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Hermus M, van der Sluis PC, Wijnhoven BPL, van der Zijden CJ, van Busschbach JJ, Lagarde SM, Kranenburg LW. Decision-making experiences of patients and partners opting for active surveillance in esophageal cancer treatment. PATIENT EDUCATION AND COUNSELING 2024; 127:108361. [PMID: 38936160 DOI: 10.1016/j.pec.2024.108361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 06/17/2024] [Accepted: 06/21/2024] [Indexed: 06/29/2024]
Abstract
OBJECTIVES This study explored the decision-making experiences of patients and their partners or primary caregiver who opted for experimental active surveillance (instead of standard surgery) for the treatment of esophageal cancer. METHODS Seventeen couples participated. Semi-structured interviews were conducted on couples' joint experiences as well as their individual experiences. Preferred and perceived role in the treatment decision-making process was assessed using the adjusted version of the Control Preferences Scale, and perceived influence on the treatment decision was measured using a visual analog scale. RESULTS Couples reflected on the decision-making process as a positive collaboration, where patients retain their autonomy by making the final decision, and partners offer emotional support. Couples reported about an overwhelming amount and sometimes conflicting information about treatments among different hospitals and healthcare providers. CONCLUSIONS Patients often involve their partner in decision-making, which they report to have enhanced their ability to cope with the disease. The amount and sometimes conflicting information during the decision-making process provide opportunities for improvement. PRACTICE IMPLICATIONS Couples can benefit from an overview of what they can expect during treatment course. If active surveillance becomes an established treatment option in the future, provision of such overviews and consistent information should become more streamlined.
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Affiliation(s)
- Merel Hermus
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Pieter C van der Sluis
- Department of Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Charlène J van der Zijden
- Department of Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan J van Busschbach
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus Cancer Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Leonieke W Kranenburg
- Department of Psychiatry, Section of Medical Psychology and Psychotherapy, Erasmus University Medical Center, Rotterdam, the Netherlands
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Akhtar MU, Bhatti ME, Fredericks S. What factors influence patient autonomy in healthcare decision-making? A systematic review of studies from the Global South. Nurs Ethics 2024:9697330241272794. [PMID: 39175161 DOI: 10.1177/09697330241272794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
BACKGROUND The principle of respect for autonomy (PRA) is a central tenet of bioethics. In the quest for a global bioethics, it is pertinent to ask whether this principle can be applied as it is to cultures and societies that are devoid of the Western sociopolitical historical pressures that led to its emergence. Relational autonomists have argued for a more inclusive approach to patient autonomy which takes into account factors such as interdependency and social relations. However, at the outset of any relational approach, it is necessary to identify underlying factors that influence patient autonomy in non-Western cultures. OBJECTIVE To conduct a review of the literature to uncover the mechanisms through which social, cultural, and religious factors influence and impact the application of the PRA in healthcare decision-making in non-Western cultures and societies. METHODS We conducted a systematic review through a comprehensive search of three major electronic databases of biomedical sciences. Returned citations were imported to Covidence, full texts were assessed for eligibility, included articles were thoroughly reviewed and data was synthesized. PRISMA guidelines were followed. RESULTS Our search retrieved 590 non-duplicate results, 50 of which were included after screening and full-text eligibility checks. The included studies were predominantly qualitative in nature, with few quantitative, mixed-methods, and review studies included. Our synthesis of data identified nine key factors that influenced patients' autonomous decision-making through cultural, social, religious, or intersectional pathways. CONCLUSION Two main conclusions emerge from this review. Firstly, there is a notable dearth of bioethical research examining the influence of diverse factors on patients' inclination towards different conceptions of autonomy. Secondly, the analysis of prevalent collectivist cultures and deference of autonomy adds value to the solution-oriented relational autonomy debate. This raises questions regarding how decision-making can be truly autonomous in the presence of such large-scale factors, warranting further attention.
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Le TD, Lin SC, Huang MC, Fan SY, Kao CY. Factors impacting the demonstration of relational autonomy in medical decision-making: A meta-synthesis. Nurs Ethics 2024; 31:714-738. [PMID: 37818823 DOI: 10.1177/09697330231200570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Relational autonomy is an alternative concept of autonomy in which an individual is recognized as embedded into society and influenced by relational factors. Social context, including social location, political structure, and social forces, significantly influence an agent to develop and exercise autonomy skills. The relational approach has been applied in clinical practice to identify relational factors impacting patient autonomy and decision-making, yet there is a knowledge gap in how these factors influence the demonstration of relational autonomy in the context of medical decisions of adults. OBJECTIVE The present study targeted the existing knowledge of what and how relational factors impact individuals making medical decisions using the theoretical framework of relational autonomy. METHODS A meta-synthesis study was utilized. Four electronic databases, including Embase, OVID Medline, CINAHL, and PubMed, were searched, along with gray literature and reference lists, to identify relevant studies. RESULTS 23 studies reporting 21 qualitative and two mixed-method studies were reviewed. Four themes emerged from the qualitative findings: (1) supportive relationships facilitate an individual's relational autonomy; (2) obtaining comprehensive information from broader sources helps individuals exercise relational autonomy; (3) undue family pressure impedes the exercising of patient relational autonomy; and (4) healthcare providers' dominant voice hampers the demonstration of relational autonomy. CONCLUSIONS Applying relational autonomy to assist adults in making well-considered decisions is essential. The meta-synthesis suggests establishing a supportive relationship between individuals, healthcare providers, and family. A supportive relationship will allow healthcare providers to make judgments in line with an individual's values and wishes with the aim of promoting relational autonomy. Advance care planning was proposed as the effective solution to obtain a consensus between individuals and their families while respecting an individual's values and preferences. Furthermore, it is considered crucial for healthcare providers to appreciate an individual's values and incorporate their preferences into recommendations.
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Affiliation(s)
| | | | - Mei-Chih Huang
- National Cheng Kung University, Taiwan
- National Tainan Junior College of Nursing, Taiwan
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Kay AC, Wells J, Goriely A, Hallowell N. Professionals' views on providing personalized recurrence risks for de novo mutations: Implications for genetic counseling. J Genet Couns 2024. [PMID: 38924179 DOI: 10.1002/jgc4.1910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 04/29/2024] [Accepted: 04/30/2024] [Indexed: 06/28/2024]
Abstract
When an apparent de novo (new) genetic change has been identified as the cause of a serious genetic condition in a child, many couples would like to know the risk of this happening again in a future pregnancy. Current practice provides families with a population average risk of 1%-2%. However, this figure is not accurate for any specific couple, and yet, they are asked to make decisions about having another child and/or whether to have prenatal testing. The PREcision Genetic Counseling And REproduction (PREGCARE) study is a new personalized assessment strategy that refines a couple's recurrence risk prior to a new pregnancy, by analyzing several samples from the parent-child trio (blood, saliva, swabs, and father's sperm) using deep sequencing and haplotyping. Overall, this approach can reassure ~2/3 of couples who have a negligible (<0.1%) recurrence risk and focus support on those at higher risk (i.e. when mosaicism is identified in one of the parents). Here we present a qualitative interview study with UK clinical genetics professionals (n = 20), which investigate the potential implications of introducing such a strategy in genetics clinics. While thematic analysis of the interviews indicated perceived clinical utility, it also indicates a need to prepare couples for the psychosocial implications of parent-of-origin information and to support their understanding of the assessment being offered. When dealing with personalized reproductive risk, a traditional non-directive approach may not meet the needs of practitioner and client(s) and shared decision-making provides an additional framework that may relieve some patient burden. Further qualitative investigation with couples is planned.
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Affiliation(s)
- Alison C Kay
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
- The Centre for Personalised Medicine, University of Oxford, Oxford, UK
| | - Jonathan Wells
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
- Clinical Genetics, St. Michael's Hospital, Bristol, UK
| | - Anne Goriely
- MRC Weatherall Institute of Molecular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NIHR Biomedical Research Centre, Oxford, UK
| | - Nina Hallowell
- Ethox Centre and Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
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De Kanter AJ, Daal MV, Gunn CJ, Bredenoord AL, Graeff ND, Jongsma KR. A value hierarchy for inclusive design of heart valve implants in regenerative medicine. Regen Med 2024; 19:289-301. [PMID: 39177570 PMCID: PMC11346526 DOI: 10.1080/17460751.2024.2357500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/16/2024] [Indexed: 08/24/2024] Open
Abstract
Aim: This paper investigates the conditions for inclusive design of regenerative medicine interventions from a bioethical perspective, taking regenerative valve implants as a showcase.Methods: A value hierarchy is construed to translate the value of justice into norms and design requirements for inclusive design of regenerative valve implants.Results: Three norms are proposed and translated into design requirements: regenerative valve implants should be designed to promote equal opportunity to good health for all potential users; equal respect for all potential users should be shown; and the implants should be designed to be accessible to everyone in need.Conclusion: The norms and design requirements help to design regenerative valve implants that are appropriate, respectful and available for everyone in need.
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Affiliation(s)
- Anne Johanna De Kanter
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Manon Van Daal
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Callum J Gunn
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, 3062 PA, The Netherlands
| | - Nienke De Graeff
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Karin R Jongsma
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
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Khan M, Ewuoso C. Epistemic (in)justice, social identity and the Black Box problem in patient care. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2024; 27:227-240. [PMID: 38353801 PMCID: PMC11076305 DOI: 10.1007/s11019-024-10194-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/31/2023] [Indexed: 05/08/2024]
Abstract
This manuscript draws on the moral norms arising from the nuanced accounts of epistemic (in)justice and social identity in relational autonomy to normatively assess and articulate the ethical problems associated with using AI in patient care in light of the Black Box problem. The article also describes how black-boxed AI may be used within the healthcare system. The manuscript highlights what needs to happen to align AI with the moral norms it draws on. Deeper thinking - from other backgrounds other than decolonial scholarship and relational autonomy - about the impact of AI on the human experience needs to be done to appreciate any other barriers that may exist. Future studies can take up this task.
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Affiliation(s)
- Muneerah Khan
- Steve Biko Centre for Bioethics, University of Witwatersrand, Johannesburg, South Africa.
| | - Cornelius Ewuoso
- Steve Biko Centre for Bioethics, University of Witwatersrand, Johannesburg, South Africa
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Pascal JM, McGowan ML, Blumling AA, Prows CA, Lipstein EA, Myers MF. Young adults' reasoning for involving a parent in a genomic decision-making research study. J Genet Couns 2024; 33:653-665. [PMID: 37632220 PMCID: PMC10895067 DOI: 10.1002/jgc4.1768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/22/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023]
Abstract
Young adults have increasing genomic testing opportunities; however, little is known about how equipped they feel about making decisions to learn personal genomic information. We conducted qualitative interviews with 19 young adults, ages 18-21 years old, enrolled in a research study where they made decisions about learning personal genomic risk for developing preventable, treatable, and adult-onset conditions and carrier status for autosomal recessive conditions. Participants had the option to include a parent in their study visit and the decision-making process. The goal of this project was to explore young adults' reasons for involving or not involving a parent in the study and to assess young adults' perspectives about parental roles in their healthcare. Nine participants included a parent in the study and ten did not include a parent. Eleven participants received genomic test results before the interview, while eight participants had not yet received their results at the time of the interview. The study team developed a coding guide and coded interview transcripts inductively and deductively using an interpretive descriptive-analytic approach. Logistical issues dominated solo participants' reasons for not involving a parent in the study, whereas those who involved a parent often cited a close relationship with the parent and the parent's previous involvement in the participant's healthcare as reasons for involving them. Both groups of participants described gradually transitioning to independent healthcare decision-making with age and felt their comfort in medical decision-making depends on the severity of and their familiarity with the situation. Participants recommended that future genomic researchers or clinicians give young adults the option to involve a parent or friend as a support person in research or clinical visits. Although young adults may have different journeys toward independent healthcare decision-making, some may benefit from continued parental or peer involvement after reaching the age of legal adulthood.
