Prioritising Healthcare Workers for Ebola Treatment: Treating Those at Greatest Risk to Confer Greatest Benefit

The Ebola epidemic in Western Africa has highlighted issues related to weak health systems, the politics of drug and vaccine development and the need for transparent and ethical criteria for use of scarce local and global resources during public health emergency. In this paper we explore two key themes. First, we argue that independent of any use of experimental drugs or vaccine interventions, simultaneous implementation of proven public health principles, community engagement and culturally sensitive communication are critical as these measures represent the most cost‐effective and fair utilization of available resources. Second, we attempt to clarify the ethical issues related to use of scarce experimental drugs or vaccines and explore in detail the most critical ethical question related to Ebola drug or vaccine distribution in the current outbreak: who among those infected or at risk should be prioritized to receive any new experimental drugs or vaccines? We conclude that healthcare workers should be prioritised for these experimental interventions, for a variety of reasons.     

Mapping out structural features in clinical care calling for ethical sensitivity: a theoretical approach to promote ethical competence in healthcare personnel and clinical ethical support services (CESS)

Clinical ethical support services (CESS) represent a multifaceted field of aims, consultancy models, and methodologies. Nevertheless, the overall aim of CESS can be summed up as contributing to healthcare of high ethical standards by improving ethically competent decision-making in clinical healthcare. In order to support clinical care adequately, CESS must pay systematic attention to all real-life ethical issues, including those which do not fall within the 'favourite' ethical issues of the day. In this paper we attempt to capture a comprehensive overview of categories of ethical tensions in clinical care. We present an analytical exposition of ethical structural features in judgement-based clinical care predicated on the assumption of the moral equality of human beings and the assessment of where healthcare contexts pose a challenge to achieving moral equality. The account and the emerging overview is worked out so that it can be easily contextualized with regards to national healthcare systems and specific branches of healthcare, as well as local healthcare institutions. By considering how the account and the overview can be applied to i) improve the ethical competence of healthcare personnel and consultants by broadening their sensitivity to ethical tensions, ii) identify neglected areas for ethical research, and iii) clarify the ethical responsibility of healthcare institutions' leadership, as well as specifying required institutionalized administration, we conclude that the proposed account should be considered useful for CESS.     

Not Fit for Purpose: The Ethical Guidelines of the Indian Council of Medical Research

In 2006, the Indian Council of Medical Research (ICMR) published its ‘Ethical guidelines for Biomedical Research on human participants’. The intention was to translate international ethical standards into locally and culturally appropriate norms and values to help biomedical researchers in India to conduct ethical research and thereby safeguard the interest of human subjects. Unfortunately, it is apparent that the guideline is not fit for purpose. In addition to problems with the structure and clarity of the guidelines, there are several serious omissions and contradictions in the recommendations. In this paper, we take a close look at the two key chapters and highlight some of the striking flaws in this important document. We conclude that ethics committees and national authorities should not lose sight of international ethical standards while incorporating local reality and cultural and social values, as focusing too much on the local context could compromise the safety of human subjects in biomedical research, particularly in India.     

Healthcare narratives from diverse communities--a self-assessment tool for healthcare providers

Research examining cultural diversity in the healthcare context has produced general themes about particular patient populations, and tools based on this research vary in their approach to improving cultural sensitivity and competency. Some tools pose questions that providers may ask patients to help them become better informed about their culture; others name areas of sensitivity that providers ought to be aware of in caring for culturally diverse patients. This tool is different. It focuses on the provider and its goal is to raise the provider's consciousness through self-reflection and examination. It consists of three parts: stories from interviews with actual patients followed by thought-provoking questions; commentaries on four of the narratives to help you measure your assessment of the ethical issues contained in each one; and a decision-making analysis grid to help you use the tool more effectively. It concludes with a bibliography for additional reading.     

