Autonomy is a concept that holds much appeal to social and legal philosophers. Within a medical context, it is often argued that it should be afforded supremacy over other concepts and interests. When respect for autonomy merely requires non-intervention, an adult’s right to refuse treatment is held at law to be absolute. This apparently simple statement of principle does not hold true in practice. This is in part because an individual must be found to be competent to make a valid (...) refusal of consent to medical treatment, and capacity to decide is not an absolute concept. But further to this, I argue that there are three relevant understandings of autonomy within our society, and each can demand in differing cases that different courses of action be followed. Judges, perhaps inadvertently, have been able to take advantage of the equivocal nature of the concept to come tacitly to decisions that reflect their own moral judgments of patients or decisions made in particular cases. The result is the inconsistent application of principle. I ask whether this is an unforeseen outcome or if it reflects a wilful disregard for equal treatment in favour of silent moral judgments in legal cases. Whatever the cause, I suggest that once this practice is seen to occur, acceptable justification of it in some cases is difficult to find. (shrink)

This essay examines the fundamental role of veterinarians in companion animal practice by developing the idea of veterinarians as strong advocates for their nonhuman animal patients. While the practitioner-patient relationship has been explored extensively in medical ethics, the relation between practitioner and animal patient has received relatively less attention in the expanding but still young field of veterinary ethics. Over recent decades, social and professional ethical perspectives on human-animal relationships have undergone major change. Today, the essential role of veterinarians is (...) not entirely clear. Furthermore, veterinarians routinely face pressure, often insidious, to refrain from pursuing their patients’ vital interests. In exploring the concept of strong patient advocacy, this essay investigates the increasingly common suggestion that veterinarians have ‘primary obligation’ and ‘first allegiance’ to their animal patients rather than to other parties, such as their clients or employers. The related concept of a fiduciary duty, which is sometimes encountered in medical ethics, is similarly explored as it applies to companion animal practice. The resultant idea of a strong patient advocate places companion animal veterinarians conceptually and ethically close to human health professionals, not least pediatricians. (shrink)

Online exam supervision technologies have recently generated significant controversy and concern. Their use is now booming due to growing demand for online courses and for off-campus assessment options amid COVID-19 lockdowns. Online proctoring technologies purport to effectively oversee students sitting online exams by using artificial intelligence systems supplemented by human invigilators. Such technologies have alarmed some students who see them as a “Big Brother-like” threat to liberty and privacy, and as potentially unfair and discriminatory. However, some universities and educators defend (...) their judicious use. Critical ethical appraisal of online proctoring technologies is overdue. This essay provides one of the first sustained moral philosophical analyses of these technologies, focusing on ethical notions of academic integrity, fairness, non-maleficence, transparency, privacy, autonomy, liberty, and trust. Most of these concepts are prominent in the new field of AI ethics, and all are relevant to education. The essay discusses these ethical issues. It also offers suggestions for educational institutions and educators interested in the technologies about the kinds of inquiries they need to make and the governance and review processes they might need to adopt to justify and remain accountable for using online proctoring technologies. The rapid and contentious rise of proctoring software provides a fruitful ethical case study of how AI is infiltrating all areas of life. The social impacts and moral consequences of this digital technology warrant ongoing scrutiny and study. (shrink)

Hymen construction and nontherapeutic male circumcision are medical nonindicated interventions that give rise to specific ethical concerns. In Europe, hymen construction is generally more contested among medical professionals than male circumcision. Yet, from a standard biomedical framework, guided by the principles of autonomy, beneficence, nonmaleficence, and justice, circumcision of boys is, as this article explains, more problematic than hymen construction. While there is a growing debate on the acceptability of infant circumcision, in the case of competent minors and adults the (...) surgery is not questioned. In the case of hymenoplasty, usually requested by a competent patient, it is recommended to only perform the operation after extensive counseling and if there are compelling conditions. The article further explores why attitudes of medical professionals toward both surgeries diverge and seeks to explain how this is largely informed by gendered and socio-cultural understandings. The arti... (shrink)

Scenarios involving the introduction of artificially intelligent (AI) assistive technologies in health care practices raise several ethical issues. In this paper, I discuss four objections to introducing AI assistive technologies in health care practices as replacements of human care. I analyse them as demands for felt care, good care, private care, and real care. I argue that although these objections cannot stand as good reasons for a general and a priori rejection of AI assistive technologies as such or as replacements (...) of human care, they demand us to clarify what is at stake, to develop more comprehensive criteria for good care, and to rethink existing practices of care. In response to these challenges, I propose a (modified) capabilities approach to care and emphasize the inherent social dimension of care. I also discuss the demand for real care by introducing the ‘Care Experience Machine’ thought experiment. I conclude that if we set the standards of care too high when evaluating the introduction of AI assistive technologies in health care, we have to reject many of our existing, low-tech health care practices. (shrink)

