Ethical dilemmas in early detection of dementia. An inventory of moral intuitions in practice

In this article we present an inventory of the moral intuitions of the health care workers who work in the field of early detection of dementia. The effects of pharmacological treatment and professional care and support may improve when dementia is detected in an early stage. Furthermore, the patient (and his family) can prepare themselves for the period to come. Health care workers recognize moral problems and tensions concerning early detection that are related to the question whether persons will benefit from knowledge in an earlier stage of dementia, because this knowledge can be a heavy burden. We asked general practitioners, home care workers, employees of the so-called 'Memory clinic' and specialists, what ethical intuitions they recognize in practice. They mentioned the following questions: when are health care professionals allowed to take initiative, is causing worries and concerns problematic, and should a diagnosis always to be told? We conclude after a first analysis that many moral questions derive from the fact that many health care professionals lack knowledge of the wishes and interests of the elderly. At the same time they try to justify their actions on the (presupposed) consent of the elderly person. We suggest that the general norm 'only act when the patient wants to be helped' in health care should also apply to detection of dementia, although it should not be taken too strictly. Another justification for early detection can be found in the benefits for the elderly people, when their wishes are no longer expressed.     

Freedom of Conscience in Health Care: Distinctions and Limits

The widespread emergence of innumerable technologies within health care has complicated the choices facing caregivers and their patients. The escalation of knowledge and technical innovation has been accompanied by an erosion of moral and ethical consensus among health providers that is reflected in the abandonment of the Hippocratic Oath as the immutable bedrock of medical ethics. Ethical conflicts arise when the values of health professionals collide with the expressed wishes of patients or the dictates of regulatory bodies and administrators. Increasing attempts by groups outside of the medical profession to limit freedom of conscience for health providers has raised concern and consternation among some health professionals. The personal and professional impact of health professionals surrendering freedom of conscience and participating in actions they deem malevolent or unethical has not been adequately studied and may not be inconsequential when considering the recognized impact of other circumstances of coerced complicity. We argue that the distinction between the two ways that freedom of conscience is exercised (avoiding a perceived evil and seeking a perceived good) provides a rational basis for a principled limitation of this fundamental freedom.     

Ethical beliefs and practices of AAPB members

Ethical codes and principles and laws govern the behavior of health-care professionals. Yet, the impact that ethical codes and laws have on the actual moral behaviors of health-care professionals is relatively unknown. A survey on the ethical beliefs and practices of health-care professionals was sent to the United States membership of the Association for Applied Psychophysiology and Biofeedback. AAPB's heterogeneous membership offers a unique opportunity to compare the ethical beliefs and behaviors of professionals across various health-care professions, educational levels, licensure and certification statuses, age, years in practice, and gender. The survey examined the respondents' ethical beliefs and practices in the domains of confidentiality, dual relationships, and professional practice. Five hundred thirty-six surveys were returned completed. The results of the survey indicate that all respondents have substantially the same reported ethical beliefs and practices across the three domains. There were no statistically significant differences between the reported ethical beliefs or practices when compared across disciplines, educational levels, licensure or certification statuses, age, or years in practice. Statistically significant gender differences were found.     

Clinician experiences of managed mental health care: a rereading of the threat

The threat mental health professionals perceive in managed care, as indicated by their writings on the subject, is re-examined in light of evidence from an ethnographic study. Fieldwork focusing on clinician experiences of managed care was carried out at an urban community mental health center. Existing explanations of "the threat"—the possibility of deprofessionalization and the potential for deterioration in the quality of care—proved inadequate to account for the power it wielded at this site, perhaps because its full impact had yet to be felt at the time of data collection. A "rereading " suggests the meaning of managed care for this group of clinicians lies in the prospect of being gradually, unknowingly, and unwillingly reprofessionalized from critics into proponents simply by virtue of continuing to practice in a managed care context, and in losing a moral vision of good mental health treatment in the process, [clinician experience, mental health, managed care, medical anthropology]     

The Ethics of Medical Practitioner Migration From Low-Resourced Countries to the Developed World: A Call for Action by Health Systems and Individual Doctors

Medical migration appears to be an increasing global phenomenon, with complex contributing factors. Although it is acknowledged that such movements are inevitable, given the current globalized economy, the movement of health professionals from their country of training raises questions about equity of access and quality of care. Concerns arise if migration occurs from low- and middle-income countries (LMICs) to high-income countries (HICs). The actions of HICs receiving medical practitioners from LMICs are examined through the global justice theories of John Rawls and Immanuel Kant. These theories were initially proposed by Pogge (1988) and Tan (1997) and, in this work, are extended to the issue of medical migration. Global justice theories propose that instead of looking at health needs and workforce issues within their national boundaries, HICs should be guided by principles of justice relevant to the needs of health systems on a global scale. Issues of individual justice are also considered within the framework of rights and social responsibilities of individual medical practitioners. Local and international policy changes are suggested based on both global justice theories and the ideals of individual justice.     

