BackgroundRespecting patients’ confidentiality is an ethical and legal responsibility for health professionals and the cornerstone of care excellence. This study aims to assess health professionals’ knowledge, attitudes, and associated factors towards patients’ confidentiality in a resource-limited setting.MethodsInstitutional based cross-sectional study was conducted among 423 health professionals. Stratified sampling methods were used to select the participants, and a structured self-administer questionnaire was used for data collection. The data was entered using Epi-data version 4.6 (...) and analyzed using SPSS, version 25. Bi-variable and multivariable binary logistic regression analyses were used to measure the association between the dependent and independent variables. Odds ratio with 95% confidence intervals and P value was calculated to determine the strength of association and to evaluate statistical significance.ResultOut of 410 participants, about 59.8% with [95% CI (54.8–68.8%)] and 49.5% with [95% CI (44.5–54.5%)] had good knowledge and favorable attitude towards patents confidentiality respectively. Being male (AOR = 1.63, 95% CI [1.03–2.59]), taking training on medical ethics (AOR = 1.73, 95% CI = [1.11–2.70]), facing ethical dilemmas (AOR = 3.07, 95% CI [1.07–8.79]) were significantly associated factors for health professional knowledge towards patients’ confidentiality. Likewise, taking training on medical ethics (AOR = 2.30, 95% CI [1.42–3.72]), having direct contact with the patients (AOR = 3.06, 95% CI [1.12–8.34]), visiting more patient (AOR = 4.38, 95% CI [2.46–7.80]), and facing ethical dilemma (AOR = 3.56, 95% CI [1.23–10.26]) were significant factors associated with attitude of health professionals towards patient confidentiality.ConclusionThe findings of this study revealed that health professionals have a limited attitude towards patient confidentiality but have relatively good knowledge. Providing a continuing medical ethics training package for health workers before joining the hospital and in between the working time could be recommended to enhance health professionals’ knowledge and attitude towards patient confidentiality. (shrink)

In this paper I present and compare the ideas behind naturalistic theories of health on the one hand and phenomenological theories of health on the other. The basic difference between the two sets of theories is no doubt that whereas naturalistic theories claim to rest on value neutral concepts, such as normal biological function, the phenomenological suggestions for theories of health take their starting point in what is often named intentionality: meaningful stances taken by the embodied (...) person in experiencing and understanding her situation and taking action in the world.Although naturalism and phenomenology are fundamentally different in their approach to health, they are not necessarily opposed when it comes to understanding the predicament of ill persons. The starting point of medical investigations is what the patient feels and says about her illness and the phenomenological investigation should include the way diagnoses of different diseases are interpreted by the person experiencing the diseases as an embodied being. Furthermore, the two theories display similarities in their emphasis of embodiment as the central element of health theory and in their stress on the alien nature of the body displayed in illness. Theories of biology and phenomenology are, indeed, compatible and in many cases also mutually supportive in the realm of health and illness. (shrink)

Acceptance of elderly or marginal health individuals as kidney donors is debated, with practices varying between centres. Transplant recipients, live kidney donors and health-care professionals caring for patients with renal failure were surveyed regarding their views on live donor kidney transplantation (LDKT) of marginal health (diabetes, hypertension, atherosclerosis, obesity, etc.) and elderly donors. Participants were recruited within a tertiary renal and transplant centre and invited to participate in focus groups and structured interviews. They also (...) completed an anonymous questionnaire. Of 464 participants who completed the questionnaire (36% health-care professionals and 64% patients), 49% and 64%, respectively, stated that marginal and elderly donors should be accepted for LDKT. In the structured interviews, emphasis was given to presenting to donor, recipient and their respective families a calculated risk regarding the effect that either a nephrectomy or transplant has on long-term quality of life. Participants stated that an independent third party in addition to the transplant team should discuss involved risks. Issues of ‘how desperate’ the recipient's situation is should also be considered. Health-care professionals stated that regardless of the strength of will of an individual to donate a kidney (despite age, health problems or personal risk), they should always have the right to say ‘no’ if performing a specific LDKT was against their professional and ethical values. About half of those surveyed considered that marginal health and elderly donors were acceptable for LDKT. Emphasis was given to the explanation to donors and recipients of the risks involved in such transplantation. (shrink)

BackgroundPatient-centeredness, respect for patient autonomy, and shared decision-making have now made it to center stage in discussions on quality of care. Knowing what actually counts in care and how it should be accomplished from the patients’ and nurses’ perspective seems crucial.AimTo explore how patients and their nurses perceive the importance and enactment of values in their healthcare.Research designAn observational, cross-sectional study using a self-developed questionnaire, consisting of 15 items related to seven values (e.g. uniqueness, autonomy, professionalism, (...) compassion, responsiveness, partnership, and empowerment) as described in the taxonomy of Bastemeijer et al.Participants and research contextThe survey was completed by 384 patients and 81 nurses. Participants were recruited on eight internal medicine wards of a 1000-bed university hospital in Belgium.Ethical considerationsThis study was approved by the ethical committee of the Ghent University Hospital (B670201836799).Findings(1) Patients and nurses prioritize values of care differently; (2) nurses report not being able to enact the values they prioritize in actual practice as much as one would like to; and (3) there is a gap in experienced delivery of a comprehensible explanation of all treatment options, a conversation based on equality, making shared decisions, and being non-judgmental between nurses and patients.DiscussionOur findings challenge nurses’ overemphasis on professional compassion and uniqueness while arguing for increased attention on authentic shared decision-making and empowerment. The first step to a patient-centered culture truly involving patients in their healthcare is communication and information provision, rather than focusing on tangible and normative constructs.ConclusionOur findings revealed differences in prioritization and actual enactment of values in care between patients and nurses. This was especially so for values related to communication, provision of complete unbiased information, and shared decision-making. Nurses should prioritize providing comprehensible information and using conversations based on equality to make decision together with patients. (shrink)

A self-designed questionnaire was given to 634 health professionals in a large teaching hospital in Hubei Province in mainland China, to clarify the participants’ attitude towards information disclosure to cancer patients. Statistic description was used to analyze the data. The item ‘inappropriate information about cancer easily leads to medical disputes’ scored highest at 3.86, while the scores of such items as ‘advantages of fully informing patients outweigh disadvantages’, ‘if their family members demand nondisclosure, you will find (...) it difficult to cooperate in good faith with patients’, and ‘telling white lies to patients disturbs you a lot’ were less than 3. The health care staff placed a high value on both the desire and priority of patients to know the truth, though most of them did not think that patients had received enough information about their disease. In order to improve cancer patients’ current state of knowledge, health professionals should learn more about informed consent, and special methods and guidelines compatible with Chinese culture are urgently required in China. (shrink)

