Developing a culturally relevant bioethics for Asian people

From the lab to the field: acceptability of using electroencephalography with Indian preschool children

Background: Measurement of social and cognitive brain development using electroencephalography (EEG) offers the potential for early identification of children with elevated risk of developmental delay. However, there have been no published reports of how acceptable EEG technology is to parents and children within communities, especially in low-resource contexts such as in low and middle income countries (LMICs), which is an important question for the potential scalability of these assessments. We use a mixed-methods approach to examine whether EEG assessments are acceptable to children and their caregivers in a low resource community setting in India. Methods: We assessed the acceptability of neurophysiology research and Braintools (a novel neurodevelopmental assessment toolkit using concurrent EEG and eye-tracking technology) using: 1) a child engagement measure, 2) interviews with caregivers (n=8); 3) survey about caregiver's experience (n=36). Framework analysis was used to analyse interview data. Results: A high level of child engagement in EEG tasks was demonstrated, with children's gaze at the screen during the task averaging at 85.4% (±12.06%) of the task time. External distractions and noise during the tasks were measured, but not found to significantly effect child's attention to the screen during EEG tasks. Key topics were examined using the framework analysis: 1) parental experience of the assessment; and 2) the acceptability of research. From topic 1, four sub-themes were identified: i) caregivers' experience of the assessment, ii) caregivers' perception of child's experience of assessment, iii) logistical barriers and facilitators to participation, and iv) recommendations for improvement. Results from interviews and the survey indicated acceptability for gaze-controlled EEG research for parents and children. From topic 2, three themes were identified: i) caregivers' understanding of the research, ii) barriers to participation, and iii) facilitators to participation. Barriers to participation mainly included logistical challenges, such as geographic location and time, whereas involvement of the wider family in decision making was highlighted as an important facilitator to partake in the research. Conclusions: We demonstrate for the first time the acceptability of conducting neurodevelopmental assessments using concurrent EEG and eye-tracking in preschool children in uncontrolled community LMIC settings. This kind of research appears to be acceptable to the community and we identify potential barriers and facilitators of this research, thus allowing for future large scale research projects to be conducted investigating neurodevelopment and risk factors for suboptimal development in LMICs.

A qualitative exploration of obtaining informed consent in medical consultations with Burma-born women

BACKGROUND

Conciliatory attitudes, respect for medical professionals and avoidance of being direct can make health consultations with Burma-born patients difficult to navigate. Coupled with linguistic barriers, this may make the sensitive nature of many women's health consultations challenging. Little is known about current practices for obtaining informed consent in this context. The objectives of this study were to explore current practices, barriers and strategies to obtaining informed consent in medical consultations with women born in Burma.

METHODS

Purposive and snowball sampling was used to recruit health practitioners (n =15, 2 male, 13 female) of different ages, years of professional experience, and country of origin, from clinics in Victoria that see a high volume of Burma-born patients. Thirty to sixty minute semi-structured interviews were conducted with four general practitioners, eight nurses and three interpreters, and de-identified audio recordings were transcribed for inductive thematic analysis.

RESULTS

Five key themes were generated: (1) cultural cognisance; (2) influence of community; (3) skilful navigation of communication; (4) favourable consultation attributes; and (5) individual tailoring of consent conversations. Differing cultural expectations, and linguistic and educational barriers, were highlighted as challenges to obtaining informed consent, whereas thoughtful utilisation of non-verbal communication, and intentional customisation of consent conversations were identified as facilitators.

CONCLUSION

The findings of this study provide practical ways to optimise the informed consent process within the Australian primary healthcare context, and reinforce that accepted Western-based practices for obtaining informed consent are not a 'one-size-fits-all' process.

Applying the good publication practice 2022 guidelines in the Asia-Pacific region: a practical guide

OBJECTIVE

The Asia-Pacific region (APAC) represents a unique environment for the publication of biomedical research, particularly industry-funded research. Awareness and adoption of international guidelines on ethical publication practices continues to increase across APAC, but the reframing and expansion of many of the recommendations in the Good Publication Practice (GPP) 2022 guidelines versus GPP3 published in 2015 have important implications for publishing industry-funded biomedical research in the region.

METHODS

This manuscript provides practical guidance for stakeholders in APAC on interpreting and applying the recommendations made in the GPP 2022 guidelines.