The use of robots in therapy for children with autism spectrum disorder raises issues concerning the ethical and social acceptability of this technology and, more generally, about human–robot interaction. However, usually philosophical papers on the ethics of human–robot-interaction do not take into account stakeholders’ views; yet it is important to involve stakeholders in order to render the research responsive to concerns within the autism and autism therapy community. To support responsible research and innovation in this field, this paper identifies a (...) range of ethical, social and therapeutic concerns, and presents and discusses the results of an exploratory survey that investigated these issues and explored stakeholders’ expectations about this kind of therapy. We conclude that although in general stakeholders approve of using robots in therapy for children with ASD, it is wise to avoid replacing therapists by robots and to develop and use robots that have what we call supervised autonomy. This is likely to create more trust among stakeholders and improve the quality of the therapy. Moreover, our research suggests that issues concerning the appearance of the robot need to be adequately dealt with by the researchers and therapists. For instance, our survey suggests that zoomorphic robots may be less problematic than robots that look too much like humans. (shrink)

When is it ethically acceptable to use artificial agents in health care? This article articulates some criteria for good care and then discusses whether machines as artificial agents that take over care tasks meet these criteria. Particular attention is paid to intuitions about the meaning of ‘care’, ‘agency’, and ‘taking over’, but also to the care process as a labour process in a modern organizational and financial-economic context. It is argued that while there is in principle no objection to using (...) machines in medicine and health care, the idea of them functioning and appearing as ‘artificial agents’ is problematic and attends us to problems in human care which were already present before visions of machine care entered the stage. It is recommended that the discussion about care machines be connected to a broader discussion about the impact of technology on human relations in the context of modernity. (shrink)

Complementary and alternative medicines (CAM) have become increasingly popular over recent decades. Within bioethics CAM has so far mostly stimulated discussions around their level of scientific evidence, or along the standard concerns of bioethics. To gain an understanding as to why CAM is so successful and what the CAM success means for health care ethics, this paper explores empirical research studies on users of CAM and the reasons for their choice. It emerges that there is a close connection to fundamental (...) principles of medical ethics. The studies also highlight that CAM’s holistic ontology of health and illness has an empowering effect on people in caring for their health, and on an even deeper level, safeguards against biomedicine’s reducing image of oneself as biological body-machine. The question is raised what lessons bioethics should draw from this emancipatory social movement for its own relationship with biomedicine. (shrink)

For trans youth, the experience of gender differs from expectations based on sex assigned at birth (Frohard-Dourlent, Dobson, Clark, Duoll, & Saewyc, 2016). To support gender health—the ability to...

Gender-affirming hormone therapy is increasingly available to support healthy development of transgender youth, but ethical concerns have been raised regarding fertility-related implications. In this article, I present data from an exploratory qualitative study of the decision-making experiences of trans youth, parents of trans youth, and healthcare providers serving trans youth related to fertility and family creation. I discuss how cisnormative and bionormative biases can impact care and contribute to ethically problematic narratives of regret. Finally, I offer recommendations to support ethically (...) sound, gender-affirmative fertility and family creation counseling with transgender youth. (shrink)

A number of Artificial Intelligence (AI) ethics frameworks have been published in the last 6 years in response to the growing concerns posed by the adoption of AI in different sectors, including healthcare. While there is a strong culture of medical ethics in healthcare applications, AI-based Healthcare Applications (AIHA) are challenging the existing ethics and regulatory frameworks. This scoping review explores how ethics frameworks have been implemented in AIHA, how these implementations have been evaluated and whether they have been successful. (...) AI specific ethics frameworks in healthcare appear to have a limited adoption and they are mostly used in conjunction with other ethics frameworks. The operationalisation of ethics frameworks is a complex endeavour with challenges at different levels: ethics principles, design, technology, organisational, and regulatory. Strategies identified in this review are proactive, contextual, technological, checklist, organisational and/or evidence-based approaches. While interdisciplinary approaches show promises, how an ethics framework is implemented in an AI-based Healthcare Application is not widely reported, and there is a need for transparency for trustworthy AI. (shrink)

The world literature shows that empirical research regarding the process of decision-making when cancer in adolescents is no longer curable has been conducted in High-income, English speaking countries. The objective of the current study was to explore in-depth and to explain the decision-making process from the perspective of Mexican oncologists, parents, and affected adolescents and to identify the ethical principles that guide such decision-making. Purposive, qualitative design based on individual, fact-to-face, semi-structured, in-depth interviews. The participants were thirteen paediatric oncologists, 13 (...) parents or primary carers, and six adolescents with incurable cancer. The participants were recruited from the paediatric oncology services of three national tertiary-care medical centres in Mexico City. The oncologists stated that they broach the subject of palliative management when they have determined that curative treatment has failed. Respect for autonomy was understood as the assent of the parent/adolescent to what the oncologist determined to be in the best interest of the adolescent. The oncologists thought that the adolescent should be involved in the decision-making. They also identified the ability to count on a palliative care clinic or service as an urgent need. For the parents, it was essential that the oncologist be truly interested in their adolescent child. The parents did not consider it necessary to inform the child about impending death. The adolescents stated that the honesty of their oncologists was important; however, several of them opted for a passive role in the decision-making process. The findings of this study evidence that to achieve good medical practice in low-middle income countries, like Mexico, it is urgent to begin effective implementation of palliative care, together with appropriate training and continuing education in the ethics of clinical practice. (shrink)

