Principlism and communitarianism

Principlism, Uncodifiability, and the Problem of Specification

In this paper I critically examine the implications of the uncodifiability thesis for principlism as a pluralistic and non-absolute generalist ethical theory. In this regard, I begin with a brief overview of W.D. Ross's ethical theory and his focus on general but defeasible prima facie principles before turning to 2) the revival of principlism in contemporary bioethics through the influential work of Tom Beauchamp and James Childress; 3) the widespread adoption of specification as a response to the indeterminacy of abstract general principles and the limitations of balancing and deductive approaches; 4) the challenges raised to fully specified principlism by the uncodifiability thesis and 5) finally offer a defense of the uncodifiability thesis against various critiques that have been raised.

Defending explicability as a principle for the ethics of artificial intelligence in medicine

The difficulty of explaining the outputs of artificial intelligence (AI) models and what has led to them is a notorious ethical problem wherever these technologies are applied, including in the medical domain, and one that has no obvious solution. This paper examines the proposal, made by Luciano Floridi and colleagues, to include a new 'principle of explicability' alongside the traditional four principles of bioethics that make up the theory of 'principlism'. It specifically responds to a recent set of criticisms that challenge the supposed need for such a principle to perform an enabling role in relation to the traditional four principles and therefore suggest that these four are sufficient without the addition of explicability. The paper challenges the critics' premise that explicability cannot be an ethical principle like the classic four because it is explicitly subordinate to them. It argues instead that principlism in its original formulation locates the justification for ethical principles in a midlevel position such that they mediate between the most general moral norms and the contextual requirements of medicine. This conception of an ethical principle then provides a mold for an approach to explicability on which it functions as an enabling principle that unifies technical/epistemic demands on AI and the requirements of high-level ethical theories. The paper finishes by anticipating an objection that decision-making by clinicians and AI fall equally, but implausibly, under the principle of explicability's scope, which it rejects on the grounds that human decisions, unlike AI's, can be explained by their social environments.

A blank check or a global public good? A qualitative study of how ethics review committee members in Colombia weigh the risks and benefits of broad consent for data and sample sharing during a pandemic

Broad consent for future use facilitates the reuse of participant-level data and samples, which can conserve limited resources by confirming research findings and facilitate the development and evaluation of public health and clinical advances. Ethics review committees (ERCs) have to balance different stakeholder concerns when evaluating the risks and benefits associated with broad consent for future use. In this qualitative study, we evaluated ERC members' concerns about different aspects of broad consent, including appropriate governance, community engagement, evaluation of risks and benefits, and communication of broad consent for future use in Colombia, which does not currently have national guidance related to broad consent for future use. We conducted semi-structured, in-depth interviews with 24 ERC members from nine Colombian ERCs. We used thematic analysis to explore ERC members' concerns related to broad consent for future use. Most ERC members expressed concern about the idea of not specifying the purposes for which data would be used and by whom and suggested that pre-specifying governance procedures and structure would address some of their concerns about broad consent. ERC members emphasized the need for engaging communities and ensuring research participants understood broad consent for future use-related language in informed consent forms. Researchers and research institutions are under increasing pressure to share public health-related data. ERC members play a central role in balancing the priorities of different stakeholders and maintaining their community's trust in public health research. Further work is needed on guidelines for developing language around broad consent, evaluating community preferences related to data sharing, and developing standards for describing governance for data or sample sharing in the research protocol to address ERC members' concerns around broad consent for future use.

The Nocebo Effect and Informed Consent-Taking Autonomy Seriously

The nocebo effect, a phenomenon whereby learning about the possible side effects of a medical treatment increases the likelihood that one will suffer these side effects, continues to challenge physicians and ethicists. If a physician fully informs her patient as to the potential side effects of a medicine that may produce nocebogenic effects, which is usually conceived of as being a requirement associated with the duty to respect autonomy, she risks increasing the likelihood that her patient will experience these side effects and therefore suffer (unnecessary) harm, a violation of the duty of nonmaleficence. If, on the other hand, she intentionally withholds side effect information in an effort to protect her patient from suffering unnecessary harm from side effects, which is consistent with the duty of nonmaleficence, she violates the duty to respect patient autonomy. In this paper, the author discusses several previous attempts to deal with the nocebo effect and explains their weaknesses. He then proposes a means of managing the nocebo effect and argues that it does not share the weaknesses found in previous approaches. He concludes with a discussion of a simple, yet practical tool that might help clinicians manage the tension resulting from the nocebo effect.