RESULTS

Key focus areas include navigating new opportunities for communicating industry-funded research, such as plain language summaries, social media, and preprints; implementing formal processes to improve the integrity of published research in APAC; and methods of promoting transparency and inclusion when publishing industry-funded research. Key APAC-specific issues, including encore presentations, leadership on publication ethics in the region, access to professional resources, and support for educating regional stakeholders are also discussed.

CONCLUSIONS

Overall, this manuscript offers a pragmatic guide for stakeholders in industry-sponsored research on applying GPP 2022 in practice with a focus on effectively integrating these guidelines in an APAC context.

What does family involvement in care provision look like across hospital settings in Bangladesh, Indonesia, and South Korea?

BACKGROUND

Family members provide care whilst staying in the patient's room across a range of cultural settings, irrespective of resource availability in many Asian countries. This has been reported as a contributing factor to the spread of several outbreaks, including COVID-19. Despite these reports, very little is known about the risk of healthcare-associated infection (HAI) transmission related to the involvement of family and private carers in the clinical setting. As a starting point to understanding this issue, this study aimed to provide insights regarding the patient care activities undertaken by family and private carers and the guidance provided to these carers around infection control measures in hospitals located in Bangladesh, Indonesia, and South Korea.

METHOD

A qualitative study involving 57 semi-structured interviews was undertaken in five tertiary level hospitals across the selected countries. Two groups of individuals were interviewed: (1) patients and their family carers and private carers; and (2) healthcare workers, including doctors, nurses, hospital managers and staff members. Drawing upon the principles of grounded theory, an inductive approach to data analysis using thematic analysis was adopted.

RESULTS

Five main themes were generated from the analysis of the data: (1) expectation of family carers staying with a patient; (2) residing in the patient's environment: (3) caring activities undertaken by family carers; (4) supporting and educating family carers and (5) communication around healthcare-associated infection and infection prevention and control.

CONCLUSION

Based on the types of activities being undertaken, coupled with the length of time family and private carers are residing within the clinical setting, coupled with an apparent lack of guidance being given around IPC, more needs to be done to ensure that these carers are not being inadvertently exposed to HAI's or other occupational risks.

From the lab to the field: acceptability of using electroencephalography with Indian preschool children

Background: Measurement of social and cognitive brain development using electroencephalography (EEG) offers the potential for early identification of children with elevated risk of developmental delay. However, there have been no published reports of how acceptable EEG technology is to parents and children within communities, especially in low-resource contexts such as in low and middle income countries (LMICs), which is an important question for the potential scalability of these assessments. We use a mixed-methods approach to examine whether EEG assessments are acceptable to children and their caregivers in a low resource community setting in India. Methods: We assessed the acceptability of neurophysiology research and Braintools (a novel neurodevelopmental assessment toolkit using concurrent EEG and eye-tracking technology) using: 1) a child engagement measure, 2) interviews with caregivers (n=8); 3) survey about caregiver’s experience (n=36). Framework analysis was used to analyse interview data. Results: Key topics were examined using the framework analysis: 1) parental experience of the assessment; and 2) the acceptability of research. From topic 1, four sub-themes were identified: i) caregivers’ experience of the assessment, ii) caregivers’ perception of child's experience of assessment, iii) logistical barriers and facilitators to participation, and iv) recommendations for improvement. From topic 2, three themes were identified: i) caregivers' understanding of the research, ii) barriers to participation, and iii) facilitators to participation. Conclusions: We demonstrate for the first time the acceptability of conducting neurodevelopmental assessments using concurrent EEG and eye-tracking in preschool children in uncontrolled community LMIC settings. This kind of research appears to be acceptable to the community and we identify potential barriers and facilitators of this research, thus allowing for future large scale research projects to be conducted investigating neurodevelopment and risk factors for suboptimal development in LMICs.

Examining the inclusion of patients and their family members in infection prevention and control policies and guidelines across Bangladesh, Indonesia, and South Korea

BACKGROUND

Although familial involvement during inpatient care is not uncommon in western countries, the types of caring activities that family members in Asian countries provide are significantly different. These activities may place the family member at risk from a health care-associated infection. This study aimed to examine whether the role of patients' families has been accounted for in the infection prevention and control (IPC) guidelines and policy, using examples from Bangladesh (low-income country), Indonesia (middle-income country), and South Korea (high-income country).