This critical notice argues for the existence of a new trend in bioethics, a complex and dynamic field of philosophical enquiry that goes beyond applied ethics and professional deontological codes. This trend supplements their traditionally “minimalist” ethics—and its concern with harm, rights or justice—with “inflationary” positions open to an integration of medicine with the humanities. By comparing and contrasting the views of two quite different philosophers, Diego Gracia and Alfred Tauber, and placing them within the theoretical background delineated by George (...) Khushf, I argue that the main contribution of this “inflationary bioethics” is an understanding of health and disease as intrinsically normative concepts, which in turn brings about a blurring of the distinction between facts and values. By refusing to construe the distinction as a dichotomy, a post-positivist philosophy of medicine must become more epistemological in order to help us clarify concepts in which the evaluative and the factual are impossible to separate. As a result, the “language of principles” in standard bioethics is being substituted by a more encompassing “language of values”; health and disease are increasingly understood as biopsychosocial phenomena; and the field is open to a process of moralization that challenges traditional models of patient autonomy and physician responsibility. (shrink)

The purpose of this study was to measure professional and personal values among nurses, and to identify the factors affecting these values. The participants were 323 Israeli nurses, who were asked about 36 personal values and 20 professional values. The three fundamental professional nursing values of human dignity, equality among patients, and prevention of suffering, were rated first. The top 10 rated values all concerned nurses' responsibility towards patients. Altruism and confidentiality were (...) not highly rated, and health promotion and nursing research were rated among the last three professional values. For personal (instrumental) values, honesty, responsibility and intelligence were rated first, while ambition and imagination were rated 14th and 16th respectively out of 18. Significant differences (P < 0.05) were found among some personal and professional values rated as functions of culture, education, professional seniority, position and field of expertise. The results may assist in understanding the motives of nurses with different characteristics and help to promote their work according to professional ethical values. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

Uses a social contingency analysis derived from behavioral psychology to compare research and practice. The components of a contingency (occasion, behavior, and consequence) present in a variety of research, treatment, and educational situations are discussed. Subjective terms such as intent, coercion, and consent are analyzed by means of a behavioral approach. Implications include the possible value of a collegial, symmetrical relationship between the professional and the individual in both research and practice domains. Such a relationship is consistent with current (...) dissatisfaction with the social fiduciary model of contractual relations between professionals and individuals. According to this model, one party exercises powers in fulfillment of a trust from the other party. There has been increasing rejection on the part of the public of this "let-us-do-the-driving," "you're-in-good-hands-with-Allstate" orientation adopted by some professionals. The suggested alternative approach, a social contractual model, has the advantage of recognizing this rejection. (39 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved). (shrink)

This chapter contains sections titled: Trends in Ethics Teaching in the Health Professions Theoretical Questions Underlying Curriculum Content Ethical Knowledge or Ethical Behavior? The Hidden Curriculum Conclusion References.

Mobile health tools are often said to empower users by providing them with the information they need to exercise control over their health. We aim to bring clarity to this claim, and in doing so explore the relationship between empowerment and autonomy. We have identified three distinct models embedded in the empowerment rhetoric: empowerment as information, empowerment as control, and empowerment as values. Each distinct model of empowerment gives rise to an associated problem. These problems, the (...) Problem of Interpretation, the Value Alignment Problem, and the Priority Problem, show that mobile health tools in their current form are either insufficient for empowerment or are self‐defeating. These digital health technologies encourage users to adopt an individualized conception of autonomy, one that may weaken the doctor–patient relationship and undermine practices in shared decision making, and ultimately may not deliver on improving the health outcomes for those that need it the most. (shrink)

In China's healthcare sector, a popular and socio-culturally distinctive phenomenon known as guanxi jiuyi, whereby patients draw on their guanxi with physicians when seeking healthcare, is thriving. Integrating anthropological investigation with normative inquiry, this paper examines medical guanxi through the lens of patient–physician trust and mistrust. The first-hand empirical data acquired – on the lived experiences and perspectives of both patients and physicians – is based on six months' fieldwork carried out in a county hospital in Guangdong, southern (...) China, which included in-depth interviews with 20 patients and 20 medical professionals. Patients who emphasized the positive effects of guanxi on patient–physician trust believed that it facilitates access to experienced medical specialists, enhances clinical communication, and reduces the financial and medical risks of over diagnosis and overtreatment by physicians. At the same time, these findings reveal patients' strong sense of mistrust, not only towards individual health professionals but also to the medical profession and China's commercialized healthcare industry. While some health professionals in the study responded favourably to medical guanxi, most were opposed to it on the grounds that it undermines professional standards and equitable healthcare. We found that the practice of medical guanxi is not morally justifiable, chiefly because it reinforces the present high levels of patient–physician mistrust and erodes trust between patients and the medical profession as a whole. In China, both the medical profession and the state need to promote patient–physician trust based on medical professionalism and institutional norms, rather than on guanxi or individual relationships. (shrink)

Terms such as ‘cultural competence’ and ‘transcultural nursing’ have comfortably taken their place in the lexicon of health care. Their high profile is a reflection of the diversity of western societies and health care’s commitment to provide care that is responsive to the values and beliefs of all who require treatment. However, the relationship between cultural competence and familiar ethical concepts such as patient autonomy has been an uneasy one. This article explores the moral (...) foundations of cultural competence, ultimately locating them in patient autonomy and patient good. The discussion of patient good raises questions about the moral relevance of a value’s rootedness in a particular culture. I argue that the moral justification for honoring cultural values has more to do with the fact that patients are strongly committed to them than it does with their cultural rootedness. Finally, I suggest an organizational approach to cultural competence that emphasizes overall organizational preparedness. (shrink)

The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the (...) dictates of regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom. (shrink)

The term “normal” is culturally ubiquitous and conceptually vague. Interestingly, it appears to be a descriptive-normative-hybrid which, unnoticedly, bridges the gap between the descriptive and the normative. People’s beliefs about normality are descriptive and prescriptive and depend on both an average and an ideal. Besides, the term has generally garnered popularity in medicine. However, if medicine heavily relies on the normal, then it should point out how it relates to the concept of health or to statistics, and what, (...) after all, normal means. Most importantly, the normativity of the normal needs to be addressed. Since the apparently neutral label “normal” can exclude, stigmatize, and marginalize people who are defined in contrast to it as abnormal, health professionals should think twice before using the term with patients. The present critical perspective advocates against using the term “normal,” as long as no understanding of a person’s individual normality has been attained. It advocates for the right to autonomously determine one’s own normality. For health professionals I do not see worthwhile benefits of subscribing to the concept of “normality” and imposing it on their patients. But I do see many risks. (shrink)

