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PubMed2004

The varying ethical attitudes towards resuscitation in Europe.

OBJECTIVE: This study was conducted to assess the varying attitudes in Europe towards ethical aspects of resuscitation in Europe. METHOD: The ethics of resuscitation is a key discussion topic in the European Resuscitation Council Advanced Life Support (ALS) course. A questionnaire was sent to all leading ALS course directors in 20 European countries. All completed the questionnaire. The results were compiled in March 2004. Views were sought on the following ethical aspects:When not to attempt resuscitation Active euthanasia When to abandon resuscitation efforts The diagnosis of death by non physicians Permission for relatives to be with the patient during resuscitation if they wish Teaching on the recently dead Breaking bad news Results: The results reveal a considerable variation in the interpretation of ethical dilemmas within European countries. It is interesting to note that the results do not necessarily conform to traditional beliefs in the characteristic differences between Northern and Southern Europe. The Mediterranean countries do not all have the same attitudes, any more than the Nordic or Central European countries share the same views. CONCLUSIONS: There remains a widespread divergence of views on ethical aspects of resuscitation with the countries of Europe that are largely unpredictable according to commonly perceived national characteristics. The trend over the past 6 years is towards a more permissive attitude. For many ethical questions there can be no clear and correct didactic answers.

Attitude of Health Personnel↗
PubMed2004

Participatory action research: considerations for ethical review.

This paper addresses the distinctive nature of participatory action research (PAR) in relation to ethical review requirements. As a framework for conducting research and reducing health disparities, PAR is gaining increased attention in community and public health research. As a result, PAR researchers and members of Research Ethics Boards could benefit from an increased understanding of the array of ethical concerns that can arise. We discuss these concerns in light of commonly held ethical requirements for clinical research (social or scientific value, scientific validity, fair subject/participant selection, favourable risk-benefit ratio, independent review, informed consent, and respect for potential and enrolled participants) and refer to guidelines specifically developed for participatory research in health promotion. We draw from our community-based experiences in mental health promotion research with immigrant and culturally diverse youth to illustrate the ethical advantages and challenges of applying a PAR approach. We conclude with process suggestions for Research Ethics Boards.

Community Mental Health Services↗
PubMed2005

The ethics of living donor lung transplantation.

A constant awareness of the risk to the living donors must be maintained with any living donor organ transplantation program, and comprehensive short- and long-term follow-up should be strongly encouraged to maintain the viability of these potentially life-saving procedures. There has been no perioperative or long-term mortality following lobectomy for living lobar lung transplantation, and perioperative risks associated with donor lobectomy seem to be similar to those seen with standard lung resections. These risks might increase, however, if the procedure is offered on an occasional basis and not within a well-established program. The long-term outcomes and functional effects of lobar donation raise important questions that are unanswered. This has proved difficult to follow closely, because of the fact that many donors live far from the transplant medical center and are reluctant to return for routine follow-up evaluation. The death of a recipient can further exacerbate this situation, because there is reluctance to insist on further routine examinations for a grieving donor. Prospective donors must be informed of the morbidity associated with lobectomy and the potential for mortality, and for potential negative recipient outcomes in regard to life expectancy and quality of life after transplantation. Although cadaveric transplantation must be considered because of the risk to the donors, living lobar lung transplantation should continue to be used under properly selected circumstances. The results reported by the authors' group and others are important if this procedure is to be considered as an option at more pulmonary transplant centers in view of the institutional, regional, and international differences in the philosophic and ethical acceptance of the use of living organ donors for transplantation. The integration of ethical discussion into topics that are relevant and of interest to thoracic surgeons, such as living lung donation, is a recent and welcome event. Many of the clinical situations that thoracic surgeons deal with on a daily basis have important and complex ethical implications, and there has been little training to deal effectively with these issues. This is changing as invited discussions on ethically compelling topics are finding their way into journals and the programs of national meetings. What may be of more importance, however, is the development of an ethics curriculum for those training in the specialty. The core curriculum recommended by the Thoracic Surgical Directors Association (which represents the leadership of the 89 approved residency training programs in the United States) has one lecture pertaining to ethics out of the several hundred offerings in its requisite curriculum. It is hoped that this will change in the near future.