Cultivating conscience: Moral neurohabilitation of adolescents and young adults with conduct and/or antisocial personality disorders

Individuals diagnosed with conduct disorder (CD) in childhood and adolescence are at risk for increasingly maladaptive and dangerous behaviors, which unchecked, can lead to antisocial personality disorder (ASPD) in adulthood. Children with CD, especially those with the callous unemotional subgroup qualifier ("limited prosocial emotions"/DSM-5), present with a more severe pattern of delinquency, aggression, and antisocial behavior, all markings of prodrome ASPD. Given this recognized diagnostic trajectory, with a pathological course playing out tragically at the individual, familial, and societal level, and lack of effective remediation via current standards of care, we posit an alternate treatment approach; case-specific compulsory moral habilitation aimed at rectifying the undeveloped affective domain of adolescents and young adults suffering from these disorders. We begin with a brief historical overview of response to mental illness, review CD and ASPD diagnostic criteria and treatment limitations, and posit a unique neurohabilitative approach that focuses on the absent affective moral development of these populations. Next, we invoke a public health safety argument to justify case-specific compulsory moral habilitation, discuss neurotechnologies to be considered in treatment, and conclude with ethical considerations and suggestions for further research.

Beyond Money: Conscientious Objection in Medicine as a Conflict of Interests

Conflict of interests (COIs) in medicine are typically taken to be financial in nature: it is often assumed that a COI occurs when a healthcare practitioner's financial interest conflicts with patients' interests, public health interests, or professional obligations more generally. Even when non-financial COIs are acknowledged, ethical concerns are almost exclusively reserved for financial COIs. However, the notion of "interests" cannot be reduced to its financial component. Individuals in general, and medical professionals in particular, have different types of interests, many of which are non-financial in nature but can still conflict with professional obligations. The debate about healthcare delivery has largely overlooked this broader notion of interests. Here, we will focus on health practitioners' moral or religious values as particular types of personal interests involved in healthcare delivery that can generate COIs and on conscientious objection in healthcare as the expression of a particular type of COI. We argue that, in the healthcare context, the COIs generated by interests of conscience can be as ethically problematic, and therefore should be treated in the same way, as financial COIs.

Modeling Lay People's Ethical Attitudes to Organ Donation: A Q-Methodology Study

BACKGROUND

Organ donation is commonly evaluated by biomedical ethicists based largely on principlism with autonomy at the top of the "moral mountain." Lay people may differ in the way they invoke and balance the various ethical interests. We explored lay people's ethical attitudes to organ donation.

METHODS

Respondents (n=196) ranked 42 opinion-statements on organ donation according to a 9-category symmetrical distribution. Statements' scores were analyzed by averaging-analysis and Q-methodology.

RESULTS

Respondents' mean (SD) age was 34.5 (10.6) years, 53% were women, 69% Muslims (30% Christians), 29% Saudis (26% Filipinos), and 38% healthcare-related. The most-agreeable statements were "Acceptable if benefit to recipient large," "Explicit donor consent and family approval for live donation," "Acceptable if directed to family member," and "Explicit donor consent and family approval for postmortem donation." The most-disagreeable statements were "Donor consent and family approval not required for postmortem donation," "Acceptable with purely materialistic motivation," and "Only donor no-known objection for postmortem donation." Women, Christians, and healthcare respondents gave higher rank to "Explicit donor consent and family approval for live donation," "Only donor family consent required for postmortem donation," and "Acceptable if organ distribution equitable," respectively, and Muslims gave more weight to donor/family harm (p ≤0.001). Q-methodology identified various ethical resolution models that were associated with religious affiliation and included relatively "motives-concerned," "family-benefit-concerned," "familism-oriented," and "religious or non-religious altruism-concerned" models. Of 23 neutral statements on averaging-analysis, 48% and 65% received extreme ranks in ≥1 women and men Q-methodology models, respectively.