Humanitarian health care practitioners working outside familiar settings, and without familiar supports, encounter ethical challenges both familiar and distinct. The ethical guidance they rely upon ought to reflect this. Using data from empirical studies, we explore the strengths and weaknesses of two ethical models that could serve as resources for understanding ethical challenges in humanitarian health care: clinical ethics and public health ethics. The qualitative interviews demonstrate the degree to which traditional teaching and values of clinical (...) health ethics seem insufficient for addressing all the realities of health care practice during humanitarian missions. They equally suggest that greater good orientations of public health ethics can thwart the best intentions of health care professionals wanting to attend to the interests of individual patients. Even though neither is complete on its own for helping guide health professionals on field missions, taken together these models have much to offer. At the same time, the narratives of the humanitarian health care workers illustrate how some of the crucial differences between public health ethics and clinical ethics generate tensions in humanitarian health practice. We offer an analysis of some of the complexities this creates for humanitarian health care ethics, and consider ways of adjudicating between the two models. (shrink)

Palliative care philosophy is based on a holistic approach to patients, but research shows that possibilities for living up to this philosophy seem limited by historical and administrative structures. From the nurse perspective, this article aims to explore nursing practice in specialised palliative homecare, and how it is influenced by organisational and cultural structures. Qualitative, semi-structured interviews with nine nurses were conducted, inspired by Bourdieu. The findings showed that nurses consolidate the doxa of medicine, including medical-professional values (...) that configure a control-oriented, positivistic approach, supported by the organising policy for clinical practice. Hierarchically, nurses were positioned under doctors: medical rounds functioned as a structuring structure for their working day. They acted as medical assistants, and the prevailing medical logic seemed to make it difficult for nurses to meet their own humanistic ideals. Only short time slots allowed nurses to prioritise psychosocial needs of patients and relatives. Point-of-actions had high priority, added financial resources and ensured that budgets were allocated. Weekly visits made it possible for nurses to measure, control and govern patients’ drugs and symptoms which was a necessity for their function as medical assistants. The findings challenge nurses to take on an ethical point of view, partly to ensure that patients and their families receive good palliative care focusing on more than medical issues and logic, and partly to strengthen the nurses’ profession in the palliative field and help them implement palliative care philosophy in practice. (shrink)

Palliative care philosophy is based on a holistic approach to patients, but research shows that possibilities for living up to this philosophy seem limited by historical and administrative structures. From the nurse perspective, this article aims to explore nursing practice in specialised palliative homecare, and how it is influenced by organisational and cultural structures. Qualitative, semi-structured interviews with nine nurses were conducted, inspired by Bourdieu. The findings showed that nurses consolidate the doxa of medicine, including medical-professional values (...) that configure a control-oriented, positivistic approach, supported by the organising policy for clinical practice. Hierarchically, nurses were positioned under doctors: medical rounds functioned as a structuring structure for their working day. They acted as medical assistants, and the prevailing medical logic seemed to make it difficult for nurses to meet their own humanistic ideals. Only short time slots allowed nurses to prioritise psychosocial needs of patients and relatives. Point-of-actions had high priority, added financial resources and ensured that budgets were allocated. Weekly visits made it possible for nurses to measure, control and govern patients’ drugs and symptoms which was a necessity for their function as medical assistants. The findings challenge nurses to take on an ethical point of view, partly to ensure that patients and their families receive good palliative care focusing on more than medical issues and logic, and partly to strengthen the nurses’ profession in the palliative field and help them implement palliative care philosophy in practice. (shrink)

The allocation of healthcare resources takes place at two distinct levels. At the macroeconomic level, policymakers decide on budgets, staffing, cost‐effectiveness thresholds, clinical guidelines and insurance payments; at the microeconomic level, healthcare professionals decide on whom to treat, what the appropriate treatment is, how much time and effort should each patient receive and how urgent the need for care is. At both levels, there is a constant social need for just allocation. Policymakers are mostly guided by abstract principles of (...) justice, thinking in terms of groups of patients, epidemiological data, impersonal statistics and economic costs. On the other hand, healthcare professionals understand the need for justice at a more personal level, as they interact with patients and, in a sense, put theory into practice. Nurses hold a unique position in healthcare systems, as, traditionally, they are closer to patients than other health professionals. This means that they have a firsthand view of the effect that their decisions have on specific patients and, therefore, nurses tend to get more influenced by their personal feelings, values and beliefs at the microeconomic level. This presentation shall examine the gap between abstract macroeconomic and concrete microeconomic health resources allocation decisions, with a particular emphasis on the role of the nurse. (shrink)

Background We present and discuss the results of a Norwegian survey of medical doctors' views on potential ethical dilemmas in professional practice. Methods The study was conducted in 2015 as a postal questionnaire to a representative sample of 1612 doctors, among which 1261 responded. We provided a list of 41 potential ethical dilemmas and asked whether each was considered a dilemma, and whether the doctor would perform the task, if in a position to do so. Conceptually, dilemmas arise because of (...) tensions between two or more of four doctor roles: the patient’s advocate, a steward of societal interests, a member of a profession and a private individual. Results 27 of the potential dilemmas were considered dilemmas by at least 50% of the respondents. For more than half of the dilemmas, the anticipated course of action varied substantially within the professional group, with at least 20% choosing a different course than their colleagues, indicating low consensus in the profession. Conclusions Doctors experience a large range of ethical dilemmas, of which many have been given little attention by academic medical ethics. The less-discussed dilemmas are characterised by a low degree of consensus in the profession about how to handle them. There is a need for medical ethicists, medical education, postgraduate courses and clinical ethics support to address common dilemmas in clinical practice. Viewing dilemmas as role conflicts can be a fruitful approach to these discussions. (shrink)