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Affiliation(s)
- Julia M Pascal
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Michelle L McGowan
- Biomedical Ethics Research Program, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
- College of Arts & Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Amy A Blumling
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA
| | - Cynthia A Prows
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA
- Division of Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ellen A Lipstein
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Melanie F Myers
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Ohio, Cincinnati, USA
- College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Grewal E, Godley J, Wheeler J, Tang KL. Use of social network analysis in health research: a scoping review protocol. BMJ Open 2024; 14:e078872. [PMID: 38803244 PMCID: PMC11129050 DOI: 10.1136/bmjopen-2023-078872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
INTRODUCTION Social networks can affect health beliefs, behaviours and outcomes through various mechanisms, including social support, social influence and information diffusion. Social network analysis (SNA), an approach which emerged from the relational perspective in social theory, has been increasingly used in health research. This paper outlines the protocol for a scoping review of literature that uses social network analytical tools to examine the effects of social connections on individual non-communicable disease and health outcomes. METHODS AND ANALYSIS This scoping review will be guided by Arksey and O'Malley's framework for conducting scoping reviews. A search of the electronic databases, Ovid Medline, PsycINFO, EMBASE and CINAHL, will be conducted in April 2024 using terms related to SNA. Two reviewers will independently assess the titles and abstracts, then the full text, of identified studies to determine whether they meet inclusion criteria. Studies that use SNA as a tool to examine the effects of social networks on individual physical health, mental health, well-being, health behaviours, healthcare utilisation, or health-related engagement, knowledge, or trust will be included. Studies examining communicable disease prevention, transmission or outcomes will be excluded. Two reviewers will extract data from the included studies. Data will be presented in tables and figures, along with a narrative synthesis. ETHICS AND DISSEMINATION This scoping review will synthesise data from articles published in peer-reviewed journals. The results of this review will map the ways in which SNA has been used in non-communicable disease health research. It will identify areas of health research where SNA has been heavily used and where future systematic reviews may be needed, as well as areas of opportunity where SNA remains a lesser-used method in exploring the relationship between social connections and health outcomes.
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Affiliation(s)
- Eshleen Grewal
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - Justine Wheeler
- Libraries and Cultural Resources, University of Calgary, Calgary, Alberta, Canada
| | - Karen L Tang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O'Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Rickli C, Stoll J, Westermair AL, Trachsel M. Comparing attitudes towards compulsory interventions in severe and persistent mental illness among psychiatrists in India and Switzerland. BMC Psychiatry 2024; 24:295. [PMID: 38637747 PMCID: PMC11025243 DOI: 10.1186/s12888-024-05710-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/24/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Psychiatrists face a major ethical challenge when deciding whether to make use of coercive measures in the treatment process of patients suffering from severe and persistent mental illness (SPMI). As India and Switzerland show major cultural, political and financial differences, it is hypothesized that attitudes towards coercive measures among Indian and Swiss psychiatrists will vary too. Exploring differences in attitudes between cultures strengthens the critical reflection on one's own stances and in consequence, on our way of action. Especially when it comes to situations involving power imbalances between patients and health practitioners, self-reflection is essential to prevent ethically inappropriate behavior. METHODS An online survey on aspects of care for patients with SPMI was sent to 3'056 members of the Indian Psychiatric Society between April and June 2020 and to 1'311 members of the Swiss Society for Psychiatry and Psychotherapy between February and March 2016. The respondents' answers were compared. This article deals with the questionnaire's items on autonomous decision making and the implementation of coercive measures in clinical practice. More precisely, participating psychiatrists were asked to rate the importance of patient's autonomy in general and their willingness to apply coercive measures regarding two specific case vignettes depicting a patient with schizophrenia and one with depression. The statistical analysis, namely descriptive data analysis and calculation of arithmetic means, Shapiro Wilks tests and Mann-Whitney U tests, was carried out using IBM SPSS Statistics version 27. RESULTS Answers were received from 206 psychiatrists in India and 457 psychiatrists in Switzerland. Indian participants tended to value autonomous decision making as slightly less important than Swiss participants (62.2% vs. 91%, p =.01). Regarding a case of severe and persistent depression, psychiatrists in the Indian group were on average more in favor of acting against the wishes of the patient (55% vs. 34.1%, p <.0001) as well as of accepting a temporary decrease in quality of life due to coercion (40% vs. 23%, p =.008). Answers concerning a case of schizophrenia revealed that Indian participants were more in favor of acting against the patient's wishes than Swiss participants (39% vs. 37%, p =.007), whereas the comparison whether to accept a temporary decrease in quality of life regarding this case showed no significant difference (p =.328). CONCLUSIONS The significant difference in attitudes towards coercive measures among Indian compared to Swiss psychiatrists found in this study might arise from a predominantly more collectivist society in India compared to Switzerland. Moreover, differences in financial resources, the organization of the health care system, and the historical background might have an influence. Continuous and critical reflection on one's own views and behavior is essential, especially if ethical principles and individual rights could be violated through a power imbalance, as in the case of coercive measures.
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Affiliation(s)
- Christina Rickli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
| | - Julia Stoll
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
| | - Anna Lisa Westermair
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
- Clinical Ethics Unit, University Hospital Basel (USB) and University Psychiatric Clinics (UPK) Basel, Basel, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital Basel (USB) and University Psychiatric Clinics (UPK) Basel, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
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Brisson J, Ravitsky V, Williams-Jones B. A Mixed-Methods Study Exploring Colombian Adolescents' Access to Sexual and Reproductive Health Services: The Need for a Relational Autonomy Approach. JOURNAL OF BIOETHICAL INQUIRY 2024:10.1007/s11673-024-10356-w. [PMID: 38532187 DOI: 10.1007/s11673-024-10356-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 03/10/2024] [Indexed: 03/28/2024]
Abstract
This study's objective was to understand Colombian adolescents' experiences and preferences regarding access to sexual and reproductive health services (SRHS), either alone or accompanied. A mixed-method approach was used, involving a survey of 812 participants aged eleven to twenty-four years old and forty-five semi-structured interviews with participants aged fourteen to twenty-three. Previous research shows that adolescents prefer privacy when accessing SRHS and often do not want their parents involved. Such findings align with the longstanding tendency to frame the ethical principle of autonomy as based on independence in decision-making. However, the present study shows that such a conceptualization and application of autonomy does not adequately explain Colombian adolescent participants' preferences regarding access to SRHS. Participants shared a variety of preferences to access SRHS, with the majority of participants attaching great importance to having their parents involved, to varying degrees. What emerges is a more complex and non-homogenous conceptualization of autonomy that is not inherently grounded in independence from parental involvement in access to care. We thus argue that when developing policies involving adolescents, policymakers and health professionals should adopt a nuanced "relational autonomy" approach to better respect the myriad of preferences that Colombian (and other) adolescents may have regarding their access to SRHS.
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Affiliation(s)
- J Brisson
- Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Montreal, Canada.
| | - V Ravitsky
- Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Montreal, Canada
| | - B Williams-Jones
- Department of Social & Preventive Medicine, School of Public Health, University of Montreal, Montreal, Canada
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Foo KF, Lin YP, Lin CP, Chen YC. Fostering relational autonomy in end-of-life care: a procedural approach and three-dimensional decision-making model. JOURNAL OF MEDICAL ETHICS 2024:jme-2023-109818. [PMID: 38527787 DOI: 10.1136/jme-2023-109818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 03/09/2024] [Indexed: 03/27/2024]
Abstract
Respect for patient autonomy is paramount in resolving ethical tensions in end-of-life care. The concept of relational autonomy has contributed to this debate; however, scholars often use this concept in a fragmented manner. This leads to partial answers on ascertaining patients' true wishes, meaningfully engaging patients' significant others, balancing interests among patients and significant others, and determining clinicians' obligations to change patients' unconventional convictions to enhance patient autonomy. A satisfactory solution based on relational autonomy must incorporate patients' competence (apart from decisional capacity), authenticity (their true desires or beliefs) and the involvement level of their significant others. To that end, we argue that John Christman's procedural approach to relational autonomy provides critical insights, such as the diachronic or socio-historical personhood, sustained critical reflection and his recent explication of the nature of asymmetrical relationships and helpful interlocutors. This study reviews Christman's account, proposes minor modifications and advocates for an integrated three-dimensional model for medical decision-making. Clarifying the relationship among the three elements promotes an ethical framework with a coherent understanding of relational autonomy. This model not only provides a descriptive and normative framework for end-of-life care practice but also reconsiders the nature of the clinician-patient relationship and its normative implications. We further present a case study to illustrate the merits of our proposed model. Altogether, our proposal will help navigate complex medical decision-making, foster trust and negotiate shared values between patients and their significant others, particularly in end-of-life care.
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Affiliation(s)
- Kar-Fai Foo
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Ping Lin
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Humanities and Education, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Pei Lin
- Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Yu-Chun Chen
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
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Bowman-Smart H, Perrot A, Horn R. Supporting patient decision-making in non-invasive prenatal testing: a comparative study of professional values and practices in England and France. BMC Med Ethics 2024; 25:34. [PMID: 38515078 PMCID: PMC10956335 DOI: 10.1186/s12910-024-01032-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 03/06/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Non-invasive prenatal testing (NIPT), which can screen for aneuploidies such as trisomy 21, is being implemented in several public healthcare systems across Europe. Comprehensive communication and information have been highlighted in the literature as important elements in supporting women's reproductive decision-making and addressing relevant ethical concerns such as routinisation. Countries such as England and France are adopting broadly similar implementation models, offering NIPT for pregnancies with high aneuploidy probability. However, we do not have a deeper understanding of how professionals' counselling values and practices may differ between these contexts. METHODS In this paper, we explore how professionals in England and France support patient decision-making in the provision of NIPT and critically compare professional practices and values. We draw on data from semi-structured interviews with healthcare professionals. RESULTS Both English and French professionals emphasised values relating to patient choice and consent. However, understandings and application of these values into the practice of NIPT provision differed. English interviewees placed a stronger emphasis on interpreting and describing the process of counselling patients and clinical care through a "principle" lens. Their focus was on non-directiveness, standardisation, and the healthcare professional as "decision-facilitator" for patients. French interviewees described their approach through a "procedural" lens. Their focus was on formal consent, information, and the healthcare professional as "information-giver". Both English and French professionals indicated that insufficient resources were a key barrier in effectively translating their values into practice. CONCLUSION Our findings illustrate that supporting patient choice in the provision of NIPT may be held as an important value in common on a surface level, but can be understood and translated into practice in different ways. Our findings can guide further research and beneficially inform practice and policy around NIPT provision.
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Affiliation(s)
- Hilary Bowman-Smart
- Ethox Centre, University of Oxford, Oxford, UK
- Monash Bioethics Centre, Monash University, Melbourne, Australia
- Biomedical Ethics Research Group, Murdoch Children's Research Institute, Melbourne, Australia
- Australian Centre for Precision Health, Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | | | - Ruth Horn
- Ethox Centre, University of Oxford, Oxford, UK.
- Institute of Ethics and History of Health in Society, University of Augsburg, Augsburg, Germany.
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Zachreson C, Savulescu J, Shearer FM, Plank MJ, Coghlan S, Miller JC, Ainslie KEC, Geard N. Ethical frameworks should be applied to computational modelling of infectious disease interventions. PLoS Comput Biol 2024; 20:e1011933. [PMID: 38512898 PMCID: PMC10956870 DOI: 10.1371/journal.pcbi.1011933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024] Open
Abstract
This perspective is part of an international effort to improve epidemiological models with the goal of reducing the unintended consequences of infectious disease interventions. The scenarios in which models are applied often involve difficult trade-offs that are well recognised in public health ethics. Unless these trade-offs are explicitly accounted for, models risk overlooking contested ethical choices and values, leading to an increased risk of unintended consequences. We argue that such risks could be reduced if modellers were more aware of ethical frameworks and had the capacity to explicitly account for the relevant values in their models. We propose that public health ethics can provide a conceptual foundation for developing this capacity. After reviewing relevant concepts in public health and clinical ethics, we discuss examples from the COVID-19 pandemic to illustrate the current separation between public health ethics and infectious disease modelling. We conclude by describing practical steps to build the capacity for ethically aware modelling. Developing this capacity constitutes a critical step towards ethical practice in computational modelling of public health interventions, which will require collaboration with experts on public health ethics, decision support, behavioural interventions, and social determinants of health, as well as direct consultation with communities and policy makers.
