Developments in Machine Learning (ML) have attracted attention in a wide range of healthcare fields to improve medical practice and the benefit of patients. Particularly, this should be achieved by providing more or less automated decision recommendations to the treating physician. However, some hopes placed in ML for healthcare seem to be disappointed, at least in part, by a lack of transparency or traceability. Skepticism exists primarily in the fact that the physician, as the person responsible for diagnosis, therapy, and (...) care, has no or insufficient insight into how such recommendations are reached. The following paper aims to make understandable the specificity of the deliberative model of a physician-patient relationship that has been achieved over decades. By outlining the (social-)epistemic and inherently normative relationship between physicians and patients, I want to show how this relationship might be altered by non-traceable ML recommendations. With respect to some healthcare decisions, such changes in deliberative practice may create normatively far-reaching challenges. Therefore, in the future, a differentiation of decision-making situations in healthcare with respect to the necessary depth of insight into the process of outcome generation seems essential. (shrink)

Now I know why so many stories have been written with the theme: “everything changed in one moment.” More than 1,000 days have come and gone, and I still remember one Sunday morning and still follow and feel the effects of one decision.

*The views in this article are the author's alone and should not be construed as policy statements of the American Medical Association.

Healthcare professionals working in intensive care units are often involved in end-of-life decision-making. No research has been done so far about these processes taking place in Croatian ICUs. The aim of this study was to investigate the perceptions, experiences, and challenges healthcare professionals face when dealing with end-of-life decisions in ICUs in Croatia. A qualitative study was performed using professionally homogenous focus groups of ICU nurses and physicians of diverse professional and clinical backgrounds at three research sites. In total, (...) six institutions at the tertiary level of healthcare were included. The constant comparative analysis method was used in the analysis of the data. Differences were found between the perceptions and experiences of nurses and physicians in relation to end-of-life decisions. Nurses’ perceptions were more focused on the context and features of immediate care, while physicians’ perceptions also included the wider sociocultural context. However, the critical issues these specific professional groups face when dealing with end-of-life decisions seem to overlap. A high variability of practices, both between individual practitioners and between different organizational units, was omnipresent. The lack of adequate legal, professional, and clinical guidelines was commonly expressed as one of the most critical source of difficulties. (shrink)

Managed care employs two business tools of managed practice that raise important ethical issues: paying physicians in ways that impose conflicts of interest on them; and regulating physicians' clinical judgment, decision making, and behavior. The literature on the clinical ethics of managed care has begun to develop rapidly in the past several years. Professional organizations of physicians have made important contributions to this literature. The statements on ethical issues in managed care of four such organizations are considered (...) here, the American Medical Association, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics. Three themes common to these statements are identified and critically assessed: the primacy of meeting the medical needs of each individual patient; disclosure of conflicts of interest in how physicians are paid; and opposition to gag orders. The paper concludes with an argument for a basic concept in the clinical ethics of managed care: physicians and institutions as economically disciplined moral co-fiduciaries of populations of patients. (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying (...) process. Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Background: The global COVID-19 pandemic has imposed challenges on healthcare systems and professionals worldwide and introduced a ´maelstrom´ of ethical dilemmas. How ethically demanding situations are handled affects employees’ moral stress and job satisfaction. Aim: Describe priority-setting dilemmas, moral distress and support experienced by nurses and physicians across medical specialties in the early phase of the COVID-19 pandemic in Western Norway. Research design: A cross-sectional hospital-based survey was conducted from 23 April to 11 May 2020. Ethical considerations: Ethical approval (...) granted by the Regional Research Ethics Committee in Western Norway (131421). Findings: Among the 1606 respondents, 67% had experienced priority-setting dilemmas the previous two weeks. Healthcare workers who were directly involved in COVID-19 care, were redeployed or worked in psychiatry/addiction medicine experienced it more often. Although 59% of the respondents had seen adverse consequences due to resource scarcity, severe consequences were rare. Moral distress levels were generally low (2.9 on a 0–10 scale), but higher in selected groups (redeployed, managers and working in psychiatry/addiction medicine). Backing from existing collegial and managerial structures and routines, such as discussions with colleagues and receiving updates and information from managers that listened and acted upon feedback, were found more helpful than external support mechanisms. Priority-setting guidelines were also helpful. Discussion: By including all medical specialties, nurses and physicians, and various institutions, the study provides information on how the COVID-19 mitigation also influenced those not directly involved in the COVID-19 treatment of patients. In the next stages of the pandemic response, support for healthcare professionals directly involved in outbreak-affected patients, those redeployed or those most impacted by mitigation strategies must be a priority. Conclusion: Empirical research of healthcare workers experiences under a pandemic are important to identify groups at risks and useful support mechanisms. (shrink)

Background Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians’ attitudes toward assisted death vary across the globe, but little is known about physicians’ actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients’ requests for assisted death in countries where these actions are not legal. Methods A survey including statements (...) concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. Results Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. Conclusions Finnish physicians’ actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal. (shrink)