Background:The concept of patient advocacy is still poorly understood and not clearly conceptualized. Therefore, there is a gap between the ideal of patient advocacy and the reality of practice. In order to increase nursing actions as a patient advocate, a comprehensive and clear definition of this concept is necessary.Research objective:This study aimed to offer a comprehensive and clear definition of patient advocacy.Research design:A total of 46 articles and 2 books published between 1850 and 2016 and related to the (...) concept of patient advocacy were selected from six databases and considered for concept analysis based on Rodgers’ evolutionary approach.Ethical considerations:This study was approved by the Research Ethics Committee of Tarbiat Modares University.Findings:The attributes of patient advocacy are safeguarding (track medical errors, and protecting patients from incompetency or misconduct of co-workers and other members of healthcare team), apprising (providing information about the patient’s diagnosis, treatment, and prognosis, suggesting alternatives of healthcare, and providing information about discharge program), valuing (maintaining self-control, enabling patients to make decisions freely, maintaining individualization and humanity, maintaining patient privacy, and acting in the patients’ values, culture, beliefs, and preferences), mediating (liaison between patients, families, and healthcare professionals, being patients’ voice, and communicate patient preferences and cultural values to members of the healthcare team), and championing social justice in the provision of healthcare (confronting inappropriate policies or rules in the healthcare system, identifying and correcting inequalities in delivery of health services, and facilitating access to community health services and health resources).Discussion and conclusion:The analysis of this concept can help to develop educational or managerial theories, design instruments for evaluating the performance of nurses in patient advocacy, develop strategies for enhancing patient advocacy, and improve the safety and quality of nursing care in the community and healthcare system. (shrink)

The paper addresses the integration of ethics into professional education related to the disciplines responsible for the conception and creation of the artificial (artefactual or technology). The ontological-epistemological paradigm of those disciplines is understood within the frame of the sciences of the artificial as established by Herbert Simon (1969). According to that paradigm, those sciences include disciplines not only related to the production of artefacts (technology), such as engineering, architecture, industrial design, etc, but also disciplines related to devised courses of (...) action aimed at changing existing situations into preferred ones, like medicine, law, education, etc. They are centered on intentional action and at their core is the activity of design, which is their common foundation and attitude, or their common culture. The science of design becomes the broader foundational discipline for any professions engaged in the intentional transformation of the world. The main distinction between design disciplines and scientific ones rests on the object-project dichotomy. Indeed, contrary to Science that sees the world as an object to be observed, Design sees the world as a project and acts upon the world through projects, which are grounded in intentions, ends, and values. Design disciplines are meant to transform the world, or part of it, and are teleological. Being so, they are embodied in an act that is ethical and their ontology-epistemology must be addressed also through practical reason to resituate all professional disciplines according to their involved nature. (shrink)

In recent years so-called Complementary and Alternative Medicine practices have made significant political and professional advances particularly in the United Kingdom : osteopathy and chiropractic were granted statutory self-regulation in the 1990s effectively giving them more professional autonomy and independence than health care professions supplementary to medicine ; the practice of acupuncture is widespread within the National Health Service for pain control; and homoeopathy is offered to patients by a few General Practitioners alongside conventional treatments. These developments (...) have had a number of consequences: one is that both CAM and Conventional and Orthodox Medical professions have had to reappraise their professional identity. In manual therapy for example, questions have been asked about the differences between physiotherapy, osteopathy and chiropractic, and what the justification is for having separate professions. A wider question concerns the relationship between CAM and COM; are CAM distinct professions or should they, as has happened to a limited extent in the UK, be absorbed into the broader field of ‘ Medicine ’ or ‘Health Care’ as adjunctive therapies. CAM professions have also had to develop, implement and enforce codes of practice for practitioners and clarify the scope of practice within a profession. At the heart of these issues lies the need to identify and clarify professional values. A key claim of CAM professions is that their practice is distinct and the outcome of treatment at least as effective and in many cases more effective than with conventional therapies. In addition, what counts as effective outcome is often different from conventional medical understanding, involving more subtle humanitarian considerations, for example. Three values are identified as being commonly held across CAM professions. These are: offering ‘natural’ treatment; being patient rather than disease focussed; and being holistic. However, these may not be as distinctive of CAM as is claimed either because the meaning is unclear or because COM professions claim similar values. The paper argues that the values that inform ‘good practice’ and ‘effective outcome’ should be seen as distinct components of professional competence. This has implications for establishing professional identity and codes of practice. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Ideal of Shared Decision Making Between Physicians and PatientsDan W. Brock (bio)IntroductionShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship.1 Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment (...) and with alternative treatments. The patient's role in this division of labor is to provide the values—his or her own conception of the good—with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.Some challenges relate to the physician's role. This facts/values division of labor seems to assume that the physician can and should provide the facts about treatment alternatives in a value-neutral form. But some have questioned whether the sciences on which medicine is based are, or can be, value free. Moreover, the concepts of health and disease, and of the normal and pathological, are held by many to be value laden. And even if it is possible for physicians to provide only value-neutral facts to the patient, should the physicians' role be restricted in this way?Other challenges that I will present in the paper are to the patient's role [End Page 28] as provider of the values for the evaluation of the different treatment alternatives. One defense of this role is based on the claim that physicians are not in a position to know reliably what is in a patient's best interests (Buchanan, forthcoming). I believe at least as influential—even if often not explicitly stated—is an extreme subjectivism about values that assumes that the patient's own ultimate values, which define his or her own conception of the good, are incorrigible. By incorrigible, I mean they cannot be mistaken. In the standard case in which treatment is pursued for the patient's benefit, this extreme subjectivism is thought to support the patient's values guiding treatment decision making and treatment. I will explore this incorrigibility claim and will argue that on each of the main philosophical conceptions of the good for persons it is indefensible and should not be the basis for shared treatment decision making.Underlying this view of the physician-patient division of labor are assumptions and beliefs about the nature and relation of facts and values, and science and ethics, that are largely the legacy of a logical positivism that has long since been rejected by most philosophers. It is time that these unstable foundations for our normative ideal of the physician-patient relation were finally removed and replaced with more defensible underpinnings.Two Models of the Physician-Patient RelationshipPositivists insisted on a relatively sharp distinction between descriptive or empirical claims and science, on the one hand, and evaluative claims and ethics, on the other.2 Descriptive statements and the claims of science were to be true or false according to whether they in fact correctly described and explained the world. By remaining properly descriptive or empirical, science could, at least in principle, be entirely value neutral or value free.In its more extreme versions, positivism held that ethical judgments lacked cognitive content, but were instead expressions of emotions or attitudes, and as such could be neither true nor false, correct or mistaken. Because no evaluative statements were held to be logically entailed by any descriptive or empirical statements, moral reasoning was thought to be properly understood not as reasoning but as attempts at nonrational persuasion.3 Many drew from this an extreme subjectivism in ethics along the lines of what I have called above the incorrigibility thesis—there is no meaningful sense in which an individual's ultimate values defining his or her own conception of the good life could be mistaken, false, or unfounded.These... (shrink)