CONCLUSION

1) On average, recipient benefit, requirement of both explicit donor consent and family approval, donor-recipient relationship, and motives were predominant considerations; 2) ranking of some statements was associated with respondents' demographics; 3) Q-methodology identified various ethical resolution models that were partially masked by averaging-analysis; and 4) strong virtue and familism approaches in our respondents provide some empirical evidence against principlism adequacy.

Lay People's Ethical Attitudes To Placebo Treatment: A Q-Methodology Study

BACKGROUND

Placebo-treatment acceptability is debated among ethicists, mostly due to conflict between respect-to-autonomy and beneficence principles. It is not clear how lay people balance these and other ethical principles.

METHODS

One hundred and eighty-seven respondents rank-ordered 42 opinion statements covering various ethical aspects of placebo-treatment, according to a 9-category symmetrical distribution. We analyzed statements' scores using averaging-analysis and by-person factor analysis (Q-methodology).

RESULTS

Respondents' mean (SD) age was 34.6 (10.6) years, 54% were women, 40% healthcare-related, 68% Muslims (31% Christians), and 39% received general education in Saudi Arabia (24% in the Philippines). On averaging-analysis, the most-agreeable statements were "Acceptable if benefit to patient large" and "Acceptable with physician intent to benefit patient". The most-disagreeable statements were "Acceptable with physician self-benefit intent" and "Acceptable with large harm to other patients". Muslims gave a higher rank to "Giving no description is acceptable", "Acceptable with small benefit to patient", and "Acceptable with physician intent to benefit patient" and a lower rank to "Acceptable to describe as inactive drug", "Acceptable with physician intent to please patient caring relative", and "Acceptable with moderate harm to other patients" (p<0.01). Q-methodology detected several ethical attitude models that were mostly multi-principled and consequentialism-dominated. The majority of Christian and Philippines-educated women loaded on a "relatively family and deception-concerned" model, whereas the majority of Muslim and Saudi Arabia-educated women loaded on a "relatively common-good-concerned" model. The majority of Christian and healthcare men loaded on a "relatively deception-concerned" model, whereas the majority of Muslim and non-healthcare men loaded on a "relatively motives-concerned" model. Of nine intent-related statements, ≥2 received extreme rank on averaging-analysis and in 100% of women and men models.

CONCLUSION

1) On averaging-analysis, patient's beneficence (consequentialism) followed by physician's intent (virtue ethics) were more important than deception (respect-to-autonomy). 2) Q-methodology identified several ethical attitude models that were mostly multi-principled and associated with respondents' demographics.

Resolving Ethical Dilemmas in a Tertiary Care Veterinary Specialty Hospital: Adaptation of the Human Clinical Consultation Committee Model

Technological advances in veterinary medicine have produced considerable progress in the diagnosis and treatment of numerous diseases in animals. At the same time, veterinarians, veterinary technicians, and owners of animals face increasingly complex situations that raise questions about goals of care and correct or reasonable courses of action. These dilemmas are frequently controversial and can generate conflicts between clients and health care providers. In many ways they resemble the ethical challenges confronted by human medicine and that spawned the creation of clinical ethics committees as a mechanism to analyze, discuss, and resolve disagreements. The staff of the North Carolina State University Veterinary Hospital, a specialty academic teaching institution, wanted to investigate whether similar success could be achieved in the tertiary care veterinary setting. We discuss the background and rationale for this method, as well as the approach that was taken to create a clinical ethics committee.