DNR decisions are frequently made in oncology and hematology care and physicians and nurses may face related ethical dilemmas. Ethics is considered a basic competence in health care and can be understood as a capacity to handle a task that involves an ethical dilemma in an adequate, ethically responsible manner. One model of ethical competence for healthcare staff includes three main aspects: being, doing and knowing, suggesting that ethical competence requires abilities of character, action and knowledge. Ethical competence can (...) be developed through experience, communication and education, and a supportive environment is necessary for maintaining a high ethical competence. The aim of the present study was to investigate how nurses and physicians in oncology and hematology care understand the concept of ethical competence in order to make, or be involved in, DNR decisions and how such skills can be learned and developed. A further aim was to investigate the role of guidelines in relation to the development of ethical competence in DNR decisions. Individual interviews were conducted with fifteen nurses and sixteen physicians. The interviews were analyzed using thematic content analysis. Physicians and nurses in the study reflected on their ethical competence in relation to DNR decisions, on what it should comprise and how it could be developed. The ethical competence described by the respondents related to the concepts being, doing and knowing. In order to make ethically sound DNR decisions in oncology and hematology care, physicians and nurses need to develop appropriate virtues, improve their knowledge of ethical theories and relevant clinical guidelines. Ethical competence also includes the ability to act upon ethical judgements. Continued ethical education and discussions for further development of a common ethical language and a good ethical working climate can improve ethical competence and help nurses and physicians cooperate better with regard to patients in relation to DNR decisions, in their efforts to act in the best interest of the patient. (shrink)

We are extremely grateful for the insightful and thought-provoking commentaries on our feature article.1 We have distilled four themes emerging from the commentaries, and we would also like to address one misunderstanding of our argument that has appeared. In our article, we explicitly acknowledge that major decisions relevant for climate protection take place at the mesolevels and macrolevels of healthcare, a point raised again in some of the commentaries.2–4 Climate protection is a societal issue, and we thank these authors for (...) the concrete proposals of potential models to guide action. Yet, to us, it still makes sense to reflect simultaneously on the responsibilities that physicians have themselves. Without wanting to put the main responsibility on them, we argue it is important to start thinking about the scope of action that physicians actually have (or not have). As we have argued the need for climate action comes ever more into focus of society, we wanted to explore whether the professional ethics of the medical professionals needs to be amended. Our argument is that this is the case, based on the reasons that climate change has a big health impact while simultaneously the health system has a strong climate impact. Based on the World Medical Association (WMA) Declaration of Geneva the focus on the individual patient is clear, but this and other important codices do also include a public health perspective. The (model) Professional Code for Physicians in Germany, for example, states in its first article that ‘Physicians serve the health of …. (shrink)

BackgroundMedical disputes, medical disturbances, verbal and physical violence against physicians, and burnout have reached epidemic levels. They may negatively impact both physicians and the healthcare system. The experience of medical disputes, medical disturbances, verbal, and physical violence, and burnout and the correlates in physicians working in public hospitals in China needed to be investigated.MethodsA nationwide cross-sectional survey study was conducted between 18 and 31 March 2019. An anonymous online questionnaire was administered. The questionnaire included the 22-item Maslach (...) Burnout Inventory-Human Services Survey. We also collected data on demographic and job-related factors, as well as physicians’ experiences of medical disputes, medical disturbances, verbal and physical violence from patients and the patients’ family members.FindingsIn total, 22,213 physicians from 144 tertiary public hospitals in all of China’s 31 provinces completed the survey. The overall burnout rate among the surveyed physicians was 31.28%. Moreover, 33.48% of physicians experienced disputes, 20.86% experienced disturbances, 48.52% experienced verbal violence, and 5.84% experienced physical violence in the past 12 months. Factors found to be significantly associated with burnout included younger age, being divorced or widowed, having a lower educational background, working in internal medicine departments, longer working hours per day, working in general hospitals, being in East China, as well as having experienced disputes, disturbances, and physical and verbal violence.InterpretationClose to a third of the Chinese doctors working in the tertiary hospitals reportedly experienced burnout, and the problem is related to the unsafe working environment caused by the worsening doctor-patient relationship. (shrink)

ObjectiveIn Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. One of the requirements is that the patient possesses decision-making capacity. The patient’s decision-making capacity is assessed by physicians.The objective of our study is to provide insight in the assessment of decision-making capacity in the context of euthanasia for patients with psychic suffering caused by a psychiatric disorder.MethodTwenty-two semistructured (...) interviews with psychiatrists and neurologists were analysed with NVivo, a qualitative analysis software to code and organise transcribed data.ResultsDifferent views and approaches regarding decision-making capacity in the context of euthanasia emerged from the data.Most of the physicians have some knowledge of the cognitive ability approach on decision-making capacity. According to this approach, four abilities constitute decision-making capacity: communication, understanding, appreciation and reasoning. We observed differences in the way these abilities are valued in relation to competence. Some physicians take additional elements into consideration when assessing decision-making capacity.Physicians acquired their knowledge on the subject in many different ways. Most of the physicians reported that decision-making capacity was not part of their training.ConclusionWe conclude that physicians assess decision-making capacity in different ways and that personal values and beliefs influence their approach. As such, a common approach in assessing the decision-making capacity of a patient among the interviewed physicians is lacking. Less arbitrariness could be obtained by consistently implementing the cognitive ability approach. (shrink)

