Physicians generally recommend that patients resuscitated with naloxone after opioid overdose stay in the emergency department for a period of observation in order to prevent harm from delayed sequelae of opioid toxicity. Patients frequently refuse this period of observation despiteenefit to risk. Healthcare providers are thus confronted with the challenge of how best to protect the patient’s interests while also respecting autonomy, including assessing whether the patient is making an autonomous choice to refuse care. Previous studies have shown that physicians (...) have widely divergent approaches to navigating these conflicts. This paper reviews what is known about the effects of opioid use disorder on decision-making, and argues that some subset of these refusals are non-autonomous choices, even when patients appear to have decision making capacity. This conclusion has several implications for how physicians assess and respond to patients refusing medical recommendations after naloxone resuscitation. (shrink)

An anthropocentric scope for clinical medical ethics (CME) has largely separated this area of bioethics from environmental concerns. In this article, we first identify and reconcile the ethical issues imposed on CME by climate change including the dispersion of related causes and effects, the transdisciplinary and transhuman nature of climate change, and the historic divorce of CME from the environment. We then establish how several moral theories undergirding modern CME, such as virtue ethics, feminist ethics, and several theories of justice, (...) promote both a flourishing of human medical practice and the environment. We conclude by defining an expanded the scope of CME as inclusive of not only patients, families, physicians, and other health professionals but other humans, non-humans, and their shared environment. We then apply this scope and theory to a widely used framework for applying CME, the Four Topics model, to construct a climate conscious approach to CME. (shrink)

In contemporary paternalism literature, persuasion is commonly not considered paternalistic. Moreover, paternalism is typically understood to be problematic either because it is seen as coercive, or because of the insult of the paternalist considering herself superior. In this paper, I argue that doctors who persuade patients act paternalistically. Specifically, I argue that trying to persuade a patient (here understood as aiming for the patient to consent to a certain treatment, although he prefers not to) should be differentiated from trying to (...) convince him (here understood as aiming for the patient to want the treatment) and recommending (the doctor merely providing her professional opinion). These three forms of influence are illustrated by summaries of video-recorded hospital encounters. While convincing and recommending are generally not paternalistic, I argue that persuasion is what I call communicative paternalism and that it is problematic for two reasons. First, the patient’s preferences are dismissed as unimportant. Second, the patient might wind up undergoing treatment against his preferences. This does not mean that persuasion always should be avoided, but it should not be undertaken lightly, and doctors should be aware of the fine line between non-paternalism and paternalism. The fact that my analysis of paternalism differs from traditional accounts does not imply that I deem these to be wrong, but rather that paternalism should be considered as a more multi-faceted concept than previous accounts allow for. (shrink)

In this article I discuss the ethical ramifications for medical ethics training of the availability of large language models (LLMs) for medical students. My focus is on the practical ethical consequences for what we should expect of medical students in terms of medical professionalism and ethical reasoning, and how this can be tested in a context where LLMs are relatively easy available. If we continue to expect ethical competences of medical professionalism of future physicians, how much – if at all (...) – should we worry that such generative AI may compromise adequate testing of medical students’ abilities in this regard? I mainly focus on assessment methods based on written assignments of the ‘student paper’ type and consider whether LLMs make it unfeasible for assessors to gauge whether output is student-generated or ‘machine-generated’ and, if so, whether this is a problem. My take on this research question unfolds in three interwoven arguments, claiming that the advent of LLMs may offer a momentum (i) to reaffirm the importance of context-sensitive interpretation and specification of ethical principles in medical ethics training, (ii) to provide more supportive circumstances to assessors to allow them to meet scoring demands entailed by the importance that is placed on medical professionalism, and (iii) to complement written assignments with verbal (group) discussion to train and test students’ skills to habitually recognize that ‘moral solutions’ can be normatively questioned and specified from various perspectives. (shrink)

Research ethics committees (RECs) evaluate whether the risk-benefit ratio of a study is acceptable. Decentralized clinical trials (DCTs) are a novel approach for conducting clinical trials that potentially bring important benefits for research, including several collateral benefits. The position of collateral benefits in risk-benefit assessments is currently unclear. DCTs raise therefore questions about how these benefits should be assessed. This paper aims to reconsider the different types of research benefits, and their position in risk-benefit assessments. We first propose a categorization (...) of research benefits, based on the types of benefits that can be distinguished from the literature and ethical guidelines. Secondly, we will reconsider the position of collateral benefits. We argue that these benefits are not fundamentally different from other benefits of research and can therefore be included in risk-benefit assessments of DCTs. (shrink)

The recent emergence of reprogramming technologies to convert brain cell types or epigenetically alter neurons and neural progenitors in vivo and in situ hold significant promises in brain repair and neuronal aging reversal. However, given the significant epigenetic and transcriptomic changes to components of the existing neuronal cells and network, we question if these reprogramming technology might inadvertently alter or erase memory engrams, conceivably resulting in changes in narrative identity or personality. We suggest that the nature of these alterations might (...) be less predictable compared to memory and personality changes known to be associated with diseases, drugs or brain stimulation therapies. While research in applying reprogramming technologies to neurological ailments and aging should continue, more targeted analyses should be put in place in animal experiments to gauge the severity and degree of memory alterations, and appropriate risk and benefit analyses should be conducted before these technologies move into human trials. (shrink)

