Imprisonment may sometimes be a justified form of punishment. Yet the U.S. carceral system suffers from appalling problems of justice—in who is put into prisons, in how imprisoned people are treated, and in downstream personal and community health impacts. Medical personnel working in prisons and jails take on risky work for highly vulnerable and underserved patients. They are to be lauded for their professional commitments. Yet at the same time, prison care undercuts the ability of medical (...) class='Hi'>personnel to uphold their own professional standards and sometimes fails in even basic health protection. Doctors in prisons are stuck between their commitment to vulnerable patients and complicity in a system that requires their participation to uphold its constitutionality. Medical ethics is frayed in prisons, and the problem deserves our attention. (shrink)

Emergency care providers regularly deal with ethical dilemmas that must be addressed. In comparison with in-hospital nurses, emergency medical service personnel are faced with more problems such as distance to resources including personnel, medico-technical aids, and information; the unpredictable atmosphere at the scene; arriving at the crime scene and providing emergency care for accident victims and patients at home. As a result of stressfulness, unpredictability, and often the life threatening nature of tasks that ambulance professionals have to (...) deal with every day, ethical decision-making has become an inevitable challenge. The content analysis approach was used to conduct the present qualitative study in Iran. The participants consisted of 14 EMS personnel selected through purposive sampling, which continued until the data became saturated. Data were collected using semi-structured interviews and analyzed concurrently with their collection through the constant comparison method. The process of data analysis resulted in the emergence of 3 main categories “respecting client’s values”, “performing tasks within the professional manner”, “personal characteristic”, and the emergence of eight sub-categories signifying participants’ experiences with regard to EDM. According to the results, when EMS personnel are faced with ethical dilemmas, they consider the client’s values and professional dignity, and perform the assigned tasks within the framework of the regulation. The findings also suggest that pre-hospital care providers assess legal consequences before making any decision. Further studies should be conducted regarding the experiences of the subordinates and other related parties. (shrink)

The global public health threat posed by infectious disease is well recognised. The obligation to treat whilst exposed to risk, and its limits, is debated with each novel serious and communicable pathogen. Within national jurisdictions, different responses are forthcoming. Some, like France in 2009, give government the power to require healthcare staff to work, and even to requisition staff, including retired professionals. Others rely on notions of solidarity and professional duty, with scope for individual discretion. Our research with staff in (...) the West Midlands in 2008/2009– including non-professionals – suggested a strong correlation between feeling a duty to work and willingness to work during a pandemic. This was more influential than removing other barriers to working. Medical military personnel can already be ordered into risky situations. Our research in 2015/16 with those who worked in the Ebola treatment unit in Sierra Leone suggested that their concerns about risk were complex: the perceived magnitude of the risk was only one factor, even though tolerance was high. The type of risk and circumstances requiring that risk to be taken were also influential.Against this background, it will be argued, with caveats, that:military medical personnel should be willing to accept greater risk than civilian medical staff;and that to maintain national health services during a communicable disease emergency:civilian medical staff ought to accept greater risks than they currently appear willing to tolerate;conscription – from civilian or military populations – is permissible, even though it may elevate personal risk. (shrink)

Since the mid-1800s, clergy, doctors, other clinicians, and military personnel who specifically facilitate their work have been designated “non-combatants”, protected from being targeted in return for providing care on the basis of clinical need alone. While permitted to use weapons to protect themselves and their patients, they may not attempt to gain military advantage over an adversary. The rationale for these regulations is based on sound arguments aimed both at reducing human suffering, but also the ultimate advantage of the (...) nation-state fielding non-combatant staff. However, this is sometimes not immediately apparent to combatant colleagues. Clinicians in the armed force are also military officers, owing a “dual loyalty” that can create conflict if their non-combatant status is not well understood. Historical examples of doctors breaching their responsibilities include prioritisation of combat capability over the rights of individual soldiers (as occurred when scarce medical resources were allocated to soldiers more likely to return to battle in preference to those most likely to die without them), use of physicians to facilitate prisoner interrogation, medical research or treatment to enhance physical performance at the expense of health, application of Medical Rules of Eligibility according to factors other than clinical need, provision of treatment contingent upon support for military objectives, and use of medical knowledge to enhance weapons. However, not being a combatant party to a conflict does not imply that the non-combatant clinician cannot act in the national interest. Indeed, by adhering to the same universal ethics as their civilian colleagues, military clinicians provide optimal care to their own troops, facilitate freedom of action in host nations, and build positive international relationships during the conflict and in the post-conflict state. (shrink)

The profession of medicine has developed codes of ethical conduct for thousands of years. From the Hippocratic Oath of ancient Greece onward to modern times, a universal and central element of such codes has expressed the imperative that a physician shall “Do no harm.”.