Physicians, registered nurses (RNs) and enrolled nurses (ENs) engaged in geriatric (n = 49) and surgical (n = 59) care at a large hospital in Sweden gave 180 accounts of morally difficult care episodes. In total, the ENs (n = 40) gave 78, the RNs (n = 38) 55 and the physicians (n = 30) 47 accounts; there were 83 from geriatric care and 97 from surgical care. Forty-nine participants were male, and 59 were female; there were no (...) differences in gender in the form and content of the moral reasoning disclosed in either morally difficult care episodes or in the complete interviews when coded as mainly narrative or propositional, or as showing a care or a justice orientation. The ENs showed a care orientation, while RNs and physicians, to an equal degree, showed both a justice and a care orientation. The ENs also used narrative reasoning more often than RNs and physicians. No differences were seen between the two health care specialties. (shrink)

Research questions and backgroundThis study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians’ uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying (...) process. Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient’s death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient’s life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. Materials and methods An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians’ concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. Results Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. Conclusions The physicians’ knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict. (shrink)

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, (...) professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them. (shrink)

In this qualitative study, we aimed to identify and compare the ethical problems perceived by physicians and nurses in intensive care units at Baskent University hospitals in Turkey. A total of 21 physicians and 22 nurses were asked to describe ethical problems that they frequently encounter in their practice. The data were analyzed using an interactive model. The core problem for both physicians and nurses was end-of-life decisions (first level). In this category, physicians were most frequently (...) concerned with euthanasia while nurses were more concerned with do-not-resuscitate orders (second level). At the third level, we saw that almost all of the participants’ responses related to negative perceptions about euthanasia. Communication and hierarchical problems were the second most reported main category. Nurses were more likely to cite problems with hierarchy than physicians. At the third level, a large percentage of nurses described communication problems with authority and hierarchical problems with physicians. In the same category, physicians were most often concerned with communication problems with patients’ relatives. The ethical problems were reported at different frequencies by physicians and nurses. We asked the participants about ethical decision-making styles. The results show that nurses and physicians do not follow a systematic pattern of ethical decision making. (shrink)

The ethics of hastened death are complex. Studies on physicians’ opinions about assisted dying exist, but changes in physicians’ attitudes towards hastened death in clinical decision-making and the background factors explaining this remain unclear. The aim of this study was to explore the changes in these attitudes among Finnish physicians. A questionnaire including hypothetical patient scenarios was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. Two scenarios of patients with advanced cancer were (...) presented: one requesting an increase in his morphine dose to a potentially lethal level and another suffering a cardiac arrest. Physicians’ attitudes towards assisted death, life values and other background factors were queried as well. The response rate was 56%. The morphine dose was increased by 25% and 34% of the physicians in 1999 and 2015, respectively. Oncologists approved the increase most infrequently without a significant change between the study years. Oncological specialty, faith in God, female gender and younger age were independent factors associated with the reluctance to increase the morphine dose. Euthanasia, but not assisted suicide, was considered less reprehensible in 2015. In both years, most physicians withheld cardiopulmonary resuscitation. Finnish physicians accepted the risk of hastening death more often in 2015 than in 1999. The physicians’ specialty and many other background factors influenced this acceptance. They also regarded euthanasia as less reprehensible now than they did 16 years ago. (shrink)

Patients in Quebec can legally obtain medical assistance in dying (MAID) if they are able to give informed consent, have a serious and incurable illness, are at the end of their lives and are in a situation of unbearable suffering. Since the Supreme Court of Canada’s 2015 Carter decision, access to MAID, under certain conditions, has become a constitutional right. Quebec physicians are now likely to receive requests for MAID from their patients. The Quebec and Canadian laws recognize a (...) physician’s right to conscientious objection, but this right is contested both in the medical ethics literature and in the public sphere. This paper presents the results of a qualitative study conducted with twenty Quebec physicians who did not integrate MAID into their medical practice, either because they were opposed to or deeply ambivalent about MAID. The interviews aimed to explore the reasons – religious and secular – for opposition to or ambivalence towards MAID. The secular reasons given by participants were grouped into four main categories: 1) the ends of medicine and professional identity, 2) the philosophy of palliative medicine and resource allocation in palliative care, 3) benevolent paternalism, the “good death”, and the interests of future selves, 4) the risk of a slippery slope and the protection of vulnerable people. (shrink)