This book is the result of a long-standing clinical and educational cooperation between a medical psychologist (Bergsma) and a medical ethicist/philosopher (Thomasma). It is thoroughly interdisciplinary in its examination of the difficulties of honoring the patient's and the physician's autonomy, especially in light of the changes in health care worldwide today. Although autonomy has become the primary standard of bioethics, little has been done to link it to the ways people actually behave, nor to its roots in the (...) healing relationship. Combining as it does the disciplines of psychology and philosophy, this book is a step in that direction. (shrink)

Adults with dysphagia experience difficulties swallowing food and fluids with potentially harmful health and psychosocial consequences. Speech pathologists who manage patients with dysphagia are frequently required to address ethical issues when patients' food culture and/ or preferences are inconsistent with recommended diets. These issues incorporate complex links between food, identity and social participation. A composite case has been developed to reflect ethical issues identified by practising speech pathologists for the purposes of illustrating ethical concerns in dysphagia (...) management. The case examines a speech pathologist's role in supporting patient autonomy when patients and carers express different goals and values. The case presents a 68-year-old man of Australian/Italian heritage with severe swallowing impairment and strong values attached to food preferences. The case is examined through application of the dysphagia algorithm, a tool for shared decision-making when patients refuse dietary modifications. Case analysis revealed the benefits and challenges of shared decision-making processes in dysphagia management. Four health professional skills and attributes were identified as synonymous with shared decision making: communication, imagination, courage and reflection. (shrink)

This paper proposes a refocusing of consent for clinical genetic testing, moving away from an emphasis on autonomy and information provision, towards an emphasis on the virtues of healthcare professionals seeking consent, and the relationships they construct with their patients. We draw on focus groups with UK healthcare professionals working in the field of clinical genetics, as well as in-depth interviews with patients who have sought genetic testing in the UK’s National Health Service. We explore (...) two aspects of consent: first, how healthcare professionals consider the act of ‘consenting’ patients; and second how these professional accounts, along with the accounts of patients, deepen our understanding of the consent process. Our findings suggest that while healthcare professionals working in genetic medicine put much effort into ensuring patients’ understanding about their impending genetic test, they acknowledge, and we show, that patients can still leave genetic consultations relatively uninformed. Moreover, we show how placing emphasis on the informational aspect of genetic testing is not always reflective of, or valuable to, patients’ decision-making. Rather, decision-making is socially contextualised – also based on factors outside of information provision. A more collaborative on-going consent process, grounded in virtue ethics and values of honesty, openness and trustworthiness, is proposed. (shrink)

In patient centred care, shared decision making is a central feature and widely referred to as a norm for patient centred medical consultation. However, it is far from clear how to distinguish SDM from standard models and ideals for medical decision making, such as paternalism and patient choice, and e.g., whether paternalism and patient choice can involve a greater degree of the sort of sharing involved in SDM and still retain their essential features. In the article, different versions of SDM (...) are explored, versions compatible with paternalism and patient choice as well as versions that go beyond these traditional decision making models. Whenever SDM is discussed or introduced it is of importance to be clear over which of these different versions are being pursued, since they connect to basic values and ideals of health care in different ways. It is further argued that we have reason to pursue versions of SDM involving, what is called, a high level dynamics in medical decision-making. This leaves four alternative models to choose between depending on how we balance between the values of patient best interest, patient autonomy, and an effective decision in terms of patient compliance or adherence: Shared Rational Deliberative Patient Choice, Shared Rational Deliberative Paternalism, Shared Rational Deliberative Joint Decision, and Professionally Driven Best Interest Compromise. In relation to these models it is argued that we ideally should use the Shared Rational Deliberative Joint Decision model. However, when the patient and professional fail to reach consensus we will have reason to pursue the Professionally Driven Best Interest Compromise model since this will best harmonise between the different values at stake: patient best interest, patient autonomy, patient adherence and a continued care relationship. (shrink)

Undisputedly, the United States’ health care system is in the midst of unprecedented complexity and transformation. In 2014 alone there were well over thirty‐five million admissions to hospitals in the nation, indicating that there was an extraordinary number of very sick and frail people requiring highly skilled clinicians to manage and coordinate their complex care across multiple care settings. Medical advances give us the ability to send patients home more efficiently than ever before and simultaneously create ethical questions (...) about the balance of benefits and burdens associated with these advances. Every day on every shift, nurses at the bedside feel an intense array of ethical issues. At the same time, administrators, policy‐makers, and regulators struggle to balance commitments to patients, families, staff members, and governing boards. Ethical responsibilities and the fiduciary, regulatory, and community service goals of health care institutions are not mutually exclusive; they must go hand in hand. If they do not, our health care system will continue to lose valued professionals to moral distress, risk breaking the public's trust, and potentially undermine patient care. At this critical juncture in health care, we must look to new models, tools, and skills to confront contemporary ethical issues that impact clinical practice. The antidote to the current reality is to create a new health care paradigm grounded in compassion and sustained by a culture of ethical practice. (shrink)

Those concerned over the excessive commercialization of health care, to the detriment of both professional and patient-centered values, commonly propose remedies that assume that meaningful change can occur largely within the health care sector. I argue instead that a major shift in the public culture and political discourse of the U.S. will be required if the commercialization of health care is to be adequately addressed. The notion that health and health care are commodities to (...) be bought and sold in the market is encouraged by the ideology that is preferably called economism, though also today labeled neoliberalism, market fundamentalism, market triumphalism, and other terms. This ideology has been successful in pushing aside alternative accounts and policies over the past four decades, so that economism-inspired policies seem both commonsensical and inevitable. This dominance of the public political discourse hides two important facts about economism — it is a quasi-religious ideology that pretends to be a reflection of economic science; and it is shot through with internal contradictions that ultimately render it self-defeating as a guide to policy. Advocates for reduced commercialism in health care must directly address economism and attempt to educate the public and policymakers about its flaws. (shrink)

The need for explicit theoretical reflection on cross-cultural bioethics continues to grow as the spread of communication technologies and increased human migration has made interactions between medical professionals and patients from different cultural backgrounds much more common. I claim that this need presents us with the following dilemma. On the one hand, we do not want to operate according to an imperialist ethical framework that denies and silences the legitimacy of cultural values other (...) than our own. On the other hand, we do not want to backslide into a form of cultural relativism that is unable to critically appraise cultural practices that are harmful, unjust, or oppressive. I examine two prominent attempts – the principlism of Tom Beauchamp and James Childress and the Contractarianism of Robert Baker – to frame cross-cultural bioethics between these two extremes and argue that both approaches have significant flaws. The principlist approach fails to provide a non-question begging way to identify cross-cultural norms that does not already assume the universal legitimacy of moral principles dominant in North American society. Baker's contractarianism cannot grapple with the realities of political power imbalances that often characterize cross-cultural moral disputes. I suggest that a naturalized feminist framework, though not free of its own theoretical difficulties, provides the best alternative for approaching moral diversity respectfully and critically. (shrink)