Four Roles of Ethical Theory in Clinical Ethics Consultation

When clinical ethics committee members discuss a complex ethical dilemma, what use do they have for normative ethical theories? Members without training in ethical theory may still contribute to a pointed and nuanced analysis. Nonetheless, the knowledge and use of ethical theories can play four important roles: aiding in the initial awareness and identification of the moral challenges, assisting in the analysis and argumentation, contributing to a sound process and dialogue, and inspiring an attitude of reflexivity. These four roles of ethical theory in clinical ethics consultation are described and their significance highlighted, while an example case is used as an illustration throughout.

Issues on Luck Egalitarianism, Responsibility, and Intercultural Healthcare Policies

This article analyzes the criteria for the distribution of healthcare services through different justice theories such as utilitarianism and liberalism, pointing out the problems that arise when providing services to a culturally diverse population. The international epidemiological setting is a favorable one for discussing personal responsibility and luck egalitarianism; however, some provisions have to be made so that healthcare institutions do not treat ethnic, cultural, religious, and linguistic minorities unfairly. The article concludes by proposing that accommodations and culturally sensible attention should be provided when possible, without affecting the equal opportunity of others to access these services.

Caring for one and all - Exploring ethical challenges in an ICU

This discussion paper explores some of the complex ethical and moral issues confronting contemporary critical care nurses. In contemporary healthcare discussions, there is an increased appreciation of the complexity of ethical challenges, the multiplicity of stakeholders and that a broad range of possible and practical outcomes exist. Furthermore, many scholars also acknowledge the limitations of principle based ethical frameworks. In seeking to build critical care nurses' capacity to negotiate the complex - and often conflicting - ethical challenges, the authors have adopted a person-centred, values-based approach in this case study. Furthermore, by exploring these complex issues, this paper supports and builds upon critical care nurses' decision making capacities in the clinical area. This case study has been purposefully left open-ended with the aim of inviting the reader to consider the questions posed in a collegial, collaborative manner within the particular context in which she/he is embedded.

Autonomy as Ideology: Towards an Autonomy Worthy of Respect

Recent criticism of the role of respect for autonomy in bioethics has focused on that principle's status as ‘dogma’ or ‘ideology’. I suggest that lying beneath many applications of respect for autonomy in medical ethics are some influential dogmas — propositions accepted, not as explicit premises or as a consequence of reasoned argument, but simply because moral problems are so frequently framed in such terms. Furthermore, I will argue that rejecting these dogmas is vital to secure and protect an autonomy worthy of respect. The concept of autonomy that is widely applied in clinical ethics emphasises decision-making competence, at the expense of considering the authenticity of those decisions. Respect for such autonomy is interpreted in largely synchronic and individual terms — concerned with the isolated decisions of individual agents — and thus neglects the diachronic and social dimensions of many moral dilemmas arising in the health care context. I will examine how these unwritten rules lead to an impoverished understanding of respect and a systematic neglect in bioethics of certain kinds of ethical consideration, and draw on insights from feminist and communitarian work on autonomy to sketch an alternative approach to understanding respect, modelled on the norms of respectful conversation — a respect that is firstly concerned with engaging with the another as a potential giver and bearer or reasons, and working with them to promote both individual and social flourishing.

"I don't need my patients' opinion to withdraw treatment": patient preferences at the end-of-life and physician attitudes towards advance directives in England and France

This paper presents the results of a qualitative interview study exploring English and French physicians' moral perspectives and attitudes towards end-of-life decisions when patients lack capacity to make decisions for themselves. The paper aims to examine the importance physicians from different contexts accord to patient preferences and to explore the (potential) role of advance directives (ADs) in each context. The interviews focus on (1) problems that emerge when deciding to withdraw/-hold life-sustaining treatment from both conscious and unconscious patients; (2) decision-making procedures and the participation of proxies/relatives; (3) previous experience with ADs and views on their usefulness; and (4) perspectives on ways in which the decision-making processes in question might be improved. The analysis reveals differences in the way patient preferences are taken into consideration and shows how these differences influence the reasons physicians in each country invoke to justify their reluctance to adhering to ADs. Identifying cultural differences that complicate efforts to develop the practical implementation of ADs can help to inform national policies governing ADs and to better adapt them to practice.