Background Respect is essential to providing high quality healthcare, particularly for groups that are historically marginalized and stigmatized. While ethical principles taught to health professionals focus on patient autonomy as the object of respect for persons, limited studies explore patients’ views of respect. The purpose of this study was to explore the perspectives of a multiculturally diverse group of low-income women living with HIV (WLH) regarding their experience of respect from their medical physicians. Methods We analyzed 57 semi-structured interviews conducted (...) at HIV case management sites in South Florida as part of a larger qualitative study that explored practices facilitating retention and adherence in care. Women were eligible to participate if they identified as African American (n = 28), Hispanic/Latina (n = 22), or Haitian (n = 7). They were asked to describe instances when they were treated with respect by their medical physicians. Interviews were conducted by a fluent research interviewer in either English, Spanish, or Haitian Creole, depending on participant’s language preference. Transcripts were translated, back-translated and reviewed in entirety for any statements or comments about “respect.” After independent coding by 3 investigators, we used a consensual thematic analysis approach to determine themes. Results Results from this study grouped into two overarching classifications: respect manifested in physicians’ orientation towards the patient (i.e., interpersonal behaviors in interactions) and respect in medical professionalism (i.e., clinic procedures and practices). Four main themes emerged regarding respect in provider’s orientation towards the patient: being treated as a person, treated as an equal, treated without blame or prejudice, and treated with concern/emotional support. Two main themes emerged regarding respect as evidenced in medical professionalism: physician availability and considerations of privacy. Conclusions Findings suggest a more robust conception of what ‘respect for persons’ entails in medical ethics for a diverse group of low-income women living with HIV. Findings have implications for broadening areas of focus of future bioethics education, training, and research to include components of interpersonal relationship development, communication, and clinic procedures. We suggest these areas of training may increase respectful medical care experiences and potentially serve to influence persistent and known social and structural determinants of health through provider interactions and health care delivery. (shrink)

This article raises the question of whether bioethics qualifies as a discipline. According to a standard definition of discipline as “a field of study following specific and well-established methodological rules” bioethics is not a specific discipline as there are no explicit “well-established methodological rules.” The article investigates whether the methodological rules can be implicit, and whether bioethics can follow specific methodological rules within subdisciplines or for specific tasks. As this does not appear to be the case, the article examines whether (...) bioethics’ adherence to specific quality criteria (instead of methodological rules) or pursuing of a common goal can make it qualify as a discipline. Unfortunately, the result is negative. Then, the article scrutinizes whether referring to bioethics institutions and professional qualifications can ascertain bioethics as a discipline. However, this makes the definition of bioethics circular. The article ends by admitting that bioethics can qualify as a discipline according to broader definitions of discipline, for example, as an “area of knowledge, research and education.” However, this would reduce bioethics’ potential for demarcation and identity-building. Thus, to consolidate the discipline of bioethics and increase its impact, we should explicate and elaborate on its methodology. (shrink)

Zusammenfassung Die Forschungs- und Regulierungsebene bei datenintensiver Forschung in der Medizin liegen auseinander. Ein heterogenes Feld aus regulierenden Institutionen mit regional ungleichen Regelungen, sowohl hinsichtlich der Dichte als auch der Restriktivität von Regelungen, steht einer globalen Entwicklung der Technologien entgegen. Trotz oder gerade wegen mangelnder global-gültiger Regulierungen können auch unverbindliche oder nur bedingt verbindliche normative Vorgaben der Orientierung dienen. Doch wie soll eine solche normative Regulierung angesichts datenintensiver Forschung in der Medizin ausgestaltet werden und woran soll sie sich orientieren? Die (...) Frage, wie konkret und detailliert man eine solche Forschung regulieren sollte, lässt sich nur im Einzelfall für bestimmte Situationen und Institutionen beantworten. Ob dabei neue Normen oder Gewichtungen von Normen vorgenommen werden sollen, oder ob die Normen und deren Gewichtung weiterhin bestehen bleiben sollen, lässt sich nur mit Verweis auf starke normative Argumente beantworten. An zwingenden Argumenten für neue Normen angesichts der datenintensiven medizinischen Forschung mangelt es bisher. Dennoch ist eine Umsetzungsarbeit von Normen, egal ob neue oder alte, und deren Anwendung auf eine neue Methode oder Technologie allemal zu erbringen. Es bedarf daher – wie schon bisher – beider: sowohl etablierter und transparent kommunizierter Normen als auch des unabhängigen Urteils zur Anwendung dieser Normen. Angesichts der besonderen Eignung für diese Aufgabe sollten auch weiterhin Ethik-Kommissionen als prozedurale Instanz bei der Bewilligung von datenintensiver Forschung in der Medizin gefordert und befähigt werden, die als unabhängige Institution ein Urteil im Einzelfall anhand vorgegebener Normen fällen. Nichtsdestotrotz können sich die veränderten Praktiken datenintensiver Forschungsprojekte auch in neuen Anforderungen an Ethik-Kommissionen niederschlagen, denen mit Reformen der Arbeitsweise begegnet werden sollte. (shrink)