Background The world literature shows that empirical research regarding the process of decision-making when cancer in adolescents is no longer curable has been conducted in High-income, English speaking countries. The objective of the current study was to explore in-depth and to explain the decision-making process from the perspective of Mexican oncologists, parents, and affected adolescents and to identify the ethical principles that guide such decision-making. Methods Purposive, qualitative design based on individual, fact-to-face, semi-structured, in-depth interviews. The participants were thirteen paediatric (...) oncologists, 13 parents or primary carers, and six adolescents with incurable cancer. The participants were recruited from the paediatric oncology services of three national tertiary-care medical centres in Mexico City. Results The oncologists stated that they broach the subject of palliative management when they have determined that curative treatment has failed. Respect for autonomy was understood as the assent of the parent/adolescent to what the oncologist determined to be in the best interest of the adolescent. The oncologists thought that the adolescent should be involved in the decision-making. They also identified the ability to count on a palliative care clinic or service as an urgent need. For the parents, it was essential that the oncologist be truly interested in their adolescent child. The parents did not consider it necessary to inform the child about impending death. The adolescents stated that the honesty of their oncologists was important; however, several of them opted for a passive role in the decision-making process. Conclusion The findings of this study evidence that to achieve good medical practice in low-middle income countries, like Mexico, it is urgent to begin effective implementation of palliative care, together with appropriate training and continuing education in the ethics of clinical practice. (shrink)

Theoretical models for physician-patient communication in clinical practice are described in literature, but none of them seems adequate for solving the communication problem in clinical practice that emerges in case of factitious disorder. Theoretical models generally imply open communication and respect for the autonomy of the patient. In factitious disorder, the physician is confronted by lies and (self)destructive behaviour of the patient, who in one way or another tries to involve the physician in this behaviour. It is no longer controversial (...) that the physician should communicate his consideration of a factitious disorder without insistence that the patient accepts this diagnosis. However, the balance between patient autonomy and open communication on the one hand, and the preservation of the patient's health, physician integrity and of a constructive physician-patient relationship on the other is easily disrupted. In this article, an epistemological model is described to facilitate a positive outcome of confrontation in treatment of factitious disorder. Analysing the problem in terms of systems theory will help the physician to assess what information is appropriate to use in which phase of the patient's treatment, while preserving the physician-patient relationship. (shrink)

In this article, I investigate how we may include investigations of actual context in the investigation of moral problems in philosophy. The article has three main parts. The focus of the first is a survey of the dominant view of how to incorporate context into moral philosophy and to exemplify this view, I investigate examples from influential introductions to moral philosophy, identifying what I call the assumption of abstraction. In the second part I present three traditions which attribute a more (...) prominent place to context in philosophical work and which therefore offer resources for thinking about context: moral contextualism, particularism and contextualism in political philosophy. Unconvinced that these resources are sufficient for an understanding of how actual context may be of importance in philosophy, I in the third part turn to a systematic investigation of three suggestions for how to incorporate actual context onto philosophy: the application approach, the bottom-up approach and the contextual approach. Furthermore, I argue that the third and most radical approach develops a superior understanding of how to include context in moral philosophy, reflecting the impossibility of making normatively neutral investigations of context in moral philosophy. (shrink)

ZusammenfassungIn zahlreichen Ländern nimmt die Zahl von Organspenden nach Kreislaufstillstand zu, obwohl in der Medizinethik verschiedene Aspekte der DCDD kritisch diskutiert werden. In unserer Arbeit identifizieren wir ethisch relevante Aspekte der DCDD basierend auf einer umfassenden Literaturanalyse. Wir fokussieren dabei insbesondere auf zwei Aspekte: vorbereitende Maßnahmen und Irreversibilität des Todeskriteriums. Danach untersuchen wir in einer weltweit durchgeführten Auswertung von Webseiten von Organspende-Organisationen und einer begleitenden Umfrage, inwieweit diese ethisch relevanten Aspekte von DCDD in der Information potenziell spendewilliger Personen eine Rolle (...) spielen. Es zeigt sich, dass in der Mehrheit der Webseiten der Organisationen auf die Thematik DCDD nicht oder kaum eingegangen wird, die befragten Verantwortlichen der Organisationen aber die Wichtigkeit der Aufklärung bei spendewilligen Personen betonen. Wir diskutieren diese Diskrepanz und weisen auf zentrale Punkte hin, über welche spendewillige Personen informiert werden sollen, wenn diese Form der Organspende in ihrem jeweiligen Land praktiziert wird. Zudem plädieren wir dafür, dass das Todeskriterium und die Prozeduren zur Todesfeststellung in der Transplantationsmedizin einheitlich sein sollen, um kritisch diskutierte Aspekte im Kontext der DCDD entschärfen zu können. (shrink)

