Medical Ethics

Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton’s all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue (...) that in the case of a twin pregnancy, there are two intuitively plausible claims: abortion is morally permissible, and it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution. There are no data in this work. (shrink)

Background: Current practice frequently fails to provide care consistent with the preferences of decisionally-incapacitated patients. It also imposes significant emotional burden on their surrogates. Algorithmic-based patient preference predictors (PPPs) have been proposed as a possible way to address these two concerns. While previous research found that patients strongly support the use of PPPs, the views of surrogates are unknown. The present study thus assessed the views of experienced surrogates regarding the possible use of PPPs as a means to help make (...) treatment decisions for decisionally-incapacitated patients. -/- Methods: This qualitative study used semi-structured interviews to determine the views of experienced surrogates [n=26] who were identified from two academic medical centers and two community hospitals. The primary outcomes were respondents’ overall level of support for the idea of using PPPs and the themes related to their views on how a PPP should be used, if at all, in practice. -/- Results: Overall, 21 participants supported the idea of using PPPs. The remaining five indicated that they would not use a PPP because they made decisions based on the patient’s best interests, not based on substituted judgment. Major themes which emerged were that surrogates, not the patient’s preferences, should determine how treatment decisions are made, and concern that PPPs might be used to deny expensive care or be biased against minority groups. -/- Conclusions: Surrogates, like patients, strongly support the idea of using PPPs to help make treatment decisions for decisionally-incapacitated patients. These findings provide support for developing a PPP and assessing it in practice. At the same time, patients and surrogates disagree over whose preferences should determine how treatment decisions are made, including whether to use a PPP. These findings reveal a fundamental disagreement regarding the guiding principles for surrogate decision-making. Future research is needed to assess this disagreement and consider ways to address it. (shrink)

Star Trek scripts have often grappled with dilemmas of medical ethics. The most explicitly medical-ethics-oriented Star Trek episode is named, aptly enough, “Ethics.” The script was written by Sara Charno and Stuart Charno, authors of two other Star Trek episodes. “Ethics” first aired on 2 March 1992. In the fall of 1992, we began to use this “Ethics” episode to motivate discussions in our first-year medical students’ course on medical ethics and the doctor-patient relationship. We asked students to write essays (...) addressing one of the many ethical dilemmas posed by the episode. Over the years, the episode has become a tradition. Both students and instructors find the formulation of dilemmas in the context of a science-fiction story to be both liberating and stimulating. In this essay, we will discuss this particular episode in some detail and then provide a brief synopsis of other episodes that might be used in ethics courses in a similar way. (shrink)

Ethical debates about liberal eugenics frequently focus on the supposed unnaturalness of its means and possible harm to autonomy. I present a Nietzsche-inspired critique focusing on intention rather than means and harm to abilities rather than to autonomy. I first critique subjective eugenics, the selection of extrinsically valuable traits, drawing on Nietzsche’s notion of ‘slavish’ values reducible to the negation of another’s good. Subjective eugenics slavishly evaluates traits relative to a negatively evaluated norm (eg, above-average intelligence), disguising a harmful intention (...) to diminish the relative value of that norm. I then argue there is no objective form of eugenics on the Nietzschean ground that abilities are not valuable intrinsically; they are valuable only if one possesses the relative power to exercise them. Abilities frustrated by conflict with other abilities or environment are harmful, while disabilities that empower one’s other abilities are beneficial. Consequently, all forms of eugenics are subject to the prior ethical critique of subjective eugenics. (shrink)

Purpose: The objective of this study is to determine the importance of supplementary medical ethics course for resident physicians. In this study, we assessed the current state of their knowledge of medical ethics and aimed to improve and deepen their understanding of clinical scenarios to increase their awareness of the link between the practice of medicine and ethical issues. Methods: The course was held for groups of 10-12 people for 3 days a week for a total of 6 hours. Tests (...) given prior to and following completion of the course were used to assess the effectiveness of a medical ethics training course in which 120 resident physicians completed. The evaluation was made on the basis of the same pre-and post-tests (14 scenarios) and direct observation of participants. Result and Discussion: The average age was 28.23 ± 4.08 and 25% were female and 75% were male. Of the participants, 68.3% were training to be internists, 24.2% were training to be surgeons, and 7.5% were training in laboratory medicine. There was a significant statistical difference between the mean total scores of both tests (p=0.00). After completing the course, residents took into account the medical ethical principles while discussing ethical decisions. Conclusion: After finishing the course, participants defended their responses in regard to issues of medical ethics more carefully and articulated their thoughts more clearly. Our experience demonstrated that the trainees benefited from a structured curriculum in medical ethics. We believe that the development and implementation of our course may serve as a case study for training resident physicians in medical ethics. (shrink)

Bioethics, Volume 36, Issue 1, Page 63-70, January 2022.