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Affiliation(s)
- Cameron Zachreson
- School of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
| | - Julian Savulescu
- Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Biomedical Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- Faculty of Philosophy, University of Oxford, Oxford, United Kingdom
| | - Freya M. Shearer
- Infectious Disease Dynamics Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael J. Plank
- School of Mathematics and Statistics, University of Canterbury, Christchurch, New Zealand
| | - Simon Coghlan
- School of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
- Centre for AI and Digital Ethics, The University of Melbourne, Parkville, Victoria, Australia
| | - Joel C. Miller
- Department of Mathematical and Physical Sciences, La Trobe University, Bundoora, Australia
| | - Kylie E. C. Ainslie
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands
- School of Public Health, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Nicholas Geard
- School of Computing and Information Systems, The University of Melbourne, Parkville, Victoria, Australia
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Nakanishi Y, Tsugihashi Y, Hayasaka A, Nishioka Y, Akahane M. Web-based questionnaire survey for exploring engagement characteristics of advance care planning in Japan: a cross-sectional study. BMC Res Notes 2024; 17:47. [PMID: 38331916 PMCID: PMC10854018 DOI: 10.1186/s13104-024-06699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 01/22/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Definitive promotion of advance care planning (ACP) practices will require policy interventions tailored to the characteristics of the Japanese population and society. However, effective policies for promoting ACP are currently lacking in Japan. This study aimed to explore the characteristics of Japanese people who engaged in ACP activities through a web-based questionnaire survey, which was administered to individuals aged 25-64 years and classified into four occupational categories (non-medical/non-caregiving professionals [general population], physicians, nurses, and caregivers). RESULTS The total sample size was 1,648, with equal occupational category and age group distributions. Respondents in the general population group were less likely to discuss or document ACP than those in the other groups. Stepwise logistic regression analysis showed a significant difference in the adjusted odds ratio (aOR) of the independent variables of "attended cardiopulmonary resuscitation (CPR) training session(s)" (aOR: 1.93; 95% confidence interval [CI]: 1.18-3.15) and "having experience in performing CPR" (aOR: 2.61; 95% CI: 1.51-4.54) for respondents who discussed ACP with their families. A significant difference was observed in the aOR of the independent variable of "having experience in performing CPR" (aOR: 4.58; 95% CI: 2.30-9.13) for respondents who documented a written record of ACP.
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Affiliation(s)
- Yasuhiro Nakanishi
- Department of Health and Welfare Services, National Institute of Public Health, 2-3-6 Minami, 351-0197, Wako, Saitama, Japan.
| | - Yukio Tsugihashi
- Department of Public Health, Health Management and Policy, Nara Medical University, 840 Shijo-Cho, 634-8521, Kashihara, Nara, Japan
| | - Akira Hayasaka
- Mathematics and Informatics, Osaka Kyoiku University, 4-698-1 Asahigaoka, 582-8582, Kashiwara, Osaka, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, 840 Shijo-Cho, 634-8521, Kashihara, Nara, Japan
| | - Manabu Akahane
- Department of Health and Welfare Services, National Institute of Public Health, 2-3-6 Minami, 351-0197, Wako, Saitama, Japan
- Department of Public Health, Health Management and Policy, Nara Medical University, 840 Shijo-Cho, 634-8521, Kashihara, Nara, Japan
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15
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Bovero A, Botto R, Mellano E, Gottardo F, Berchialla P, Carletto S, Geminiani GC. Loss of Personal Autonomy and Dignity-Related Distress in End-Of-Life Cancer Patients. Am J Hosp Palliat Care 2024; 41:179-186. [PMID: 36974952 DOI: 10.1177/10499091231166373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
The objective of this cross-sectional study is to investigate Dignity-Related Loss of Personal Autonomy (DR-LPA) intended as loss of relational independence causing dignity-related distress. Moreover, it analyzes its possible relationships with demoralization, spirituality, quality of life, hope, and coping styles in a sample composed of 207 end-of-life cancer patients. These variables have been assessed through the following rating scales: Patient Dignity Inventory - Italian version, Demoralization Scale - Italian version, Functional Assessment of Cancer Therapy Scale - General Measure, Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being, Brief Coping Orientation to Problem Experienced, and Herth Hope Index. The results have shown that most of the DR-LPA items were considered a problem by most patients. Functional, social, emotional, and spiritual wellbeing, disheartenment, age, and sex emerged as significant predictors of DR-LPA. In conclusion, this study showed that DR-LPA can be a relevant concern for patients at the end-of-life and for this reason it becomes necessary for psychosocial provides to consider it to deliver better dignity conserving care.
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Affiliation(s)
- Andrea Bovero
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
| | - Rossana Botto
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
| | - Elena Mellano
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
| | - Francesco Gottardo
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
| | - Paola Berchialla
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Sara Carletto
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
| | - Giuliano C Geminiani
- Clinical Psychology Unit, Department of Neuroscience, Hospital 'Città della Salute e della Scienza', University of Turin, Turin, Italy
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Scheeres‐Feitsma TM, Schaafsma P, van der Steen JT, van Delden JJM. Commentary: Can an effective end-of-life intervention for advanced dementia be viewed as moral? ALZHEIMER'S & DEMENTIA (AMSTERDAM, NETHERLANDS) 2024; 16:e12531. [PMID: 38496715 PMCID: PMC10941533 DOI: 10.1002/dad2.12531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 03/19/2023] [Indexed: 03/19/2024]
Abstract
We comment on Dr. Terman's considerations on the moral justification of ceasing assisted feeding and hydration for people with advanced dementia. The core idea of his paper is that an advance directive can solve future dilemmas regarding assisted feeding. We submit that this static instrument is unfit for the complex and dynamic nature of assessing how to deal with refusals to eat, in particular for people with dementia. It overvalues the past in relation to the present situation and leaves no room for the possibility of changing wishes. Moreover, the perspectives of professional caregivers and families are not addressed because the focus is entirely on individual autonomy in early dementia. Multiple perspectives should be considered in interpreting directives and the actual situation in light of the patient's view of life in order to realistically account for what is morally justifiable in care in advanced dementia.
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Affiliation(s)
| | | | - Jenny T. van der Steen
- Department of Public Health and Primary CareLeiden University Medical CenterLeidenthe Netherlands
- Department of Primary and Community CareRadboud university medical centerNijmegenthe Netherlands
- Radboudumc Alzheimer CenterNijmegenthe Netherlands
| | - Johannes J. M. van Delden
- Department of Bioethics and Health HumanitiesUniversity Medical Center UtrechtUtrechtthe Netherlands
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17
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Rost M, Stuerner Z, Niles P, Arnold L. Between "a lot of room for it" and "it doesn't exist"-Advancing and limiting factors of autonomy in birth as perceived by perinatal care practitioners: An interview study in Switzerland. Birth 2023; 50:1068-1080. [PMID: 37593797 DOI: 10.1111/birt.12757] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Numerous studies show that negative birth experiences are often related to birthing people's loss of autonomy. We argue that a fetal-focused decision-making framework and a maternal-fetal conflict lens are often applied, creating a false dichotomy between autonomy and fetal beneficence. Given the high prevalence of autonomy-depriving decision-making, it is important to understand how autonomy can be enhanced. METHODS We interviewed 15 Swiss perinatal care practitioners (eight midwives, five physicians, and two doulas) and employed reflexive thematic analysis. We offer a reflection on underlying assumptions and researcher positionality. RESULTS We generated two descriptive themes: advancing and limiting factors of autonomy. Numerous subthemes, grouped at the levels of companion, birthing person, practitioners, birthing person-practitioner relationship, and structural determinants are also defined. The most salient advancing factors were practitioners' approaches to decision-making, antenatal contacts, and structural determinants. The most salient limiting factors were various barriers within birthing people (e.g., expertise, decisional capacity, and awareness of own rights), practitioners' attitudes and behavior, and structural determinants. DISCUSSION The actualization of autonomy is multifactorially determined and must be understood against the background of power structures both underlying and inherent to decision-making in birth. Practitioners attributed a significant proportion of limited autonomy to birthing people themselves. This reinforces a "mother-blame" narrative that absolves obstetrics of primary responsibility. Practitioners' recognition of their contributions to upholding limits on autonomy should be leveraged to implement training towards rights-based practice standards. Most importantly, autonomy can only fully materialize if the underlying sociocultural, political, and medical contexts undergo a fundamental change.
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Affiliation(s)
- Michael Rost
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Zelda Stuerner
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - Paulomi Niles
- Rory Meyers College of Nursing, New York University, New York, USA
| | - Louisa Arnold
- Institute of Psychology, Friedrich-Schiller University Jena, Jena, Germany
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18
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Yang F, Leng A, Wang J, Jing J, Leiter RE, Sharma RK, Krakauer EL, Jia Z. Association Between Primary Decision-Maker and Care Intensity Among Patients With Advanced Cancer in Mainland China. Am J Hosp Palliat Care 2023; 40:1349-1356. [PMID: 36598338 DOI: 10.1177/10499091221150768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Purpose: In China, decisions regarding the treatment of seriously ill patients are usually made by family caregivers. This study aimed to explore the association between the primary decision-makers and the intensity of care given to patients with advanced cancer in China. Methods: We conducted a survey of family members and other caregivers representing 828 cancer patients who died between July 2013 and July 2016. The survey asked: "After the physician conveyed that the disease is incurable, what treatment did the patient and caregiver prefer?" and "Who was the primary decision-maker?" We compared the treatment intensity with locus of decision-making using multivariable logistic regression, adjusting for socio-demographic and clinical covariates informed. Results: Of the 792 patients in our sample, the majority were male (67·2%), 60 years or older (64·0%), married (82·2%), lived with family (98·2%), had medical insurance (94·8%), earned below-average income (53·5%), lived rurally (61·5%), had a gastrointestinal cancer diagnosis (50·8%), experienced moderate or severe pain (86·3%), never received palliative care (80·4%) and had caregivers as primary decision-makers (70·6%). We found that patients were more likely to receive intensive disease-modifying treatments when the primary decision-maker were their children (adjusted odds ratio [AOR] = 1·86, 95% CI:1·26-2·74), spouse (AOR = 2·04, 95% CI:1·26-3·30), or other caregivers (AOR = 3·46, 95% CI:1·24-9·69). Conclusions: When patients with advanced cancer in China did not make their own medical decisions, they were more likely to receive intensive disease-modifying treatments at the end-of-life. Actions should be taken to better understand and ensure that caregivers' decisions reflect the values and presence of patients.
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Affiliation(s)
- Fei Yang
- Tsinghua Shenzhen International Graduate School, Tsinghua University, Shenzhen, China
| | - Anli Leng
- School of Political Science and Public Administration, Shandong University, Jinan, China
| | - Jian Wang
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Jun Jing
- Department of Sociology and Public Health Research Center, Tsinghua University, Beijing, China
| | - Richard E Leiter
- Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, WA, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Eric L Krakauer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Zhimeng Jia
- Temmy Latner Centre for Palliative Care, Toronto, ON, Canada
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19
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Khawaja Z, Bélisle-Pipon JC. Your robot therapist is not your therapist: understanding the role of AI-powered mental health chatbots. Front Digit Health 2023; 5:1278186. [PMID: 38026836 PMCID: PMC10663264 DOI: 10.3389/fdgth.2023.1278186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Artificial intelligence (AI)-powered chatbots have the potential to substantially increase access to affordable and effective mental health services by supplementing the work of clinicians. Their 24/7 availability and accessibility through a mobile phone allow individuals to obtain help whenever and wherever needed, overcoming financial and logistical barriers. Although psychological AI chatbots have the ability to make significant improvements in providing mental health care services, they do not come without ethical and technical challenges. Some major concerns include providing inadequate or harmful support, exploiting vulnerable populations, and potentially producing discriminatory advice due to algorithmic bias. However, it is not always obvious for users to fully understand the nature of the relationship they have with chatbots. There can be significant misunderstandings about the exact purpose of the chatbot, particularly in terms of care expectations, ability to adapt to the particularities of users and responsiveness in terms of the needs and resources/treatments that can be offered. Hence, it is imperative that users are aware of the limited therapeutic relationship they can enjoy when interacting with mental health chatbots. Ignorance or misunderstanding of such limitations or of the role of psychological AI chatbots may lead to a therapeutic misconception (TM) where the user would underestimate the restrictions of such technologies and overestimate their ability to provide actual therapeutic support and guidance. TM raises major ethical concerns that can exacerbate one's mental health contributing to the global mental health crisis. This paper will explore the various ways in which TM can occur particularly through inaccurate marketing of these chatbots, forming a digital therapeutic alliance with them, receiving harmful advice due to bias in the design and algorithm, and the chatbots inability to foster autonomy with patients.