Cultural competency--the caregiver connection

Healthcare that is respectful and ethical must also be culturally competent, and a variety of tools are available to empower caregivers to provide culturally competent care. This article reviews the tools that the University of Michigan Health Care System's Program for Multicultural Health provides to caregivers throughout its many services. Cultural competency begins with self-awareness and knowledge, but it is also to embark upon a lifelong journey. Progress is cumulative, and assessment is an important part of the process.     

Vulnerability,Harm, and Compromised Ethics Revealed by the Experiences of Queer Birthing Women in Rural Healthcare

Phenomenological interviews with queer women in rural Nova Scotia reveal significant forms of trauma experienced during labour and birth. Situating the accounts of participants within both phenomenological and intersectional analyses reveals harms enabled by structurally embedded heteronormative and homophobic healthcare practices and policies. Our account illustrates the breadth and depth of harm experienced and outlines how these violate core ethical principles and values in healthcare.     

International service learning programs: ethical issues and recommendations

Inequities in global health are increasingly of interest to health care providers in developed countries. In response, many academic healthcare programs have begun to offer international service learning programs. Participants in these programs are motivated by ethical principles, but this type of work presents significant ethical challenges, and no formalized ethical guidelines for these activities exist. In this paper the ethical issues presented by international service learning programs are described and recommendations are made for how academic healthcare programs can carry out international service learning programs in a way that minimizes ethical conflicts and maximizes benefits for all stakeholders. Issues related to project sustainability and community involvement are emphasized.     

Deceased‐directed donation: Considering the ethical permissibility in a multicultural setting

This paper explores the ethics of deceased‐directed donation (DDD) and brings a unique perspective to this issue—the relevance of providing family‐centered care and culturally sensitive care to deceased donors, potential recipients, and their families. The significance of providing family‐centered care is becoming increasingly prevalent, specifically in pediatric healthcare settings. Therefore, this topic is especially relevant to those working with and interested in pediatrics. As the world is becoming more diverse with globalization, assessing the cultural aspect of the ethics of DDD is increasingly salient. We provide a brief overview of DDD across the globe, review prominent arguments both for and against DDD, consider family‐centered and culturally specific considerations, and offer considerations for the development of a policy or guideline. We determine that the practice of DDD is ethically defensible in certain circumstances and congruent with providing both family‐centered and culturally sensitive care. Our analysis is relevant to any country with a diverse population and any healthcare provider or institution that operates under a framework of family‐centered care, such as those in pediatric hospitals.     

Neuroplasticity and temporal retardation of development (paedomorphic morphology) inhuman evolution: A consideration of biological requirements for the plasticity of human cognition and the potential acquisition of culturally dependent ethical world views

The fact thatHomo sapiens have one of the longest childhoods in the animal kingdom is a most significant factor when considering the biological requirements for cultural evolution. The so-called long childhood is necessary for the intergenerational transmission of learned skills and behaviors that defined culture. It is important to distinguish between behavior motivated byinstinct and behavior that islearned as a result of having been reared in a culturally dependent environment. Our neotenic development occasions an ability to learn a variety of culturally dependent behaviors. Since we are born, quite literally, as human embryos, we must recognize that our brain undergoes the bulk of its development post-natally. It is significant that at the same time the brain develops its distinctive axon-neuron network structure, persons are learning culturally dependent accepted patterns of behavior that are related to (amongst many other things) language, altruism, aggression, rites, filial, proprieties, etc. The old reductionistic nature-nurture issue is best understood as a complex array of developmental processes in which environmental stimuli (nurture) may affect the physiological development (nature) of the brain. The early plasticity of human cognition may be, to a significant degree, shaped and physiologically constrained by environmental factors (especially in the early years of development). The presence of a diversity of environmental influences the world over suggests the possibility that a person's intolerance of foreign ethical belief systems may stem from a genuine inability to conceive of ethical relationships in a manner far removed from one's daily life and native environment. After consideration of the effects of neuroplasticity and human neotenic development, it is argued that a viable sociobiological research agenda must study not only those ethical behaviors that seem to beshared across cultures, but also those behaviors that stem from culturally distinctive attitudes that arenot shared across cultural boundaries.     

