Beyond individualism: Is there a place for relational autonomy in clinical practice and research?

Should the family have a role in deceased organ donation decision-making? A systematic review of public knowledge and attitudes towards organ procurement policies in Europe

GOAL

To assess public knowledge and attitudes towards the family's role in deceased organ donation in Europe.

METHODS

A systematic search was conducted in CINHAL, MEDLINE, PAIS Index, Scopus, PsycINFO, and Web of Science on December 15th, 2017. Eligibility criteria were socio-empirical studies conducted in Europe from 2008 to 2017 addressing either knowledge or attitudes by the public towards the consent system, including the involvement of the family in the decision-making process, for post-mortem organ retrieval. Screening and data collection were performed by two or more independent reviewers for each record.

RESULTS

Of the 1482 results, 467 studies were assessed in full-text form, and 33 were included in this synthesis. When the deceased has not expressed any preference, a majority of the public support the family's role as a surrogate decision-maker. When the deceased expressly consented, the respondents' answers depend on whether they see themselves as potential donors or as a deceased's next-of-kin. Answers also depend on the relationship between the deceased and the decision-maker(s) within the family, and on their ethnic or cultural background.

CONCLUSIONS

Public views on the authority of the family in organ donation decision-making requiere further research. A common conceptual framework and validated well-designed questionnaires are needed for future studies. The findings should be considered in the development of Government policy and guidance regarding the role of families in deceased organ donation.

Definition and Recommended Cultural Considerations for Advance Care Planning in Japan: A Systematic Review

Although Delphi studies in Western countries have provided a consensus for practices pertaining to advance care planning (ACP), their findings may not be applicable to Asian countries with distinct, family-oriented cultures. This systematic review aimed to synthesize the definitions of and evidence for ACP and analyze recommended practices in Japan. We conducted a systematic review using narrative synthesis in December 2018. Key words were searched from Ichushi-Web by NPO Japan Medical Abstracts Society, Citation Information by the National Institute of Informatics, and Japanese Institutional Repositories Online databases. In addition, in August 2019, we conducted hand searching using Google Scholar and Google. We included original Japanese articles that addressed factors regarding ACP (e.g. definitions, elements, roles and tasks, and timing of ACP). Data were synthesized using thematic analysis. The study protocol was registered prospectively (PROSPERO: CRD42020152391). Of the 3,512 studies screened, 27 were included: 22 quantitative and 5 qualitative. Five-position statements/guidelines were added by hand searching. Definitions and several distinct practice patterns of ACP and the importance of families' roles were identified. Unique recommendations addressed the importance of properly eliciting patients' preferences that are the best for both patients and families, engaging the public to raise awareness of ACP, and developing policies and guidelines for ACP. We identified the definition of and unique recommendations for ACP based on Japanese cultural values and norms. Further research is needed to evaluate the recommendations provided in this systematic review.

The Lived Experience of Interdependence: Support Worker Relationships and Implications for Wider Rehabilitation

Engaging in a meaningful life where one can exercise autonomy has been proposed as a key aim of rehabilitation. Influenced by a neoliberal worldview, this has traditionally been characterised by a pursuit towards individual functional independence in which one completes tasks and activities unassisted. However for many persons, individual functional independence may not be a realistic, prioritised or beneficial goal. Many individuals must learn to work with support workers to exercise choice and control. Such relationships extend beyond a transactional nature and involve many subtle characteristics. In this article, I draw on my lived experience of partnering with support workers to illustrate the complexity of such relationships and how they can enable interdependence to serve as a vehicle to self-determination. I finish with some ideas about what rehabilitation can do to recognise the important role human connections play in facilitating interdependence. Understanding the nature of these relationships is necessary to provide services which value interdependence, supporting people to pursue a meaningful life following impairment.

Lived time and the affordances of clinical research participation

In this article, we address the problem of participation and the dominant focus on motivations in clinical research. We explore participation as a relational mode of 'being in time' in Alzheimer's dementia prevention-a field profoundly shaped by changing bodies through time, as well as promissory trends towards future-oriented preventative medicine. Analysis of interviews with older adults in a clinical trial platform demonstrates that what research 'does' or might (not) 'do' for participants emerges as temporalities of participants' everyday lives become entangled with the possibilities, constraints and demands of biomedical 'research time'. As well as consistent desires to help (future) others, we identify incidental possibilities for care that emerged from continued research participation. We argue that longitudinal research participation can productively be understood as a set of evolving affordances: whereby differing limits and possibilities for care and agency emerge in a world where dementia cannot be cured. Future trial participation is considered in terms of 'therapeutic affordances', which are likely to fluctuate as certain lived or imagined futures unfold. As such, we open up a conceptual space to think about why, how, and critically, when participation happens, as it emerges in relation to lived times of ageing and everyday life.

Update of the recommendations of the Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group for the approach to COVID-19 in Intensive Care Medicine

INTRODUCTION

The Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group have previously issued health service and management recommendations for critically ill patients with COVID-19. Due to the evolution of knowledge, the panel of experts was again convened to review the current evidence and issue updated recommendations.

METHODS

A national panel of experts who declared that they had no conflicts of interest regarding the development of the recommendations was assembled. Operational questions were developed based on the PICO methodology, and a rapid systematic review was conducted by consulting different bibliographic sources. The panel determined the direction and strength of the recommendations using two Delphi rounds, conducted in accordance with the principles of the GRADE system. A strong recommendation received the wording "is recommended", and a weak recommendation was written as "is suggested."

RESULTS

A total of 48 recommendations and 30 suggestions were issued, covering the following topics: diagnosis of SARS-CoV-2 infection, coinfection and superinfection; criteria for admission, cure and suspension of isolation; organization of services; personal protective equipment; and respiratory support and other specific therapies (antivirals, immunomodulators and anticoagulation).

CONCLUSION

These recommendations, specifically oriented to the Portuguese reality but that may also apply to Portuguese-speaking African countries and East Timor, aim to support health professionals in the management of critically ill patients with COVID-19. They will be continuously reviewed to reflect the progress of our understanding and the treatment of this pathology.

Analyzing the paradigmatic cases of two persons with a disorder of consciousness: reflections on the legal and ethical perspectives

BACKGROUND

Media have increasingly reported on the difficulties associated with end-of-life decision-making in patients with Disorders of Consciousness (DOC), contextualizing such dilemma in detailed accounts of the patient's life. Two of the first stories debated in the scientific community were those related to the cases of two women, one American, the other Italian, who captured attention of millions of people in the first years of this third millennium.

METHODS

Much has been written about the challenges of surrogate decision-making for patients in DOC, but less has been written comparing these challenges across legal systems and cultures. In our paper, we propose a systematic analysis of the final legal documents written by the American and Italian Courts in relation to the two cases, developing our discussion around three areas: the level of certainty/reliability of diagnosis and prognosis, the reconstruction of self-expression, time of illness and time of care. They are examples of the typical issues discussed by legal authors and allow us to understand the link and the difference between the legal and ethical perspectives.