In an increasingly interconnected global community, severe disasters or disease outbreaks in one country or region may rapidly impact global health security. As seen during the responses to the earthquakes in Haiti and Japan, Typhoon Haiyan in the Philippines, and the current Ebola outbreak in West Africa, local response capacities can be rapidly overwhelmed and international assistance may be necessary to support the affected region to respond and recover and to protect other countries from the spread of disease. For example, (...) President Obama stated on September 16, 2014, that “if the [Ebola] outbreak is not stopped now, we could be looking at hundreds of thousands of people infected, with profound political and economic and security implications for all of us…. [T]his…is not just a threat to regional security — it’s a potential threat to global security if these countries break down…. And that’s why…I directed my team to make this a national security priority.”. (shrink)

As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between October 2014 and (...) April 2015 in one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and ‘empty beds’ presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants’ ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values. We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers’ experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers. (shrink)

Background As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. Method Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between October (...) 2014 and April 2015 in one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. Results Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and ‘empty beds’ presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants’ ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values. Conclusion We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers’ experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers. (shrink)

This article argues that medical personnel of armed forces occupy a ‘peace role’, which continues and dominates their professional ethos during armed conflict. The specific role and its associated legal and ethical obligations are elaborated, and on that basis arguments are provided why and how the work of military healthcare providers is interpreted as a continuation of peace during war.

Osoba odnosno osobni identitet kao izvorno filozofski pojmovi nalaze primjenu i u medicinskim diskursima. Usto se njihova tumačenja ne izvode isključivo iz historijskog konteksta filozofijskih i teologijskih predodžbi, već poprimaju etičku dimenziju na razini ljudskog ponašanja. Njihovo osebujno značenje dosežu u interakciji između liječnika i pacijenta, interakciji koja se manifestira u tjelesno-fenomenalnoj interpretaciji personaliteta: isti se proteže od autonomije i svojevoljnosti refleksivno ustrojene svijesti do prividne disocijacije tijela i osobe u okviru pojma moždane smrti. Razumijevanje čovjeka kao osobe pritom je (...) dio one antropološke paradigme koja u medicinskim kriznim situacijama predstavlja temelj etički opravdanog ophođenja s njime. Deficit izazvan gubitkom osobne autonomije time postaje smjernicom k onoj deficijentnoj tjelesnosti koju je medicina definirala kao predmet vlastita istraživanja.Person and personal identity, originally philosophical concepts, find its application also in medical discourses. Moreover, their interpretations are not derived exclusively from historical context of philosophical and theological ideas, but acquire an ethical dimension on the level of human behaviour. Their special meaning is obtained in the patient-physician interaction, which is manifested in the bodily-phenomenal interpretation of personality: this ranges from autonomy and purposiveness of a reflectively structured consciousness to the apparent dissociation of the body and the person in the concept of brain death. The understanding of the human being as person is thereby a part of the anthropological paradigm that presents the basis for ethically acceptable action in medical crisis situations. The deficiency caused by the loss of personal autonomy is therefore an indication of a deficient corporeality, which medicine has chosen as its research object..La personne et l’identité personnelle, en tant que concepts à l’origine philosophiques, trouvent également leur application dans les discours médicaux. Ce faisant leurs inteprétations ne sont pas tirées uniquement du contexte historique des représentations philosophiques et théologiques, mais gagnent une dimension éthique à l’échelle du comportement humain. Ils prennent leur signification particulière dans l’interaction entre le médecin et le patient, laquelle se manifeste dans l’interprétation physico-phénoménale de la personnalité : celle-ci s’étend de l’autonomie et de l’arbitraire d’une conscience organisée de manière réflexive jusqu’à la dissociation apparente du corps et de la personne dans le cadre de la notion de mort cérébrale. La compréhension de l’homme en tant que personne fait en même temps partie de ce paradigme anthropologique qui dans des situations médicales de crise représente la base d’un rapport avec lui éthiquement justifié. Le déficit subi par la perte de l’autonomie personnelle est ainsi également une indication de ce physique déficient que la médecine a désigné comme objet de sa recherche.Person und personale Identität finden als ursprünglich philosophische Begriffe auch in medizinischen Diskursen Anwendung. Dabei leiten sich ihre Deutungen nicht allein aus dem historischen Kontext philosophischer und theologischer Vorstellungen ab, sondern gewinnen eine ethische Dimension auf der Ebene menschlichen Verhaltens. Ihre besondere Bedeutung erlangen sie in der Auseinandersetzung zwischen Arzt und Patient, die sich in einer leiblich-phänomenalen Interpretation der Personalität offenbart: diese reicht von der Autonomie und Willentlichkeit eines reflexiven geordneten Bewusstseins bis zur scheinbaren Dissoziierung von Leib und Person im Begriff des Hirntodes. Das Verständnis des Menschen als Person ist dabei Teil jenes anthropologischen Paradigmas, das die Grundlage eines ethisch verantwortbaren Umganges mit diesem in medizinischen Krisensituationen darstellt. Der im Verlust personaler Autonomie erlebte Mangel ist damit auch ein Hinweis auf jene defiziente Leiblichkeit, welche sich die Medizin zum Forschungsgegenstand erkoren hat. (shrink)

A reflection on the philosophical concept of morality, its values and human conduct and the obligations of medical personnel to conform to the recognised standard practices.