Alcohol use has been recognized as a challenge in eldercare and social care, and some anticipate that problems related to alcohol use will increase in the future as the current adult generation has high alcohol consumption rates. Accordingly, it is suggested that care workers are at risk of becoming passive bystanders to the destructive lifestyles of vulnerable older adults and even facilitating these lifestyles. In the present paper, we suggest that alcohol exacerbates and underscores inherent difficulties in eldercare, such as (...) finding an appropriate balance between the personal freedom of the older adult and the responsibility of the care worker to provide care. The specific focus in the paper regard the communication and interaction involving values between people in eldercare in cases of problematic alcohol‐related situations to uncover the difficulties. We found it noteworthy that the objectives and perspectives of older adults, care workers, managers and relatives have implications regarding their interactions and communications because their varying experiences involve values that are not necessarily aligned. Sometimes, care workers have no choice but to act against what, in the public sphere and to the other care workers, is ruled out by virtue of their professional ethics. It is suggested that care workers describe and judge situations where alcohol is present paradoxically by virtue of their professional ethics, yet regulate their care to preserve the dignity of older adults, even when they find the situation to be an apparent dilemma. (shrink)

Malaysia had its first four patients with COVID-19 on 25 January 2020. In the same week, the World Health Organization declared it as a public health emergency of international concern. The pandemic has since challenged the ethics and practice of medicine. There is palpable tension from the conflict of interest between public health initiatives and individual’s rights. Ensuring equitable care and distribution of health resources for patients with and without COVID-19 is a recurring ethical challenge for clinicians. Palliative care aims (...) to mitigate suffering caused by a life-limiting illness, and this crisis has led to the awareness and urgency to ensure it reaches all who needs it. We share here the palliative care perspectives and ethical challenges during the COVID-19 pandemic in Malaysia. (shrink)

This paper argues, against the prevailing view, that consent to privacy policies that regular internet users usually give is largely unproblematic from the moral point of view. To substantiate this claim, we rely on the idea of the right not to know (RNTK), as developed by bioethicists. Defenders of the RNTK in bioethical literature on informed consent claim that patients generally have the right to refuse medically relevant information. In this article we extend the application of the RNTK to online (...) privacy. We then argue that if internet users can be thought of as exercising their RNTK before consenting to privacy policies, their consent ought to be considered free of the standard charges leveled against it by critics. (shrink)

Among feminist philosophers, there are two lines of argument that sexist values are illegitimate in science, focusing on epistemic or ethical problems. This article supports a third framework, elucidating how value-laden science can enable epistemic oppression. My analysis demonstrates how purported knowledge laden with sexist values can compromise epistemic autonomy and contribute to paternalism and misogyny. I exemplify these epistemic wrongs with a case study of the morning-after pill during its 2006 switch to over-the-counter availability and its new drug label (...) from the US Food and Drug Administration that it “may prevent implantation.” Antiabortion science advisers created this label to protect zygotes based on debated value judgments that were later concealed. This zygote-centric knowledge enabled them to shape potential users by instructing “good mothers” that they ought to protect zygotes and punishing “bad mothers” by refusing their requests for the drug. Therefore, I argue that the sexist values and gender norms of antiabortionists that prioritize zygotic health are illegitimate in this context because they cause epistemic injustices and perpetuate epistemic oppression. Furthermore, I advocate against blanket protections for the “right to conscience” and “religious freedom” of healthcare providers because they reinforce the epistemic oppression of women, especially those on the margins.Content Warning: This article discusses sexual assault and refusals to provide contraception to patients, including survivors. (shrink)

BackgroundThe Western-European concept of libertarian rights-based autonomy, which advocates respect for individual rights, may conflict with African cultural values and norms. African communitarian ethics focuses on the interests of the collective whole or community, rather than rugged individualism. Hence collective decision-making processes take precedence over individual autonomy or consent. This apparent conflict may impact informed consent practice during biomedical research in African communities and may hinder ethical principlism in African bioethics. This study explored African biomedical researchers' perspectives regarding informed consent (...) and potential limitations to the principle of respect for autonomy in African communities.MethodsWe conducted a qualitative study based on in-depth interviews with 12 biomedical researchers, five females and seven males aged 34 to 74 years, currently working at an African university. Interviews lasted 35–40 min each and involved semi-structured open-ended interviews, which allowed participants to offer information about their perceptions and feelings regarding respect for autonomy and informed consent as practised in Africa. Empirical data from the interviews were recorded, transcribed, and analysed using thematic content analysis, together with an interrogation of relevant scientific literature about African communitarian ethics, making evaluations and drawing inferences consistent with the empirical bioethics approach.ResultsBased on these interviews and analysis of relevant literature, we found that informed consent is difficult to apply in an African context because it derives from a Western conception of libertarian rights-based autonomy. Most respondents pointed out that it was challenging to implement informed consent in the African setting. Furthermore, communalism, customary beliefs, spirituality, and relational autonomy are predominant in most African communities, as exemplified by the African moral philosophies of Ubuntu/botho and Ukama, which emphasize communitarianism over individual rights. We also found that language, education, poverty, and cultural beliefs are barriers to obtaining proper informed consent in African communities.ConclusionsWe conclude that there are limitations to applying the principle of respect for autonomy and informed consent in African communities, especially in the context of human biomedical research. We recommend using a more relational approach, such as Ross’s prima facie duties, to implement informed consent in African communities. (shrink)

