Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. -/- Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. -/- The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversations.

Objective: Patients' satisfaction is one of the most important goals in complete denture therapy, and there are many factors influencing this parameter. This study aimed to determine patient satisfaction with conventional removable complete denture made by clinical year students at the Faculty of Dentistry, Al Azhar University - Gaza. Methods: A sample of 85 patient who had conventional removable complete denture made by clinical year students at the Faculty of Dentistry Al Azhar University - Gaza filled a questionnaire two (...) months after denture insertion. The questionnaire involving four sections including personal information, history, denture evaluation in aspects of mastication, speech, aesthetics and retention, and patient comfort. Results: Of the 85 patient studied, 81% were males, and the mean age was 60.3 years SD+-9.64. The majority (n= 67, 79 %) lost their teeth because of bad oral hygiene. The overall satisfaction level was (92.1%), and patients were more satisfied with their upper denture. A significant association was found between the patient satisfaction and prior denture use experience (p=0.013). No significant correlation was established between the patient satisfaction and their gender (p=0.188), age group (p=0.640) and employment status (p=0.667).Conclusion: The patients have shown a high level of overall satisfaction. A significant association was found between the overall satisfaction level of patients and prior denture use experience. No statistically significant association was observed between the overall satisfaction level of patients and with each of age group, employment status and gender. (shrink)

In contemporary bioethics, the autonomy of the patient has assumed considerable importance. Progressing from a more limited notion of informed consent, shared decision making calls upon patients to voice the desires and preferences of their authentic self, engaging in choice among alternatives as a way to exercise deeply held values. One influential opinion in Jewish bioethics holds that Jewish law, in contradistinction to secular bioethics, limits the patient's exercise of autonomy only in those instances in which treatment choices are (...) sensitive to preferences. Here, we analyze a discussion in the Mishna, a foundational text of rabbinic Judaism, regarding patient autonomy in the setting of religiously mandated fasting, and commentaries in the Babylonian and Palestinian Talmuds, finding both a more expansive notion of such autonomy and a potential metaphysical grounding for it in the importance of patient self-knowledge. (shrink)

Phenomenology gives rise to certain ontological considerations that have far-reaching implications for standard conceptions of patient autonomy in medical ethics, and, as a result, the obligations of and to patients in clinical decision-making contexts. One such consideration is the phenomenological reduction in classical phenomenology, a core feature of which is the characterisation of our primary experiences as immediately and inherently meaningful. This paper builds on and extends the analyses of the phenomenological reduction in the works of Husserl, Heidegger, and (...) Merleau-Ponty in order to identify and explain its implications for our current understanding of the principle of respect for patient autonomy and the norms of clinical decision making. (shrink)

In this paper, I argue for a fundamentally different kind of moral luck, Patient Moral Luck (PML). Unlike traditional moral luck, PML concerns the amount of moral consideration that different moral patients — that is, creatures (including human beings) with moral status — will be owed, independent of factors in their control. PML, I argue, entails that morality itself appears to sanction and even obligate actions which, along predictable patterns, involve repeatedly failing to equally consider certain moral patients (...) - and repeatedly the same people - over sustained periods of time, through no fault of their own. And often these people will be members of groups who are already worse off through no fault of their own, thus exacerbating unjust inequalities. I defend the existence and normative puzzle of PML by introducing the notion of “moral force” - roughly, the amount of considerative weight a given moral patient is owed by some deliberating agent or group of agents. I then argue that this will vary widely between different moral patients through no fault or credit of their own. This, I claim, is inconsistent with the intuition that supports Equal Consideration principles in moral theory. I conclude by considering how we can minimize or mitigate PML without a radically revisionary normative theory. (shrink)

It is common to distinguish moral rules, reasons, or values that are agent-relative from those that are agent-neutral. One can also distinguish moral rules, reasons, or values that are moment-relative from those that are moment-neutral. In this article, I introduce a third distinction that stands alongside these two distinctions—the distinction between moral rules, reasons, or values that are patient-relative and those that are patient-neutral. I then show how patient-relativity plays an important role in several moral theories, gives us a better (...) understanding of agent-relativity and moment-relativity, and provides a novel objection to Derek Parfit’s “appeal to full relativity” argument. (shrink)

Background: Patient participation in clinical ethics support services has been marked as an important issue. There seems to be a wide variety of practices globally, but extensive theoretical or empirical studies on the matter are missing. Scarce publications indicate that, in Europe, patient participation in CESS varies from region to region, and per type of support. Practices vary from being non-existent, to patients being a full conversation partner. This contrasts with North America, where PP seems more or less standard. (...) While PP seems to be on the rise in Europe, there is no data to confirm this. This study sought a deep understanding of both habits and the attitudes towards PP in the Netherlands, including respondents’ practical and normative perspectives on the matter. Methods and Results: We developed a national survey on PP for Dutch CESS staff. Our survey comprised a total of 25 open and close-ended questions, focused on four topics related to PP goals of CESS, status quo of PP, ideas and ideals concerning PP, and obstacles for PP. Discussion: The four most important findings were that: Patient participation in Dutch CESS is far from standard. Views on patient participation are very much intertwined with the goals of ethics support. Hesitations, fears and perceived obstacles for PP were not on principle and Most respondents see PP as a positive opportunity, yet requiring additional training, practical guidance and experience. Conclusions: Various normative reasons require PP. However, PP seems far from standard and somewhat rare in Dutch CESS settings. Our respondents did not raise many principled objections to PP. Instead, reasons for the lack of PP are intertwined with viewpoints on the goals of CESS, which seemingly focus on supporting health care professionals. Training and practical guidance was thought to be helpful for gaining experience for both CESS staff and HCPs. (shrink)

