Biomedical Ethics

Background: Positioned at the frontlines of the battle against COVID-19 disease, nurses are at increased risk of contraction, yet as they feel obligated to provide care, they also experience ethical pressure. Research question and objectives: The study examined how Israeli nurses respond to ethical dilemmas and tension during the COVID-19 outbreak, and to what extent this is associated with their perceived risk and motivation to provide care? Research design: The study implemented a descriptive correlative study using a 53-section online questionnaire, (...) including 4 open-ended questions. Participants and research context: The questionnaire was complete by 231 registered and intern nurses after being posted on nurses’ Facebook and WhatsApp groups, and through snowball sampling. Ethical considerations: The research was pre-approved by the ethics committee of the Faculty of Social Welfare and Health Sciences at the University of Haifa, Israel. Findings: In all, 68.8% of the respondents had received some form of training about COVID-19. Respondents positioned themselves at perceived high risk levels for contracting the virus. About one-third feared going to work because of potential contraction and due to feeling inadequately protected. While 40.9% were scared to care for COVID-19 patients, 74.7% did not believe they have the right to refuse to treat certain patients. When asked about defining an age limit for providing patients with scarce resources (such as ventilation machines) in cases of insufficient supplies, respondents stated that the maximum age in such scenarios should be 84 (standard deviation (SD = 19) – yet most respondents (81.4%) believed that every patient has the right to receive optimal treatment, regardless of their age and medical background. Discussion: Correlating with their strong commitment to care, nurses did not convey intention to leave the profession despite their stress, perceived risk, and feelings of insufficient support and protection at work. The nurses did not hold a utilitarian approach to resource allocation, thereby acknowledging the value of all people and their entitlement to care, regardless of optimal outcomes. Conclusion: While experiencing significant personal risk and emotional burden, nurses conveyed strong dedication to providing care, and did not regret working in the nursing profession, yet they did seek a supportive climate for their needs and ethical concerns. (shrink)

Background: In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient’s advance directives and implement them. Objectives: To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services. Research design, participants, and context: This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and Emergency Medical (...) Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis. Ethical considerations: This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients’ anonymity and willingness to participate in the study were guaranteed. Findings: There were four types of barriers that hindered the proper management of patients’ advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals’ decision-making. Discussion: These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals’ beliefs and the opinions of colleagues and family members, can also influence the professionals’ final decisions. Conclusion: The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated. (shrink)

Evidence-based nursing practice is based on three pillars: the available research, known preferences of the patient or patient group and the professional experience of the nurse. For all pillars, research is the tool to expand the evidence we have, but when implementing evidence-based practice in paediatric nursing two of the pillars demand that children are included as respondents: practice research on the nursing interventions in paediatrics and the preferences of patients, something recognized by scholars and practitioners. But including a vulnerable (...) group as children in nursing research raises specific ethical issues that need to be considered by researchers. What are ethical considerations that are currently raised about doing research with children and what do we learn by synthesizing the narrative of these studies of why the issues are raised and which solutions can be offered for these issues? In this article, considerations on three ethical principles according to the Belmont report are described by examining recent research. Twenty-one studies were found addressing relevant ethical aspects including vulnerability, gaining consent, designing quantitative or qualitative research methods and considerations regarding the execution of the study. Ethical considerations should be much more a case of continuous awareness and attitude, then box-ticking exercise, although there are sufficient international guidelines available specifically for research that includes children to aid researchers. (shrink)

Background: Error communication includes both reporting errors to superiors and disclosing their consequences to patients and their families. It significantly contributes to error prevention and safety improvement. Yet, some errors in intensive care units are not communicated. Objectives: The aim of the present study was to explore factors affecting error communication in intensive care units. Design and participants: This qualitative study was conducted in 2019. Participants were 17 critical care nurses purposively recruited from the intensive care units of 2 public (...) hospitals affiliated to Iran University of Medical Sciences, Tehran, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional content analysis method proposed by Graneheim and Lundman. Ethical considerations: The Ethics Committee of Iran University of Medical Sciences, Tehran, Iran approved the study (code: IR.IUMS. REC.1397.792). Participants were informed about the study aim and methods and were ensured of data confidentiality. They were free to withdraw from the study at will. Written informed consent was obtained from all of them. Findings: Factors affecting error communication in intensive care units fell into four main categories, namely the culture of error communication (subcategories were error communication organizational atmosphere, clarity of processes and guidelines, managerial support for nurses, and learning organization), the consequences of errors for nurses and nursing (subcategories were fear over being stigmatized as incompetent, fear over punishment, and fear over negative judgments about nursing), the consequences of errors for patients (subcategories were monitoring the effects of errors on patients and predicting the effects of errors on patients), and ethical and professional characteristics (subcategories were ethical characteristics and inter-professional relationships). Discussion: The results of this study show many factors affect error communication, some facilitate and some prohibit it. Organizational factors such as the culture of error communication and the consequences of error communication for the nurse and the patient, as well as individual and professional characteristics, including ethical characteristics and interprofessional relationship, influence this process. Conclusion: Errors confront nurses with ethical challenges and make them assess error consequences and then, communicate or hide them based on the results of their assessments. Health authorities can promote nurses’ error communication through creating a supportive environment for them, developing clear error communication processes and guidelines, and providing them with education about the principles of ethical practice. (shrink)

