Children in foster care are considered a “vulnerable population” in clinical care and research, with good reason. These children face multiple medical, psychological, and social risks that obligate the child welfare and healthcare systems to protect them from further harms. An unintended consequence of the “vulnerable population” designation for children in foster care is that it may impose barriers on tracking and studying their health that creates gaps in knowledge that are key to their receipt of medical care and good (...) outcomes. These gaps in knowledge have implications for justice, beneficence, and maleficence and serve to undermine “protection” of this population. Here we review the challenges of research regarding children in foster care, particularly medically complex children, and offer specific recommendations to include children in foster care in medical research. (shrink)

In this paper, we discuss the lack of consideration given to children in the COVID-19 health systems policy response to the pandemic. We do this by focusing on the case of children with complex medical needs. We argue that, in broad terms, health systems policies that were implemented during the pandemic failed adequately to meet our obligations to both children generally and those with complex medical needs by failing to consider those needs and so to give them fair protection against (...) harm and disadvantage. We argue that justice requires that the distinct needs and vulnerabilities of children with medical complexities are explicitly integrated and prioritised in decisions concerning healthcare and operational planning in the recovery phase and beyond. (shrink)

Approximately one in 10 children in foster care are medically complex and require intensive medical supervision, frequent hospitalization, and difficult medical decision making. Some of these children are in foster care because their parents cannot care for their medical needs; other parents are responsible for their child’s medical needs due to abuse or neglect. In either case, there can be uncertainty about the role that a child’s biological parents should play in making serious medical decisions. Here we highlight some of (...) the ethical challenges inherent in making these decisions for children in foster care, as seen through the lenses of a child welfare provider, an inpatient care physician, and a primary care pediatrician. (shrink)

Background: With the number of young people with medical complexity increasing, an increasing number must navigate the transition to adulthood. This transition, in part, involves a situational transition in which young people and their families must access new services in the adult system. Objectives: To explore how societal ideologies, communities, and organizations represent the foundation of barriers to access to services. Research Design: The discussion in this paper, framed within a social justice perspective, outlines barriers to access to services (...) at the societal and community levels including societal ideologies, differences in philosophies of care in pediatric and adult care, physical environments, and availability of services. Ethical Considerations: Since this is an exploratory discussion paper, no ethical approval was required. Findings and Conclusion: Based on analysis of the literature from a social justice perspective, it is suggested that the adult health care and social service systems do not provide the supports and services necessary to empower young people and their families to achieve their goals and maintain their health and quality of life. It is, thus, an ethical issue that the transfer from pediatric to adult services is occurring in the absence of appropriate services. Recommendations at the individual, community and policy levels highlight how nurses can address this ethical issue to promote more equitable access to services. (shrink)

This article presents an analysis of contractual relations in sport from the standpoint of the Croatian legislative system. Due to the complexity of the subject matter, the author considers only a small fragment of it - the significance and the role of sport in Croatian society and the law of contracts „as a cornerstone on which „sports law“ has been built and which is of primary importance in most areas where there is an interface between sport and the law, (...) irrespective of whether the sport is being played at an elite level or at a more humble one“. Bearing in mind the limited extent of this article, the autor tries to provide some clarifications and some guidance on how to deal with the designation and the determination of the applicable law for contracts in the sporting context. Considering that there are different legal regimes which may come into play with regard to the designation of the law applicable to contracts in the sporting context, the author first presents the determination of the applicable law according to the Rome I Regulation and then according to the Croatian Arbitration Act, Swiss Private International Law Act and the CAS Code of Sports-related Arbitration, as the most common in sports practice. Then, the author deals with contracts concluded with minor athletes and the determination of the law applicable to some preliminary questions. Finally, the author presents her perception of the problems encountered and some suggestions for the improvement of the existing legal framework. (shrink)

Health systems are integrating medical-legal partnerships (MLPs) into clinical care and increasingly center “complex care” patients. These patients have intersecting medical and social needs and often face systemic inequities that exacerbate their chronic health conditions. This paper describes a role for MLPs in hospital quality initiatives; examines the ethics of MLPs assisting with guardianship and institutionalization of hospital patients including marginalized groups; and advocates for MLP interventions designed to address intersectional and ethical concerns.

