BMC Medical Ethics最新文献

Background: During the COVID-19 pandemic, virtual visiting technologies were rapidly integrated into the care offered by intensive care units (ICUs) in the UK and across the globe. Today, these technologies offer a necessary adjunct to in-person visits for those with ICU access limited by geography, work/caregiving commitments, or frailty. However, few empirical studies explore the ethical issues associated with virtual visiting. This study aimed to explore the anticipated or unanticipated ethical issues raised by using virtual visiting in the ICU, such that healthcare professionals can be informed about how to carry out virtual visits ethically, safely and productively.

Methods: We used a descriptive exploratory qualitative research approach recruiting a convenience sample of newly-graduated junior doctors facilitating ICU virtual visits in a tertiary academic centre. Eight newly graduated junior doctors, seven female and one male, aged 23-27, participated in semi-structured interviews. We analysed transcripts using an inductive coding approach.

Results: Five overarching themes emerged. Two of the themes namely, 'fulfilling a moral instinct to connect families' and 'promoting autonomy', arose from participants' descriptions of how virtual visits aligned with healthcare standards and practices they considered ethical. Three further themes, 'preserving dignity and privacy', 'managing emotional distress', and 'providing equitable access' to virtual visiting technologies, highlight how virtual visits might exacerbate ethical issues related to family communications.

Conclusion: Virtual visiting may potentially both ameliorate and exacerbate aspects of ethical healthcare delivery for ICU patients and family members. ICU team members should consider unique ethical considerations related to using virtual visiting. We recommend virtual communications skills training for staff and advocate for the use of easily accessible educational resources for families who wish to visit critically unwell patients remotely.

Background/objective: The act of surgery involves harming vulnerable patients with the intent that the results will improve their health and, ultimately, help the patients. Such activities will inevitably entail moral decisions, yet the ethics of surgery has only recently developed as a field of medical ethics. Within this field, it is striking how few accounts there are of actions within the operating room. The aim of this systematic review was to investigate how much of the scientific publications on surgical ethics focus on what take place inside the operating room and to explore the ethical issues included in the publications that focus on medical ethics in the operating room.

Methods: We conducted a systematic search of the Medline and Embase databases using a PICO model and the search terms "surgery", "ethics" and "operating room". Papers were included if they focused on doctors, entailed activities inside the operating room and contained some ethical analysis. Thematic synthesis was used for data extraction and analysis.

Findings: Fewer than 2% of the scientific publications on surgical ethics included activities inside the operating room. A total of 108 studies were included in the full-text analysis and reported according to the RESERVE guidelines. Eight content areas covered 2/3 of the included papers: DNR orders in the OR, overlapping surgery, donation of organs, broadcasting live surgery, video recordings in the OR, communication/teamwork, implementing new surgical technology, and denying blood to Jehovah's Witness.

Discussion/conclusions: This systematic review indicates that only a small fraction of scientific publications on the ethics of surgery focus on issues inside the operating room, accentuating the need for further research to close this gap. The ethical issues that repeatedly arose in the included papers included the meaning of patient autonomy inside the operating room, the consequences of technological advances in surgery, the balancing of legitimate interests, the dehumanising potential of the OR, and the strong notion of surgeon responsibility.

Background: Clinical Ethics Consultations (CECs) are used by healthcare systems to offer healthcare practitioners a structured level of support to approach ethical questions. The objective of this study was to detail the elements of surveyed CECs and offer guidance in the approach to future ethics consultations at a regional healthcare system.

Methods: This cohort study has a qualitative and quantitative retrospective approach, surveying ethics consultations through the dates of 4/27/22 to 4/26/24. A documentary sheet was created, and information was entered via online data-gathering forms. The cases are from a range of specialties within a regional healthcare system servicing Minnesota, Wisconsin, and North Dakota.

Results: 103 CECs were performed within the study period across the regional healthcare system. Consultations were identified through retrospective review of the internal CEC database, and patient information was collected through the medical record. Decision-making was often performed by a substitute decision-maker (N = 54), occurring in 70.1% of cases with known decision makers. CECs were documented in an ethics-specific note in the patient medical record in 37 of 82 (45.1%) documented patient cases. It was common for physicians to mention the ethics consultation in their patient notes, occuring in 51 of 82 (62.2%) of documented patient cases. Age was recorded in 92.0% (N = 91) of unique patient cases; the median age was 62 years. Ethical questions concerning end-of-life care were the most common cause for consultation (N = 35, 34%), and CECs were most commonly requested in general medicine or hospitalist departments (N = 38, 45.2%). Most consultations resulted in resolution at time of initial consultation with the ethics call team.

