Research question and aimClinical Ethics Committees (CECs) aim to support healthcare professionals (HPs) and healthcare organizations to deal with the ethical issues of clinical practice. In 2020,...

Introduction: Clinical practice guidelines (CPGs) are an important source of justification for clinical decisions in modern evidence-based practice. Yet, we have given little attention to how they argue their evidence. In particular, how do CPGs argue for treatment with long-term medications that are increasingly prescribed to older patients? Approach and rationale: I selected six disease-specific guidelines recommending treatment with five of the medication classes most commonly prescribed for seniors in Ontario, Canada. I considered the stated aims (...) of these CPGs and the techniques employed towards those aims. Finally, I reconstructed and logically analysed the arguments supporting recommendations for pharmacotherapy. Analysis: The primary function of CPGs is rhetorical, or persuasive, and their means of persuasion include both a display of their credibility and their argumentation. Arguments supporting pharmacotherapy recommendations for the target population follow a common inductive pattern: statistical generalization from randomized controlled trial (RCT) and meta-analysis evidence. Two of the CPGs also argue their treatment recommendations for older patients in this style, while three fail to justify pharmacotherapy specifically for the older population. Discussion: The arguments analysed lack the auxiliary assumptions that would warrant making a generalization about the clinical effectiveness of medications for the older population. Guidelines reason using simple induction, while ignoring important inferential gaps. Future guidelines should aspire to be well-reasoned rather than simply evidence-based; argue from a plurality of evidence; be wary of hasty inductions; appropriately limit the scope of their recommendations; and avoid making law-like, prescriptive generalizations. (shrink)

Clinical practice is where the clinical encounter and decision-making occur. Thus, it constitutes the focus of medicine. Since the time of Hippocrates, it has been composed of five activities that have come to be known as anamnesis, i.e., history taking or clinical interview, diagnosis, prognosis, therapy, and prevention. These five activities are fundamental features of the healing relationship. The present chapter is devoted to the analysis and discussion of their logical, methodological, and philosophical problems. Usually, the (...) patient expects the physician to be an expert of her specialty devoid of a bad reputation. This constitutes what may be called a good doctor, i.e., one whose clinical decisions are right and good in most cases, at least in as many cases as another expert in the same area also achieves. In what follows, we shall analyze the characteristics and presuppositions of such right and good clinical decisions. To this end, we shall undertake a conceptual analysis of the clinical encounter and its outcomes, in order to develop a theory of clinical practice. Our analysis consists of the following five parts: 9.1 The Clinical Encounter; 9.2 Anamnesis and Diagnosis; 9.3 Prognosis; 9.4 Therapy; 9.5 Prevention. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.1 (2005) 1-7 [Access article in PDF] Clinical Practice, Science, and the Unconscious Douglas McConnell Neil Pickering Keywords psychotherapy, cognitive science, neuroscience, computational view of mind. This volume of Philosophy, Psychiatry, & Psychology is devoted to questions about the unconscious mind. The philosophical complexities and difficulties associated with the unconscious are many and, despite widespread confusion and disagreement as to the nature of (...) the unconscious mind, it is used as a concept informing psychotherapy. It is therefore not surprising that papers in a special edition on the unconscious might be weighted heavily toward uncovering a justifiable conceptual niche for the unconscious and elaborating on some of the main conceptual connections. Although this makes for a slightly more philosophical edition of PPP than usual, those perhaps less interested in philosophy and more interested in actual psychiatric practice can incorporate the concepts and insights developed in these papers into their practice as they see fit.The three main articles take three quite distinct approaches to the unconscious. Schechtman (2005) addresses the need for a theory of personal identity to incorporate the unconscious and presents one that does so by developing some central Lockian intuitions. Church (2005) investigates whether the kinds of things happening in the unconscious can be explained by cognitive operations not normally associated with consciousness, specifically, spatial structuring of experience. McConnell and Gillett (2005) clarify some of Lacan's ontology of the mind where the language encountered and used by the subject provides the structure for their unconscious.The aim of this introduction is to ask and try to answer a question that logically precedes those raised in the articles in the light of the therapeutic use of the unconscious. When dealing with psychoanalysis or psychoanalytic concepts in an Anglo-American context, the struggle that psychoanalysis has had and continues to have in a psychiatric domain ruled by science is never far from the spotlight. Indeed Hinshelwood (2005) also picks up the importance of this conflict when replying to McConnell and Gillett. It seems to be historically true that the unconscious has fallen out of favor in scientific and psychiatric circles (it is no surprise that psychiatric training is largely based in "hard," that is, biological and biochemical science) particularly over the last 50 years or so. But is the scientific skepticism to be found about the use of the unconscious well-founded? And how does the continued utilization [End Page 1] of the unconscious by the therapist fit into current practice given this skepticism? Psychotherapy and the Unconscious In psychotherapy, the therapist and the client together construct a story that explains why the client is having some form of difficulty in his or her life. The stated aim is to enable the client to overcome this difficulty by gaining an understanding of what has generated it. Doing so may be a first step to dealing with that conflict. For example, an office worker who is scared of the boss and whose life at work is a misery as result may come to think that the boss is a reminder of some threatening figure from childhood and that the reaction is a regression to infantile behavior. Knowing this, the fear of the boss can be revisited—perhaps reconfigured, perhaps overcome—and life may improve. In the process of therapy, the relation of the figure from childhood to the boss is made conscious. But it was still operative before it was made explicit, even though the client did not realize it and some would say that the client's unconscious had somehow buried the memory from childhood or hidden from the client the relation of this memory of a threatening figure to the boss.A description of the content of the unconscious is, then, an intentional description involving the client's thought life, one made to help an individual understand otherwise unintelligible (to that individual) feelings, beliefs, desires, actions, and so on. Subjects' intentions are their normatively structured mental representations of, and attitudes toward, the world (e.g., "He is my boss"; "I am afraid of him"). An intentional unconscious description then takes an intentional form... (shrink)