Ethics, Clinical↗
PubMed2005

Compliance with HIPAA regulations: ethics and excesses.

HIPAA regulations have been seen by many physicians as providing innumerable administrative hoops that require jumping through with no clear benefit for individual patients. Although this article has not comprehensively explored the requirements of HIPAA regulations, it has focused on the issues of "incidental disclosures" that are so important to the daily interactions of physicians and patients. Through the use of illustrative cases, it has been shown that HIPAA regulations frequently are based on well-accepted ethical principles. Although one should never conclude that changing something from an ethical responsibility to a legal responsibility makes it more important, there is no question that HIPAA regulations have forced physicians to consider more carefully how confidential information may be transmitted to others. As such, physicians should look on HIPAA regulations as largely supporting the use of professional judgment in providing good quality medical care. Although not all aspects of HIPAA are grounded in ethical practices, the overall thrust of the HIPAA regulations is consistent with the ethical practice of medicine and surgery. As a result of this general alignment of the legal and ethical requirements, more attention should be directed by physicians at using good judgment in deciding how to disclose private information, rather than adopting an unreasonable approach that confidentiality may never be breached. As Lo and colleagues have very appropriately pointed out: In the context of inadvertent disclosure, the legal risks of good practice are very low. Physicians should work with risk managers and practice administrators to develop policies that promote good communication in patient care, while taking appropriate steps to protect patient privacy. By adopting such an approach to HIPAA, physicians can abide by the regulations while maintaining high ethical standards and minimizing the impact of the new requirements on physician-patient relationships.

Ethics, Clinical↗
PubMedDate not supplied

[Ethical foundations of institutional psychotherapy].

HISTORICAL ASPECTS: The idea behind this work is to have an ethical examination of the institutional psychotherapy movement which has long influenced French public psychiatry and which has progressively, since the 80s, been subject to growing doubts. In the first part, institutional psychotherapy is presented. It is a model for theoretical development and practice in psychiatric care. It came into being just following the end of the Second World War at the same time as modern medical ethics. Its principles come on the one hand, from recognition of asylums' pathogenic effects--which led to the crushing of the patient's being--and on the other, through recognition of the uniqueness of each person and the subjectivity of mental suffering. These elements gave rise to creativity within the world of medicine and, in the sector, generated the science of psychiatry which advocated for continuity in care (both inpatient and outpatient) and preventive work directed at the population. This movement called for the use of the institution in its dynamic aspect which promotes exchanges and allows patients to situate or resituate themselves in historic and symbolic dimensions. It privileges a high level of transversality, maximum communication, favouring speaking out loud and responsibility. It requires a permanent analysis of the institutional counter transference (emotional reactions of the caregivers involved, their interrelations and the social and material organization of the institution) which determines the therapeutic action itself. THEORICAL BASIS: In a second part, its theoretical foundations and its practice shall be investigated in light of the guiding concepts of medical ethics (justice, autonomy, beneficence, non-malfeasance). Institutional psychotherapy responds to the need for justice by considering the patient as a whole and by conceiving each patient as being like oneself despite the differences (associated with the mode of hospitalization, the social or diagnostic category). The principle of autonomy lies always at care's horizon, made concrete in practice by notions of habitability, orientation to place and time, references, by activities and by meetings. The principle of beneficence was the basis for round-the-clock intakes, the use of an established theoretical model and clinical practice centred on the patient's words. Institutional analysis attempts not to repeat the alienation felt by the patient, alienation being associated with the treatment environment, and draws from the principle of non-malfeasance. It therefore appears that the approach of institutional psychotherapy conforms with ethical requirements, given its major interest in the subject who aspires to find meaning in life. CURRENT SITUATION: The third part discusses current orientations in care related to the explosion in neuroscience and technology, the promotion of the citizen as an individual, and legal doctrine, budgetary constraints, and new demands made on psychiatry from the social and political domains. The widespread trend towards simplification, swollen with hypotheses from neuroscientific research, is progressively reducing mental illness to target symptoms. The recovery of the notion of citizenship through technological capture and ideological strains in contemporary culture have also affected a suspension of the subject as a thinking and desiring being, and exempted caregivers from considering transferral phenomena, indicated with the appearance of new signifiers: user, stress, plague, network. The new medical-technical jargon of scales, tables, and management participates in the same process of patient objectification and care compartmentalization. In this context, under the cover of science and generally good actions, psychiatry has become biologisized, whilst being diluted from its social aspect, even as it becomes more repressive for patients. CONCLUSION: This observation leads to the conclusion, in the fourth part, that there is a need for psychiatry, which within its own discipline has a hard time finding sufficient resources, to refocus itself ethically. This enlightenment could come within a multi-disciplinary ethical space, uniting practitioners and psychiatric caregivers, psychoanalysts, philosophers, sociologists, neurobiologists etc. The research should concern the legitimacy of the principles that underlie psychiatric action in its care and preventive aspects.