Defining standard of care in the developing world: the intersection of international research ethics and health systems analysis

In recent years there has been intense debate regarding the level of medical care provided to 'standard care' control groups in clinical trials in developing countries, particularly when the research sponsors come from wealthier countries. The debate revolves around the issue of how to define a standard of medical care in a country in which many people are not receiving the best methods of medical care available in other settings. In this paper, we argue that additional dimensions of the standard of care have been hitherto neglected, namely, the structure and efficiency of the national health system. The health system affects locally available medical care in two important ways: first, the system may be structured to provide different levels of care at different sites with referral mechanisms to direct patients to the appropriate level of care. Second, inefficiencies in this system may influence what care is available in a particular locale. As a result of these two factors locally available care cannot be equated with a national 'standard'. A reasonable approach is to define the national standard of care as the level of care that ought to be delivered under conditions of appropriate and efficient referral in a national system. This standard is the minimum level of care that ought to be provided to a control group. There may be additional moral arguments for higher levels of care in some circumstances. This health system analysis may be helpful to researchers and ethics committees in designing and reviewing research involving standard care control groups in developing country research.     

Tissue banking training courses: Polish experience

Personnel directly involved in the donation, procurement, testing, processing, preservation, storage and distribution of human tissues and cells should be appropriately qualified and provided with timely and relevant training according to EU directives. In the time of new tissue and cells regulations implementation such a training system existed in Poland only at a local level. The first training programme outlines for various groups of health professionals engaged in tissue banking practice was created in co-operation with the Institute for LifeLong Learning at University of Barcelona in 2006. This initial training courses were financially supported by EU Transition Facility Programme 2004. Then, starting from 2006, based on previous experience, system of advanced training courses was created. This training programme was financially supported by the National Programme for the Development of Transplantation Medicine 2006–2009—POLGRAFT financed by Polish Ministry of Health. During 2006 and 2007 first set of tissue banking initial training courses were provided according to TF 2004 project. Over 200 pathologists, forensic medicine specialists and other medical doctors responsible for donor screening and classification, medical directors of tissue establishments, technical staff; tissue graft users: orthopaedic surgeons, neurosurgeons, cardiosurgeons and ophthalmologists were trained. Between 2006 and 2009 there were organized 8 advanced tissue banking training courses according to POLGRAFT programme. There were organized both theoretical and practical courses on various aspects of tissue for over 350 persons. We present our experience in organisation of international and national tissue banking training courses.     

Imported diseases: an assessment of trends

Increasing travel, migration and other forms of international exchange have given a new importance to imported diseases in Canada. This is reflected in the maintenance of an immigration medical screening program, the development of specialized clinics in major cities, increasing interest in tropical medicine and international health, and the designation of a national reference centre for parasitology.The introduction of a point system for immigration selection in 1967 gave rise to a burgeoning influx of people from developing countries that may have plateaued only within the past year. While tuberculosis is probably the single most important health problem in immigration, parasitic infections are of increasing concern. The popularity of overseas travel among Canadians is now also a major factor in the introduction of exotic diseases into Canada. Importation of disease by international trade is far less common than by travel and immigration.On a community health scale a system of monitoring trends of immigration to Canada and travel of Canadians to and from countries with a known risk would likely provide the best indicator of trends in disease importation. Thus, there was an increase of almost threefold (11.6% to 31.1%) between 1965 and 1975 in the proportion of immigration to Canada from countries with a malaria risk and a 2.78-fold increase between 1967 and 1974 in the overall amount of Canadian travel to such countries from which statistics were available.     

Recommendations on COVID-19 triage: international comparison and ethical analysis

On March 11, 2020 the World Health Organization classified COVID-19, caused by Sars-CoV-2, as a pandemic. Although not much was known about the new virus, the first outbreaks in China and Italy showed that potentially a large number of people worldwide could fall critically ill in a short period of time. A shortage of ventilators and intensive care resources was expected in many countries, leading to concerns about restrictions of medical care and preventable deaths. In order to be prepared for this challenging situation, national triage guidance has been developed or adapted from former influenza pandemic guidelines in an increasing number of countries over the past few months. In this article, we provide a comparative analysis of triage recommendations from selected national and international professional societies, including Australia/New Zealand, Belgium, Canada, Germany, Great Britain, Italy, Pakistan, South Africa, Switzerland, the United States, and the International Society of Critical Care Medicine. We describe areas of consensus, including the importance of prognosis, patient will, transparency of the decision-making process, and psychosocial support for staff, as well as the role of justice and benefit maximization as core principles. We then probe areas of disagreement, such as the role of survival versus outcome, long-term versus short-term prognosis, the use of age and comorbidities as triage criteria, priority groups and potential tiebreakers such as ‘lottery’ or ‘first come, first served’. Having explored a number of tensions in current guidance, we conclude with a suggestion for framework conditions that are clear, consistent and implementable. This analysis is intended to advance the ongoing debate regarding the fair allocation of limited resources and may be relevant for future policy-making.     