The Ethical Imperative to Move to a Seven-Day Care Model

Whilst the nature of human illness is not determined by time of day or day of week, we currently structure health service delivery around a five-day delivery model. At least one country is endeavouring to develop a systems-based approach to planning a transition from five- to seven-day healthcare delivery models, and some services are independently instituting program reorganization to achieve these ends as research, amongst other things, highlights increased mortality and morbidity for weekend and after-hours admissions to hospitals. In this article, we argue that this issue does not merely raise instrumental concerns but also opens up a normative ethical dimension, recognizing that clinical ethical dilemmas are impacted on and created by systems of care. Using health policy ethics, we critically examine whether our health services, as currently structured, are at odds with ethical obligations for patient care and broader collective goals associated with the provision of publicly funded health services. We conclude by arguing that a critical health policy ethics perspective applying relevant ethical values and principles needs to be included when considering whether and how to transition from five-day to seven-day models for health delivery.     

The Challenges of Research Informed Consent in Socio‐Economically Vulnerable Populations: A Viewpoint From the Democratic Republic of Congo

In medical research, the ethical principle of respect for persons is operationalized into the process of informed consent. The consent tools should be contextualized and adapted to the different socio‐cultural environment, especially when research crosses the traditional boundaries and reaches poor communities. We look at the challenges experienced in the malaria Quinact trial, conducted in the Democratic Republic of Congo, and describe some lessons learned, related to the definition of acceptable representative, the role of independent witness and the impact of socio‐economic vulnerability. To ensure children's protection, consent is required by the parents or, in their absence, by a legally mandated representative. In our setting, children's responsibility is often entrusted permanently or temporarily to relatives or friends without a tribunal mandate. Hence, a notion of ‘culturally acceptable representative’ under supervision of the local Ethics Committee may be more suitable. To ensure protection of illiterate subjects, an independent witness is required to confirm that the consent was freely given. However, in low‐literacy contexts, potential witnesses often don't have any previous relationship with patient and there may be power‐unbalance in their relationship, rather than genuine dialogue. In poor communities, trial participation may be seen as an opportunity to secure access to healthcare. Poverty may also lead to ‘competition’ to access the research‐related benefits, with a risk of disturbance at societal or household level. Adjusting consent procedures to sociocultural and socioeconomic realities is essential for fulfilling the underlying ethical principles. This requires a collaborative dialogue between researchers, regulators and ethics committees.     

Moral courage in medicine--disclosing medical error

Medical error is an inevitable occurrence that stresses the relationship between healthcare professionals and their patients. The number of errors is shocking; so too, is the revelation that few medical errors are routinely disclosed. When healthcare providers fail to inform patients of harm-causing medical error, then trust in the patient/provider relationship is broken and many ethical challenges surface. To successfully restore trust and perhaps lower liability costs, healthcare providers must avoid pointing fingers and adopt a policy of honesty and full disclosure.     

Newborns in crisis: An outline of neonatal ethical dilemmas in humanitarian medicine

Newborn infants are among those most severely affected by humanitarian crises. Aid organisations increasingly recognise the necessity to provide for the medical needs of newborns, however, this may generate distinctive ethical questions for those providing humanitarian medical care. Medical ethical approaches to neonatal care familiar in other settings may not be appropriate given the diversity and volatility of humanitarian disasters, and the extreme resource limitations commonly faced by humanitarian aid missions. In this paper, we first systematically review existing guidelines relating to the treatment and resuscitation of newborns in humanitarian crises, finding little substantive ethical guidance for those providing humanitarian healthcare. We next draw on paradigm cases and published literature to identify and describe some of the major ethical questions common to these settings. We divide these questions into quality of life considerations, allocation of limited resources, and conflicting cultural norms and values. We finally suggest some preliminary recommendations to guide ethical decision‐making around resuscitation of newborns and withdrawal of treatment in humanitarian settings.     