ABSTRACTThis essay introduces the notion of a literary clinical practice for which it remains essential to continue to consider those texts that open up a place for a readership, or audience, or even a civilization to consider the endlessly generative failure of its literature to write mental health. Concerned with mental illness that is an effect of language on the subject, the body, and of the enigma of the truth as cause, psychoanalysis is the crucial interlocutor for any (...) literary clinical concern with the maladies of literature and society. In order to re-assess the utility of Shakespeare’s Hamlet to contemporary problems such as depression – perhaps the dominant symptom of our time – this essay attempts a reconsideration of Jacques Lacan’s famous seminar on Hamlet from the perspective of the contemporary clinic of the Lacanian orientation in psychoanalysis led by Jacques-Alain Miller. (shrink)

Background: Ethics support services are growing in Europe to help doctors in dealing with ethical difficulties. Currently, insufficient attention has been focused on the experiences of doctors who have faced ethical difficulties in these countries to provide an evidence base for the development of these services.Methods: A survey instrument was adapted to explore the types of ethical dilemma faced by European doctors, how they ranked the difficulty of these dilemmas, their satisfaction with the resolution of a recent ethically difficult case (...) and the types of help they would consider useful. The questionnaire was translated and given to general internists in Norway, Switzerland, Italy and the UK.Results: Survey respondents ranged in age from 28 to 82 years, and averaged 25 years in practice. Only a minority reported having access to ethics consultation in individual cases. The ethical difficulties most often reported as being encountered were uncertain or impaired decision-making capacity , disagreement among caregivers and limitation of treatment at the end of life . The frequency of most ethical difficulties varied among countries, as did the type of issue considered most difficult. The types of help most often identified as potentially useful were professional reassurance about the decision being correct , someone capable of providing specific advice , help in weighing outcomes and clarification of the issues . Few of the types of help expected to be useful varied among countries.Conclusion: Cultural differences may indeed influence how doctors perceive ethical difficulties. The type of help needed, however, did not vary markedly. The general structure of ethics support services would not have to be radically altered to suit cultural variations among the surveyed countries. (shrink)

Good Clinical Practice is an international quality standard for conducting trials that involve participation of human subjects. Currently, the most widely accepted international document forming the base for GCP is the ICH Harmonised Tripartite Guideline for GCP, which defines in detail the responsibilities and obligations of parties engaged in clinical research. The purpose of this paper is to analyse how compliance with GCP provides protection of the trial subjects and assures quality and credibility of the data obtained.