Biomedical research, on the one hand, contributes to important goals from generation of knowledge about the human body to the development and testing of therapeutics of all kinds. On the other hand, it can produce serious and sometimes unforeseeable consequences. In the ethical analysis of these two aspects of biomedical research, two important argumentative strategies play a major role. First, slippery slope arguments are used to warn of potential risks and to highlight knowledge-based limitations. Second, a dual-use problem describes the (...) challenge that already established techniques can be used for both morally wrong and morally right purposes. These two argumentative strategies appear to share several similarities, which will be investigated in this article. For this purpose, the article will first provide clear working definitions for both types of argument. This lays the foundation for the further ethical analysis. In a second step, and in order to investigate the similarities and differences of the argumentative strategies with an example from current ethical debates, CRISPR-Cas9, a currently very promising tool of genome editing, will be examined. The extent to which the possible applications of this genome editing tool can be addressed by slippery slope arguments or the dual use problem will be investigated. For this purpose, selected studies involving the use of CRISPR-Cas9 will be examined. Based on this two-step, analytic and example-based comparison of slippery-slope argumentation and dual-use considerations, the article will detail the ethically relevant difference between the two argumentative strategies and at the same time contribute to the ongoing ethical debate about CRISPR-Cas9. (shrink)

The application of human right frameworks is an increasingly important part of efforts to accelerate progress in global mental health. Much of this has been driven by several influential legal and policy instruments, most notably the United Nations’ Convention on the Rights of Persons with Disabilities, as well as the World Health Organization’s QualityRights Tool Kit and Mental Health Action Plan. Despite these significant developments, however, much more needs to be done to prevent human rights violations. This chapter focuses on (...) a critical component of this broader challenge, which is the question of how best to regulate and reduce the use of coercive measures. The recent literature on coercion in psychiatry – which addresses involuntary commitment, seclusion, restraint, and forced medication – represents a useful resource that can help guide tractable solutions in global mental health. These issues are evaluated from the perspective of global health governance, and several general recommendations are made in order to improve monitoring and enforcement, provide guidance for domestic legislative reform, and strengthen health systems. (shrink)

Generative AI enables automated, effective manipulation at scale. Despite the growing general ethical discussion around generative AI, the specific manipulation risks remain inadequately investigated. This article outlines essential inquiries encompassing conceptual, empirical, and design dimensions of manipulation, pivotal for comprehending and curbing manipulation risks. By highlighting these questions, the article underscores the necessity of an appropriate conceptualisation of manipulation to ensure the responsible development of Generative AI technologies.

Bioethics has increasingly become a standard part of medical school education and the training of healthcare professionals more generally. This is a promising development, as it has the potential to help future practitioners become more attentive to moral concerns and, perhaps, better moral reasoners. At the same time, there is growing recognition within bioethics that nonideal theory can play an important role in formulating normative recommendations. In this chapter we discuss what this shift toward nonideal theory means for ethical curricula (...) within healthcare education. In particular, we contend that more attention to the particularities of historical and social context needs to be incorporated into bioethics training. To make this argument, we focus on two examples: teaching units on race and medicine and those that focus on stigma and coercion in mental health. For both, we show how a pedagogical approach in which educators focus on social injustice could influence how practitioners engage in ethics in the clinic. This chapter, then, demonstrates what a commitment to nonideal theory can mean practically when it comes to bioethics education. (shrink)

Background The expressions of a “wish to hasten death” or “wish to die” raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the “wish to hasten death/die” based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and (...) how the meanings behind the “wish to hasten death/die” relate to and are interpreted in light of ethical principles in palliative care. Methods We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare’s framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330. Results Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the “wish to hasten death” and/or “wish to die” were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the “wish to hasten death”. Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles. Conclusions This meta-ethnographic review shows a reduced number of qualitative studies on the “wish to hasten death” and/or “wish to die” explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed. (shrink)

The aim of this paper is to get from a phenomenology of birth towards an ethics of obstetric care: Human rights violations in obstetrics are currently a globally debated phenomenon. Research suggests that maltreatment is widespread and a global phenomenon. However, the prevalence cannot yet be clearly quantified. In view of this problem, it is necessary to take the subjective perspective of those affected seriously. Narrative and phenomenological accounts of birth experiences could help to foster the dialogue between persons giving (...) birth and health professionals. First, I will present narrative accounts of birth experiences recorded by feminist phenomenologists. Second, I will interpret these narrative accounts within a feminist phenomenological framework in order to contribute to a phenomenology of birth, which, in a third step, shall help to develop an ethics of obstetric care. In engaging with the phenomenology of care outlined by feminist care ethicists, I will analyze the elements and conditions of good care, and draw conclusions for an ethic of obstetric and midwifery care. Drawing additionally on the theory of relational autonomy, my paper argues for a relational implementation of self-determination in childbirth. Lastly, I will discuss to what extent the ethical ideal of care has an affinity to the midwifery model of childbirth, and how the current situation of obstetrics prevents a women-centered birth culture. (shrink)