RESULTS

The legal approach to the two cases has some common elements: the need to be certain about the diagnosis and prognosis and the fact that the clinical criteria are necessary in determining the most appropriate treatments, although these criteria are not sufficient unless they are supplemented by the patient's will. The issue of relations takes on importance both from a legal and an ethical point of view, but from two different perspectives. While ethics safeguards relationships by guaranteeing their differences and makes them reconcilable, law safeguards relationships by guaranteeing the cold forms of respect, equality, impartiality, symmetry, reciprocity, and irreversibility. In this perspective, the link between the time of care and the decision of the family members assumes importance.

CONCLUSIONS

The most interesting point that emerges from our analysis is the issue of relationships and how they affect decisions, both from a legal and ethical point of view. For this reason, during the patients' hospitalization, it is necessary to identify ways in which they might give their opinion about the moral issues underlying their choices.

Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns

Interest in maternal mental health research is growing around the world. Maternal mental health research studies in Malawi have, for instance, sought to determine and establish the incidence and prevalence of depression and anxiety in pregnant people and the factors that contribute to experiences of these states. This article reports stakeholder perspectives on potential community concerns with biopsychosocial mental health research (which might include collecting blood samples) in Malawi. These perspectives were generated through a town hall event that featured five focus group discussions with various participants. In this article, we reflect on key themes from these discussions, demonstrating the endurance of long-standing concerns and practices around autonomy, consent, and the drawing of blood. We conclude by arguing that, while maternal mental health research conducted in Malawi could benefit Malawian women and children, consultation with community stakeholders is necessary to inform whether and how such research should be conducted.

Societal perceptions of caregivers linked to culture across 20 countries: Evidence from a 10-billion-word database

Caregivers play an indispensable role in society. In 2017, 41 million family caregivers in the United States provided approximately 34 billion hours of care to their aging parents, spouses, partners and friends. The estimated economic value of their unpaid contributions amounted to $470 billion. Despite their invaluable contributions, caregivers often operate in a reality of inadequate social support. Little is known about the factors linked to the societal perceptions of caregivers, and our study seeks to contribute by filling this gap. Importantly, whether society honors or stigmatizes caregivers is critical as it could impact caregiving decisions and either exacerbate or ameliorate caregiver burden. We leveraged an online media database of 10 billion words collated from over 28 million articles, across 20 countries, to analyze societal perceptions of caregivers. Of the 20 countries, 18 evidenced neutral to positive perceptions of caregivers. Bangladesh and Ghana had the most positive perceptions, while Sri Lanka and Tanzania had the most negative perceptions. Aging demographics and culture (individualism, masculinity and uncertainty avoidance) were significantly associated with perceptions of caregivers. Findings suggest that positive perceptions of caregivers can be better cultivated when caring is lauded as a virtuous act that aids in reducing the care deficit. This study is among the first to analyze the societal perceptions of caregivers globally, and lays the groundwork to design culturally sensitive interventions that increase society's appreciation for caregivers.

Keeping institutional logics in arm’s length: emerging of rogue practices in a gray zone of everyday work life in healthcare

We set out to explore the practice-level cognitive structures and associated practices characterizing the daily routine work of physicians by conducting a qualitative study in the Turkish healthcare field, in which a recent government-led healthcare reform was implemented causing logic multiplicity. Contrary to the accumulated knowledge in institutional logics literature, a bulk of which suggests that actors craft and enact various practices in managing plural and at times conflicting institutional templates strictly within the confines of higher order societal logics, this study shows that while ground level actors may not exercise complete freedom and maneuverability in relation to pre-established social structures, they do incorporate unconventional schemas of action; namely rogue practices, into their embodied practical activity, which over time become routinized in their day-to-day work lives. Unraveling the dynamics of micro-level practices of highly professionalized ground level actors as they pertain to atypical logical orientations substantially advances our understanding of the unknown or unseen side of how and under which conditions certain or various combinations of institutional logics are employed during day-to-day activities.

Which ethical values underpin England's National Health Service reset of paediatric and maternity services following COVID-19: a rapid review

OBJECTIVE

To identify ethical values guiding decision making in resetting non-COVID-19 paediatric surgery and maternity services in the National Health Service (NHS).

DESIGN

A rapid review of academic and grey literature sources from 29 April to 31 December 2020, covering non-urgent, non-COVID-19 healthcare. Sources were thematically synthesised against an adapted version of the UK Government's Pandemic Flu Ethical Framework to identify underpinning ethical principles. The strength of normative engagement and the quality of the sources were also assessed.

SETTING

NHS maternity and paediatric surgery services in England.

RESULTS

Searches conducted 8 September-12 October 2020, and updated in March 2021, identified 48 sources meeting the inclusion criteria. Themes that arose include: staff safety; collaborative working - including mutual dependencies across the healthcare system; reciprocity; and inclusivity in service recovery, for example, by addressing inequalities in service access. Embedded in the theme of staff and patient safety is embracing new ways of working, such as the rapid roll out of telemedicine. On assessment, many sources did not explicitly consider how ethical principles might be applied or balanced against one another. Weaknesses in the policy sources included a lack of public and user involvement and the absence of monitoring and evaluation criteria.

CONCLUSIONS

Our findings suggest that relationality is a prominent ethical principle informing resetting NHS non-COVID-19 paediatric surgery and maternity services. Sources explicitly highlight the ethical importance of seeking to minimise disruption to caring and dependent relationships, while simultaneously attending to public safety. Engagement with ethical principles was ethics-lite, with sources mentioning principles in passing rather than explicitly applying them. This leaves decision makers and healthcare professionals without an operationalisable ethical framework to apply to difficult reset decisions and risks inconsistencies in decision making. We recommend further research to confirm or refine the usefulness of the reset phase ethical framework developed through our analysis.

The importance of living well now and relationships: A qualitative study of the barriers and enablers to engaging frail elders with advance care planning

BACKGROUND

The population of frail elders is growing, and due to their vulnerability to sudden deterioration, advance care planning is particularly important. However, advance care planning is uncommon for multiple reasons, some of which are linked to the perceptions of frail elders and their families.

AIM

To explore the barriers and enablers to advance care planning engagement with frail elders.

DESIGN

Qualitative in-depth interviews with thematic analysis.

SETTING/PARTICIPANTS

Purposive sample of 10 frail elders and 8 nominated family members using a community-based older persons' service run by a large urban UK hospice. Frail elders had capacity, were ⩾65 (median 85, range 71-95), scored 6 or 7 (median 6.5) on the Clinical Frailty Scale, and 70% were female.

RESULTS

Key barriers were: Advance care planning is unclear, in terms of meaning and the language used; Lack of relevance, with frail elders preferring to focus on living well now; and the Importance of family, relationships and home, and the influence of relationship on end of life decision-making. Engagement strategies included preparing the frail elder for advance care planning conversations and using a gentle, honest, individualised approach.

CONCLUSIONS

Essential enablers for frail elders are understanding what advance care planning is and why it may be relevant to them. For professionals, enablers include recognising the importance of living well now and relational decision-making. To further support advance care planning, recommendations include early engagement and re-conceptualising advance care planning as an ongoing process which encompasses current and future care. Further research is needed in different cultures and care contexts.