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20
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López-Deflory C, Perron A, Miró-Bonet M. Nurses' ways of talking about their experiences of (in)justice in healthcare organizations: Locating the use of language as a means of analysis. Nurs Inq 2023; 30:e12584. [PMID: 37485718 DOI: 10.1111/nin.12584] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/25/2023]
Abstract
Nurses have their own ways of talking about their experiences of injustice in healthcare organizations. The aim of this article is to describe how nurses talk about their work-life experiences and discuss the discursive effects that arise from nurses' use of language regarding their political agency. To this end, we present the findings garnered from a study focused on exploring how nurses deploy their political agency to project their idea of social and political justice in public healthcare organizations and how they face the challenges and uncertainties of (re)thinking their institutional order when it does not resonate with their professional ethos. We then discuss the implications that nurses' use of language has in relation to their ability to deploy their political agency to oppose the forms of injustice they face in their daily practice. We conclude by stating that careful attention should be placed on understanding the discursive implications of nurses' use of language on their individual and collective emancipation in healthcare organizations.
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Affiliation(s)
- Camelia López-Deflory
- Department of Nursing and Physiotherapy, University of the Balearic Islands, Palma, Balearic Islands, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Balearic Islands, Spain
- Qualitative and Critical Health Research Group, University of the Balearic Islands, Palma, Balearic Islands, Spain
| | - Amélie Perron
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Margalida Miró-Bonet
- Department of Nursing and Physiotherapy, University of the Balearic Islands, Palma, Balearic Islands, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Balearic Islands, Spain
- Qualitative and Critical Health Research Group, University of the Balearic Islands, Palma, Balearic Islands, Spain
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Jose Henrique A, Rodney P, Hall W, Thorne S, Joolaee S. Women's autonomy for managing labour pain in a relational context: An interpretive description study. J Clin Nurs 2023; 32:7390-7401. [PMID: 37272285 DOI: 10.1111/jocn.16780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
AIM To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors. BACKGROUND Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions. DESIGN We used an interpretative description approach to conduct this study. METHOD A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist. RESULTS Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences. CONCLUSIONS Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth. RELEVANCE TO CLINICAL PRACTICE Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain. PATIENT OR PUBLIC CONTRIBUTION Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.
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Affiliation(s)
| | - Patricia Rodney
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Wendy Hall
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Sally Thorne
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Soodabeh Joolaee
- Iran University of Medical Sciences, Tehran, Iran
- Research Ethics & Regulatory Specialist, Fraser Health Authority, Vancouver, British Columbia, Canada
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Zhu T, Martina D, van der Heide A, Korfage IJ, Rietjens JAC. The role of acculturation in the process of advance care planning among Chinese immigrants: A narrative systematic review. Palliat Med 2023; 37:1063-1078. [PMID: 37309994 PMCID: PMC10503260 DOI: 10.1177/02692163231179255] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Acculturation is the process of two different cultures coming into contact. It is unclear how acculturation influences Chinese immigrants' engagement in advance care planning due to the complexity and multifaceted nature of both acculturation and advance care planning. AIMS To synthesize evidence regarding the role of Chinese immigrants' acculturation in their engagement in advance care planning. DESIGN Systematic mixed-method review, registered in PROSPERO (CRD42021231822). DATA SOURCES EMBASE, MEDLINE, Web of Science, and Google Scholar were searched for publications until January 21, 2021. RESULTS Twenty-one out of 1112 identified articles were included in the analysis. Of those 21 articles, 17 had a qualitative design and 13 originated from the United States. Three of four quantitative studies reported that higher acculturation levels were associated with better knowledge or higher rate of engagement in advance care planning. Analysis of qualitative studies showed that Chinese immigrants' engagement in advance care planning was associated with their: (1) self-perceived cultural identity (native or non-native); (2) interpretation of filial piety (traditional or modern); and (3) interpretation of autonomy (individual or familial). To facilitate their engagement, Chinese immigrants prefer an implicit approach, non-family-related initiators, contextualization advance care planning in Chinese culture and using Chinese language. CONCLUSION Chinese immigrants' willingness to engage in advance care planning varied with their acculturation level. To engage them in advance care planning, we recommend adapting the introduction of advance care planning to address people's perceptions of their cultural identity, filial piety, and autonomy, as well as their preference for certain approach, initiator, context, and language.
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Affiliation(s)
- Tingting Zhu
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Diah Martina
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Medical Oncology, Erasmus MC Cancer Institute, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Division of Psychosomatic and Palliative Medicine, Department of Internal Medicine, Universitas Indonesia, Jakarta, Indonesia
- Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ida J Korfage
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Judith AC Rietjens
- Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Design, Organization and Strategy, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, The Netherlands
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Teti SL. A troubling foundational inconsistency: autonomy and collective agency in critical care decision-making. THEORETICAL MEDICINE AND BIOETHICS 2023; 44:279-300. [PMID: 36973596 DOI: 10.1007/s11017-023-09608-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/11/2023] [Indexed: 06/18/2023]
Abstract
'Shared' decision-making is heralded as the gold standard of how medical decisions should be reached, yet how does one 'share' a decision when any attempt to do so will undermine autonomous decision-making? And what exactly is being shared? While some authors have described parallels in literature, philosophical examination of shared agency remains largely uninvestigated as an explanation in bioethics. In the following, shared decision-making will be explained as occurring when a group, generally comprised of a patient and or their family, and the medical team become a genuine intentional subject which acts as a collective agent. Collective agency can better explain how some medical decisions are reached, contrary to the traditional understanding and operationalization of 'autonomy' in bioethics. Paradoxically, this often occurs in the setting of high-stakes moral decision-making, where conventional wisdom would suggest individuals would most want to exercise autonomous action according to their personally held values and beliefs. This explication of shared decision-making suggests a social ontology ought to inform or displace significant aspects of autonomy as construed in bioethics. It will be argued that joint commitments are a fundamental part of human life, informing and explaining much human behavior, and thus suggesting that autonomy - conceived of as discrete, individuated moral reasoning of a singular moral agent - is not an unalloyed 'good.'
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Affiliation(s)
- Stowe Locke Teti
- Center for Clinical and Organizational Ethics, Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, Fairfax, VA, 22042, USA.
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24
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Scheeres-Feitsma TM, van Laarhoven AJJMK, de Vries R, Schaafsma P, van der Steen JT. Family involvement in euthanasia or Physician Assisted Suicide and dementia: A systematic review. Alzheimers Dement 2023; 19:3688-3700. [PMID: 37186445 DOI: 10.1002/alz.13094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/17/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE To assess how families are involved in situations of euthanasia or physician assisted suicide (PAS) in dementia. DESIGN Systematic review searching literature in nine databases from inception up to October 2021. We included studies on family involvement in euthanasia from the perspective of persons with dementia and family caregivers. Themes were formulated through thematic analysis. The design was registered at Prospero (CRD42022298215). RESULTS We assessed 215 of 4038 studies in full text; 19 met the inclusion criteria of which 13 empirical studies. Themes included for people with dementia: being a burden; stage of dementia, and permissibility of euthanasia/PAS. Themes for family were the burden of care, responsibility toward the euthanasia or PAS wish, permissibility of euthanasia/PAS. CONCLUSION The wish for euthanasia/PAS arises in situations of burdensome care and fear of future deterioration. The family feels entrusted with the responsibility to enact upon the death wish. In shaping this responsibility, four roles of family can be distinguished: carer, advocate, supporter, and performer. Family as in need of support themselves is understudied.
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Affiliation(s)
| | | | - Ralph de Vries
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - Jenny T van der Steen
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Zhao J, McBride CM, Campbell GP, Pentz RD, Escoffery C, Konomos M, Bellcross C, Ward K, Shepperd JR, Guan Y. Your Family Connects: A Theory-Based Intervention to Encourage Communication about Possible Inherited Cancer Risk among Ovarian Cancer Survivors and Close Relatives. Public Health Genomics 2023; 26:77-89. [PMID: 37487468 PMCID: PMC10614520 DOI: 10.1159/000531772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/26/2023] [Indexed: 07/26/2023] Open
Abstract
INTRODUCTION Encouraging family communication about possible genetic risk has become among the most important avenues for achieving the full potential of genomic discovery for primary and secondary prevention. Yet, effective family-wide risk communication (i.e., conveying genetic risk status and its meaning for other family members) remains a critical gap in the field. We aim to describe the iterative process of developing a scalable population-based communication outreach intervention, Your Family Connects, to reach ovarian cancer survivors and close relatives to communicate the potential for inherited risk and to consider genetic counseling. METHODS Relational-level theories (e.g., interdependence theory) suggest that interventions to promote family cancer risk communication will be most effective if they consider the qualities of specific relationships and activate motives to preserve the relationship. Informed by these theories, we collaborated with 14 citizen scientists (survivors of ovarian cancer or relatives) and collected 261 surveys and 39 structured interviews over 12 weeks of citizen science activities in 2020. RESULTS The citizen science findings and consideration of relational-level theories informed the content and implementation of Your Family Connects (www.yourfamilyconnects.org). CS results showed survivors favor personal contact with close relatives, but relatives were open to alternative contact methods, such as through health professionals. Recognizing the need for varied approaches based on relationship dynamics, we implemented a relative contact menu to enable survivors identify at-risk relatives and provide multiple contact options (i.e., survivor contact, health professional contact, and delayed contact). In line with relational autonomy principles, we included pros and cons for each option, assisting survivors in choosing suitable contact methods for each relative. DISCUSSION Our developed intervention represents a novel application of relational-level theories and partnership with citizen scientists to expand genetic services reach to increase the likelihood for fair distribution of cancer genomic advances. The Your Family Connects intervention as part of a randomized trial in collaboration with the Georgia Cancer Registry compared with standard outreach.