METHODS

The World Health Organization website and Institutional Repository for Information Sharing, Centers for Disease Control and Prevention website, Australian Government Web Archive, Open Grey, Grey Matters, World Bank, and advanced Google search, as well as the Health Department/Ministry of Health websites for each target country and 4 western countries (Australia, Canada, England, and the United States) were searched. Other databases, such as Embase, Medline, CINAHL, Global Health, ProQuest databases, Google scholar, Web of Science, and Scopus were also searched. This was to review the reflection of the cultural influence in IPC policies/guidelines by reviewing those from the global organizations, which are often used as a blueprint for policy development, as well as those from western countries, which hold different cultures in care arrangement. Search was conducted with attention to the key areas: definition and role of carer in the acute health care facility, involvement of patients/family members in IPC activities, patient and family member hand hygiene, and IPC education.

RESULTS

Ninety-two articles were identified based on the criteria for the study. Only 6 acknowledged that care is provided to hospitalized patients by their family members, and only 1 recommended that family members receive the same level of training as health care workers on IPC precautions. Other guides recommended the provision of information on IPC measures as means of patient involvement in the IPC program. Recognition of family caregivers or inclusion of them in the IPC strategies was not included in the target countries' guidelines.

CONCLUSIONS

Although health care workers are the primary actors when it comes to providing care in acute health care settings, it is important to expand the IPC guides by considering the role of other caregivers. Policies and guidelines should reflect the cultural influence over healthcare. This is especially true when cultural values strongly influence over healthcare arrangements and the healthcare accommodates these cultural influences in the practice. Further work needs to be undertaken on the level of training/education provided to family members in Bangladesh, Indonesia, and South Korea.

What Does It Mean for a Case to be 'Local'?: the Importance of Local Relevance and Resonance for Bioethics Education in the Asia-Pacific Region

Contemporary bioethics education has been developed predominately within Euro-American contexts, and now, other global regions are increasingly joining the field, leading to a richer global understanding. Nevertheless, many standard bioethics curriculum materials retain a narrow geographic focus. The purpose of this article is to use local cases from the Asia-Pacific region as examples for exploring questions such as 'what makes a case or example truly local, and why?', 'what topics have we found to be best explained through local cases or examples?', and 'how does one identify a relevant local case?' Furthermore, we consider the global application of local cases to help extend the possible scope of the discussion, opening new avenues for the development of practical bioethics educational materials. We begin with a background description and discussion of why local cases enhance bioethics education, move to an overview of what is currently available and what is not for the region, and then outline a discussion of what it means to be local using example cases drawn from Hong Kong, Australia, Pakistan, and Malaysia. We are not creating a casebook but rather constructing by example a toolbox for designing active and dynamic learning cases using regional diversity as contextualised cases with generalised principles.

Common medical ethical issues faced by healthcare professionals in KSA

Objective

There are growing concerns about ethical issues in the healthcare system. This study was conducted to determine the nature of common ethical issues faced by healthcare providers in a tertiary-care hospital in KSA.

Method

This cross-sectional study comprised a self-administered questionnaire given to the physicians working at King Abdulaziz Medical City Hospital-Riyadh, Ministry of National Guard Health Affairs (KAMC-RD, MNGHA). We used a convenience sampling technique during symposia and conferences.

Results

We distributed 240 questionnaires amongst the physicians and recorded a response rate of 80%; 68% (136) of the respondents were men, while 82.5% were Saudis. The mean age of the group was 34.08 ± 10.43 years. Only 69% (138) of the physicians had ever received any formal teaching in bioethics. Most physicians (77.5%) demanded clear guidelines to help them to take appropriate ethical decisions on therapeutic futility, whereas 54% felt that they sometimes overtreat their patients.

Conclusion

This study reported a lack of knowledge in certain healthcare-related ethical issues in a significant proportion of the physicians. There is a need for a standard educational agenda for medical ethics for healthcare providers, not only during medical school but also after graduation and during clinical rounds.

The Top 10 Ethical Challenges in Dental Practice in Indian Scenario: Dentist Perspective

Aim:

This exploratory qualitative research is an attempt to assess the health care ethical challenges in dental practice in an Indian scenario.