Conclusions: Recommendations for increased frequency and timing of policy review are given based on the results of the data presented. Using interpretation of the CECs in this study, we offer recommendations towards the use and documentation of ethics consultations in the era of open notes, open the door towards areas of future research, and ultimately promote use of CECs for more favorable patient outcomes.

This paper explores public perceptions of the Hippocratic Oath (Physician's Oath) in the U.K. Results of a questionnaire administered online to 106 adults indicated that the majority were of the opinion that their primary and secondary health care doctors had taken the Oath (88% and 86% respectively). A majority thought that nurses, paramedics, psychotherapists and graduate scientists and researchers should also take some form of professional oath. Elements of the Oath which were deemed most important included that it is a sworn oath, that doctors should not harm patients, act in the best interests of patients, abide by the principles of autonomy and informed consent and maintain patient confidentiality. A significant proportion - about 20% - of the UK public felt that doctors had forgotten their Hippocratic Oath during COVID-19 lockdowns and associated vaccination programme, suggesting that recent history may have damaged the public faith in the medical profession.

Background: There is limited information on the ethical issues encountered in living donor organ transplants performed on refugees and asylum seekers. This study investigates the ethical challenges faced by Syrian refugees under temporary protection in Türkiye who engage in living donor organ transplants.

Methods: From April to July 2022 in Istanbul, the research employed a qualitative design involving semi-structured, in-depth interviews with 27 participants, including organ donors and recipients. The analysis utilized a thematic analytic method.

Results: The findings elucidate two principal themes related to ethical concerns: justice and autonomy. Under the justice theme, several sub-themes emerged, highlighting the multifaceted challenges Syrian refugees face in accessing healthcare services. These include migration and language barriers, significantly impeding their ability to understand medical procedures and rights. Financial difficulties and restricted movement within the country further complicate their access to necessary healthcare. Despite these hurdles, refugees benefit from free access to organ transplantation services and medications, a policy underscoring Türkiye's commitment to healthcare equity for protected populations. The autonomy theme addresses the ethical handling of donor consent and motivation. The results indicate that Syrian refugees undergo a transplantation process free from coercion, with rigorous oversight by organ transplant ethics committees ensuring the prevention of donor abuse. However, despite these protective measures, challenges persist in the informed consent process, primarily due to language barriers that hinder effective communication between healthcare providers and patients. While the efforts of healthcare professionals to assist are recognized as alleviating some difficulties, the broader issues of access to comprehensive health services remain a significant concern. These barriers suggest a need for enhanced linguistic and financial support to improve healthcare accessibility for refugees.

Conclusions: This study posits that the healthcare framework provided by Türkiye to Syrians under temporary protection can serve as a model for international human rights and social justice. However, it also emphasizes the importance of addressing the persistent obstacles that limit healthcare access for asylum seekers. Recommendations for policy enhancements focus on improving language services, increasing financial support, and expanding the accessibility of comprehensive health services to ensure equitable health outcomes for refugees.

Background: The differences in clinical bioethics between the Mediterranean and Latin American cultures have not been analyzed. The objective of the study is to compare the ethical conflicts that internists in Spain, Mexico and Argentina have.

Methods: Cross-sectional observational study through a survey directed at internists from Spain, Argentina and Mexico. The survey was administered to affiliated members of the National Societies of Internal Medicine across three countries via an online platform.

Results: 762 internists participated, 261 from Spain, 154 from Argentina and 347 from Mexico. The main ethical conflicts that internists in Spain, Argentina and Mexico have are related (in order) to the end of life, to the clinical relationship and to the patient's autonomy. Withholding and withdrawing life-sustaining treatment is the most frequent conflict in Spain and Argentina and the second in Mexico.

Conclusions: Internists from Spain and Argentina identify very similar ethical conflicts. Furthermore, they consider them more frequent and difficult than in Mexico. In Argentina they are less satisfied with the way they are resolved. To explain these differences, socio-cultural factors are postulated, among others: paternalism, individualism, masculinity, organization of the health system, formal training in bioethics and assessment of death.

Background: The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices.

Methods: Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software.

Results: Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines.

Conclusion: To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges.

