Next SectionWhilst there has been considerable debate about the fit between moral theory and moral reasoning in everyday life, the way in which moral problems are defined has rarely been questioned. This paper presents a qualitative analysis of interviews conducted with 15 general practitioners (GPs) in South Australia to argue that the way in which the bioethics literature defines an ethical dilemma captures only some of the range of lay views about the nature of ethical problems. The bioethics literature has (...) defined ethical dilemmas in terms of conflict and choice between values, beliefs and options for action. While some of the views of some of the GPs in this study about the nature of their ethical dilemmas certainly accorded with this definition, other explanations of the ethical nature of their problems revolved around the publicity associated with the issues they were discussing, concern about their relationships with patients, and anxiety about threats to their integrity and reputation. The variety of views about what makes a problem a moral problem indicates that the moral domain is perhaps wider and richer than mainstream bioethics would generally allow. (shrink)

BackgroundHumanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care—a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, (...) the WHO released a guide on‘Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises’—the first guidance on the topic by an international body.AimsThis paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.ImplicationsIn parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance. (shrink)

The COVID-19 pandemic highlights the relevance of adequate decision making at both public health and healthcare levels. A bioethical response to the demand for medical care, supplies and access to critical care is needed. Ethically sound strategies are required for the allocation of increasingly scarce resources, such as rationing critical care beds. In this regard, it is worth mentioning the so-called ‘last bed dilemma’. In this paper, we examine this dilemma, pointing out the main criteria used to solve it and (...) argue that we cannot face these ethical issues as though they are only a dilemma. A more complex ethical view regarding the care of COVID-19 patients that is focused on proportional and ordinary treatments is required. Furthermore, discussions and forward planning are essential because deliberation becomes extremely complex during an emergency and the physicians’ sense of responsibility may be increased if it is faced only as a moral dilemma. (shrink)

A public health emergency, as the COVID-19 pandemic, may lead to shortages of potentially life-saving treatments. In this situation, it is necessary, justifiable and proportionate to have decision tools in place to enable healthcare professionals to triage and prioritise access to those resources. An ethically sound framework should consider the principles of beneficence and fair allocation. Scientific Societies across Europe were concerned with this problem early in the pandemic and published guidelines to support their professionals and institutions. This article aims (...) to compare triage policies from medical bodies across Europe, to characterise the process of triage and the ethical values, principles and theories that were proposed in different countries during the first outbreak of COVID-19. (shrink)

Aims:The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.Background:Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.Design:Systematic literature review and narrative synthesis (November (...) 2015–March 2016).Data sources:Ovid MEDLINE®In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO®1967–Present, CINAHL®Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts.Review methods:Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.Results:In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.Conclusion:We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress. (shrink)

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing p...

There has recently been interest in applying the techniques of systematic review to bioethics literature. In this paper, I identify the three models of systematic review proposed to date in bioethics: systematic reviews of empirical bioethics research, systematic reviews of normative bioethics literature, and systematic reviews of reasons. I argue that all three types yield information useful to scholarship in bioethics, yet they also face significant challenges particularly in relation to terminology and time. Drawing on my recent experience conducting a (...) systematic review, I suggest that complete comprehensiveness may not always be an appropriate goal of a literature review in bioethics, depending on the research question. In some cases, all the relevant ideas may be captured without capturing all the relevant literature. I conclude that systematic reviews in bioethics have an important role to play alongside the traditional broadbrush approach to reviewing literature in bioethics. (shrink)

In emergencies and disasters, ethics are affected by both personal and organizational factors. Given the lack of organizational ethical guidelines in the disaster management system in Iran, the present study was conducted to explain the personal factors affecting ethics and ethical behaviors among disaster healthcare workers. The present qualitative inquiry was conducted using conventional content analysis to analyze the data collected from 21 in-depth unstructured interviews with healthcare workers with an experience of attending one or more fields of disaster. According (...) to the data collected, personal factors can be classified into five major categories, including personal characteristics such as age and gender, personal values, threshold of tolerance, personal knowledge and reflective thinking. Without ethical guidelines, healthcare workers are intensely affected by the emotional climate of the event and guided by their beliefs. A combination of personal characteristics, competences and expertise thus form the basis of ethical conduct in disaster healthcare workers. (shrink)

The terrorist attacks of 2001 were a reminder that individual and collective safety cannot be taken for granted. Since then, physicians, alongside public health professionals and other healthcare professionals as well as nonhealthcare personnel, have been developing plans to enhance the protection of public health and the provision of medical care in response to various threats, including acts of terrorism or bioterrorism. Included in those plans are strategies to attend to large numbers of victims and help prevent greater harm to (...) even larger populations. (shrink)

BackgroundDespite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature.MethodsRapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ (...) in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.Results393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.ConclusionsOnly 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research. (shrink)