A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are conventionally grounded in (...) a decision maker’s own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients’ evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients’ higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are. (shrink)

Owing to its grappling with a motley of intricate socioeconomic, as well as medico-legal, crises, Haiti has found itself bereft of some of its people, many of whom have had to leave the Caribbean country in search of improved lives elsewhere. Receiving some of the Haitian refugees fleeing abject poverty, unemployment, and other harms and barriers has been the United States, one of Haiti's northern neighbors and a country that has played an outcome-determinative, if not outsized, role in steering the (...) country toward its presently hobbled state. Drawing on the U.S.’s recent treatment of Haitian refugees, this paper argues that U.S. reception of Haitian immigrants rubs salt in the wound of a long history of dehumanizing and oppressive abuses endured by Haitians. Furthermore, and more importantly, this paper posits that U.S. failure to wholly embrace its legal obligation to accept Haitian refugees under international law needs to be understood in the light of the specific horrors inflicted by science, in pre-independence Haiti, on non-consenting, Afro-Haitian experimental subjects. And by extension, such a contextually-nuanced understanding is crucial in shaping the delivery of healthcare services to Haitian refugees fortunate enough to remain in the U.S. —as an awareness and appreciation of the socio-historical context of patients' lived experiences, i.e., their complete social history, can furnish important clues vis-à-vis the presence and etiologies of disease, influence the foci of physical exams, and generally pave the way for the provision of cost-efficient and evidence-based care. (shrink)

Objective: This study aimed to determine the diagnostic value of median nerve cross-sectional area (MNCSA; mm2), which can be measured using ultrasonography (US), compared with electrophysiological parameters in patients with mild and moderate carpal tunnel syndrome (CTS). Methods: The study included 72 wrists of 25 patients with CTS diagnosis and 23 healthy controls. Median and ulnar sensory and motor nerve conduction study results and MNCSA values determined by US, of all subjects were recorded. Electrophysiological and US data of (...) the patient and control groups were compared, and a correlation between MNCSA and velocity and latency of sensory and motor conduction of median nerves was investigated. Moreover, Receiver operating characteristic ROC curve analysis was performed to determine the cut-off value for diagnosing CTS with MNCSA. Differences between the mean MNCSA values, median nerve sensory conduction velocity (SCV), and motor distal latency (MDL) were statistically significant between the groups. Results: Differences between the mean MNCSA values of grade 1 CTS patients with very mild CTS and those of the healthy controls were statistically significant. There was a moderate and significant negative correlation between MNCSA and SCV values and a low and significant positive correlation between MNCSA and MDL values. In addition, there was a moderate and significant positive correlation between MNCSA values and grades. A cut-off value of 10.25 mm2, which was obtained by the ROC analysis, enabled the differentiation of patients and controls with a sensitivity of 80% and specificity of 76%. Conclusion: We suggest that MNCSA, which is calculated using US, has high sensitivity and specificity values and is used as a firstline diagnostic tool with electromyography. (shrink)

Advanced AI systems are rapidly making their way into medical research and practice, and, arguably, it is only a matter of time before they will surpass human practitioners in terms of accuracy, reliability, and knowledge. If this is true, practitioners will have a prima facie epistemic and professional obligation to align their medical verdicts with those of advanced AI systems. However, in light of their complexity, these AI systems will often function as black boxes: the details of their contents, calculations, (...) and procedures cannot be meaningfully understood by human practitioners. When AI systems reach this level of complexity, we can also speak of black-box medicine. In this paper, we want to argue that black-box medicine conflicts with core ideals of patient-centered medicine. In particular, we claim, black-box medicine is not conducive for supporting informed decision-making based on shared information, shared deliberation, and shared mind between practitioner and patient. (shrink)

Objective: There are benefits and risks of giving patients more granular control of their personal health information in electronic health record (EHR) systems. When designing EHR systems and policies, informaticists and system developers must balance these benefits and risks. Ethical considerations should be an explicit part of this balancing. Our objective was to develop a structured ethics framework to accomplish this. -/- Methods: We reviewed existing literature on the ethical and policy issues, developed an ethics framework called a “Points (...) to Consider” (P2C) document, and convened a national expert panel to review and critique the P2C. -/- Results: We developed the P2C to aid informaticists designing an advanced query tool for an electronic health record (EHR) system in Indianapolis. The P2C consists of six questions (“Points”) that frame important ethical issues, apply accepted principles of bioethics and Fair Information Practices, comment on how questions might be answered, and address implications for patient care. -/- Discussion: The P2C is intended to clarify whatis at stake when designers try to accommodate potentially competing ethical commitments and logistical realities. The P2C was developed to guide informaticists who were designing a query tool in an existing EHR that would permit patient granular control. While consideration of ethical issues is coming to the forefront of medical informatics design and development practices, more reflection is needed to facilitate optimal collaboration between designers and ethicists. This report contributes to that discussion. (shrink)