Medical assistance in dying legislation in Canada followed much deliberation after the Supreme Court of Canada’s ruling in Carter v. Canada. Included in this deliberation was the Special Joint Committee on Physician Assisted Dying’s recommendation to extend MAID legislation beyond the inclusion of adults to mature minors. Children's agency is a construct advanced within childhood studies literature which entails eliciting children’s voices in order to recognise children as active participants in constructing their own childhoods. Using this framework, we consider the (...) possible extension of MAID legislation to most minors. We highlight important questions regarding how insights from children’s voices could be mobilised in the life or death context of MAID. We conclude that children’s voices have the potential to help determine their eligibility for MAID; however, incorporating children's voices in the context of MAID requires careful consideration due to the complexity of voice. (shrink)

In recent times, daily, ordinary medical practices have incontrovertibly been developing under the condition of complexity. Complexity jeopardizes the moral core of practicing medicine: helping people, with their illnesses and suffering, in a medically competent way. Practical wisdom has been proposed as part of the solution to navigate complexity, aiming at the provision of morally good care. Practical wisdom should help practitioners to maneuver in complexity, where the presupposed linear ways of operating prove to be insufficient. (...) However, this solution is unsatisfactory, because the proposed versions of practical wisdom are too individualistic of nature, while physicians are continuously operating in varying teams, and dealing with complicated technologies and pressing structures. A second point of critique is, that these versions are theory based, and thus insufficiently attuned to the actual context of everyday medical practices. Now, our proposal is to use an approach of practical wisdom that enables medical practices to counter the complexity issue and to re-invent the moral core of medical practicing as well. This implies a practice oriented approach, as thematized by practice theory, qualitative empirical research from the inside, and abduction from actual performed practical wisdom towards an apt understanding of phronèsis. (shrink)

There is a need to increase the number of practicing medical doctors in South Africa. We examine the ethical implications of patients’ rights being affected in medical education in a South African context.The South African legal framework advocates public healthcare access. Yet, the State’s ethical obligations when it comes to guaranteeing public healthcare access, conflict with its utilitarian policy, that allows for medical education to help achieve the State’s public healthcare commitments, at the cost of eroding patients’ rights, and accepts (...) that certain actions are imperative, in line with Ubuntu, which is tenable yet nuanced. A patient treated by a licenced doctor today, benefits because other patients have allowed themselves to be used as hands-on learning material for medical students yesterday.Healthcare institutions need to take cognisance of the numbers of medical students that patients can reasonably be expected to endure. There is a need for the Health Professions Council of South Africa and medical schools to adopt guidelines on reasonable levels of medical student-patient interaction, and medical student-to-patient ratios in healthcare delivery. (shrink)

Scott Waterman's reflection on his experience with chronic pain and alternative treatments raises a fundamental question in medical epistemology: How can we know that an intervention will help people who are suffering?Waterman's details his trial of an alternative therapy with a dubious pathophysiological rationale. Despite the lack of research demonstrating its efficacy, and a lack of therapeutic benefit for him in particular, he acknowledges its benefit to others who were more attitudinally predisposed to it. This leads him to conclude that (...) one's personal beliefs and explanatory hypotheses play a role in the healing process. From this he concludes that data from clinical studies conducted according to... (shrink)

We received 23 spirited commentaries on our target article from across the disciplines of philosophy, economics, evolutionary genetics, molecular biology, criminology, epidemiology, and law. We organize our reply around three overarching questions: (1) What is a cause? (2) How are randomized controlled trials (RCTs) and within-family genome-wide association studies (GWASs) alike and unalike? (3) Is behavior genetics a qualitatively different enterprise? Throughout our discussion of these questions, we advocate for the idea that behavior genetics shares many of the same pitfalls (...) and promises as environmentally oriented research, medical genetics, and other arenas of the social and behavioral sciences. (shrink)

