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PubMed1993

How to critically evaluate positions on obstetric ethics.

We identify three tools for the critical evaluation of positions on obstetric ethics. The first is the distinction between descriptive and normative obstetric ethics. The second comprises the "Six Cs" of rigorous ethical analysis and argument: clarity, consistency, coherence, clinical applicability, clinical adequacy and completeness. The third is the avoidance of pitfalls that might arise from failing to acknowledge the inherent limitations of fields that contribute to normative obstetric ethics: law, region, professional consensus, uses of authority and philosophy.

Bioethical Issues↗
PubMed2006

Cluster randomized controlled trials in primary care: an introduction.

BACKGROUND: Cluster randomized trials occur when groups or clusters of individuals, rather than the individuals themselves, are randomized to intervention and control groups and outcomes are measured on individuals within those clusters. Within primary care, between 1997 and 2000, there has been a virtual doubling in the number of published cluster randomized trials. A recent systematic review, specifically within primary care, found study quality to be both generally lower than that reported elsewhere and not to have shown any recent quality improvement. OBJECTIVE: To discuss the design, conduct and analysis of cluster randomized trials within primary care in terms of the appropriate expertise required, potential bias, ethical considerations and expense. DISCUSSION: Compared with trials that involve the randomization of individual participants, cluster randomized trials are more complex to design and analyse and, for a given sample size, have decreased power and a broadening of confidence intervals. Cluster randomized trials are specifically prone to potential bias at two levels-the cluster and individual. Regarding the former, it is recommended that cluster allocation be undertaken by a party independent to the research team and careful consideration be given to ensure minimal cluster attrition. Bias at the individual level can be overcome by identifying trial participants before randomization and at this time obtaining consent for intervention, data collection or both. A unique ethical aspect to cluster randomized trials is that cluster leaders may consent to the trial on behalf of potential cluster members. Additional costs of cluster randomized trials include the increased number of patients required, the complexity in their design and conduct and, usually, the need to recruit clusters de novo. CONCLUSION: Cluster randomized trials are a powerful and increasingly popular research tool. They are uniquely placed for the conduct of research within primary-care clusters where intracluster contamination can occur. Associated methodological issues are straightforward and surmountable and just need careful consideration and management.

Bias↗
PubMed2005

Current ethical dilemmas in clinical practice in Europe.

The need for clinical ethics support is increasingly recognised by clinicians and health services across Europe, and many countries already have clinical ethics committees. The range of ethical issues for which clinicians may require support is likely to show some similarity across countries, but differences in the frequency and type of ethical issue will also be seen, related to cultural, economic, and systematic differences between countries. In this paper I consider some of the common ethical issues faced by clinicians, drawing on my knowledge and experience of the UK situation, and informed by discussions with other European colleagues. I consider some specific examples to illustrate general issues, and suggest some possible areas of difference that will be important in addressing clinical ethics support in a European wide context.

Bioethical Issues↗
PubMed2001

The many faces of autonomy.

The challenge in maintaining patient autonomy regarding medical decision-making and confidentiality lies not only in control over information transferred to and regarding patients, but in the ambiguity of autonomy itself. Post-modernity is characterized by the recognition of not just numerous accounts of autonomy, but by the inability in a principled fashion to select one as canonical. Autonomy is understood as a good, a right-making condition, and an element of human flourishing. In each case, it can have a different content, depending in part on whether it is given a nomological or a volitional construal. Different accounts of autonomy can lead to strikingly different understandings of appropriate behavior, including the argument that one ought on behalf of autonomy to liberate individuals from the sense of autonomy they themselves affirm. In the face of competing accounts of moral probity, autonomy in a secular morality and bioethics must by default be understood in terms of the permission of patients, which makes space for numerous moral accounts and different communal construals of free choice, which in turn will legitimate different practices of informing patients and maintaining confidentiality.

Bioethical Issues↗