This paper addresses the nurse manager's role regarding chemically-dependent nurses in the workplace. The manager may intervene by: terminating the contract of the impaired colleague; notifying a disciplinary committee; consulting with a counselling committee; or referring the impaired nurse to an employee assistance programme. A dilemma may arise about which of these interventions is ethically the best. The ethical theories relevant to nursing involve ethical relativism, utilitarianism, Kantian ethics, Kohlberg's justice, and Gilligan's ethic of care. Nurse managers first need to (...) understand these theories in order to clarify their own perceptions and attitudes towards chemical dependency, and then satisfactorily resolve this ethical dilemma. Education and social learning are routes to a better understanding of chemical dependency and to broadening the ethical dimensions of nurse managers. (shrink)

While greatly appreciative of Kaveny's important study of a neglected form of religious/moral discourse in the public square, this essay critically examines her metaphors for prophetic indictments and finds the metaphor of moral chemotherapy particularly problematic and the metaphor of warfare, connected with the just-war tradition, more promising. It stresses the difficulty, if not the impossibility, of avoiding contempt in prophetic indictments, as Kaveny conceives them, and finds her proposed solutions to this problem—standing with the people and expressing empathy and (...) compassion toward them—inadequate to the task. It further argues that attending to prophetic imagination, in addition to prophetic denunciation, can broaden the scope of practical deliberation and, at the same time, increase possible prophetic contributions to moral and political discourse. (shrink)

Public health ethics, like the field of public health it addresses, traditionally has focused more on practice and particular cases than on theory, with the result that some concepts, methods, and boundaries remain largely undefined. This paper attempts to provide a rough conceptual map of the terrain of public health ethics. We begin by briefly defining public health and identifying general features of the field that are particularly relevant for a discussion of public health ethics.Public health is primarily concerned with (...) the health of the entire population, rather than the health of individuals. Its features include an emphasis on the promotion of health and the prevention of disease and disability; the collection and use of epidemiological data, population surveillance, and other forms of empirical quantitative assessment; a recognition of the multidimensional nature of the determinants of health; and a focus on the complex interactions of many factors—biological, behavioral, social, and environmental—in developing effective interventions. (shrink)

Tom Beauchamp and I were asked by the editors of The Journal of Medicine and Philosophy to prepare “intellectual autobiographies,” with particular attention to sources and influences on our work, including but not limited to Principles of Biomedical Ethics. Of course, it is artificial and even impossible to try fully to separate the “intellectual” from other aspects of our lives. So, while emphasizing the “intellectual” aspects of my autobiography, I have attended to other aspects, too. The huge debts of gratitude (...) I owe also mix the “intellectual” and other aspects of life. (shrink)

BackgroundThe issue of stigma is very important in the battle against HIV/aids in Africa since it may affect patient attendance at healthcare centres for obtaining antiretroviral medications and regular medical check-ups. Stigmatization creates an unnecessary culture of secrecy and silence based on ignorance and fear of victimization. This study was designed to determine if there is external stigmatization of people living with HIV and AIDS by health care workers at a tertiary hospital in KwaZulu-Natal province, South Africa. The study investigated (...) the impact of knowledge of HIV/aids by HCWs on treatment of patients, as well as the comfort level and attitude of HCWs when rendering care to PLWHA.MethodsA descriptive cross sectional study was designed to collect data using an anonymous self-administered structured questionnaire from 334 HCWs. The study was conducted in clinical departments of a large multidisciplinary 922-bed tertiary care teaching hospital in Durban, KZN.ResultsOverall HCWs had an above average knowledge about HIV/aids although some gaps in knowledge were identified. Tests of statistical significance showed that there was association between level of education and knowledge of HIV/aids ; occupation and knowledge of HIV/aids ; and gender and knowledge of HIV/aids. Test for comfort level was only significant for gender, with males showing more comfort and empathy when dealing with PLWHA. The study also revealed that patients were sometimes tested for HIV without informed consent before surgery, due to fear of being infected, and there was some gossiping about patients' HIV status by HCWs, thereby compromising patient confidentiality. The majority of HCWs showed a willingness to report incidents of stigmatization and discrimination to higher authorities, for better monitoring and control.ConclusionsAlthough knowledge, attitude and comfort level of HCWs taking care of PLWHA was above average, enforcement of existing antidiscrimination laws and continuing education in medical ethics and healthcare law, would greatly improve the performance of HCWs taking care of PLWHAs. More psychological support and counselling should be provided to HCWs, to further reduce the impact of stigmatization and discrimination against PLWHA. (shrink)

Extracorporeal membrane oxygenation (ECMO) is typically viewed as a time-limited intervention—a bridge to recovery or transplant—not a destination therapy. However, some patients with decision-making capacity request continued ECMO support despite a poor prognosis for recovery and lack of viability as a transplant candidate. In response, critical care teams have asked for guidance regarding the ethical permissibility of unilateral withdrawal over the objections of a capacitated patient. In this article, we evaluate several ethical arguments that have been made in favor of (...) withdrawal, including distributive justice, quality of life, patients’ rights, professional integrity, and the Equivalence Thesis. We find that existing justifications for unilateral withdrawal of ECMO support in capacitated patients are problematic, which leads us to conclude that either: (1) additional ethical arguments are necessary to defend this approach or (2) the claim that it is not appropriate to use ECMO as a destination therapy should be questioned. (shrink)