Health services internationally struggle to ensure health care is “person-centered” (or similar). In part, this is because there are many interpretations of “person-centered care” (and near synonyms), some of which seem unrealistic for some patients or situations and obscure the intrinsic value of patients’ experiences of health care delivery. The general concern behind calls for person-centered care is an ethical one: Patients should be “treated as persons.” We made novel use of insights from the capabilities approach to (...) characterize person-centered care as care that recognizes and cultivates the capabilities associated with the concept of persons. This characterization unifies key features from previous characterisations and can render person-centered care applicable to diverse patients and situations. By tying person-centered care to intrinsically valuable capability outcomes, it incorporates a requirement for responsiveness to individuals and explains why person-centered care is required independently of any contribution it may make to health gain. (shrink)

Abstract:Respect for persons protects patients regarding their own healthcare decisions. Patient informed choice for altruism (PICA) is a proposed means for a fully autonomous patient with decisionmaking capacity to limit his or her own treatment for altruistic reasons. An altruistic decision could bond the patient with others at the end of life. We contend that PICA can also be an advance directive option. The proxy, family, and physicians must be reminded that a patient’s altruistic treatment refusal should be respected.

Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both children and adults seeks to establish guidelines for the use of extracorporeal membrane oxygenation if there are not enough resources to treat every patient. Experts in critical care, end-of-life care, bioethics, (...) and health policy discuss if age should guide rationing decisions. (shrink)

Patient-funded trials are gaining traction as a means of accelerating clinical translation. However, such trials sidestep mechanisms that promote rigor, relevance, efficiency, and fairness. We recommend that funding bodies or research institutions establish mechanisms for merit review of patient-funded trials, and we offer some basic criteria for evaluating PFT protocols.

Patient preference predictors aim to solve the moral problem of making treatment decisions on behalf of incapacitated patients. This commentary on a case of an unrepresented patient at the end of life considers 3 related problems of such predictors: the problem of restricting the scope of inputs to the models (the “scope” problem), the problem of weighing inputs against one another (the “weight” problem), and the problem of multiple reasonable solutions to the scope and weight problems (the “multiple reasonable (...) models” problem). Each of these problems poses challenges to reliably implementing patient preference predictors in important, high-stakes health care decision making. This commentary also suggests a way forward. (shrink)

Paul Ricoeur argues that narration is lived life. Therefore, human experience has a narrative dimension, ie, it has a narrative structure and every effort you want to make for the human need to consider the narrative. For this reason, the text theory is converted to Ricoeur in a general model for the study of human action, since this is conceived as an open work to anyone who can read it. Given this general framework for discussion, we have deepened the notion (...) of the patient as “text”, and described their richness for reflection of bioethics and medical act, rescuing the value of listening, prudence, responsibility and rediscovering a place for the principle of autonomy and casuistry. -/- Paul Ricoeur sostiene que la narración es vida vivida. Por lo tanto, la experiencia humana posee una dimensión narrativa, es decir, tiene una estructura narrativa y todo esfuerzo que quiera dar cuenta de lo humano tendrá que contar con lo narrativo. Por esta razón, la teoría del texto se convierte para Ricoeur en un modelo general para el estudio de la acción humana, pues esta es concebida como una obra abierta a cualquiera que pueda leer. Teniendo en cuenta este marco general de reflexión, hemos profundizado en la noción del paciente como “texto”, y describimos su riqueza para la reflexión de la bioética y el actuar médico, rescatando el valor de la escucha, la prudencia, la responsabilidad y redescubriendo un lugar para el principio de autonomía y la casuística. (shrink)

With the ageing of the Portuguese population, there are more people in dependency situations and needing long-term care (LTC). In this context, it is important to ensure the quality of life (QoL) of those individuals, and that quality can be measured through their health-related quality of life (HRQoL) and overall well-being. Also, understanding how perceived service quality (PSQ) can be related to how people perceive their QoL is pertinent since service quality is an important factor to achieve patient health outcomes. (...) To develop this project, a LTC unit located in the district of Lisbon was chosen, the LTC unit of Arruda dos Vinhos. The main objective was to assess the relation between the PSQ, the HRQoL and the overall well-being of patients receiving LTC at the LTC unit of Arruda dos Vinhos. A project based on a case study was performed, through interviews based on the items of the SERVPERF, EQ-5D and ICECAP-O questionnaires, which were then analysed through content analysis. Results showed there is a relation between PSQ and HRQoL and between HRQoL and overall well-being. It was also possible to realise that to better evaluate the quality of this specific service, other subjects as the activities performed at the LTC unit, the physiotherapy service and the food provided, should be taken in consideration. Concluding, there is a relation between PSQ and the QoL of the patients receiving LTC at the LTC unit of Arruda dos Vinhos, when quality of life is measured through HRQoL. (shrink)

A number of bioethicists have been critical of the power of the family to “veto” a patient’s decision to posthumously donate her organs within opt-in systems of organ procurement. One major objection directed at the family veto is that when families veto the decision of their deceased family member, they do something wrong by violating or failing to respect the autonomy of that deceased family member. The goal of this paper is to make progress on answering this objection. I do (...) this in two stages. First, I argue that the most plausible interpretation of what happens when a person registers as an organ donor in an opt-in system is that she gives her consent to the state to posthumously remove her organs for transplantation purposes. Call this the Authorization Account. Second, given the Authorization Account, I argue by analogy that when families veto an individual’s decision to donate and the individual’s organs are not in the end removed, neither the doctors nor the family violate the individual’s autonomy in any morally objectionable sense. Call this the Nonremoval Thesis. I argue that since the Nonremoval Thesis is true, we do not violate or fail to respect the autonomy of registered donors when we fail to remove their organs because their family has objected. (shrink)