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Affiliation(s)
- Jingsong Zhao
- Department of Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA,
| | - Colleen M McBride
- Department of Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Gavin P Campbell
- Department of Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | - Rebecca D Pentz
- Department of Hematology and Oncology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Cam Escoffery
- Department of Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
| | | | | | - Kevin Ward
- Georgia Center for Cancer Statistics, Emory University, Atlanta, Georgia, USA
| | - James R Shepperd
- Department of Psychology, University of Florida, Gainesville, Florida, USA
| | - Yue Guan
- Department of Behavioral, Social and Health Education Sciences, Emory University, Atlanta, Georgia, USA
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Negash WD, Kefale GT, Belachew TB, Asmamaw DB. Married women decision making autonomy on health care utilization in high fertility sub-Saharan African countries: A multilevel analysis of recent Demographic and Health Survey. PLoS One 2023; 18:e0288603. [PMID: 37440579 DOI: 10.1371/journal.pone.0288603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND Women's decision-making autonomy has a potential impact on the scale-up of health care utilization. In high fertility countries, evidence regarding women's decision-making autonomy on their health care utilization and its associated factors is limited and inconclusive. Hence, it is important to investigate women decision-making autonomy on their health care utilization and associated factors in high fertility countries in sub-Saharan Africa. METHODS The data source for this study was obtained from recent Demographic and Health Surveys that were comprised of a weighted sample of 178875 reproductive age women. A multilevel mixed-effect binary logistic regression model was fitted. The odds ratios, along with the 95% confidence interval were generated to identify individual and community-level factors associated with women's autonomy in health care decision-making. A p-value less than 0.05 was declared as statistical significance. RESULTS In this study, 42% (95% CI: 41.7, 42.3) of women were able to exercise their reproductive autonomy. The highest (74.8%) and the lowest (19.74%) magnitude of women autonomy was found in Angola and Mali, respectively. In multilevel analysis; age of women 25-34 years, 35 and above (AOR = 1.34, 95% CI: 1.29, 1.39), and (AOR = 1.78, 95% CI: 1.75, 1.90), women's primary and secondary educational level (AOR = 1.25, 95% CI: 1.20, 1.31), and (AOR = 1.44, 95% CI: 1.32, 1.54), husband primary and secondary educational level (AOR = 1.24, 95% CI: 1.18, 1.29), and (AOR = 1.21, 95% CI: 1.15, 1.27), women who had work (AOR = 1.67, 95% CI: 1.59, 1.74) female household heads (AOR = 1.44, 95% CI: 1.37, 1.51), media exposure (AOR = 1.04, 95% CI: 1.09, 1.18), health insurance coverage (AOR = 1.26, 95% CI: 1.17, 1.36), urban residence (AOR = 1.14, 95% CI: 1.09, 1.19), community education (AOR = 2.43, 95% CI: 2.07, 2.85) and low community poverty level (AOR = 1.27, 95% CI: 1.08, 1.49) were predictor variables. CONCLUSION AND RECOMMENDATION Although every woman has the right to make her own health care decisions, this study showed that almost 58% of them had no role in making decisions about their health care utilization. Thus, each country Government should support women's decision making autonomy regarding their healthcare utilization through mass media and extensive behavioral education.
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Affiliation(s)
- Wubshet Debebe Negash
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Getachew Teshale Kefale
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadele Biresaw Belachew
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Desale Bihonegn Asmamaw
- Department of Reproductive Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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27
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Barnoy S, Dagan E, Kim S, Caiata-Zufferey M, Katapodi MC. Privacy and utility of genetic testing in families with hereditary cancer syndromes living in three countries: the international cascade genetic screening experience. Front Genet 2023; 14:1109431. [PMID: 37229185 PMCID: PMC10203600 DOI: 10.3389/fgene.2023.1109431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Background: Hereditary breast and ovarian cancer and Lynch syndrome are associated with increased lifetime risk for common cancers. Offering cascade genetic testing to cancer-free relatives of individuals with HBOC or LS is a public health intervention for cancer prevention. Yet, little is known about the utility and value of information gained from cascade testing. This paper discusses ELSI encountered during the implementation of cascade testing in three countries with national healthcare systems: Switzerland, Korea, and Israel. Methods: A workshop presented at the 5th International ELSI Congress discussed implementation of cascade testing in the three countries based on exchange of data and experiences from the international CASCADE cohort. Results: Analyses focused on models of accessing genetic services (clinic-based versus population-based screening), and models of initiating cascade testing (patient-mediated dissemination versus provider-mediated dissemination of testing results to relatives). The legal framework of each country, organization of the healthcare system, and socio-cultural norms determined the utility and value of genetic information gained from cascade testing. Conclusion: The juxtaposition of individual versus public health interests generates significant ELSI controversies associated with cascade testing, which compromise access to genetic services and the utility and value of genetic information, despite national healthcare/universal coverage.
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Affiliation(s)
- Sivia Barnoy
- Department of Nursing, Tel-Aviv University, Tel-Aviv, Israel
| | - Efrat Dagan
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Sue Kim
- College of Nursing, Yonsei University, Seoul, South Korea
| | - Maria Caiata-Zufferey
- Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Maria C. Katapodi
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Tommel J, Kenis D, Lambrechts N, Brohet RM, Swysen J, Mollen L, Hoefmans MJF, Pusparum M, Evers AWM, Ertaylan G, Roos M, Hens K, Houwink EJF. Personal Genomes in Practice: Exploring Citizen and Healthcare Professionals' Perspectives on Personalized Genomic Medicine and Personal Health Data Spaces Using a Mixed-Methods Design. Genes (Basel) 2023; 14:786. [PMID: 37107544 PMCID: PMC10137790 DOI: 10.3390/genes14040786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Ongoing health challenges, such as the increased global burden of chronic disease, are increasingly answered by calls for personalized approaches to healthcare. Genomic medicine, a vital component of these personalization strategies, is applied in risk assessment, prevention, prognostication, and therapeutic targeting. However, several practical, ethical, and technological challenges remain. Across Europe, Personal Health Data Space (PHDS) projects are under development aiming to establish patient-centered, interoperable data ecosystems balancing data access, control, and use for individual citizens to complement the research and commercial focus of the European Health Data Space provisions. The current study explores healthcare users' and health care professionals' perspectives on personalized genomic medicine and PHDS solutions, in casu the Personal Genetic Locker (PGL). A mixed-methods design was used, including surveys, interviews, and focus groups. Several meta-themes were generated from the data: (i) participants were interested in genomic information; (ii) participants valued data control, robust infrastructure, and sharing data with non-commercial stakeholders; (iii) autonomy was a central concern for all participants; (iv) institutional and interpersonal trust were highly significant for genomic medicine; and (v) participants encouraged the implementation of PHDSs since PHDSs were thought to promote the use of genomic data and enhance patients' control over their data. To conclude, we formulated several facilitators to implement genomic medicine in healthcare based on the perspectives of a diverse set of stakeholders.
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Affiliation(s)
- Judith Tommel
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Daan Kenis
- Department of Philosophy, University of Antwerp, Rodestraat 14, 2000 Antwerp, Belgium
| | | | - Richard M. Brohet
- Department of Epidemiology and Statistics, Isala Hospital, Dokter van Heesweg 2, 8025 AB Zwolle, The Netherlands
| | | | | | | | - Murih Pusparum
- VITO Health, Boeretang 200, 2400 Mol, Belgium
- Data Science Institute, I-Biostat, Hasselt University, 3500 Hasselt, Belgium
| | - Andrea W. M. Evers
- Health, Medical, and Neuropsychology Unit, Institute of Psychology, Faculty of Social and Behavioural Sciences, Leiden University, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands
| | | | - Marco Roos
- Department of Human Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Kristien Hens
- Department of Philosophy, University of Antwerp, Rodestraat 14, 2000 Antwerp, Belgium
| | - Elisa J. F. Houwink
- Department of Family Medicine, Mayo Clinic, 221 Fourth Avenue SW, Rochester, MN 55905, USA
- Department of Public Health and Primary Care (PHEG), Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Sonnauer F, Frewer A. Trojan technology in the living room? Ethik Med 2023. [DOI: 10.1007/s00481-023-00756-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
Abstract
Abstract
Definition of the problem
Assistive technologies, including “smart” instruments and artificial intelligence (AI), are increasingly arriving in older adults’ living spaces. Various research has explored risks (“surveillance technology”) and potentials (“independent living”) to people’s self-determination from technology itself and from the increasing complexity of sociotechnical interactions. However, the point at which self-determination of the individual is overridden by external influences has not yet been sufficiently studied. This article aims to shed light on this point of transition and its implications.
Arguments
The identification of this “tipping point” could contribute to analysis of familiar issues of conflict between the ethical principles of beneficence and respect for autonomy. When using technology in the living spaces of older adults, relationships, among other factors, may play a crucial role in older adult’s self-determination. We find the tipping point to occur subjectively and variably. To this end, the article combines theoretical ethical considerations with two examples from a qualitative study illustrating the perspective of older adults aged 65–85 years.
Conclusion
The study of the tipping point underscores the importance of perceiving an older person’s perspective. Particularly at the tipping point, this might be the only way to effectively identify whether the individual concerned perceives their self-determination as externally overridden. In conceptualizing the tipping point itself as well as its variability, we might create the basis for a normative call to shift the tipping point to promote self-determination and prevent overriding the will of older adults. We highlight individual, relational, and societal implications of our findings.
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Wang RH, Tannou T, Bier N, Couture M, Aubry R. Proactive and Ongoing Analysis and Management of Ethical Concerns in the Development, Evaluation, and Implementation of Smart Homes for Older Adults With Frailty. JMIR Aging 2023; 6:e41322. [PMID: 36892912 PMCID: PMC10037176 DOI: 10.2196/41322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 01/28/2023] [Accepted: 01/31/2023] [Indexed: 03/10/2023] Open
Abstract
Successful adoption and sustained use of smart home technology can support the aging in place of older adults with frailty. However, the expansion of this technology has been limited, particularly by a lack of ethical considerations surrounding its application. This can ultimately prevent older adults and members of their support ecosystems from benefiting from the technology. This paper has 2 aims in the effort to facilitate adoption and sustained use: to assert that proactive and ongoing analysis and management of ethical concerns are crucial to the successful development, evaluation, and implementation of smart homes for older adults with frailty and to present recommendations to create a framework, resources, and tools to manage ethical concerns with the collaboration of older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities. To support our assertion, we reviewed intersecting concepts from bioethics, specifically principlism and ethics of care, and from technology ethics that are salient to smart homes in the management of frailty in older adults. We focused on 6 conceptual domains that can lead to ethical tensions and of which proper analysis is essential: privacy and security, individual and relational autonomy, informed consent and supported decision-making, social inclusion and isolation, stigma and discrimination, and equity of access. To facilitate the proactive and ongoing analysis and management of ethical concerns, we recommended collaboration to develop a framework with 4 proposed elements: a set of conceptual domains as discussed in this paper, along with a tool consisting of reflective questions to guide ethical deliberation throughout the project phases; resources comprising strategies and guidance for the planning and reporting of ethical analysis throughout the project phases; training resources to support leadership, literacy, and competency in project teams for the analysis and management of ethical concerns; and training resources for older adults with frailty, their support ecosystems, and the public to support their awareness and participation in teams and ethical analysis processes. Older adults with frailty require nuanced consideration when incorporating technology into their care because of their complex health and social status and vulnerability. Smart homes may have a greater likelihood of accommodating users and their contexts with committed and comprehensive analysis, anticipation, and management of ethical concerns that reflect the unique circumstances of these users. Smart home technology may then achieve its desired individual, societal, and economic outcomes and serve as a solution to support health; well-being; and responsible, high-quality care.