OBJECTIVES: Life-sustaining treatment at the end of life gives rise to many ethical problems in Japan. Recent surveys of Japanese physicians suggested that they tend to treat terminally ill patients aggressively. We studied why Japanese physicians were reluctant to withhold or withdraw life-support from terminally ill patients and what affected their decisions. DESIGN AND PARTICIPANTS: A qualitative study design was employed, using a focus group interview with seven physicians, to gain an in-depth understanding of attitudes and rationales (...) in Japan regarding medical care at the end of life. RESULTS: Analysis revealed that physicians and patients' family members usually make decisions about life-sustaining treatment, while the patients' wishes are unavailable or not taken into account. Both physicians and family members tend to consider withholding or withdrawing life-sustaining treatment as abandonment or even killing. The strongest reason to start cardiopulmonary resuscitation- and to continue it until patients' family members arrive-seems to be the family members' desire to be at the bedside at the time of death. All physicians participating in our study regarded advance directives that provide information as to patients' wishes about life-sustaining treatment desirable. All expressed concern, however, that it would be difficult to forego or discontinue life-support based on a patient's advance directive, particularly when the patient's family opposed the directive. CONCLUSION: Our group interview suggested several possible barriers to death with dignity and the appropriate use of advance directives in Japan. Further qualitative and quantitative research in this regard is needed. (shrink)

There is widespread concern among public health and emergency response officials that there could be a shortage of health care providers in a public health emergency. At least the following three factors could cause an inadequate supply of physicians, nurses, and other health care providers: the severity of the emergency might greatly increase the demand for health services and outstrip the available supply; health care providers might become unavailable because of their own high rates of illness, as was the (...) case in the SARS epidemic; and many health care providers might not report for duty for personal, family, or professional reasons.One way of addressing the shortage is to encourage health care providers from unaffected areas or parts of the country to volunteer their services. A variety of measures have been enacted to facilitate the use of such volunteers. (shrink)

Hymenoplasty, practiced in societies wherein a woman's virginity signifies honour, is a controversial surgery raising a multitude of ethical issues. There is a dearth of research uncovering the views of physicians who perform hymenoplasty, especially in sexually conservative cultures, such as Iran. Interviews were conducted with five Iranian physicians who perform hymenoplasty to determine their ethical views on the surgery. The interview findings suggest that Iranian physicians risk punitive consequences if they are discovered to be offering hymenoplasty. (...) However, some continue to cautiously perform the procedure out of a moral obligation to protect the welfare of women seeking it, even if they are personally conflicted about the surgery. (shrink)

Given the wide-reaching and detrimental impact of COVID-19, its strain on healthcare resources, and the urgent need for—sometimes forced—public health interventions, thorough examination of the ethical issues brought to light by the pandemic is especially warranted. This paper aims to identify some of the complex moral dilemmas faced by senior physicians at a major medical centre in Saudi Arabia, in an effort to gain a better understanding of how they navigated ethical uncertainty during a time of crisis. This qualitative (...) study uses a semistructured interview approach and reports the findings of 16 interviews. The study finds that participants were motivated by a profession-based moral obligation to provide care during the toughest and most uncertain times of the pandemic. Although participants described significant moral dilemmas during their practice, very few identified challenges as ethical in nature, and in turn, none sought formal ethics support. Rather, participants took on the burden of resolving ethical challenges themselves—whenever possible—rationalising oft fraught decisions by likening their experiences to wartime action or by minimising attention to the moral. In capturing these accounts, this paper ultimately contemplates what moral lessons can, and must be, learnt from this experience. (shrink)

This research investigates the impact of various factors on ethical behavior of 180 not-for-profit hospital employees. Ethical behavior of peers, ethical behavior of successful managers, and emotional intelligence had a significant positive impact on ethical behavior of respondents. Physicians and hospital employees with political connections within the organization were significantly less ethical than other employees. The results have many implications for researchers and healthcare practitioners.

In pursuit of my ultimate objective of being in control of my self-deliverance at the time when my physical condition no longer warrants continuance, I have joined the Hemlock Society of Los Angeles. The Society urges its members to explore with their personal physicians this subject well in advance of the actual moment of necessity, and in particular the problem of acquiring a lethal dose of a drug that will provide a release consistent in quality with the degree of (...) peace and serenity sought in life. It is my hope that we can find a process commensurate with your moral and professional concerns which will allow us to collaborate. (shrink)

The legalization of euthanasia, both in the Netherlands and in other countries is usually justified in reference to the right to autonomy of patients. Utilizing recent Dutch jurisprudence, this article intends to show that the judicial proceedings on euthanasia in the Netherlands have not so much enhanced the autonomy of patients, as the autonomy of the medical profession. Keywords: allowing to die, criminal law, euthanasia, law enforcement, legal aspects, legislation, medical ethics, medical profession, self determination, the Netherlands, voluntary euthanasia, withholding (...) treatment CiteULike Connotea Del.icio.us What's this? (shrink)