[Re]considering Respect for Persons in a Globalizing World

Contemporary clinical ethics was founded on principlism, and the four principles: respect for autonomy, nonmaleficence, beneficence and justice, remain dominant in medical ethics discourse and practice. These principles are held to be expansive enough to provide the basis for the ethical practice of medicine across cultures. Although principlism remains subject to critique and revision, the four-principle model continues to be taught and applied across the world. As the practice of medicine globalizes, it remains critical to examine the extent to which both the four-principle framework, and individual principles among the four, suffice patients and practitioners in different social and cultural contexts. Using the four-principle model we analyze two accounts of surrogate decision making - one from the developed and one from the developing world - in which the clinician undertakes medical decision-making with apparently little input from the patient and/or family. The purpose of this analysis is to highlight challenges in assessing ethical behaviour according to the principlist model. We next describe cultural expectations and mores that inform both patient and clinician behaviors in these scenarios in order to argue that the principle of respect for persons informed by culture-specific ideas of personhood may offer an improved ethical construct for analyzing and guiding medical practice in a globalized and plural world.

Ethical issues regarding related and nonrelated living organ donors

The ethics of the clinical practice of transplanting human organs for end-stage organ disease is a fascinating topic. Who is the "owner" of the transplantable organs of a deceased, brain-dead patient? Who should have a right to receive these organs? Who set the boundaries between a living donor's autonomy and a "paternalistic" doctor? What constitutes a proper consent? These questions are only some of the ethical issues that have been discussed in the last 60 years. All of these ethical issues are intensified by the fact that supply of human organs does not match demand, and that, as a consequence, living-donor organ transplantation is widely utilized. The aim of this article is not to be exhaustive but to present the general ethical principles of beneficence, nonmaleficence, and justice as applied to organ transplantation. Moreover, the topic of reimbursement for organ donation is also discussed.

Effects of brain lesions on moral agency: ethical dilemmas in investigating moral behavior

Understanding how the "brain produces behavior" is a guiding idea in neuroscience. It is thus of no surprise that establishing an interrelation between brain pathology and antisocial behavior has a long history in brain research. However, interrelating the brain with moral agency--the ability to act in reference to right and wrong--is tricky with respect to therapy and rehabilitation of patients affected by brain lesions. In this contribution, we outline the complexity of the relationship between the brain and moral behavior, and we discuss ethical issues of the neuroscience of ethics and of its clinical consequences. First, we introduce a theory of moral agency and apply it to the issue of behavioral changes caused by brain lesions. Second, we present a typology of brain lesions both with respect to their cause, their temporal development, and the potential for neural plasticity allowing for rehabilitation. We exemplify this scheme with case studies and outline major knowledge gaps that are relevant for clinical practice. Third, we analyze ethical pitfalls when trying to understand the brain-morality relation. In this way, our contribution addresses both researchers in neuroscience of ethics and clinicians who treat patients affected by brain lesions to better understand the complex ethical questions, which are raised by research and therapy of brain lesion patients.

The right to life in a suicidal state

This paper considers when the State must take positive steps to protect the right to life of a suicidal patient. Using recent developments across the Council of Europe which challenge the traditional 'ugly Samaritan' approach of many common law systems, it contends that whenever and wherever public authorities know or ought to know of a real and immediate risk to the life of an identifiable person, they must take reasonable precautions to minimise it. Even J. S. Mill's approach to liberty, it is suggested, would tolerate this limited degree of State interference. However, notions of autonomy and dignity, the unpredictability of human behaviour, and the need to avoid unduly burdening the State must influence what it means to act reasonably.

Towards Principles-Based Approaches to Governance of Health-related Research using Personal Data

Technological advances in the quality, availability and linkage potential of health data for research make the need to develop robust and effective information governance mechanisms more pressing than ever before; they also lead us to question the utility of governance devices used hitherto such as consent and anonymisation. This article assesses and advocates a principles-based approach, contrasting this with traditional rule-based approaches, and proposes a model of principled proportionate governance. It is suggested that the approach not only serves as the basis for good governance in contemporary data linkage but also that it provides a platform to assess legal reforms such as the draft Data Protection Regulation.