Background: Social inequities in health systems are threats to global health. Considering the important role of nurses in establishing social justice, identification of factors affecting nurses’ participation in this area can contribute to the development of social justice. Objective: This study aimed to identify factors affecting nurses’ participation in establishing social justice in the health system. Research design and methods: The study was conducted using conventional qualitative content analysis approach. Purposive sampling was used to select 14 participants in 2019. The (...) data were collected through semi-structured interviews and analyzed concurrently with data gathering. Participants and research context: In total, six faculty members, five nursing managers, and three clinical nurses from three different universities were interviewed. Ethical considerations: The research was approved by the Ethics Committee of Urmia University of Medical Sciences in Iran. Findings: Four main themes were found, including inadequate professional authority, insufficient attention to social justice in the area of education, clinical concerns as barriers to professional presence in society, and reflection of personality traits in the profession. These are the main factors affecting nurses’ participation in establishing social justice in the health system. Discussion: Authorities need to take effective steps to establish social justice through reforming the health system’s policy-making and power-acquisition domains, promoting nurses’ involvement in social factors in health issues, and adding professional values as a part of nursing curriculum. The clinical practice environment can also be helpful through providing quality, safe, and cost-effective services. In addition, fair and efficient recruitment process for new nurses can contribute to the establishment of social justice in the health system. Conclusion: Macro-level managerial factors such as policy, education, and clinical environment, along with personal factors, play a significant role in the participation of nursing profession in establishing social justice. (shrink)

Background: Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health. Purpose: To examine the ethical challenges encountered by nurses caring for patients with the novel coronavirus pneumonia (COVID-19) and to provide nurses with suggestions and support regarding promotion of their mental health. Research design and method: A qualitative study was carried out using a (...) qualitative content analysis. The participants were 18 nurses who agreed to attend an interview and describe their own experiences of providing care to COVID-19 patients in China. They were purposively sampled, and structured, in-depth interviews were performed. Data were iteratively collected and analyzed from February to March 2020. Ethical considerations: The proposal was approved by the Research Ethics Committee of the Second Hospital of Shandong University, China. Findings: The findings revealed three main themes and 10 categories. The themes were the following: (1) ethical challenges (people with COVID-19, inequality, professional ethics, and job competency); (2) coping styles (active control and planning, seeking support as well as catharsis, and staying focused); and (3) impacts on career (specialized nursing skills, scientific research ability, and management skills). Conclusion: Nurses faced ethical challenges on multiple fronts in caring for COVID-19 patients. The results may help nurses with more safety, ethics, and humanistic care in nursing practice. (shrink)

Background: Discussing direct-to-consumer advertising of prescription drugs during a visit could affect prescribing practices and provider–patient relationship. Research objectives: The study examines advanced practice nurse prescribers’ perceptions of direct-to-consumer advertising and its effects on nurse–patient relationship, prescriptive authority, and appropriateness of patient clinical requests. Research design: A cross-sectional survey design was implemented. Participants and research context: The random sample consisted of 316 nurses (27.17% response rate) in one of the Midwestern states in the United States. Pearson’s chi-square analysis and multiple/multinomial (...) logistic regression analyses were used. Ethical considerations: Permission to conduct the study was obtained from the university’s Institutional Review Board. Participation was voluntary, and measures were taken to protect the anonymity and confidentiality of consenting participants. Findings: Most nurses (69%) believed that patients were “poor or very poor” at assessing the relevance of drug advertisements, 61% reported that the increase in drugs advertisements directed at patient was “a bad or a very bad thing,” and only 16% thought the advertisements were accurate to “a very or to a great extent.” Improved nurse–patient relationship was associated with factors such as the patient not bringing printed material, seeking nurse’s opinion only, taking responsibility for their health, and not challenging nurse’s prescriptive authority. Discussion: Advertising discussion during a visit could improve as well as pose a challenge to a nurse–patient relationship and nurse’s prescriptive authority. Conclusion: The positives of discussing advertising information can be maximized and the negatives minimized through enhanced interpersonal nurse–patient communication. (shrink)

Background: Why nurses remain in the profession is a complex question. However, strong values can be grounds for their remaining, meaning nurses evaluate the qualitative worth of different desires and distinguish between senses of what is a good life. Research question: The overall aim is to explore and argue the relevance of strong evaluations for remaining in the nursing profession. Research design: This theoretical article based on a hermeneutical approach introduces the concept strong evaluations as described by the Canadian philosopher (...) Charles Taylor and provides examples of nurses’ experiences in everyday nursing care drawn from a Norwegian empirical study. Participants and research context: Data collected in the original study consisted of qualitative interviews and qualitative follow-up interviews with 13 nurses. The research context was the primary and secondary somatic and psychiatric health service, inside as well as outside institutions. Ethical consideration: The article uses data from an original empirical study approved by the Norwegian Social Science Data Services. Information was given and consent obtained from the participants. Findings: Remaining in the nursing profession can be understood as revolving around being a strong evaluator. This has been concretized in issues of being aware of different incidents in life and having capacities as a nurse. Discussion: Why nurses remain is discussed in relation to how nurses have shaped themselves by reflecting on what is of significance in their life. However, being a strong evaluator cannot be seen as the casual condition for remaining. Conclusion: Remaining in the nursing profession is obviously not a contingent matter, rather it is a matter concerned with the qualitative worth of different desires and values. Nurses’ awareness of a life choice impacts on whether they remain or not. Consequently, nurses may need to articulate and reflect on their priorities for remaining. (shrink)