We analyzed the patients’ perception of prenatal diagnosis of fetal cardiac pathology, and the reasons for choosing to continue with pregnancy despite being eligible to receive a medical termination of pregnancy. We also identified the challenges, the motives interfering in decision-making, and the consequences of the decisions on pregnancy, child and mother. This descriptive, prospective and longitudinal study was conducted in France, amongst pregnant women who wished to continue their pregnancy despite an unfavorable medical advice. Socio-demographic data were collected through (...) a questionnaire. Such questionnaire covered information assessing the parents/mother’s perception of prenatal diagnosis, and medical termination of pregnancy, their interpretation of the established diagnosis and their motives for not considering pregnancy termination. 72 eligible patients were analyzed over one year: mean age 33 ± 6.89 years, 47 patients had already given birth to ≥1 healthy child. Mean gestational age at the detection of fetal cardiac pathologies was 30 ± 4.37 weeks of amenorrhea. Patients decided to keep the child after 3 ± 1.25 consultations. 56 patients made their decision with their husbands and 16 made their decision alone. Reasons for declining the medical termination were culpability and responsibility, ideologies and convictions, mistrust and hope. Newborns of 67 patients died with a mean survival duration of 38 days. Patient informed consent should be sought before any decision in neonatology, even if conflicting with the medical team’s knowledge and the pregnant mother’s benefits. Decisions to accept or decline pregnancy termination depend on the patients’ psychological character, ideologies, convictions, and mistrust in the diagnosis/prognosis, or hope in the fetus survival. (shrink)

Book reviewed in this article: The New Health Care For Profit: Doctors and Hospitals in a Competitive Environment. Edited by Bradford H. Gray The Healing Mission and the Business Ethic. By Robert M. Cunningham The Medical Industrial Complex. By Stanley Wohl.

The dilemma of incapacitated patients with acute medical problems who want or try to leave the hospital is a common problem in American clinical ethics. One need only listen to clinicians who work...

Respectfulness is demanded of doctors and predicts more positive patient health-related outcomes, but research is scarce on ways to promote it. This study explores two ways to conceptualize unconditional respect from medical students, defined as respect paid to people on the basis of their humanity, in order to inform strategies to increase it. Unconditional respect conceptualized as an attitude suggests that unconditional respect and conditional respect are additive, whereas unconditional respect conceptualized as a personality trait suggests that people who are (...) high on unconditional respect afford equal respect to all humans regardless of their merits. One hundred and eighty-one medical students completed an unconditional respect measure then read a description of a respect-worthy or a non-respect-worthy man and indicated their respect towards him. The study found a main effect for unconditional respect and a main effect for target respect-worthiness but no interaction between the two when respect paid to the target was assessed, supporting the attitude-based conceptualization. This suggests that unconditional respect can be increased through relevant interventions aimed at increasing the relative salience to doctors of the human worth of individuals. Interventions to increase unconditional respect are discussed. (shrink)

The aim of the paper is to examine the possible relationships between the different dimensions of aesthetics on the one hand, and medical practice and medical ethics on the other hand. Firstly, I consider whether the aesthetic perception of the human body is relevant for medical practice. Secondly, a possible analogy between the artistic process and medical action is examined. The third section concerns the comparison between medical ethical judgements and aesthetic judgement of taste. It is concluded that the mutual (...) relevance between the aesthetic sphere, moral judgement and medical practice can be understood only if we recognize these spheres as distinct. (shrink)