Alasdair MacIntyre is a contemporary philosopher of Ethics and Politics best known for his book “After virtue”, 1981. The originality and relevance of this work lie in the presentation of his articles from the 1970’s about medicine and medical ethics, which are unexplored in Bioethics. In these articles, MacIntyre criticizes changes in society transforming the physician-patient relationship: fragmentary moral views, individualism, misunderstanding of scientism and fallibility of the practice, as well as the lost background of common values and medical authority. (...) From a teleological perspective, MacIntyre describes internal goods of medicine and physician’s virtues: reliability, fairness, courage, humility and even, friendship. (shrink)

Background Euthanasia is a topic of intense ethical debate and it is illegal in most countries at present, including Sri Lanka. The aim of this descriptive cross-sectional study of medical students and practicing doctors was to explore the acceptance of euthanasia and physician assisted suicide, and factors influencing this opinion. Methods A customised online questionnaire which explored opinions on euthanasia was administered to first and final year medical undergraduates in University of Colombo and practicing doctors with more than 5 years (...) of work experience at The National Hospital of Sri Lanka. Attitudes on euthanasia and PAS were also assessed with the attitudes towards euthanasia Scale, which is a 10-item questionnaire. Results A total of 425 individuals responded, which included 143 first-year medical undergraduates, 141 final-year medical undergraduates and 141 practicing doctors. More participants favoured legalizing euthanasia than those directly opposing it, but a significant proportion remained undecided. The mean scores of ATE questionnaire from the whole sample were generally unfavourable towards euthanasia/PAS. Accepting euthanasia as an option for oneself was the strongest predictor of favouring euthanasia/PAS or supporting its legalization. Conclusion In this cross-sectional survey, more respondents supported legalisation of euthanasia in Sri Lanka than those openly opposing it. Yet, a significant minority that responded as “undecided” for legalisation, were more likely to have unfavourable ATE. (shrink)

Medical ethics would be better if people were taught to think more clearly about well-being or the concept of what is good for a person. Yet for a variety of reasons, bioethicists have generally paid little attention to this concept. Here, I argue, first, that focusing on general theories of welfare is not useful for practical medical ethics. I argue, second, for what I call the “theory-without-theories approach” to welfare in practical contexts. The first element of this approach is a (...) focus on examining important and relatively uncontroversial constituents of welfare as opposed to general theories. The second key element is a framework for thinking about choice in relation to welfare, a framework I refer to as “the mild objectivity framework.” I conclude with illustrations of the way in which the “theory without theories approach” can improve thinking in medicine. (shrink)

This brief and remarkably inexpensive book by the distinguished Professor Maehle of Durham University is composed of five detailed studies of aspects of nineteenth and twentieth century British med...

Although Theravada Buddhism and Roman Catholicism agree on the moral justification for palliative sedation, they differ on the premises underlying the justification. While Catholicism justifies palliative sedation on the ground of the Principle of Double Effect, Buddhism does so on the basis of the Third Noble Truth. Despite their theological differences, Buddhism and Catholicism both value the moral significance of the physician’s intent to reduce suffering and both respect the sanctity of life. This blurs the demarcation line between Buddhism and (...) Catholicism regarding the moral justification of palliative sedation. -/- . (shrink)

Aiming at the allocation of scarce medical resources, Immanuel and other scholars have put forward a set of influential ethical values and guiding principles. It assigns the priority of resource allocation to those whose lives can be saved and maximized, those who can bring the greatest instrumental value, and those who are the worse off. For other members of society, random selection under the same conditions is adopted. Following the Rawlsian "lexical order, lexicographical" rule, this priority arrangement requires that the (...) "utilitarian principle" should be placed before the "equality principle", and the "instrumental difference principle", the "integrity difference principle" and the "fair opportunity principle" in turn acts on specific distribution agents. Although the framework and its priority rules have obvious drawbacks when faced with Medical Resources Squeeze and other dilemmas, with the help of an understanding of its internal structure, it can effectively respond to the four core issues in the allocation of scarce medical resources. (shrink)