Few cross-national studies have been conducted on academic dishonesty. The aim of this study was to explore students’ disclosed levels of academic dishonesty between New Zealand and Nigeria. The measures obtained included incidence, acceptability, and justification of dishonest action. It was hypothesized that there would be differences between the two groups and that differences could be explained in terms of deontology, cultural relativism, utilitarianism, rational fair exchange, and/or response bias. There were 844 medical and health science (...) students who participated in the study and completed a questionnaire that explored incidence, acceptability, and justification of dishonest action. A binary logistic regression revealed that age and incidence were significant predictors of country allocation. Nigerian students reported more engagement in dishonest behaviors, and it is argued that these students have diverse cultural expectations, language variances, response strategies, norms, beliefs, and values. Educational interventions are essential to address concerns related to academic dishonesty such as promoting cross-cultural discourse, providing study skills programs, utilizing peer mentoring, creating formal exchange strategies, and endorsing honor codes. (shrink)

Using samples from the U.S. and Puerto Rico, we examine cross-cultural differences in cultural value dimensions, and relate these to act and rule utilitarian orientations, and ethical decision making of business professionals. Although these places share the same legal environment, culturally they are distinct. In addition to tests of between-group differences, a model in which utilitarian orientation mediates the influence of cultural values on ethical decisions was evaluated at the individual level of analysis. Results (...) indicated national culture differences on three cultural values, but no between-group differences on utilitarian orientations and ethical decisions. Significant indirect effects were found; act utilitarian orientation mediated the effects of two values activity orientation and universalism on ethical decision making. Implications for international management practices and business ethics are discussed. (shrink)

Over the past twenty years there has been a shift in medical law and practise to increasingly distrust the judgement of health professionals. An increasing number of codes of conduct, disciplinary bodies, ethics committees and bureaucratic policies now prescribe how health professional and health researchers should act and relate to their patients. The result of this, Mark Henaghan argues, has been to undermine trust and professional judgement in health professionals, while simultaneously failing to (...) trust the patient to make decisions about their care. This book will look at the issue of health professionals and trust comparatively in a number of countries including the USA, Canada, Australia, New Zealand and the UK. The book will show by historical analysis of legislation, case law, disciplinary proceedings reports, articles in medical and law journals and protocols produced by management teams in hospitals, how the shift from trust to lack of trust has happened. Drawing comparisons between situations where trust is respected such as in emergency situations, and where it is not for example routine decisions such as obtaining consent for an anaesthetic procedure, the book shows how this erosion of trust has the potential to dehumanise the special nature of the relationship between healthcare professionals and patients. The effect of this is that the practice of health care is turned into a mechanistic enterprise controlled by "management processes" rather than governed by trust and individual care and judgement. This book will be an invaluable resource for students and scholars of medical law and medical sociology, public policy-makers and a range of associated professionals, from health service managers to medical science and clinical researchers. (shrink)

“Lay epidemiology” is a term used to describe the processes through which health risks are understood and interpreted by laypeople. It is seen as a barrier to public health when the public disbelieves or fails to act on public health messages. Two elements to lay epidemiology are proposed: empirical beliefs about the nature of illness and values about the place of health and risks to health in a good life. Both elements have to be (...) dealt with by effective public health schemes or programmes, which would attempt to change the public’s empirical beliefs and values. This is of concern, particularly in a context in which the lay voice is increasingly respected. Empirically, the scientific voice of standard epidemiology should be deferred to by the lay voice, provided a clear distinction exists between the measurement of risk, which is empirical, and its weighting, which is based on values. Turning to engagement with values, health is viewed to be an important value and is discussed and reflected on by most people. Public health professionals are therefore entitled and advised to participate in that process. This view is defended against some potential criticisms. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 9.4 (2002) 387-394 [Access article in PDF] Psychosis Good and Bad:Values-Based Practice and the Distinction Between Pathological and Nonpathological Forms of Psychotic Experience Mike C. Jackson and K. W. M. Fulford IN TWO PAPERS in this issue of Philosophy, Psychiatry, and Psychology, Marek Marzanski and Mark Bratton (2002) and Caroline Brett (2002) develop important critiques, from the perspectives respectively of Christian theology and (...) Eastern philosophy, of our 1997 analysis of the distinction between pathological and nonpathological forms of psychotic experience (Jackson and Fulford 1997).In this response, we briefly summarize the main points from our 1997 analysis; we consider, separately, the important although very different challenges to that analysis from the perspectives of our two critics; and we briefly indicate the main lines of recent developments in policy, practice, and research in mental health as they relate to this important area of human experience. The Jackson and Fulford (1997) Analysis In our 1997 paper, we presented three case studies from a larger series (Jackson 1991, 1997, 2001) selected with the express aim of bringing into focus the conceptual difficulties that arise at the borderline between psychotic illness and what we called benign spiritual experience. On the basis of these case studies we argued thatspiritual experiences, which are essentially benign, can involve explicitly psychotic phenomenology; traditional psychiatric diagnostic methods, which focus on the form and content of beliefs and experiences, are not capable of distinguishing between pathological and nonpathological forms of such psychotic experiences; [End Page 387]evaluation of such experiences (and claims about "illness" and health more generally) necessarily involves value judgments as well as judgments about matters of fact (specifically, the "facts" of traditional descriptive psychopathology); and more specifically, the distinction between pathological and nonpathological phenomena concerns the way in which they are embedded in the structure of the values and beliefs by which the actions of the subjects concerned are defined: "In the case of pathological psychotic phenomena," we argued, "there is a radical failure of action.... In the case of spiritual psychotic phenomena, action is radically enhanced" (Jackson and Fulford 1997, 55).We then proposed a cognitive problem-solving model of psychotic experiences. This model suggests that such experiences can be a normal and adaptive psychological response to existential crises, such as loss of meaning or purpose in life, coming to terms with death or bereavement, and so on (Batson and Ventis 1982; Jackson, 1991, 1997, 2001). The model is consistent with a subsequent position paper published by the British Psychological Society arguing the case for a psychological formulation of psychotic experiences and cognitive-behavioural methods in their management (2000).In the case of nonpathological psychotic experience, the psychotic elements of the experience promote a paradigm shift in the individual's underlying assumptions, which effectively resolves their impasse and allows them to move forward. This is normally a self-limiting process, in that when the individual is able to utilize their insight, it acts to resolve the stress which triggered it. In pathological psychosis, this process fails for various possible reasons, which were not explored in any depth in that paper (but see Jackson 2001 for a more detailed discussion). The Challenge From Marzanski and Bratton Marek Marzanski and Mark Bratton reexamine the questions raised by our cases from a Christian theological perspective (Marzanski and Bratton 2002). They suggest a theologically based definition of spiritual experience according to which the criteria for "genuine" experience concerns its context within the development of the individual's religious faith. In Bratton and Marzanski's account, these criteria are based on a Christian value system.They present three cases of their own, which, in contrast to the three cases in our 1997 paper, vividly illustrate how phenomena that may be valued negatively from a medical perspective (i.e., as defined by us in terms of their consequences for action), may, at one and the same time, be valued positively from a religious perspective (i.e., in terms of their consequences for the... (shrink)