Regarding the appropriateness of deception in clinical practice, two (apparently conflicting) claims are often emphasised. First, that ‘clinicians should not deceive their patients.’ Second, that deception is sometimes ‘in a patient’s best interest.’ Recently, Hardman has worked towards resolving this conflict by exploring ways in which deceptive and non-deceptive practices extend beyond consideration of patients’ beliefs. In short, some practices only seem deceptive because of the (common) assumption that non-deceptive care is solely aimed at fostering true beliefs. Non-deceptive (...) care, however, relates to patients’ non-doxastic attitudes in important ways as well. As such, Hardman suggests that by focusing on belief alone, we sometimes misidentify non-deceptive care as ‘deceptive’. Further, once we consider patients’ beliefs and non-doxastic attitudes, identifying cases of deception becomes more difficult than it may seem. In this essay, I argue that Hardman’s reasoning contains at least three serious flaws. First, his account of deception is underdeveloped, as it does not state whether deception must be intentional. The problem is that if intention is not required, absurd results follow. Alternatively, if intention is required, then identifying cases of deception will be much easier (in principle) than Hardman suggests. Second, Hardman mischaracterises the ‘inverse’ of deceptive care. Doing so leads to the mistaken conclusion that common conceptions of non-deceptive care are unjustifiably narrow. Third, Hardman fails to adequately separate questions about deception from questions about normativity. By addressing these issues, however, we can preserve some of Hardman’s most important insights, although in a much simpler, more principled way. (shrink)

The evidence-based practice movement fails to pay attention to and to respect sufficiently the fundamental differences that exist between clinical practice and the kind of research that is modeled on the natural sciences. According to M. Polanyi knowledge, will always have a tacit dimension that is not possible to operationally define. This paper argues that the tacit dimension is especially important in clinical knowledge. This represents a challenge to the dominance of positivism and to the evidence-based (...) practice movement. As psychiatrists, we must be able to attend to the patient's perspective, his subjective experience and context. Clinical practice is a careful balance between dialogue and technique. Evidence-based psychiatry might tilt this balance toward a more technical attitude. This could pose problems, considering the importance of the so-called nonspecific factors in psychotherapy. (shrink)

Are clinical practice guidelines a means for improving the quality of health care? For saving money in the health care system? For solving the malpractice problem? For making the health care system work better for all? Or, are they a recipe for disaster? This overview sets out conceptual, definitional, and practical aspects of clinical practice guidelines as a broad framework for reflecting on the issue of what guidelines are and why they count. It draws mainly on (...) work done since 1990 at the Institute of Medicine and focuses on five questions. First, what are guidelines, and who develops them? Second, what criteria or principles should be used to create good guidelines? Third, what problems or pitfalls exist in developing and disseminating guidelines? Fourth, in what ways can guidelines help improve medical care, and in what ways will they not be as practical or useful, particularly with respect to quality of care? Finally, what ethical context might guide deliberations on this topic? (shrink)

Critical thinking is a complex, dynamic process formed by attitudes and strategic skills, with the aim of achieving a specific goal or objective. The attitudes, including the critical thinking attitudes, constitute an important part of the idea of good care, of the good professional. It could be said that they become a virtue of the nursing profession. In this context, the ethics of virtue is a theoretical framework that becomes essential for analyse the critical thinking concept in nursing care and (...) nursing science. Because the ethics of virtue consider how cultivating virtues are necessary to understand and justify the decisions and guide the actions. Based on selective analysis of the descriptive and empirical literature that addresses conceptual review of critical thinking, we conducted an analysis of this topic in the settings of clinical practice, training and research from the virtue ethical framework. Following JBI critical appraisal checklist for text and opinion papers, we argue the need for critical thinking as an essential element for true excellence in care and that it should be encouraged among professionals. The importance of developing critical thinking skills in education is well substantiated; however, greater efforts are required to implement educational strategies directed at developing critical thinking in students and professionals undergoing training, along with measures that demonstrate their success. Lastly, we show that critical thinking constitutes a fundamental component in the research process, and can improve research competencies in nursing. We conclude that future research and actions must go further in the search for new evidence and open new horizons, to ensure a positive effect on clinical practice, patient health, student education and the growth of nursing science. (shrink)

To help professionals in all health care disciplines grapple with ethical issues, Ahronheim (medicine, New York Medical College), Moreno (biomedical ethics, U. of Virginia) and Zuckerman (Center for Ethics in Medicine, Beth Israel Medical Center) review the history and theory of clinical ethics and present 31 case studies analyzed from medical, ethical and legal perspectives. This second edition expands the original discussions of ethical dilemmas caused by advances in medical genetics, organ transplants, HIV medicine and other developments. The appendix (...) includes Internet references, suggested readings and other resources. (shrink)