Background: Nurses who practice limitation of therapeutic effort become fully involved in emotionally charged situations, which can affect them significantly on an emotional and professional level. Objectives: To describe the experience of intensive care nurses practicing limitation of therapeutic effort. Method: A qualitative, phenomenological study was performed within the intensive care units of the Madrid Hospitals Health Service. Purposeful and snowball sampling methods were used, and data collection methods included semi-structured and unstructured interviews, researcher field notes, and participants’ personal letters. (...) The Giorgi proposal for data analysis was used on the data. Ethical considerations: This study was approved by the Ethical Research Committee of the relevant hospital and by the Ethics Committee of the Rey Juan Carlos University and was guided by the ethical principles of voluntary enrollment, anonymity, privacy, and confidentiality. Results: In total, 22 nurses participated and 3 themes were identified regarding the nurses’ experiences when faced with limitation of therapeutic effort: (a) experiencing relief, (b) accepting the medical decision, and (c) implementing limitation of therapeutic effort. Conclusion: Nurses felt that, although they were burdened with the responsibility of implementing limitation of therapeutic effort, they were being left out of the final decision-making process regarding the same. (shrink)

Patients with borderline personality disorder are frequent users of inpatient mental health units, with inpatient crisis intervention often used based on the risk of suicide. However, this can present an ethical dilemma for nursing and medical staff, with these clinician responses shifting between the moral principles of beneficence and non-maleficence, dependent on the outcomes of the actions of containing or tolerating risk. This article examines the use of crisis intervention through moral duties, intentions and consequences, culminating in an action/consequence model (...) of risk management, used to explore potential outcomes. This model may be useful in measuring adherence and violation of the principles of beneficence and non-maleficence and therefore an aid to clinical decision making. (shrink)

Background: Evolving technology and scientific advancement have increased the chances of survival of the extremely premature baby; however, such survival can be associated with some severe long-term morbidities. Research question: The research investigates the caregiving and ethical dilemmas faced by neonatal nurses when caring for extremely premature babies (defined as ≤24 weeks’ gestation). This article explores the issues arising for neonatal nurses when they considered the philosophical question of ‘what if it was me and my baby’, or what they believed (...) they would do in the hypothetical situation of going into premature labour and delivering an extremely premature baby. Participants: Data were collected via a questionnaire to Australian neonatal nurses and semi-structured interviews with 24 neonatal nurses in New South Wales, Australia. Ethical considerations: Relevant ethical approvals have been obtained by the researchers. Findings: A qualitative approach was used to analyse the data. The theme ‘imagined futures’ was generated which comprised three sub-themes: ‘choice is important’, ‘not subjecting their own baby to treatment’ and ‘nurses and outcome predictions’. The results offer an important and unique understanding into the perceptions of nursing staff who care for extremely premature babies and their family, see them go home and witness their evolving outcomes. The results show that previous clinical and personal experiences led the nurses in the study to choose to have the belief that if in a similar situation, they would choose not to have their own baby resuscitated and subjected to the very treatment that they provide to other babies. Conclusion: The theme ‘imagined futures’ offers an overall understanding of how neonatal nurses imagine what the life of the extremely premature baby and his or her family will be like after discharge from neonatal intensive care. The nurses’ past experience has led them to believe that they would not want this life for themselves and their baby, if they were to deliver at 24 weeks’ gestation or less. (shrink)

Background: The research question for this study was as follows: Is the Code of Ethics for Nurses in Italy (Code) a valid or useful decision-making instrument for nurses faced with ethical problems in their daily clinical practice? Method: Focus groups were conducted to analyze specific ethical problems through 11 case studies. The analysis was conducted using sections of the Code as well as other relevant documents. Each focus group had a specific theme and nurses participated freely in the discussions according (...) to their respective clinical competencies. Ethical considerations: The executive administrative committee of the local nursing licensing council provided approval for conducting this project. Measures were taken to protect the confidentiality of consenting participants. Findings: The answer to the research question posed for this investigation was predominantly positive. Many sections of the Code were useful for discussion and identifying possible solutions for the ethical problems presented in the 11 cases. Conclusion: We concluded that the Code of Ethics for Nurses in Italy can be a valuable aid in daily practice in most clinical situations that can give rise to ethical problems. (shrink)

Community-based interventions (CBIs) show promise as effective and cost-effective obesity prevention initiatives. CBIs are typically complex interventions, including multiple settings, strategies and stakeholders. Cost-effectiveness evidence, however, generally only considers a narrow range of costs and benefits associated with anthropometric outcomes. While it is recognised that the complexity of CBIs may result in broader non-health societal and community benefits, the identification, measurement, and quantification of these outcomes is limited. This study aimed to understand the perspectives of stakeholders on the broader benefits (...) of CBIs and their measurement, as well as perceptions of CBI cost-effectiveness. Purposive sampling was used to recruit participants from three stakeholder groups (lead researchers, funders, and community stakeholders of CBIs). Online semi-structured interviews were conducted, taking a constructivist approach. Coding, theme development and analysis were based on published guidance for thematic analysis. Twenty-six stakeholders participated in the interviews (12 lead researchers; 7 funders; 6 community stakeholders). Six key themes emerged; (1) Impacts of CBIs (health impacts and broader impacts); (2) Broader benefits were important to stakeholders; (3) Measurement of benefits are challenging; (4) CBIs were considered cost-effective; (5) Framing CBIs for community engagement (6) Making equitable impacts and sustaining changes—successes and challenges. Across all stakeholders, broader benefits, particularly the establishment of networks and partnerships within communities, were seen as important outcomes of CBIs. Participants viewed the CBI approach to obesity prevention as cost-effective, however, there were challenges in measuring, quantifying and valuing broader benefits. Development of tools to measure and quantify broader benefits would allow for more comprehensive evaluation of the cost-effectiveness of CBIs for obesity prevention. (shrink)