Ethical dilemmas are part of medicine, but the type of challenges, the frequency of their occurrence and the nuances in the difficulties have not been systematically studied in low-income settings. The objective of this paper was to map out the ethical dilemmas from the perspective of Ethiopian physicians working in public hospitals. A national survey of physicians from 49 public hospitals using stratified, multi-stage sampling was conducted in six of the 11 regions in Ethiopia. Descriptive statistics were used (...) and the responses to the open-ended question “If you have experienced any ethical dilemma, can you please describe a dilemma you have encountered in your own words?” were analyzed using a template analysis process. A total of 587 physicians responded, and 565 met the inclusion criteria. Twelve of 24 specified ethically challenging situations were reported to be experienced often or sometimes by more than 50% of the physicians. The most frequently reported challenge concerned resource distribution: 93% agreed that they often or sometimes had to make difficult choices due to resource limitation, and 83% often or sometimes encountered difficulties because patients were unable to pay for the preferred course of treatment. Other frequently reported difficulties were doubts about doing good or harming the patient, relating to conflicting views, concern for family welfare, disclosure issues and caring for patients not able to consent. Few reported dilemmas related to end-of-life issues. The 200 responses to the open-ended question mirrored the quantitative results. Ethiopian physicians report ethical challenges related more to bedside rationing and fairness concerns than futility discussions and conflicts about autonomy as described in studies from high-income countries. In addition to the high report of experienced challenges, gravity of the dilemmas that are present in their narratives are striking. Recognition of the everyday experiences of physicians in low-income settings should prompt the development of ethics teaching and support mechanisms, discussion of ethical guidelines as well as increase our focus on how to improve the grave resource scarcity they describe. (shrink)

How does gender affect work rewards for professionals in a state-run economy? Using surveys from physicians in Estonia in 1991, the authors first found that the gender of the physician did not affect the level of formal rewards. However, because the state allocated formal rewards on the basis of professional purity, which was negatively correlated with feminization, specialties that had the greatest proportion of women also had the lowest formal rewards. These findings contrast with the author's findings for the (...) level of informal “black market” rewards. Women were less likely to receive informal rewards than men, especially if they worked in subfields high in professional purity. The authors conclude that the link between professional purity and feminization is critical in explaining pay differences informal work rewards while gender itself is the critical factor in explaining informal reward differences. (shrink)

Compassion is mentioned in the Principles of the American Medical Association but not in the Code of Ethics of the Canadian Medical Association. In this article, we assess the case for including compassion in a code of ethics for physicians. We argue that, properly understood, there is a strong case for including compassion in codes of ethics for physicians on the basis that it is both clinically and ethically central to the practice of medicine.

Background Making the right decisions, while simultaneously showing respect for patient autonomy, represents a great challenge to nursing home staff in the issues of life-prolonging treatment, hydration, nutrition and hospitalisation to dying patents in end-of-life. Objectives To study how physicians and nurses protect nursing home patients' autonomy in end-of-life decisions, and how they justify their practice. Design A qualitative descriptive design with analysis of the content of transcribed in-depth interviews with physicians and nurses. Participants Nine physicians and (...) ten nurses in 10 nursing homes in Norway. Results and interpretations Assessment of the patient's competence to consent to treatment is almost absent. The physicians build their practice on the principles of beneficence and nonmaleficence. Nurses tend to trust the patients' rejection of life support, even when the patients have difficulty speaking or suffer from dementia. Relatives were, according to the health personnel, included in decision-making processes to a very limited extent. However, futile life support is sometimes provided contrary to the physicians' judgement of what constitutes the patient's best interest on occasions when they are pressurised by next of kin. Conclusions The study reveals a need to improve decision-making routines according to ethical ideals and legislation. Conflicts between relatives and healthcare professionals in the decision-making process deflect the focus from searching for the best possible treatment for the terminal patient. Further discussion is required as to whether the concept of autonomy is applicable in situations in which the patient is impaired and dying. (shrink)

This qualitative research examines the influence of animosity on physicians during clinical encounters and its ethical implications. Semi-structured interviews were conducted with ten Israeli-Jewish physicians: four treated Syrians and six treated Palestinian terrorists/Hezbollah militants or Palestinian civilians. An interpretive phenomenological analysis was used to uncover main themes in these interviews. Whereas the majority of physicians stated they are obligated to treat any patient, physicians who treated Syrians exhibited stronger emotional expression and implicit empathy, while less referring (...) to the presence of the Israeli-Arab conflict. In contrast, physicians who treated enemy combatants or Palestinian civilians showed the exact opposite. Linking these results to the “Implicit Bias” theory, the role of empathy and the beneficence principle in medical ethics, we argue that: the unconscious decreased emotional involvement among the latter group of physicians is a deficiency that needs to be recognized; and this deficiency undermines the principle of beneficence, thereby possibly influencing the fulfillment of the commitment to treat patients. Acknowledging and addressing the potential emotional and ethical deficiencies entailed in encounters with the so-called enemy-patients are of importance to the global medical community, since such encounters are increasingly an integral part of the current political realities faced by both the developed and developing worlds. (shrink)