Methodology:

Qualitative indepth interview was conducted on 20 dental professionals to assess the ethical challenges prevailing in dental practice in Indian scenario. After obtaining the responses the verbatims were categorized into categories and finally 36 themes emerged. Later from two group of 6 panellists each after conducting focus group discussion the themes of ethical issues occurring in dental practice were ranked based on order of significance impact on the practice, patient and society using Delphi method.

Result:

The top ten ethical challenges listed by the panellists are inadequate sterilization and waste management in dental clinics, poor knowledge and attitude towards ethics among our dental practitioners, in competence among dental professional, increase in cost of oral health service, poor informed consent process, requirement of consensus about the treatment procedures among dentists, Conflict in Advertising, clustering of dental clinics in urban areas, disagreement with treatment modalities among dentist and patient, poor medical record maintenance among our dental practitioners.

Conclusion:

The study attempts to bring the prevailing ethical challenges in oral health care practice in Indian scenario.

A Question of Social Justice: How Policies of Profit Negate Engagement of Developing World Bioethicists and Undermine Global Bioethics

We identify the ways the policies of leading international bioethics journals limit the participation of researchers working in the resource-constrained settings of low- and middle-income countries (LMICs) in the development of the field of bioethics. Lack of access to essential scholarly resources makes it extremely difficult, if not impossible, for many LMIC bioethicists to learn from, meaningfully engage in, and further contribute to the global bioethics discourse. Underrepresentation of LMIC perspectives in leading journals sustains the hegemony of Western bioethics, limits the presentation of diverse moral visions of life, health, and medicine, and undermines aspirations to create a truly "global" bioethics. Limited attention to this problem indicates a lack of empathy and moral imagination on the part of bioethicists in high-income countries, raises questions about the ethics of bioethics, and highlights the urgent need to find ways to remedy this social injustice.

Beyond a Western Bioethics in Asia and Its Implication on Autonomy

Despite flourishing as a multidisciplinary subject, the predominant view in bioethics today is based on Anglo-American thought. This has serious implications for a global bioethics that needs to be contextualized to local cultures and circumstances in order to be relevant. Being the largest continent on the earth, Asia is home to a variety of cultures, religions and countries of different economic statuses. While the practice of medicine in the East and West may be similar, its ethical practices do differ. Thus, the Western understanding of autonomy may not be wholly applicable in the Asian setting, especially in the setting of breaking bad news, giving consent, determining best interests and deciding on end-of-life care. This article explores these topics in depth, attempting to find shared integrating factors, but at the same time arguing for a modified ethical application of autonomy, based on Asian beliefs.

Balancing cultural pluralism and universal bioethical standards: a multiple strategy

If we want to take firm the importance of universal principles in Bioethics, but at the same time we want to take seriously the importance of cultural diversity and pluralism, it is necessary to adopt a multifaceted approach. In the article I argue that a possible way out is a sort of hermeneutic approach, in order to reduce the ambivalence that stems from the dual recognition of cultural diversity and universal value of human rights. Through this approach conflicting principles and traditions can be harmonized within a common framework, at least to some extent. Such an approach, in my perspective, can be implemented as a strategy of interpretation, which can hold together different conceptions and common principles.

Vulnerability

Collating the concepts of vulnerability through five regional perspectives on bioethics from the United States, Europe, Latin America, Africa, and Asia, this article proposes a means of integration between the different approaches in order to seek a theoretical and normative basis for the field of global bioethics. It argues that only through opening continuous, critical, and self-critical dialogue within the international bioethical community will it be possible to achieve a sufficiently global understanding of vulnerability that is capable of identifying the means needed for addressing the conditions that leave certain groups and individuals more susceptible to “wounding” than others.

A workable model for the management of hyperglycemia in non-critically ill patients in an Asian population

OBJECTIVE

The clinical efficacy of applying a western model for managing hyperglycemia in hospitalized patients in Asia has not been studied.

METHODS

For this observational case-control study, we divided six medical wards into two groups, an intervention group and a control group. The intervention group, consisting three medical wards on the same floor, received care under a computer-assisted consulting model in which special care was automatically indicated for patients who had two successive high glucose measurements in 1 day. The control group, consisting of another three medical wards distributed on different floors, received regular care. Outcome measures were baseline and post-intervention patient-day weighted mean glucose, percentage of patient-day weighted glucose ≥180 mg/dL, proportion of glucose level 100-180 mg/dL, and prevalence of inpatient hyperglycemia (>180 mg/dL) and hypoglycemia (individual measurement <70 mg/dL and patient-day with any measurement <70 mg/dL).

