U.S. immigration policies and enforcement can make immigrants fearful of accessing healthcare. Although current immigration policies restrict enforcement in “sensitive locations” including healthcare facilities, there are reports of enforcement actions in such settings.

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration (VA) facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients (n = 32) and managers (n = 38); semi-structured interviews with managers (n = 31), clinicians (n = 55), and ethics committee chairpersons (n = 21). Data were analyzed using content analysis. Managers reported that the greatest ethical challenge (...) was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

BackgroundClinical ethical practice (CEP) is required for healthcare workers (HCWs) to improve health-care delivery. However, there are gaps between accepted ethical standards and CEP in Ethiopia. There have been limited studies conducted on CEP in the country. Therefore, this study aimed to determine the magnitude and associated factors of CEP among healthcare workers in healthcare facilities in Ethiopia.MethodFrom February to April 2021, a mixed-method study was conducted in 24 health facilities, combining quantitative and qualitative methods. (...) Quantitative (survey questionnaire) and qualitative (semi-structured interviews) data were collected. For quantitative and qualitative data analysis, Stata version 14 and Atlas.ti version 7 were utilized. Multiple logistic regression and thematic analysis for quantative and qualitative respectively used.ResultsFrom a total of 432 study participants, 407 HCWs were involved in the quantitative analysis, 36 participants were involved in five focus group discussions (FGDs), and eleven key informant interviews (KIIs) were involved in the qualitative analysis. The score of good CEP was 32.68%. Similarly, the scores of good knowledge and attitude were 33.50% and 25.31%, respectively. In the multiple logistic regression models, satisfaction with the current profession, availability of functional CECs, compassionate leaders, previously thought clinical ethics in pre-service education and good attitude were significant factors associated with CEP. Among these significant factors, knowledge, compassionate leaders, poor infrastructure, a conducive environment and positive attitudes were also determinants of CEP according to qualitative findings.ConclusionsThe CEP in health care services in Ethiopia is low. Satisfaction with the current profession, functional CECs, positive attitude, compassionate leaders and previously thought clinical ethics were significant factors associated with CEP. The Ministry of Health (MoH) should integrate interventions by considering CECs, compassionate leadership, and positive attitudes and enhance the knowledge of health professionals. Additionally, digitalization, intersectoral collaboration and institutionalization are important for promoting CEP. (shrink)

To promote ethical practices, healthcare managers must understand the ethical challenges encountered by key stakeholders. To characterize ethical challenges in Veterans Administration facilities from the perspectives of managers, clinicians, patients, and ethics consultants. We conducted focus groups with patients and managers ; semi-structured interviews with managers, clinicians, and ethics committee chairpersons. Data were analyzed using content analysis. Managers reported that the greatest ethical challenge was fairly distributing resources across programs and services, whereas clinicians identified the effect of resource (...) constraints on patient care. Ethics committee chairpersons identified end-of-life care as the greatest ethical challenge, whereas patients identified obtaining fair, respectful, and caring treatment. Perspectives on ethical challenges varied depending on the respondent's role. Understanding these differences can help managers take practical steps to address these challenges. Further, ethics committees seemingly, are not addressing the range of ethical challenges within their institutions. (shrink)

ObjectivesThe study evaluated nurses’ perceptions on the benefits, drawbacks, and their roles in initiating and implementing advance directives at private and public secondary healthcare units.MethodsThe study adopted a cross-sectional, comparative-descriptive research design and was anchored on the structural functional theory. A total of 401 nurses were chosen on purpose. The data was collected between January and March 2018 among nurses at the selected hospitals. Analysis was done via SPSSv28.0.1.0.ResultsCompared to nurses working in private healthcare facilities, the majority (...) of nurses at the public healthcare facilities indicated a more favorable opinion of AD’s benefits and felt they had a substantial involvement in the development and execution of AD than their private counterpart. Similarly, 60.7% of nurses employed by the government agreed that AD has some disadvantages compared to those employed by the private sector. Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; 0.78 times less likely than Muslim to disagree that AD has flaws; and 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, though not significant.ConclusionMaking decisions at the end-of-life can be challenging, thus AD should be supported across the board in the healthcare industry. Nurses should be trained on their role in developing and implementing AD, as well as on its advantages and how to deal with its challenges. (shrink)

Spiritual care is a profession in transformation. It is evolving from a denominationally bound profession into a specific kind of healthcare profession. In the Netherlands, as elsewhere, debates are going on about the introduction of standards in public services such as health care. Many spiritual counsellors oppose standardization of spiritual care. Most importantly, standards seem to conflict with their sanctuary position as well as with the ?theory of presence? that many spiritual counsellors adhere to. A questionnaire was distributed among (...) spiritual counsellors asking them about the nature and number of standards they work with and the positive and negative effects of these standards on their daily work. This exploratory study shows that only a few spiritual counsellors work with standards. It also reveals that those who work with standards are neutral to positive about the ways in which standards influence their work. In particular, spiritual counsellors working with standards state that doing so does not conflict with their sanctuary position, nor with their ?being present?. The responses suggest that it does not seem to be standards as such but rather the social setting within which the standards are used that determines the effects that standards have on the content and quality of spiritual care. The paper concludes with some recommendations and suggestions for further investigation. (shrink)

Concern about the rapid ageing of all societies reaches alarming proportions as healthcare inequities are steeply rising, prompting the elderly to live longer but subject to insufficient social protection and healthcare in the wake of dwindling public resources. The aged population of developing nations are facing additional hardships due to the growing gap between needs and the financial reductions of public institutions, retirement funds, and the trend towards privatization of essential services turned into commodities. Current approaches to allocation (...) of insufficient resources without ageist discrimination are briefly discussed: individual self‐care aimed at successful, active and healthy ageing based on resourcefulness of the privileged elderly; utilitarian approaches founded on QALY and fair innings, and human rights focused on the plights of the elderly. These approaches cannot apply to resources poor nations, who need to engage in context‐bound bioethics dealing with the realities of their exposed ageing population. A developing world bioethics is needed to face the plights of the elderly in countries with low and middle‐income and insufficient social capital. Suggested are: 1) a phenomenological approach based on the interaction of bioethics and ethnology, furthering grass‐roots input from the elderly; 2) Create small communities –campus‐like boroughs– to simplify accessibility to social services and healthcare facilities, as an alternative to the high‐cost WHO proposal of age‐friendly large cities. (shrink)