This volume provides a comprehensive analysis of the history, development and other legal aspects relating to International Medical Law and covers issues arising from not only the physician-patient relationship, but also with many wider juridical relations involved in the broader field of medical care in the international arena.00After a general introduction, the book examines the evolution of medical law in different civilizations that existed all over the world. It systematically describes the sources of this law from conventions, (...) treaties along with discussing the important role played by the courts, international institutions and other bodies related to the medical field. The comprehensive coverage includes public health law, international spread and prevention of diseases. This volume covers medical ethics and clinical ethics; considerations to facets of the medical professionals and patients relationship such as rights and responsibilities of the physicians, beneficence, consent, privacy, rights of patients and risk management. Also covered are issues of international concern like medical criminal activities, human and drug trafficking, trade in human organs, human medical research, as well as matters dealing with bio-technology in relation to bio-safety, bio-security, bio-genetics, bio-ethics, and the role of medical personnel in armed conflicts. (shrink)

During the Nazi regime (1933–1945), more than 300 000 psychiatric patients were killed. The well‐calculated killing of chronic mentally ‘ill’ patients was part of a huge biopolitical program of well‐established scientific, eugenic standards of the time. Among the medical personnel implicated in these assassinations were nurses, who carried out this program through their everyday practice. However, newer research raises suspicions that psychiatric patients were being assassinated before and after the Nazi regime, which, I hypothesize, implies that the motives (...) for these killings must be investigated within psychiatric practice itself. An investigation of the impact of the interplay between the notes left by nurses and those by psychiatrists illustrates the active role of the psychiatric medical record in the killing of these patients. Using theoretical insights from Michel Foucault and philosopher Giorgio Agamben and analyzing one part of a particularly rich patient file found in the Langenhorn Psychiatric Asylum in the city of Hamburg, I demonstrate the role of the record in both constructing and deconstructing patient subjectivities. De‐subjectifying patients condemned them to specific zones in the asylum within which they were reduced to their ‘bare life’‐ a precondition for their physical assassination. (shrink)

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigation of military health personnel reporting abuse, degradation, or signs of torture. Mounting information from many sources, including Pentagon documents, the International Committee of the Red Cross, Amnesty International, Human Rights Watch, etc., indicate that medical personnel (...) failed to maintain medical records, conduct routine medical examinations, provide proper care of disabled and injured detainees, accurately report illnesses and injuries, and falsified medical records and death certificates. Medical personnel and medical information was also used to design and implement psychologically and physically coercive interrogations. The United States military medical system failed to protect detainee's human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism. (shrink)

Medical collaboration with authoritarian regimes historically has served to facilitate the use of torture as a tool of repression and to justify atrocities with the language of public health. Because scholarship on medicalized killing and biomedicalist rhetoric and ideology is heavily focused on Nazi Germany, this article seeks to expand the discourse to include other periods in which medicalized torture occurred, specifically in Argentina from 1976 to 1983, when the country was ruled by the Proceso de Reorganización Nacional military (...) regime. The extent to which medical personnel embedded themselves within the Proceso regime’s killing apparatus has escaped full recognition by both scholars and human rights activists. This article reconstructs the narrative of the Proceso’s human rights abuses to argue that health professionals knowingly and often enthusiastically facilitated, oversaw, and participated in every phase of the “disappearance,” torture, and mass murder process. (shrink)

Military doctors and nurses, working neither as pure soldiers nor as merely doctors or nurses, may face a ‘role conflict between the clinical professional duties to a patient and obligations, express or implied, real or perceived, to the interests of a third party such as an employer, an insurer, the state, or in this context, military command’. This conflict is commonly called dual loyalty. This chapter gives an overview of the military and the medical ethic and of the resulting (...) dual loyalty problem for medical personnel working in the military. It considers how dual loyalties relate to being a professional, something medical personnel are the paradigmatic examples of, but also something military personnel claim to be. Against that background, the chapter elaborates on the medical rules of eligibility used in Afghanistan, and on the policies concerning military involvement in local healthcare, to see what the existing rules and policies are, and whose interests they serve. (shrink)