Are clinical practice guidelines a means for improving the quality of health care? For saving money in the health care system? For solving the malpractice problem? For making the health care system work better for all? Or, are they a recipe for disaster? This overview sets out conceptual, definitional, and practical aspects of clinical practice guidelines as a broad framework for reflecting on the issue of what guidelines are and why they count. It draws mainly on (...) work done since 1990 at the Institute of Medicine and focuses on five questions. First, what are guidelines, and who develops them? Second, what criteria or principles should be used to create good guidelines? Third, what problems or pitfalls exist in developing and disseminating guidelines? Fourth, in what ways can guidelines help improve medical care, and in what ways will they not be as practical or useful, particularly with respect to quality of care? Finally, what ethical context might guide deliberations on this topic? (shrink)

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM (...) approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

It is sometimes suggested that the physician should offer the patient “just the facts,” preferably in a “value-free manner,” explain the different options, and then leave it to the patient to make the choice. This paper explores the extent to which this adviser model is realistic. The clinical decision process and the various components of clinical reasoning are discussed, and a distinction is made between the biological, empirical, empathic/hermeneutic and ethical components. The discussion is based on the ethical (...) norms of the public health services in the Nordic countries, and the problems are illustrated by a clinical example. It is concluded that the adviser model is unrealistic. Patient information is important, but the complexity of clinical reasoning makes it impossible to separate facts and value judgments. It is claimed that there is an inherent element of paternalism in clinical decision-making and that clinical practice presupposes a mutual trust between physician and patient. (shrink)

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical (...) investigator and to professional organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies. (shrink)

Discusses concepts of agency and free will from the perspective of clinical practice and feminism. Following a definition of agency that locates it in a relational context , the problematized nature of subjective experience is explored from both a feminist and a psychoanalytic perspective. These considerations set the stage for examining the contradictions and dilemmas of clinical practice devoted to individual change and improving lives as well as political values and ideology devoted to social change, suggesting (...) the history of incest in Western culture and practice as an example. The need to act/practice despite uncertainty is acknowledged, relating the position of the practitioner to the responsibilities of being a parent. 2012 APA, all rights reserved). (shrink)

The British National Institute for Health and Clinical Excellence has recently released new guidelines for the diagnosis, treatment and prevention of the psychiatric category antisocial personality disorder. Evident in these recommendations is a broader ambiguity regarding the ontology of ASPD. Although, perhaps, a mundane feature of much of medicine, in this case, ontological uncertainty has significant ethical implications as a product of the profound consequences for an individual categorised with this disorder. This paper argues that in refraining from emphasising (...) uncertainty, NICE risks reifying a controversial category. This is particularly problematical given that the guidelines recommend the identification of individuals “at risk” of raising antisocial children. Although this paper does not argue that NICE is “wrong” in any of its recommendations, more emphasis should have been placed on discussions of the ethical implications of diagnosis and treatment, especially given the multiple uncertainties associated with ASPD. It is proposed that these important issues be examined in more detail in revisions of existing NICE recommendations, and be included in upcoming guidance. This paper thus raises key questions regarding the place and role of ethics within the current and future remit of NICE. (shrink)

This new study provides a thorough analysis of the ethical reasoning of doctors and nurses. Based on extensive interviews, Soren Holm's work demonstrates how qualitative research methods can be used to study ethical reasoning, and that the results of such studies are important for normative ethics, that is, the analysis of how health care professionals ought to act.

Regarding the appropriateness of deception in clinical practice, two (apparently conflicting) claims are often emphasised. First, that ‘clinicians should not deceive their patients.’ Second, that deception is sometimes ‘in a patient’s best interest.’ Recently, Hardman has worked towards resolving this conflict by exploring ways in which deceptive and non-deceptive practices extend beyond consideration of patients’ beliefs. In short, some practices only seem deceptive because of the (common) assumption that non-deceptive care is solely aimed at fostering true beliefs. Non-deceptive (...) care, however, relates to patients’ non-doxastic attitudes in important ways as well. As such, Hardman suggests that by focusing on belief alone, we sometimes misidentify non-deceptive care as ‘deceptive’. Further, once we consider patients’ beliefs and non-doxastic attitudes, identifying cases of deception becomes more difficult than it may seem. In this essay, I argue that Hardman’s reasoning contains at least three serious flaws. First, his account of deception is underdeveloped, as it does not state whether deception must be intentional. The problem is that if intention is not required, absurd results follow. Alternatively, if intention is required, then identifying cases of deception will be much easier (in principle) than Hardman suggests. Second, Hardman mischaracterises the ‘inverse’ of deceptive care. Doing so leads to the mistaken conclusion that common conceptions of non-deceptive care are unjustifiably narrow. Third, Hardman fails to adequately separate questions about deception from questions about normativity. By addressing these issues, however, we can preserve some of Hardman’s most important insights, although in a much simpler, more principled way. (shrink)