RESULTS

At baseline, the patient-day weighted mean glucose level was 181.6 mg/dL. All parameters were comparable between the intervention and control groups with the exception of prevalence of hypoglycemia, which was found to be higher in the intervention group. After intervention, patient-day weighted mean glucose levels for intervention and control groups were 169.9 mg/dL and 176.7 mg/dL, respectively (p < 0.001). The intervention group had a reduction in hypoglycemia and the control group an increase.

CONCLUSION

This computer-assisted consulting model was found to be potentially very workable for the management of inpatient hyperglycemia in hospitals with high patient volumes in Asia.

Medical ethics in sub-Sahara Africa: closing the gaps

BACKGROUND

Health care providers are expected to have the skills and knowledge relevant to their field and should also be familiar with the ethical and legal expectations that arise out of the standard practices.

OBJECTIVES

To elucidate the practice of the health care providers in relation to healthcare ethics in Nigeria.

METHODS

A self-administered structured questionnaire was devised and distributed to staff of two tertiary health care facilities in Northern Nigeria. The questionnaire comprised of detailed questions regarding day-to-day aspects of Medical ethical issues.

RESULTS

A total of 307(76.2%) out of 403 health care providers responded to the questionnaire. The median age of the respondents was 34 years. More than half 168(54.7%) of the respondents disagreed as to whether "Ethical conduct is important only to avoid legal action. Many respondents 135 (44.0%) agreed to adhering to "patient's wishes", on the other hand over two-third of the respondents 211 (68.7%) agreed that "doctor should do what is best" irrespective of the patient's opinion. There were significant differences (p<0.05) between the perception of physicians and non-physicians on many ethical issues.

CONCLUSION

This study has shown gap in knowledge and practice of healthcare ethics among health care providers. There is a need for periodic education on clinical ethics in our hospitals.

Perspectives from South and East Asia on clinical and research ethics: a literature review

A review was conducted of English-language peer-reviewed and gray literature on health and ethics written by authors from Bangladesh, China, India, and Pakistan. This was supplemented by the knowledge of co-authors who are involved in bioethics capacity building in these countries. Of the identified literature that focused on the application of Western principles, it largely discussed informed consent and revealed norms in clinical decision-making that include physician paternalism, family involvement in decision-making, and reluctance to provide information that might upset patients. It appears that Western ethical principles may be interpreted and applied in unexpected ways. The literature further indicates that, although there is some consistency with Western ideas, Islamic, Confucian, and Indian religious and philosophical traditions contain concepts not reflected in international guidance. Findings suggest scholars from these countries seek to enter into a bioethics dialogue with the potential to enrich and inform "international" frameworks.

Should Patients and Family be Involved in "Do Not Resuscitate" Decisions? Views of Oncology and Palliative Care Doctors and Nurses

Background:

“Do not resuscitate” (DNR) orders are put in place where cardiopulmonary resuscitation is inappropriate. However, it is unclear who should be involved in discussions and decisions around DNR orders.

Aim:

The aim was to determine the views of oncology and palliative care doctors and nurses on DNR orders.

Materials and Methods:

A questionnaire survey was conducted on 146 doctors and nurses in oncology and palliative care working within a tertiary specialist cancer center in Singapore.

Results:

Perceived care differences as a result of DNR determinations led to 50.7% of respondents reporting concerns that a DNR order would mean that the patient received a substandard level of care. On the matter of DNR discussions, majority thought that patients (78.8%) and the next of kin (78.1%) should be involved though with whom the ultimate decision lay differed. There was also a wide range of views on the most appropriate time to have a DNR discussion.

Conclusions:

From the viewpoint of oncology and palliative care healthcare professionals, patients should be involved at least in discussing if not in the determination of DNR orders, challenging the norm of familial determination in the Asian context. The varied responses highlight the complexity of decision making on issues relating to the end of life. Thus, it is important to take into account the innumerable bio-psychosocial, practical, and ethical factors that are involved within such deliberations.