Constraints in Clinical Cardiology and Personalized Medicine: Interrelated Concepts in Clinical Cardiology

Systems biology is established as an integrative computational analysis methodology with practical and theoretical applications in clinical cardiology. The integration of genetic and molecular components of a disease produces interacting networks, modules and phenotypes with clinical applications in complex cardiovascular entities. With the holistic principle of systems biology, some of the features of complexity and natural progression of cardiac diseases are approached and explained. Two important interrelated holistic concepts of systems biology are described; the emerging field of personalized medicine and the constraint-based thinking with downward causation. Constraints in cardiovascular diseases embrace three scientific fields related to clinical cardiology: biological and medical constraints; constraints due to limitations of current technology; and constraints of general resources for better medical coverage. Systems healthcare and personalized medicine are connected to the related scientific fields of: ethics and legal status; data integration; taxonomic revisions; policy decisions; and organization of human genomic data.

Some Unresolved Ethical Challenges in Healthcare Decision-Making: Navigating Family Involvement

Family involvement in healthcare decision-making for competent patients occurs to varying degrees in many communities around the world. There are different attitudes about who should make treatment decisions, how and why. Legal and professional ethics codes in most jurisdictions reflect and support the idea that competent patients should be enabled to make their own treatment decisions, even if others, including their healthcare professionals, disagree with them. This way of thinking contrasts with some cultural norms that put more emphasis on the family as a decision-making entity, in some circumstances to the exclusion of a competent patient. Possible tensions may arise between various combinations of patient, family members and healthcare professionals, and healthcare professionals must tread a careful path in navigating family involvement in the decision-making process. These tensions may be about differences of opinion about which treatment option is best and/or on who should have a say or influence in the decision-making process. While some relevant cultural, legal and policy considerations vary from community to community, there are ethical issues that healthcare professionals need to grapple with in balancing the laws and professional codes on decision-making and the ethical principle of respecting patients and their autonomy. This paper will highlight and propose that a partial resolution to these issues may lie in relational understandings of autonomy, which in principle justify interventions by healthcare professionals and family that support patients in decision-making.

The promise of public health ethics for precision medicine: the case of newborn preventive genomic sequencing

Precision medicine aims to tailor medical treatment to match individual characteristics and to stratify individuals to concentrate benefits and avoid harm. It has recently been joined by precision public health-the application of precision medicine at population scale to decrease morbidity and optimise population health. Newborn preventive genomic sequencing (NPGS) provides a helpful case study to consider how we should approach ethical questions in precision public health. In this paper, I use NPGS as a case in point to argue that both precision medicine and precision public health need public health ethics. I make this argument in two parts. First, I claim that discussions of ethics in precision medicine and NPGS tend to focus on predominantly individualistic concepts from medical ethics such as autonomy and empowerment. This highlights some deficiencies, including overlooking that choice is subject to constraints and that an individual's place in the world might impact their capacity to 'be responsible'. Second, I make the case for using a public health ethics approach when considering ethics and NPGS, and thus precision public health more broadly. I discuss how precision public health needs to be construed as a collective enterprise and not just as an aggregation of individual interests. I also show how analysing collective values and interests through concepts such as solidarity can enrich ethical discussion of NPGS and highlight previously overlooked issues. With this approach, bioethics can contribute to more just and more appropriate applications of precision medicine and precision public health, including NPGS.

Honneth: Contribuições para o cuidar em enfermagem à luz do amor, direito e solidariedade

Introdução: Compreender a relação intersubjetiva que permeia o cuidado de enfermagem requer reconhecimento recíproco enfermeiro e paciente e/ou familiar. Para tanto, é necessário refletir sobre a construção do próprio ser humano consolidado no amor, no direito e na solidariedade. Objetivo: Refletir sobre o saber e fazer do cuidado de enfermagem a partir do respeito aos três padrões de reconhecimento conforme Honneth: amor, direito e solidariedade. Materiais e Métodos: Revisão integrativa da literatura, com busca nas bases de dados eletrônicas, nacionais e internacionais, a partir de descritores controlados e palavras relacionadas. Utilizou-se também a obra “Luta por Reconhecimento: a gramática moral dos conflitos sociais”. Resultados: Foram incluídos 16 artigos na revisão. Os resultados apontaram a práxis da enfermagem frente à escolha/recusa do cuidado respaldado no respeito mútuo, nas legalidades e nas reflexões frente à complexidade subjetiva do paciente e sua autonomia. Discussão: O amor, direito e solidariedade, compreendidos no processo de cuidado em enfermagem são vistos na literatura como uma construção história e social de reconhecimento mútuo, assim como relação intersubjetiva entre o profissional e o indivíduo, buscando estabelecer respeito à dignidade humana e à sua autonomia. Desrespeitar tais relações resultam em desumanização e desmoralização do sujeito. Conclusões: O respeito às dimensões do amor, direito e solidariedade contribuem para o reconhecimento do cuidado de enfermagem e autonomia do paciente.

The time has come to extend the 14-day limit

For the past 40 years, the 14-day rule has governed and, by defining a clear boundary, enabled embryo research and the clinical benefits derived from this. It has been both a piece of legislation and a rule of good practice globally. However, methods now allow embryos to be cultured for more than 14 days, something difficult to imagine when the rule was established, and knowledge gained in the intervening years provides robust scientific rationale for why it is now essential to conduct research on later stage human embryos. In this paper, I argue that the current limit for embryo research in vitro should be extended to 28 days to permit research that will illuminate our beginnings as well as provide new therapeutic possibilities to reduce miscarriage and developmental abnormalities. It will also permit validation of potentially useful alternatives. Through consideration of current ethical arguments, I also conclude that there are no coherent or persuasive reasons to deny researchers, and through them humanity, the knowledge and the innovation that this will generate.

What Should Clinicians Do When a Patient's Autonomy Undermines Her Being Treated Equitably?

Language and cultural barriers can impede communication between patients and clinicians, exacerbating health inequity. Additional complications can arise when family members, intending to protect their loved ones, ask clinicians to lie or not disclose to patients their diagnoses, prognoses, or intervention options. Clinicians must express respect for patients' and families' cultural, religious, and social norms regarding health care decision making, but they might also be ethically troubled by some decisions' effects on patients' health outcomes. This article suggests strategies for clinicians trying to overcome linguistic and cultural barriers to equitable patient care.