Public health emergencies such as pandemics can put health systems in a position where they need to ration medical equipment and interventions because the resources available are not sufficient to meet demand. In public health management, the fair allocation of resources is a permanent and cross-sector issue since resources, and especially economic resources, are not infinite. During the COVID-19 pandemic resources need to be allocated under conditions of extreme urgency and uncertainty. One very problematic aspect has concerned intensive care medicine (...) and age discrimination has been among the most hotly discussed issues, as age has been touted as a probable criterion for selection. In this paper we analyse some documents originating from scientific societies and medical associations, mainly related to EU sphere and available in English, French, Spanish and Italian (Switzerland, Spain, Belgium, France, England and Italy), concerning the criteria for admission to the intensive care units. We highlights how, in most of these documents, it is explicitly stated that “age itself” is not a criterion for patient selection. Our conclusion is that these criteria should be defined in advance of a crisis situation and be grounded in clinical indicators. Establishing “cut-off” policies with regard to criteria such as age or chronic disability is definitely an unjustifiable form of discrimination even in the context of a public health emergency. (shrink)

In modern medicine, health risks are often managed through the collection of health data and subsequent intervention. One of the goals of clinical genetics, for example, is to identify genetic predisposition to disease so that individuals can intervene to prevent potential harms. But recently, some clinicians have suggested that patients should undergo less testing and monitoring in an effort to reduce overdiagnosis and overtreatment. In this paper, I explore how clinicians navigate the tension between identifying real disease risks for their (...) patients with concerns about overdiagnosis and overtreatment. I focus on clinicians ordering genetic testing for inherited cardiovascular diseases. Of the genes determined to be “clinically actionable” by the American College of Medical Genetics and Genomics (ACMG), half are related to cardiovascular diseases. But, due in part to high levels of uncertainty surrounding cardiovascular genetics, there is still disagreement within the field about how to order and interpret these tests. Based on semi-structured, in-depth interviews with 20 clinicians who order genetic testing for cardiovascular diseases, I find that there is considerable variability in the ways that clinicians determine which types of genetic tests are appropriate for their patients and how they interpret test results. Most importantly, I find that many providers do not presume that more genetic data will lead to better care. Instead, increased genetic data can lead to confusion and inappropriate treatment. This re-valuation of the utility of medical data is crucial for bioethicists to explore, especially as medical fields are sorting through increasing amounts of data. (shrink)

Bioethics as a philosophical discipline deals with matters of life and death. How it deals with them, however, depends on the kind of life particular bioethicists focus on and the kind of value they assign to it. Natural-law ethicists and conservative Kantians emphasize biological human life regardless of its developmental stage. Integrative bioethicists also embrace nonhuman life if it can be protected without harming humans. Liberal and utilitarian moralists concentrate on life that is sentient and aware of itself, to the (...) exclusion of biological existence devoid of these. Extinctionist and antinatalist philosophers believe that life’s value is negative and that its misery should be alleviated and terminated by not bringing new individuals into existence. As the last-mentioned approach reverses the idea of life’s positive value, it could be called oibethics. (shrink)

In the ethics of algorithms, a specifically epistemological analysis is rarely undertaken in order to gain a critique (or a defense) of the handling of or trust in medical black box algorithms (BBAs). This article aims to begin to fill this research gap. Specifically, the thesis is examined according to which such algorithms are regarded as epistemic authorities (EAs) and that the results of a medical algorithm must completely replace other convictions that patients have (preemptionism). If this were true, it (...) would be a reason to distrust medical BBAs. First, the author describes what EAs are and why BBAs can be considered EAs. Then, preemptionism will be outlined and criticized as an answer to the question of how to deal with an EA. The discussion leads to some requirements for dealing with a BBA as an EA. (shrink)

It is a common view that artificial systems could play an important role in dealing with the shortage of caregivers due to demographic change. One argument to show that this is also in the interest of care-dependent persons is that artificial systems might significantly enhance user autonomy since they might stay longer in their homes. This argument presupposes that the artificial systems in question do not require permanent supervision and control by human caregivers. For this reason, they need the capacity (...) for some degree of moral decision-making and agency to cope with morally relevant situations (artificial morality). Machine ethics provides the theoretical and ethical framework for artificial morality. This article scrutinizes the question how artificial moral agents that enhance user autonomy could look like. It discusses, in particular, the suggestion that they should be designed as moral avatars of their users to enhance user autonomy in a substantial sense. (shrink)

Teaching ethics is crucial to health sciences education. Doing it well requires a willingness to engage contentious social issues. Those issues introduce conflict and risk, but avoiding them ignores moral diversity and renders the work of ethics education irrelevant. Therefore, when (not if) contentious issues and moral differences arise, they must be acknowledged and can be addressed with humility, collegiality, and openness to support learning. Faculty must risk moments when not everyone will “feel safe,” so the candor implied in psychological (...) safety can emerge. The deliberative and social work of ethics education involves generous listening, wading into difference, and wondering together if our beliefs and arguments are as sound as we once thought. By forecasting the need for candid engagement with contentious issues and moral difference, establishing ground rules, and bolstering due process structures for faculty and students, a riskier and more relevant ethics pedagogy can emerge. Doing so will prepare everyone for the moral diversity they can expect in our common life and in practice. (shrink)