According to the widely accepted principles of beneficence and distributive justice, I argue that healthcare providers and facilities have an ethical duty to reduce the ecological footprint of the services they provide. I also address the question of whether the reductions in footprint need or should be patient-facing. I review Andrew Jameton and Jessica Pierce’s claim that achieving ecological sustainability in the healthcare sector requires rationing the treatment options offered to patients. I present a number of reasons (...) to think that we should not ration health care to achieve sufficient reductions in a society’s overall consumption of ecological goods. Moreover, given the complexities of ecological rationing, I argue that there are good reasons to think that the ethical duty to reduce the ecological footprint of health care should focus on only nonpatient-facing changes. I review a number of case studies of hospitals who have successfully retrofitted facilities to make them more efficient and reduced their resource and waste streams. (shrink)

Background Shared decision-making in healthcare is a collaborative process where patients are supported to make informed decisions according to their preferences. Healthcare decisions affect patients' lives which necessitates patients to participate in decisions concerning their health. This study explored experiences and ethical issues related to shared decision-making in a rural healthcare setting. Methods An exploratory qualitative study was conducted at Budumba Health Centre III and Butaleja Health Centre III in rural Eastern Uganda. In this study, 23 in-depth (...) interviews were conducted among 12 healthcare providers and 11 patients. Data was analyzed thematically using NVivo-12 plus software. Results Four themes emerged which included: Paternalistic cultures of care, challenges, strategies for improvement, and ethical issues. Patients at both facilities expressed the need to be involved in decision-making processes. However, many stressed that they are not engaged in decision-making about their health. Many healthcare providers noted that shared decision-making could improve patient prognosis but are faced with challenges related to low male involvement and the influence of cultural and religious practices, including myths and patriarchal attitudes which impact effective patient engagement. Ethical issues identified include concerns about informed consent, privacy and confidentiality, deception, and harm. Conclusions This study highlighted the need for better sensitization of patients and comprehensive training for healthcare providers to minimize and resolve ethical issues that emerge during shared decision-making processes. Therefore, targeted interventions are needed to enhance decision-making processes in rural healthcare including but not limited to developing shared decision-making manual and continuous training of healthcare providers to ethically engage patients. Further research is needed to explore larger facilities with a bigger scope including patients under 18 years of age and and their surrogates. (shrink)

Background During the first wave of the new coronavirus (COVID-19) pandemic, the sudden increase in hospitalised patients put medical facilities in southern Switzerland under severe pressure. During this time, bachelor’s degree programs in nursing, physiotherapy and occupational therapy were disrupted, and students in their second year were displaced. Students experienced the continuous reorganisation of their traineeship as healthcare facilities adapted to a climate of uncertainty. Purpose The aim of this study was to investigate the degree of moral (...) distress and the ethical issues most often encountered by physiotherapy, nursing and occupational therapy students enrolled in a traineeship during the first wave of the COVID-19 pandemic in southern Switzerland. Participants and research context The sample consisted of 102 participants, and the response rate was 81.6%. Research design Based on a pragmatic approach, a mixed-method with a convergent design was adopted. Data were collected between 30 April 2020 and 14 May 2020, via a survey administered to all occupational therapy, physiotherapy and nursing students in their fourth semester. Ethical considerations Given that no vulnerable persons were involved, the Ethics Committee of Southern Switzerland waived authorisation. However, all measures were put into place to protect participants by guaranteeing their anonymity and confidentiality. Results and discussion The data analysis showed that the main source for moral distress was ‘poor teamwork’ and that the moral issues encountered most often by students were related to the appropriateness of care and working conditions, with a clear reference to students’ own safety and that of their loved ones; the other concerns reported included the loss of learning opportunities and the perceived lack of technical knowledge and skills. Conclusions This survey offers a faithful overview of physiotherapy, nursing and occupational therapy students’ experience during the first pandemic wave. This study also identifies some key recommendations for healthcare professions’ education. (shrink)

Tertiary healthcare ethics (HCE) consultation occurs when an HCE consultant at a healthcare facility requests guidance from one or more senior HCE consultants who are not members of that facility’s HCE consultation service. Tertiary HCE consultants provide advanced HCE guidance and/or mentoring to facility (secondary) HCE consultants, mirroring healthcare consultation in clinical practice. In this article, we describe advantages and challenges of providing tertiary HCE consultation through a hub-and-spoke model administered by a national integrated HCE service.

Healthcare reforms in India have been a much-debated issue in the recent past. While the debate has focused mainly on the right to healthcare, another by-product that has evolved out of the debate was the current problem of medical malpractice and the healthcare law. The last decade has seen an increase in the healthcare facilities in the country. This, however, has come with a bulk of medical error cases which the courts have entertained. According to (...) reports, there has been an increase in medical litigation cases by 400% in the last decade. There are about 5.2 million cases of medical error in the country every year. While there exists a standard legal system in the country which entertains such complaints of medical malpractice, the attempt by regulators and medical practitioners should be to reduce these cases. This paper seeks to analyze the extent to which medical malpractice cases affect consumers. It analyzes the existing medical liability system which has mainly evolved through the jurisprudence laid down by the English courts and critiques it. It also looks into the major reasons for such medical mishaps. Authors argue that a “No-Fault” system may give better outcomes. They analyze this by looking at the no-fault liability model implemented in New Zealand. Narratives of no-fault liability being implemented in India have also been used. These are showcased from instances of Motor Vehicles Act, 1988, and Clinical Trial regulations. It is also argued that a by-product of a no-fault liability system is stringent regulations which are used to reduce the possibility of medical mishaps altogether. Lastly, the possible problems of the no-fault liability system are discussed in the paper. (shrink)