While the implementation of digital technology in psychiatry appears promising, there is an urgent need to address the implications of the absence of ethical design in the early development of such technologies. Some authors have noted the gap between technology development and ethical analysis and have called for an upstream examination of the ethical issues raised by digital technologies. In this paper, we address this suggestion, particularly in relation to digital healthcare technologies for patients with schizophrenia spectrum disorders. The introduction (...) of digital technologies in psychiatry offers a broad spectrum of diagnostic and treatment options tailored to the health needs and goals of patients’ care. These technologies include wearable devices, smartphone applications for high-immersive virtual realities, smart homes, telepsychiatry and messaging systems for patients in rural areas. The availability of these technologies could increase access to mental health services and improve the diagnostics of mental disorders.Additional Instruction AbstractIn this descriptive review, we systematize ethical concerns about digital technologies for mental health with a particular focus on individuals suffering from schizophrenia. There are many unsolved dilemmas and conflicts of interest in the implementation of these technologies, such as (1) the lack of evidence on efficacy and impact on self-perception; (2) the lack of clear standards for the safety of their daily implementation; (3) unclear roles of technology and a shift in the responsibilities of all parties; (4) no guarantee of data confidentiality; and (5) the lack of a user-centered design that meets the particular needs of patients with schizophrenia. mHealth can improve care in psychiatry and make mental healthcare services more efficient and personalized while destigmatizing mental health disorders. To ensure that these technologies will benefit people with mental health disorders, we need to heighten sensitivity to ethical issues among mental healthcare specialists, health policy makers, software developers, patients themselves and their proxies. Additionally, we need to develop frameworks for furthering sustainable development in the digital technologies industry and for the responsible usage of such technologies for patients with schizophrenia in the clinical setting. We suggest that digital technology in psychiatry, particularly for schizophrenia and other serious mental health disorders, should be integrated into treatment with professional supervision rather than as a self-treatment tool. (shrink)

The American Journal of Bioethics, Volume 11, Issue 9, Page 20-21, September 2011.

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials (...) to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child. (shrink)

Informed consent is normally understood as something that a patient gives prior to a medical intervention that can render it morally permissible. Whether or not it must be given prior to the intervention is debated. Some have argued that subsequent consent—that is, consent given after a medical intervention—can also render an otherwise impermissible act permissible. If so, then a patient may give her consent to an intervention that has already been performed and thereby justify a physician’s act retroactively. The purpose (...) of this paper is to argue that even if subsequent consent can render an otherwise impermissible act permissible, doctors are still blameworthy if they rely on it when prior consent could be given, because they would be banking on the justification of their interventions. Since doctors can only guess if patients will consent after the fact, they would be placing their patients at unreasonable risk of being disrespected as persons. (shrink)

Psychedelics such as psilocybin reliably produce significantly altered states of consciousness with a variety of subjectively experienced effects. These include certain changes to perception, cognition, and affect,1 which we refer to here as the acute subjective effects of psychedelics. In recent years, psychedelics such as psilocybin have also shown considerable promise as therapeutic agents when combined with talk therapy, for example, in the treatment of major depression or substance use disorder.2 However, it is currently unclear whether the aforementioned acute subjective (...) effects are necessary to bring about the observed therapeutic effects of psilocybin and other psychedelics. This uncertainty has sparked a lively—though still largely hypothetical—debate on whether psychedelics without subjective effects (“nonsubjective psychedelics” or “non-hallucinogenic psychedelics”) could still have the same therapeutic impact, or whether the acute subjective effects are in fact necessary for this impact to be fully realized.3,4,5. (shrink)

OBJECTIVES: To determine the epidemiology and the underlying pathological conditions of natural deaths among motor vehicle drivers. Sudden death while driving may cause damage to properties, other vehicles or road users. Although the Medical Commission on Accident Prevention recommended restrictions to drivers at risk of sudden death due to their medical conditions, these restrictions are useless if they do not result in greater safety to the public. DESIGN: A retrospective study of natural deaths of motor vehicle drivers. SETTING: Natural deaths (...) of motor vehicle drivers reported to the coroner for Birmingham and Solihull. SUBJECTS: 86 consecutive natural deaths of motor vehicle drivers in a five-year period between 1984 and 1988. RESULTS: Of the 86 fatalities reviewed, 80 (93%) sudden deaths were caused by ischaemic heart disease. Fifty vehicles were involved in collision with 32 properties, 20 other vehicles and six pedestrians. Fifty-one out of 80 cardiac deaths had past cardiac history and three had reported chest pain prior to the sudden death. CONCLUSION: An applied normative ethical assessment based on the basic moral principles of autonomy, justice, beneficence and non-maleficence are discussed. We conclude that medical screening of drivers has little benefit for the drivers or other persons. (shrink)

In order to involve children in the decision-making process about participation in medical research it is widely recommended that the child’s assent be sought in addition to parental consent. However, the concept of assent is fraught with difficulties, resulting in confusion among researchers and ethics committees alike.