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Affiliation(s)
- Rosalie H Wang
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Thomas Tannou
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal, Centre intégré universitaire de santé et de services sociaux (CIUSSS) - Centre-Sud-de-l'île-de-Montréal, Montréal, QC, Canada
- Centre d'Investigation Clinique de l'Institut National de la Santé et de la Recherche Médicale (INSERM CIC) 1431, Centre Hospitalier Universitaire de Besançon, Besançon, France
| | - Nathalie Bier
- Centre de recherche de l'Institut universitaire de gériatrie de Montréal, Centre intégré universitaire de santé et de services sociaux (CIUSSS) - Centre-Sud-de-l'île-de-Montréal, Montréal, QC, Canada
- Programme d'ergothérapie, École de réadaptation, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Mélanie Couture
- École de Travail social, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Régis Aubry
- Centre d'Investigation Clinique de l'Institut National de la Santé et de la Recherche Médicale (INSERM CIC) 1431, Centre Hospitalier Universitaire de Besançon, Besançon, France
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31
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Lee ES, Hiratsuka Y, Suh SY, Won SH, Kim SH, Yoon SJ, Choi SE, Choi H, Ahn HY, Kim Y, Hui D, Cheng SY, Chen PJ, Wu CY, Mori M, Morita T, Yamaguchi T, Tsuneto S. Clinicians' Prediction of Survival and Prognostic Confidence in Patients with Advanced Cancer in Three East Asian Countries. J Palliat Med 2023. [PMID: 36888535 DOI: 10.1089/jpm.2022.0380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
Background: Little is known about accuracy and confidence of clinicians' prediction of survival (CPS) in East-Asian countries. Objective: We aimed to examine accuracy of CPS for 7-, 21-, and 42-day survival in palliative inpatients and its association with prognostic confidence. Design: An international prospective cohort study in Japan (JP), Korea (KR), and Taiwan (TW). Setting/Subjects: Subjects were inpatients with advanced cancer admitted to 37 palliative care units in three countries. Measurements: Discrimination of CPS was investigated through sensitivity, specificity, overall accuracy, and area under the receiver operating characteristics curves (AUROCs) according to 7-, 21-, and 42-day survival. The accuracies of CPS were compared with those of Performance Status-based Palliative Prognostic Index (PS-PPI). Clinicians were instructed to rate confidence level on a 0-10-point scale. Results: A total of 2571 patients were analyzed. The specificity was highest at 93.2-100.0% for the 7-day CPS, and sensitivity was highest at 71.5-86.8% for the 42-day CPS. The AUROCs of the seven-day CPS were 0.88, 0.94, and 0.89, while those of PS-PPI were 0.77, 0.69, and 0.69 for JP, KR, and TW, respectively. As for 42-day prediction, sensitivities of PS-PPI were higher than those of CPS. Clinicians' confidence was strongly associated with the accuracy of prediction in all three countries (all p-values <0.01). Conclusions: CPS accuracies were highest (0.88-0.94) for the seven-day survival prediction. CPS was more accurate than PS-PPI in all timeframe prediction except 42-day prediction in KR. Prognostic confidence was significantly associated with the accuracy of CPS.
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Affiliation(s)
- Eon Sook Lee
- Department of Family Medicine, Ilsan-Paik Hospital, Inje University, College of Medicine, Goyang, South Korea
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Takeda General Hospital, Aizu Wakamatsu, Japan.,Department of Palliative Medicine, Tohoku University School of Medicine, Sendai, Japan
| | - Sang-Yeon Suh
- Department of Medicine, Dongguk University Medical School, Seoul, South Korea.,Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Seon-Hye Won
- Department of Family Medicine, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Sun-Hyun Kim
- Department of Family Medicine, School of Medicine, Catholic Kwandong University, International St. Mary's Hospital, Incheon, South Korea
| | - Seok-Joon Yoon
- Department of Family Medicine, Chungnam National University Hospital, Daejeon, South Korea
| | - Sung-Eun Choi
- Department of Statistics, Dongguk University, Seoul, South Korea
| | - Hana Choi
- Department of Statistics, Dongguk University, Seoul, South Korea
| | - Hong-Yup Ahn
- Department of Statistics, Dongguk University, Seoul, South Korea
| | - Yoonjoo Kim
- Department of Nursing, College of Healthcare Science, Far East University, Eumseong-gun, Chungcheongbuk-do, South Korea
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, and School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London, London, United Kingdom
| | - Chien-Yi Wu
- Department of Family Medicine, Kaohsiung Medical University Hospital, and School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Masanori Mori
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | | | - Satoru Tsuneto
- Department of Human Health Sciences, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Chang DH, Dumanski SM, Ahmed SB. Female sex-specific considerations to improve rigor and reproducibility in cardiovascular research. Am J Physiol Heart Circ Physiol 2023; 324:H279-H287. [PMID: 36563011 DOI: 10.1152/ajpheart.00462.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cardiovascular disease is the leading cause of death in women. Despite recognition of sex-specific differences in cardiovascular health, females are underrepresented across all aspects of cardiovascular research, playing a key role in reducing rigor and reproducibility in cardiovascular research and contributing to these poorer health outcomes. Therefore, we propose a framework to capture factors associated with the female sex at the preclinical, recruitment, data collection, and data analysis stages. In preclinical cardiovascular research, female experimental models are commonly excluded despite similar variability in findings compared with males. To reduce this sex bias, the inclusion of female models and the incorporation of sex as a biological variable are critical to improve reproducibility and inform clinical research and care. Although funding agencies have mandated the inclusion of women in clinical trials, greater efforts are needed to achieve optimal participation-to-prevalence ratio to increase the generalizability of results to real-world settings. Female participants face more stringent exclusion criteria in research compared with males owing to sex-specific factors. However, their routine exclusion from cardiovascular research is not only unethical but limits generalizability and applicability to clinical practice. Identifying sex assigned at birth, collecting information on female sex-specific and -predominant factors associated with cardiovascular health and risk, and stratifying data by sex, including adverse events, are essential to ensure reproducibility and relevance of findings to target populations. Increasing female representation and the incorporation of female sex-specific cardiovascular risk factors in cardiovascular research will not only lead to enhanced rigor and reproducibility but improved cardiovascular health for all.
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Affiliation(s)
- Danica H Chang
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sandra M Dumanski
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sofia B Ahmed
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Kidney Disease Network, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Howe EG. When Should Providers Defer versus Impose Their Views? THE JOURNAL OF CLINICAL ETHICS 2023; 34:289-295. [PMID: 37991734 DOI: 10.1086/727439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
AbstractThis piece discusses perhaps the most agonizing ethical decision ethics consultants and other providers encounter. This is the extent to which providers should defer decisions to patients or to their proxy decision makers as opposed to imposing their own views as to what they think is ethically right. It discusses the most difficult issues these providers may encounter, especially when they wish to depart from authoritative bodies' standards or guidelines, and it presents initial steps providers may take to help patients and their families work together to resolve these dilemmas more harmoniously. It highlights how providers may inadvertently impose flawed biases on patients and families. Finally, it discusses how providers should take initiative with both parties to offer to help appeal when these avenues already exist and seek to establish the appellate procedures when they are absent.
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Alfahmi MZ. Patients' preference approach to overcome the moral implications of family-centred decisions in Saudi medical settings. BMC Med Ethics 2022; 23:128. [PMID: 36474278 PMCID: PMC9724249 DOI: 10.1186/s12910-022-00868-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 11/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In Saudi clinical settings, cultural influences can give a patient's family authority to override the patient's autonomous right to make informed health-related decisions. Cultural values should not prevent patients from exercising their genuine preferences when making medical decisions in their own best interests. DISCUSSION This article discusses the moral implications of family-centred medical decisions for autonomous patients who are competent and capable of making decisions. The author argues that socio-cultural values do not justify the decision to override patient autonomy when patients express a preference for making their own choices. CONCLUSION The author recommends the use of a model of shared decision-making that accounts for both individual and relational conceptions of autonomy, approaching patients' preferences in all medical encounters with the aim of minimising the potential for socio-cultural values to undermine patient autonomy. Although this approach is a safeguard against both family and medical paternalism, allowance is made for clinicians to act in weakly paternalistic ways when patients at high risk of exacerbating existing medical conditions are likely to benefit from delaying or limiting the disclosure of potentially distressing but non-fatal diagnoses and prognoses. Thus, the author argues that even in a culture that supports family involvement in management decisions, physicians should respect patient autonomy by asking patients for their preferences in the disclosure of their medical diagnoses, prognoses and management options and verifying patients' preferences about the roles they wish their families to play (if any) in health-related decisions.
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van Beinum A, Murphy N, Weijer C, Gruben V, Sarti A, Hornby L, Dhanani S, Chandler J. Family experiences with non-therapeutic research on dying patients in the intensive care unit. JOURNAL OF MEDICAL ETHICS 2022; 48:845-851. [PMID: 34261806 DOI: 10.1136/medethics-2021-107311] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 06/29/2021] [Indexed: 05/20/2023]
Abstract
Experiences of substitute decision-makers with requests for consent to non-therapeutic research participation during the dying process, including to what degree such requests are perceived as burdensome, have not been well described. In this study, we explored the lived experiences of family members who consented to non-therapeutic research participation on behalf of an imminently dying patient.We interviewed 33 family members involved in surrogate research consent decisions for dying patients in intensive care. Non-therapeutic research involved continuous physiological monitoring of dying patients prior to and for 30 min following cessation of circulation. At some study centres participation involved installation of bedside computers. At one centre electroencephalogram monitoring was used with a subset of participants. Aside from additional monitoring, the research protocol did not involve deviations from usual end-of-life care.Thematic analysis of interviews suggests most family members did not perceive this minimal-risk, non-therapeutic study to affect their time with patients during the dying process, nor did they perceive research consent as an additional burden. In our analysis, consenting for participation in perimortem research offered families of the dying an opportunity to affirm the intrinsic value of patients' lives and contributions. This opportunity may be particularly important for families of patients who consented to organ donation but did not proceed to organ retrieval.Our work supports concerns that traditional models of informed consent fail to account for possible benefits and harms of perimortem research to surviving families. Further research into consent models which integrate patient and family perspectives is needed.
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Affiliation(s)
- Amanda van Beinum
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Sociology and Anthropology, Carleton University Faculty of Arts and Social Sciences, Ottawa, Ontario, Canada
| | - Nick Murphy
- Philosophy, Western University, London, Ontario, Canada
| | - Charles Weijer
- Philosophy, Western University Faculty of Arts and Humanities, London, Ontario, Canada
- Medicine, Epidemiology and Biostatistics, Western University Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Vanessa Gruben
- Common Law, University of Ottawa Faculty of Law, Ottawa, Ontario, Canada
| | - Aimee Sarti
- Medicine, Ottawa Hospital General Campus, Ottawa, Ontario, Canada
- Critical Care Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Laura Hornby
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Deceased Donation, Canadian Blood Services Organ Donation and Transplantation, Ottawa, Ontario, Canada
| | - Sonny Dhanani
- Critical Care Research, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
- Division of Pediatric Critical Care, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Jennifer Chandler
- Common Law, University of Ottawa Faculty of Law, Ottawa, Ontario, Canada
- Medicine, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
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36
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Kawaguchi K, Ide K, Kondo K. Family social support and stability of preferences regarding place of death among older people: a 3-year longitudinal study from the Japan Gerontological Evaluation Study. Age Ageing 2022; 51:6730557. [PMID: 36173990 PMCID: PMC9521793 DOI: 10.1093/ageing/afac210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND it remains unclear how family relationships could affect stability of end-of-life care preferences. OBJECTIVE to describe change patterns of preferred place of death (POD) among older people and to examine associations between family social support and stability of preferences regarding POD. METHODS this longitudinal study of 1,200 noninstitutionalized independent Japanese older people aged over 65 years used panel data between 2016 and 2019 from the Japan Gerontological Evaluation Study (JAGES). Preference stability was defined as the congruence of preferred POD based on questionnaires between baseline and follow-up. We performed multiple logistic regression analysis and gender-stratified analysis to examine associations between social support (spouse, children living together and children living apart) and preference stability. RESULTS only 40.9% of participants had stable preferences. For a spouse, both receiving and providing social support was associated with less stable preferences (OR: 0.63, 95% CI: 0.43-0.93; OR: 0.55, 95% CI: 0.38-0.80, respectively), and providing social support to children living apart was associated with more stable preferences (OR: 1.35, 95% CI: 1.03-1.76). In gender-stratified analysis, significant associations between preference stability and providing social support to a spouse among women (OR: 0.53, 95% CI: 0.34-0.82) and providing social support to children living apart among men (OR: 1.72, 95% CI: 1.16-2.55) were observed. CONCLUSIONS family social support was associated with the stability of preferences, and the associations differed by support resources and gender. Incorporating family members in the process of end-of-life care discussion may be necessary for establishing stable preferences.