Background: The complexity of diagnostic presentations of an inpatient psychiatry population requires an integrative approach to health and well-being. In this sense, the primary need of this research aims at developing clinical strategies and healthier coping skills for anger, anxiety, and depression; promoting self-esteem, healthier sleep, and anxiety reduction; as well as enhancing mood and emotional–behavioral regulation via exercise and nutrition education. Objectives: The primary objective is to promote exercise, fitness, and physical health in inpatient psychiatry patients. The secondary (...) objective includes therapeutic management of depressive symptoms and patient-centered approach to mania, angry outbursts, and generalized disruptive behavior. The tertiary objective is promoting research in the psychophysiological effectors of exercise and nutrition education in combination with psychotherapy. Method: Monitoring self-reported changes in mood and general well-being via administration of surveys and questionnaires pre- and postexercise sessions. Results: The research yielded positive outcomes in all areas investigated, suggesting the positive effects of exercise and mind–body strategies in the context of psychotherapy in inpatient psychiatry. Conclusion: Physical exercise may be a helpful way to reduce mental health disorders in the context of inpatient psychiatry by targeting anxiety, depression, anger, psychomotor agitation, and muscle tension and addressing stressors and triggers and to develop a more balanced and integrated sense of self. (shrink)

Except in extraordinary circumstances, patients' clinical care should reflect their preferences. Incapacitated patients cannot report their preferences. This is a problem. Extant solutions to the problem are inadequate: surrogates are unreliable, and advance directives are uncommon. In response, some authors have suggested developing algorithmic "patient preference predictors" (PPPs) to inform care for incapacitated patients. In a recent paper, Earp et al. propose a new twist on PPPs. Earp et al. suggest we personalize PPPs using modern machine learning (...) (ML) techniques. In this paper, I argue that, contrary to Earp et al.'s claim, personalized patient preference predictors are neither technically feasible nor ethically desirable. (shrink)

The slogan “Do Your Own Research” (DYOR) is often invoked by people who are distrustful, even downright sceptical, of recognized expert authorities. While this slogan may serve various rhetorical purposes, it also expresses an ethic of inquiry that valorises independent thinking and rejects uncritical deference to recognized experts. This paper is a qualified defence of this ethic of inquiry in one of the central contexts in which it might seem attractive. I use several case studies of patient activist groups to (...) argue that these groups often engage in valuable independent research that advances biomedical knowledge. In doing so they demonstrate the value of “lay expertise” and the epistemic as well as political necessity of not simply deferring to recognized experts. I also give some reasons why patient activist groups often produce valuable biomedical knowledge: they are examples of what I call “research collectives”. Research collectives are research communities that differ from the traditional research communities we find in universities and research institutes in that their members typically lack formal relevant scientific credentials and training. But they are similar in that they have internal structures—training procedures, norms of discussion, venues for holding discussions—that facilitate the production of knowledge. I finish by suggesting that future research into the differences and similarities between research collectives and traditional research communities is required. (shrink)

Recently, Jardas _et al_ have convincingly defended the patient preference predictor (PPP) against a range of autonomy-based objections. In this response, I propose a new autonomy-based objection to the PPP that is not explicitly discussed by Jardas _et al_. I call it the ‘objection from higher-order preferences’. Even if this objection is not sufficient reason to reject the PPP, the objection constitutes a pro tanto reason that is at least as powerful as the ones discussed by Jardas _et al._.

In a rigorous systematic review, Dukhanin and colleagues categorize metrics and evaluative tools of the engagement of patient, public, consumer, and community in decision-making in healthcare institutions and systems. The review itself is ably done and the categorizations lead to a useful understanding of the necessary elements of engagement, and a suite of measures relevant to implementing engagement in systems. Nevertheless, the question remains whether the engagement of patient representatives in institutional or systemic deliberations will lead to improved clinical outcomes (...) or increased engagement of individual patients themselves in care. Attention to the conceptual foundations of patient engagement would help make this systematic review relevant to the clinical care of patients. (shrink)

There are two main questions that any account of corporate lawyers’ moral obligations needs to answer: (1) Do corporate lawyers have moral obligations to third parties? and (2) In cases of conflict between obligations to the corporation and obligations to third parties, which should prevail? This Article offers answers to these questions in the context of lawyers working in medical corporations. I argue that lawyers do have moral obligations to third parties, and that in cases where patients’ rights are (...) being violated by a medical company, patients’ rights should prevail. Consequently, attorney–client confidentiality rules should be relaxed to allow for attorney disclosures in egregious cases of potential harm to third parties. (shrink)