Modern Myths and Medical Consumerism is concerned with the loss of a sense of limit in technological medicine today, and the way in which the denial of death leads to an uncontrollable, consumeristic multiplication of needs. Taking its starting point from C. G. Jung¿s analytical psychology, the book gives a symbolic interpretation based on archetypal, philosophical and socio-psychoanalytic ideas developed through the author¿s personal experience, moving from the medical to the psychoanalytical paradigm. Lanfranchi depicts ideal sources of medicine, based on (...) archetypal material drawn from Greek myth, and discusses the progressive steps of the doctor¿s consciousness¿ evolution up to contemporary times. Critiquing current medicine and its ¿modern myths¿, the book suggests the prevailing model of economic development is unsustainable, and provides prospects of a more contained ecological medicine and an ethical approach that will allow readers to reflect and move towards a more qualified attitude to mortality. The book meets the need to transform medicine into a critical domain of human experience, capable of providing essential services consistent with the naturalness of death and environmental sustainability. As such, it will be vital reading to academics in the fields of psychotherapy, analytical psychology, psychiatry and medicine, and those with a philosophical or sociological background. (shrink)

The practice of covertly administering medications to patients without their consent is often discussed in the framework of legal questions around the right of patients to consent and refuse medical treatment. However, this practice also raises significant questions surrounding the professional duties and obligations of health care professionals as it relates to the decision-making process of whether to engage in the covert administration of medications. In this paper, I present an overview of the origin of those duties and obligations, and (...) discuss how those duties and obligations when seen from different perspectives may either justify or prohibit the practice. Further, I discuss whether the duties and obligations of health care professionals as they are currently framed are suited to address the complexities of this issue both from the health care professional and patient perspectives. This analysis is conducted in the context of duties and obligations that arise from not only legal framework but also from the ethical requirements from professional codes of ethics. (shrink)

Slippery slope‐, taboo‐breaking‐ or Nazi‐analogy‐arguments are common, but not uncontroversial examples of the complex relationship between bioethics and the various ways of using historical arguments in these debates. In our analysis we examine first the relationship between bioethics and medical history both as separate disciplines and as argumentative practices. Secondly, we then analyse six common types of historical arguments in bioethics (slippery slope‐, analogy‐, continuity‐, knockout/taboo‐, ethical progress‐ and accomplice‐arguments), some as arguments within the academic debate of bioethics, others as (...) arguments within political and public debates over bioethical issues. We conclude by suggesting to bioethicists to better understand historical arguments as socially and culturally embedded practices of critical reflection of power, medical and government paternalism and possible future scenarios. More interdisciplinarity between ethicists and medical historians is needed to appropriately rationalize and understand the different legacies. (shrink)

L'A. mette in parallelo quattro fonti interrelate della tradizione narrativa relativa al passaggio delle conoscenze filosofiche e mediche da Alessandria a Baghdad. I testi esaminati, presentati in traduzione inglese, sono di Alfarabi , dello storico al-Masudi , del medico ibn-Ridwan del Cairo e del medico ibn-Gumay . Le origini della tradizione testuale sono individuate in un canone di insegnamenti ippocratici e galenici originatosi ad Alessandria poco prima della conquista araba, e comprendente i cosiddetti Summaria alexandrinorum. L'A. si sofferma inoltre sulla (...) propaganda anticristiana connessa a tali testi e sugli insegnamenti di logica e filosofia aristotelica, con particolare riferimento alla redazione di Alfarabi. Una bibliografia chiude il saggio. (shrink)

Discussion of a “duty to recontact” emerged as technological advances left professionals considering getting back in touch with patients they had seen in the past. While there has been much discussion of the duty to recontact as a matter of theory and ethics, there has been rather little empirically based analysis of what this “duty” consists of. Drawing on interviews with 34 professionals working in, or closely with, genetics services, this paper explores what the “duty to recontact” means for healthcare (...) professionals involved in genetics. Using a discourse analytic framework, the paper identifies three system generated discourses on recontact (governance, legal and responsibilizing discourses) and three lifeworld discourses (situating recontact as a formal duty; more loosely as an obligation; and as a personal sense of responsibility). In summary, the paper shows that the “duty” to recontact involves a complex interplay of system responsibilities with professional duties, responsibilities and obligations. (shrink)