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

Changing faces of war and war-like situations have led in recent years to new forms of military deployment. They range from the so called "war on terrorism" with e.g Operation Enduring Freedom or humanitarian interventions (e.g. Kosovo 1999) to deployments within disaster relief missions as lately in Haiti. These pose not only moral, legal, and organizational challenges to states and the international community but also put individual soldiers and military (medical) personnel in situations that their classical formation does (...) not prepare them for. For they face (i) situations not sufficiently covered/ regulated by international humanitarian (IHL) law and/or (ii) tasks that are not within the range of the "classical soldier". These changing needs require new forms of education in the military and highlight the role of ethical education as many of the dilemmas cannot be resolved by sole reference to the IHL. In addition to a solid knowledge of the law of armed conflict (LOAC), military personnel should therefore acquire fundamental skills of ethical reasoning in dilemma situations. Our article aims at (i) outlining the goals of a military medical ethics education that responds to these needs and the practical challenges of present-day military deployment and (ii) present how the ICMM tries to integrate these goals in its educational program. (shrink)

Medical personnel sometimes face a seeming conflict between a duty to respect patient confidentiality and a duty to warn or protect endangered third parties. The conventional answer to dilemmas of this sort is that, in certain circumstances, medical professionals have an obligation to breach confidentiality. Kenneth Kipnis has argued, however, that the conventional wisdom on the nature of medical confidentiality is mistaken. Kipnis argues that the obligation to respect patient confidentiality is unqualified or absolute, since unqualified (...) policies can save more lives in the long run. In this paper, I identify the form of Kipnis’s argument and present a challenge to it. I conclude that, as matters stand now, a qualified confidentiality policy is the more rational choice. (shrink)

Little research has explored the perceptions of military medical providers in the deployed environment and how their perceptions may change over time across an extended military conflict. To our knowledge, no studies have examined military medical providers’ opinions on readiness for their roles in the post-9/11 contingency operations. What has been published indicates that, during the height of Operation Iraqi Freedom, military medical providers often deployed with little notice and minimal formal training. The present report examines data (...) obtained from multiple cohorts of military medical providers (N = 321) deployed to Iraq between 2005 and 2009. Despite varying degrees of support from the U.S. public, our findings indicate that U.S. Air Force military medical providers’ support for the people of Iraq, their belief in the mission, and their ability to influence change did not vary with time. (shrink)

When militaries mention loyalty as a value they mean loyalty to colleagues and the organisation. Loyalty to principle, the type of loyalty that has a wider scope, plays hardly a role in the ethics of most armed forces. Where military codes, oaths and values are about the organisation and colleagues, medical ethics is about providing patient care impartially. Being subject to two diverging professional ethics can leave military medical personnel torn between the wish to act loyally towards (...) colleagues, and the demands of a more outward looking ethic. This tension constitutes a test of integrity, not a moral dilemma. (shrink)

What I call medically enabled suicides have four distinctive features: 1. They are instigated by actions of a suicidal individual, actions she intends to result in a physiological condition that, absent lifesaving medical interventions, would be otherwise fatal to that individual. 2. These suicides are ‘completed’ due to medical personnel acting in accordance with recognized legal or ethical protocols requiring the withholding or withdrawal of care from patients (e.g., following an approved advance directive). 3. The suicidal individual (...) acts purposefully to ensure that medical personnel will act on these protocols. 4. These suicides do not involve medical personnel providing aid in dying in the standard sense, either through (a) active voluntary euthanasia, or (b) assistance by means of prescriptions, etc. -/- Regardless of how common medically enabled suicides are, they raise compelling questions at the interface of medicine and individual choice. After first clarifying the concept of medically enabled suicide and exploring some of the reasons why it might be attractive to suicidal individuals, I then investigate two apparent dilemmas that medically enabled suicides raise for medical care providers. The first alleges that medical care providers may not contribute to harming their patients, and so they may not contribute to their patients’ suicides. The second alleges that if care providers, as a matter of personal conscience, believe that suicide is wrong, then they may not be compelled to contribute to their patient’s acting wrongly by assenting to the wishes of a patient pursuing medically enabled suicide. Both dilemmas arise from the fact that while medical personnel are bound by widely accepted precepts of medical ethics to honor the competent wishes of their patients, medically enabled suicides entangle them in their patients’ suicidal plans in ways that result in their contributing to those suicides. I conclude that neither dilemma should be resolved in the direction of medical personnel having the right to refrain from involvement in medically enabled suicides. Thus, while we may find medically enabled suicide distasteful or exploitative, a strong case cannot be made that medical personnel refusing to involve themselves in such suicides is ethically permissible. (shrink)