Zusammenfassung Patientinnen und Patienten steht das Recht auf Behandlung nach ihren eigenen Vorstellungen auch dann zu, wenn sie aktuell keinen eigenen Willen bilden können. Advance Care Planning (ACP), als ein spezielles Verfahren der gesundheitlichen Vorsorgeplanung, zielt darauf ab, dieses Dilemma durch eine Willensbestimmung im Voraus aufzulösen. Besonders ausgebildete Gesprächsbegleiter*innen bieten an, bei der Ermittlung, Formulierung und Dokumentation eines solchen, die individuelle gesundheitliche Situation berücksichtigenden Willens zu helfen. Das Umfeld der Betroffenen soll in den Gesprächsprozess einbezogen und es soll organisatorisch gesichert (...) werden, dass deren Willensbestimmung den aktuell Behandelnden im Bedarfsfall faktisch zugänglich ist. Das Verfahren kombiniert also ein kommunikatives mit einem institutionellen Element. Aus ethischer Sicht stellen sich dabei zwei wesentliche Herausforderungen. Erstens erfordert Gesprächsbegleitung mit einem so komplexen Ziel Kompetenzen und setzt bestimmte Haltungen voraus, wie sie für Professionen im strengen Sinne typisch sind. Daher wäre es wichtig, entsprechende professionelle Normen explizit zu machen, beispielsweise in Form eines Berufs-Kodex. Zweitens muss das Verfahren trotz seiner institutionellen Form für die Betroffenen freiwillig sein. Dies ist entscheidend für die Validität des Prozesses, aber auch für dessen Ergebnis. Denn wenn Letzteres rechtlich bindend sein soll, müssen die Betroffenen freiverantwortlich, d. h. ohne sog. Willensmängel handeln können. Es ist deshalb ethische Pflicht, beim Eintritt in und im Verlauf der Beratung auf die Freiwilligkeit zu achten. (shrink)

Culture, health, and medicine intersect in various ways—and not always without friction. This paper examines how liberal multicultural states ought to interact with diverse communities which hold different health-related or medical beliefs and practices. The debate is fierce within the fields of medicine and bioethics as to how traditional medicines ought to be regarded. What this debate often misses is the relationship that medical traditions have with cultural identity and the value that these traditions can have beyond the confines of (...) the clinical setting. This paper will attempt to bring some clarity to the discussion. In so doing, it will delve into some controversial areas: (1) the debate around whether liberal states ought to embrace multiculturalism, (2) the existence and nature of group-differentiated rights, (3) the question of whether healthcare systems ought to embrace medical pluralism, and (4) what this would entail for policymakers, clinicians, and patients. Ultimately, I argue that liberal democratic states with multicultural populations ought to recognize medical pluralism as a matter of respecting group-differentiated and individual human rights. (shrink)

Ambient assisted living technologies are increasingly presented and sold as essential smart additions to daily life and home environments that will radically transform the healthcare and wellness markets of the future. An ethical approach and a thorough understanding of all ethics in surveillance/monitoring architectures are therefore pressing. AAL poses many ethical challenges raising questions that will affect immediate acceptance and long-term usage. Furthermore, ethical issues emerge from social inequalities and their potential exacerbation by AAL, accentuating the existing access gap between (...) high-income countries and low and middle-income countries. Legal aspects mainly refer to the adherence to existing legal frameworks and cover issues related to product safety, data protection, cybersecurity, intellectual property, and access to data by public, private, and government bodies. Successful privacy-friendly AAL applications are needed, as the pressure to bring Internet of Things devices and ones equipped with artificial intelligence quickly to market cannot overlook the fact that the environments in which AAL will operate are mostly private. The social issues focus on the impact of AAL technologies before and after their adoption. Future AAL technologies need to consider all aspects of equality such as gender, race, age and social disadvantages and avoid increasing loneliness and isolation among, e.g. older and frail people. Finally, the current power asymmetries between the target and general populations should not be underestimated nor should the discrepant needs and motivations of the target group and those developing and deploying AAL systems. Whilst AAL technologies provide promising solutions for the health and social care challenges, they are not exempt from ethical, legal and social issues. A set of ELSI guidelines is needed to integrate these factors at the research and development stage. (shrink)

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics (...) of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice. (shrink)

Aims To examine the understanding of the ethical dilemmas associated with Big Data and artificial intelligence (AI) among Jordanian medical students, physicians in training, and senior practitioners. Methods We implemented a literature-validated questionnaire to examine the knowledge, attitudes, and practices of the target population during the period between April and August 2023. Themes of ethical debate included privacy breaches, consent, ownership, augmented biases, epistemology, and accountability. Participants’ responses were showcased using descriptive statistics and compared between groups using t-test or ANOVA. (...) Results We included 466 participants. The greater majority of respondents were interns and residents (50.2%), followed by medical students (38.0%). Most participants were affiliated with university institutions (62.4%). In terms of privacy, participants acknowledged that Big Data and AI were susceptible to privacy breaches (39.3%); however, 59.0% found such breaches justifiable under certain conditions. For ethical debacles involving informed consent, 41.6% and 44.6% were aware that obtaining informed consent posed an ethical limitation in Big Data and AI applications and denounced the concept of “broad consent”, respectively. In terms of ownership, 49.6% acknowledged that data cannot be owned yet accepted that institutions could hold a quasi-control of such data (59.0%). Less than 50% of participants were aware of Big Data and AI’s abilities to augment or create new biases in healthcare. Furthermore, participants agreed that researchers, institutions, and legislative bodies were responsible for ensuring the ethical implementation of Big Data and AI. Finally, while demonstrating limited experience with using such technology, participants generally had positive views of the role of Big Data and AI in complementing healthcare. Conclusion Jordanian medical students, physicians in training and senior practitioners have limited awareness of the ethical risks associated with Big Data and AI. Institutions are responsible for raising awareness, especially with the upsurge of such technology. (shrink)

As climate change risks intensify, I welcome Ray and Cooper’s call for bioethicists to engage with environmental injustice, though I am pessimistic it is another false dawn for bioethics engagement...