This paper argues that substantive ethical rules serve a critical ethical function, even in those cases where we should deviate from those rules. Assuming that the rules are valid provides decision-makers with the context essential to reaching a well-justified decision. Recognizing this helps to reconcile two attractive but incompatible positions regarding the evaluation of healthcare ethics consultants. The first position is that ethical rules can validly be used to evaluate the quality of consultants’ advice, ensuring conformity to standards promoted by (...) a significant portion of medical ethicists. The second position—the message of ethical particularism—is that we should not evaluate consultants according to strict rules, since good ethical advice may deviate from even the most carefully wrought moral rules. Steering a path between these extremes, I argue that we should evaluate the quality of consultations by examining whether consultants have communicated the relevant ethical rules to participants as ethical presumptions. In communicating presumptions, a consultant provides an indispensable ingredient to ethical decision-making, while leaving open the possibility that the ethical course of action involves violating the very ethical rules that one should presume. (shrink)

The Pharmaceutical Benefits Scheme, operating in Australia under the National Health Act 1953, provides citizens equal access to subsidised pharmaceuticals. With ever-increasing costs of medicines and global financial pressure on all commodities, the sustainability of the PBS is of crucial importance on many social and political fronts. Direct-to-consumer advertising (DTCA) of prescription medicines is fast expanding, as pharmaceutical companies recognise and reinforce marketing potentials not only in healthcare professionals but also in consumers. DTCA is currently prohibited in Australia, but pharmaceutical (...) companies continuously lobby for the ban to be lifted. There is evidence that such marketing strategies influence consumer behaviour and concerns have been raised about whether DTCA could affect government expenditure on the PBS in Australia. This pharmacy-based study explored Australian consumer attitudes towards DTCA and whether consumer attitudes regarding DTCA differ based on socioeconomic status, measured in terms of income and education. Consumers from different socioeconomic areas in Sydney were asked to respond to a survey about an advertisement created specifically for the promotion of a mock prescription medicine. Their views about the intent, value and reliability of the advertisement were explored. The study found that consumers of lower socioeconomic status were more likely to perceive DTCA as a source of valuable and reliable medical information, and that they were more likely to request an advertised medication from their physician. If DTCA of prescription medicines was to be introduced in Australia, an increase in government expenditure on the PBS would be anticipated. Findings of this study also expose a deficit in respect for patients’ right to autonomy and informed consent which should be based on evidence-based, unbiased, information rather than advertisements. (shrink)

The right to refuse treatment is generally accepted in the legal and bioethics discourses; however, the use of advance directives remains contentious. Some jurisdictions have introduced statutory frameworks to govern the creation and implementation of advance directives, underpinned primarily by the recognition of respect for personal autonomy. Although there are no legislation and judicial decisions on advance decision-making in Malaysia, the considered view is that healthcare practitioners perceived its utility in managing patient care. This paper examines the potential and challenges (...) of applying a statutory framework in Malaysia, drawing from relevant regulatory examples. It argues for greater public awareness within the healthcare discourse and knowledge dissemination regarding the availability, usage and clinical guidance on advance decision-making. The main conclusion drawn from this exploratory analysis is that further understanding of and education about advance decision-making within the population and healthcare practitioners should precede the implementation of a statutory regime in Malaysia. (shrink)

Evidence suggests that the incidence of research misconduct is not in decline despite efforts to improve awareness, education and governance mechanisms. Two responses to this problem are favoured: first, the promotion of an agent-centred ethics approach to enhance researchers’ personal responsibility and accountability, and second, a change in research culture to relieve perceived pressures to engage in misconduct. This article discusses the challenges for both responses and explains how normative coherence through values alignment might assist. We argue that research integrity (...) and research ethics convey mixed messages, which are likely to contribute to a form of normative confusion. For the successful adoption of an agent-centred approach, normative coherence is needed between the two. To facilitate normative coherence, we propose that research ethics and research integrity be underpinned by a shared set of moral values that can be enacted via codes and guidelines and imbue research environments. Furthermore, to facilitate culture change, the same normative coherence is necessary at all levels of an institution. Only via values alignment between institutional aims, management, institutional practices and researchers can an ethical culture become truly embedded in research institutions. (shrink)

This article aims to explore the attitudes and behaviors of persons with intellectual and developmental disabilities related to their information privacy when using information technology. Six persons with IDD were recruited to participate to a series of 3 semistructured focus groups. Data were analyzed following a hybrid thematic analysis approach. Only 2 participants reported using IT every day. However, they all perceived IT use benefits, such as an increased autonomy. Participants demonstrated awareness of privacy concerns, but not in situations involving (...) the use of technology; their awareness is not transferred to the abstract context of IT use. Privacy breaches were revealed to be a major risk for persons with IDD, who did not seem to understand how their personal information was used. Most protection mechanisms and tools reported were those suggested and implemented by caregivers and close relatives who had a great influence on the participants’ attitudes and behaviors toward IT and privacy. Our findings suggest that when using IT, persons with IDD often experience the consequences of a trade-off between autonomy and privacy. Further research and action is needed to support persons with IDD to understand and balance the benefits of IT use and the inherent threats to information privacy. (shrink)