Background: In Ontario, Canada, patients who lack decision-making capacity and have no family or friends to act as substitute decision-makers currently rely on the Office of the Public Guardian and Trustee to consent to long-term care (nursing home) placement, but they have no legal representative for other placement decisions. Objectives: We highlight the current gap in legislation for difficult transition cases involving unrepresented patients and provide a novel framework for who ought to assist with making these decisions and how these (...) decisions ought to be made. Research design: This paper considers models advanced by Volpe and Steinman with regard to who ought to make placement decisions for unrepresented patients, as well as current ethical models for analyzing how these decisions should be made. Participants and research context: We describe an anonymized healthcare transition case to illustrate the fact that there is no legally recognized decision-maker for placement destinations other than long-term care facilities and to show how this impacts all stakeholders. Ethical considerations: The case provided is an anonymized vignette representing a typical transition case involving an unrepresented patient. Findings: As a result of a gap in provincial legislation, healthcare providers usually determine the appropriate placement destination without a clear framework to guide the process and this can cause significant moral distress. Discussion: We argue for a team decision-making approach in the short term, and a legislative change in the long-term, to respect the patient voice, evaluate benefit and risk, enhance collaboration between healthcare providers and patients, and promote social justice. We believe that our approach, which draws upon the strengths of interprofessional teams, will be of interest to all who are concerned with the welfare and ethical treatment of the patients for whom they care. Conclusions: One of the main strengths of our recommendation is that it provides all members of the healthcare team (including nurses, social workers, therapists, and others) an increased opportunity to advocate on behalf of unrepresented patients. (shrink)

Background Mental healthcare users and patients were described as a particularly vulnerable group in the debate on the burdens of the COVID-19 pandemic. Just what this means and what normative conclusions can be derived from it depend to a large extent on the underlying concept of vulnerability. While a traditional understanding locates vulnerability in the characteristics of social groups, a situational and dynamic approach considers how social structures produce vulnerable social positions. The situation of users and patients in different (...) psychosocial settings during the COVID-19 pandemic has not yet been comprehensively considered and ethically analyzed under the aspect of situational vulnerability. Methods We present the results of a retrospective qualitative analysis of a survey of ethical challenges in different mental healthcare facilities of a large regional mental healthcare provider in Germany. We evaluate them ethically using a dynamic and situational understanding of vulnerability. Results Difficulties in implementing infection prevention measures, restrictions of mental health services in favor of infection prevention, social isolation, negative health effects on mental healthcare users and patients, and challenges in implementing regulations on state and provider levels within the local specificities emerged across different mental healthcare settings as ethically salient topics. Conclusions Applying a situational and dynamic understanding of vulnerability allows the identification of specific factors and conditions that have contributed to an increased context-dependent vulnerability for mental healthcare users and patients. These factors and conditions should be considered on the level of state and local regulations to reduce and address vulnerability. (shrink)

Active shooter incidents have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how (...) should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI? (shrink)

Payers have shaped the healthcare system in the United States as fee-for-service has facilitated a care model that prioritizes volume over the sake of patient care. This worsens health disparities, especially in safety net facilities where ancillary social work is both necessary clinically and completely uncompensated. Using concepts from Iris Marion Young’s Responsibility for Justice, it can be concluded that payers have a moral responsibility for reimbursing social care to address historical injustices. In this article, I describe the (...) ethical hazards in paying for social care and propose a way to finance this through value-based payments. (shrink)

Responding to a major pandemic and planning for allocation of scarce resources under crisis standards of care requires coordination and cooperation across federal, state and local governments in tandem with the larger societal infrastructure. Maryland remains one of the few states with no state-endorsed ASR plan, despite having a plan published in 2017 that was informed by public forums across the state. In this article, we review strengths and weaknesses of Maryland’s response to COVID-19 and the role of the Maryland (...) Healthcare Ethics Committee Network in bridging gaps in the state’s response to prepare health care facilities for potential implementation of ASR plans. Identified “lessons learned” include: Deliberative Democracy Provided a Strong Foundation for Maryland’s ASR Framework; Community Consensus is Informative, Not Normative; Hearing Community Voices Has Inherent Value; Lack of Transparency & Political Leadership Gaps Generate a Fragmented Response; Pandemic Politics Requires Diplomacy & Persistence; Strong Leadership is Needed to Avoid Implementing ASR … And to Plan for ASR; An Effective Pandemic Response Requires Coordination and Information-Sharing Beyond the Acute Care Hospital; and The Ability to Correct Course is Crucial: Reconsidering No-visitor Policies. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Healthcare is Demanding:Patience is a Virtue!Andrea TorrenceNursing is a rewarding career, but it can also be extremely challenging, depending on the type of patient you are assigned to. In my career, I have had a number of "difficult" patients, and every situation required a specific type of approach. Understanding how to interact with a difficult patient is a talent and requires a level of patience that exceeds the (...) normal amount one may have. As a nurse, if you want to be successful, you must have patience. Along with many natural characteristics required to be successful in nursing, patience, in my opinion, is the most required quality required for nursing. The difficult patient can be an emotional burden to the care provider. These burdens are not always related to the tasks associated with care. The patient that is emotionally exhausting is far more complex than a patient who requires physical work. Nursing is a trying and risky career, but the nurse is obligated to provide the best care possible to all patients regardless of how difficult that person may be.Our cardiac surgical telemetry unit received a patient from the emergency room diagnosed with a minor psychiatric problem and tachycardia (a fast heart rate). This patient required medical clearance before going to the psychiatric unit for further evaluation. At our facility, this frequently happens, depending on how many psychiatric beds are available and on the patient's medical status. There were no clinical indications for this patient to require a bedside caregiver—a bedside caregiver is assigned to a patient that may somehow be classified as a danger to themselves or others—and the patient was not "pink-slipped." Patients who may not be safe to leave the hospital once they've been evaluated in the emergency room will be pink-slipped for an inpatient evaluation. Also, suicidal or homicidal patients are pink-slipped until they undergo an extensive evaluation and are deemed safe to leave on their own. A pink slip is a legal hold document. The patient that we received at the time of her admission required neither. The initial description of the patient revealed that she was a young, pleasant, ambulatory (able to walk with no problems) woman and completely oriented (understands and can comprehend). This patient did not have any pain or complaints documented on her emergency room assessment. She was corporative and followed instructions.As soon as we received the patient to the unit, she began to protest the need for pain medication. There were no orders for pain medication because there was no notation of pain in the emergency room. The nurse addressed the patient's pain with the admitting physician and Tylenol was ordered. When the patient heard that the physician ordered Tylenol, she became very angry. The patient wanted a stronger medication. I have a reputation for connecting with patients who become angry, and those who are classified as difficult, so the primary nurse asked me to speak to this patient. After a brief conversation, I was able to calm the patient, and she returned to her room quietly. The patient was apologetic and sincere. I used a calm approach, reassuring words of affirmation, and the perfect body language to de-escalate this patient. I was pleased with myself because only a simple combination of techniques was used to resolve the patient's anger, and at that time, a therapeutic connection was made.The nurse entered the patient's room and noticed that the roommate looked somewhat bewildered, [End Page E11] but she did not address the roommate. The nurse was focused on completing her patient's admission assessment. After the nurse completed the assessment, the order for the patient to wear telemetry was discussed. Telemetry is a physician's order to continuously monitor the heart's function while hospitalized. Because the patient was mildly tachycardic, telemetry was ordered. The patient immediately refused the order and told the nurse that she was not going to wear the monitor. The nurse explained the need and informed the patient that she would not be confined to the bed while wearing it. The nurse left the room to find me to discuss the... (shrink)