Liminal spaces in neurosurgery - tensions between expectations of the patient and their surgeon at the threshold of informed consent

Purpose: The concept of 'liminality', describing the universal human experience of transition in status, has been shown to be relevant in addressing the provision of healthcare needs within clinical medicine. Consent may be viewed as a threshold which patients must cross between a state of integration of information to a state of transformation into knowledge. This article reframes gaps in the modern surgical approach to the process of 'informed consent' via the lens of liminality, drawing on key illustrative cases from the medicolegal evolution in the UK and Commonwealth.Materials and methods: A focused literature search was performed for informative medical legal cases addressing or contributing to the understanding of "informed consent". Searches and references to sources of case law were performed using Westlaw and Hein Online databases. Searches for secondary sources for interpretation and discussions of case law and concepts, as well as topics of liminality and autonomy, were performed via PubMed and Academia databases and relevant online resources.Results: The paper organizes the illustrative material using the following approach:- a discussion and dissection of the i) evolution of consent as a duty to warn, comprising a summary of landmark cases, ii) materiality of risks and what a particular patient would wish to know and iii) conceptual relevance of troublesome knowledge, relational autonomy and threshold concepts in learning to key examples in case law and the process of informed consent.Conclusions: Modern surgical practice of informed consent must strive for clarity of mutual understanding. The framework of liminality allows us to understand the in-between states encountered during the patient's journey. An ability to recognize such gaps in expectations, and develop tools to promote transformational learning, would allow the surgeon to evolve from prudent practitioner to patient mentor at the threshold of informed consent.

Preferences on the Timing of Initiating Advance Care Planning and Withdrawing Life-Sustaining Treatment between Terminally-Ill Cancer Patients and Their Main Family Caregivers: A Prospective Study

Background: The Western individualistic understanding of autonomy for advance care planning is considered not to reflect the Asian family-centered approach in medical decision-making. The study aim is to compare preferences on timing for advance care planning initiatives and life-sustaining treatment withdrawal between terminally-ill cancer patients and their family caregivers in Taiwan. Methods: A prospective study using questionnaire survey was conducted with both terminally-ill cancer patient and their family caregiver dyads independently in inpatient and outpatient palliative care settings in a tertiary hospital in Northern Taiwan. Self-reported questionnaire using clinical scenario of incurable lung cancer was employed. Descriptive analysis was used for data analysis. Results: Fifty-four patients and family dyads were recruited from 1 August 2019 to 15 January 2020. Nearly 80% of patients and caregivers agreed that advance care planning should be conducted when the patient was at a non-frail stage of disease. Patients’ frail stage of disease was considered the indicator for life-sustaining treatments withdrawal except for nutrition and fluid supplements, antibiotics or blood transfusions. Patient dyads considered that advance care planning discussions were meaningful without arousing emotional distress. Conclusion: Patient dyads’ preferences on the timing of initiating advance care planning and life-sustaining treatments withdrawal were found to be consistent. Taiwanese people’s medical decision-making is heavily influenced by cultural characteristics including relational autonomy and filial piety. The findings could inform the clinical practice and policy in the wider Asia–Pacific region.

Physicians communicating with women at genetic risk of breast and ovarian cancer: Are we in the middle of the ford between contradictory messages and unshared decision making?

BRCA1/2 genetic testing offers tremendous opportunities for prevention, diagnosis and treatment of breast and ovarian cancer. Women acquire valuable information that can help them to make informed decisions about their health. However, knowing one's susceptibility to developing cancer may be burdensome for several women, as this risk needs to be managed over time through a continuous dialogue with multiple healthcare professionals. We explored how communication between physicians and unaffected women carrying BRCA1/2 germline pathogenic variants was experienced by women in relation to their genetic risk. Data came from qualitative interviews conducted in Switzerland with 32 unaffected women carrying BRCA1/2 pathogenic variants and aware of their genetic status for at least 3 years. We identified three different types of message as conveyed by physicians to women: (1) a normative message, (2) an over-empowering message, and (3) a minimizing message. On one hand, we found that women are exposed to contradictory messages, often simultaneously, in their interactions with healthcare professionals during their post-genetic testing journey. On the other hand, women's reports highlighted the absence of shared decision-making in such interactions. The combination of these two findings resulted in a strong sense of disorientation, frustration, and powerlessness among participants. Healthcare professionals interacting with high cancer risk women are urged to align in favor of a both concerted and shared decision-making approach when discussing options for managing genetic risk.

Autonomy in HIV testing: a call for a rethink of personal autonomy in the HIV response in sub-Saharan Africa

The author reviews various conceptions of autonomy to show that humans are actually not autonomous, strictly speaking. He argues for a need to rethink the personal autonomy approaches to HIV testing in sub-Saharan Africa (SSA) countries. HIV/AIDS has remained a leading cause of disease burden in SSA. It is important to bring this disease burden under control, especially given the availability of current effective antiretroviral regimens in low- and middle-income countries. In most SSA countries the ethic or value of personal autonomy or self-determination is promoted as primary in HIV testing decision-making. SSA policymakers have an ontological and moral duty to adopt HIV testing policies that reflect human and medical realities, relationships, local contexts, and respect human rights for both individuals and others who are affected by HIV in society. Without rethinking the value of autonomy in HIV testing decision-making, the article cautions that attainment of the Sustainable Development Goal (SDG) 3 and the UNAIDS fast-track strategy that explicitly call to end the epidemic by 2030 will not be feasible for SSA.

Understanding childbirth pain in Brazilian women: A qualitative descriptive study

BACKGROUND

The pain associated with childbirth is a cause of severe pain, and the literature suggests that it can be influenced by psychosocial influences, the environment, and cognitive processes, creating the overall experience of childbirth. Therefore, the investigation of women's childbirth pain experience is essential.

AIM

The purpose of this study is to understand women's childbirth pain and determine which influences can contribute to building different experiences.

METHOD

A qualitative descriptive approach was adopted to explore the women's childbirth pain experiences, by understanding the influences on their experiences. Data were collected through in-depth interviews with 21 women in a hospital setting in São Paulo, Brazil, and analysed by thematic analysis.

RESULTS

Three major themes emerged from the analysis: (1) experiencing childbirth pain, (2) face-to-face with pain, and (3) empowerment needs.

DISCUSSION

Many factors influence how Brazilian women manage pain and shape their experience during childbirth. The findings suggest that when women had a positive experience, they asked for minimal support, demonstrated balance, and expressed that the pain was manageable; when they had unfavourable experiences, they regarded pain as a threat and a punishment and associated it with unpleasant emotions.

CONCLUSION

The results outlined concerns that should be addressed in the provision of specific, appropriate care for women, to support them in improving their experience during childbirth.

Protective or connective professionalism? How connected professionals can (still) act as autonomous and authoritative experts

Traditionally, professionals such as medical doctors, lawyers, and academics are protected. They work within well-defined jurisdictions, belong to specialized segments, have been granted autonomy, and have discretionary spaces. In this way, they can be socialized, trained, and supervised, case-related considerations and decisions can be substantive (instead of commercial), and decisions can be taken independently. Ideally, these decisions are authoritative and accepted, both by clients as well as society (stakeholders) who trust professional services. This ideal-typical but also ‘ideal’ imagery always had its flaws; nowadays, shortcomings are increasingly clear. ‘Protective professionalism’ is becoming outdated. Due to heterogeneity and fragmentation within professional fields, the interweaving of professional fields, and dependencies of professional actions on outside worlds, professionals can no longer isolate themselves from others and outsiders. At first sight, this leads to a ‘decline’, ‘withering away’, or ‘hollowing out’ of professionalism. Or it leads to attempts to ‘reinstall’, ‘reinvent’, or ‘return to’ professional values and spaces. In this article, we avoid such ‘all or nothing’ perspectives on changing professionalism and explore the ‘reconfiguration’ of professionalism. Professional identities and actions can be adapted and might become ‘hybrid’, ‘organized’, and ‘connected’. Professional and organizational logics might be interrelated; professionals might see organizational (or organizing) duties as belonging to their work; and professional fields might open up to outside worlds. We particularly explore connective professionalism, arguing that we need more fundamental reflections and redefinitions of what professionalism means and what professionals are. We focus on the question of how professional action can be related to others and outsiders and remain ‘knowledgeable’, ‘autonomous’, and ‘authoritative’ at the same time. This can no longer be a matter of expertise, autonomy, and authority as fixed and closed entities. These crucial dimensions of professional action become relational and processual. They have to be enacted on a continuous basis, backed by mechanisms that make professionalism knowledgeable, independent, and authoritative in the eyes of others.