This article explores the effects of naming and describing disability in law and medicine. Instead of focusing on substantive issues like medical treatment or legal rights, it will address questions which arise in relation to the use of language itself. When a label which is attached to a disability is associated with a negative meaning, this can have a profound effect on the individual concerned and can create stigma. Overly negative descriptions of disabilities can be misleading, not only for the (...) individual, but also more broadly in society, if there are inaccurate perceptions about disability in the social context. This article will examine some relevant examples of terminology, where these issues arise. It will also suggest that the role of medicine and the law in naming and describing disability is particularly important because in these areas there is, perhaps more than anywhere else, a recognized source of authority for the choice of terminology. Labels and descriptions used in the medical and legal contexts can not only perpetuate existing stigmatization of disabled people, but can also contribute to creating stigma at its source, given that the words used in these contexts can constitute an exercise of power. (shrink)

Rarely do everyday discussions of ethical issues invoke ethical theories. Even ethicists deploy ethical theories less frequently than one might expect. In my experience, the most powerful ethical arguments rarely appeal to an ethical theory. How is this possible? I contend that ethical argumentation can proceed successfully without invoking any ethical theory because the structure of good ethical argumentation involves leveraging a sturdy norm, where the norm is usually far more specific than a complete ethical theory. To illustrate this idea, (...) I present the argumentative structure of five powerful articles in the ethics literature. I further argue that the present model of ethical argumentation is consistent with the coherence model of ethical justification, but the former need not--and usually should not--invoke the latter explicitly for various practical reasons. (shrink)

Critics of medical aid in dying (MAID) often argue that it is impermissible because background social conditions are insufficiently good for some persons who would utilize it. I provide a critical evaluation of this view. I suggest that receiving MAID is a sort of “hard choice,” in that death is prima facie bad for the individual and only promotes that person’s interests in special circumstances. Those raising this objection to MAID are, I argue, concerned primarily about the effects of injustice (...) on hard choices. I show, however, that MAID and other hard choices are not always invalidated by injustice and that what matters is whether the injustice can be remediated given certain constraints. Injustice invalidates a hard choice when it can, reasonably, be remedied in a way that makes a person’s life go better. I consider the implications of this view for law and policy regarding MAID. (shrink)

Artificial intelligence (AI) is a powerful tool for several healthcare tasks. AI tools are suited to optimize predictive models in medicine. Ethical debates about AI’s extension of the predictive power of medical models suggest a need to adapt core principles of medical ethics. This article demonstrates that a popular interpretation of the principle of justice in healthcare needs amendment given the effect of AI on decision-making. The procedural approach to justice, exemplified with Norman Daniels and James Sabin’s accountability for reasonableness (...) conception, needs amendment because, as research into algorithmic fairness shows, it is insufficiently sensitive to differential effects of seemingly just principles on different groups of people. The same line of research generates methods to quantify differential effects and make them amenable for correction. Thus, what is needed to improve the principle of justice is a combination of procedures for selecting just criteria and principles and the use of algorithmic tools to measure the real impact these criteria and principles have. In this article, the author shows that algorithmic tools do not merely raise issues of justice but can also be used in their mitigation by informing us about the real effects certain distributional principles and criteria would create. (shrink)

Human decisions are increasingly supported by decision support systems (DSS). Humans are required to remain “on the loop,” by monitoring and approving/rejecting machine recommendations. However, use of DSS can lead to overreliance on machines, reducing human oversight. This paper proposes “reflection machines” (RM) to increase meaningful human control. An RM provides a medical expert not with suggestions for a decision, but with questions that stimulate reflection about decisions. It can refer to data points or suggest counterarguments that are less compatible (...) with the planned decision. RMs think against the proposed decision in order to increase human resistance against automation complacency. Building on preliminary research, this paper will (1) make a case for deriving a set of design requirements for RMs from EU regulations, (2) suggest a way how RMs could support decision-making, (3) describe the possibility of how a prototype of an RM could apply to the medical domain of chronic low back pain, and (4) highlight the importance of exploring an RM’s functionality and the experiences of users working with it. (shrink)

Artificial intelligence (AI) systems have demonstrated impressive performance across a variety of clinical tasks. However, notoriously, sometimes these systems are “black boxes.” The initial response in the literature was a demand for “explainable AI.” However, recently, several authors have suggested that making AI more explainable or “interpretable” is likely to be at the cost of the accuracy of these systems and that prioritizing interpretability in medical AI may constitute a “lethal prejudice.” In this paper, we defend the value of interpretability (...) in the context of the use of AI in medicine. Clinicians may prefer interpretable systems over more accurate black boxes, which in turn is sufficient to give designers of AI reason to prefer more interpretable systems in order to ensure that AI is adopted and its benefits realized. Moreover, clinicians may be justified in this preference. Achieving the downstream benefits from AI is critically dependent on how the outputs of these systems are interpreted by physicians and patients. A preference for the use of highly accurate black box AI systems, over less accurate but more interpretable systems, may itself constitute a form of lethal prejudice that may diminish the benefits of AI to—and perhaps even harm—patients. (shrink)