Patient autonomy and choice in healthcare: self-testing devices as a case in point

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility.

New perspectives on the theory of justice: implications for physical therapy ethics and clinical practice

Recent revisions of physical therapy codes of ethics have included a new emphasis concerning health inequities and social injustice. This emphasis reflects the growing evidence regarding the importance of social determinants of health, epidemiological trends for health service delivery, and the enhanced participation of physical therapists in shaping health care reform in a number of international contexts. This perspective article suggests that there is a "disconnect" between the societal obligations and aspirations expressed in the revised codes and the individualist ethical frameworks that predominantly underpin them. Primary health care is an approach to health care arising from an understanding of the nexus between health and social disadvantage that considers the health needs of patients as expressive of the health needs of the communities of which they are members. It is proposed that re-thinking ethical frameworks expressed in codes of ethics can both inform and underpin practical strategies for working in primary health care. This perspective article provides a new focus on the ethical principle of justice: the ethical principle that arguably remains the least consensually understood and developed in the ethics literature of physical therapy. A relatively recent theory of justice known as the "capability approach to justice" is discussed, along with its potential to assist physical therapy practitioners to further develop moral agency in order to address situations of health inequity and social injustice in clinical practice.

Communitarianism and the ethics of communicable disease: some preliminary thoughts

Communicable diseases, especially those that are highly contagious, are on the rise and each of us, no matter who we are or where we live, is equally at risk of transmitting contagious diseases to others as we are of contracting such diseases from others. Because contagious diseases are as readily passed state-to-state as person-to-person, we all have a stake in every country's ability to enact effective infectious disease control policies, while policies grounded in shared values are more likely to gain widespread acceptance and thereby prove most effective. This paper suggests that principlism proved invaluable as an ethical framework for resolving hard medical cases and setting health care policy because it nicely "fits" dilemmas that arise in the context of the special relationship between doctors and patients or within family units. It then argues that communitarianism provides the better foundation for crafting infectious diseases control policies because contagious diseases, which often pass between perfect strangers, raise questions about the moral obligations we owe to (or are entitled to demand of) people with whom we share no "special" relationship. Accordingly, a socially embedded framework such as communitarianism may be a better fit for the more socially embedded ethical dilemmas of communicable diseases.

Professional ethics in pharmacy: the Australian experience

Objective

The profession of pharmacy has the unique characteristic of having both professional and business orientations. There is today, in addition to this unique characteristic, a strong shift in pharmacy towards more involvement in patient-centred health care, and increased emphasis on the patient's best interests and autonomy, within a framework of what is known as ‘bioethics’. With this shift of professional focus comes a heightened level of responsibility due to increased expectations of the patient and greater involvement in healthcare and decision making at a personal level with the patient. There is therefore inherent in this increased involvement an increased propensity for ethical problems to arise. The aim of this study is to investigate the application of ethical theory in the practice of pharmacy in New South Wales (NSW), Australia.

Method

Semi-structured interviews were carried out with 25 practitioners. The content of transcribed interviews was qualitatively analysed for emerging themes. Themes were identified by the primary researcher and independently validated by the other investigators.

Key findings

The majority of pharmacists interviewed in NSW Australia practised within a theoretical framework of ‘best interests of the patient’. Pharmacists experienced dilemmas in practice involving a number of ethical principles. Pharmacists relied on common sense to circumvent such dilemmas and never referred to their professional code of ethics. There appeared to be a general lack of training, and a varying perception of difficulty with decision making, regarding ethical dilemmas encountered, depending on issues such as legal requirements, personal opinions or financial demands.

Conclusion

Findings of this study indicated primarily that pharmacists in Australia regard the ethical principle of ‘best interest’ of the patient as the fundamental framework within which they practice. Pharmacists experience ethical dilemmas in practice, predominantly in the community setting, relying on logical reasoning, practical skills and personal morals to manage the situation, rather than consulting with a code of ethics. Also of significance in this study was the finding that financial pressure had a strong negative impact on the decision making and application of ethical principles of younger pharmacists in practice.