An instrument for assessing the quality of informed consent documents for elective procedures: development and testing

OBJECTIVE

To develop a nationally applicable tool for assessing the quality of informed consent documents for elective procedures.

DESIGN

Mixed qualitative-quantitative approach.

SETTING

Convened seven meetings with stakeholders to obtain input and feedback on the tool.

PARTICIPANTS

Team of physician investigators, measure development experts, and a working group of nine patients and patient advocates (caregivers, advocates for vulnerable populations and patient safety experts) from different regions of the country.

INTERVENTIONS

With stakeholder input, we identified elements of high-quality informed consent documents, aggregated into three domains: content, presentation and timing. Based on this comprehensive taxonomy of key elements, we convened the working group to offer input on the development of an abstraction tool to assess the quality of informed consent documents in three phases: (1) selecting the highest-priority elements to be operationalised as items in the tool; (2) iteratively refining and testing the tool using a sample of qualifying informed consent documents from eight hospitals; and (3) developing a scoring approach for the tool. Finally, we tested the reliability of the tool in a subsample of 250 informed consent documents from 25 additional hospitals.

OUTCOMES

Abstraction tool to evaluate the quality of informed consent documents.

RESULTS

We identified 53 elements of informed consent quality; of these, 15 were selected as highest priority for inclusion in the abstraction tool and 8 were feasible to measure. After seven cycles of iterative development and testing of survey items, and development and refinement of a training manual, two trained raters achieved high item-level agreement, ranging from 92% to 100%.

CONCLUSIONS

We identified key quality elements of an informed consent document and operationalised the highest-priority elements to define a minimum standard for informed consent documents. This tool is a starting point that can enable hospitals and other providers to evaluate and improve the quality of informed consent.

Surrogacy relationships: a critical interpretative review

Based on a critical interpretative review of existing qualitative research investigating accounts of 'lived experience' of surrogates and intended parents from a relational perspective, this article proposes a typology of surrogacy arrangements. The review is based on the analysis of 39 articles, which belong to a range of different disciplines (mostly sociology, social psychology, anthropology, ethnology, and gender studies). The number of interviews in each study range from as few as seven to over one hundred. Countries covered include Australia, Canada, Greece, India, Iran, Israel, Italy, Mexico, Norway, Russia, Sweden, UK, Ukraine, and the USA. Most studies focus only on surrogacy practices in one country (although often with intended parents from other countries), and some include several countries (e.g. interviewees from several countries or fieldwork in different field-sites). The proposed typology goes beyond the division between altruistic versus commercial, and traditional versus gestational surrogacy, in order to inform further research and to contribute to bioethical and policy debates on surrogacy in a transnational context. Four types of relations are identifiable: open, restricted, structured, and enmeshed. The criteria which influence these relationships are: the frequency and character of contact pre- and post-birth; expectations of both parties; the type of exchange involved in surrogacy arrangements; and cultural, legal, and economic contexts. The theoretical contribution of the article is to further the development of a relational justice approach to surrogacy.

Communicating genetic information to family members: analysis of consent forms for diagnostic genomic sequencing

Communicating results from genomic sequencing to family members can play an essential role allowing access to surveillance, prevention, treatment or prophylactic measures. Yet, many patients struggle with communication of these results and it is unclear to what extent this is discussed during the consent process. We conducted an online systematic search and used content analysis to explore how consent forms for genomic sequencing address communication of genetic information to family members. Our search yielded 68 consent forms from 11 countries. Although 57 forms alluded to the familial nature of results, forms varied in their discussion of the potential familial implications of results. Only 11 addressed communication of genetic information with family members, with differences in who would be responsible for this process. Several forms offered patients options regarding communication, even in countries where national guidelines and legislation allow for the disclosure of results in the absence of patient consent. These findings are concerning because they show how forms may potentially mislead patients and health care professionals about whether communication is permissible in cases where the patient does not consent. We suggest that providers and health care professionals reconsider how consent forms address communicating genetic information to family members.

The problem with reproductive freedom. Procreation beyond procreators' interests

Reproductive freedom plays a pivotal role in debates on the ethics of procreation. This moral principle protects people's interests in procreative matters and allows them discretion over whether to have children, the number of children they have and, to a certain extent, the type of children they have. Reproductive freedom's theoretical and political emphasis on people's autonomy and well-being is grounded in an individual-centred framework for discussing the ethics of procreation. It protects procreators' interests and significantly reduces the permissible grounds for interference by third parties. In this article I show that procreative decisions have far-reaching effects on the composition and size of the population. The upshot of considering these effects allows for the appreciation of the inadequacy of a framework that solely considers individual (i.e. procreators') interests to discuss the ethics of procreation. To address such inadequacy, I assess costs and benefits of past and present proposals to reflect on procreation in such a way as to consider its far-reaching effects. I conclude by arguing that reproductive freedom should be defended as an imperfect but instrumentally necessary tool. This framing would enable those participating in debates on the ethics of procreative decisions to work towards an ethical framework that accounts for the cumulative effects of these decisions.

Autonomy and its impact on midwifery practice

Objective

To explore the definition of autonomy, its significant features and impacts on midwifery practice.

Method

Combined keywords searched were performed on electronic databases: Scopus, Science Direct and Medline within EBSCOhost and Google Scholar. Data were extracted and analysed corresponding to the objectives of this review.

Findings

A total of eight studies (n=8) were included (one quantitative and seven qualitative). Autonomy is the central element in midwifery that is commonly linked with informed choices; decision-making and power to control over a situation. In order for a midwife to be autonomous, important attributes include knowledge and skills (being confident, and the ability to think critically). It was also found that infrastructure and culture at work impacts autonomy in midwifery practice.

Conclusion

Albeit a limited number of studies were included in the review, this review provides an important platform for understanding the principles and concepts that underpin autonomy in midwifery practice.

Rebuilding and guiding a care community: A grounded theory of end-of-life nursing care practice in long-term care settings

AIMS

To investigate the end-of-life (EOL) nursing care practice process in long-term care (LTC) settings for older adults in Japan.

DESIGN

A qualitative study based on grounded theory developed by Corbin and Strauss.

METHODS

Sampling, interviewing, and analysis were performed cyclically, with results for each stage used as the basis for data collection and next-stage analysis decisions. Semi-structured interviews were conducted from March 2015-March 2019 with 22 nurses from eight LTC settings. Analysis was performed using coding, constant comparison, and emerging categories.

