discrimination. This analysis is written from a rights-based ethics approach by referring to rights held by nurses and patient populations. Nurse migration highlights conflicts between nurses and between nurses and healthcare systems. Increased awareness of ethical challenges surrounding nurse migration must be addressed to enhance the well-being of nurses and patient populations. (shrink)

The Fourth Edition of this bestselling, highly regarded book has been fully revised to incorporate changes in law and clinical guidance making a vital impact on patient management, encompassing: The Equalities Act 2010 which provides a right of older people to treatment without discrimination ; Case law on withdrawing nutrition and hydration ; Updated guidance on resuscitation from the Resuscitation Council, the British Medical Association and the Royal College of Nursing ; The redefining of good medical practice by (...) the General Medical Council ; The abolition of the Liverpool Care Pathway with an updated guidance on end of life care and advance care planning. Expanded throughout, this new edition also integrates two entirely new chapters covering testamentary capacity and role of the physician, and religious beliefs and end of life issues. Its practical, reflective and informative approach continue to make it essential reading for all health professionals, particularly trainees, involved in making difficult decisions in the care of older persons. It is also highly recommended for undergraduate medical students. (shrink)

The transgender population generally faces rights violations and discrimination in their day-to-day lives, which was exacerbated during the recent pandemic. This necessitates close scrutiny from an ethics perspective. Following directives from a 2014 Supreme Court judgement, Kerala became the first Indian state to implement a comprehensive policy to enforce the constitutional rights of transgender people. Despite such positive actions, a basic social tendency not to respect gender diversity has led to discrimination and marginalization. This was very evident (...) during the pandemic. In this empirical work, we have documented the lives of the transgender community during the pandemic wherein they share experiences related to livelihood, interaction with the healthcare system, and acceptance in society vis-à-vis the pandemic. Simply providing third-gender status will not help the gender-marginalized community to grow to their fullest potential and have a better lifestyle on par with others in mainstream society. (shrink)

This bibliographical study involved first the exploitation of four data-banks: Medline, CNRS, Bioethics and AIDS, with the following key words (in conjunction with AIDS): ethics, human rights, confidentiality, legislation, jurisprudence. A total of 412 references were listed between 1983 and the end of 1987. Examination of the quantitative increase of articles over these years shows that, while references to AIDS and/or HIV infection--referred to as 'AIDS' for brevity--increased by about one third per year, the number of papers treating ethical (...) problems linked to AIDS doubled each year. This increase makes it clear that these problems are important and pressing, that they are evolving rapidly and can be given no easy solution. After reading and analysis of accessible articles in readily comprehensible languages, the different themes can be classified in two categories: 1: Measures intended to protect society (starting with the most coercive); quarantine and isolation; discriminatory measures concerning specific groups; non-respect of the confidential nature of medical information; application of the penal code; screening; obligatory declaration and registration; testing of blood given by donors; vaccination and medical innovations, therapeutic assays; information, education. 2. Measures intended to protect the individual: fundamental rights of the patient: his/her right to confidentiality, to information and to treatment; civil rights: civil liberty, right to education, right to work, etc...; rights of the healthy individual: right of those in contact with the patients, safety of hospital staff, of those receiving blood-transfusions, etc... The legislation adopted in the various countries and the main opinions to be found in these articles are listed and analysed, and for each particular theme it is possible to refer to a list of the 232 most important articles. While the debate seems to concentrate on the conflict between the right of society to protect itself against the spread of infection and the 'civil' rights of the infected minorities, our conclusion tends to reduce this antagonism, showing that, particularly as far as the confidential nature of medical information is concerned, measures intended to protect the individual also protect society. (shrink)

Part 1. Foundations -- Reasoning about ethics -- Ethical theories and perspectives -- Three core concepts in medical ethics : best interests, autonomy and rights -- An introduction to law -- Doctors and patients : relationships and responsiblities -- Part 2. Core topics -- Consent -- Capacity -- Mental health -- Confidentiality -- Resource allocation -- Children and young people -- Disability and disease -- Reproductive medicine -- End of life -- Organ transplantation -- Research -- Part 3. (...) Extensions -- Neuroethics -- Genethics -- Information ethics -- Public health ethics. (shrink)