Pregnancy is a frequently applied exclusion criteria for many forms of research. Common justifications for this exclusion include the potential for teratogenicity, as well as the potential for physiologic changes in pregnancy to impact the research itself. The systematic exclusion of pregnant persons from clinical studies has created a significant gap in knowledge regarding medication safety and efficacy in pregnancy, which continues to cause significant harm to pregnant persons in need of medical therapy. To produce meaningful data and facilitate effective (...) knowledge translation to the clinical setting, special consideration to the pharmacology of pregnancy, as well as to outcomes of concern for this population is essential. The exclusion of pregnant participants from research is not ethically justifiable, as it violates the principles of autonomy, justice and nonmaleficence. While the inclusion of pregnant patients in research presents it’s own challenges, with appropriate methodological, ethical, and clinical considerations, we may be able to narrow the knowledge gap and improve drug availability and safety for pregnant patients and their children. (shrink)

The target article by Laacke et al. focuses on the specific context of identifying people in social media with a high risk of depression by using artificial intelligence technologies. I...

Evaluating readiness for discharge from the intensive care unit (ICU) is a critical aspect of patient care. Whereas evidence-based criteria for ICU admission have been established, practical criteria for discharge from the ICU are lacking. Often discharge guidelines simply state that a patient no longer meets ICU admission criteria. Such discharge criteria can be interpreted differently by different healthcare providers, leaving a clinical void where misunderstandings of patients’ readiness can conflict with perceptions of what readiness means for patients, families, and (...) healthcare providers. In considering ICU discharge readiness, the use and application of ethical principles may be helpful in mitigating such conflicts and achieving desired patient outcomes. Ethical principles propose different ways of understanding what readiness might mean and how clinicians might weigh these principles in their decision-making process. This article examines the concept of discharge readiness through the lens of the most widely cited ethical principles (autonomy [respect for persons], nonmaleficence/beneficence, and justice) and provides a discussion of their application in the critical care environment. Ongoing bioethics discourse and empirical research are needed to identify factors that help determine discharge readiness within critical care environments that will ultimately promote safe and effective ICU discharges for patients and their families. (shrink)

Persons with dementia often prefer to participate in decisions about their health care, but may be prevented from doing so because healthcare decision-making law facilitates use of advance directives or surrogate decision makers for persons with decisional impairments such as dementia. Federal and state disability law provide alternative decision-making models that do not prevent persons with mild to moderate dementia from making their own healthcare decisions at the time the decision needs to be made. In order to better promote autonomy (...) and wellbeing, persons with dementia should be accommodated and supported so they can make their own healthcare decisions. (shrink)

Social Networking Services provide services in return for rights to commercialize users’ personal data. We argue that what makes this transaction permissible is not users’ autonomous consent but the provision of sufficiently valuable opportunities to exchange data for services. We argue that the value of these opportunities should be assessed for both (a) a range of users with different decision-making abilities and (b) third parties. We conclude that regulation should shift from aiming to ensure autonomous consent towards ensuring that users (...) face options that they will use to advance individual and common interests. (shrink)

The generally agreed upon principle that legality and ethics can come apart is frequently overlooked in our professional ethics education and decision-making procedures. The crux of the issue is that we teach in our philosophy classes that the law can sometimes be unethical, but then clearly state in nursing codes of ethics that students should always follow the law. The law could no doubt give us some reason to choose action A over action B, but in professional contexts we frequently (...) treat the law as a side-constraint that limits the logical space of choices to exclude even consideration of action B. If B is the mandatory action, this in effect forces professionals to do something unethical by preventing them from ever seeing the ethical action as an option. This is a problem. Ultimately we concede that there might be an irresolvable tension in competing normative interests in ethics and the law, though we suggest that a more nuanced approach to ethical code formation could help alleviate the issue somewhat. (shrink)

In recent years there have been several calls in professional and academic journals for healthcare personnel in Canada to raise the profile of postcolonial theory as a theoretical and explanatory framework for their practice with Indigenous people. In this paper I explore some of the challenges that are likely to confront those healthcare personnel in engaging with postcolonial theory in a training context. I consider these challenges in relation to three areas of conflict. First I consider conflicts around paradigms of (...) knowledge, wherein postcolonial theory operates from a different base from most professional knowledge in health care. Second I consider conflicts of ideology, wherein postcolonial theory is largely at odds with Canada’s political and popular cultures. And finally I consider issues around the question of Canada’s legitimacy, which postcolonial theory puts in doubt. I suggest ways in which these conflicts might be addressed and managed in the training context, and also identify potential positive outcomes that would be enabling for healthcare personnel, and might also contribute to an improvement in Canada’s relationship with its indigenous peoples. (shrink)