What position on dualism does medicine require? Our understanding of that ques- tion has been dictated by holism, as defined by the biopsychosocial model, since the late twentieth century. Unfortunately, holism was characterized at the start with con- fused definitions of ‘dualism’ and ‘reductionism’, and that problem has led to a deep, unrecognized conceptual split in the medical professions. Some insist that holism is a nonreductionist approach that aligns with some form of dualism, while others insist it’s a reductionist view (...) that sets out to eradicate dualism. It’s important to consider each version. Nonreductive holism is philosophically consistent and clinically unprob- lematic. Reductive holism, however, is conceptually incoherent—yet it is the basis for the common idea that the boundary between medical and mental health disorders must be vague. When we trace that idea through to its implementation in medical practice, we find evidence that it compromises the safety of patient care in the large portion of cases where clinicians grapple with diagnosis at the boundary between psychiatry and medicine. Having established that medicine must embrace some form of nonreduc- tionism, I argue that Chalmers’ naturalistic dualism is a stronger prima facie candidate than the nonreductive alternatives. Regardless of which form of nonreductionism we prefer, some philosophical corrections are needed to give medicine a safe and coherent foundation. (shrink)

Background Health care professionals have to judge the appropriateness of treatment in critical care on a daily basis. There is general consensus that critical care interventions should not be performed when they are inappropriate. It is not yet clear which chances of survival are considered necessary or which risk for serious disabilities is acceptable in quantitative terms for different stakeholders to start intensive care treatment. Methods We performed an anonymous online survey in a random sample of 1,052 participants recruited via (...) email invitation and social media. Age, sex, nationality, education, professional involvement in health care, critical care medicine and treatment decisions in critical care medicine as well as personal experience with critical illness were assessed as potential influencing variables. Participants provided their opinion on the necessary chances of survival and the acceptable risk for serious disabilities to start a high-risk or uncomfortable therapy for themselves, relatives or for their patients on a scale of 0–100%. Results Answers ranged from 0 to 100% for all questions. A three-peak pattern with different distributions of the peaks was observed. Sex, education, being a health care professional, being involved in treatment decisions and religiosity influence these opinions. Male respondents and those with a university education would agree that a risky and uncomfortable treatment should be started even with a low chance of survival for themselves, relatives and patients. More respondents would choose a lower necessary chance of survival when deciding for patients compared to themselves or relatives to start a risky and uncomfortable treatment. On the other hand, the majority of respondents would accept only a low risk of severe disability for both themselves and their patients. Conclusion No cut-off can be identified for the necessary chances of survival or the acceptable risk of disability to help quantify the “inappropriateness” of critical care treatment. Sex and education are the strongest influencing factors on this opinion. The large variation in personal opinions, depending on demographic and personality variables and education needs to be considered in the communication between health care professionals and patients or surrogates. (shrink)

Background In the Canadian Alliance for Healthy Hearts and Minds cohort, participants underwent magnetic resonance imaging of the brain, heart, and abdomen, that generated incidental findings. The approach to managing these unexpected results remain a complex issue. Our objectives were to describe the CAHHM policy for the management of IFs, to understand the impact of disclosing IFs to healthy research participants, and to reflect on the ethical obligations of researchers in future MRI studies. Methods Between 2013 and 2019, 8252 participants (...) were recruited with a follow-up questionnaire administered to 909 participants at 1-year. The CAHHM policy followed a restricted approach, whereby routine feedback on IFs was not provided. Only IFs of severe structural abnormalities were reported. Results Severe structural abnormalities occurred in 8.3% of participants, with the highest proportions found in the brain and abdomen. The majority of participants informed of an IF reported no change in quality of life, with 3% of participants reporting that the knowledge of an IF negatively impacted their quality of life. Furthermore, 50% reported increased stress in learning about an IF, and in 95%, the discovery of an IF did not adversely impact his/her life insurance policy. Most participants would enrol in the study again and perceived the MRI scan to be beneficial, regardless of whether they were informed of IFs. While the implications of a restricted approach to IF management was perceived to be mostly positive, a degree of diagnostic misconception was present amongst participants, indicating the importance of a more thorough consent process to support participant autonomy. Conclusion The management of IFs from research MRI scans remain a challenging issue, as participants may experience stress and a reduced quality of life when IFs are disclosed. The restricted approach to IF management in CAHHM demonstrated a fair fulfillment of the overarching ethical principles of respect for autonomy, concern for wellbeing, and justice. The approach outlined in the CAHHM policy may serve as a framework for future research studies. Clinical trial registration https://clinicaltrials.gov/ct2/show/NCT02220582. (shrink)