Influenza vaccine scarcity 2004-05: implications for biosecurity and public health preparedness

In the event of a bioterrorist event or a pandemic flu outbreak, it might be necessary to ration vaccine or other treatments. In this article, researchers examine how medical and public health decision makers negotiated the unanticipated 2004-05 influenza vaccine shortage, using the regional hospital system headquartered in Pittsburgh, Pennsylvania, as the focal study site. This account of that case study describes the circumstances that contributed to the national and local vaccine shortage; the improvisation by health policymakers, hospital administrators, physicians, and nurses to prevent influenza cases despite the shortfall; and some of the legal, fiscal, logistical, social, and political pressures that local health professionals faced in deciding who should receive the limited supply of influenza vaccine. This instance of an acute vaccine shortage provided an opportunity to examine the practical and ethical dilemmas of managing medical resources during a public health emergency.     

Alternative models of organisation are needed.

Anyone considering a fundamental rethink of the role of consultants risks exposing tensions in the medical profession that have characterised the development of medical practice since the 18th century. That tense story was one of beds and money, power and domination. Rethinking the role of consultants must now take into account the relationship between consultants and their specialist colleagues and general practitioners; examine the distribution of work between consultants and junior doctors; and relate the contribution of the consultant as specialist to that of other health professionals. After half a century of a national health service characterised by equity of access to care, we urgently need to debate the roles of those who work in it and in doing so to focus primarily on the needs of patients.     

ARE PATIENTS’ DECISIONS TO REFUSE TREATMENT BINDING ON HEALTH CARE PROFESSIONALS?

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.     

Great Expectations: Teaching Ethics to Medical Students in South Africa

Many academic philosophers and ethicists are appointed to teach ethics to medical students. We explore exactly what this task entails. In South Africa the Health Professions Council's curriculum for training medical practitioners requires not only that students be taught to apply ethical theory to issues and be made aware of the legal and regulatory requirements of their profession, it also expects moral formation and the inculcation of professional virtue in students. We explore whether such expectations are reasonable. We defend the claim that physicians ought to be persons of virtuous character, on the grounds of the social contract between society and the profession. We further argue that since the expectations of virtue of health care professionals are reasonable, it is also sound reasoning to expect ethics teachers to try to inculcate such virtues in their students, so far as this is possible. Furthermore, this requires of such teachers that they be suitable role models of ethical practice and virtue, themselves. We claim that this applies to ethics teachers who are themselves not members of the medical profession, too, even though they are not bound by the same social contract as doctors. We conclude that those who accept employment as teachers of ethics to medical students, where as part of their contractual obligation they are expected to inculcate moral values in their students, ought to be prepared to accept their responsibility to be professionally ethical, themselves.     

Medical Student Knowledge of Neglected Tropical Diseases in Peru: A Cross-Sectional Study

In developing countries, education to health-care professionals is a cornerstone in the battle against neglected tropical diseases (NTD). Studies evaluating the level of knowledge of medical students in clinical and socio-demographic aspects of NTD are lacking. Therefore, a cross-sectional study was conducted among students from a 7 year-curriculum medical school in Peru to assess their knowledge of NTD by using a pilot survey comprised by two blocks of 10 short questions. Block I consisted of socio-demographic and epidemiological questions whereas block II included clinical vignettes. Each correct answer had the value of 1 point. Out of 597 responders (response rate: 68.4%), 583 were considered to have valid surveys (male:female ratio: 1:1.01; mean age 21 years, SD ± 2.42). Total knowledge showed a raising trend through the 7-year curriculum. Clinical knowledge seemed to improve towards the end of medical school whereas socio-demographic and epidemiological concepts only showed progress the first 4 years of medical school, remaining static for the rest of the curricular years (p = 0.66). Higher mean scores in socio-demographic and epidemiological knowledge compared to clinical knowledge were seen in the first two years (p<0.001) whereas the last three years showed higher scores in clinical knowledge (p<0.001). In conclusion, students from this private medical school gained substantial knowledge in NTD throughout the career which seems to be related to improvement in clinical knowledge rather than to socio-demographic and epidemiological concepts. This study assures the feasibility of measuring the level of knowledge of NTD in medical students and stresses the importance of evaluating education on NTD as it may need more emphasis in epidemiological concepts, especially at developing countries such as Peru where many people are affected by these preventable and treatable diseases.     