This essay argues that service-learning pedagogy is an important tool in pre-health humanities education that provides benefits to the community and produces more compassionate, culturally competent, and community-responsive future healthcare professionals. Further, beginning this approach at the baccalaureate level instills democratic and collaborative values at an earlier, crucial time in the career socialization process. The discussion focuses on learning outcomes and reciprocity between the university and community in a Medical Humanities course for junior and senior premedical (...) students, an elective in the premedical curriculum. The course includes an experiential learning element in which students shadow physicians and a service-learning component in which students complete medically-relevant service work, working with partners such as the veteran’s hospital, a hospice home, and organizations that serve individuals with disabilities. We cover topics such as narrative medicine, ethics, cross-cultural medicine, patient/practitioner relationships, the human life cycle, and the illness experience, and the writing, discussion, and reflection we engage in is enriched by the real-world experiences from which the students are able to draw. The shadowing and service experiences and the classroom texts and topics combine to form a symbiosis that leads to especially meaningful teaching and learning outcomes. (shrink)

National legislation, as well as arguments of experts, in Germany and Israel represent opposite regulatory approaches and positions in bioethical debates concerning end-of-life care. This study analyzes how these positions are mirrored in the attitudes of laypeople and influenced by the religious views and personal experiences of those affected. We qualitatively analyzed eight focus groups in Germany and Israel in which laypeople were asked to discuss similar scenarios involving the withholding or withdrawing of treatment, physician-assisted suicide, and euthanasia. In both (...) countries, respect for patient autonomy and patients’ wishes to die with dignity found broad consent. Laypeople argued in favor of accepting such wishes when they were put down in an advance directive. Laypeople in non-religious groups in both countries argued on the basis of a respect for autonomy for the possibility of euthanasia in severe cases but, at the same time, cautioned against its possible misuse. National contrast was apparent in the moral reasoning of lay respondents concerning the distinction between withholding and withdrawing treatment. The modern religious laypeople in Israel, especially, argued strongly, on the basis of the halakhic tradition, against allowing the withdrawal of treatment in accord with a patient’s wish. We conclude by discussing the emergent notion of shared responsibility and views of professional responsibility, which we connect through relevant cultural themes such as religion and national culture. (shrink)

Background An increasing number of studies on physicians’ professionalism have been done since the 2002 publication of Medical Professionalism in the New Millennium: A Physician Charter. The Charter proposed three fundamental principles and ten responsibilities. However, most studies were done in developed countries, and few have been done in China. Additionally, few studies have examined the effect of patient-centered hospital culture (PCHC) on physicians’ professionalism. We aimed to investigate physicians’ medical professionalism in public hospitals in China, and to assess mediating (...) effect of professional attitudes in the relationship of PCHC with professional behaviours. Methods Self-administered questionnaires including professional attitudes (20 items) and behaviours (10 items) survey and PCHC scale (22 items) were given to clinical physicians in five public hospitals, China. The mediating effect of professional attitudes in the relationship of PCHC with professional behaviours was tested. Result 232 valid questionnaires were collected. More than 90% (208) respondents agreed with 15 of 20 specific statements on medical professionalism. As for the responsibility of improving quality of care, 54 (23%) respondents disagreed with reporting of incompetent colleagues and as for the responsibility of maintaining professional competence, 49 (21%) disagreed with recertification. More than 185 (83%) respondents reported that they sometimes, usually, or always showed the four positive behaviours on the questionnaire, and 173 (77%) reported that they never showed the six negative behaviours. Mediating effect analysis revealed that two dimensions of PCHC (i.e. value/institution culture and behaviour/material culture) had a significant positive impact on physicians’ professional behaviour, and professional attitude played a complete mediation role between them, but another dimension of PCHC (i.e. negative evaluation of hospital) directly affected professional behaviour without influencing professional attitude. Conclusion Chinese physicians showed positive professional attitudes and behaviours. Different dimensions of PCHC affected physicians’ attitudes and behaviours in different ways. (shrink)

This paper aims to elucidate some dysfunctional aspects of health care utilisation by combining concepts from modern systems theory and from psychoanalysis. Contemporary health care in industrialised countries can be conceived as a social system in terms of modern systems theory. According to this theory, social systems are operating on the basis of a ‘guiding difference,’ which in the case of health care is the distinction between ‘healthy’ and ‘ill.’ Its rigidity in adhering to the healthy-ill (...) dichotomy exposes health care to being collusively entangled in the interpersonal defence arrangements of patients. In the psychoanalytic view, individual conflicts can be warded off from consciousness not only by intrapsychic defence, but also by interpersonal defence mechanisms. These mechanisms involve the patients’ close social environment, often including doctors and hospitals. The functioning and the motivational structure of health care itself shows features of neurotic defence: Not only its representatives, but health care as a whole act in a rigid, obsessive manner in order to separate the healthy from the ill and to battle against (presumed) diseases. This obsession sometimes results in excessive diagnostic activism and in inconsiderate application of aggressive medical treatments. Both are inappropriate with regard to the salient problem of modern medicine: the increase of chronic nonfatal diseases like depression and chronic pain. The described defence mechanisms are unconscious not only to patients but also to health care professionals (let alone health politicians), and are contributing to dysfunctional health care overuse. (shrink)

Nancy Jecker (2013) mounts a sustained and formidable critique of Norman Daniels's prudential lifespan account (PLA) as a reliable basis for justice between age groups in the responsible allocation...