Medical assistance in dying (MAiD) in Canada is a complex, novel interprofessional practice governed by stringent legal criteria. Often, patients need assistance navigating the system, and MAiD providers/assessors struggle with the administrative challenges of MAiD. Resultantly, the role of the MAiD care coordinator has emerged across the country as a novel practice dedicated to supporting access to MAiD and ensuring compliance with regulatory requirements. However, variability in the roles and responsibilities of MAiD care coordinators across Canada has highlighted the need (...) for accountability and standardization for this practice. This manuscript constitutes a first attempt to describe this emerging role, through discussion of proposed standards of practice, as well as roles and responsibilities, and ethical duties of this emergent professional practice. We detail the core commitments of MAiD care coordinators to patients, providers/assessors and institutions involved in the MAiD process. We address the core competencies that inform the unique skillset required by MAiD care coordinators to facilitate high-quality care, while highlighting the moral and ethical considerations embedded in this work. To illustrate the complexity of the MAiD care coordinator role, case examples involving ethical dilemmas encountered in practice are included. Finally, a code of ethics is proposed to serve as a guide for appropriate professional practice and conduct. This manuscript is intended to illustrate the importance of transparency and accountability for this new role that provides service to vulnerable patients and families; this is especially critical as the ethical complexity of MAiD is likely to increase with future changes in legislation opening MAiD access to new populations. (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)

Recent scholarship in medical humanities has expressed strong concern over the ability of pharmaceuticals companies to medicalize discomfort and subsequently invent diseases. In this article, I explore the clinical debates over the ontology of the sinus headache as a possible counter-case. Extending Foucault’s concept of principles or rarefaction, this paper documents the efforts of clinicians to resist the pharmaceutically-provided understanding of the sinus headache. In so doing, it offers institutions of rarefaction and rarefactive assemblages as useful heuristics for the exploration (...) of disease legitimization discourse. (shrink)

Medical ethics involve more than a prohibition against advertising or solicitation of patients, or a limit on the height of the letters on a doctor's office door. The true ethics of health care are the fundamental values that guide-or should guide-physicians in every aspect of their interaction with patients, their families, and society at large. Professional ethics is a complex and controversial issue, but one that must be dealt with in an era of increasing skepticism about the practice of medicine. (...) Medical Stewardship is a carefully reasoned historical and philosophical inquiry into the origins of our notions of medical ethics, and the ways in which a true sense of the doctor's proper role can be restored. Tracing the development of medical ethics from ancient times to the modern era, Dr. Kepler consides them in relation to the medical profession of today. He considers several areas seldom discussed in works on medical ethics: the exploitation of the patient, preventive versus disease treatment, ethical problems in medical education, drug abuse by physicians, the ethics of organized medicine, and some important but under-utilized roles of the physician. (shrink)

Aim: The aim of this paper is to present the development and evaluation of an art psychotherapy brief treatment method for complex depression for patients referred to mental health services.Background: Art Psychotherapy literature describes a range of processes of relational change through the use of arts focused and relationship focused interventions. Complex depression has a prevalence of 3% of the population in the West and it is recorded that in 2016 only 28% of that population were receiving psychological treatment. This (...) study was developed to test the hypothesis of whether an accessible and acceptable approach to the treatment of complex depression could be developed in relation to existing evidence-based practice within mental health services.Method: The United Kingdom Medical Research Council phased guidance for complex intervention development was used to develop the intervention. The process included producing a literature overview, systematic description of clinical practice, including a logic model and a clinical protocol. The art psychotherapy protocol described an arts-based dynamic interpersonal therapy approach, offered 1:1 over 24 sessions. Further to this the intervention was tested for referrer acceptability. The intervention is in the early stages of evaluation, using changes to the patient's depression and anxiety measured pre- and post-treatment with a follow-up measure at 3 months following completion of treatment.Results: Phase I of the study provided a good basis for developing a logic model and protocol. The authors found that there was good clinical consensus about the use of a structured clinical art psychotherapy method and the literature overview was used to support specific examples of good practice. The verification of clinical coherence was represented by a logic model and clinical protocol for delivering the intervention. The acceptability study demonstrated very high levels of acceptability for referrers reporting that ADIT was acceptable for patients with complex/major depression, that they were likely to refer to ADIT in the future that the use of arts was likely to improve accessibility the use of arts was likely to improve outcomes and that offering ADIT was an effective use of mental health resources.Discussion: Phase I of this intervention development study demonstrated theoretical and practice coherence resulting in a clinical protocol and logic model. Whilst Phase II of this study showed promising results, Phase II would need to be sufficiently scaled up to a full trial to further test the intervention and protocol. (shrink)