Position papers on artificial intelligence (AI) ethics are often framed as attempts to work out technical and regulatory strategies for attaining what is commonly called trustworthy AI. In such papers, the technical and regulatory strategies are frequently analyzed in detail, but the concept of trustworthy AI is not. As a result, it remains unclear. This paper lays out a variety of possible interpretations of the concept and concludes that none of them is appropriate. The central problem is that, by framing (...) the ethics of AI in terms of trustworthiness, we reinforce unjustified anthropocentric assumptions that stand in the way of clear analysis. Furthermore, even if we insist on a purely epistemic interpretation of the concept, according to which trustworthiness just means measurable reliability, it turns out that the analysis will, nevertheless, suffer from a subtle form of anthropocentrism. The paper goes on to develop the concept of strange error, which serves both to sharpen the initial diagnosis of the inadequacy of trustworthy AI and to articulate the novel epistemological situation created by the use of AI. The paper concludes with a discussion of how strange error puts pressure on standard practices of assessing moral culpability, particularly in the context of medicine. (shrink)

Artificial intelligence (AI) plays a rapidly increasing role in clinical care. Many of these systems, for instance, deep learning-based applications using multilayered Artificial Neural Nets, exhibit epistemic opacity in the sense that they preclude comprehensive human understanding. In consequence, voices from industry, policymakers, and research have suggested trust as an attitude for engaging with clinical AI systems. Yet, in the philosophical and ethical literature on medical AI, the notion of trust remains fiercely debated. Trust skeptics hold that talking about trust (...) in nonhuman agents constitutes a category error and worry about the concept being misused for ethics washing. Proponents of trust have responded to these worries from various angles, disentangling different concepts and aspects of trust in AI, potentially organized in layers or dimensions. Given the substantial disagreements across these accounts of trust and the important worries about ethics washing, we embrace a diverging strategy here. Instead of aiming for a positive definition of the elements and nature of trust in AI, we proceed ex negativo, that is we look at cases where trust or distrust are misplaced. Comparing these instances with trust expedited in doctor–patient relationships, we systematize these instances and propose a taxonomy of both misplaced trust and distrust. By inverting the perspective and focusing on negative examples, we develop an account that provides useful ethical constraints for decisions in clinical as well as regulatory contexts and that highlights how we should not engage with medical AI. (shrink)

Hamas militants have raped and mutilated the bodies of dozens of men and women in Israel during their attack and captivity in Gaza. The exact extent of these atrocities, however, is unknown. For reasons of this sort and others, prosecuting sexual abusers during armed conflicts is notoriously difficult. In an attempt to make a legal case against Hamas militants, the Israeli authorities have recently ordered civilian hospitals to breach medical confidentiality and report unidentified data of patients who have suffered bodily (...) mutilation and sexual abuse during the Hamas attack or during captivity in Gaza. Patients were not informed about this policy. This article first establishes a case for why medical confidentiality is such an important existential and normative value. In this light, it then argues that the Israeli policy is morally unjustified. (shrink)

Political opportunism of the far-right threatens the efficacy of public health policies and political stability in general. In this commentary, we outline some of the ways that the European far-right has misused public health concerns as propaganda tools. This is a significant threat to the goals of making health and science more inclusive, and we recommend some policies for mitigating the racist effect of the far-right. Notably, we recommend (a) transparency in health policies and robust implementation of the rule of (...) law, (b) the use of operative public values and human rights in health policy making, and (c) investment in decolonizing mindsets which may be corrosive of health policies. (shrink)

Rising rates of female incarceration within the United States are incompatible with the lack of federal standards outlining the rights of incarcerated mothers and their children. A robust body of evidence demonstrates that prison nurseries, programmes designed for mothers to keep their infants under their care during detainment or incarceration, provide essential and beneficial care that could not otherwise be achieved within the current carceral infrastructure. These benefits include facilitation of breastfeeding, bonding during a critical period of child development, and (...) decreased recidivism rates for participants. Legal precedent exists to support the rights of the mother to continue to parent their child but remains in stark opposition to current prison infrastructure that could allow them to do so. Existing state policies also have inconsistent mechanisms for determining child eligibility and should move to centre decision-making on a case-by-case basis. This work will demonstrate that a just society, supported by law and ensuring maternal–child welfare supports the establishment of prison nursery programmes as a part of the existing right to healthcare for incarcerated individuals. (shrink)

Opponents of legalised assisted dying often assert that palliative care is worse in countries where assisted dying has been legalised, and imply that legalised assisted dying makes palliative care worse. This study considers five versions of this claim: that it is difficulty to access expert palliative care in countries where assisted dying has been legalised, that those countries rank low in their quality of end‐of‐life care; that legalising assisted dying doesn't expand patient choice in respect of palliative care; that growth (...) in palliative care services has stalled in countries where assisted dying has been legalised; and that legalised assisted dying impedes the growth of palliative care or causes it to decline. In each case, it concludes that neither argumentation nor evidence supports these claims. (shrink)