Background Since the enactment of the euthanasia law in the Netherlands, there has been a lively public debate on assisted dying that may influence the way patients talk about euthanasia and physician-assisted suicide with their physicians and the way physicians experience the practice of EAS. Aim To show what developments physicians see in practice and how they perceive the influence of the public debate on the practice of EAS. Methods We conducted a secondary analysis of in-depth interviews (...) with 28 Dutch physicians who had experience with a complex case of EAS. Respondents were recruited both by the network of physicians working for SCEN as well as via a national questionnaire, wherein participating physicians could indicate their willingness to be interviewed. Results Three themes came up in analysing the interviews. First, the interviewed physicians experienced a change in what patients would expect from them: from a role as an involved caregiver to being the mere performer of EAS. Second, interviewees said that requests for EAS based on non-medical reasons came up more frequently and wondered if EAS was the right solution for these requests. Last, respondents had the impression that the standards of EAS are shifting and that the boundaries of the EAS regulation were stretched. Conclusions The perceived developments could make physicians less willing to consider a request for EAS. Our results also raise questions about the role of physicians and of EAS in society. (shrink)

High technology and nursing: ethical dilemmas nurses and physicians face on high‐technology units in Norway Results from two studies of ethical dilemmas nurses and doctors experience on two high‐technology units are compared and discussed. The qualitative comparative methodology of grounded theory was used to generate theoretical frameworks grounded in the empirical realities of the units. The ethical dilemmas they faced were related to: treating the one vs. the common good; end of life questions; and resource allocations with inadequate staffing. (...) Similarities were related to intensity and urgency of nursing care and patient treatment, clear nursing ideologies based on treating humans within a framework of hope, embracing technology and scarce resources. Differences between the two study units were patient diagnosis, hierarchical structure on one unit while one had a vertical structure and decision‐making processes, and finally how nursing knowledge and autonomy were used. The two studies demonstrated that clinical, ethical and administrative interactions and decisions are highly compounded, stressful and intertwined. (shrink)

The paper reports results of the very first survey-based study on the prevalence, frequency and nature of ethical or other non-medical difficulties faced by Polish physicians in their everyday clinical practice. The study involved 521 physicians of various medical specialties, practicing mainly in inpatient healthcare. The study showed that the majority of Polish physicians encounter ethical and other non-medical difficulties in making clinical decisions. However, they confront such difficulties less frequently than their foreign peers. Moreover, Polish doctors (...) indicate different circumstances as a source of the experienced problems. The difficulties most often reported relate to (i) patients (or their proxies) requests for medically non-indicated interventions; (ii) problems with communication with patients (or their proxies) due to the patients’ negative attitude, unwillingness to cooperate, or aggression; and (iii) various difficulties with obtaining informed consent. Polish physicians report difficulties associated with disagreements among care givers or scarcity of resources less frequently than doctors from other countries. The study’s findings provide support for the thesis that a significant portion of Polish physicians still follow a traditional, paternalistic, and hierarchical model of healthcare practice. Instead of promoting patient’s empowerment, engagement, and rights, they often consider these ideas as a threat to physicians’ professional authority and autonomy. The study leads to the conclusion that due to insufficient training in medical ethics, communication skills, and medical law, many Polish physicians lack the knowledge and competence necessary to adequately respond to challenges posed by modern healthcare practice. (shrink)

We report the results of an investigation of nurses’ and physicians’ sensitivity to ethical dimensions of clinical practice. The sample consisted of 113 physicians working in general medical settings, 665 psychiatrists, 150 nurses working in general medical settings, and 145 nurses working in psychiatry. The instrument used was the Moral Sensitivity Questionnaire (MSQ), a self-reporting Likert-type questionnaire consisting of 30 assumptions related to moral sensitivity in health care practice. Each of these assumptions was categorized into a theoretical dimension (...) of moral sensitivity: relational orientation, structuring moral meaning, expressing benevolence, modifying autonomy, experiencing moral conflict, and following the rules. Significant differences in responses were found between health care professionals from general medical settings and those working in psychiatry. The former agreed to a greater extent with the assumptions in the categories ‘meaning’ and ‘autonomy’ and to a lesser degree with the categories ‘benevolence’ and ‘conflict’. Moreover, those from the psychiatric sector agreed to a greater extent to the use of coercion if necessary. Significant differences were also found for some of the MSQ categories, between physicians and nurses, and between males and females. (shrink)