Background: The ability to consent promotes children’s access to health services. Healthcare providers should assess and arrive at a clinical judgement about the child’s maturity and mental capacity to obtain valid consent. Research objective: The objective of the study was to determine practices employed by South African healthcare providers to obtain consent for treatment from children. Research design: A qualitative, explorative, descriptive research design was used and the study was contextual. Participants and research context: In all, 24 healthcare providers (professional (...) nurses and medical practitioners) were purposively sampled from a hospital and primary health clinics. Semi-structured interviews were used. Ethical consideration: Ethical approval was obtained from the Institutional Review Board and gatekeepers. Written informed consent was obtained from each participant. Findings: Healthcare providers’ current practices in obtaining consent from children revealed inconsistency in implementation as well as the yardstick used to determine children’s mental capacity. Building trust with children, sharing information and assessment were interlinked in obtaining consent. Discussion: The inconsistent practice has implications for children’s access to healthcare services. Conclusion: Inconsistent practices in the implementation of consent laws have the potential to violate children’s rights to bodily and psychological integrity, access to health services and having their opinions heard and be taken into consideration. Through uncovering the current perceptions and practices and a literature review, guidelines intended for use by the Department of Health could be developed. (shrink)

Consent forms given to potential subjects in research protocols typically contain a sentence like this: “You have a right to withdraw from this study at any time without penalty.” If you have ever served on an institutional review board or a research ethics committee, you have no doubt read such a sentence often. Moreover, codes of ethics governing medical research endorse such a right. For example, paragraph 24 of the Declaration of Helsinki says, “The subject should be informed of (...) the right… to withdraw consent to participate at any time without reprisal.” Similarly, section C of the Belmont Report says that subjects must be informed that they have the right “to withdraw at any time from the research.” And in section 46.116 of the Common Rule, it says that one of the elements of informed consent must include a statement that “the subject may discontinue participation at any time without penalty or loss of benefit to which the subject is otherwise entitled.”. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Nursing Ethics:A Selected Bibliography, 1987 to PresentDoris Mueller Goldstein (bio)The ethics of nursing is emerging as a discipline distinct from bioethics or medical ethics. Although these areas have many concerns in common, nurses are demonstrating that their perspective can make a unique contribution to ethical debate.An especially dynamic area of discussion within nursing ethics is the philosophy of caring. The work on moral development by Harvard educator Carol (...) Gilligan in her book, In a Different Voice, is pivotal in this discussion (IV B, Cooper 1989). Jean Watson, a nurse at the University of Colorado Center for Human Caring, also has written extensively on the philosophy of caring. She states that "an ethic of caring has a distinct moral position: caring is attending and relating to a person in such a way that the person is protected from being reduced to the moral status of objects...." (I, Watson 1988).Even as the philosophy of caring becomes more predominant, however, nurses today are often drawn away from the caring role by forces prevalent in the modern hospital. First, modern technology can divert the nurse's attention away from the patient and toward the operation of complex equipment, and second, large hospitals are often managed as bureaucracies (I, Fitzpatrick 1988).A recent study examined the frequency and seriousness of ethical issues encountered in nursing practice (IV A, Berger 1991). A survey instrument that included 32 potential ethical issues was developed by the authors. Respondents were asked to identify what kinds of issues concerned them and with what frequency, and to indicate what resources were used to cope with these dilemmas. The study found that nurses were frequently faced with inadequate staffing, heroic measures for prolonging life, inappropriate resource allocation, situations where patients are being discussed inappropriately, and coping with irresponsible activity of colleagues.The variety of ethical dilemmas encountered on a daily basis by nurses and their expressed interest in developing a moral grounding for the profession of [End Page 177] nursing, along with increased attention to ethical issues in nursing education have led to an explosion in the literature on these topics. In the preparation of this bibliography over 1,000 citations were retrieved in computer searches of various databases: BIOETHICSLINE, MEDLINE and CATLINE (National Library of Medicine), CINAHL (Current Index to Nursing and Allied Health Literature), BOOKS IN PRINT PLUS, and ETHX (the online public access catalog for articles at the National Reference Center for Bioethics Literature). What is offered here is a small sampling of that literature. Books and special issues of periodicals are briefly annotated, but citations to articles are simply arranged by broad subject, and within that, alphabetically by author. The subcategories reflect the topics receiving the most discussion in current literature.This bibliography updates "The Ethics of Nursing: A Selected Bibliography," by Doris Mueller Goldstein, which covered the earlier literature and was published as an appendix to Ethical Decision Making in Nursing Administration (I, Silva 1990).I. BooksAustralian Nursing Federation. Ethics: Nursing Perspectives, vol. 2. North Fitzroy, Victoria: The Federation, 1989. 102 p. (Publisher's address: 373-375 St. Georges Road, postal code 3068.) The National Professional Development Committee of Australia fostered the publication of a second volume of papers on nursing ethics. Articles cover patients' rights, ethical theory in decisionmaking behaviors, the nurse and the DNR order, and whistleblowing. Several appendices represent difficult-to-obtain documents, such as the RANF (Royal Australian Nursing Federation) position statements on terminal care, AIDS and occupational health, professional practice problems, and conscientious objection.Bandman, Elsie L., and Bandman, Bertram. Nursing Ethics Through the Life Span. 2nd ed. Norwalk, CT: Appleton & Lange, 1990. 288 p. Following an extensive review of the moral foundations of decision making in nursing, the authors take the reader through a chronology of nursing ethics issues as they occur in the human life span, beginning with the procreative family period and concluding with the end of life. Each chapter contains discussion questions—an aid to educators using this as a textbook.Benjamin, Martin, and Curtis, Joy. Ethics in Nursing. 2nd ed. New York: Oxford University Press, 1986. 206 p. An overview of the nature of ethical inquiry and theory is followed by... (shrink)