Ethics, Clinical↗
PubMed1998

Ethical issues in publication of research.

We often think of research ethics mostly in connection with the processes of intervention, data collection, and analysis, but ethics does not stop there. The process of preparing publications involves a number of ethical considerations, including continued protection of the rights of human subjects; reporting findings truthfully, accurately, and completely and using one's own words to do so, or appropriately citing the work of others; and ensuring that authorship credit and acknowledgments accurately reflect the contributions of others. No foolproof way exists to ensure that only ethical publications see print; however, including content on publication ethics in all research courses, publishing clear policies related to ethical expectations in journals, and engaging in discussion of these issues with colleagues are a good start toward that goal.

Clinical Nursing Research↗
PubMed1998

A survey of the ethical considerations in randomised trials for lung cancer.

BACKGROUND: In order to promote a more productive debate on the ethics of randomised clinical trials (RCTs), we present a survey on the ethical aspects of published RCTs for lung cancer. METHODS: Data from 92 published reports of RCTs for lung cancer, as identified from the Cancerlit 1993-1995 database were supplemented by a questionnaire mailed to the authors of those publications. The analysis focused on respect of autonomy, non-maleficence, beneficence, and justice as the ethical principles applicable to society, patients in trials, patients not included in RCTs and physicians. ETHICAL ANALYSIS: The benefits to society include an objective evaluation of new treatments. The principle of autonomy was often violated for patients who were inadequately informed about the disease or about RCT. In some trials with prolonged recruitment, the principle of non-maleficence was not fully respected since patients continued to be randomised in spite of an obvious advantage of one of the treatments. When compared to those not included in a trial, patients in RCTs were reported to benefit from more precise standards, superior quality assurance of diagnostic and therapeutic procedures, more attention from the physician, easier appointments and easier access to hospitalisation. However, these benefits diminish patients' autonomy and lead to injustice towards patients not included in the trials. While benefits to physicians were usually modest and in proportion to their contribution, an influence upon their autonomy cannot be excluded. CONCLUSION: More attention to the aforementioned ethical caveats of RCTs should alleviate the ethical costs and might also bring more patients into future trials.

Ethics, Medical↗
PubMed2002

Implications of organizational ethics to healthcare.

Organizational ethics is an emerging field concerned with the study and practice of the ethical behaviour of organizations. For effective application to healthcare settings, we argue that organizational ethics requires attention to organizations' special characteristics combined with tools borrowed from the fields of business ethics and bioethics. We identify and discuss several implications of this burgeoning field to healthcare organizations, showing how organizational ethics can facilitate policy making, accountability, self-evaluation, and patient and business perspectives. In our conclusion, we suggest an action plan for healthcare organizations to help them respond appropriately to their ethical responsibilities.

Decision Making, Organizational↗
PubMed2003

The ethics of end-of-life decisions in the elderly: deliberations from the ECOPE study.

Is age a factor underlying clinical decision-making? Should age be a criterion in the allocation of health care resources? Is it correct to criticize this approach as 'ageism'? What role does 'paternalism' play? These questions are the focus of this chapter which takes an interdisciplinary perspective of clinical ethics in order to provide an ethical evaluation of the situation of the elderly in health care. First, the text of the chapter is based on the descriptive level referring to (a) clinical ethics consultation, (b) the ECOPE study on 'Ethical Conditions of Passive Euthanasia' focusing on decision-making, and studies about age as a factor in clinical decisions, such as the American SUPPORT study. Second, at the normative level, ethical deliberations are discussed for and against age as a criterion for allocating health care resources. Finally, it is suggested that the differences in evidence to be found about the role of age as a factor in clinical decision-making may be due to the different national health policies as well as to the insufficient awareness of ethical principles violated by covert 'ageist' attitudes.