There is a perpetrator historiography of the Holocaust and a Jewish historiography of the Holocaust. The former has received the lion’s share of attention in bioethics, particularly in the form of warnings about medicine’s potential for complicity in human atrocity. However, stories of Jewish physicians during the Holocaust are instructive for positive bioethics, one that moves beyond warnings about what not to do. In exercising both explicit and introspective forms of resistance, the heroic work of Jewish physicians in (...) the ghettos and concentration camps tells us a great deal about the virtues and values of medicine. In this article, we frame the stories of four of these Jewish physicians in ways that are instructive for contemporary medicine. By far, the most widely recognized and discussed figure is Viktor Frankl, whose work on hope and the meaning of suffering remains essential insofar as medicine inherently confronts disease and death. Less discussed in bioethics and medical humanities are the cases of Mark Dworzecki, Karel Fleischmann, and Gisella Perl. Dworzecki’s efforts to encourage others in the Vilna Ghetto to document their experiences illustrates the power of narrative for the human experience and the notion of ethics as narrative in the face of suffering. Fleischmann’s art underscores not only the importance of reflective practices for professionals as a form of simultaneous introspection and testimonial, but illuminates hope amid sheer hopelessness. This hope, which was comparatively implicit in much of Fleishmann’s art, is explicated as a method by Frankl, becoming a form of therapy for both physicians wrestling with their professional work, and patients wrestling with their illnesses and diseases. Finally, Perl’s resistance to Mengele’s orders highlights the importance of moral action, not just reflective reaction. The experiences of each of these figures, while certainly located in the unique horrors of Holocaust Germany, portends lessons for today’s physicians faced with moral distress and ethical dilemma in the face of suffering, interpersonal relationships, and socio-political conflicts that increasingly test the professed ideals of medicine. In this article we briefly tell the story of each of these physicians and connect the lessons therein to contemporary medical practice. (shrink)

IntroductionFrontline healthcare workers have faced significant plight during the ongoing Coronavirus disease 2019 pandemic. Studies have shown their vulnerabilities to depression, anxiety disorders, post-traumatic stress, and insomnia. In a developing country like India, with a rising caseload, resource limitations, and stigma, the adversities faced by the physicians are more significant. We attempted to hear their “voices” to understand their adversities and conceptualize their resilience framework.MethodsA qualitative approach was used with a constructivist paradigm. After an initial pilot, a socio-demographically heterogeneous (...) population of 172 physicians working in COVID-designated centers were purposively sampled from all over India. Following in-depth virtual interviews using a pre-formed semi-structured guide, the data was transcribed and translated verbatim. The interview was focused on their challenges, needs, and processes of coping and support. Charmaz’s grounded theory was used for analysis supplemented by NVivo 10 software.ResultsFear of infection, uncertainty, stigma, guilt, and social isolation emerged as the main challenges. Simultaneously, their “unmet needs” were flexible work policies, administrative measures for better medical protection, the sensitivity of media toward the image of HCW, effective risk communication for their health, and finally, social inclusion. Their resilience “framework” emerged as a process while navigating these adversities and consisted of three facets: forming a “resilient identity,” managing the resilience, and working through the socio-occupational distress. The role of mental well-being, social network, peer support, problem negotiation, and self-care emerged as the key coping strategies.ConclusionThe study findings support the global call for better psychosocial health and quality of life of the frontline HCWs. Their “unheard voices” explored in the study can anchor subsequent resilience-enhancing interventions and policies. Guidelines focusing on the psychological wellbeing of frontline HCWs need to be grounded in their unmet needs and lived experiences. (shrink)

During the coronavirus disease 2019 pandemic, the public has often expressed great appreciation toward medical personnel who were often shown in the media expressing strong emotions about the situation. To examine whether the perception of people on a physician is in fact influenced by whether the physician treats patients with COVID-19 and the emotions they expressed in response to the situation, 454 participants were recruited in May 2020. Participants saw facial expressions of anger, sadness, happiness, and neutrality which supposedly were (...) shown by physicians who were presented as working either in COVID-19 wards or in an internal medicine ward. Participants rated how competent, empathetic, caring, and likable each physician was, to what degree they would wish to be treated by each physician, and what salary each physician deserved. Physicians treating patients with COVID-19 were seen more positively and as deserving higher pay; they appeared more competent, caring, likable, and were more likely to be chosen as a caregiver compared to physicians not treating patients with COVID-19. The expressed emotions of physicians had a strong impact on how they were perceived, yet this effect was largely unrelated to whether they treated patients with COVID-19 or not such that happy physicians seemed more empathetic, caring, and likable than the physicians who showed negative emotions. Positive regard toward physicians treating patients with COVID-19 was associated with the fact that they were seen as saving lives and not due to the risk imposed by their work. (shrink)