The telepathology and teleradiology network in Croatia.

Telepathology as a demanding branch of telemedicine poses a real challenge to experts. The introduction of telepathology in underprivileged countries with poor infrastructure and low health-care budget is a difficult task. On the other hand these countries would mostly benefit by introducing telemedicine/telepathology. In our experience it is possible to build an efficient telepathology/teleradiology network using analogue telephone links and still image transmission, and a store and forward mode of operation. This experience is based on the application of telepathology in Croatia for seven years leading to a national teleradiology network. In this paper the ideas, development and software solutions in the process of establishing a national telepathology and teleradiology network are highlighted.     

La consultation médicale avant un départ en pays tropical

This article specifies the key factors that must be taken into consideration during medical examinations before travel to tropical countries. The factors include vaccinations and vaccine contraindications, antimalarial prophylaxis and drug interactions, diarrhoea prevention, special precautions for certain travellers (children, pregnant women, the elderly, and immunosuppressed persons), and general prophylaxis.     

Claude Bernard Distinguished Lecture. Becoming a truly helpful teacher: considerably more challenging, and potentially more fun, than merely doing business as usual

Few medical faculty members are adequately prepared for their instructional responsibilities. Our educational traditions were established before we had research-based understandings of the teaching-learning process and before brain research began informing our understandings of how humans achieve lasting learning. Yet, there are several advantages you may have. If your expertise is at one of the frontiers of human biology, your teaching can be inherently fascinating to aspiring health professionals. If your work has implications for human health, you have another potential basis for engaging future clinicians. And, thanks to Claude Bernard's influence, you likely are "process oriented," a necessary mindset for being an effective teacher. There are also challenges you may face. Your medical students will mostly become clinicians. Unless you can help them see connections between your offerings and their future work, you may not capture and sustain their interest. To be effective, teachers, like clinicians, need to be interactive, make on-the-spot decisions, and be "emotional literate." If you aren't comfortable with these demands, you may have work to do toward becoming a truly helpful teacher. Program changes may be needed. Might your program need to change 1) from being adversarial and controlling to being supportive and trust based or 2) from mainly dispensing information to mainly asking and inviting questions? In conclusion, making changes toward becoming a truly helpful teacher can bring benefits to your students while increasing your sense of satisfaction and fulfillment as a teacher. If you choose to change, be gentle with yourself, as you should be when expecting your students to make important changes.     

Ethical issues for vaccines and immunization

Vaccination is the only type of medical intervention that has eliminated a disease successfully. However, both in countries with high immunization rates and in countries that are too impoverished to protect their citizens, many dilemmas and controversies surround immunization. This article describes some of the ethical issues involved, and presents some challenges and concepts for the global community.     

Dialogic Consensus In Clinical Decision-Making

This paper is predicated on the understanding that clinical encounters between clinicians and patients should be seen primarily as inter-relations among persons and, as such, are necessarily moral encounters. It aims to relocate the discussion to be had in challenging medical decision-making situations, including, for example, as the end of life comes into view, onto a more robust moral philosophical footing than is currently commonplace. In our contemporary era, those making moral decisions must be cognizant of the existence of perspectives other than their own, and be attuned to the demands of inter-subjectivity. Applicable to clinical practice, we propose and justify a Habermasian approach as one useful means of achieving what can be described as dialogic consensus. The Habermasian approach builds around, first, his discourse theory of morality as universalizable to all and, second, communicative action as a cooperative search for truth. It is a concrete way to ground the discourse which must be held in complex medical decision-making situations, in its actual reality. Considerations about the theoretical underpinnings of the application of dialogic consensus to clinical practice, and potential difficulties, are explored.     

Demographic shifts and medical training

The rapid aging of populations in developing countries as compared to those in the developed world has implications for medical training in these places. Moreover, the growing globalization of employment for many health professionals means that demographic shifts have implications for the training of health professionals worldwide such that curriculums in developing countries may not meet the needs of those who practice in industrialized countries. Chronic and degenerative diseases as well as problems of multiple pathology are likely to increase with an aging population. Consequently, multiple pathology makes current medical training so likely to lead to inappropriate and poor quality of care. In addition, increasing subspecialization in medicine provides doctors who are unable to deal with the complexity of multiple pathology. Undergraduate medical education reforms are also forcing specific training in geriatric medicine out of the curriculums.