The ethics of anaesthesia learning curves

While the concept of the 'learning curve' is widely accepted and understood in medical education, the ethical appreciation of what this involves for patients has been under-represented in medical journals. Advances in medical technology have produced an armoury of diagnostic and therapeutic invasive procedures, which must be perfected by anaesthetists for the benefit of patients. Anaesthetic training involves practice using patients, which potentially exposes patients to excess procedural risk. However, such risk can be minimised through close supervision of trainees and the development of non-patient training aids. Most importantly, for training to be ethical, it must involve the patient: it is for patients to decide whether they consent to taking part in training and their consent should always be sought where possible.

Ethics in Canadian health technology assessment: A descriptive review

Background: Despite the mandate to examine the medical, ethical, and economic implications of the development and use of health technology, health technology assessment (HTA) reports often emphasize the epidemiologic and economic aspects, and omit ethical considerations. This study examines both whether and how ethical issues are incorporated into HTA.

Objectives: We aim to (i) review a set of Canadian HTA reports for ethics content, (ii) describe the strategies used to incorporate ethically relevant information into HTA, and (iii) determine the presence of implicit ethical issues in a sample of HTA reports.

Methods: Descriptive and qualitative content analysis of 608 HTA reports produced by six Canadian HTA agencies from January 1997 to December 2006.

Results: We found that (i) a minority (17 percent) of Canadian HTA reports addressed ethical issues, (ii) secondary research predominates while primary analysis is rare, (iii) implicit ethical issues are present in HTA reports that do not purport to address ethics.

Conclusions: Canadian HTA reports rarely explicitly, and then only superficially, address ethics, though implicit ethical issues abound.

Ethical issues related to BRCA gene testing in orthodox Jewish women

Persons exhibiting mutations in two tumor suppressor genes, BRCA1 and BRCA2, have a greatly increased risk of developing breast and/or ovarian cancer. The incidence of BRCA gene mutation is very high in Ashkenazi Jewish women of European descent, and many issues can arise, particularly for observant Orthodox women, because of their genetic status. Their obligations under the Jewish code of ethics, referred to as Jewish law, with respect to the acceptability of various risk-reducing strategies, may be poorly understood. In this article the moral direction that Jewish law gives to women regarding testing, confidentiality, and other issues is explored. The intent is to broaden nurses' knowledge of how a particular religious tradition could impact on decision making around genetics testing, with the aim of enhancing their understanding of culturally sensitive ethical care.

Is groin injecting an ethical boundary for harm reduction?

BACKGROUND

Femoral vein (or groin) injecting by street drug users is an emerging public health issue in the UK. It has been proposed that groin injecting is becoming normalised among UK injecting drug users (IDUs), yet harm reduction strategies are currently piecemeal and some may be crossing the boundary of responsible provision of information. This paper discusses the interventions available to service providers dealing with groin injecting and explores the utility of ethical frameworks for informing service provider decisions.

METHODS

Methods analysis of possible service provider responses using White and Popovits' ethical decision-making framework.

RESULTS

The use of ethical frameworks suggest that different types of groin injectors should receive different interventions. Injectors for whom the groin is a site of 'last resort' should be given information about how to inject there less dangerously, whereas 'convenience' groin injectors should be actively encouraged to inject elsewhere.

CONCLUSION

Groin injecting is a behaviour which represents a boundary for some harm reduction practices (such as providing 'how to' booklets to all injectors) as well as being an argument for more complex and environmentally appropriate harm reduction responses such as drug consumption rooms and training IDUs to maintain healthier injecting sites.

Overview of psychiatric ethics VI: newer approaches to the field

OBJECTIVE

The aim of this paper is to consider two recent approaches to moral philosophy - postmodernism and discourse ethics - and evaluate their potential contribution to psychiatric ethics.