Background:To better understand the kinds of ethical challenges that emerge when using coercion in mental healthcare, and the importance of these ethical challenges, this article presents a systematic review of scientific literature.Methods:A systematic search in the databases MEDLINE, PsychInfo, Cinahl, Sociologicals and Web of Knowledge was carried out. The search terms derived from the population, intervention, comparison/setting and outcome. A total of 22 studies were included.Ethical considerations:The review is conducted according to the Vancouver Protocol.Results:There are few studies that study ethical (...) challenges when using coercion in an explicit way. However, promoting the patient’s best interest is the most important justification for coercion. Patient autonomy is a fundamental challenge facing any use of coercion, and some kind of autonomy infringement is a key aspect of the concept of coercion. The concepts of coercion and autonomy and the relations between them are very complex. When coercion is used, a primary ethical challenge is to assess the balance between promoting good and inflicting harm. In the included studies, findings explicitly related to justice are few. Some studies focus on moral distress experienced by the healthcare professionals using coercion.Conclusion:There is a lack of literature explicitly addressing ethical challenges related to the use of coercion in mental healthcare. It is essential for healthcare personnel to develop a strong awareness of which ethical challenges they face in connection with the use of coercion, as well as challenges related to justice. How to address ethical challenges in ways that prevent illegitimate paternalism and strengthen beneficent treatment and care and trust in connection with the use of coercion is a ‘clinical must’. By developing a more refined and rich language describing ethical challenges, clinicians may be better equipped to prevent coercion and the accompanying moral distress. (shrink)

IntroductionThe idea of video recording in the operating room with panoramic cameras and microphones is a new concept that is changing the approach to medical activities in the OR. However, VR in the OR has brought up many concerns regarding patient privacy and has highlighted legal and ethical issues that were never previously exposed.AimTo review the literature concerning these aspects and provide a better ethical and legal understanding of the new challenges concerning VR in the OR.ConclusionsThere is a disparity between (...) the two main legal models concerning VR in the OR, namely the European legal system ) and the American legal framework ). This difference mainly deals with two distinct bioethical paradigms: GDPR places a strong emphasis on protecting patients’ privacy to improve the public health system, whereas HIPAA indicates the need to generate protocols to safeguard the risks connected to medical activity and patient privacy. Following from this point, we may argue that, at the ethical and bioethical level, GDPR and HIPAA depend mainly on two different ethical models: a perspective based on moral acquaintances and weak proceduralism, respectively. It is worth noting the importance of developing additional guidelines concerning different world regions to avoid the ethical problems that may emerge when simply applying a foreign paradigm to a very different culture. (shrink)

Background: Publications and discussions of survey research in empirical bioethics have steadily increased over the past two decades. However, findings often differ among studies with similar research questions. As a consequence, ethical reasoning that considers only parts of the existing literature and does not apply systematic reviews tends to be biased. To date, we lack a systematic review (SR) methodology that takes into account the specific conceptual and practical challenges of empirical bioethics. Methods: The steps of systematically reviewing empirical findings (...) in bioethics are presented and critically discussed. In particular, (a) the limitations of traditional SR methodologies in the field of empirical bioethics are critically discussed, and (b) conceptual and practical recommendations for SRs in empirical bioethics that are (c) based on the authors’ review experiences in healthcare ethics are presented. Results: A 7-step approach for SRs of empirical bioethics is proposed: (1) careful definition of review question; (2) selection of relevant databases; (3) application of ancillary search strategies; (4) development of search algorithms; (5) relevance assessment of the retrieved references; (6) quality assessment of included studies; and (7) data analysis and presentation. Conceptual and practical challenges arise because of various peculiarities in reviewing empirical bioethics literature and can lead to biased results if they are not taken into account. Conclusions: If suitably adapted to the peculiarities of the field, SRs of empirical bioethics provide transparent information for ethical reasoning and decision-making that is less biased than single studies. (shrink)

Background As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. Method Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between October 2014 and April (...) 2015 in one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. Results Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and ‘empty beds’ presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants’ ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values. Conclusion We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers’ experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers. (shrink)

As part of its response to the 2014 Ebola outbreak in west Africa, the United Kingdom government established an Ebola treatment unit in Sierra Leone, staffed by military personnel. Little is known about the ethical challenges experienced by military medical staff on humanitarian deployment. We designed a qualitative study to explore this further with those who worked in the treatment unit. Semi-structured, face-to-face and telephone interviews were conducted with 20 UK military personnel deployed between October 2014 and April 2015 in (...) one of three roles in the Ebola treatment unit: clinician; nursing and nursing assistant; and other medical support work, including infection control and laboratory and mortuary services. Many participants reported feeling ethically motivated to volunteer for deployment, but for some personal interests were also a consideration. A small minority had negative feelings towards the deployment, others felt that this deployment like any other was part of military service. Almost all had initial concerns about personal safety but were reassured by their pre-deployment 'drills and skills', and personal protective equipment. Risk perceptions were related to perceptions about military service. Efforts to minimise infection risk were perceived to have made good patient care more difficult. Significantly, some thought the humanitarian nature of the mission justified tolerating greater risks to staff. Trust in the military institution and colleagues was expressed; many participants referred to the ethical obligation within the chain of command to protect those under their command. Participants expected resources to be overwhelmed and ‘empty beds’ presented a significant and pervasive ethical challenge. Most thought more patients could and should have been treated. Points of reference for participants’ ethical values were: previous deployment experience; previous UK/National Health Service experience; professional ethics; and, distinctly military values. We report the first systematic exploration of the ethical challenges face by a Western medical military in the international response to the first major Ebola outbreak. We offer unique insights into the military healthcare workers’ experiences of humanitarian deployment. Many participants expressed motivations that gave them common purpose with civilian volunteers. (shrink)

This paper analyses the concept of empirical ethics as well as three meta-ethical fallacies that empirical ethics is said to face: the is-ought problem, the naturalistic fallacy and violation of the fact-value distinction. Moreover, it answers the question of whether empirical ethics (necessarily) commits these three basic meta-ethical fallacies.