Epileptogenesis involves an increase in excitatory synaptic strength in the brain in a manner similar to synaptic potentiation. In the present study we investigated the mechanisms of short-term synaptic potentiation in patients with focal epilepsy by using 5 Hz repetitive transcranial magnetic stimulation (rTMS), a non invasive neurophysiological technique able to investigate the mechanisms of synaptic plasticity in humans. Ten patients with focal idiopathic cortical epilepsy were studied. 5 Hz-rTMS (10 stimuli-trains, 120% of motor threshold, RMT) was delivered (...) over the first dorsal interosseus (FDI) motor area of both (affected and unaffected) hemispheres. Changes in the motor evoked potential (MEP) size in the FDI muscle during the trains and the RMT were measured and compared between the hemispheres. 5 Hz-rTMS was also delivered in a group of healthy subjects over both hemispheres. 5 Hz-rTMS in patients elicited a reduced MEP facilitation compared to normal subjects. The reduced MEP amplitude was more evident in the affected hemisphere than in the unaffected hemisphere. RMT in the affected hemisphere was higher than in the unaffected hemisphere and in healthy subjects. Our findings showing a decreased response to 5 Hz-rTMS over the affected hemisphere, differently from the expected results suggest a reduced cortical excitability in epileptic patients. We hypothesize an altered balance between excitatory and inhibitory circuits in epileptic patients under chronic therapy. (shrink)

In this chapter, our focus is the role played by notions of rationality in the diagnosis of mental disorders, and in the practice of overriding patient autonomy in psychiatry. We describe and evaluate different hypotheses concerning the relationship between rationality and diagnosis, raising questions about what features underpin psychiatric categories. These questions reinforce widely held concerns about the use of diagnosis as a justification for overriding autonomy, which have motivated a shift to mental incapacity as an alternative justification. However, this (...) approach too has recently been criticized from a mental disability rights perspective. Our analysis of the relationship between mental capacity and rationality is used to illuminate these concerns, and to investigate further the relationship between rationality and psychiatric diagnosis. (shrink)

This report describes a questionnaire-based study on 309 adult patients attending the Dental Outpatients Department of Bangladesh Medical College and Hospital, Dhaka during December 2000 to March 2001. The aim of the study was to determine the oral health knowledge of the patients in relation to their age, gender, economic and educational status. Almost two third (63.1%) of the subjects correctly said that pan chewing was bad for teeth. Three fourth (78.3%) of the subjects gave correct answer on (...) question of how to prevent teeth decay. When question was asked about cause of teeth decay, bleeding gum and action of fluoride on teeth, only 38.2%, 41.4% and 32.3% could give correct answer respectively. With a few exceptions, knowledge of oral health was comparatively poor among the older generation, females, less educated and less privileged group. (shrink)

Precision medicine functions by grouping patients along genetic, molecular, and related ‘-omics’ factors. This stratification relies on large, growing databases of patient-volunteered information. Both private companies and government bodies incentivize patients to volunteer this genetic information appealing to the creation of collaborative patient partnerships and the concept of empowerment. This paper aims to address two related questions: (1) what is the actual nature of patient participation in precision medicine research? And (2) is this participation in precision medicine research (...) really that empowering for the average patient? I contend that firstly, the nature of this participation is best conceived of as merely contributory. Contributory participation, as it will be shown, falls short of collaboration. The partnership created by participation in precision medicine research is not one of sharing values, equal say in decisions, or shared benefit. Secondly, I contend that there are important caveats to claims that patient participation in precision medicine is empowering. Empowerment is hindered by the type of participation, the practical use or actionability of genetic data, genetic literacy, the cost of precision drugs for patients that qualify for them, and bioethical considerations of informed consent. (shrink)

Does DBS change a patient’s personality? This is one of the central questions in the debate on the ethics of treatment with Deep Brain Stimulation (DBS). At the moment, however, this important debate is hampered by the fact that there is relatively little data available concerning what patients actually experience following DBS treatment. There are a few qualitative studies with patients with Parkinson’s disease and Primary Dystonia and some case reports, but there has been no qualitative study yet (...) with patients suffering from psychiatric disorders. In this paper, we present the experiences of 18 patients with Obsessive-Compulsive Disorder (OCD) who are undergoing treatment with DBS. We will also discuss the inherent difficulties of how to define and assess changes in personality, in particular for patients with psychiatric disorders. We end with a discussion of the data and how these shed new light on the conceptual debate about how to define personality. (shrink)

ABSTRACT When patients refuse to receive medical treatment, the consequences of honouring their decisions can be tragic. This is no less true of patients who autonomously decide to refuse treatment. I distinguish three possible implications of these autonomous decisions. According to the Permissibility Claim, such a decision implies that it is permissible for the patient who has made the autonomous decision to forego medical treatment. According to the Anti‐Paternalism Claim, it follows that health‐care professionals are not morally permitted (...) to treat that patient. According to the Binding Claim it follows that these decisions are binding on health‐care professionals. My focus is the last claim. After arguing that it is importantly different from each of the first two claims, I give two arguments to show that it is false. One argument against the Binding Claim draws a comparison with cases in which patients autonomously choose perilous positive treatments. The other argument appeals to considered judgments about cases in which disincentives are used to deter patients from refusing sound treatments. (shrink)

Abstract: Artificial Intelligence (AI) is rapidly becoming a cornerstone of modern healthcare, offering unprecedented capabilities in diagnostics, treatment planning, patient care, and healthcare management. This paper explores the transformative impact of AI on the healthcare sector, examining how it enhances patient outcomes, improves the efficiency of medical practices, and introduces new ethical and operational challenges. By analyzing current applications such as AI-driven diagnostic tools, personalized medicine, and hospital management systems, this paper highlights the significant advancements AI has brought to the (...) field. However, the integration of AI also raises concerns related to data privacy, algorithmic bias, and the displacement of healthcare professionals. This study provides a comprehensive overview of these developments, offering insights into the future potential of AI in revolutionizing healthcare while addressing the ethical considerations that must accompany its adoption. The findings suggest that while AI holds the promise of transforming healthcare delivery, careful consideration of its implications is essential to ensure equitable and effective implementation. (shrink)