Zusammenfassung Die informierte Einwilligung von Teilnehmer:innen gilt in vielen Fällen als Voraussetzung auch für die rein datenbasierte medizinische Forschung. In diesem Kontext wird ein Modell der breiten Einwilligung (_Broad Consent_) diskutiert. In Deutschland hat die Medizininformatik-Initiative einen konkreten Vorschlag für deutsche Kliniken ausgearbeitet, der eine Gültigkeit der Einwilligung für einen Zeitraum von 30 Jahren vorsieht. Der vorliegende Artikel diskutiert vor diesem Hintergrund die Frage, wie der Anspruch der Informiertheit in dieser zeitlichen Perspektive einzuordnen ist. Die Praxis der Einwilligung wird dabei (...) so verstanden, dass sie auf die Verwirklichung von Wohlergehen, persönlicher Souveränität und Vertrauen ausgerichtet ist. Eine anzunehmende Informationsasymmetrie zwischen Forschungsteilnehmenden, Forschenden, und datenspeichernden Institutionen wird dabei als spezifisches Kontextmerkmal herausgestellt. Um dieser Informationsasymmetrie in angemessener Weise zu begegnen, so die These, ist eine kontinuierliche Weitergabe von verständlich aufbereiteten Informationen an Forschungsteilnehmende notwendig, um die Wahrnehmung persönlicher Souveränität zu ermöglichen. (shrink)

ContextIn many cases, informed consent of participants is considered a prerequisite even for exclusively data-based medical research. In this context, a model of broad consent is being discussed. In Germany, the Medizininformatik-Initiative (Medical Informatics Initiative) has developed a proposal for broad consent for German hospitals which suggests a validity period of 30 years.Definition of the problemAgainst this background, the article discusses how the claim of consent beinginformedhas to be regarded in a temporal perspective. The practice of consent is here understood (...) to be oriented towards the realization of well-being, personal sovereignty, and trust. In the context of medical research, an asymmetry of access to information between research participants, researchers, and data-storing institutions has to be assumed.Argument and conclusionThe article argues that in order to appropriately address this information asymmetry, a continuous dissemination of comprehensibly prepared information to research participants is necessary to enable personal sovereignty. (shrink)

The article critically responds to "A Planetary Health Pledge for Health Professionals in the Anthropocene" which was published by Wabnitz et al. in The Lancet in November 2020. It focuses on the different roles and responsibilities of a physician. The pledge is criticised because it neglects the different roles, gives no answers in case of conflicting goals, and contains numerous inconsistencies. The relationship between the Planetary Health Pledge and the Declaration of Geneva is examined. It is argued that the Planetary (...) Health Pledge should have supplemented the Declaration of Geneva instead of changing it. (shrink)

Doctors routinely refuse donation offers from prospective living kidney donors with certain comorbidities such as diabetes or obesity out of concern for donor wellbeing. This refusal occurs despite the ongoing shortage of kidney transplants and the superior performance of living donor kidney transplants compared to those from deceased donors. In this paper, we argue that this paternalistic refusal by doctors is unjustified and that, within limits, there should be greater acceptance of such donations. We begin by describing possible weak and (...) strong paternalistic justifications of current conservative donor acceptance guidelines and practices. We then justify our position by outlining the frequently under-recognised benefits and the routinely overestimated harms of such donation, before discussing the need to respect the autonomy of willing donors with certain comorbidities. Finally, we respond to a number of possible objections to our proposal for more liberal kidney donor acceptance criteria. We use the situation in Australia as our case study, but our argument is applicable to comparable situations around the world. (shrink)

Leading paradigms of clinical ethics consultation closely follow a biomedical model of care. In this paper, we present a theoretical reflection on the underlying biomedical model of disease, how it shaped clinical practices and patterns of ethical deliberation within these practices, and the repercussions it has on clinical ethics consultations for patients with chronic illness. We contend that this model, despite its important contribution to capturing the ethical issues of day-to-day clinical ethics deliberation, might not be sufficient for patients presenting (...) with chronic illnesses and navigating as “lay experts” of their medical condition(s) through the health care system. Not fully considering the sources of personal knowledge and expertise may lead to epistemic injustice within an ethical deliberation logic narrowly relying on a biomedical model of disease. In caring “for” and collaboratively “with” this patient population, we answer the threat of epistemic injustice with epistemic modesty and humility. We will propose ideas about how clinical ethics could contribute to an expansion of the biomedical model of care, so that important aspects of chronic illness experience would flow into clinical-ethical decision-making. (shrink)

In their most informative text, Zuk et al. (2023) describe the perspectives researchers take on DBS and aDBS when discussing changes in patients’ personality, mood, or behavior. To this end, Zuk et...

This essay explores three issues in respect for autonomy that pose unfinished business for the concept. By this, I mean that the dialogue over them is ongoing and essentially unresolved. These are: whether we ought to respect persons or their autonomous choices; the role of relational autonomy; and whether nonhuman animals can be autonomous. In attending to this particular set of unfinished business, I highlight some critical moral work left aside by the concept of respect for autonomy as understood in (...) Beauchamp and Childress’ Principles of Biomedical Ethics. Specifically, while significant pragmatic traction is gained by the authors’ focus on autonomous choice, carving such a focus out from the broader questions of moral respect and the autonomy of the person leaves aside a number of questions that we might have thought a view about respect for autonomy in biomedicine ought to answer. These include: How should physicians respond when autonomous patients make decisions that appear nonautonomous? What is the impact of the view that autonomy is “relational” for cross-cultural differences in how autonomy is respected? If chimpanzees can be autonomous, what does that mean for how they should be treated? (shrink)

In their article “Three Kinds of Decision-Making Capacity for Refusing Medical Interventions,” Navin et al. (2022) argue that we should recognize two forms of decision-making capacity (DMC) besides...