With a growing global population of migrants, understanding the complex dynamics between healthcare providers and policy restrictions is crucial for ensuring equitable access to healthcare. The main objective of this qualitative study was to explore the ethical challenges faced by health care providers in the provision of health care to migrants. We conducted in –depth interviews with 11 healthcare providers, which were analysed using thematic analyse. Atlas ti software was used to analysis the data. Healthcare workers (...) reported facing ethical challenges as a result of not being able to provide medical care to migrant patients because healthcare policies deny them access to healthcare. These policies make it difficult for healthcare professionals to fulfil their duties in accordance with their oath. Failure to provide healthcare to migrant patients can cause moral distress for healthcare workers and affect their well-being. Reporting migrant patients to the police was mentioned as another ethical challenge, which is a breach of confidentiality. Several healthcare providers have developed strategies to address the limitations of migrants’ access to healthcare, including encouraging migrants to access healthcare from their home country and using private healthcare facilities. Health policies influence the way health care providers carry out their tasks, which can either positively or negatively impact access for vulnerable migrant groups. To address the challenges faced by healthcare providers in implementing their professional ethics, inclusive policies should be introduced, and human rights and ethics training should be provided, as well as ongoing dialogue to ensure that healthcare providers fulfil their professional obligations toward all migrant patients. (shrink)

The COVID-19 pandemic prompted a nudge for public–private cooperation in healthcare to rapidly cope with limited resource. However, Vietnam’s historical reliance on a public healthcare system, combined with a traditional emphasis on socialization in the Polanyian sense, hindered the swift integration of the private sector. This research investigates path dependency in Vietnam’s public health sector, using theories including path dependency, Karl Polanyi’s double movement with legal analysis method to analyze the interplay of historical decisions, and socialist policies in (...) healthcare. Recognizing these institutional and market governance flaws, a deeper understanding of the role of law becomes vital in crafting strategies for a more resilient and sustainable healthcare system in Vietnam. In this article, Ho Chi Minh City is chosen as a case study due to its notable mix of public–private healthcare facilities and its status as a leading area in infection cases during the third COVID-19 wave. The article suggests that there should be a change in the way public and private sectors work together, one that is more in line with market-driven solutions which requires solid legal framework for cooperation beyond merely mobilizing resources. (shrink)

The ethics of providing health care in resource-poor environments is a complex topic. It implies two related questions: What can we do with the resources on hand? Of all the things we can do, which ones should we do? “Resource-poor” environments are situations in which clinicians, organizations, or healthcare systems have the knowledge and skills, but not the means, to carry out highly effective and beneficial interventions. Determinants of a population’s health often rely less on disease and injury management (...) than on recognizing and meeting their basic needs. Many of the world’s people with the greatest health problems live in fragile contexts and remote areas. Their access to food, safe water, personal safety, improved sanitation facilities, and health care remains elusive, with availability often based on socioeconomic status, gender, ethnicity, or geography. Of course, ethical international healthcare work also requires an understanding of the illnesses and injuries that most frequently plague the population. To function ethically and to know both what can and what should be done with available resources, individuals and organizations involved in international healthcare must be experienced, adaptable, culturally sensitive, inspired, situationally aware, beneficent, courageous, honest, and fair. (shrink)

Background: Frontline healthcare providers are consistently exposed to potentially traumatic events while assisting patients with COVID-19. Post-traumatic growth happens when a person can transform trauma and use adversity in one’s advantage. In response to limited studies on positive outcomes that may occur from the pandemic; this study aimed to elucidate the positive impact of coping with COVID-19 outbreak on mental health, such as PTG.Methodology: The study comprised a sample of 691 healthcare providers 59% female, including physicians and nurses, (...) working in public health facilities in Kosovo, with an average age of 41.6 years. They were asked to complete a questionnaire with four parts: Socio-demographic, GHQ-28, COPE and PTGI. A deterioration of mental health with somatic symptoms leading to the escalation due to COVID-19 outbreak was found.Results: Female healthcare providers reported more clinical symptoms as well as higher coping skills scores than men. The domains in which positive changes were most frequently observed were Relating to Others, New Possibilities and Personal Strength. There was no significant direct effect of mental health on PTG in the mediation model, though a significant indirect effect was observed for coping skills.Conclusion: The results suggest that levels of mental health exacerbation do not play a conclusive role in determining levels of PTG, as long coping mechanisms are in place. The development and implementation of interventions to minimize COVID-19-related mental health consequences, by fostering PTG among healthcare providers could be highly beneficial in pandemic response work. (shrink)

Healthcare cybersecurity is increasingly targeted by malicious hackers. This sector has many vulnerabilities and health data is very sensitive and valuable. Consequently, any damage caused by malicious intrusions is particularly alarming. The consequences of these attacks can be enormous and endanger patient care. Amongst the already-implemented cybersecurity measures and the ones that need to be further improved, this paper aims to demonstrate how penetration tests can greatly benefit healthcare cybersecurity. It is already proven that this approach has enforced (...) cybersecurity in other sectors. However, it is not popular in healthcare since many prejudices still surround the hacking practice and there is a lack of education on hackers’ categories and their ethics. The present analysis aims to comprehend what hacker ethics is and who ethical hackers are. Currently, hacker ethics has the status of personal ethics; however, to employ penetration testers in healthcare, it is recommended to draft an official code of ethics, comprising principles, standards, expectations, and best practices. Additionally, it is important to distinguish between malicious hackers and ethical hackers. Amongst the latter, penetration testers are only a sub-category. Acknowledging the subtle differences between ethical hackers and penetration testers allows to better understand why and how the latter can offer their services to healthcare facilities. (shrink)