Iam appreciative of the thoughtful comments and the diversity of the commentators’ perspectives and backgrounds. I take Hoffman’s original argument about psychotropic medications as risking ‘hyponarrativity’ as my starting point and my reply to her critique will naturally lead to a discussion of psychotherapeutic approach, importance of weighing Mr. A’s underlying autism and important bioethical considerations.It is important to imbed this case within the acuity of its clinical context: This individual presented for psychiatric hospitalization in the context of a...

The exponential digitization of medical data has led to a transformation of the practice of medicine. This change notably raises a new complexity of issues surrounding health IT. The proper use of these communication tools, such as telemedicine, e-health, m-health the big medical data, should improve the quality of monitoring and care of patients for an information system to "human face". Faced with these challenges, the author analyses in an ethical angle the patient-physician relationship, sharing, transmission and storage of (...) medical information, setting pins to an ethic for the digitization of medical information. Drawing on good practice recommendations closely associated with values, this model is developing tools for reflection and present the keys to understanding the decision-making issues that reflect both the technological constraints and the complex nature of human reality in medicine. (shrink)

Complex adaptive systems and nursingThere have been numerous references to complexity theory and complex systems in the recent healthcare literature, including nursing. However, exaggerated claims have (in my view) been made about how they can be applied to health service delivery, and there is a widespread tendency to misunderstand some of the concepts associated with complexity thinking (usually justified by describing the misconception as a metaphor). These conceptscanbe extended to systems and structures in healthcare organisations but, at this (...) stage in the development of complexity science, only in a modest and very cautious way. In this paper I first outline some of the key ideas in the theory of complex adaptive systems, and then suggest that they have been distorted by a series of influential articles in the medical literature. I go on to present a simple case study of my own and undertake a complexity analysis of it. In the conclusion I suggest that we should beware of some outdated ideas being trotted out in the guise of complexity — an exciting and diverse area of enquiry that those old ideas do not, in fact, resemble. (shrink)

Essays and articles in the November‐December 2022 issue of the Hastings Center Report explore the complexities of medical decision‐making. A case‐study essay, for example, argues that the dismaying decision to perform resuscitation efforts on a patient who had obviously been dead for some time can be understood in the context of the harmful practice of defensive medicine. A narrative essay concerns whether an adolescent with locked‐in syndrome should be asked her wishes about life‐sustaining interventions, and the articles illuminate the ethical (...) value of the parental role in pediatric decision‐making, an array of ways in which patient decision‐making is interdependent, and the limitations of measures designed to evaluate the quality of a patient's decision and decision‐making process. (shrink)

The case of Baby G raises some of the most difficult decisions confronting parents and health-care professionals. Given the context-specific nature of most medical decisions affecting children, the principles and standards of child rights and the U.N. Convention on the Rights of the Child will not clearly articulate the best interests of the child in every situation. A child rights–based approach will, however, provide the factors that must be considered, methods for their analysis, and the procedural safeguards that must surround (...) decision-making related to complex medical situations facing children, families, and providers. This approach can facilitate both.. (shrink)