In 12 narratives, medical workers from Afghanistan, Darfur, Gaza, Iraq, Israel, Myanmar, and Ukraine describe the day-to-day challenges of providing quality medical care in austere conflict zones. Faced with severe shortages of supplies, overwhelmed by sick and injured civilians and soldiers, and subject to constant attacks on medical personnel and facilities, the contributors to this collection confront difficult dilemmas of justice, medical impartiality, neutrality, burnout, and moral injury as they struggle to fulfill their duties as (...) medical professionals, military officers, and conscientious citizens. (shrink)

Health information technology in hospitals can be approached as a tool to reduce health care costs and improve hospital efficiency and profitability, increase the quality of healthcare services, and make the transition to patient-centered healthcare. A hospital’s efficiency and profitability depends on linking IT with the knowledge and motivation of medical personnel. It is important to design and execute a knowledge management strategy as a part of the implementation of IT in hospital management. A Diagnosis-Related Groups system was (...) introduced in Poland in 2008 as a basis for settlements between hospitals and the National Health Fund. The importance and role of a DRG system in management of healthcare entities was emphasized based on a survey of medical professionals from two hospitals in the Lubelskie province. The goal of a survey is to assess the knowledge of medical professionals about the DRG system and how the medical personnel uses the DRG system in order to achieve the strategic goals of the organization. A newly developed survey was used to assess the medical personnel’s knowledge of DRG, using 12 closed and 5 open questions. The survey was conducted on 160 medical employees from two hospitals in the Lubelskie province. In conclusion, medical personnel’s DRG knowledge unambiguously contributes to reducing hospital costs and increasing profitability. The DRG related knowledge enables personnel to obtain value from data by applying DRG data-driven decisions. (shrink)

Military Medical Ethics for the 21st Century is the first full length, broad-based treatment of this important subject. Written by an international team of practitioners and academics, this book provides interdisciplinary insights into the major issues facing military-medical decision makers and critically examines the tensions and dilemmas inherent in the military and medical professions. In this book the authors explore the practice of battlefield bioethics, medical neutrality and treatment of the wounded, enhancement technologies for war fighters, (...) the potential risks of dual-use biotechnologies, patient rights for active duty personnel, military medical research and military medical ethics education in the 21st Century. (shrink)

Contemporary medical education must train skilled and compassionate health care professionals who are rigorous in their approach to patient care and their pursuit of knowledge and solutions. Problem-based learning has been widely introduced, but there is no evidence that it leads to better outcomes than more traditional programs, and fundamental gaps in conceptual knowledge may result. Recently, emphasis has been placed on a solid grounding in underlying concepts combined with a systems-based approach, and ability to transfer information and solve (...) problems. Integrating traditional scientific and clinical disciplines with progressive and continuous assessment, may be a better means of achieving the combined aims of clinically relevant curriculum design, vertical integration of medical knowledge, and facilitation of the continuum of training. Being adaptable and flexible, cognisant of costs, and driven by evidence are key features of delivering medical education and contemporary medical practice. Educational research should lead to continuous improvement, but innovation without evaluation and attention to costs may create as many, or more, problems as are solved. (shrink)

Background Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics support has proven useful to address and manage such challenges. This paper explores how prehospital emergency personnel manage ethical challenges. The study is part of a larger action research project to develop and test an approach to clinical ethics support that is sensitive to the context of emergency medicine. Methods (...) We explored ethical challenges and management strategies in three focus groups, with 15 participants in total, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. Focus groups were audio-recorded and transcribed verbatim. The approach to data analysis was systematic text condensation approach. Results We stratified the management of ethical challenges into actions before, during, and after incidents. Before incidents, participants stressed the importance of mutual understandings, shared worldviews, and a supportive approach to managing emotions. During an incident, the participants employed moral perception, moral judgments, and moral actions. After an incident, the participants described sharing ethical challenges only to a limited extent as sharing was emotionally challenging, and not actively supported by workplace culture, or organisational procedures. The participants primarily managed ethical challenges informally, often using humour to cope. Conclusion Our analysis supports and clarifies that confidence, trust, and safety in relation to colleagues, management, and the wider organisation are essential for prehospital emergency personnel to share ethical challenges and preventing moral distress turning into burnout. (shrink)

Almost all articles on education in medical ethics present proposals for or describe experiences of teaching students in different health professions. Since experienced staff also need such education, the purpose of this paper is to exemplify and discuss educational approaches that may be used after graduation. As an example we describe the experiences with a five-day European residential course on ethics for neonatal intensive care personnel. In this multidisciplinary course, using a case-based approach, the aim was to enhance (...) the participants' understanding of ethical principles and their relevance to clinical and research activities. Our conclusion is that working with realistic cases encourages practising nurses and physicians to apply their previous knowledge and new concepts learnt in the course, thus helping them to bridge the gap between theory and practice. (shrink)