This article considers the strengths and potential contributions of participatory visual methods for healthcare quality improvement research. It argues that such approaches may enable us to expand our understanding of ‘patient experience’ and of its potential for generating new knowledge for health systems. In particular, they may open up dimensions of people’s engagement with services and treatments which exceed both the declarative nature of responses to questionnaires and the narrative sequencing of self reports gathered through qualitative interviewing. I will (...) suggest that working with such methods may necessitate a more reflexive approach to the constitution of evidence in quality improvement work. To this end, the article will first consider the emerging rationale for the use of visual participatory methods in improvement before outlining the implications of two related approaches—photo-elicitation and PhotoVoice—for the constitution of ‘experience’. It will then move to a participatory model for healthcare improvement work, Experience Based Co-Design. It will argue that EBCD exemplifies both the strengths and the limitations of adequating visual participatory approaches to quality improvement ends. The article will conclude with a critical reflection on a small photographic study, in which the author participated, and which sought to harness service user perspectives for the design of psychiatric facilities, as a way of considering the potential contribution of visual participatory methods for quality improvement. (shrink)

Budgets of governments and private insurances are limited. Not all drugs and services that appear beneficial to patients or physicians can be covered. Is there a core set of benefits that everyone should be entitled to? If so, how should this set be determined? Are fair decisions just impossible, if we know from the outset than not all needs can be met? While early work in bioethics has focused on clinical issues and a narrow set of principles, in recent years (...) there has been a marked shift towards addressing broader population-level issues, requiring consideration of more demanding theories in philosophy, political science, and economics. At the heart of bioethics' new orientation is the goal of clarity on a complex set of questions in rationing and resource allocation. Rationing and Resource Allocation in Healthcare: Essential Readings provides key excerpts from seminal and pertinent texts and case studies about these topics, contextualized by original introductions. The volume is divided into three broad sections: Conceptual Distinctions and Ethical Theory; Rationing; and Resource Allocation. Containing the most important and classic articles surrounding the theoretical and practical issues related to rationing and how to allocate scare medical resources, this collection aims to assist and inform those who wish to be a part of bioethics' 21st century shift including practitioners and policy-makers, and students and scholars in the health sciences, philosophy, law, and medical ethics. (shrink)

As part of a special issue on the intersection between bioethics and political philosophy, I argue that strong intuitions about how the state ought to allocate healthcare are incompatible with quite influential autonomy-centric and neutral strains of liberal political theory. Specifically, I maintain that it is uncontroversial that we should routinely distribute medical treatments in public hospitals in ways that have little to no bearing on patients’ ability to pursue a wide array of ends and further that we cannot (...) easily avoid making judgments of which ways of life are good (or bad) when making such distributions. These intuitions tell against the principles that the state in general should aim merely to protect individuals’ rights to choose their own ways of life and should not take sides on which lives are good (or bad) when adopting policy or law. I show that this tension, which has not been thoroughly addressed in the literature, manifests in at least three types of healthcare decisions, viz., which types of treatments should be offered to patients, how to prioritize among types of treatments, and who should receive a certain type of treatment. I do not prescribe how to resolve the tension, that is, whether to reject autonomy-centric and neutral forms of liberalism or revise judgments about how public medical facilities should allocate healthcare, but instead establish the point that one must choose between them. (shrink)

This article reports on qualitative research conducted in KwaZulu-Natal, South Africa, among researchers and gate-keepers of health facilities in the province. Results suggest disparate but not irreconcilable perceptions of the social value of research in provincial health facilities. This study found that researchers tended to emphasize the contribution of research to the generation of knowledge and to the health of future patients while gate-keepers of health facilities tended to emphasize its contribution to the healthcare system and (...) to current patients. Furthermore, relations between research stakeholders were perceived to be somewhat fragile, making it difficult for stakeholders to achieve consensus about the social value of research, as well as on ways to maximize value. Interventions to negotiate a shared perspective on the social value of research would appear to be warranted, and the findings of this study suggest some focus areas for such intervention. (shrink)

Background: The recent COVID-19 pandemic has highlighted the deficiencies that characterize the functioning of the Italian national health system. Prisons have always mirrored the most radical expressions of these weaknesses. During the early stages of the pandemic, prison facilities across Italy underwent a series of changes dictated by the need to ensure the safety of the prisoners and staff. The adoption of these rules contributed to a total or partial redefinition of many central facets of life in prison, such (...) as intake procedures for new arrivals and the ways prisoners were allowed to communicate with their families.Objectives: The aim of this qualitative study was to analyze the testimony of penitentiary healthcare workers in prisons throughout Italy to determine the impact of COVID-19 on their professional and personal lives.Participants: Thirty-eight participants were contacted and 20 decided to participate in the interview. The sample was made up of 10 women and 10 men. All the participants were members of the healthcare staff of a penitentiary facility. All were recruited through an Italian association whose mission is the development, promotion, and implementation of social solidarity projects including prisoners' social and health care. This study was facilitated through representatives serving in nine different regions of Italy. The participants were divided according to their professional roles in prisons.Method: In-depth interviews were conducted by telephone or online using telecommunication platforms. The transcribed texts underwent thematic analysis using the Atlas.ti software to identify patterns of meaning across the dataset.Results: Four main themes emerged from the analysis: Interpersonal difficulties, management and operational difficulties, the personal distress and bereavement of healthcare workers, and the distress of inmates. The importance of relationship management skills when interacting with prisoners emerged as a key topic in many interviews, and the participants highlighted the need for adequate training. The increase in prisoners' anxiety made communication more difficult.Conclusions: The findings suggest that healthcare workers in jails need emergency-oriented training. Participants described their feeling of loneliness and quasi-abandonment when carrying out their duties during the pandemic. In particular, they underscored the need for psychological guidance to better manage altered reactions with prisoners and colleagues as a result of heightened death anxiety and isolation. (shrink)