The Direction of Medical Ethics The direction bioethics, and specifically medical ethics, will take in the next few years will be crucial. It is an emerging specialty that has attempted a great deal, that has many differing agendas, and that has its own identity crisis. Is it a subspecialty of clinical medicine? Is it a medical reform movement? Is it a consumer pro tection movement? Is it a branch of professional ethics? Is it a ra tionale for legal decisions and (...) agency regulations? Is it something physicians and ethical theorists do constructively together? Or is it a morally concentrated attack on high technology, with the prac titioners of scientific medicine and the medical ethicists in an adversarial role? Is it a conservative endeavor, exhibiting a Frankenstein syn drome in Medical Genetics ("this time, they have gone too far"), or a Clockwork Orange syndrome in Psychotherapy ("we have met hods to make you talk-walk-cry-kill")? Or does it suffer the afflic tion of overdependency on the informal fallacy of the Slippery Slope ("one step down this hill and we will never be able to stop") that remains an informal fallacy no matter how frequently it's used? Is it a restricted endeavor of analytic philosophy: what is the meaning of "disease," how is "justice" used in the allocation of medical resources, what constitutes "informed" or "consent?" Is it applied ethics, leading in clinical practice to some recommenda tion for therapeutic or preventive action? This incomplete list of questions indicates just how complex. (shrink)

Purpose Medical students receive a varying amount of training in medical ethics and are expected to navigate clinical ethical dilemmas innately. There is little literature on attempts to navigate ethical dilemmas experienced during early clinical experiences and whether current curricula prepare students for these dilemmas. This study explores the different ethical dilemmas experienced by medical students on their third-year clerkships and analyzes the factors, sources, and resolutions proposed by them.Methods From 2016 to 2018, third-year medical students completed a written assignment (...) to describe, analyze, and reflect on a clinical situation in which they experienced an ethical dilemma. They identified specific ethical dilemmas present, potential preventative and aftermath solutions, and reflected on their professional development from their experience. The research team utilized applied thematic analysis to identify themes and patterns in the data. A thematic matrix was utilized to examine similarities and differences across medical students.Results Of the 162 reflections, 144 (88.9%) students indicated an ethical dilemma that included issues related to autonomy and beneficence. Of these, 116 (71.6%) students found the two ethical principles in direct conflict. Students identified three common sources of this conflict: lack of communication; unclear understanding of clinical policies regarding family authority and psychiatric capacity; and medical negligence. Lastly, students suggested different solutions for dealing with and preventing this conflict.Conclusion Our findings suggest that an overwhelming number of students face ethical challenges when confronted with medical situations that raise conflicts between autonomy and beneficence. Their recommended solutions reveal an appeal among students to have tools and strategies in place to ease the need to make difficult decisions. Medical students might be better served by learning about the complexities of ethical decision-making and the likelihood of experiencing moral distress when they feel an inability to implement what they envision as the best solution. (shrink)

A physician says, "I have an ethical obligation never to cause the death of a patient," another responds, "My ethical obligation is to relieve pain even if the patient dies." The current argument over the role of physicians in assisting patients to die constantly refers to the ethical duties of the profession. References to the Hippocratic Oath are often heard. Many modern problems, from assisted suicide to accessible health care, raise questions about the traditional ethics of medicine and the medical (...) profession. However, few know what the traditional ethics are and how they came into being. This book provides a brief tour of the complex story of medical ethics evolved over centuries in both Western and Eastern culture. It sets this story in the social and cultural contexts in which the work of healing was practiced and suggests that, behind the many different perceptions about the ethical duties of physicians, certain themes appear constantly, and may be relevant to modern debates. The book begins with the Hippocratic medicine of ancient Greece, moves through the Middle Ages, Renaissance and Enlightenment in Europe, and the long history of Indian and Chinese medicine, ending as the problems raised modern medical science and technology challenge the settled ethics of the long tradition. (shrink)

