Background: Nursing students on clinical placements as part of their professional training are routinely faced with situations involving ethical conflicts. The initial act of perceiving a situation as causing an ethical dilemma is the result of both the students’ personal values, drawn from their culture and families, and of the professional knowledge and values that they have acquired through training and experience. Objectives: Nursing students’ experiences on clinical placements in primary care settings were investigated in order to identify situations that (...) they perceived as involving ethical conflict and describe the elements they took into consideration during their decision-making processes in these situations. Methods: The research design was qualitative descriptive case study. Around 50 students from three different intakes to a nursing degree answered a questionnaire and discussed it in focus groups. Ethical considerations: The study was designed in accordance with the principles guiding research with human beings and was approved by the Human Research Ethics Committee. Results: Synthesised into two principal axes: (a) ethical conflicts in primary care, linked with the domains of working processes, professional nursing ethics and human and social rights and (b) students’ decision-making processes – realisation, reflection and intervention. Conclusion: The student nurses saw themselves both as actors and spectators in situations involving ethical problems and demanding moral deliberation, demonstrating the ability to base their arguments soundly. They tended to emphasise the possibilities offered by dialogue and that different ethical values must be respected to find fair solutions to ethical problems. (shrink)

Culture creates the context within which individuals experience life and comprehend moral meaning of illness, suffering and death. The ways the patient, family and the physician communicate and make decisions in the end-of-life care are profoundly influenced by culture. What is considered as right or wrong in the healthcare setting may depend on the socio-cultural context. The present article is intended to delve into the cross-cultural perspectives in ethical decision making in the end-of-life scenario. We attempt to address the dynamics (...) of the roles of patient, family and physician therein across two countries from East and West, namely, India and Germany. In India, where illness is more a shared family affair than an individual incident, a physician is likely to respect the family’s wishes and may withhold the ‹naked truth’ about the diagnosis of a fatal disease to the patient. In Germany, a physician is legally required to inform the patient about the disease. In India, advance directive being virtually non-existent, the family acts as the locus of the decision-making process, taking into account the economic cost of available medical care. In Germany, advance directive is regarded as mandatory and healthcare is covered by insurance. Family and the physician appear to play larger roles in ethical decision making for patients in India than for those in Germany, who place greater emphasis on autonomy of the individual patient. Our study explicates how culture matters in ethical decision-making and why the bioethical discourse is necessary in the concrete realities of the socio-cultural context. To explore the possibility of finding a common ground of morality across different cultures while acknowledging and respecting cultural diversity, thus remains a formidable challenge for the bioethicists. (shrink)

The aim of regenerative medicine is to reconstruct tissue that has been lost or pathologically altered. Therapeutic cloning seems to offer a method of achieving this aim; however, the ethical debate surrounding human therapeutic cloning is highly controversial. Artificial parthenogenesis—obtaining embryos from unfertilised eggs—seems to offer a way to sidestep these ethical pitfalls. Jacques Loeb , the founding father of artificial parthogenesis, faced negative public opinion when he published his research in 1899. His research, the public’s response to his findings, (...) and his ethical foundations serve as an historical argument both for the communication of science and compromise in biological research. (shrink)

The National Institute for Health and Clinical Excellence (hereafter NICE) was created in 1998 to give guidance on which treatments should be provided by the British National Health Service, and to whom. So it has a crucial role as an agent of distributive justice. In this paper I argue that it is failing to adequately explain and justify its decisions in the public arena, particularly in terms of distributive justice; and that this weakens its legitimacy, to the detriment of the (...) National Health Service as a whole. I argue that this failure arises from the fact that NICE works within the frameworks of positivist science and liberal ethics, largely to the exclusion of other perspectives. This narrowness of view prevents NICE from properly connecting with the range of moral concerns represented in the population. I argue for NICE’s deliberations to become more inclusive, both in terms of epistemology, and also in terms of ethical perspectives. And I suggest a range of perspectives that could usefully be included. Finally I offer a framework of structures, philosophies and discussion process that will enable competing perspectives to be debated fairly and productively in this process. (shrink)