Background: Financial relationships between clinical guideline authors and pharmaceutical companies introduce conflicts of interest (COI), potentially biasing guideline recommendations. Thus, proper management of COI is paramount for clinical guideline authors. Nevertheless, little is known about COI among neurology clinical guideline authors. This study aimed to evaluate the financial relationships between pharmaceutical companies and authors of Clinical Practice Guideline for Headache Disorders (CPGHD) in Japan.

Methods: This is a retrospective analysis of 2016-2020 personal payments data disclosed by all pharmaceutical companies affiliated with the Japan Pharmaceutical Manufacturers Association. We examined amounts and fraction of personal payments to all 57 CPGHD authors and all neurologists board-certified by the Japanese Society of Neurology. Payment data was descriptively analyzed at individual author level.

Results: Among 57 CPGHD authors, 56 (98.3%) received personal payments totaling $2.7 million from pharmaceutical companies between 2016 and 2020. Median five-year payments were $89,955 for CPGHD authors, while $521 for board-certified neurologists. The CPGHD chairperson and vice chairperson received substantial payments during the guideline development period. Nevertheless, because of less rigorous and transparent COI policy compared to international standard policies, only 10 authors disclosed their financial relationships with the pharmaceutical companies in the guideline.

Conclusions: More than 98% of CPGHD authors received much higher personal payments from pharmaceutical companies than those to board-certified neurologists during the guideline development period in Japan.

Background: Advance Care Planning via Group Visits (ACP-GV) is a patient-centered intervention facilitated by a clinician using a group modality to promote healthcare decision-making among veterans. Participants in the group document a "Next Step" to use in planning for their future care needs. The next step may include documentation of preferences in an advance directive, discussing plans with family, or anything else to fulfill their ACP needs. This evaluation seeks to determine whether there are identifiable subgroups of group participants with differing needs prior to delivery of the ACP-GV program and, if so, to use information about the subgroups to enhance the program offered to veterans in United States Department of Veterans Affairs (VA) healthcare settings.

Methods: We conducted a secondary analysis of national data from a quality improvement evaluation. Patient- and provider-level data from administrative healthcare records for VA users in all 50 states, territories, and the District of Columbia provides data on veterans attending ACP-GV during federal fiscal years 2018-2022 (N = 26,857). Latent class analysis seeks to identify the various subgroups of veterans based on their level of ACP self-efficacy before attending ACP-GV and any demographic differences across the resulting subgroups of veterans attending ACP-GV. ACP self-efficacy is derived from seven items obtained from a participant worksheet used during the group.

Results: Analysis revealed two distinct groups of veterans, distinguishable by their pre-ACP-GV levels of one aspect of ACP self-efficacy: prior knowledge of ACP. Veterans with higher prior knowledge of ACP are associated with an identified next step focused on checking their current AD status and updating it, and veterans with lower ACP prior knowledge are associated with identifying a next step to discuss ACP more fully with family. Differences in age, sex, race, ethnicity, and marital status exist across subgroups of veterans.

Conclusion: Greater attention must be paid to ACP and veterans' prior knowledge of ACP to consistently encourage annual review and status updates.

Background: The Dutch Euthanasia law permits euthanasia in patients with advanced dementia lacking decisional capacity based on advance euthanasia directives. Nevertheless, physicians encounter difficulties assessing the criteria for due care in such cases. This study explores the perspectives of legal experts on the fulfillment of these criteria and the potential for additional legal guidance to support physicians' decision-making processes.

Methods: A qualitative study was conducted with legal experts. Two focus group sessions were conducted. The data analysis was conducted iteratively, with the data being interpreted using thematic content analysis and the framework method.

Results: Participants emphasize the importance of considering the patient's current wishes and informing them about the limitations of advance euthanasia directives. While representatives and healthcare professionals can assist in interpreting wishes, the final decision regarding euthanasia rests with the physician. The participants also discuss the challenges posed by pre-recorded wishes due to changing preferences. Furthermore, they present different views on the value of life wishes of patients with advanced dementia. While some participants prioritize life wishes over advance euthanasia directives, others question whether such expressions still reflect their will. Participants find it essential to assess unbearable suffering in the context of the current situation. Participants acknowledge the necessity to interpret advance euthanasia directives but also current expressions and they entrust this interpretation to physicians, viewing them as the primary authority, despite consulting multiple sources.

Conclusions: The Dutch Euthanasia law's due care criteria are open norms -which are open in substance and require further elaboration, mostly determined on a case-by-case basis to the field standards of the profession-, placing the responsibility on physicians to interpret advance euthanasia directives and patient expressions. Despite potential support from various sources of information, there is limited additional legal guidance available to assist physicians in making decisions.