Religion and medical ethics

Religious traditions of medical ethics tend to differ from more secular approaches by stressing limitations on autonomous decision-making, by more positively valuing the experience of suffering, and by drawing on beliefs and values that go beyond empiric verification. I trace the impact of these differences for some of the world's great religious traditions with respect to four issues: (1) religious conscientious objection to medical treatments; (2) end-of life decision-making, including euthanasia, physician-assisted suicide, and the withholding or withdrawing of life-sustaining treatments; (3) definitions of moral personhood (defining life's beginning and end); and (4) human sexuality.

Respect for cultural diversity and the empirical turn in bioethics: a plea for caution

In the last two decades, there have been numerous calls for a culturally sensitive bioethics. At the same time, bioethicists have become increasingly involved in empirical research, which is a sign of dissatisfaction with the analytic methods of traditional bioethics. In this article, I will argue that although these developments have broadened and enriched the field of bioethics, they can easily be construed to be an endorsement of ethical relativism, especially by those not well grounded in academic moral philosophy. I maintain that bioethicists must resist the temptation of moving too quickly from cultural relativism to ethical relativism and from empirical findings to normative conclusions. Indeed, anyone who reasons in this way is guilty of the naturalistic fallacy. I conclude by saying that properly conceptualized, empirical research and sensitivity to cultural diversity should give rise to objective rational discourse and criticism and not indiscriminate tolerance of every possible moral practice. Bioethics must remain a normative discipline that is characterized by rigorous argumentation.

Factors influencing preferences of Korean people toward advance directives

Although Korean society has begun to seek a way of utilizing advance directives, there is not much known about the factors influencing the average Korean person's preference toward advance directives. The purpose of this study was to examine factors, in addition to demographic variables, influencing preferences regarding advance directives. These include: to what extent people's awareness of advance directives, preferences of extending their life at the end of life, experience of illness and medical care, and family functioning independently influence the preferences toward advance directives. The participants were 382 community-dwelling Korean people. The data analysis was performed using hierarchical multiple logistic regression analysis. The findings showed that a majority of Korean people had a positive preference on advance directives and the factors influencing their preferences for advance directives were the preferences against the use of life-sustaining treatment at the end of life, a good self-rated heath status, and an unsatisfactory family functioning.

Hypertension management: lifestyle interventions in a transcultural context

Hypertension is a risk factor for cardiovascular and kidney diseases. According to estimation, the prevalence of hypertension will increase unless extensive and effective preventive measures are implemented. The diversity of languages and cultures of the hypertensive patients requiring adequate blood pressure control make communications difficult in many instances. Nursing intervention for patients to adopt a healthy lifestyle requires effective communication. But the communication problems encountered in a culturally diverse context can result in undesirable outcomes for the patients and the health-care team. This paper describes the production of a document to assist staff address the difficulty in intercultural communication, which could be used anywhere in the world. This document can facilitate nursing intervention to achieve optimal hypertension management in a transcultural context, responding to the challenge regarding preventive measures to halt increase in hypertension prevalence.

Research ethics for mental health science involving ethnic minority children and youths

In response to U.S. Public Health Service projects promoting attention to disparities in the outcomes of mental health treatments, in July 2001, the American Psychological Association, the National Institute of Mental Health, and the Fordham University Center for Ethics Education convened a group of national leaders in bioethics, multicultural research, and ethnic minority mental health to produce a living document to guide ethical decision making for mental health research involving ethnic minority children and youths. This report summarizes the key recommendations distilled from these discussions.

The importance of patient autonomy at birth

It has always been recognised that the practice of medicine requires an ethical base. This ethical base also provides a backbone for a legal framework. Until recently paternalism was the accepted norm in the physician-patient relationship. Based on knowledge and experience the physician decided what treatment was in the best interests of the patient. However, in recent years medicine has changed from a predominantly paternalistic profession to one that is more patient centred. The physician informs and advises the patient but it is the patient who makes the decision. This is reflected in the change to principle-based medical ethics. The central concept in principle-based medical ethics is patient autonomy. This paper explores the application of autonomy and the legal requirement of informed consent to the clinical practice of obstetric anaesthesia. Autonomy requires that a patient has capacity to make a decision. Whether labouring women have capacity is discussed. There are times when patients are not able to act autonomously and the roles of advance directives (which can include birth plans) and substitute decision makers become important. The application of ethical practice to research in obstetric anaesthesia is considered.