Contemporary clinical ethics was founded on principlism, and the four principles: respect for autonomy, nonmaleficence, beneficence and justice, remain dominant in medical ethics discourse and practice. These principles are held to be expansive enough to provide the basis for the ethical practice of medicine across cultures. Although principlism remains subject to critique and revision, the four-principle model continues to be taught and applied across the world. As the practice of medicine globalizes, it remains critical to examine the extent to which (...) both the four-principle framework, and individual principles among the four, suffice patients and practitioners in different social and cultural contexts. Using the four-principle model we analyze two accounts of surrogate decision making – one from the developed and one from the developing world – in which the clinician undertakes medical decision-making with apparently little input from the patient and/or family. The purpose of this analysis is to highlight challenges in assessing ethical behaviour according to the principlist model. We next describe cultural expectations and mores that inform both patient and clinician behaviors in these scenarios in order to argue that the principle of respect for persons informed by culture-specific ideas of personhood may offer an improved ethical construct for analyzing and guiding medical practice in a globalized and plural world. (shrink)

Should we be allowed to refuse any involvement of artificial intelligence technology in diagnosis and treatment planning? This is the relevant question posed by Ploug and Holm in a recent article in Medicine, Health Care and Philosophy. In this article, I adhere to their conclusions, but not necessarily to the rationale that supports them. First, I argue that the idea that we should recognize this right on the basis of a rational interest defence is not plausible, unless we are willing (...) to judge each patient’s ideology or religion. Instead, I consider that the right must be recognized by virtue of values such as social pluralism or individual autonomy. Second, I point out that the scope of such a right should be limited at least under three circumstances: if it is against a physician’s obligation to not cause unnecessary harm to a patient or to not provide futile treatment, in cases where the costs of implementing this right are too high, or if recognizing the right would deprive other patients of their own rights to adequate health care. (shrink)

The day-to-day work of clinical ethics consultants and healthcare ethics committees can easily become overly routine. Too much routine, however, comes with a risk that morally important practices will be reduced to mere bureaucratic formalities, while practitioners become desensitized to ethically significant distinctions between cases. Clinical ethics consultation and organizational ethics must be set within the broader social and cultural context of the healthcare environment. This practice requires looking beyond mere legal compliance and the routinely false assumption that there are (...) unambiguous ethical norms that easily govern clinical ethics and hospital policy formation. Together the essays in this issue of HEC Forum challenge readers to rethink taken-for-granted assumptions regarding patient care, physician obligation, clinical ethics consultation, and organizational ethics. (shrink)

Central to this essay is the understanding that varied communities may have an inherent and unrecognised culture of their own and this culture may be detrimental to their core. Bioethics constitutes one such community and is embedded in norms and values comprising its own culture. I use exclusion of religion or simply ‘irreligion’ as an example of a cultural element that may be established and so shape the culture of bioethics. Irreligious bioethics includes both overt religious preclusion and the more (...) pervasive form of religious marginalisation. This norm is narrated into the culture of bioethics with justifications sustaining it. Irreligious bioethics is inadmissible as it claims illegitimate neutrality, is a misuse of expertise and results in a variety of harms. As bioethics is influential in society, those engaged should be critically reflective and aware of harmful cultural elements whilst also possessing the honesty, courage and capacity to change them. (shrink)

One of the goals of medicine is to improve well-being, in line with the principle of beneficence. Likewise, scientists claim that the goal of human embryonic stem cell research is to find treatments for diseases. In hESC research, stem cells are harvested from a 5-day-old embryo. Surplus embryos from infertility treatments or embryos created for the sole purpose of harvesting stem cells are used in the research, and in the process the embryos get destroyed. The use of human embryos for (...) research purpose raises ethical concern. In this context, the religious leaders play the role to be the moral compass and “reality check” to engage with the public. In Malaysia, the Ministry of Health has outlined the Guidelines for Stem Cell Research and Therapy, reflecting on Islamic principles. Since there has not been much focus on the viewpoints of other faiths in Malaysia, this study attempts to explore the ethical guiding principles deliberated by religious leaders from the Buddhist, Hindu and Catholic traditions and identify if there is a common ground between the mainstream religious views and principles of medical ethics, in relation to hESC research. Eleven religious leaders representing the Buddhist, Hindu and Catholic traditions were interviewed. Interestingly, though reasoning of religious leaders came from different angles, their underlying concerns revolve around the values of “do no harm” and “intention to save lives”. These values are also the key principles in medical ethics. The findings are applied to answer the question as to whether religious and medical guiding principles can co-exist and complement in ethical decision-making, without compromising the values. (shrink)

Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite (...) health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients’ right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence, as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment. (shrink)