The COVID‐19 pandemic created healthcare backlogs of routine primary and preventive care, elective procedures, dental care, and mental healthcare appointments across the world. So far, governments are responding by enacting pandemic recovery policies that expand their healthcare sector activity, without much, if any, consideration of its effects on the environmental crisis that is (among other things) worsening human health and health equity. This study argues that, as a matter of health and social justice, governments have an ethical responsibility to equitably (...) reduce the backlog with minimal environmental damage. To do so, a first key action is to give priority to policy options that minimise negative human impacts on the environment. Yet these policies alone will not be sufficient to address the backlog, particularly in relation to elective procedures. The study therefore contends that a second key action for governments is to enact the policy options that are best able to equitably reduce the remainder of the backlog, while accelerating the transition to sustainable health care in ways that are best able to reduce the specific environmental costs of those policy options. It concludes by considering whether limits apply to governments' ethical responsibilities that ultimately mean accelerating the transition to sustainable health care is not required when addressing the backlog. (shrink)

The term slow code refers to an intentional reduction in the pace or intensity of resuscitative efforts during a medical emergency. This can be understood as an intermediate level between full code (full resuscitation efforts) and no code (no resuscitation efforts) and serves as a symbolic gesture when intervention is considered medically futile. While some previous research acknowledges the slow code as an integral part of clinical practice, many ethicists have condemned the practice as dishonest and causing unnecessary pain for (...) the patient. As the public's views on this issue have been largely absent from the discussion to date, two vignette experiments were performed to investigate their perceptions. The findings indicate that laypersons believe that slow codes are commonplace and often prefer them over a no code. While a full code was perceived as the standard approach and rated most ethical and least punishable, the present results do not support the widespread assumption that laypersons generally oppose slow codes, and this finding should inform ethical discussion and clinical practice. (shrink)

Current clinical research lacks diversity in those that participate. This lack of diversity is concerning given its importance for successful drug development. The frequency and severity of many diseases, along with the pharmacological properties of therapies, can display significant differences based on patient diversity. A clinical trial population that is more reflective of these differences will help researchers better understand the therapeutic profile of the treatment and provide generalizable knowledge to the medical community. The advent of decentralized clinical trial designs (...) is meant to help address this lack of diversity by using portable digital health technologies and virtual interactions to enhance clinical trial access and broaden participation. By leveraging these technologies, trial conduct can occur at locations other than traditional research sites. This shift in trial location may help address some of the logistical, educational, engagement, and trust barriers that have historically prevented enrollment of diverse populations. However, these types of trials still have limitations. Ethical concerns around justice, equity, and diversity will still exist with decentralized clinical trials, which could be mediated using clinical research vehicles. When utilized, this modality may enhance the scientific design and conduct of clinical trials and better follow these ethical principles. These enhancements and improved ethical direction could be accomplished through increasing community involvement, improving health literacy, supporting more diverse trial sites, creating community‐based research footholds, fostering connections with researchers, limiting technical challenges, and preventing data security issues. (shrink)

Today’s medical ethics involve two different viewpoints based on how we understand the role of conscience in medicine and the purpose of healthcare. The first view, called the health-directed model, sees medicine as a way to improve health and promote healing, while also respecting the values of both patients and doctors. In this model, doctors need some discretionary space to decide how to achieve the best health outcomes in their practice. On the other hand, the service-provider model sees the main (...) goal of medicine as providing a service, especially healthcare, with a strong focus on protecting patient autonomy. In this view, doctors are required to provide care even when it goes against their personal beliefs. The goal of this article is to explore the foundations and arguments of these two medical models. Understanding the key ideas behind these models is important for deciding whether to support or oppose conscientious objection in medical ethics. Additionally, the article aims to figure out which model makes a stronger case and to offer advice on how to engage with the opposing view from a virtue ethics perspective. (shrink)

Clinical decision-making in old-age care is a complex and ethically sensitive process. Despite its importance, research addressing the challenges of clinical decision-making in old-age care within this cultural context is limited. This study aimed to explore the challenges and ethical concerns in clinical decision-making in old-age care in Ethiopia. This qualitative study employed an inductive approach with data collected via semi-structured interviews with 20 older patients and 26 health professionals recruited from healthcare facilities in Ethiopia. Data were analysed using reflexive (...) thematic analysis. Our analysis identified three key themes. First, participants highlighted perceptions that older patients’ religious beliefs interfere with the clinical decisions both older patients and health professionals make. Second, older patients often receive limited information from health professionals about their diagnosis and treatment. Third, families of older patients appear to strongly influence clinical decisions made by older patients or health professionals. This research enhances the understanding of clinical decision-making in old-age care within Ethiopia, a context where such research is scarce. As a result, this study contributes towards advancing the deliberation of ethical dilemmas that health professionals who work with older patients in Ethiopia might face. A key implication of the study is that there is a need for more ethics and cultural competence training for health professionals working with older patients in Ethiopia. (shrink)

Since 2020, physician associations have become more vocal about confronting racism, initiating a wide range of advocacy efforts, making programming changes, and issuing public statements on the topic. However, associations have directed their enthusiasm about addressing racism toward an overly broad range of statements, initiatives, and legislative advocacy. In this essay, we provide some guidance regarding which race‐based actions are best suited for physicians' professional associations. We describe traits of three types of physician associations in the United States—state, specialty, and (...) affinity—highlighting characteristics of each and discussing their strengths and weaknesses regarding different types of action around racism. It is our hope that we might direct concerned physicians toward initiatives that draw upon association strengths and that can serve as the basis for association‐specific advocacy niches—and away from initiatives that enable associations to signal that they are engaged in racial‐equity work without accountability or efficacy. (shrink)