This paper examines how death is managed in a larger regional hospital within the Norwegian health‐care. The central focus of my paper concerns variations in how healthcare personnel enact death and handle the dead patient. Over several decades, modern standardised hospital death has come under critique in the western world. Such critique has resulted in changes in the standardisation of hospital deaths within Norwegian health‐care. In the wake of the hospice movement and with greater focus on palliative care, doors (...) have gradually been opened and relatives of the deceased are now more often invited to participate. I explore how the medical practice around death along with the procedure manual of post‐mortem care at Trondheim University Hospital has changed. I argue that in the late‐modern context, standardisation of hospital death is a multidimensional affair, embedded in a far more comprehensive framework than the depersonalised medico‐legal. In the late‐modern Norwegian hospital, interdisciplinary negotiation and co‐operation has allowed a number of different agendas to co‐exist, without any ensuing loss of the medical power holder's authority to broker death. I follow Mol's notion of praxiographic orientation of the actor–network approach while exploring this medical practice. (shrink)

The military might of the modern era poses devastating threats to humankind. Wars result from struggles for material or ideological power. In this context the probability of flouting agreements made during peaceful times is great. The rights of victims and the rights of medical personnel are vulnerable to State and military momentum in the quest for sovereignty. Scholars, scientists and physicians enjoy little enough influence during times of peace and we should be sanguine about their influence during war. (...) But we also must avoid becoming co-opted by partisan political forces. The universal ideals for which we strive, need to be cherished and kept central in our field of vision if we are to rise above man's basest instincts and if we are to preserve professional integrity, individuality and humanitarian concern for the sanctity of life — even the lives of our foes who are engaged in battle against us. Such compassion also recognizes the coercion implicit in recruiting persons into wars they detest and which pits them against their own image. Man's inhumanity to man, most evident during war, must not be allowed to pervade the sanctuary of medical care. Health professionals must constantly be encouraged to serve humankind with empathy and compassion and great social effort needs to be expended to facilitate this role globally and under all conditions. (shrink)

With a global commitment to scaling up AIDS care and treatment in resource-poor settings for some of the most HIV-affected countries in Africa, availability of antiretroviral treatment is no longer the principal obstacle to expanding access to treatment. A shortage of trained healthcare personnel to initiate treatment and manage patients represents a more challenging barrier to offering life-saving treatment to all patients in need. Physician-centered treatment policies accentuate this challenge. Despite evidence that task shifting for nurse-centered AIDS patient care (...) is effective and can alleviate severe physician shortages that currently obstruct treatment scale-up, political commitment and policy action to support task shifting models of care has been slow to absent. In this paper we review the evidence in support of task shifting for AIDS treatment in Africa and argue that continued policy inaction amounts to unwarranted healthcare rationing and as such is ethically untenable. (shrink)

The existing literature in medical ethics does not serve the practical needs of medical students and trainees very well. Medical students or junior doctors often have their own set of ethical concerns and the dilemmas that arise are generally beyond their direct control. The editors have addressed the gap in the literature by compiling a series of case studies from around the world and inviting an international team of leading ethicists and clinicians to comment on them. This (...) volume includes over 80 actual cases that cover the range of possible problems a medical trainee may encounter on the ward. (shrink)

Professor Charles Foster1 argues that the recent decision by the Supreme Court2 on the process of making decisions about medical treatment in people who lack capacity due to a prolonged disorder of consciousness is fostering medical paternalism. He considers that the judgment shows ‘ deference to the guidelines of various organisations ’ and then that ‘ The guidance has effectively become a definitive statement of the relevant obligations,’ concluding that ‘ This usurps the function of the law.’ Healthcare (...) teams make all decisions concerning medical care provided; no-one else can. Both the clinicians themselves, and any guidance provided to them, must comply with the Mental Capacity Act 2005.3 Lady Black’s judgment makes clear that ‘ The basic protective structure is established by the MCA 2005 ’ and that the associated Code of Practice4 ‘ contains valuable guidance ’. She specifically highlights that the decision-maker must ensure that ‘ account has been taken of the patient’s previously expressed wishes and those of people close to him, as well as the opinions of other medical personnel. The MCA 2005 requires this to happen, and is reinforced by the professional guidance available to doctors.’ The Act says: ‘ He must consider, so far as is reasonably ascertainable— 1. the person’s past and present wishes and feelings (and, in …. (shrink)