In “Communication Breakdown: Probing the Limits of Narrative Medicine and its Discontents”, David J. Leichter engages practical experience teaching medical ethics in the college classroom to explore opportunities—and limits—of narrative engagement within medical ethics and clinical practice. Leichter raises concerns regarding potential epistemic harms, both testimonial and hermeneutical, when individuals, or their pain, cannot be adequately recognized through expressive modes traditionally understood as “narrative.” While I largely agree with Leichter’s worries about narrative authority and limits, I challenge his characterization of (...) “narrative medicine.” In response, I suggest that “narrative medicine” is more than merely narrative engagement in medicine. As theorized by Rita Charon, “narrative medicine” involves an inclusive approach to what narrative is, and more than mere mastery of “narrative competency.” I argue that at least one way to conceptualize “narrative medicine” is as a technical term, which refers to the process of attention, representation, and affiliation Charon develops as the achievement of narrative medicine. When understood in this technical way, narrative medicine can both resist and respond to the kinds of epistemic harms about which Leichter is rightfully worried. (shrink)

In the article I prove the separateness of professional medical ethics in three ways: 1. By showing differences between the normative rank of responsibilities within general and professional ethics. 2. By justifying affiliation of professional medical ethics within the appropriation model which is a type of applied ethics characterized by its unique properties. 3. By justifying historical professionalism as the ethics that is proper for the medical profession; for this kind of ethical internalism the content of professional ethics is the (...) sole work of medical professional organizations as well as individual doctors. In the final part of the article I reconstruct the actual and postulated relations between professional ethics and professionalism as well as between academic bioethics and public bioethics. The aim of this reconstruction is to indicate the optimal from the perspective of ethical education place of professional ethics within the ethics education system for professionalists. (shrink)

In this paper, I bring together Jewish and Buddhist philosophical resources to develop a notion of radical responsibility that can confront a complicity within nursing and health care between empathy and (neo)liberal white supremacist hegemony. My inspiration comes from Angela Davis's call for building coalitions to advance struggles for peace and justice. I proceed as follows. First, I note ways phenomenology clarifies empathy's seeming foundational role in nursing care, and how such a formulation can be complicit with assumptions about private (...) individualism. Second, I turn to the Jewish philosophies of Martin Buber and Emmanuel Levinas, and their advocacy for a kind of responsibility that precedes the constitution of individuality as this can provide a resource for action and practice circumventing liberal influenced empathy. I note critical reservations about direct and practical application of Levinasian ethics in nursing care, and turn to engaged Buddhist philosophies of interdependence—such as in Thich Nhat Hanh and the Dalai Lama—as a corrective. Third, I conclude by indicating ways interreligious radical responsibility can reorient us toward housekeeping habits of character and away from exceptional crisis management, noting specific examples and actions in health care, nursing education and nursing scholarship. (shrink)

While the era following the Bland decision in 19931 might be thought of as the time when concepts such as ‘futility’ were placed under pressure and scrutiny, it’s an idea that has been debated for at least forty years. In a 1983 JME commentary Bryan Jennett distinguishes three kinds of reason why Cardiopulmonary Resuscitation might be withheld: > ‘… that CPR would be futile because it is very unlikely to be successful; that quality of life after CPR is likely to (...) be changed to so poor a level as to be a greater burden than the benefit gained from prolongation of life, and that quality of life is already so poor due to chronic or terminal disease that life should not be prolonged by CPR.’ pp-142-1432 This crisp definition seems as applicable as it did then, but it was not the final word on the concept. Mitchell, Kerridge and Lovat explore, as others did in the post-Bland and Quinlan eras, how ‘futility’ might apply to those in a …. (shrink)