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Affiliation(s)
| | - Kazushige Ide
- Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba 260-8670, Japan
| | - Katsunori Kondo
- Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences, Chiba University, Chiba 260-8670, Japan,Department of Geriatric Evaluation, Center for Gerontology and Social Science, National Center for Geriatrics and Gerontology, Obu 474-8511, Japan
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Pinto da Silva S, de Freitas C, Silva S. Medical ethics when moving towards non-anonymous gamete donation: the views of donors and recipients. JOURNAL OF MEDICAL ETHICS 2022; 48:616-623. [PMID: 34172523 DOI: 10.1136/medethics-2020-106947] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 04/15/2021] [Accepted: 05/04/2021] [Indexed: 06/13/2023]
Abstract
Drawing on the views of donors and recipients about anonymity in a country that is experiencing a transition towards non-anonymous gamete donation mandated by the Constitutional Court, we explore how the intersection between rights-based approaches and an empirical framework enhances recommendations for ethical policy and healthcare. Between July 2017 and April 2018, 69 donors and 147 recipients, recruited at the Portuguese Public Bank of Gametes, participated in this cross-sectional study. Position towards anonymity was assessed through an open-ended question in a self-report questionnaire, which was subject to content analysis. Preference for an anonymous donation regime was mentioned by 82.6% of donors and 89.8% of recipients; and all those with children. Instead of the rights-based reasoning used by the Constitutional Court, donors highlighted concerns over future relationships and recipients focused on socioethical values linked with the safeguard of safety, privacy and confidentiality. The remaining participants advocated the choice between anonymity or non-anonymity (double-track policy), invoking respect for their autonomy. The complex, diverse ethical views and reasoning of donors and recipients expand a traditionally dichotomous discussion. Their perspectives challenge the transition towards non-anonymity and international guidelines, raising awareness to the need for their involvement in the design of policies to enable choice according to their values and preferences, and of psychosocial counselling responsive to their socioethical concerns and sensitive to their parental status. Empirical frameworks complement rights-based approaches to uphold justice, fairness and equal respect, and to incorporate utility, beneficence and non-maleficence in policymaking and healthcare in the transition towards non-anonymity.
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Affiliation(s)
- Sandra Pinto da Silva
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Cláudia de Freitas
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | - Susana Silva
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
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Liu L, Daum C, Miguel Cruz A, Neubauer N, Perez H, Ríos Rincón A. Ageing, technology, and health: Advancing the concepts of autonomy and independence. Healthc Manage Forum 2022; 35:296-300. [PMID: 35924794 PMCID: PMC9425715 DOI: 10.1177/08404704221110734] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The global pandemic expedited the adoption of AgeTech solutions that aim to help older adults maintain their autonomy and independence. This article examines the negative impact of the Western worldview of autonomy and independence on older adults. Negative impact can manifest as ageism and may be compounded by intersections of identities with race, gender, and culture. We propose an inclusive framework for health leaders, one that is not binary or categorical, but instead, on a continuum: (1) relational autonomy which assumes that relationships form one's identity; therefore, no one is autonomous to the exclusion of others, and (2) interdependence which proposes that one's lifestyle choice is supported by interreliance with aspects of one's environment. We examine two examples of AgeTech from the perspective of relational autonomy and interdependence and discuss how health leaders can use this inclusive framework to ensure that their services do not discriminate against older adults.
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Affiliation(s)
- Lili Liu
- 8430University of Waterloo, Waterloo, Ontario, Canada
| | - Christine Daum
- 8430University of Waterloo, Waterloo, Ontario, Canada.,70412University of Alberta, Edmonton, Alberta, Canada
| | - Antonio Miguel Cruz
- 8430University of Waterloo, Waterloo, Ontario, Canada.,70412University of Alberta, Edmonton, Alberta, Canada.,Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | | | - Hector Perez
- 8430University of Waterloo, Waterloo, Ontario, Canada
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The Communication Chain of Genetic Risk: Analyses of Narrative Data Exploring Proband–Provider and Proband–Family Communication in Hereditary Breast and Ovarian Cancer. J Pers Med 2022; 12:jpm12081249. [PMID: 36013197 PMCID: PMC9409642 DOI: 10.3390/jpm12081249] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Low uptake of genetic services among members of families with hereditary breast and ovarian cancer (HBOC) suggests limitations of proband-mediated communication of genetic risk. This study explored how genetic information proceeds from healthcare providers to probands and from probands to relatives, from the probands’ perspectives. Using a grounded-theory approach, we analyzed narrative data collected with individual interviews and focus groups from a sample of 48 women identified as carriers of HBOC-associated pathogenic variants from three linguistic regions of Switzerland. The findings describe the “communication chain”, confirming the difficulties of proband-mediated communication. Provider–proband communication is impacted by a three-level complexity in the way information about family communication is approached by providers, received by probands, and followed-up by the healthcare system. Probands’ decisions regarding disclosure of genetic risk are governed by dynamic and often contradictory logics of action, interconnected with individual and family characteristics, eventually compelling probands to engage in an arbitrating process. The findings highlight the relevance of probands’ involvement in the communication of genetic risk to relatives, suggesting the need to support them in navigating the complexity of family communication rather than replacing them in this process. Concrete actions at the clinical and health system levels are needed to improve proband-mediated communication.
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40
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Bhattarai S, Adhikari A, Rayamajhee B, Dhungana J, Singh M, Koirala S, Shakya DR. Participatory Approach to Develop Evidence-Based Clinical Ethics Guidelines for the Care of COVID-19 Patients: A Mixed Method Study From Nepal. Front Public Health 2022; 10:873881. [PMID: 35832276 PMCID: PMC9272001 DOI: 10.3389/fpubh.2022.873881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
During health emergencies such as the COVID-19 pandemic, healthcare workers face numerous ethical challenges while catering to the needs of patients in healthcare settings. Although the data recapitulating high-income countries ethics frameworks are available, the challenges faced by clinicians in resource-limited settings of low- and middle-income countries are not discussed widely due to a lack of baseline data or evidence. The Nepali healthcare system, which is chronically understaffed and underequipped, was severely affected by the COVID-19 pandemic in its capacity to manage health services and resources for needy patients, leading to ethical dilemmas and challenges during clinical practice. This study aimed to develop a standard guideline that would address syndemic ethical dilemmas during clinical care of COVID-19 patients who are unable to afford standard-of-care. A mixed method study was conducted between February and June of 2021 in 12 government designated COVID-19 treatment hospitals in central Nepal. The draft guideline was discussed among the key stakeholders in the pandemic response in Nepal. The major ethical dilemmas confronted by the study participants (50 healthcare professionals providing patient care at COVID-19 treatment hospitals) could be grouped into five major pillars of ethical clinical practice: rational allocation of medical resources, updated treatment protocols that guide clinical decisions, standard-of-care regardless of patient's economic status, effective communication among stakeholders for prompt patient care, and external factors such as political and bureaucratic interference affecting ethical practice. This living clinical ethics guideline, which has been developed based on the local evidence and case stories of frontline responders, is expected to inform the policymakers as well as the decision-makers positioned at the concerned government units. These ethics guidelines could be endorsed with revisions by the concerned regulatory authorities for the use during consequent waves of COVID-19 and other epidemics that may occur in the future. Other countries affected by the pandemic could conduct similar studies to explore ethical practices in the local clinical and public health context.
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Affiliation(s)
- Suraj Bhattarai
- Department of Global Health, Global Institute for Interdisciplinary Studies (GIIS), Kathmandu, Nepal
| | - Anurag Adhikari
- Department of Infection and Immunology, Kathmandu Research Institute for Biological Sciences (KRIBS), Lalitpur, Nepal
| | - Binod Rayamajhee
- Department of Infection and Immunology, Kathmandu Research Institute for Biological Sciences (KRIBS), Lalitpur, Nepal
- School of Optometry and Vision Science, Faculty of Medicine and Health, UNSW, Sydney, NSW, Australia
| | - Jaya Dhungana
- Department of Global Health, Global Institute for Interdisciplinary Studies (GIIS), Kathmandu, Nepal
| | - Minu Singh
- Department of Infection and Immunology, Kathmandu Research Institute for Biological Sciences (KRIBS), Lalitpur, Nepal
| | - Sarun Koirala
- Department of Anatomy, B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
- Nepali Unit of International Chair in Bioethics, Dharan, Nepal
| | - Dhana Ratna Shakya
- Nepali Unit of International Chair in Bioethics, Dharan, Nepal
- Department of Psychiatry, B.P. Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal
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41
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Nishimura M, Dening KH, Sampson EL, de Oliveira Vidal EI, de Abreu WC, Kaasalainen S, Eisenmann Y, Dempsey L, Moore KJ, Davies N, Bolt SR, Meijers JMM, Dekker NL, Miyashita M, Nakanishi M, Nakayama T, van der Steen JT. Cross-cultural conceptualization of a good end of life with dementia: a qualitative study. Palliat Care 2022; 21:106. [PMID: 35676673 PMCID: PMC9175529 DOI: 10.1186/s12904-022-00982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/19/2022] [Indexed: 09/25/2023] Open
Abstract
Background Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models. Methods We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies. Results Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes. Conclusions The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model. Trial registration The Graduate School and Faculty of Medicine Kyoto University (R1924–1). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00982-9.
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Affiliation(s)
- Mayumi Nishimura
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan.
| | | | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK
| | - Edison Iglesias de Oliveira Vidal
- Botucatu Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, Botucatu, SP, 18618-687, Brazil
| | - Wilson Correia de Abreu
- Center for Health Technology and Services Research, University of Porto (ESEP/CINTESIS), R. Dr. Plácido da Costa, 4200-450, Porto, Portugal
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Yvonne Eisenmann
- Department of Palliative Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Laura Dempsey
- Department of Nursing and Healthcare, Technological University of the Shannon: Midlands Midwest, Dublin Road, Athlone, Co Westmeath, N37 HD68, Ireland
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,National Ageing Research Institute Inc., Royal Melbourne Hospital, Royal Park Campus, Gate 4, Building 8, 34-54 Poplar Rd, Parkville, VIC, 3052, Australia
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,Research Department of Primary Care and Population Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Sascha R Bolt
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Judith M M Meijers
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands.,Zuyderland Care, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162, BG, Sittard-Geleen, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Pieter de la Court Wassenaarseweg 52, 2333, AK, Leiden, The Netherlands
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333, ZD, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
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Abstract
Patients in need of palliative care are often described as vulnerable. Being vulnerable can sometimes be interpreted as the opposite of being autonomous, if an autonomous person is seen as an independent, self-sufficient person who forms decisions independently of others. Such a dichotomous view can create a situation where one has experiences of vulnerability that cannot be reconciled with the central ethical principle of autonomy. The article presents a feminist ethical perspective on the conceptualisation of vulnerability in the context of palliative care. It does so through the lens of the concepts of inherent and pathogenic vulnerability from the taxonomy on vulnerability suggested by Mackenzie et al. To differentiate between forms of vulnerability, is important since even though vulnerability can be regarded as a shared life condition it can be the product of practices creating harm to the patient. The article also presents an analysis of how vulnerability can be included in the interpretation of the ethical principle of autonomy, in order to be relevant in palliative care where vulnerability is salient, namely, as relational autonomy. Furthermore, two practical implications for nursing practice are suggested. Firstly, to acknowledge vulnerability as a shared life condition one needs training in order to neither be overwhelmed by one's own vulnerability, nor become invulnerable when facing vulnerability in others. Secondly, to foster relational autonomy includes navigating between the patient exercising their autonomy within a framework of relations, and shielding the patient from paternalistic practices. Nurses could be particularly suited for this role, which includes creating an environment which is open and supportive; navigating between patient, family and staff; seeing and acknowledging the complex situation in which patient autonomy is actually played out; and promoting patient autonomy.
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Affiliation(s)
- Sofia Morberg Jämterud
- Department of Thematic Studies, Technology and Social Change, Linköping University, Linköping, Sweden
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Abstract
Datafication shapes and gradually transforms societies. Given this impact, issues of justice around data-driven practices have received more and more attention in recent years as shown, for example, by various reports and guidelines on artificial intelligence and data ethics. In this article, we elaborate on and defend two claims. First, these discourses on justice tend to center primarily around conceptions of fairness. We argue that justice in connection with datafication relates to, but ultimately encompasses more than, solely fairness. Second, although it is an important project to clarify what justice in connection with datafication encompasses, we argue that attention toward attitudes and practices of data solidarity have so far been largely overlooked. They are, however, indispensable as a catalytic element to advance toward data justice in practice. New technologies such as big data, machine learning, and artificial intelligence are rapidly generating new opportunities and challenges for various social practices. At the same time, they raise important ethical questions. For example, for whom will these opportunities and advantages result in benefits, and who bears the burdens? A fundamental issue is which individuals and groups with their respective claims and particularities are involved and affected by the use of ever-increasing amounts of data and the inferences drawn from them. To navigate this terrain, reference is often made to the notion of justice. Such reference can be helpful to the extent that we are clear about what justice entails and what it takes to get there. In this article, we argue that justice requires us to make visible the claims of those left out, excluded, or disadvantaged in and around the use of data. To this end, we put forward the concept of data solidarity and examine its interplay with data justice.