CONCLUSION

Postmodern ethics arose from the perceived moral failures of the grand theories of ethics, as evident in the horrors of the twentieth century. As a result, such approaches to ethics emphasize the individual's moral situation in a particular context, such as the doctor-patient relationship. Postmodern approaches have some relevance to current and future psychiatric practice. Discourse ethics sees ethical norms generated by a process of a discourse procedure, in which all members of a discourse are able to express their views. Discourse ethics allows the generation of moral 'norms', which are universal in as far as all those affected by them can accept their consequences. Applied to professional ethics, psychiatrists are members of a large group engaged in a discourse with diverse parts of society, yet exist within small moral communities in which micro-discourses are compatible with different individual ethical positions.

Overview of psychiatric ethics III: principles-based ethics

OBJECTIVE

The aim of this paper is to consider the application of principle-based medical ethics to psychiatry.

CONCLUSIONS

Principles-based medical ethics is a useful tool for resolving ethical dilemmas in psychiatry in that clinical aspects of ethical dilemmas can be better articulated then in other methods . The ethical dilemmas unique to psychiatry, such as those related to impairment of autonomy, present a challenge to the method. After considering a case example, we conclude that psychiatrists can best utilise a principles based approach to ethical dilemmas when they combine this with a level of critical reflection in the light of other ethical theories, such as virtue ethics, as well as close consideration of the clinical and social context of the ethical dilemma.

Solidarity: a (new) ethic for global health policy

This article explores solidarity as an ethical concept underpinning rules in the global health context. First, it considers the theoretical conceptualisation of the value and some specific duties it supports (ie: its expression in the broadest sense and its derivative action-guiding duties). Second, it considers the manifestation of solidarity in two international regulatory instruments. It concludes that, although solidarity is represented in these instruments, it is often incidental. This fact, their emphasis on other values and their internal weaknesses diminishes the action-guiding impact of the solidarity rules. The global health and human subject research scene needs a completely new instrument specifically directed at means by which solidarity can be achieved, and a reformed infrastructure dedicated to realising that value.

Competent patients' refusal of nursing care

Competent patients' refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a 'negotiated reliance' response where nurses and others tread as lightly as possible on the patient's autonomy while negotiating a compromise, but are obligated to match the patient's sacrifice by extending themselves beyond their usual professional practice.

"It's like Tuskegee in reverse": a case study of ethical tensions in institutional review board review of community-based participatory research

Community-based participatory research (CBPR) addresses the social justice dimensions of health disparities by engaging marginalized communities, building capacity for action, and encouraging more egalitarian relationships between researchers and communities. CBPR may challenge institutionalized academic practices and the understandings that inform institutional review board deliberations and, indirectly, prioritize particular kinds of research. We present our attempt to study, as part of a CBPR partnership, cigarette sales practices in an inner-city community. We use critical and communitarian perspectives to examine the implications of the refusal of the university institutional review board (in this case, the University of California, San Francisco) to approve the study. CBPR requires expanding ethical discourse beyond the procedural, principle-based approaches common in biomedical research settings. The current ethics culture of academia may sometimes serve to protect institutional power at the expense of community empowerment.

Rights of and duties to non-consenting patients--informed refusal in the developing world

The principle of informed refusal poses a specific problem when it is invoked by a pregnant woman who, in spite of having accepted her pregnancy, refuses the diagnostic and/or therapeutic measures that would ensure the well-being of her endangered fetus. Guidelines issued by professional bodies in the developed world are conflicting: either they allow autonomy and informed consent to be overruled to the benefit of the fetus, or they recommend the full respect of these principles. A number of medical ethicists advocate the overruling of alleged irrational or unreasonable refusal for the benefit of the fetus. The present essay supports the view of fetal rights to health and to life based on the principle that an 'accepted' fetus is a 'third person'. In developing countries, however, the implementation of the latter principle is likely to be in conflict with a 'communitarian' perception of the individual -- in this case, the pregnant woman. Within the scope of the limitations to the right to autonomy of J.S. Mill's 'harm principle', the South African Patients' Charter makes provision for informed refusal. The fact that, in practice, it is not implemented illustrates the well-known difficulty of applying Western bioethical principles in real life in the developing world.