Cardiovascular disease is the leading cause of death of women in the United States, yet cardiovascular research is disproportionately conducted using male human subjects and male animal models. This article deploys Katrina Hutchison’s (2019) analysis of gender disparity in clinical trials as a moral aggregation problem to address the problem of underrepresentation of women in cardiovascular research. I identify cost concerns, convenience, pregnancy, and negligence as potential reasons for the underrepresentation of women in CVD research. Finally, I suggest that multilevel (...) strategies will be needed to eliminate sex disparity in CVD research and improve patient care. (shrink)

One of the most important health developments is the caesarean section, which saves lives when mother and newborn are at risk. But while it has no benefit when used outside the need, it also carries a variety of risks, such as each surgery. Caesarean section presents risks such as complications caused by exposure to anesthesia in the mother, increased bleeding after delivery, prolongation of discharge, and delayed recovery. In addition to these, it also creates an economic burden. Reasons such as (...) the fact that the expectant mother is not adequately informed about the birth, wants her doctor to be present during the birth, thinks that a caesarean section is safer are some elements that lead the expectant mother to the cesarean section option. This, along with some risks, leads to the emergence of ethical problems. The purpose of this study is to analyze the reasons why cesarean section is requested other than necessary situations and to discuss the ethical problems caused by this situation and to offer solutions. In the study, the ethical dimensions of the caesarean performed without indication were mentioned. This review study was prepared to discuss the frequency, causes and possible solution suggestions for cesarean, which carries some risks like any surgical intervention, although it does not have any benefits for the mother and newborn when performed outside of medical necessity, based on ethical dimensions. (shrink)

This book sheds light on various ethical challenges military and humanitarian health care personnel face while working in adverse conditions. Contexts of armed conflict, hybrid wars or other forms of violence short of war, as well as natural disasters, all have in common that ordinary circumstances can no longer be taken for granted. Hence, the provision of health care has to adapt, for example, to a different level of risk, to scarce resources, or uncommon approaches due to external incentives or (...) requirements. This affects the practice of health care as well as its ethics. This book offers a panoramic overview on various challenges healthcare faces in extraordinary situations and provides new insights from practitioners’ as well as from academic scholars’ perspectives. (shrink)

Journal of Religious Ethics, Volume 49, Issue 2, Page 245-269, June 2021.

In this article, part of a special issue on meaning in life and medical ethics, I argue that several issues encountered in a bioethical context are not adequately addressed only with values such as morality and welfare. I maintain, more specifically, that the value of what makes a life meaningful is essential to being able to provide conclusive judgements about which decisions to make. After briefly indicating how meaningfulness differs from rightness and happiness, I point out how it is plausibly (...) central to making decisions in six ‘life and death’ matters. My aim is not to draw any firm conclusions about what to do when it comes to these topics, but rather to show that in order to arrive at any, one cannot plausibly ignore the category of life’s meaning that has, until recently, been nearly absent from Western bioethics since its inception. (shrink)

William Simkulet has recently criticised Colgrove et al’s defence against what they have called inconsistency arguments—arguments that claim opponents of abortion (OAs) act in ways inconsistent with their underlying beliefs about human fetuses (eg, that human fetuses are persons at conception). Colgrove et al presented three objections to inconsistency arguments, which Simkulet argues are unconvincing. Further, he maintains that OAs who hold that the fetus is a person at conception fail to act on important issues such as the plight of (...) frozen embryos, poverty and spontaneous abortion. Thus, they are morally negligent. In response, we argue that Simkulet has targeted a very narrow group of OAs, and so his criticisms are inapplicable to most OAs. We then explain why his responses to each of Colgrove et al’s objections do not succeed, even for this restricted group. Finally, we note that Simkulet fails to provide evidence for his claims regarding OAs’ supposed failures to act, and we show that OAs veritably do invest resources into these important issues. We conclude that Colgrove et al’s reasons for rejecting inconsistency arguments (en masse) remain intact. (shrink)

As a medical ethicist, I want to explain why college vaccination requirements decidedly do not violate the core principles of medical ethics which include avoiding or lessening harms, promoting benefits, respecting people and their informed and free choices, and promoting justice and fairness. In particular, vaccine requirements do not violate the respect-related requirement to not selfishly “use” and abuse others as “means” for someone else’s benefit. Since false claims on important issues often have dire consequences, it’s important to explain why (...) medical ethics supports vaccinating college students. (shrink)

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

Laacke et al. investigate the ethical implications of possible artificial intelligence systems that automatically detect signs of depression by analyzing data from social media. The art...