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Affiliation(s)
- Matthias Braun
- Research Group Ethics and Governance of Emerging Technologies, Department of Systematic Theology, Friedrich-Alexander-University Erlangen-Nuremberg, Kochstraße 6, 91054 Erlangen, Germany
| | - Patrik Hummel
- Philosophy and Ethics Group, Department of Industrial Engineering & Innovation Sciences, TU Eindhoven, De Zaale, Atlas 9.328, Eindhoven, the Netherlands
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Prainsack B. Beyond Vaccination Mandates: Solidarity and Freedom During COVID-19. Am J Public Health 2022; 112:232-233. [PMID: 35080926 PMCID: PMC8802576 DOI: 10.2105/ajph.2021.306619] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Barbara Prainsack
- Barbara Prainsack is with the Department of Political Science, University of Vienna, Vienna, Austria
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45
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Weller S, Lyle K, Lucassen A. Re-imagining ‘the patient’: Linked lives and lessons from genomic medicine. Soc Sci Med 2022; 297:114806. [PMID: 35219975 PMCID: PMC8943276 DOI: 10.1016/j.socscimed.2022.114806] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 02/07/2022] [Accepted: 02/10/2022] [Indexed: 11/17/2022]
Abstract
How ‘the patient’ is imagined has implications for ethical decision-making in clinical practice. Patients are predominantly conceived in an individualised manner as autonomous and independent decision-makers. Fields such as genomic medicine highlight the inadequacies of this conceptualisation as patients are likely to have family members who may be directly affected by the outcome of tests in others. Indeed, professional guidance has increasingly taken a view that genetic information should, at times, be regarded as of relevance to families, rather than individuals. What remains absent from discussions is an understanding of how those living through/with genomic testing articulate, construct, and represent patienthood, and what such understandings might mean for practice, particularly ethical decision-making. Employing the notion of ‘linked lives’ from lifecourse theory, this article presents findings from a UK-based qualitative longitudinal study following the experiences of those affected by the process and outcomes of genomic testing. The article argues that there is a discord between lived experiences and individualised notions of ‘the patient’ common in conventional bioethics, with participants predominantly locating their own decision-making within the matrix of linked lives in which they are embedded. In the quest to gain ‘answers’, many took an intra or intergenerational view, connecting their own experiences to those of past generations through familial narratives around probable explanations, and/or hopes and expectations for the health of imagined future generations. The article argues that a re-imagining of ‘the patient’, that reflects the complex and shifting nature of patienthood, will be imperative as genomic medicine is mainstreamed. How ‘the patient’ is imagined has implications for ethical decision-making. Genomic medicine shows the shortcomings of individualised notions of ‘the patient’. Instead, a ‘linked lives’ lens highlights the ensembles of relationships affected. Participants reported more collective inter/intra-generational views of patienthood. Re-imagining patienthood beyond the individual is vital as genomics is mainstreamed.
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Affiliation(s)
- Susie Weller
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK.
| | - Kate Lyle
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics, Law and Society (CELS); Wellcome Centre for Human Genetics, University of Oxford, UK; Clinical Ethics, Law and Society (CELS) - Southampton, Faculty of Medicine, University of Southampton, UK
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Huschke S. 'The System is Not Set up for the Benefit of Women': Women's Experiences of Decision-Making During Pregnancy and Birth in Ireland. QUALITATIVE HEALTH RESEARCH 2022; 32:330-344. [PMID: 34852686 PMCID: PMC8727824 DOI: 10.1177/10497323211055461] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
In this article, I draw on in-depth qualitative interviews with 23 women, conducted in 2019/2020, focusing on their involvement in decision-making during pregnancy and birth. The study is located in Ireland, where comparably progressive national policies regarding informed choice in labour and birth clash with the day-to-day reality of a heavily medicalised, paternalistic maternity care system. I represent the subjective experiences of a diverse group of women through in-depth interview excerpts. In my analysis, I move beyond describing what is happening in the Irish maternity system to discussing why this is happening - relating the findings of the research to the international literature on authoritative knowledge, technocratic hospital cultures and risk-based discourses around birth. In the last section of the article, I offer concrete, empirically grounded and innovative recommendations how to enhance women's involvement in decision-making.
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Affiliation(s)
- Susann Huschke
- Public and Patient Involvement (PPI) Research Unit (School of Medicine) and Health Research Institute, University of Limerick, Limerick, Ireland
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Nasu K, Fukahori H, Miyashita M. Long-term care nurses' perceptions of a good death for people with dementia: A qualitative descriptive study. Int J Older People Nurs 2021; 17:e12443. [PMID: 34957680 DOI: 10.1111/opn.12443] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 11/26/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The number of people with dementia (PwD) dying in long-term care (LTC) settings is expected to increase. However, effective care strategies to promote a good death for PwD remain unclear. This study aimed to explore nurses' perceptions of a good death for PwD in LTC settings for older adults. METHODS Interviews were conducted with 19 nurses providing end-of-life care in LTC settings for older adults in Japan. The transcribed texts were analysed using inductive content analysis. RESULTS We identified two themes: (1) ambiguity and (2) preparedness. Participants perceived that there was ambiguity regarding a good death for PwD and emphasised the need for preparedness of those around PwD for a good death. Five categories represented preparedness: (a) reaffirming the original personality before dementia; (b) respecting that PwD change; (c) interpreting and fulfilling obscure desires, feelings, and sensations; (d) providing care consistent with an agreed-upon natural death process; and (e) maintaining relationships. CONCLUSION Long-term care nurses should encourage families and multidisciplinary team members, including the nurses themselves, to prepare for a good death of the PwD. Future research should focus on healthcare professionals' perspectives on advance care planning in the early stages of dementia, as well as the perceptions of PwD, their family members and other healthcare professionals regarding the natural death process.
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Affiliation(s)
- Katsumi Nasu
- Yasuda Women's University, Hiroshima, Japan.,Keio Research Institute at SFC, Kanagawa, Japan
| | - Hiroki Fukahori
- Faculty of Nursing and Medical Care, Keio University, Kanagawa, Japan
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Gordon DR, Koenig BA. "If relatives inherited the gene, they should inherit the data." Bringing the family into the room where bioethics happens. NEW GENETICS AND SOCIETY 2021; 41:23-46. [PMID: 36090688 PMCID: PMC9454889 DOI: 10.1080/14636778.2021.2007065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/05/2021] [Indexed: 05/25/2023]
Abstract
Biological kin share up to half of their genetic material, including predisposition to disease. Thus, variants of clinical significance identified in each individual's genome can implicate an exponential number of relatives at potential risk. This has renewed the dilemma over family access to research participant's genetic results, since prevailing U.S. practices treat these as private, controlled by the individual. These individual-based ethics contrast with the family-based ethics- in which genetic information, privacy, and autonomy are considered to be familial- endorsed in UK genomic medicine and by participants in a multi-method study of U.S. research participants presented here. The dilemma reflects a conflict between U.S. legal and ethical frameworks that privilege "the individual" and exclude "the family" versus actual human genetics that are simultaneously individual and familial. Can human genetics succeed in challenging bioethics' hegemonic individualism to recognize and place the family at the center of the room where bioethics happens?
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Affiliation(s)
- Deborah R. Gordon
- Department of Humanities and Social Sciences, University of California, San Francisco, California, USA
| | - Barbara A. Koenig
- Department of Humanities and Social Sciences, University of California, San Francisco, California, USA
- Program in Bioethics, University of California, San Francisco, California, USA
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Morberg Jämterud S, Snoek A, van Langen IM, Verkerk M, Zeiler K. Qualitative study of GPs' views and experiences of population-based preconception expanded carrier screening in the Netherlands: bioethical perspectives. BMJ Open 2021; 11:e056869. [PMID: 34887284 PMCID: PMC8663082 DOI: 10.1136/bmjopen-2021-056869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Between 2016 and 2017, a population-based preconception expanded carrier screening (PECS) test was developed in the Netherlands during a pilot study. It was subsequently made possible in mid-2018 for couples to ask to have such a PECS test from specially trained general practitioners (GPs). Research has described GPs as crucial in offering PECS tests, but little is known about the GPs' views on PECS and their experiences of providing this test. This article presents a thematic analysis of the PECS practice from the perspective of GPs and a bioethical discussion of the empirical results. DESIGN Empirical bioethics. A thematic analysis of qualitative semi-structured interviews was conducted, and is combined with an ethical/philosophical discussion. SETTING The Netherlands. PARTICIPANTS 7 Dutch GPs in the Netherlands, interviewed in 2019-2020. RESULTS Two themes were identified in the thematic analysis: 'Choice and its complexity' and 'PECS as prompting existential concerns'. The empirical bioethics discussion showed that the first theme highlights that several areas coshape the complexity of choice on PECS, and the need for shared relational autonomous decision-making on these areas within the couple. The second theme highlights that it is not possible to analyse the existential issues raised by PECS solely on the level of the couple or family. A societal level must be included, since these levels affect each other. We refer to this as 'entangled existential genetics'. CONCLUSION The empirical bioethical analysis leads us to present two practical implications. These are: (1) training of GPs who are to offer PECS should cover shared relational autonomous decision-making within the couple and (2) more attention should be given to existential issues evoked by genetic considerations, also during the education of GPs and in bioethical discussions around PECS.
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Affiliation(s)
| | - Anke Snoek
- Department of Health, Ethics and Society, Maastricht University, Maastricht, The Netherlands
| | - I M van Langen
- Department of Genetics, University of Groningen, Groningen, The Netherlands
| | - Marian Verkerk
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kristin Zeiler
- Department of Thematic Studies, Linköping University, Linkoping, Sweden
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50
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Gómez-Vírseda C, Usanos RA. Relational autonomy: lessons from COVID-19 and twentieth-century philosophy. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2021; 24:493-505. [PMID: 34173944 PMCID: PMC8233626 DOI: 10.1007/s11019-021-10035-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 05/04/2023]
Abstract
COVID-19 has turned many ethical principles and presuppositions upside down. More precisely, the principle of respect for autonomy has been shown to be ill suited to face the ethical challenges posed by the current health crisis. Individual wishes and choices have been subordinated to public interests. Patients have received trial therapies under extraordinary procedures of informed consent. The principle of respect for autonomy, at least in its mainstream interpretation, has been particularly questioned during this pandemic. Further reflection on the nature and value of autonomy is urgently needed. Relational autonomy has been proposed as an alternative account of autonomy that can more adequately respond to contemporary ethical issues in general and to a pandemic such as the one we are currently facing in particular. As relational autonomy is an emerging notion in current bioethics, it requires further consideration and development to be properly operationalized. This paper aims to show how six different philosophical branches--namely, philosophy of nature, philosophical anthropology, existential phenomenology, discourse ethics, hermeneutics, and cultural anthropology--have incorporated the category of relation throughout the twentieth century. We first delve into primary philosophical sources and then apply their insights to the specific field of medical ethics. Learning from the historical developments of other philosophical fields may provide illumination that will enable bioethics to experience a successful "relational turn", which has been partially initiated in contemporary bioethics but not yet achieved.
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Affiliation(s)
- Carlos Gómez-Vírseda
- Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35/3, 3000 Louvain, Belgium
| | - Rafael Amo Usanos
- Bioethics Chair at the Universidad Pontificia Comillas, C/Universidad Comillas, 3, 28049 Madrid, Spain
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