Although prisons provide on-site primary care, the corrections system relies on external hospitals to provide a variety of healthcare services. Compared to the general population, incarcerated patients experience higher rates of chronic medical conditions, mental illness, substance abuse, cancer, traumatic brain injury, assault, and communicable disease. Certain specialties of clinicians are likely to encounter patients who are incarcerated, which makes it important for clinicians to understand how medical decision-making may differ when the patient is a prisoner. The corrections (...) system retains custody of inmates and is responsible for their welfare, including facilitating necessary medical care. However, this does not permit corrections personnel or a warden to automatically assume the role of the patient's medical decision-maker. Except for narrow exceptions, prisoners do not lose their rights to medical decision-making. In some instances, corrections staff or the prison warden have improperly asserted authority to act as the patient's medical decision-maker, such as when the patient lacks decision-making capacity. This violates ethical principles of bodily integrity, respect, and fairness. This paper provides an overview of medical decision-making for incarcerated patients, how surrogate decision-maker hierarchies apply to incarcerated patients without decision-making capacity, and special considerations for this subset of patients. (shrink)

Medical confidentiality is a core concept of professionalism and should be an integral part of pregraduate and postgraduate medical education. The aim of our study was to define the factors influencing attitudes towards patient confidentiality in everyday situations in order to define the need for offering further education to various subgroups of physicians. All internists and general practitioners who were registered members of the association of physicians in Geneva or who were working in the department of internal medicine (...) or in the medical polyclinic of the University Hospital of Geneva in 2004 received a standardised questionnaire. Physicians were asked to indicate for seven vignettes whether a violation of confidentiality had occurred and whether the violation was not important, important or serious (scores 1–3; no violation = 0). 508 completed questionnaires were returned (participation rate 55%). Physicians who had worked in the hospital for more than 20 years identified violations of confidentiality more often than physicians with less hospital experience. Binary logistic regression showed that ethics education, total years of professional experience, being an internist, having a private practice, the length of working in private practice and gender were factors associated with correct identification of violations and their severity. However, each factor played a specific role only for single cases or a small number of situations (Cronbach α <0.6). Postgraduate education programs on confidentiality should be offered to a wide range of physicians and should address specific hypothetical situations in which there is a risk of avoidable breaches of confidentiality. (shrink)

During asymmetric war, state armies must care for their local allies, detainees and the civilian population in two contexts: acute care for those wounded during military operations and medical care for the general population as required by the Geneva Conventions. Constrained by scarce resources, state armies face a number of moral dilemmas that affect care on the ground.Triage. As they deploy, state armies allocate in-theater medical resources to care for their soldiers. In-theater care does not provide for long-term (...) treatment. Its purpose is to return warfighters to active duty or to quickly evacuate them to the US or Europe for comprehensive medical care. Limited beds and personnel make it impossible to provide the local population with the level of care that Western soldiers receive. As a result, the US and other armies develop complex and often arbitrary rules to treat civilians. The inability to provide high-level care to all, creates tensions with local civilians and host country allies.Ensuring local medical care. The Geneva Conventions require occupying armies to “ensure the medical needs of the civilian population.” Specifying these needs is a medical and moral challenge. What level satisfies this requirement? How much aid should the occupying power provide? How best to distribute existing resources? How should state armies protect NGOs that provide significant medical care and often find themselves under attack by insurgents?Medical Diplomacy. While the purpose of medical care is to treat the sick and injured, medical care also serves security needs. Medical care is a long-established tool to win the hearts and minds of the local population. Since the Vietnam War, however, critics have charged that medical diplomacy subverts the purpose of medicine, places medical personnel in the service of war and provides poor medical care. (shrink)

Background In neonatal intensive care, a child's death is often preceded by a medical decision. Nurses, social workers and pastors, however, are often excluded from ethical case deliberation. If multiprofessional ethical case deliberations do take place, participants may not always know how to perform to the fullest. Setting A level-IIID neonatal intensive care unit of a paediatric teaching hospital in the Netherlands. Methods Structured multiprofessional medical ethical decision-making (MEDM) was implemented to help overcome problems experienced. Important features were: (...) all professionals who are directly involved with the patient contribute to MEDM; a five-step procedure is used: exploration, agreement on the ethical dilemma/investigation of solutions, analysis of solutions, decision-making, planning actions; meetings are chaired by an impartial ethicist. A 15-item questionnaire to survey staff perceptions on this intervention just before and 8 months after implementation was developed. Results Before and after response rates were 91/105 (87%) and 85/113 (75%). Factor analysis on the questionnaire suggested a four-factor structure: participants' role; structure of MEDM; content of ethical deliberation; and documentation of decisions/conclusions. Effect sizes were 1.67 (p<0.001), 0.69 (p<0.001) and 0.40 (p<0.01) for the first three factors respectively, but only 0.07 (p=0.65) for the fourth factor. Nurses' perceptions of improvement did not significantly exceed those of physicians. Conclusion Professionals involved in ethical case deliberation perceived that the process of decision-making had improved; they were more positive about the structure of meetings, their own role and, to some extent, the content of ethical deliberation. Documentation of decisions/conclusions requires further improvement. (shrink)