The dominant, individualistic understanding of autonomy that features in clinical practice and research is underpinned by the idea that people are, in their ideal form, independent, self-interested and rational gain-maximising decision-makers. In recent decades, this paradigm has been challenged from various disciplinary and intellectual directions. Proponents of ‘relational autonomy’ in particular have argued that people’s identities, needs, interests – and indeed autonomy – are always also shaped by their relations to others. Yet, despite the pronounced and nuanced critique (...) directed at an individualistic understanding of autonomy, this critique has had very little effect on ethical and legal instruments in clinical practice and research so far. In this article, we use four case studies to explore to what extent, if at all, relational autonomy can provide solutions to ethical and practical problems in clinical practice and research. We conclude that certain forms of relational autonomy can have a tangibl... (shrink)

From their own practices, the authors offer insight into potential ethical dilemmas that may frequently develop in an applied psychology setting in which sport psychology is also being practiced. Specific ethical situations offered for the reader's consideration include confidentiality with coaches, administration, parents, and athlete-clients; accountability in ethical billing practices and accurate diagnosing; identification of ethical boundaries in nontraditional practice settings (locker room, field, rink, etc.); and establishment of professional competence as it relates to professional practice and marketing.

Psychoanalytic Theory, Research and Clinical Practice: Reading Joseph D. Lichtenberg explores both Lichtenberg’s psychoanalytic theoretical contributions and innovations in clinical technique, and how these have influenced the work of other psychoanalysts and researchers. Lichtenberg’s approach integrates a developmental perspective on the life cycle, self-psychology, attachment theory, and his theory of motivational systems. The commentaries in this volume are divided into several sections. Section One is devoted to informal interviews with Lichtenberg that portray an account of the evolution (...) of psychoanalysis through Lichtenberg’s eyes interwoven with the development of his own psychoanalytic identity. Section Two celebrates the role of friendship within his psychoanalytic circle, and Section Three highlights his leadership role in the development of creative structures: the journal _Psychoanalytic Inquiry; _The Institute for Contemporary Psychotherapy and Psychoanalysis and its training programs; and the ongoing Creativity Seminar. Additional sections provide commentary by psychoanalysts and researchers which demonstrate Lichtenberg’s theoretical and clinical impact on his colleagues. Psychoanalytic Theory, Research and Clinical Practice provides an in-depth encounter with a major contributor to the psychoanalytic field. Engagement with the openness, flexibility, and inquiring spirit of Joseph D. Lichtenberg offers respect for and hope in the psychoanalytic process. This book is essential reading for psychoanalysts, mental health professionals, and graduate students interested in how theory, research and technique are creatively integrated by a renowned psychoanalytic clinician and teacher. (shrink)

This special issue reconsiders the contributions that phenomenology can make to the development and practice of a clinicat science of psychology. In it, we suggest that earlier attempts to apply phenomenological principles were influenced heavily by psychoanalysis, with few, if any, alternative versions of a "depth" psychology available on which to draw in reframing the nature of psychopathology and its treatment. We suggest that this lingering presence of psychoanalysis runs counter to the founding principles of phenomenological method and offer (...) a few examples of a constructive alternative grounded in Husserl's transcendental phenomenology. Borrowing from Mohanty, we offer this approach as a respectful-as opposed to suspicious-phenomenology, and begin to outline ways in which a transcendental ly-grounded psychology reconceptualizes both clinical research and practice, from the initial intake interview and interpretation of interview data to the aims and strategies of psychological interventions. (shrink)