Next SectionPurpose The importance of recognising patient dignity has been realised in recent years. Despite being a central phenomenon in medicine, dignity is a controversial concept, the definition of which in healthcare centres is influenced by a multitude of factors. The aim of this study was to explore the perspective of Iranian patients on respect for their dignity in healthcare centres. Methods With the use of purposeful sampling, 20 patients were interviewed over an 11-month period in three educational (...) hospitals affiliated with the government. They were questioned about experiences related to respect for their dignity during their hospital encounter. Data were processed by qualitative content analysis. Results Data analysis identified nine categories and four themes. Respondents expressed their expectations and attitudes about dignity by the following themes: seeking a haven; disrespecting privacy; communicating in a vacuum; and disregard for secondary caregivers. They described how respect for their privacy, effective communication, access to facilities, and a regard for the requirements of their companions made them feel that their dignity had been conserved. Conclusions The findings indicate that almost no patient is satisfied with the quality of services with respect to maintenance of their dignity. Regardless of their hospital location and state of health, most participants had common complaints. These findings agree with the literature and confirm that grounds should be provided for conserving dignity in the healthcare system. To reach this goal, healthcare professionals should be aware of the factors that violate or preserve dignity from the patient's perspective. (shrink)

Residents with dementia in long-term care facilities (LTCFs) often receive antipsychotic (AP) medications without clear clinical indications. One non-clinical factor influencing the use of APs in LTCFs is low staff levels. Often, using APs is viewed and rationalised by healthcare professionals in LTCFs as a lesser evil option to manage low staff levels. This paper investigates the ethical plausibility of using APs as a lesser of two evils in resource-constrained LTCFs. I examine the practice vis-à-vis the three frequently (...) invoked conditions of lesser evil justifications as specified in the wider philosophical literature. These conditions include (1) the necessity condition, (2) the condition of sensitivity to both deontic (ie, constraint-based) and non-deontic (ie, outcome-based) considerations and (3) the commensurability condition. I argue that there are considerable difficulties in demonstrating that the practice in question satisfies the conditions of lesser evil justifications. In particular, there are major difficulties in satisfying the condition of sensitivity to deontic and outcome-based considerations, and the commensurability condition. I also argue that the current philosophical debate on lesser-evil justifications is not straightforwardly applicable to the practice of using APs for non-clinical purposes in LTCFs. I contend that caregivers are not so-called ‘generic’ agents, and the assumed rarity of lesser evil cases is questionable. I conclude that until further work is done to resolve these issues, the lesser evil reasoning cannot be, at least routinely, used to formulate robust moral justifications for the practice in question. (shrink)

COVID-19 is a new type of coronavirus that has spread all over the world and has caused a global epidemic that affected all parts of society. Healthcare professionals that are involved in the diagnosis, treatment, and care of patients diagnosed with coronavirus have been under a heavy burden both physically and psychologically during the fight against this disease. Articles published on protecting the mental health of healthcare professionals during the epidemic have stated that healthcare professionals should be (...) supported to prevent the negative effects of the epidemic on them. This new situation requires developing appropriate strategies for coping with the COVID-19 pandemic, due to the given heavy burden by healthcare professionals. Therefore, the determination of effective approaches for the protection of mental health of healthcare professionals and increasing their protective factors, such as psychological resilience, has got great importance. Positive religious coping contents can be seen among the protective factors that affect the psychological resilience of healthcare professionals. Positive religious coping behaviors, such as refuge in Allah, praying, and reading Qur'an, not only provides a spiritual strength against the troubles of life but also provides a sense of control, peace, and security. This research aims to examine the relationship between religious coping and psychological resilience in healthcare professionals during the COVID-19 pandemic. Ethical approval for this research was obtained from Atatürk University Social and Human Science Ethics Committee (12.04.2021 dated and 88656144-000.E.2100103436 numbered). Descriptive research and correlational methods were used in the study. The population of the research consists of personnel working in health facilities operating throughout the country. The sample consists of doctors, nurses, pharmacists, midwives, and other health workers working in these health institutions. The Snowball sampling method was used in this study. For this aim, a Google Forms was established and 293 health workers in more than 40 provinces have filled this form. Personal Information Form, Religious Coping Scale, and Brief Psychological Resilience Scale were used as data collection tools. These data collection tools were used to determine whether positive and negative religious coping and psychological resilience differs according to gender and age. In addition to the above-mentioned aim, the relationship between positive and negative religious coping and resilience was examined in this study. T-test and ANOVA were applied in the analysis of demographic variables. Correlation and regression analysis were used to test the relationship between the variables. Findings obtained from this study have revealed that the levels of religious coping and psychological resilience of healthcare professionals differ according to their demographic characteristics. Results have shown that while there is no significant difference between women and men in terms of using positive religious coping methods, men use negative religious coping methods more frequently than women. Results have also revealed that positive coping methods are used more frequently as age increases and psychological resilience increased with age. Correlation analysis has shown that there is a significant relationship between positive religious coping and psychological resilience. Results of regression analysis have shown that positive religious coping is a significant predictor of psychological resilience. This result shows that positive religious coping is an important variable that affects psychological resilience. Results have suggested that there is a need to develop a program with religious/spiritual content that can help healthcare professionals to overcome this difficult process more easily by increasing their psychological resilience. Results obtained from this study may not only contribute to other rehabilitative studies that can be carried out for healthcare professionals during and after the pandemic but also provide scientific data for possible academic studies on this subject. (shrink)

Background On December 2017 the Italian Parliament approved law n. 219/2017 “Provisions for informed consent and advance directives” regarding challenging legal and bioethical issues related to healthcare decisions and end-of life choices. The law promotes the person’s autonomy as a right and provides for the centrality of the individual in every scenario of health care by mean of three tools: informed consent, shared care planning and advance directives. Few years after the approval of the law, we conducted a survey (...) among physicians working in four health care facilities specific for the care of people suffering from psychiatric disorders, cognitive disorders and dementia located in the North of Italy aiming to investigate their perceived knowledge and training need, attitudes regarding law n. 219/2017 provisions, and practices of implementation of the law. Methods A semi-structured questionnaire was developed on an online platform. The invitation to participate in the survey was sent by email to the potential participants. Information was collected by means of the online platform (Google Forms) which allows to export data in a spreadsheet (Windows Excel) to perform basic statistical analysis (frequency distributions, bar chart representation). Results Twenty-five out of sixty physicians participated in the survey. None of the respondents value their knowledge of the law as very good, 10 good, 13 neither poor nor good, 1 poor and 1 very poor. All the respondents want to learn more about the law (21 yes and 4 absolutely yes). The majority of respondents agrees with the content of the law as a whole (3 absolutely agree, 13 agree), and on each provision. The question on the clarity of the concept of capacity in the law received mixed answers and this impacted on the physicians’ opinion regarding the legitimacy in principle for our groups of patients to realize shared care planning and write advance directives. Thirteen physicians neither introduced the theme of shared care planning nor arranged for shared care planning and the main reason for this was that no patient was in a clinical situation to require it. When shared care planning is realized, a variability in terms of type and number of meetings, mode of tracking and communication is registered. Conclusions Our survey results indicate a need for more clarity regarding the interpretation and implementation of the law in the patient groups under study. There are in particular two related areas that deserve further discussion: (1) the question of whether these patient groups are in principle legitimized by the law to realize shared care planning or write advance directives; (2) the notion of capacity required by the law and how this notion can be declined in real-life situations. (shrink)