RESULTS

The core category, "guiding the rebuilt care community to assist the dying resident" comprised five categories: "assessing the resident's stage," "harmonizing care with the dying process," "rebuilding a care community," "helping community members care for the resident," and "encouraging community members to give meaning." The participants were described as "traditional village elders" who were the integral members of the care community, as well as guides who helped and encouraged the community.

CONCLUSION

Results revealed the holistic process of EOL nursing-care practice in Japan. Nurses aimed to allow LTC residents to die as social human beings, surrounded by people, and not just responding physical and psychological distress. Such practice requires nursing expertise, healthcare skills, and leadership qualities to build and serve care communities. Nurses must also consider residents' uncertainties and vulnerabilities as well as their cultural backgrounds.

IMPACT

This study showed that the nurses hold unique roles in providing dying people with care from a community. These findings can potentially be applied for developing a universal model for LTC nurses in many aging populations, to modify their EOL care practice, educate new LTC nurses, and collaborate with other healthcare professionals.

From Expectations to Experiences: Consumer Autonomy and Choice in Personal Genomic Testing

Background: Personal genomic testing (PGT) offers individuals genetic information about relationships, wellness, sporting ability, and health. PGT is increasingly accessible online, including in emerging markets such as Australia. Little is known about what consumers expect from these tests and whether their reflections on testing resonate with bioethics concepts such as autonomy.Methods: We report findings from focus groups and semi-structured interviews that explored attitudes to and experiences of PGT. Focus group participants had little experience with PGT, while interview participants had undergone testing. Recordings were transcribed and analyzed using thematic analysis. Findings were critically interpreted with reference to bioethics scholarship on autonomy.Results: Fifty-six members of the public participated in seven focus groups, and 40 individuals were interviewed separately. Both groups valued the choice of PGT, and believed that it could motivate relevant actions. Focus group themes centered on the perceived value of choices, knowledge enabling action and knowledge about the self. Interview themes suggest that participants reflexively engage with their PGT information to make meaning, and that some appreciate its shortcomings. Critical interpretation of findings shows that while consumers of PGT are able to exercise a degree of autonomy in choosing, they may not be able to achieve a substantive conceptualization of autonomy, one that promotes alignment with higher-order desires.Conclusions: PGT consumers can critically reason about testing. However, they may uncritically accept test results, may not appreciate drawbacks of increased choice, or may overestimate the potential for information to motivate behavioral change. While consumers appear to be capable of substantive autonomy, they do so without ongoing support from companies. PGT companies promote a problematic ("default") account of autonomy, reliant on empowerment rhetoric. This leaves consumers vulnerable to making decisions inconsistent with their higher-order desires. As PGT expands, claims about its power and value need to be carefully drawn.

Self-care as care left undone? The ethics of the self-care agenda in contemporary healthcare policy

Self-care, or self-management, is presented in healthcare policy as a precursor to patient empowerment and improved patient outcomes. Alternatively, critiques of the self-care agenda suggest that it represents an over-reliance on individual autonomy and responsibility, without adequate support, whereby 'self-care' is potentially unachievable and becomes 'care left undone'. In this sense, self-care contributes to a blame culture where ill-health is attributed to personal behaviours or lack thereof. Furthermore, self-care may represent a covert form of rationing, as the fiscal means to enable effective self-care and supplement, or replace, self-care capacities, is not provided. This paper explores these arguments through a contemporary ethical analysis of the self-care agenda. The terms self-care and self-management are used interchangeably throughout whereby self-management is understood as a point in the wider self-care continuum.

The influence of values in shared (medical) decision making

Definition of the problem

The Shared Decision Making model is becoming increasingly popular also in the German-speaking context, but it only considers values of patients to be relevant for medical decisions. Nevertheless, studies show that the values of physicians are also influential in medical decisions. Moreover, physicians are often unaware of this influence, which makes it impossible to control it.

Arguments

The influence of both patients’ and physicians’ values is examined from an empirical and normative perspective. The review about the empirical data provides a necessary overview about the status quo, whereas I deduct rules for value-influenced behaviour in the decision making process in the normative approach. Therefore, different scenarios are taken into account to explore in which situations it is acceptable for physicians to let their values be part of the decision making process. The conscious use of values is only possible, when physicians are aware of their influence. To raise awareness, the best option would be to educate future physicians about it in their training. Therefore, this article provides a teaching concept for a unit that could be part of an ethics class for physicians in training. Furthermore, patient’s rights and responsibilities in the decision making process are discussed.

Conclusion

I conclude that it is necessary to take the influence of values (more) into account and include this knowledge into the training of physicians. Conclusively, recommendations for patients and physicians and their dealing with values in shared decision making processes are suggested.

Resisting big data exploitations in public healthcare: free riding or distributive justice?

We draw on findings from qualitative interviews with health data researchers, GPs and citizens who opted out from NHS England's care.data programme to explore controversies and negotiations around data sharing in the NHS. Drawing on theoretical perspectives from science and technology studies, we show that the new socio-technical, ethical and economic arrangements were resisted not only on the basis of individual autonomy and protection from exploitation, but also as a collective effort to protect NHS services and patient data. We argue that the resulting opt-outs were a call for more personal control over data use. This was not because these citizens placed their personal interests above those of society. It was because they resisted proposed arrangements by networks of stakeholders, not seen as legitimate, to control flows and benefits of NHS patient data. Approaching informed consent this way helps us to explore resistance as a collective action for influencing the direction of such big data programmes towards the preservation of public access to healthcare as well as the distribution of ethical decision-making between independent, trustworthy institutions and individual citizens.

Relational autonomy: what does it mean and how is it used in end-of-life care? A systematic review of argument-based ethics literature

BACKGROUND

Respect for autonomy is a key concept in contemporary bioethics and end-of-life ethics in particular. Despite this status, an individualistic interpretation of autonomy is being challenged from the perspective of different theoretical traditions. Many authors claim that the principle of respect for autonomy needs to be reconceptualised starting from a relational viewpoint. Along these lines, the notion of relational autonomy is attracting increasing attention in medical ethics. Yet, others argue that relational autonomy needs further clarification in order to be adequately operationalised for medical practice. To this end, we examined the meaning, foundations, and uses of relational autonomy in the specific literature of end-of-life care ethics.

METHODS

Using PRESS and PRISMA procedures, we conducted a systematic review of argument-based ethics publications in 8 major databases of biomedical, philosophy, and theology literature that focused on relational autonomy in end-of-life care. Full articles were screened. All included articles were critically appraised, and a synthesis was produced.

RESULTS

Fifty publications met our inclusion criteria. Twenty-eight articles were published in the last 5 years; publications were originating from 18 different countries. Results are organized according to: (a) an individualistic interpretation of autonomy; (b) critiques of this individualistic interpretation of autonomy; (c) relational autonomy as theoretically conceptualised; (d) relational autonomy as applied to clinical practice and moral judgment in end-of-life situations.