Age Factors↗
PubMed2005

Is an interdisciplinary session on ethics and law in obstetrics and gynaecology effective?

OBJECTIVE: To evaluate the effects of an interdisciplinary session on medical ethics and legal issues related to obstetrics and gynaecology on medical students' knowledge, attitudes, and behaviours. METHODS: Second-year medical students at the University of Alberta were asked to complete surveys before and after an interdisciplinary panel session on ethics and legal issues in reproductive health. Survey questions were related to knowledge of ethics and law, attitudes toward controversial topics in reproductive health, and predicted behaviours in specific clinical scenarios. In the postsession survey, students were asked to evaluate the session's usefulness and impact. RESULTS: Fifty-seven students completed both the pre- and postsession surveys. Most students listed family, religion, culture, peer groups, scientific thought and theory, and school and education as influences on their own personal ethics and morality. Fifty-five students (97%) stated that the panel session was useful. Most students (79%) reported that the session increased their knowledge of ethical and legal issues in reproductive health. Many students felt that the panel session would change the way they practise in similar clinical situations (63%). The panel session appeared to affect knowledge and predicted behaviour. CONCLUSION: A large-group interdisciplinary panel session can influence medical students' knowledge and future behaviours related to ethics and law in obstetrics and gynaecology. Medical students gave this session a high rating.

Adult↗
PubMed2004

Physicians' practices related to the use of terminal sedation: moral and ethical concerns.

OBJECTIVE: Although terminal sedation (TS) has generally been seen as legal and ethically acceptable, ethical and moral issues remain. Little is known about the use of TS in general clinical practice and about how TS is viewed by physicians, given moral and ethical concerns. The objectives of this study are (1) to describe attitudes of physicians regarding terminal sedation; (2) to explore demographic characteristics, such as age, gender, subspecialty, and number of years in practice, that might be related to the use of TS; and (3) to compare physicians who have and have not used TS on the degree to which they view TS as moral and consistent with their professional and personal ethics. METHODS: An anonymous survey of New Jersey physicians was conducted at the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine. A 39-item questionnaire assessing general opinions about, experiences with, and religious, moral, ethical attitudes toward TS and other end-of-life treatments was utilized. RESULTS: A majority of physicians (73%) had used TS for a patient. Most (93%) said there were circumstances under which they would use TS. With regard to questions about whether TS would be "immoral," "would violate my religious beliefs," "would violate my professional ethics" and "is inconsistent with the physician's role of preserving life," approximately 55% of those who have used TS disagreed; for those who have not used TS, approximately 35% disagreed. SIGNIFICANCE OF RESULTS: Professional education and opportunities for discussion appear necessary to help reconcile the conflicts raised in the use of this end-of-life treatment strategy.

Adult↗
PubMed1997

Ethical issues in community mental health: cases and conflicts.

Ethical issues pervade community mental health yet, surprisingly, the field has been virtually ignored in the academic realm of medical ethics. In the past decade, the ethical questions in psychiatry which have attracted the most scrutiny are derived from the "dramatic" issues of psychiatrist-patient sexual relationships, the tradition's practice of involuntary commitment, and the therapist's duty to warn potential victims at the expense of breaching a client's confidentiality (Eth, 1990; Dyer, 1988; Bloch, Chodoff, 1991). Yet the "pragmatic," and more pervasive, ethical tensions which arise in the daily practice of community psychiatrists have warranted little attention. Both medical ethics and community psychiatry suffer as a result. Nonetheless, ethical reasoning is intricately entwined in the decisions and relationships which make up the community mental health setting. For example, trying to determine what is the "right" thing to do for a client inevitably entails judgments about moral, social and legal matters. In other words, no decision in the clinical setting is purely psychiatric (Perlin, 1989).