Background Home care nurses are central in providing holistic and compassionate care to patients in home-based palliative care. Ethical caring competency is essential for home care to sustain nurses’ integrity in the face of moral adversity. Interprofessional collaboration is vital for ensuring ethical decision-making and providing patient-centered care in home-based palliative care settings. Aim This study explored the predictive roles of interprofessional collaboration and moral resilience on ethical caring competency among home care nurses in home-based palliative care. Methods A cross-sectional (...) survey of 400 nurses was conducted from October to December 2023, utilizing standardized scales to measure interprofessional collaboration, moral resilience, and ethical caring competency. A convenience sample of 400 home care nurses was also included in this study. Correlation and linear regression analysis were used to clarify the associative and predictive findings. Ethical Considerations Ethical approval from the ethics committee, institutional permission, and informed consent from the participants were obtained for data collection. Results Correlation analysis showed significant positive correlations between the ethical caring competency, interprofessional collaboration, and moral resilience constructs, with coefficients ranging from 0.482 to 0.967. Linear regression revealed that management of collaborative systems and total moral resilience significantly predict ethical caring competency, explaining 14.6% and 36.6% of its variance, respectively. Other variables, such as the effects of collaboration and communication, did not significantly influence ethical caring competency. Conclusion The study highlights the significant impact of interprofessional collaboration, particularly the management of collaborative systems and moral resilience, on enhancing ethical caring competency among nurses. Implications Enhancing interprofessional collaboration and moral resilience through targeted strategies in nursing practice and education can significantly improve ethical caring competencies. These efforts are essential for delivering high-quality, patient-centered care and for fostering a healthcare environment that respects the ethical principles guiding nursing practice. (shrink)

While early modern Spain may seem a world away, it is an extremely rich and relevant context for gaining a better understanding of the Rhetoric of Health, specifically the power of metaphor, in the related spheres of policy-making and public debate. It was a time and place in which the urban populace’s physical well-being depended upon the fortunes of theatrical performances due to a system of alms for hospitals driven by ticket receipts. Anti-theatricalists argued that the immoral nature of theatrical (...) performances made them spiritually and medically detrimental to society. Pro-theatricalists argued that plays were always a public good on balance because they raised much-needed funds for hospitals. Instead of producing a conflict between morality and public health, each side reinforced their connection until the two topics became nearly inseparable in the sphere of public debate. While pro-theatricalists mainly stayed with their arguments about funding hospitals, anti-theatricalists developed a new strategy of literalising the metaphor of theatre as a “plague of the republic” and arguing that immoral entertainment brought literal disease to the populace as a punishment from God. This exemplifies Stephen Pender’s observation of how, in an early modern medical context, “Rhetoric as a way of perceiving probabilities and adjusting one’s argument to the audience and circumstance offers a model of ethical action and interaction”. This article is organised chronologically to track specific adjustments to a specific public-health debate that rely upon moral metaphors of medicine. Each side wrangled over these metaphors in an effort to break a deadlock in a public-health policy debate with entertainment, finance, and morality at its centre. By the end of the seventeenth century, anti-theatricalists finally found their best rhetorical weapon in the literalisation of the “plague of the republic” metaphor, but it only offered a short-term solution to banning theatre contingent upon the ebb and flow of epidemics. Simultaneously, the finance structure of funding hospitals began to erase the role of hospitals from the longstanding debate about the morality of public theatre. The case of early modern Spain provides valuable lessons about the power of metaphor in the Rhetoric of Healthcare that are still applicable today. (shrink)

In 2021 and 2022, researchers carried out an implementation trial that considered how the capsule sponge test might be used to screen for Barrett’s oesophagus using a mobile clinic in East Anglia. This paper offers insights from 15 months of ethnographic fieldwork studying the trial. It aims to highlight the value of the test in offering reassurance to worried patients, particularly to those with a family history of oesophageal adenocarcinoma. It also considers the variety of aims people held for the (...) capsule sponge test, including the hope that it would address their symptoms of acid reflux, and the conflict that sometimes emerged as a result. The second half of the paper uses fieldwork carried out in virtual support groups for people with Barrett’s oesophagus to explore experiences postdiagnosis, which sometimes were defined by fear of future cancers. It describes notable differences between the care offered to people with morphological risk conditions like Barrett’s oesophagus and the care given to those with genetic risk conditions, including the provision of genetic counselling. More broadly, the paper highlights a tension between patient-centred and risk-centred medicine that is likely to grow as healthcare services continue to shift towards preventative approaches. (shrink)

Members of the Ethics and Public Policy Committee of the International Society of Nurses in Genetics prepared this article to assist nurses in interpreting the American Nurses Association (2015) Code of Ethics for Nurses with Interpretive Statements (Code) within the context of genetics/genomics. The Code explicates the nursing profession’s norms and responsibilities in managing ethical issues. The nearly ubiquitous application of genetic/genomic technologies in healthcare poses unique ethical challenges for nursing. Therefore, authors conducted literature searches that drew from various professional (...) resources to elucidate implications of the code in genetic/genomic nursing practice, education, research, and public policy. We contend that the revised Code coupled with the application of genomic technologies to healthcare creates moral obligations for nurses to continually refresh their knowledge and capacities to translate genetic/genomic research into evidence-based practice, assure the ethical conduct of scientific inquiry, and continually develop or revise national/international guidelines that protect the rights of individuals and populations within the context of genetics/genomics. Thus, nurses have an ethical responsibility to remain knowledgeable about advances in genetics/genomics and incorporate emergent evidence into their work. (shrink)