People with dementia at times exhibit threatening and physically aggressive behavior toward care staff in residential aged care facilities (RACFs). Current clinical guidelines recommend judicious use of antipsychotic (AP) medications when there is an immediate risk of harm to care staff in RACFs and non-pharmacological interventions have failed to avert the threats. This article examines an account of how this recommendation can be ethically defensible: caregivers in RACFs may have a prima facie ethical justification, in certain cases, to use (...) APs as an act of self-defense. The author examines whether such uses of APs meet the three commonly invoked conditions of ethically permissible acts of self-defense—namely, the conditions of liability, proportionality, and necessity—and argues that such conditions obtain only in a restricted range of cases. The liability constraint can be satisfied if residents are the only ones who are causally responsible for the threats they pose. Further, the condition of proportionality obtains if there is sufficient objective ground to demonstrate that the harm of using the medications does not outweigh the good to be secured. Lastly, the necessity condition obtains when the medications are used at their lowest effective dosage and caregivers in RACFs can reasonably assume that, for the purpose of averting threats posed by residents, the use of APs is the only available course of action. Not meeting any of these fairly stringent conditions renders uses of APs as acts of self-defense in RACFs morally impermissible actions. -/- . (shrink)

Evaluating the impact of clinical ethics support services remains a challenging task. 1 Against this background, we applaud the authors for developing a theoretical framework that aims to explain how repeated moral case deliberations may promote ‘practical wisdom’ in healthcare professionals and improve the quality of care in health facilities. 2 In our view, it is of particular value to draw attention to the learning processes that may be induced by ethics support services. Understanding such learning processes on (...) the individual and organisational level is a prerequisite for longitudinal research designs that may be suitable to study the impact of specific ethics support services on criteria deemed relevant in patient care. 3 In our comment, we would like to focus on one aspect, which we deem necessary to be able to explain the possible impact of ethics support on the quality of healthcare. This is the... (shrink)

Armed conflict can destroy both a healthcare system and the people who comprise it. Where the facilities themselves may take decades to rebuild, this collection of essays is evidence of the remarkable resilience of healthcare providers working in these conflict zones. Twelve narratives are shared by doctors, nurses, and other staff working in current crises in places such as Afghanistan, Darfur, Gaza, Iraq, Myanmar, Syria, and Ukraine. The essays reveal logistical, personal, and ethical challenges of providing fundamental (...) healthcare services under. (shrink)

At healthcare facilities worldwide, women during childbirth undergo medical procedures they haven’t consented to and experience mistreatment and disrespect. This phenomenon is recognized as obstetric violence (OV), a distinct form of gender violence. The resulting trauma carries both immediate and long-term implications, making it vital to address for promoting women’s health. OV is partly shaped by a narrow, paternalistic conception of vulnerability. A flawed conception of the vulnerability of pregnant women and fetuses has opened the door to medical (...) control and coercion during childbirth. In this paper we examine what role notions of vulnerability play in perpetuating OV and consider recent attitudinal shifts in research ethics as a model for addressing it. (shrink)

This research addresses the challenges related to the collection and transmission of measurement data during the monitoring of military and other strategically significant objects. The solution involved creating a proprietary distributed system that operates on Wi-Fi technology and leverages the national military radio communication system for long-distance data transfer. Measurements were gathered for several key parameters, including the distance between cracks and joints, magnetometer readings, and the position and potential tilt of objects across three axes based on accelerometer and gyroscope (...) data. A significant aspect of the study was the server setup, which allowed for the creation of new data reception channels. These channels were essential for the further processing and analysis of measurement results. This system is capable of addressing complex issues such as predicting the technical condition of strategically important objects. The thoroughness of the analysis enables the identification and diagnosis of potential errors, as well as the detection of delays within the communication system. Additionally, optimizing energy consumption parameters extended the duration of research activities at remote locations, which ultimately prolongs the lifespan and maintenance intervals of the control system. The flexibility in programming the module boards and compatibility with various electronic measuring sensors make it possible to adjust the system for a wide range of applications. This adaptability significantly broadens the scope of research, expanding it to diverse fields such as agriculture, ecology, energy, healthcare, meteorology, and more. (shrink)

Examining the ways and extent to which systemic factors affect health outcomes with regard to quality, affordability and access to curative healthcare, this explorative book compares the relative merits of tax-funded Beveridge systems and insurance-based Bismarck systems. The Law and Policy of Healthcare Financing charts and compares healthcare system outcomes throughout 11 countries, from the UK to Colombia. Thematic chapters investigate the economic and legal explanations for the relevant similarities, variations and trends across the globe. Concluding that (...) systemic factors may be less significant than previously believed, this comprehensive book notes that no one system consistently outperforms the others, yet incentives and funding improvements may lift performances across all curative healthcare systems. Analytical and comparative, this book will be of interest to academics working in the fields of health law and health economics. Public authorities including health ministries, policymakers and international health organisations will also find this to be an invaluable resource. (shrink)

In the competitive and globalized scenario, organizations are interested in enhancing employee–organization relationship. Perceived organizational support is one way to understand employee–organization relationship. This study examines the impact of various work-related experiences of healthcare professionals on perceived organizational support. The work experience comprises employees’ experience with i) formal support through human resource practices and facility in the workplace and ii) informal social support from supervisors and coworkers in the workplace. A survey is conducted among healthcare professionals including medical (...) officers and staff nurses working in primary health centers in the state of Tamil Nadu. The results of the study proved the positive impact of human resource practices (such as pay and rewards, and job autonomy), social support (such as supervisor support and coworker support), and health facility on perceived organizational support. The career growth opportunities showed a negative impact on perceived organizational support. The supervisor support and coworker support showed higher influence on perceived organizational support than human resource practices and health facility. The study has contributed to the literature on human resource practices and perceived organizational support. The results of the study have provided inputs on how to enhance perceived organizational support of healthcare professionals and about healthcare professionals’ perception of human resource practices that could be incorporated while making policies related to public health. (shrink)