Commitment of Persons with Psychiatric Disorders↗
PubMed2002

Ethical issues in geriatric medicine: a unique problematic?

It is commonly believed that geriatric medicine generates a distinctive set of ethical problems. Implicated are such issues as resource allocation, competence and consent, advance directives, medical futility and deliberate death. It is also argued that it would be unjust to allow the elderly to compete with younger populations for expensive and scarce healthcare resources because the elderly "have already lived," and that treating them the same as these other populations would diminish the available resources unfairly, prolong a life of inevitably failing health and result in increased health care expenditures. In fact, however, this perception of ethical uniqueness is mistaken. Differences in medical conditions, demographics and aetiology should not be allowed to obscure the fact that ethical issues in geriatric medicine are essentially the same as those faced in any other area of health care, and that the solutions that are adopted in the geriatric context must be consistent with the ethical principles that are followed elsewhere. The paper argues that the root of the mistaken perception lies in the abandonment of the Hippocratic mandate of medicine and in an unreflective adherence to the belief that medical advances are inevitably beneficial. It is suggested that a return to patient-centred medicine and the use of ethics impact analyses before introducing medical advances may be ethically appropriate.

Aged↗
PubMed1991

Ethics, an emerging subdiscipline of obstetric ultrasound, and its relevance to the routine obstetric scan.

Ethics is an emerging subdiscipline of obstetric ultrasound because there are clinical dimensions of obstetric ultrasound that only ethics can identify and address. These dimensions concern the ethical obligations of physicians to their patients. Ethics is defined as the disciplined study of morality. Two fundamental principles of ethics are described, beneficence and respect for autonomy. How ethics can bring to light clinical dimensions of obstetric ultrasound that are insufficiently appreciated is illustrated with the example of the routine use of obstetric ultrasound in the second trimester. The authors conclude that prenatal informed consent for sonogram should be an integral part of obstetric care in countries, such as the United States, in which routine ultrasound is not endorsed.

Beneficence↗
PubMed2003

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses.

Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.

Adaptation, Psychological↗
PubMed2001

Virtue ethics in a pluralistic world.

The practice of pediatric surgery is at the crossroads of 2 specialties, pediatrics and surgery. At that vantage point, many ethical dilemmas can be seen. It is important for the pediatric surgeon to understand the special place of ethics in the care of children and how that care is influenced by society. The purpose of this report is to introduce the perspective of virtue ethics as an avenue to problem solving in ethical dilemmas in pediatric surgery. Virtue ethics relies more on the physician-focused view of character and ideal behavior as opposed to more patient-based rules of action. This ethical theory must be placed on the background of our changing society with an increasing plurality of values. The medical community of pediatric surgery must remain involved in the dialogue concerning these dilemmas in the care of children.

Attitude of Health Personnel↗
PubMed2001

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

Journal Article↗
PubMed2002

Introduction of contextual legal issues in an interdisciplinary program for the study of ethical dilemmas in obstetrics and gynecology for third-year medical students.

OBJECTIVE: To introduce contextual legal issues, and the role of law in resolving ethical dilemmas, in a women's health ethics curriculum for third-year medical students. METHODS: Seventeen third-year medical students at Emory University School of Medicine, rotating on an 8-week obstetrics and gynecology clerkship, and 8 third-year law students from the Georgia State University College of Law attended four 1-hour ethics sessions conducted by an obstetrician and gynecologist, a law professor and an ethics fellow. Each student group completed a short survey to evaluate the effectiveness of the sessions. RESULTS: The overwhelming majority, 20 of 25 (80%) of the combined student group ranked the sessions a level 6 or 7 (the highest level) and suggested continuation of the interdisciplinary group format. The majority of the combined student group, 14 of 25 (56%), also viewed the multidisciplinary nature of the group as the most helpful aspect of the sessions. For the medical students, additional helpful aspects included having the legal perspective from persons who actually study the law. For the law students, other helpful aspects included the informal roundtable discussion format and the structured 4-quadrant model. CONCLUSION: Incorporation of medical and law students into a discussion group for resolving ethical dilemmas is a satisfying method for discussion of legal issues in the women's health ethics curriculum. It enriches the understanding of students from both disciplines.

Attitude of Health Personnel↗