CONCLUSIONS

Three main conclusions were reached. First, literature on relational autonomy tends to be more a 'reaction against' an individualistic interpretation of autonomy rather than be a positive concept itself. Dichotomic thinking can be overcome by a deeper development of the philosophical foundations of autonomy. Second, relational autonomy is a rich and complex concept, formulated in complementary ways from different philosophical sources. New dialogue among traditionally divergent standpoints will clarify the meaning. Third, our analysis stresses the need for dialogical developments in decision making in end-of-life situations. Integration of these three elements will likely lead to a clearer conceptualisation of relational autonomy in end-of-life care ethics. This should in turn lead to better decision-making in real-life situations.

Is it acceptable to contact an anonymous egg donor to facilitate diagnostic genetic testing for the donor-conceived child?

We discuss a case where medically optimal investigations of health problems in a donor-conceived child would require their egg donor to participate in genetic testing. We argue that it would be justified to contact the egg donor to ask whether she would consider this, despite her indicating on a historical consent form that she did not wish to take part in future research and that she did not wish to be informed if she was found to be a carrier of a 'harmful inherited condition'. We suggest that we cannot conjecture what her current answer might be if, by participating in clinical genetic testing, she might help reach a diagnosis for the donor-conceived child. At the point that she made choices regarding future contact, it was not yet evident that the interests of the donor-conceived child might be compromised by her answers, as it was not foreseen that the egg donor's genome might one day have the potential to enable diagnosis for this child. Fertility consent forms tend to be conceptualised as representing incontrovertible historical boundaries, but we argue that rapid evolution in genomic practice means that consent in such cases is better seen as an ongoing and dynamic process. It cannot be possible to compel the donor to aid in the diagnosis of the donor-conceived child, but she should be given the opportunity to do so.

Consent and Autonomy in the Genomics Era

PURPOSE OF REVIEW

Genomic tests offer increased opportunity for diagnosis, but their outputs are often uncertain and complex; results may need to be revised and/or may not be relevant until some future time. We discuss the challenges that this presents for consent and autonomy.

RECENT FINDINGS

Popular discourse around genomic testing tends to be strongly deterministic and optimistic, yet many findings from genomic tests are uncertain or unclear. Clinical conversations need to anticipate and potentially challenge unrealistic expectations of what a genomic test can deliver in order to enhance autonomy and ensure that consent to genomic testing is valid.

SUMMARY

We conclude that 'fully informed' consent is often not possible in the context of genomic testing, but that an open-ended approach is appropriate. We consider that such broad consent can only work if located within systems or organisations that are trustworthy and that have measures in place to ensure that such open-ended agreements are not abused. We suggest that a relational concept of autonomy has benefits in encouraging focus on the networks and relationships that allow decision making to flourish.

Reconsidering the 'self' in self-management of chronic illness: Lessons from relational autonomy

Self-management is often presented as a panacea for chronic disease care. It plays an important role at the policy level and increasingly guides the delivery of health care services. Self-management approaches to care are founded on traditional individualistic views of autonomy in which the patient is understood as being independent, rational, self-interested, and self-governing. This conceptualization of autonomy has been challenged, particularly by feminist scholars. In this paper I review predominant critiques of self-management and the traditional individualistic view of autonomy. I propose that a relational approach to autonomy, which is premised on social embeddedness and attends to social, political, and material conditions, is a more sound conception of autonomy capable of taking into consideration the complexities of illness experiences. I suggest that integrating a relational perspective of autonomy into self-management will be valuable in guiding its progression and elaborate ways in which self-management research and practice could benefit from incorporating a relational approach to autonomy.

Research involving adults lacking capacity to consent: a content analysis of participant information sheets for consultees and legal representatives in England and Wales

BACKGROUND

Research involving adults who lack the capacity to provide informed consent can be challenging. In England and Wales there are legal provisions for consulting with others who know the person with impaired capacity. The role of the 'proxy' (or 'surrogate') is to advise researchers about the person's wishes and feelings or to provide consent on the person's behalf for a clinical trial of a medicine. Information about the study is usually provided to the proxy; however, little information is available to proxies about their role, or the appropriate legal and ethical basis for their decision, to help inform their decision-making. The aim of this study was to analyse the written information that is provided to consultees and legal representatives.

METHODS

Studies including adults lacking capacity to consent which utilised consultees or legal representatives were identified using the UK Clinical Trials Gateway database. A representative sample (n = 30) were randomly selected. Information sheets and other study documents provided to proxies were obtained, and relevant content was extracted. Content analysis was conducted through four stages: decontextualisation of the unit of analysis, recontextualisation, categorisation, and compilation. The data were summarised narratively according to each theme and category.

RESULTS

Considerable variation was found in the written information sheets provided to proxies. Most directed proxies to consider the wishes and feelings of the person who lacked capacity and to consult with others during the decision-making process. However, a small number of studies extended the scope of the proxy's role to consider the person's suitability or eligibility for the study. Particular discrepancies were found in information provided to those acting as consultees or legal representatives in a professional, as opposed to a personal, capacity. Incorrect uses of terminology were frequently found, and a small number of studies inaccurately interpreted the law.

CONCLUSIONS

Despite undergoing ethical review, study documents lacked essential information, incorrectly used terminology, and conflated professionals' clinical and representation roles. Future recommendations include ensuring proxies are provided with adequate and accurate information which complies with the legal frameworks. Further research is needed to explore the information and decision-making needs of those acting as consultees and legal representatives.

The involvement of family in the Dutch practice of euthanasia and physician assisted suicide: a systematic mixed studies review

BACKGROUND

Family members do not have an official position in the practice of euthanasia and physician assisted suicide (EAS) in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as a starting point for further empirical and ethical inquiry.

METHODS

A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies.

RESULTS

Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons (not) to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families' experiences and grief after EAS. 4) Family and 'the good euthanasia death' according to Dutch physicians.

CONCLUSION

Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making.

What deserves our respect? Reexamination of respect for autonomy in the context of the management of chronic conditions

The global increase in patients with chronic conditions has led to increased interest in ethical issues regarding such conditions. A basic biomedical principle-respect for autonomy-is being reexamined more critically in its clinical implications. New accounts of this basic principle are being proposed. While new accounts of respect for autonomy do underpin the design of many public programs and policies worldwide, addressing both chronic disease management and health promotion, the risk of applying such new accounts to clinical setting remain understudied. However, the application of new accounts of respect for autonomy to clinical settings could support disrespectful attitudes toward or undue interference with patients with chronic conditions. Reconsidering autonomy and respect using Kantian accounts, this paper proposes respect for persons as an alternative basic bioethical principle to respect for autonomy. Unlike the principle of respect for persons in the Belmont Report, our principle involves respecting any patient's decisions, behaviors, emotions, or life-style regardless of his or her "autonomous" capabilities. Thus, attitudes toward patients should be no different irrespective of the assessment of their decisional or executive capabilities.