Healthcare workers experience moral injury (MI), a violation of their moral code due to circumstances beyond their control. MI threatens the healthcare workforce in all settings and leads to medical errors, depression/anxiety, and personal and occupational dysfunction, significantly affecting job satisfaction and retention. This article aims to differentiate concepts and define causes surrounding MI in healthcare. A narrative literature review was performed using SCOPUS, CINAHL, and PubMed for peer-reviewed journal articles published in English between 2017 and 2023. Search terms included (...) “moral injury” and “moral distress,” identifying 249 records. While individual risk factors predispose healthcare workers to MI, root causes stem from healthcare systems. Accumulation of moral stressors and potentially morally injurious events (PMIEs) (from administrative burden, institutional betrayal, lack of autonomy, corporatization of healthcare, and inadequate resources) result in MI. Individuals with MI develop moral resilience or residue, leading to burnout, job abandonment, and post-traumatic stress. Healthcare institutions should focus on administrative and climate interventions to prevent and address MI. Management should ensure autonomy, provide tangible support, reduce administrative burden, advocate for diversity of clinical healthcare roles in positions of interdisciplinary leadership, and communicate effectively. Strategies also exist for individuals to increase moral resilience, reducing the impact of moral stressors and PMIEs. (shrink)

Background Although it is the moral duty of physicians to protect vulnerable patients, there are no data on how vulnerability is perceived in clinical practice. This study explores how physicians classify someone as “vulnerable”. Method Thirty-three physicians were initially questioned about resource allocation problems in their work. The results of these interviews were examined with qualitative study software to identify characteristics associated with vulnerability in patients. Data were conceptualized, classified and cross-linked to highlight the major determinants of vulnerability. (...) The findings revealed the principal factors that make patients vulnerable in clinical practice, according to our definition of vulnerability: the likelihood of having one’s interests unjustly considered. Results Vulnerability can arise as a result of a mismatch between the characteristics of patients and physicians, the healthcare system, the treatment, or the communication between physicians and patients. Vulnerability appears as a gap between a patient’s needs and the means intended to meet them. Vulnerability can further be the result of doing too little or too much for patients. This result suggests that structures provided by healthcare systems are not as differentiated as they should be to cover all situations. Our initial definition of vulnerability was illustrated and supported by our results, showing that it encompasses all factors involved, not solely personal characteristics, indicating the need for a more pragmatic approach for use in clinical practice. Conclusion Vulnerability is not due to a single factor but appears under certain circumstances when there is a discrepancy between a patient’s interests and the care provided, despite existing compensation systems. (shrink)

BackgroundRespect for confidentiality is important to safeguard the well-being of patients and ensure the confidence of society in the doctor-patient relationship. The aim of our study is to examine real situations in which there has been a breach of confidentiality, by means of direct observation in clinical practice.MethodsBy means of direct observation, our study examines real situations in which there has been a breach of confidentiality in a tertiary hospital. To observe and collect data on these situations, we (...) recruited students enrolled in the Medical Degree Program at the University of Cordoba. The observers recorded their entries on standardized templates during clinical internships in different departments: Internal Medicine; Gynecology and Obstetrics; Pediatrics; Emergency Medicine; General and Digestive Surgery; Maxillofacial Surgery; Plastic Surgery; Orthopedics and Traumatology; Digestive; Dermatology; Rheumatology; Mental Health; Nephrology; Pneumology; Neurology; and Ophthalmology.ResultsFollowing 7138 days and 33157 h of observation, we found an estimated Frequency Index of one breach per 62.5 h. As regards the typology of the observed breaches, the most frequent were related to the consultation and/or disclosure of clinical and/or personal data to medical personnel not involved in the patient’s clinical care, as well as people external to the hospital. As regards their severity, severe breaches were the most frequent, accounting for 46.7 % of all incidents. Most of the reported incidents were observed in public areas, such as corridors, elevators, the cafeteria, stairs, and locker rooms.ConclusionsIn addition to aspects related to hospital organization or infrastructure, we have shown that all healthcare personnel are involved in confidentiality breaches, especially physicians. While most are committed unintentionally, a non-negligible number are severe, repeated breaches, thus suggesting a certain carelessness, perhaps through ignorance about certain behaviors that can jeopardize patient confidentiality. (shrink)

Physicians commonly recommend ?placebo treatments?, which are not believed to have specific efficacy for the patient's condition. Motivations for placebo treatments include complying with patient expectations and promoting a placebo effect. In this article, we focus on two key empirical questions that must be addressed in order to assess the ethical legitimacy of placebo treatments in clinical practice: 1) do placebo treatments have the potential to produce clinically significant benefit? and 2) can placebo treatments be effective in promoting (...) a therapeutic placebo response without the use of deception? We examine evidence from clinical trials and laboratory experiments bearing on these two questions. The conclusion is reached that based on currently available evidence, it is premature to judge whether placebo treatments are ethically justifiable, with the possible exception of acupuncture for pain relief. (shrink)