Patients with serious illnesses or injuries may decide to quit their medical treatment if they think paying the fees will put their families into destitution. Without treatment, it is likely that fatal outcomes will soon follow. We call this phenomenon “near-suicide”. This study attempted to explore this phenomenon by examining how the seriousness of the patient’s illness or injury and the subjective evaluation of the patient’s and family’s financial situation after paying treatment fees affect the final decision on the (...) treatment process. Bayesian Mindsponge Framework (BMF) analytics were employed to analyze a dataset of 1042 Vietnamese patients. We found that the more serious the illnesses or injuries of patients were, the more likely they were to choose to quit treatment if they perceived that paying the treatment fees heavily affected their families’ financial status. Particularly, only one in four patients with the most serious health issues who thought that continuing the treatment would push themselves and their families into destitution would decide to continue the treatment. Considering the information-filtering mechanism using subjective cost–benefit judgments, these patients likely chose the financial well-being and future of their family members over their individual suffering and inevitable death. Our study also demonstrates that mindsponge-based reasoning and BMF analytics can be effective in designing and processing health data for studying extreme psychosocial phenomena. Moreover, we suggest that policymakers implement and adjust their policies (e.g., health insurance) following scientific evidence to mitigate patients’ likelihood of making “near-suicide” decisions and improve social equality in the healthcare system. (shrink)

Disclosure in clinical practice is aimed at promoting patient autonomy, usually culminating in patient choice (e.g., to consent to an operation or not, or between different medications). In medical ethics, there is an implicit background assumption that knowing more about (X) automatically translates to greater, or more genuine, autonomy with respect to one's choices involving (X). I challenge this assumption by arguing that in rare cases, withholding information can promote a patient's autonomy (understood as the capacity for rational choice in (...) alignment with one's values and goals). (shrink)

An AI-based “patient preference predictor” (PPP) is a proposed method for guiding healthcare decisions for patients who lack decision-making capacity. The proposal is to use correlations between sociodemographic data and known healthcare preferences to construct a model that predicts the unknown preferences of a particular patient. In this paper, I highlight a distinction that has been largely overlooked so far in debates about the PPP–that between algorithmic prediction and decision-making–and argue that much of the recent philosophical disagreement stems from (...) this oversight. I show how three prominent objections to the PPP only challenge its use as the sole determinant of a choice, and actually support its use as a source of evidence about patient preferences to inform human decision-making. The upshot is that we should adopt the evidential conception of the PPP and shift our evaluation of this technology towards the ethics of algorithmic prediction, rather than decision-making. (shrink)

KEY POINTS In Canada, commercial data brokers collect deidentified patient data from pharmacies, private drug insurers, the federal government and medical clinics without patient consent. Although pharmaceutical companies are the data brokers’ primary customers, academics and nonprofit and public entities also use commercial data sets, given the absence of a coordinated public approach to collecting these data across Canada. Risks of commercialized patient data include loss of anonymity, surveillance and marketing, discrimination and violation of Indigenous data sovereignty. Coordinated infrastructure for (...) the collection and coordination of health data across Canada and updated privacy legislation would protect individuals and communities and enable appropriate data uses. (shrink)

Deep Brain Stimulation (DBS) is a relatively new, experimental treatment for patients suffering from treatment-refractory Obsessive Compulsive Disorder (OCD). The effects of treatment are typically assessed with psychopathological scales that measure the amount of symptoms. However, clinical experience indicates that the effects of DBS are not limited to symptoms only: patients for instance report changes in perception, feeling stronger and more confident, and doing things unreflectively. Our aim is to get a better overview of the whole variety of (...) changes that OCD patients experience during DBS treatment. For that purpose we conducted in-depth, semi-structured interviews with 18 OCD patients. In this paper, we present the results from this qualitative study.We list the changes grouped in four domains: with regard to (a) person, (b) (social) world, (c)characteristics of person-world interactions, and (d) existential stance. We subsequently provide an interpretation of these results. In particular, we suggest that many of these changes can be seen as different expressions of the same process; namely that the experience of anxiety and tension gives way to an increased basic trust and increased reliance on one’s abilities. We then discuss the clinical implications of our findings, especially with regard to properly informing patients of what they can expect from treatment, the usefulness of including CBT in treatment, and the limitations of current measures of treatment success. We end by making several concrete suggestions for further research. (shrink)

New technologies such as smart sensors improve rehabilitation processes and thereby increase older adults’ capabilities to participate in social life, leading to direct physical and mental health benefits. Wearable smart sensors for home use have the additional advantage of monitoring day-to-day activities and thereby identifying rehabilitation progress and needs. However, identifying and selecting rehabilitation priorities is ethically challenging because physicians, therapists, and caregivers may impose their own personal values leading to paternalism. Therefore, we develop a discussion template consisting of a (...) series of adaptable questions for the patient–physician encounter based on the capability approach. The goal is to improve geriatric rehabilitation and thereby increase participation in social life and well-being. To achieve this goal, we first analyzed what is considered important for participation on basis of the capability approach, human rights, and ethics of care. Second, we conducted an ethical analysis of each of the four identified dimensions of participation: political, economic, socio-cultural, and care. To improve compliance with rehabilitation measures, health professionals must align rehabilitation measures in an open dialogue with the patient’s aspiration for participation in each dimension. A discussion template based on the capability approach allows for a proactive approach in patient information and stimulates a critical assessment of treatment alternatives while reducing the risk of imposing personal values. (shrink)