BackgroundImportance of awareness of medical ethics and its integration into medical curriculum has been frequently highlighted. Study 1 aimed to assess the knowledge, attitude, and reported practices of medical ethics among clinicians at Patan Academy of Health Sciences, a tertiary care teaching hospital in Nepal. Study 2 was conducted to assess whether there was a difference in knowledge, attitude, and reported practices of medical ethics among doctors who received formal medical ethics education during undergraduate studies and those who did not.MethodsTwo (...) cross-sectional surveys using self-administered questionnaires were conducted. Study 1 included 72 participants; interns, medical officers, and consultants working at Patan Academy of Health Sciences. Study 2 was a comparative study conducted among 54 medical officers who had received formal medical ethics education and 60 medical officers who did not.ResultsParticipants who had completed post-graduate education had higher knowledge, practice, and overall combined scores. Participants with ethics education had higher knowledge, attitude, practice, and overall score. Most participants preferred consulting colleagues if an ethical dilemma arose. Fewer participants had heard of the Declaration of Helsinki. Most participants thought doctors to be most capable of judging what is best for the patient. Case scenarios in which participants demonstrated poor practice were ethical issues concerning truth-telling, end-of-life decisions, treating HIV/aids patients, treating a minor, and reporting colleague’s errors.ConclusionsThis study found that participants who have received medical ethics education have higher knowledge, attitude, and practice scores. The results further justify the need for medical ethics education to be a part of the core medical curriculum. A blame-free environment where seniors can be approached for advice should be created. Research ethics should also be given attention. During medical ethics training, ethical issues where doctors perform poorly should be given more priority and should be discussed in a country-specific context. (shrink)

Both the diagnosis and medical treatment of gender dysphoria —particularly in children and adolescents—have been the subject of significant controversy in recent years. In this paper, we outline the means by which GD is diagnosed in children and adolescents, the currently available treatment options, and the bioethical issues these currently raise. In particular, we argue that the families and healthcare providers of children presenting with GD currently face two main ethical dilemmas in decision making regarding treatment: the pathway dilemma and (...) the consent dilemma. (shrink)

Background Best interests is a ubiquitous principle in medical policy and practice, informing the treatment of both children and adults. Yet theory underlying the concept of best interests is unclear and rarely articulated. This paper examines bioethical literature for theoretical accounts of best interests to gain a better sense of the meanings and underlying philosophy that structure understandings. Methods A scoping review of was undertaken. Following a literature search, 57 sources were selected and analysed using the thematic method. Results Three (...) themes emerged. The first placed best interests within the structure of wider theory, noting relationships with consequentialism, deontology, prudential value theory, rights and political philosophy. The second mapped a typology of processes of decision-making, among which best interests was ambiguously positioned. It further indicated factors that informed best interests decision-making, primarily preferences, dignity and quality of life. The final theme considered best interests from a relational perspective. Conclusions Characterisation of best interests as strictly paternalist and consequentialist is questionable: while accounts often suggested a consequentialist basis for best interests, arguments appeared philosophically weak. Deontological accounts, found in law and Kantianism, and theories of political liberalism influenced accounts of best interests, with accounts often associating best interests with negative patient preferences. There was much more emphasis on negative interests than positive interests. Besides preference, factors like dignity and quality of life were held to inform best interests decisions, but generally were weakly defined. To the extent that preferences were unable to inform decision making, decisions were either made by proxy authority or by an intersubjective process of diffuse authority. Differing approaches reflect bifurcations in liberal philosophy between new liberalism and neo-liberalism. Although neither account of authority appears dominant, bias to negative interests suggests that bioethical debate tends to reflect the widespread ascendancy of neo-liberalism. This attitude was underscored by the way relational accounts converged on private familial authority. The visible connections to theory suggest that best interests is underpinned by socio-political trends that may set up frictions with practice. How practice negotiates these frictions remains a key question. (shrink)