Ethics and Rationing Access to Dialysis in Resource‐Limited Settings: The Consequences of Refusing a Renal Transplant in the South African State Sector

Resource constraints in developing countries compel policy makers to ration the provision of healthcare services. This article examines one such set of Guidelines: A patient dialysing in the state sector in South Africa may not refuse renal transplantation when a kidney becomes available. Refusal of transplantation can lead to exclusion from the state‐funded dialysis programme. This Guideline is legally acceptable as related to Constitutional stipulations which allow for rationing healthcare resources in South Africa. Evaluating the ethical merit of the Guideline, and exploring the ethical dilemma it poses, proves a more complex task. We examine the actions of healthcare professionals as constrained by the Guideline. From a best interests framework, we argue that in these circumstances directing patient decision making (pressurising a patient to undergo renal transplantation) is not necessarily unethical or unacceptably paternalistic. We then scrutinise the guideline itself through several different ethical ‘lenses’. Here, we argue that bioethics does not provide a definitive answer as to the moral merit of rationing dialysis under these circumstances, however it can be considered just in this context. We conclude by examining a potential pitfall of the Guideline: Unwilling transplant recipients may not comply with immunosuppressive medication, which raises questions for policies based on resource management and rationing.     

Religious pluralism and the ethics of healthcare

Democratic societies that separate church and state face major challenges in accommodating religious convictions. This applies especially to determining healthcare policies. Building on our prior work on the demands and limits of religious accommodation in democratic societies, we propose a set of ethical standards that can guide societies in meeting this challenge. In applying and defending these standards, we explore three topics: vaccine resistance, abortion, and concerns about rights to healthcare. We clarify these and other issues of religious accommodation and propose ethical standards for approaching these and other problems.     

Indigenous Research: A Commitment to Walking the Talk. The Gudaga Study—an Australian Case Study

Increasingly, the role of health research in improving the discrepancies in health outcomes between Indigenous and non-Indigenous populations in developed countries is being recognised. Along with this comes the recognition that health research must be conducted in a manner that is culturally appropriate and ethically sound. Two key documents have been produced in Australia, known as The Road Map and The Guidelines, to provide theoretical and philosophical direction to the ethics of Indigenous health research. These documents identify research themes considered critical to improving the health of the nation’s Indigenous peoples. They also provide values that, from an Indigenous perspective, are foundational to an ethical research process. This paper examines these research themes and values within the context of a current longitudinal birth cohort study of Indigenous infants and children in south-west Sydney: the Gudaga Study. Considerable time and effort have been invested in being true to the values stated in these documents: reciprocity; respect; equality; responsibility; survival and protection; and spirit and integrity. We have learnt that it is vital to be true to these values when conducting Indigenous health research—to quite literally “walk the talk”.     

THE ETHICS OF INTERCOUNTRY ADOPTION: WHY IT MATTERS TO HEALTHCARE PROVIDERS AND BIOETHICISTS

The goal of this paper is both modest and ambitious. The modest goal is to show that intercountry adoption should be considered by ethicists and healthcare providers. The more ambitious goal is to introduce the many ethical issues that intercountry adoption raises. Intercountry adoption is an alternative to medical, assisted reproduction option such as in vitro fertilization (IVF), intracytoplasmic sperm injection, third party egg and sperm donation and surrogacy. Health care providers working with assisted reproduction are in a unique position to introduce their clients to intercountry adoption; however, providers should only do so if intercountry adoption is ethically equal or superior to the alternatives. This paper first presents a brief history of intercountry adoption. The second section compares intercountry adoption with medical alternatives. The third section examines the unique ethical challenges that are not shared by other medical alternatives. The final section concludes that it is simplistic for a healthcare provider to promote intercountry adoption unconditionally; however, in situation where intercountry adoption is practiced conscientiously it poses no greater ethical concern than several medical alternatives. This conclusion is preliminary and is intended as a start for further discussion.     