In this paper, we defend three claims about what it will take for an AI system to be a basic moral patient to whom we can owe duties of non-maleficence not to harm her and duties of beneficence to benefit her: (1) Moral patients are mental patients; (2) Mental patients are true intentional systems; and (3) True intentional systems are systematically flexible. We suggest that we should be particularly alert to the possibility of such systematically flexible true (...) intentional systems developing in the areas of exploratory robots and artificial personal assistants. Finally, we argue that in light of our failure to respect the well-being of existing biological moral patients and worries about our limited resources, there are compelling moral reasons to treat artificial moral patiency as something to be avoided at least for now. (shrink)

Healthcare professionals decide wisely about personalized medicine, treatment plans, and resource allocation by utilizing big data analytics and machine learning. To guarantee that algorithmic recommendations are impartial and fair, however, ethical issues relating to prejudice and data privacy must be taken into account. Big data analytics and machine learning have a great potential to disrupt healthcare, and as these technologies continue to evolve, new opportunities to reform healthcare and enhance patient outcomes may arise. In order to investigate the patient’s outcomes (...) with empirical evidence, this research was conducted using an online survey to incorporate healthcare professionals, patient’s reviews, and clinical staff. The data were analyzed using SmartPLS 4.0 to predict the structural model. The findings revealed a direct impact as positive influence of using machine learning on healthcare performance and patient outcomes through big data analytics. Moreover, it is evident that this can lead to personalized treatment plans, early interventions, and improved patient outcomes. Additionally, big data analytics can help healthcare providers optimize resource allocation, improve operational efficiency, and reduce costs. The impact of big data analytics on patient outcome and healthcare performance is expected to continue to grow, making it an important area for investment and research. (shrink)

Suicide is a major public health issue in many industrialized countries. It is one of the top ten causes of death and older age is a significant risk factor for suicide. For example, in Japan older adults (age ≥ 65) shared about 18.5% of total population but account for 24% of all suicide, in Taiwan, older adults representing 12.4% of the total population and account for 28.9% of suicide death. Dementia is a broad term for a progressive deterioration in memory (...) ability and dementia patients ran higher risk for suicide. (shrink)

The notion that the family is the unit of care for family doctors has been enigmatic and controversial. Yet systems theory and the biopsychosocial model that results when it is imported into medicine make the family system an indispensable and important component of family medicine. The challenge, therefore, is to provide a coherent, plausible account of the role of the family in family practice. Through an extended case presentation and commentary, we elaborate two views of the family in family medicine (...) — treating the patient in the family and treating the family in the patient — and defend both as appropriate foci for care by family doctors. The practical problem that arises when the family is introduced into health care is deciding when to concentrate on the family system. The moral problems that arise concern how extensively doctors may become involved in the personal lives of their patients and families. The patient-centered clinical method provides a strategy for handling both problems. Thus, making the family a focus of care in family medicine can be justified on theoretical, practical, and moral grounds. (shrink)

In order to determine whether current (or future) machines have a welfare that we as agents ought to take into account in our moral deliberations, we must determine which capacities give rise to interests and whether current machines have those capacities. After developing an account of moral patiency, I argue that current machines should be treated as mere machines. That is, current machines should be treated as if they lack those capacities that would give rise to psychological interests. Therefore, they (...) are moral patients only if they have non-psychological interests. I then provide an account of what I call teleo interests that constitute the most plausible type of non-psychological interest that a being might have. I then argue that even if current machines have teleo interests, they are such that agents need not concern themselves with these interests. Therefore, for all intents and purposes, current machines are not moral patients. (shrink)

Objectives: This study aimed to fill the gap between Vietnamese diabetic patients' needs and care through a qualitative study asking about their experiences with diabetes and quality of care. -/- Methods: Interviews with five diabetic patients were conducted at a tertiary general hospital located in southern Vietnam. The transcribed data were first subjected to quantitative text analysis using KH Coder to identify major categories of frequently used words, followed by a qualitative analysis of selected cases using the Steps (...) for Coding and Theorization (SCAT) method. -/- Results: The major categories of frequently used words were chronic health conditions, services, facilities, insurance, patient-doctor communication, and medication. SCAT analysis of three selected cases identified six themes: “Disregarding the disease at the early stage,” “Fear of complications,” “Satisfaction with hospital services and medical staff,” “Insurance-related problems,” “Long waiting times,” and “Communication barriers between patients and doctors.” Patients were satisfied with improved hospital facilities and services; however, the overloading of one hospital led to long waiting times and communication difficulties with doctors. Difficulties with health insurance were also observed, and patients were rather passive in disease management and needed to be empowered through improved communication with doctors and other care providers. -/- Conclusion: These findings from our trial of introducing a qualitative study into service evaluation suggest that listening to patients can help health providers learn their perspectives and be more responsive to their needs. (shrink)