Current empirical studies of moral behavior of healthcare professionals are almost entirely focused on self-reports, usually collected under the assumption that an ethical disposition characterizes individuals across various contexts. It is well known, however, that individuals adjust their behavior to what they see being done by those in their peer group. That presents a methodological challenge to traditional research within a community of peers because the behavior of each individual is both the result of norms and a contributor to the (...) norms of others. Computer simulations can be used to address this methodological challenge. A Markov replicator model that runs on an Excel spreadsheet was used to investigate a community with four agent types in the dental community: devious practitioners, ethical practitioners who avoid involvement in the poor ethics of others, ethical practitioners who accept it as part of their professional responsibility to challenge colleagues who act unprofessionally, and those who enforce ethical standards. A panel of leaders in the profession independently estimated parameters for the model and criteria for a possible distribution of agent types in the community. The simulation converged on distributions of the agent types that were very similar to the expectations of the panel. The simulation suggests the following characteristics of such moral communities: The structure of such communities is robust across a wide distribution. It appears that reduction in unethical behavior is more sensitive to the way ethical practitioners interact with each other than to sanctions the enforcement community imposes on unethical practitioners, and that large external interventions will be short lived. (shrink)

One of the ethical issues that has been raised recently regarding emerging neurotherapies is that people will be coerced explicitly or implicitly in the workplace or in schools to take cognitive enhancing drugs. This article builds on this discussion by showing how the law may pressure people to adopt emerging neurotherapies. It focuses on a range of private law doctrines that, unlike the criminal law, do not come up very often in neuroethical discussions. Three doctrines—the doctrine of mitigation, the standard (...) of care in negligence, and child custody determinations in family law—are addressed to show how the law may pressure people to consent to treatment by offering a choice between accepting medical treatment and suffering a legal disadvantage. The doctrines considered in this article apply indirect pressure to submit to treatment, unlike court-ordered medical treatment, which applies direct pressure and is not addressed here. The outcome of this discussion is to show that there is a greater range of social pressures that may encourage the uptake of novel neurotherapies than one might initially think. Once treatments that were developed and offered with therapeutic benefits in mind become available, their existence gives rise to unintended legal consequences. This certainly does not mean we should cease developing new therapies that may be of tremendous benefit to patients, but it does raise some questions for physicians and for legal policy-makers. How should physicians, who are required by medical ethical principles to obtain valid consent to treatment, react to a patient’s reluctant consent that is driven by legal pressure? From the legal policy perspective, are our legal doctrines satisfactory or should they be changed because, for example, they unduly promote the collective interest over individual freedom to reject medical treatment or because they channel us toward economically efficient treatments to the detriment of more costly but potentially superior approaches of dealing with behavioural problems? (shrink)

On reading “Algorithms for Ethical Decision-Making in the Clinical: A Proof of Concept,” I imagined that for some the fundamental problem with the authors' approach is the very...

Consider manipulation in which one agent, avoiding force, threat, or fraud mobilizes some non-concern motive of another so as to induce this other to behave or move differently than she would otherwise have behaved or moved, given her circumstances and her initial ranking of concerns. As an instance, imagine that I get us to miss the opening of a play that I have grudgingly agreed to attend by engaging your sublimated compulsive tendency to check the stove when we are halfway (...) to the theatre. Such motive manipulation is, I take it, widely regarded as morally worrisome. If it really is morally worrisome, then we should be able to explain adequately why it is so. But existing condemnations of manipulation come up short in this regard. In this paper, I develop and defend a more plausible account of the moral status of this phenomenon. (shrink)

The use of drones in public healthcare is suggested as a means to improve efficiency under constrained resources and personnel. This paper begins by framing drones in healthcare as a social experiment where ethical guidelines are needed to protect those impacted while fully realizing the benefits the technology offers. Then we propose an ethical framework to facilitate the design, development, implementation, and assessment of drones used in public healthcare. Given the healthcare context, we structure the framework according to the four (...) bioethics principles: beneficence, non-maleficence, autonomy, and justice, plus a fifth principle from artificial intelligence ethics: explicability. These principles are abstract which makes operationalization a challenge; therefore, we suggest an approach of translation according to a values hierarchy whereby the top-level ethical principles are translated into relevant human values within the domain. The resulting framework is an applied ethics tool that facilitates awareness of relevant ethical issues during the design, development, implementation, and assessment of drones in public healthcare. (shrink)

A comprehensive analysis of the evolving conditions that provided for the emergence and autonomization of the field of bioethical inquiry, as well as the social, cultural and political background against which its birth can be set, should enlighten us about the problematic nature that characterises it from its very onset. Those conditions are: abuses in experimentation on human subjects, availability of new biomedical technologies, the challenging of prevalent medical paradigms and the ultimate meaning and purpose of medical care, new scientific (...) and social fields of concern dealing with ecology and environmental health, genetic engineering and biotechnologies, demographics, behavioural manipulation, reproductive medicine, etc., the upsurge of social movements raising issues of medical importance, and the need for an ethics for the technological age. The scope and meaning of bioethics is best defined by the overriding questions that open up the field of both theoretical and practical bioethical inquiry rather than by the individual responses given to such questions by the most prominent spokesmen in bioethics. (shrink)