ObjectiveInvestigating the mental health status of Chinese resident physicians during the 2019 new coronavirus outbreak.MethodsA cluster sampling method was adopted to collect all China-wide resident physicians during the epidemic period as the research subjects. The Symptom Checklist-90 self-rating scale was used to assess mental health using WeChat electronic questionnaires.ResultsIn total, 511 electronic questionnaires were recovered, all of which were valid. The negative psychological detection rate was 93.9%. Among the symptoms on the self-rating scale, more than half of the (...) Chinese resident physicians had mild to moderate symptoms of mental unhealthiness, and a few had asymptomatic or severe unhealthy mental states. In particular, the detection rate of abnormality was 88.3%, obsessive-compulsive symptoms was 90.4%, the sensitive interpersonal relationship was 90.6%, depression abnormality was 90.8% /511), anxiety abnormality was 88.3%, hostility abnormality was 85.3%, terror abnormality was 84.9%, paranoia abnormality was 86.9%, psychotic abnormalities was 89.0%, and abnormal sleeping and eating status was 90.8%. The scores of various psychological symptoms of pediatric resident physicians were significantly lower than those of non-pediatrics.ConclusionThe new coronavirus epidemic has a greater impact on the mental health of Chinese resident physicians. (shrink)

Background: Advances in biomedical sciences, technologies and care practices have resulted in an increase in ethical problems and a resulting growth of difficulties encountered by health workers in their professional activity. Objective: The main objective of this study was to analyse knowledge in the ethical field and experience with and the propensity for using ethics consultations by nurses and physicians. Methods: Between March and June 2014, a cross-sectional observational study was conducted on a sample of 351 nurses and 128 (...) physicians in four central Italian hospitals. For data collection, a semi-structured questionnaire was used, consisting of 21 items divided into four sections exploring (1) demographic and occupational characteristics, (2) knowledge in the ethics field, (3) experience with ethical issues and (4) the propensity to use ethics consultation. Ethical considerations: Research ethics approval was obtained from the Italian Nurses Professional Board. Results: The results show that both nurses and physicians are faced with ethically sensitive situations. Nurses were found to have better judgement concerning their own knowledge than physicians, but more physicians were found to have a deeper level of specific training in ethics issues. The propensity to ask for ethics consultations to address ethical issues was found to be significantly associated with the degree to which ethical issues have deepened (and the level of experience acquired in this field). Conclusion: The presence of a consulting service that can lead to shared choices may represent, together with basic and continuing education, a valid support for professional growth in the ethical field for both physicians and nurses. (shrink)

On March 9, 1993, in the first ruling of its kind, the Maryland Court of Appeals declared that physicians and hospitals may be sued for failing to inform patients of a practitioner’s human immunodeficiency virus status. What is more significant, these suits may be pursued even in instances when the physician has followed universal precautions and the patient did not contract the virus that causes acquired immunodeficiency syndrome. The Maryland court addressed two central questions in Faya v. Almaraz. First, (...) do HIV-infected physicians have a legal duty to inform their patients of their HIV status? And, second, can patients recover damages for fear induced by a physician’s conduct? While one finds numerous precedents that authorize actions to recover damages based purely on fear of disease and emotional distress, the Faya court’s holdings on the issue significantly expand the scope of potential liability. Moreover, the court’s analysis of the informed consent and HIV-infected physician issue is incomplete, inconsistent, and represents an unjustified and unwise departure from traditional informed consent theory. It, and its progeny, may have widespread and dire repercussions. (shrink)

The practice of medicine involves obtaining, evaluating and analyzing information drawn from a variety of sources; thus physicians assess and act upon information that varies in terms of both reliability and the extent to which it may be directly perceived. In the hospital setting, physicians’ progress notes provide a record of this process that serves as a primary means of communication between treaters who are not co-present with one another; accordingly, in order to permit independent evaluation of the (...) information they contain, physicians have developed a repertoire of linguistic devices to express differing attitudes towards the information that their notes convey. In this article, through the microanalysis of a pediatric resident’s note, I demonstrate how physicians use evidential markers, including the passive voice and agentless constructions, to construct frameworks of credibility and responsibility that both underlie and enable medical work. These grammatical devices permit the physician-reader to weigh for himself or herself the evidence which supports the conclusions reached. (shrink)

Objective To compare assessments of the decision-making competencies of psychiatric inpatients as provided by physicians, nurses, relatives and an assessment tool.Methods This study was carried out at the psychiatry clinic of Kocaeli University Hospital from June 2007 to February 2008. The decision-making competence of the 83 patients who participated in the study was assessed by physicians, nurses, relatives and MacCAT-T.Results Of the 83 patients, the relatives of 73.8% of them, including the parents of 47.7%, were interviewed during the (...) study. A moderately good consistency between the competency assessments of the nurses versus those of the physicians, but a poor consistency between the assessments of the physicians and nurses versus those of the patients’ relatives, was determined. The differences in the competency assessment obtained with the MacCAT-T versus the evaluations of the physicians, nurses and patients’ relatives were statistically significant.Conclusions Our findings demonstrate those physicians, nurses and the patients’ relatives have difficulty in identifying patients lacking decision-making competence. Therefore, an objective competence assessment tool should be used along with the assessments of physicians and nurses, both of whom can provide clinical data, as well as those of relatives, who can offer insights into the patient's moral values and expectations. (shrink)