The adaptive BCI known as ‘closed-loop deep brain stimulation’ (clDBS) is a device that stimulates the brain in order to prevent pathological neural activity and automatically adjusts stimulation levels based on computational algorithms that detect or predict those pathological processes. One of the prominent ethical concerns raised by clDBS is that, by inhibiting or modulating the undesirable neural states of a cognitive agent automatically, the device potentially undermines her autonomy. It has been argued that clDBS is not a threat because (...) autonomy is fundamentally relational, i.e., it essentially depends on external (e.g., social or cultural) factors. If the relational approach to autonomy includes human-computer interaction, then the mechanisms of clDBS, even if external to the brain and exerting some degree of control over the individual, may support her autonomy. However, DBS applications are substantially different from one another, each involving a specific neurological or psychiatric condition, neural target, mechanism and symptom(s), and therefore at least some of them may not fit into the relational analysis. I examine different clDBS applications for treatment resistant depression and claim that while internal capsule/ventral striatum (VC/VS) clDBS is a case of relational autonomy, subgenual cingulate gyrus (Cg25) clDBS is not. Autonomy (relational or otherwise) requires some degree of self-regulation of our motivational states, which is supported by VC/VS DBS but is absent in Cg25 DBS. In Cg25 DBS the device itself directly influences motivational states, thus substituting or overriding (instead of supporting) the auto-regulatory cognitive processes required for autonomous action. (shrink)

Moral distress is defined as the inability to act according to one’s own core values. During the COVID-19 pandemic, moral distress in medical personnel has gained attention, related to the impact of pandemic-associated factors, such as the uncertainty of treatment options for the virus and the accelerated pace of deaths. Measures to provide aid and mitigate the long-term pandemic effect on providers are starting to be designed. Yet, little has been said about the moral distress experienced by patients and the (...) relational and additive effect on provider moral distress. Pandemic-associated factors affecting moral distress in patients include the constraining effects of isolation on spiritual and religious traditions as well as the intentional separation of patients from their families. This paper will explore the idea that patients are suffering their own moral distress and further how this impacts the intensity of moral distress experienced by the providers—nurses and physicians. The paucity of research in this area with the implications on patient’s distress, decision making, and distress experienced by providers compels further investigation and analysis. (shrink)

Although rapid genomic sequencing (RGS) is improving care for critically ill children with rare disease, it also raises important ethical questions that need to be explored as its use becomes more widespread. Two such questions relate to the degree of consent that should be required for RGS to proceed and whether it might ever be appropriate to override parents’ decisions not to allow RGS to be performed in their critically ill child. To explore these questions, we first examine the legal (...) frameworks on securing consent for genomic sequencing and how they apply to the specific context of RGS for critically ill children. We then use a tool from clinical ethics, the Zone of Parental Discretion, to explore two case studies and identify under which circumstances it might be appropriate for parental refusal of RGS to be overridden. We argue that RGS may be a context where, in addition to assessing the complexity of the test offered, it is ethically appropriate to consider an effect on patient outcomes when deciding the degree of consent required. We also suggest that there are some contexts where it may be ethically justified to perform RGS, even when it is actively against the wishes of the parents. More work is needed to examine exactly how ‘time-sensitive’ exceptions to current guidance on consent for genomic sequencing could be formulated and operationalised for RGS for critically ill-children. (shrink)

In their article “A Research Ethics Framework for the Clinical Translation of Healthcare Machine Learning,” McCradden et al. highlight the various gaps that emerge when artificial intelligen...

Definition of the problem The umbrella term “explicability” refers to the reduction of opacity of artificial intelligence (AI) systems. These efforts are challenging for medical AI applications because higher accuracy often comes at the cost of increased opacity. This entails ethical tensions because physicians and patients desire to trace how results are produced without compromising the performance of AI systems. The centrality of explicability within the informed consent process for medical AI systems compels an ethical reflection on the trade-offs. Which (...) levels of explicability are needed to obtain informed consent when utilizing medical AI? Arguments We proceed in five steps: First, we map the terms commonly associated with explicability as described in the ethics and computer science literature, i.e., disclosure, intelligibility, interpretability, and explainability. Second, we conduct a conceptual analysis of the ethical requirements for explicability when it comes to informed consent. Third, we distinguish hurdles for explicability in terms of epistemic and explanatory opacity. Fourth, this then allows to conclude the level of explicability physicians must reach and what patients can expect. In a final step, we show how the identified levels of explicability can technically be met from the perspective of computer science. Throughout our work, we take diagnostic AI systems in radiology as an example. Conclusion We determined four levels of explicability that need to be distinguished for ethically defensible informed consent processes and showed how developers of medical AI can technically meet these requirements. (shrink)

Unconsented pelvic exams under anesthesia are assaults cloaked in defense of healthcare education. Preemptive linguistic qualifiers “presumed” or “implied” attempt to justify such violations with flippancy toward their oxymoronic implications: to suggest a priori that consent can be assumed undermines its otherwise standalone social, ethical, and medico-legal reverence. In this paper I conceptualize “medical sexual assault” and argue that presumed consent for intimate exams exemplifies its definition. By bluntly describing pelvic exams as “penetration,” this work aims to reify the intimate (...) reality of the clinical label “pelvic exam” and to call attention to cisheteronormative and androcentric assumptions involved in its practice. Additionally, this scholarship seeks to create a foundation toward broader work in conceptualizing clinical rape culture. Given recent national survey data indicating a surprising frequency of unconsented intimate exams, detailed language as to their problematics is necessary for ongoing legal and ethical efforts. Explicit consent for intimate exams must be the standard of care for conscious and unconscious patients. (shrink)