Patient referral management is an integral part of clinical practice. However, in low-resource settings, referrals are often delayed. The World Health Organization categorizes three types of referral delays; delay in seeking care, in reaching care and in receiving care. Using two case studies of maternal referrals (from a low-resource state in India), this article shows how a culture of downstream blaming permeates referral practice in India. With no referral guidelines to follow, providers in higher-facilities evaluate the clinical decision-making of (...) their peers in lower-facilities based on patient outcome, not on objective measures. The fear of punitive action for an unfavorable maternal outcome is a larger driving factor than patient safety. The article argues for the need to formulate an ecosystem where patient responsibility is shared across the health system. In conclusion, it discusses possible solutions which can bridge communication and information gap between referring facilities. (shrink)

Ford, Norman Catholic healthcare facilities fulfil their mission in the world of the sick and dying of all ages. Challenges occasionally arise to remain faithful to their identity and mission in a world whose ethical standards are changing. This article discusses the nature of the challenges ahead.

Healthcare facilities in receiving countries regularly encounter guest workers whose need for acute or subacute care triggers the prospect of termination of employment and repatriation. In these scenarios, country‐specific migration and employment policies and norms of medical professionalism and ethics offer some guidance, but also create tensions. It is not clear under what conditions such medical repatriation is ethically permissible.This paper analyses the application of a previously articulated criteria for the ethical medical repatriation of undocumented immigrants, to the (...) situation of documented guest workers, with focus on the context of Singapore. We examine how these standards could be adapted and applied to the provision of care for guest workers, and argue that healthcare institutions and medical professionals have a duty to intervene in employers’ decisions to repatriate guest workers for medico‐economic reasons when repatriation essentially amounts to ‘patient dumping’. Barriers and challenges in implementing the criteria, and their possible solutions will be discussed. (shrink)

The 2015 judgment of the Namibia Supreme Court in Government of the Republic of Namibia v LM and Others set an important precedent on informed consent in a case involving the coercive sterilisation of HIV-positive women. This article analyses the reasoning and factual narratives of the judgment by applying Neil Manson and Onora O’Neill’s approach to informed consent as a communicative process. This is done in an effort to understand the practical import of the judgment in the particular context of (...) resource constrained public healthcare facilities through which many women in southern Africa access reproductive healthcare. While the judgment affirms certain established tenets in informed consent to surgical procedures, aspects of the reasoning in context demand more particularised applications of what it means for a patient to have capacity and to be informed, and to appropriately accommodate the disruptive role of power dynamics in the communicative process. (shrink)

Background: While numerous studies have shown the positive impact of free healthcare policies, the ethical issues raised by these policies in low-income countries have received little attention. In Burkina Faso, in July 2016, user fees were removed at healthcare facilities for children under 59 months of age and for “mothers”, i.e., for reproductive care. These eligibility criteria are, reportedly, sometimes difficult to comprehend or to enforce. The purpose of this study is twofold: 1) to understand the perceptions (...) and practices of health workers and beneficiaries regarding compliance with eligibility criteria for free care and 2) to explore the ethical tensions that have arisen and possible ways of resolving them. Methodology: In late 2018, a cross-sectional qualitative study was conducted in five rural communities in Boulsa, Burkina Faso. Semi-directed individual interviews were conducted with healthcare personnel (n=10) and mothers of young children (n=10) who were purposefully selected with the assistance of community health workers. Interviews were recorded and transcribed. A thematic content analysis was conducted on all materials. Themes were identified, discussed and reformulated between team members. Results: The study reveals the presence of practices to circumvent strict compliance with the eligibility criteria for free access. Common circumventing practices include hiding the exact age of children aged 60 months or older and using eligible persons for stockpiling drugs or for receiving a free consultation for the benefit of other household members. These practices result from ethical and economic tensions experienced by the beneficiaries. But they also raise ethical dilemmas for healthcare providers since they have to enforce compliance with the eligibility criteria while realizing the financially precarious position of the households. Informal mechanisms are introduced at the community level to reconcile the healthcare providers’ dissonance. Conclusion: The implementation of the user fee abolition policy in Burkina Faso is being carried out through local reinvention mechanisms to overcome ethical tensions related to the compliance with the eligibility criteria. (shrink)

Intersex pediatric surgery is a family of surgical practices performed by pediatric urologists which aim to clarify the sex of an individual with differences/disorders of sexual development, specifically those with ‘intersex’ conditions. It aims to functionally and aesthetically disambiguate an individuals’ binary sex that is obscured by intersex conditions. I ethically reassess intersex pediatric surgery in light of contemporary biotechnology, formal specialization in pediatric urology and long-term data on the efficacy of intersex pediatric surgery, finding that there are only select (...) contexts in which intersex pediatric surgery is morally justifiable. I develop novel, operationalizable and testimonially-informed moral criteria to regulate intersex pediatric surgery, working out the details for how medical professionals in pediatric healthcare facilities are best able to facilitate and augment the decision-making of parents as they decide whether intersex pediatric surgery is in the best interests of their child with intersex conditions. (shrink)

Professional ethics has currently raised its public profile in the UK as part of social anxiety around governance of health and social care, fuelled by catastrophically bad practice identified in particular healthcare facilities. Professional ethics is regulated by compliance with abstracted, normative codes but experienced as contextualised exercise of personal qualities, understanding and engagement. This study examined how practitioners from one speciality of occupational therapy, an Allied Health Profession, develop ethical practice through dialogical engagement in local OT communities (...) of practice, supporting and modifying understanding of and approaches to specific situations experienced as ethically difficult and individual reflection on the personal bildungsroman underpinning their own professional practice. Engagement in community of practice and personal reflection contributed to ethical development for participating OTs. Opportunities to engage in peer OT groups and professional reflection should be considered by employers as integral to productive practice and not a distraction from it. (shrink)