Background: Patients’ rights are universal values that must be respected; however, it is not easy to put such values and principles into effect as approaches and attitudes differ from individual to individual, from society to society, and from country to country. If we want to reach a general conclusion about the status of patient rights in the world as whole, we should examine the situation in individual countries. Objective: To study the effect of training sessions for nurses about (...) patients’ rights on the perceptions of nurses and patients in two Egyptian hospitals. Methods: Quasi-experimental with pre- and posttest design was used in this study. Two groups of participants were included in the study: the first with 97 nurses and the second with 135 patients. A questionnaire sheet was used for nurses and patients to assess their perceptions about patients’ rights before starting sessions. The training sessions were developed based on the baseline information gathered in the assessment phase and related literature. After the implementation of the sessions, a posttest was immediately conducted for nurses, while for patients the posttest was conducted 1 month after implementation to evaluate the effect of the nurses’ training sessions on the patients’ perceptions. The same tools were used in pretest and posttest. Ethical considerations: Written approval was sought and obtained from the administrators of the studied hospitals prior to conducting the study. Oral consent was obtained from nurses and patients willing to participate. Confidentiality and anonymity of the participants were strictly maintained through code numbers on the questionnaires. Results: The improvement in nurses’ knowledge and perceptions about patients’ rights after implementation of the training sessions was remarkable. Moreover, an improvement in patients’ perceptions regarding their rights was reported. Conclusion: Repetition of the training sessions is suggested to achieve continuous improvement. Provision of posters and booklets about a bill of patient rights within the hospitals and conduction of further study to examine nurses’ performance and patients’ satisfaction based on code of ethics are recommended. (shrink)