The coupled growth of population aging and international migration warrants attention on the methods and solutions available to adult children living overseas to provide distance caregiving for their aging parents. Despite living apart from their parents, the transnational informal care literature has indicated that first-generation immigrants remain committed to carry out their filial caregiving obligations in extensive and creative ways. With functions to remotely access health information enabled by emergency, wearable, motion, and video sensors, remote monitoring technologies (RMTs) may thus (...) also allow these international migrants to be alerted in sudden changes and remain informed of their parent’s state of health. As technological solutions for caregiving, RMTs could allow independent living for older persons while any unusual deviations from normal health patterns are detected and appropriately supported. With a vignette of a distance care arrangement, we engage with concepts such as filial piety, in-absentia caregiving distress, and the social exchange theory, as well as the upholding of shifting cultural ideals to illustrate the complex dynamic of the satisfaction and quality of the informal caregiving relationship. This paper extends the traditional ethical issues in technology-aided caregiving, such as autonomy, privacy, and justice, to be considered within the context of distance care. We also posit newer ethical considerations such as consent in power imbalances, harm to caregivers, and stigma. These known and new ethical issues aim to encourage further ethically conscious design and use of RMTs to support distance care for older persons. (shrink)

Like COVID-19, new infectious disease outbreaks emerge almost annually, and studies predict that this trend will continue due to a variety of factors, including an aging population, ease of travel, and globalization of the economy. In response to episodic public health crises, governments and organizations develop, implement, and enforce policies, procedures, protocols, and programs. The epidemiological triad is both a model of disease causation and fundamentally used to design and deploy such control measures. Here we adapt this model to the (...) workplace setting and use the epidemiological triad to characterize the related ethical challenges in implementing the control measures employers face as a guide for a workplace intervention framework. Through this approach, our aim is to show how an integrated ethical framework, grounded in epidemiological principles, has important implications for how we categorize, understand, and resolve the difficult decisions that emerge in the workplace under pandemic conditions. (shrink)

This article presents a radical claim: American medical ethics is broken, and it needs love to be healed. Due to a unique set of cultural and economic pressures, American medical ethics has adopted a mechanistic mode of ethical reasoning epitomized by the doctrine of principlism. This mode of reasoning divorces clinicians from both their patients and themselves. This results in clinicians who can ace ethics questions on multiple‐choice tests but who fail either to recognize a patient's humanity or to navigate (...) the ethical quandaries into which they are frequently thrown. Drawing on personal experience as well as the philosophical work of Augustine of Hippo, Simone Weil, and Iris Murdoch, we propose a novel ethical approach grounded in a conception of neighbor love, specifically, the virtue of love understood as attention to a sufferer's humanity. We conclude with five practical recommendations for reimagining medical ethics education oriented around the virtue of love. (shrink)

The article discusses ways of developing bioethical guidance in the Orthodox Christian discourse. Here, “ethical” refers to what contributes to holiness, “un-ethical” refers to sin as what hinders man’s foundational calling to holiness. To explore the development of guidance for emerging bioethical issues, we use the “therapeutic” understanding of treatment for sin in two senses. (1) It refers to the spiritual means provided by the “hospital” of the Orthodox Church for healing the fallenness of human nature in general; and (2) (...) it helps identify in particular cases both what counts as transgression of unconditional boundaries (defining what is illicit for everyone) and what is advisable in order to help particular persons to choose rightly within the area of the “more or less licit” (or “permissible”). Sources of the Orthodox faith that frame the general understanding of the boundaries between the permissible and the impermissible reflect the work of the Holy Spirit in the Church framing her Sacred (Holy) Tradition. In Holy Tradition, prayers, as communion with God, occupy a central position. This is why Orthodox moral reasoning, and thus also Orthodox bioethics, takes the form of liturgical bioethics. Penalties of excommunication determine hard boundaries that believers should not overstep: when crossing such boundaries, they enter on a spiritually dangerous path that completely distracts them away from God. Many minor sins, by contrast, have not been codified in Canons. They are not taken to remove the sinner completely from contact with the Lord. Within this realm of actions, it depends on a person’s spiritual maturity whether such actions are classified as sinful. Thus, an act can be counted merely as a small offense if committed by a beginner, while that same act can become a grave sin for an advanced believer. Due to acceleration of the technological progress, Orthodox recourse to Holy Tradition encounters ever-new challenges. There are bioethical issues that had not surfaced at the time of the Fathers of the Church. Today, Bishops gathered at a local council can supply the guidance lacking on a newly emerging bioethical problem. Even if ratified only by such local councils, the resulting decrees can also be regarded as the expression of the Holy Spirit working within a local Church and conveying His guidance. The article illustrates this source of Christian bioethics by reference to how the Russian Orthodox Church orients and develops its position on the ethics of reproductive technologies. (shrink)

Volume 20, Issue 3, March 2020, Page 75-77.