Introduction Current treatments for pain have limited benefits and worrying side effects. Some studies suggest that pain is reduced when clinicians deliver positive messages. However, the effects of positive messages are heterogeneous and have not been subject to meta-analysis. We aimed to estimate the efficacy of positive messages for pain reduction. -/- Methods We included randomized trials of the effects of positive messages in a subset of the studies included in a recent systematic review of context factors for treating pain. (...) Several electronic databases were searched. Reference lists of relevant studies were also searched. Two authors independently undertook study selection, data extraction, risk of bias assessment, and analyses. Our primary outcome measures were differences in patient- or observer-reported pain between groups who were given positive messages and those who were not. -/- Results Of the 16 randomized trials (1703 patients) that met the inclusion criteria, 12 trials had sufficient data for meta-analysis. The pooled standardized effect size was −0.31 (95% confidence interval [CI] −0.61 to −0.01, p = 0.04, I2 = 82%). The effect size remained positive but not statistically significant after we excluded studies considered to have a high risk of bias (standard effect size −0.17, 95% CI −0.54 to 0.19, P = 0.36, I2 = 84%). -/- Conclusion Care of patients with chronic or acute pain may be enhanced when clinicians deliver positive messages about possible clinical outcomes. However, we have identified several limitations of the present study that suggest caution when interpreting the results. We recommend further high-quality studies to confirm (or falsify) our result. -/- FUNDING -/- Alexander Mebius research has been funded through the ERC grant "Philosophy of Pharmacology: Safety, Statistical Standards, and Evidence Amalgamation" (GA: 639276). (shrink)

Narratives have come to influence medicine, giving rise to a new approach called "narrative medicine". In this paper, we consider the patient as a text, an open book in which physicians and healthcare professionals, but also from which they can and should learn a great deal. By delving into the narrative perspective of understanding the patient and their situation, we discover how the patient is the object of the physician's compassion, but also how he or she becomes the subject of (...) that compassion. We conclude that it is important for physicians to spend time in their undergraduate and graduate medical education exploring and using the value of narratives to help them categorize their lived experiences and those of patients. -/- As narrativas estão chegando a influenciar na medicina, dando origem a uma nova abordagem chamada " medi-cina narrativa ". Neste trabalho consideramos o paciente como um texto, em outras palavras, um livro aberto que o médico intervém, mas também, que deve aprender muito. Aprofundar-se um pouco na perspectiva narrativa da compreensão do paciente e de sua situação ajuda a descobrir como o paciente é objeto da compaixão dos médicos, embora também como se converte em sujeito desta compaixão. Concluímos que é importante que os médicos dediquem mais tempo em sua formação médica inicial, bem como em sua formação permanente, para explorar o valor das narrativas que ajudam a categorizar suas experiências e a dos pacientes. -/- Las narraciones han llegado a influir en la medicina, dando lugar a un nuevo enfoque llamado " medicina narrativa ". En este trabajo consideramos al paciente como un texto, es decir, un libro abierto que el médico interviene, pero también del que el médico puede y necesita mucho aprender. Ahondar un poco en la perspectiva narrativa de la comprensión del paciente y de su situación nos ayuda a descubrir cómo el paciente es objeto de la compasión de los médicos, pero también cómo se convierte en sujeto de esa compasión. Concluimos que es importante que los médicos dediquen tiempo en su formación médica inicial, así como en su formación permanente, a explorar y explotar el valor de las narraciones, que les ayuden a categorizar sus experiencias vividas y las de los pacientes. (shrink)

Last year saw the 20th anniversary edition of JECP, and in the introduction to the philosophy section of that landmark edition, we posed the question: apart from ethics, what is the role of philosophy ‘at the bedside’? The purpose of this question was not to downplay the significance of ethics to clinical practice. Rather, we raised it as part of a broader argument to the effect that ethical questions – about what we should do in any given situation – are (...) embedded within whole understandings of the situation, inseparable from our beliefs about what is the case, what it is that we feel we can claim to know, as well as the meaning we ascribe to different aspects of the situation or to our perception of it. Philosophy concerns fundamental questions: it is a discipline requiring us to examine the underlying assumptions we bring with us to our thinking about practical problems. Traditional academic philosophers divide their discipline into distinct areas that typically include logic: questions about meaning, truth and validity; ontology: questions about the nature of reality, what exists; epistemology: concerning knowledge; and ethics: how we should live and practice, the nature of value. Any credible attempt to analyse clinical reasoning will require us to think carefully about these types of question and the relationships between them, as they influence our thinking about specific situations and problems. So, the answers to the question we posed, about the role of philosophy at the bedside, are numerous and diverse, and that diversity is illustrated in the contributions to this thematic edition. (shrink)

My question in the chapter is this: could (and should) the role of the physician be construed as that of a friend to the patient? I begin by briefly discussing the “friendship model” of the physician-patient relationship—according to which physicians and patients could, and perhaps should, be friends—as well as its history and limitations. Given these limitations, I focus on the more one-sided idea that the physician could, and perhaps should, be a friend to the patient (a “physician-qua-friend model” (...) of the physician-patient relationship). I show that given recent developments in our understanding of the physician-patient relationship, this idea is far from asinine. I then make the case that the most plausible conception of the physician-qua-friend model incorporates the following components: (a) a common goal, that is, one that physician and patient share; (b) certain forms of equality between physician and patient; (c) an ideal of a caring physician. Finally, I show how the model can be instantiated in a certain type of physician-patient interaction, namely, in physician-assisted dying. (shrink)

Built-in decision thresholds for AI diagnostics are ethically problematic, as patients may differ in their attitudes about the risk of false-positive and false-negative results, which will require that clinicians assess patient values.