Definition of the problem Few concepts in recent ethical debates have enjoyed as much popularity as the concept of discrimination. However, a comparative discussion of the concept, including its conceptual nuances and its ethical significance for health care, has so far been lacking. The aim of this paper is to develop a nuanced understanding of discrimination based on the philosophical and sociological literature against the background of ethically relevant medical and nursing scenarios. Methods Using practical examples from health care, (...) we discuss direct, indirect, and statistical discrimination; we examine the importance of intentions and the role of collective actors. In addition, we analyze which social groups may experience discrimination and the respective importance of forms of epistemic injustice. Conclusions We argue that despite its complexity, the concept offers significant added value because it allows us to highlight forms of disadvantage that go beyond the violation of individual specific rights or interests. As a knowledge-based system of great societal influence, health care exhibits some characteristics that can foster discrimination. Acknowledging this fact is essential in order to effectively address discrimination. (shrink)

Medical ethics needs to be on its guard against those in military or political power who would seek to subvert its most basic tenets in order to serve their own endsEmergencies and warlike situations often force medical personnel to follow orders and perform actions or duties pertaining to their field of expertise in flagrant violation of their professional code of ethics. Opposing such orders may be contextually impossible, or elicit unduly high personal costs. Medical ethics, while lamenting (...) these impositions, is often reduced to passive and silent disagreement. In recent years, however, biomedical ethics has become active in accepting and supporting these estrangements from accepted standards and values of the healthcare professions, coming up with justifications of torture; suggesting non-treatment of the wounded, depending on their combatant status; prompting collaboration in the development of biological weapons, and disregarding informed consent.Physicians’ participation in torture has been unanimously condemned and, although acknowledging that such conduct “is the result of the displacement of their medical vocation by the doctrine of ‘national security’”, such an “ideological substrate” has nevertheless been deemed untenable.1 Perpetrators were found to have committed their deeds in an ethical void2; this was recognised, but in no way did it serve to excuse physicians from the duty of opposing induced suffering and assuaging its effects to the best of their abilities.Torture in its “humane” form has been defended on utilitarian grounds,3 using weak arguments that are unable to justify physicians’ active participation in torture. For the most part, professional ethics has remained adamant in its undaunted disapproval of medical non-therapeutic involvement in violent scenarios such as war, terrorism, and even torture. Nobody would have thought, in earlier times, that medical ethics could take any other position than to unrelentingly reject physicians’ participation in torture, …. (shrink)

The consent and community engagement process for research with Indigenous communities is rarely evaluated. Research protocols are not always collaborative, inclusive or culturally respectful. If participants do not trust or understand the research, selection bias may occur in recruitment, affecting study results potentially denying participants the opportunity to provide more knowledge and greater understanding about their community. Poorly informed consent can also harm the individual participant and the community as a whole. Invited by local Aboriginal community leaders of the Fitzroy (...) Valley, the Kimberley, Western Australia, The Picture Talk project explores the consent process for research. Focus groups of Aboriginal community members were conducted to establish preferences for methods of seeking individual consent. Transcripts were analysed through NVivo10 Qualitative software using grounded theory with inductive and deductive coding. Themes were synthesised with quotes highlighted. Focus groups with Aboriginal community members were facilitated by a Community Navigator as a cultural guide and interpreter and a researcher. Participants were recruited from all main language groups of the Fitzroy Valley – Gooniyandi, Walmajarri, Wangkatjungka, Bunuba and Nikinya. Participants were aged ≥18 years, with 5 female groups and one male group. Themes identified include: Reputation and trust is essential; The Community Navigator is key; Pictures give the words meaning – milli milli versus Pictures; Achieving consensus in circles; Signing for consent; and Research is needed in the Valley. Aboriginal communities of the Fitzroy Valley recommend that researchers collaborate with local leaders, develop trust and foster a good reputation in the community prior to research. Local Aboriginal researchers should be employed to provide cultural guidance throughout the research process and interpret local languages especially for elders. Pictures are preferred to written text to explain research information and most prefer to sign for consent. The Fitzroy Valley welcomes research when collaborative and for the benefit of the community. Future research could include exploring how to support young people, promote health screening and improve understanding of medical knowledge. (shrink)