This paper argues that two characteristics of social life impinge importantly upon medical attempts to maintain high ethical standards. The first is the tension between the role of ethics in protecting the patient and maintaining the solidarity of the profession. The second derives from the observation that the foundations of contemporary medical ethics were laid at a time of one-to-one doctor-patient relations while nowadays most doctors work in or are associated with large-scale organisations. Records cease to be the (...) property of individual doctors, become available not only to other doctors but also to educational and social work personnel. Making records openly available to patients is suggested as the only antidote to this irreversible loss of individual practitioner control. The importance for doctors of understanding the nature of professional and bureaucratic organisations in order to deal with the hazards involved is stressed as is the responsibility of the General Medical Council to regulate medical competence as well as personal behaviour. (shrink)

A discussion of Christian ethics focuses on the physician's image as a parent, warrior against death, expert, and teacher, and the oath that guides his or her practice.

AbstractBackgroundEthical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel. MethodsThe study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended (...) by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim.ResultsThe participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks.ConclusionFrom the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems. (shrink)

ABSTRACTThis article analyzes the outcomes of the first medical interpreter vocational training course for Eritrean asylum seekers in Israel. Our study draws on the work of Phyllis Butow et al. on medical interpreters’ perceptions of their role, including the challenges they face; on Elena Ragazzi’s call for a flexible evaluation of vocational training outcomes; and on Pierre Bourdieu’s concept of “cultural capital” as an empowering tool for change. The course was initiated in 2013 in response to difficulties experienced (...) by medical personnel and Eritrean asylum seekers regarding the provision of health services for refugees. The outcomes of the course led to four main conclusions: it was a positive learning endeavor that led graduates to better jobs; it was an empowering experience that enabled graduates to better care for themselves and their loved ones, and enhanced their understanding of their rights as asylum seekers; it was perceived as a project of inclusion that created a safe and reassuring environment within the otherwise hostile reality of state-orchestrated exclusion, yet it also induced a sense of frustration in that it had no impact on the unjust social structure in which the asylum seekers live; and the course was helpful in developing the graduates’ understanding of their complex role as medical interpreters. (shrink)

Although organizational and situational factors have been found to predict burnout, not everyone employed at the same workplace develops it, suggesting that becoming burnt out is a complex, multifaceted phenomenon. The aim of this study was to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among two groups of health care personnel from the same workplaces, one group on sick leave owing to medically assessed burnout (n = 20) and one group who showed no (...) indications of burnout (n = 20). The results showed that higher levels of stress of conscience, a perception of conscience as a burden, having to deaden one’s conscience in order to keep working in health care and perceiving a lack of support characterized the burnout group. Lower levels of stress of conscience, looking on life with forbearance, a perception of conscience as an asset and perceiving support from organizations and those around them (social support) characterized the non-burnout group. (shrink)

Beginning in 1868, the United States Army Medical Museum issued a request to Army medical personnel situated in ‘Indian country’ for specimens of skulls from Native Americans. The purpose of this collection was to promote the study of craniometry, a branch of racial science commonly used to delineate the different varieties of mankind and to rank them according to their perceived intellectual attributes. Yet, as this paper argues, the efforts of Army surgeons in amassing hundreds of crania (...) for the Army Medical Museum were not matched by a similar level of commitment on the part of racial researchers. In examining why this seemingly impressive collection fell rapidly into disuse, this paper explores the creation and abandonment of one of the largest craniological collections formed in the United States in relation to the trajectory of craniometrical studies during this period. It also questions the link between the interests of racial researchers in the late nineteenth century and those of government policy makers, arguing that the two might not have been particularly closely aligned in the case of craniological research in Washington. (shrink)

A novel method of teaching military medical ethics, medical ethics and military ethics in the Israel Defense Force (IDF) Medical Corps, essential topics for all military medical personnel, is discussed. Very little time is devoted to medical ethics in medical curricula, and even less to military medical ethics. Ninety-five per cent of American students in eight medical schools had less than 1 h of military medical ethics teaching and few knew (...) the basic tenets of the Geneva Convention. Medical ethics differs from military medical ethics: the former deals with the relationship between medical professional and patient, while in the latter military physicians have to balance between military necessity and their traditional priorities to their patients. The underlying principles, however, are the same in both: the right to life, autonomy, dignity and utility. The IDF maintains high moral and ethical standards. This stems from the preciousness of human life in Jewish history, tradition and religious law. Emphasis is placed on these qualities within the Israeli education system; the IDF teaches and enforces moral and ethical standards in all of its training programmes and units. One such programme is ‘Witnesses in Uniform’ in which the IDF takes groups of officers to visit Holocaust memorial sites and Nazi death camps. During these visits daily discussions touch on intricate medical and military ethical issues, and contemporary ethical dilemmas relevant to IDF officers during active missions. (shrink)