Ethics as ritual: smoothing over moments of dislocation in biomedicine

Applications of biomedical R&D currently imply substantial societal concerns. This paper explores, based on semi-structured interviews with scientists in Norway, how biomedical researchers experience and tackle such concerns in their daily work. It shows how ritualised routine responses to dislocatory moments help maintain order in the daily work of the interviewed scientists; they do not address directly but instead smooth over concerns by a ritualised way of using ethics. This may foreclose substantive reflection and function as a stabiliser for 'business as usual'. Overall, the current way of responding to concerns as described by the interviewees may contribute to a depoliticisation of important issues. The paper contributes to sociological work on ethics by linking it to recent discussions on Responsible Research and Innovation (RRI) and by the empirical research presented. The insights can also help improve science policies such as RRI.

Korean Physicians' Perspectives on Prognostication in Palliative Care: A Qualitative Study

BACKGROUND

Prognostication is an essential component of palliative care for patients with advanced cancer but also poses challenges. Little is known about physicians' perspectives on prognostication and prognostic tools used in palliative care practice in Eastern countries.

OBJECTIVES

To explore Korean physicians' perspectives and experiences with prognostication in their palliative care practices.

METHODS

Semi-structured interviews were conducted in Korea in 11 palliative care physicians. A constant comparative and grounded theory approach was used to derive themes from interview transcripts.

RESULTS

Participants on average had 6.4 (SD = 4.5, range 0.5-15) years of hospice and palliative care experience. We identified 4 main themes about prognostication: (1) the importance of prognostication (to help patients and their families prepare for death, to determine the appropriate time of transition to hospice care, to facilitate appropriate decision making, and to facilitate communication with patients and their families); (2) difficulties of prognostication (discomfort estimating the exact date of death); (3) basis of prognostication (clinical prediction of survival as well as prognostic scores); and (4) areas for further research (need for a simpler scoring system or parameters to predict survival with greater certainty).

CONCLUSION

Palliative care physicians in Korea reported similar perceptions about the role and challenges inherent in prognostication compared to clinicians in Western cultures. However, they emphasize the need to predict final days to keep families with dying patients, reflecting family-centered aspects of Asian culture. They reported frustrations with inaccurate prognostication schemas and called for the development of simpler, more accurate predictors as a focus of future research.

New perspectives on substituted relational autonomy for shared decision-making in critical care

In critical care when unconscious patients are assisted by machines, humanity is mainly ensured by respect for autonomy, realised through advance directives or, mostly, reconstructed by cooperation with relatives. Whereas patient-centred approaches are widely discussed and fostered, managing communication in complex, especially end-of-life, situations in open intensive care units is still a point of debate and a possible source of conflict and moral distress. In particular, healthcare teams are often sceptical about the growing role of families in shared decision-making and their ability to represent patients’ preferences. New perspectives on substituted relational autonomy are needed for overcoming this climate of suspicion and are discussed through recent literature in the field of medical ethics.

Sociocultural determinants of nomadic women's utilization of assisted childbirth in Gossi, Mali: a qualitative study

BACKGROUND

In sub-Saharan Africa (SSA), nomads account for 30 to 60 million people. Their mobility, due to a constant search for pastures and water points, makes health services less accessible to them. Few nomadic women use assisted delivery, which increases the risk of maternal mortality. The reasons behind this limited use have been poorly documented. The objective of this study was to understand the sociocultural determinants of assisted childbirth by nomadic women.

METHODS

We conducted a qualitative research in the health area of Gossi (Mali), mainly populated by nomads. Data were collected through a literature review, 26 semi-structured interviews, a non-participant observation, and a logbook. Nomadic women who gave birth in the past three months were included in the study, whether they used assisted delivery or not. A thematic content analysis was performed with QDA Miner software.

RESULTS

The study identified a complex combination of determinants resulting in the use or non-use of assisted childbirth by the nomads of Gossi. Several participants recognized the value of assisted delivery but gave birth at home. They identified sociocultural determinants related to their representations and bodily experiences; the risks and emotions (fear, stress, anxiety) associated with pregnancy; the onset of labor and delivery; and their weak autonomy in terms of movement, decision-making, and economic agency. Nomadic women are not free in their movements, and in order to seek care, they require the permission and support of a man (husband, brother, or father). Furthermore, the participants are housewives, and men control family resources and make decisions regarding all financial matters. Assisted delivery is often only considered when there are complications.

CONCLUSION

This research has made it possible to understand the sociocultural determinants of the use of assisted childbirth among nomadic women, which should be taken into account when organizing health services for these populations.

Communication of Information about Genetic Risks: Putting Families at the Center

Genetic information is a family affair. With the expansion of genomic technologies, many new causal genes and variants have been established and the potential for molecular diagnoses increased, with implications not only for patients but also their relatives. The need for genetic counseling and intrafamilial circulation of information on genetic risks grew accordingly. Also, the amount and, particularly, the complexity of the information to convey multiplied. Sharing information about genetic risks with family members, however, has never been an easy matter and often becomes a source of personal and familial conflicts and distress. Ethical requisites generally prevent healthcare professionals from directly contacting their consultands' relatives (affected or still at risk), who often feel unsupported throughout that process. We discuss here the communication of genetic risks to family members. We first consider genomic testing as a basis for family-centered health care, as opposed to a predominant focus on the individual. We reviewed the literature on sharing genetic risk information with family members, and the associated ethical issues for professionals. Some clinical cases are presented and discussed, and key issues for meeting the needs of individuals and families are addressed. We argue that genetic information is inextricably linked to the family and that communicating about genetic risks is a process grounded within the broader milieu of family relationships and functioning. We conclude for the need for a more family-centered approach and interventions that can promote sensitive attitudes to the provision of genetic information to and within the family, as well as its inclusion in educational and training programmes for genetic healthcare professionals.

Advance Care Planning for Older People with Cancer and Its Implications in Asia: Highlighting the Mental Capacity and Relational Autonomy

With dramatically increasing proportions of older people, global ageing has remarkably influenced healthcare services and policy making worldwide. Older people represent the majority of patients with cancer, leading to the increasing demand of healthcare due to more comorbidities and inherent frailty. The preference of older people with cancer are often ignored, and they are considered incapable of making choices for themselves, particularly medical decisions. This might impede the provision of their preferred care and lead to poor healthcare outcomes. Advance care planning (ACP) is considered an effective intervention to assist older people to think ahead and make a choice in accordance with their wishes when they possess capacity to do so. The implementation of ACP can potentially lead to positive impact for patients and families. However, the assessment of mental capacity among older adults with cancer might be a crucial concern when implementing ACP, as loss of mental capacity occurs frequently during disease deterioration and functional decline. This article aims to answer the following questions by exploring the existing evidence. How does ACP develop for older people with cancer? How can we measure mental capacity and what kind of principles for assessment we should apply? What are the facilitators and barriers when implementing an ACP in this population? Furthermore, a discussion about cultural adaptation and relevant legislation in Asia is elucidated for better understanding about its cultural appropriateness and the implications. Finally, recommendations in relation to early intervention with routine monitoring and examination of capacity assessment in clinical practice when delivering ACP, reconciling patient autonomy and family values by applying the concept of relational autonomy, and a corresponding legislation and public education should be in place in Asia. More research on ACP and capacity assessment in different cultural contexts and policy frameworks is highlighted as crucial factors for successful implementation of ACP.