As medical ethics and professionalism education continues to equip medical students and residents with long-lasting tools, educators should continue to supplement proven teaching strategies with engaging, relatable, and generationally appropriate didactic supplements. However, popular teaching aids have recently been criticized in the literature and summative information on alternatives is absent. The purpose of this review is to evaluate and assess the functional use and application of short form audiovisual didactic supplements or "icebreakers" in medical ethics and professionalism teaching. A systematic (...) review of both the medical and humanities literature was conducted from inception to August 1, 2019. Final articles were subjected to a qualitative appraisal and thematic analysis. Thirteen articles were included for final analysis. Sixty-nine percent of the studies were published after 2000. Two studies were qualitative, one study was quantitative, and the remaining articles were commentaries. Short form audiovisual media was most popular outside of the United States. Sixty-nine percent of articles advocated for self-contained media in the form of trigger films or short films/videos, while the remaining articles discussed the use of TV/film clips. Producibility of media was exclusive to short/trigger films. Nine themes were identified in the content analysis: adaptability, conversation catalyst, effective, engaging, nuance, practice, producibility, real, and subject diversity. The three most common themes in descending order of frequency were: conversation catalyst, realness, and adaptability. Trigger films represent an effective and unique pedagogical strategy in supplementing current medical ethics and professionalism teaching at the medical school level. (shrink)

People who receive a ‘solid’ organ transplant from a deceased person may experience imaginative challenges in making sense of how the transfer impacts their own past and future, as shown in existing scholarship. Building on such work, this article considers how the temporalities of medical encounter itself may also become temporally ambiguous, posing representational challenges both pre-transplantation and post-transplantation. The dominant narrative of transplant in transplantation journals and hospital communications, both clinical and patient-facing, presents surgery as a healing moment, yet (...) the recipient’s experience of hospital, pharmacology and daily self-monitoring may be disorienting in multiple ways which resist conventional conceptions of medical temporalities of cure. Examining memoirs by Robert Pensack and Richard McCann, this article suggests the transplant temporalities may be fruitfully approached through scholarship of ‘queering’ time and ‘crip’ time. While the medical narrative of transplant focuses on the event of transplantation, these texts construct post-transplant time as still profoundly structured by waiting, expectation and suspense, the transformed body less healed than permanently contingent and fragile in different ways. I do not purport to uncover the ‘truth’ of bleak survival hidden within a story of the miraculous. Rather, I am reaching for a critical practice to recognise subtle entanglements of medicalised time, and identify a tension and synthesis between miracle and the chronic, an insight which may also be of service for other critical approaches to memoir of heroic medicine. (shrink)

A peer commentary on an AJOB article by Kyle Fritz called "Unjustified Asymmetry: Positive Claims of Conscience and Heartbeat Bills.".

In this paper, we consider the role of conversations in contributing to healthcare quality improvement. More specifically, we suggest that conversations can be important in responding to what we call ‘normative complexity’. As well as reflecting on the value of conversations, the aim is to introduce the dimension of normative complexity as something that requires theoretical and practical attention alongside the more recognised challenges of complex systems, which we label, for short, as ‘explanatory complexity’. In brief, normative complexity relates to (...) the inherent difficulty of deciding what kinds of changes are ‘improvements’ or, more broadly, what is valuable in healthcare. We suggest that explanatory and normative complexity intersect and that anyone interested in healthcare improvement needs to be sensitive to both. After briefly introducing the idea of normative complexity, we consider some contrasting examples of conversations, reflecting on how they do and might contribute to healthcare quality. We discuss both conversations that are deliberately organised and facilitated and more informally occurring and routine conversations. In the first half of the paper, we draw on some examples of orchestrated and routine conversations to open up these issues. In the second half of the paper, we bring some more theoretical lenses to bear on both conversations and normative complexity, summarise what we take to be the value of conversations and draw together some of the implications of our discussion. In summary, we argue that conversations can play a crucial role in negotiating the normative complexity of healthcare quality improvement because of their capacity to hold together a plurality of perspectives, to contribute and respond to emergence and to help underpin institutional conditions for empathy and imagination. (shrink)