Current trends in teaching ethics of healthcare practices

The unprecedented progress in bio-medical sciences and technology during the last few decades has resulted in great transformations in the concepts of health and disease, health systems and healthcare organisation and practices. Those changes have been accompanied by the emergence of a broad range of ethical dilemmas that confront health professionals more frequently. The classical Hippocratic ethical principles, though still retaining their relevance and validity, have become insufficiently adequate in an increasing range of problems and situations. Healthcare that has been practised for centuries on the basis of a direct doctor-patient relationship has been increasingly transformed into a more complex process integrating the health-team, the patient (healthcare seeker) and the community. Systematic review of the specialised literatures revealed that Healthcare Ethics education has become a basic requirement for any training programme for health professionals, and should cover the different stages of undergraduate, postgraduate and continuing education. Both theoretical foundations and practical skills are required for the appropriate ethical reasoning, ethical attitude and decision-making abilities. There is growing evidence that physicians' professional and moral development is not only determined by the formal curriculum of ethics; rather more, it is determined by the moral environment of the professional practice, the 'hidden curriculum' which deserves serious consideration by medical education.     

Medical Students’ Opinions About the Commercialization of Healthcare: A Cross-Sectional Survey

There are serious concerns about the commercialization of healthcare and adoption of the business approach in medicine. As market dynamics endanger established professional values, healthcare workers face more complicated ethical dilemmas in their daily practice. The aim of this study was to investigate the willingness of medical students to accept the assertions of commercialized healthcare and the factors affecting their level of agreement, factors which could influence their moral stance when market demands conflict with professional values. A cross-sectional study was conducted in three medical schools in Turkey. The study population consisted of first-, third-, and sixth-year students, and 1,781 students participated in total. Students were asked to state if they agreed with the assertions of commercialized healthcare. Of all students, 87.2 per cent agreed with at least one of the assertions, and one-fifth (20.8 per cent) of them agreed with more than half of the assertions. First-year students significantly agreed more with some assertions than third- and sixth-year students. Being female, having mid-level family income, choosing medicine due to idealistic reasons, and being in the third or sixth years of medical study increased the probability of disagreement. Also, studying in a medical school that included integrated lectures on health policies, rights related to health, and health inequities, along with early field visits, increased the probability of disagreement. This study suggests that agreement with the assertions of commercialized healthcare might be prevalent among students at a considerable level. We argue that this level of agreement is not compatible with best practice in professional ethics and indicates the need for an educational intervention in order to have physicians who give priority to patients’ best interests in the face of market demands.     

NAVIGATING THE MURKY INTERSECTION BETWEEN CLINICAL AND ORGANIZATIONAL ETHICS: A HYBRID CASE TAXONOMY

Ethical challenges that arise within healthcare delivery institutions are currently categorized as either clinical or organizational, based on the type of issue. Despite this common binary issue‐based methodology, empirical study and increasing academic dialogue indicate that a clear line cannot easily be drawn between organizational and clinical ethics. Disagreement around end‐of‐life treatments, for example, often spawn value differences amongst parties at both organizational and clinical levels and requires a resolution to address both the case at hand and large‐scale underlying system‐level confounders. I refer to issues that contain elements of both clinical and organizational issues as hybrids and propose a new taxonomy to characterize hybrid cases. I contend that salient contextual features of an ethical issue, such as where it is identified, who it impacts and where it is ideally resolved in relation to its scope of impact, should inform procedure. Implementation of a Hybrid taxonomy viewing ethical issues as existing on a continuum furthers that end. The primary goals are to 1) systematize thinking about ethical issues that arise within healthcare delivery institutions and 2) allow the content of the ethical challenge to drive the process, rather than continuing to rely on the traditional binary issue‐based choice. Failure to capture the complexity of hybrid situations perpetuates incomplete information and ultimately an inchoate resolution that creates more questions than answers.