In this article, we focus on the definition and application of the sliding scale of capacity. We show that the current interpretations of the sliding scale confound distinct features of the medical decision, such as its urgency, its severity, or its complexity, that do not always covary.We propose that the threshold for assessing capacity should be adjusted based solely on the cognitive complexity of the decision at hand. We further suggest that the complexity of a decision should (...) be identified based on a patient’s particular cognitive deficits. We utilize the current research on the types of deficits that characterize amnestic dementias and examine which types of medical decisions might be most complex for patients with that type of dementia. We conclude that applying the sliding scale based on individualized judgments of cognitive complexity will improve accuracy of assessment of capacity and enable capable patients to participate in medical decision making. (shrink)

As medical technology has advanced, the question of medical futility has become a topic of intense debate both within the medical community and within society as a whole. However, a unanimous definition thereof is yet to be decided—some commentators are sceptical as to whether an agreement will ever be reached—and this continues to lead to difficulties, tension, and even legal action when a treating physician disagrees with a patient and/or a patient’s family regarding care and treatment options. Although living in (...) a pluralistic society presents one of the major reasons as to why, despite 30 years of intense discussion, no consensus has been made; the issue of medical futility will always be complex as it is, by nature, multifaceted, and numerous elements—including possible risks, evidence of the probability of benefit, the wishes of the patient (and family), professional standards, and cost—interact. Nevertheless, the global medical community has seen the development of two distinctly different approaches to medical futility: one in which the autonomy of patients is of paramount importance in the decision whether or not to pursue a treatment; and one in which beneficence and primum non nocere—first do no harm—are almost entirely the clinician’s prerogative, and whereby he/she has a duty to refuse any treatment for which the potential risks outweigh the potential benefits for the patient. Recently, however, there has been a rejection of this dichotomous view of medical futility and the apparent “power struggle” between physician and patient, and a positive movement towards a more collaborative decision-making process that highlights the necessity of communication, aiming to result in the obtainment of the best possible outcome for each patient as an individual. (shrink)

Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between “medical” and “social” egg freezing —contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the “regulatory boundary-work” around the “medical”–”social” distinction in different egg freezing regulations. Based on systematic documents’ analysis we present a cross-national comparison of the way the “medical”–”social” differentiation finds expression in regulatory frameworks (...) in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: the definition of MEF and its distinctiveness—highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it ; and hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between “medical” and “social” are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects. (shrink)

Medically unexplained symptoms (MUS) remain recalcitrant to the medical profession, proving less suitable for homogenic treatment with respect to their aetiology, taxonomy and diagnosis. While the majority of existing medical research methods are designed for large scale population data and sufficiently homogenous groups, MUS are characterised by their heterogenic and complex nature. As a result, MUS seem to resist medical scrutiny in a way that other conditions do not. This paper approaches the problem of MUS from a philosophical point of (...) view. The aim is to first consider the epistemological problem of MUS in a wider ontological and phenomenological context, particularly in relation to causation. Second, the paper links current medical practice to certain ontological assumptions. Finally, the outlines of an alternative ontology of causation are offered which place characteristic features of MUS, such as genuine complexity, context-sensitivity, holism and medical uniqueness at the centre of any causal set-up, and not only for MUS. This alternative ontology provides a framework in which to better understand complex medical conditions in relation to both their nature and their associated research activity. (shrink)

... and the baby has a large VSD. Otherwise appears well, gaining weight, smiling. No apnea, never been on ventilator. Local cardiac surgeon refused to operate, saying that surgery would be inappropriate. Have reached out to other centers, and some state that they never perform what they said was “futile” heart surgery on children with Trisomy 18, while other sites say they have and will continue to perform these operations. Can someone explain to me what is going on? In the (...) realm of medical care—given enough patients, clinicians, and time—conflict is inevitable. Someone will want to do something, such as give a drug or start a new form of technologic support, and someone else will think that this is a... (shrink)