This paper explores the dilemma faced by mental healthcare professionals in balancing treatment of mental disorders with promoting patient well-being and flourishing. With growing calls for a more explicit focus on patient flourishing in mental healthcare, we address two inter-related challenges: the lack of consensus on defining positive mental health and flourishing, and how professionals should respond to patients with controversial views on what is good for them. We discuss the relationship dynamics between healthcare providers (...) and patients, proposing that ‘liberal’ approaches can provide a pragmatic framework to address disagreements about well-being in the context of flourishing-oriented mental healthcare. We acknowledge the criticisms of these approaches, including the potential for unintended paternalism and distrust. To mitigate these risks, we conclude by suggesting a mechanism to minimize the likelihood of unintended paternalism and foster patient trust. (shrink)

Research has shown that addressing and integrating the existential dimension in treatment settings reduce symptoms like anxiety, depression and substance abuse. Healthcare chaplains are key personnel in this practice. A nationwide, cross-sectional survey influenced by a mixed-methods approach was used to examine the attitudes, practices, understanding and perceptions of mental health professionals, including healthcare chaplains, regarding the value of addressing the existential dimension in treatment programmes. The existential group practice was led by the healthcare chaplains as an integrated (...) part of specialist mental health services. A positive and open attitude towards addressing the existential dimension was identified among the informants. Despite this, a small gap between attitude and practice was reported. Existential, religious and spiritual concerns are reported as part of the existential dimension and as relevant topics to be discussed in specialist mental health services. The findings indicate that the existential group practice could have a positive influence on the co-leaders’ competence to address existential, religious and spiritual concerns; however, this should be further investigated. (shrink)

Health care professionals’ and trainees’ conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians’ changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe (...) others. At least two important expressions of moral damage in the context of health care are these: callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others’ needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere,1 and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here. (shrink)

This paper examines a number of questions about the degree to which the clinical practice of medicine is affected, if at all, by the legal systems in four countries: Chile, Germany, Japan and the United States. The focus on these four countries in four different regions of the world offers a unique perspective within which to examine medical treatment decisions made by patients and their proxies or surrogates, the potential role for universal written instruments such as advance directives, the (...) cross-professional tensions between clinical and legal concerns in very distinct cultures, and the degree to which legal activities can change or affect clinical realities in the context of these different political and health care systems. We have incorporated, whenever relevant, the insights of many disciplines, including the social sciences, in analyzing the existing interrelations between law and behavior in this specific context. Der Beitrag untersucht, inwieweit die klinische Praxis in vier Ländern mit unterschiedlichen Rechtssystemen und Berufskulturen durch Rechtsnormen oder das Verständnis von Recht beeinflußt wird. Es wird gefragt, welche Funktion rechtliche Interventionen bei der Veränderung von Verhaltensnormen in unterschiedlichen Gesundheitssystemen haben können. Folgende Themenbereiche werden diskutiert: Entscheidungen über die medizinische Behandlung, die von Patienten und ihren Angehörigen oder Stellvertretern getroffen werden; die mögliche Rolle umfassender schriftlicher Verfügungen wie z.B. der Patiententestamente ; die berufsübergreifenden Spannungen zwischen medizinischen und rechtlichen Belangen in sehr unterschiedlichen Kulturen; der Einfluß, den gesetzgeberische Aktivitäten im Kontext der verschiedenen politischen und Gesundheitssysteme auf die medizinische Wirklichkeit haben. Bei ihrer Analyse der in diesem Zusammenhang bestehenden Beziehungen im Verhältnis von Recht und Verhalten haben die Autoren die Erkenntnisse vieler Disziplinen unter Einschluß der Sozialwissenschaften, soweit sie als relevant erscheinen, in ihren Beitrag eingearbeitet. (shrink)

Patients have to be respected with dignity as the masters of their own lives. The problem, however, is that autonomy may become so dominant and the fundamental value of caring in professional nursing that the patient’s dignity is affected. The aim of this article is to point out some of the issues with the interplay between autonomy, also called self-management and dignity. Given voice to the patient perspective the background is provided by cases from research conducted through qualitative (...) interviews with patients and expanded by summarizing empirical research concerning the interplay between autonomy and dignity. The search strategy and the research question gave five empirical research papers and three theoretical studies and concept analyses. A concise overview of the relevant research contains information about all the major elements of the studies. The background research and an interpretative summary address new issues to be taken into account in dignity conserving care. (shrink)

Background The ethical principle of justice demands that resources be distributed equally and based on evidence. Guidelines regarding forgoing of CPR are unavailable and there is large variance in the reported rates of attempted CPR in in-hospital cardiac arrest. The main objective of this work was to study whether local culture and physician preferences may affect spur-of-the-moment decisions in unexpected in-hospital cardiac arrest. Methods Cross sectional questionnaire survey conducted among a convenience sample of physicians that likely comprise code team members (...) in their country. The questionnaire included details regarding respondent demographics and training, personal value judgments and preferences as well as professional experience regarding CPR and forgoing of resuscitation. Results Of the 675 questionnaires distributed, 617 were completed and returned. Country of practice and level of knowledge about resuscitation were strongly associated with avoiding CPR performance. Mexican physicians were almost twicemore likely to forgo CPR than their Israeli and Indonesian/Malaysian counterparts [OR1.84, p = 0.038]. Mexican responders also placed greater emphasison personal and patient quality of life. In multivariate analysis, degree of religiosity was most strongly associated with willingness to forgo CPR; orthodox respondents were more than twice more likely to report having forgone CPR for apatient they do not know than secular and observant respondents, regardless of the country of practice [OR 2.12, p = 0.003]. Conclusions In unexpected in-hospital cardiac arrest the decision to perform or withhold CPR may be affected by physician knowledge and local culture as well as personal preferences. Physician CPR training should include information regarding predictors of patient outcome at as well as emphasis on differentiating between patient and personal preferences in an emergency. (shrink)

The scarcity of resources during the COVID‐19 pandemic caused ethical dilemmas in prioritizing patients for treatment. Medical and ethical guidance only emphasizes clinical procedures but does not consider the sociocultural aspect. This study explored the perception of former COVID‐19 patients and their families on the decision‐making process of the patient's selection at a time of scarcity of resources. The result will inform the development of an ethical guide for allocating scarce resources that aligns with Indonesian culture. We conducted (...) qualitative research with in‐depth interviews between May ‐ December 2022 involving sixteen participants from various cities in Indonesia. We transcribed the interviews and analyzed the results using thematic analysis. This study found that doctor's decisions often differed from patient's expectations in allocating scarce resources, and therefore, it should be communicated appropriately. Medical decisions were not sufficiently made ethically, but must also be made communicatively. In Indonesia's strong communal culture, community involvement was essential to distributing limited resources. A better approach to ethical education, including adequate communication skills, is necessary to prepare health professionals for facing unpredictable future pandemics. (shrink)