Between professional values, social regulations and patient preferences: medical doctors' perceptions of ethical dilemmas

Moral distress among physicians in Norway: a longitudinal study

OBJECTIVES

To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses.

DESIGN

Longitudinal survey.

SETTING

Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021.

PARTICIPANTS

1499 physicians in 2004 and 2316 physicians in 2021.

MAIN OUTCOME MEASURES

The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work.

RESULTS

Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements.

CONCLUSION

In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

Analyzing the Evolution of Medical Ethics Education: A Bibliometric Analysis of the Top 100 Cited Articles

Ethics education plays a pivotal role in healthcare by providing professionals and students with the essential competencies to navigate intricate ethical challenges. This study conducts a comprehensive bibliometric analysis of the most-cited articles on ethics education, investigating parameters such as citation count, document types, geographical origin, journal analysis, publication year, author analysis, and keyword usage. The findings reveal a substantial impact characterized by high citation counts and the influence of a prominent publication focusing on the hidden curriculum and structure of medical education. Moreover, the analysis demonstrates a discernible increase in research output since 2000, signaling a growing recognition of the significance of ethics education in the healthcare domain. Notably, specific journals, particularly those dedicated to medical education and ethics, emerge as major contributors in this field, publishing many articles. Renowned authors have made noteworthy contributions, and emerging themes encompass the ethical implications of virtual reality and artificial intelligence in healthcare education. Additionally, undergraduate medical education garners significant attention, emphasizing the importance of establishing ethical values and professionalism early. Overall, this study highlights the imperative of interdisciplinary collaboration and the necessity for effective ethics education programs to equip healthcare professionals with the requisite skills to navigate complex ethical challenges. The findings inform educators, curriculum developers, and policymakers about enhancing ethics education and ensuring the ethical competence of future healthcare practitioners.

Psychiatric Hospital Ethics Committee Discussions Over a Span of Nearly Three Decades

Various types of health settings use clinical ethics committees (CEC) to deal with the ethical issues that confront both healthcare providers and their patients. Although these committees are now more common than ever, changes in the content of ethical dilemmas through the years is still a relatively unexplored area of research. The current study examines the major topics brought to the CEC of a psychiatric hospital in Israel and explores whether there were changes in their frequency across nearly three decades. The present paper reports on a thematic analysis of the written verbatim transcripts from 466 ethical topics brought to the CEC between the years 1991 and 2016. The following major topics related to ethical dilemmas were identified: confidentiality (30%), patient autonomy (23%), health records (14%), dual relationship (12%), allocation of resources (11%), inappropriate professional and personal conduct (9%), and multicultural sensitivity (1%). Topics related to confidentiality increased significantly over the years, as did inappropriate professional and personal conduct. In addition, the analysis showed that the content of the ethical cases and the resolutions suggested by the CEC also varied over the years. In conclusion, although most ethical topics have remained relatively stable over time, the discourse around them has evolved, requiring a dynamic assessment and reflection by the mental health practitioners serving as members of a CEC.

Guidelines and clinical priority setting during the COVID-19 pandemic - Norwegian doctors' experiences

BACKGROUND

In the first phase of the COVID-19 pandemic, strong measures were taken to avoid anticipated pressure on health care, and this involved new priorities between patient groups and changing working conditions for clinical personnel. We studied how doctors experienced this situation. Our focus was their knowledge about and adherence to general and COVID-19 specific guidelines and regulations on priority setting, and whether actual priorities were considered acceptable.

METHODS

In December 2020, 2 316 members of a representative panel of doctors practicing in Norway received a questionnaire. The questions were designed to consider a set of hypotheses about priority setting and guidelines. The focus was on the period between March and December 2020. Responses were analyzed with descriptive statistics and regression analyses.

RESULTS

In total, 1 617 (70%) responded. A majority were familiar with the priority criteria, though not the legislation on priority setting. A majority had not used guidelines for priority setting in the first period of the pandemic. 60.5% reported that some of their patients were deprioritized for treatment. Of these, 47.5% considered it medically indefensible to some/a large extent. Although general practitioners (GPs) and hospital doctors experienced deprioritizations equally often, more GPs considered it medically indefensible. More doctors in managerial positions were familiar with the guidelines.

CONCLUSIONS

Most doctors did not use priority guidelines in this period. They experienced, however, that some of their patients were deprioritized, which was considered medically indefensible by many. This might be explained by a negative reaction to the externally imposed requirements for rationing, while observing that vulnerable patients were deprioritized. Another interpretation is that they judged the rationing to have gone too far, or that they found it hard to accept rationing of care in general. Priority guidelines can be useful measures for securing fair and reasonable priorities. However, if the priority setting in clinical practice is to proceed in accordance with priority-setting principles and guidelines, the guidelines must be translated into a clinically relevant context and doctors' familiarity with them must improve.

Ethical challenges experienced by prehospital emergency personnel: a practice-based model of analysis

Background

Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. In prehospital emergency medicine, decision-making commonly takes place in everyday life, under time pressure, with limited information about a patient and with few possibilities of consultation with colleagues. This paper explores the ethical challenges experienced by prehospital emergency personnel.

Methods

The study was grounded in the tradition of action research related to interventions in health care. Ethical challenges were explored in three focus groups, each attended by emergency medical technicians, paramedics, and prehospital anaesthesiologists. The participants, 15 in total, were recruited through an internal information network of the emergency services. Focus groups were audio-recorded and transcribed verbatim.

Results

The participants described ethical challenges arising when clinical guidelines, legal requirements, and clinicians’ professional and personal value systems conflicted and complicated decision-making processes. The challenges centred around treatment at the end of life, intoxicated and non-compliant patients, children as patients—and their guardians, and the collaboration with relatives in various capacities. Other challenges concerned guarding the safety of oneself, colleagues and bystanders, prioritising scarce resources, and staying loyal to colleagues with different value systems. Finally, challenges arose when summoned to situations where other professionals had failed to make a decision or take action when attending to patients whose legitimate needs were not met by the appropriate medical or social services, and when working alongside representatives of authorities with different roles, responsibilities and tasks.

Conclusion

From the perspective of the prehospital emergency personnel, ethical challenges arise in three interrelated contexts: when caring for patients, in the prehospital emergency unit, and during external collaboration. Value conflicts may be identified within these contexts as well as across them. A proposed model of analysis integrating the above contexts can assist in shedding light on ethical challenges and value conflicts in other health care settings. The model emphasises that ethical challenges are experienced from a particular professional perspective, in the context of the task at hand, and in a particular, the organisational setting that includes work schedules, medical guidelines, legal requirements, as well as professional and personal value systems.

Enhancing patient safety by integrating ethical dimensions to Critical Incident Reporting Systems

BACKGROUND

Critical Incident Reporting Systems (CIRS) provide a well-proven method to identify clinical risks in hospitals. All professions can report critical incidents anonymously, low-threshold, and without sanctions. Reported cases are processed to preventive measures that improve patient and staff safety. Clinical ethics consultations offer support for ethical conflicts but are dependent on the interaction with staff and management to be effective. The aim of this study was to investigate the rationale of integrating an ethical focus into CIRS.

METHODS

A six-step approach combined the analysis of CIRS databases, potential cases, literature on clinical and organizational ethics, cases from ethics consultations, and experts' experience to construct a framework for CIRS cases with ethical relevance and map the categories with principles of biomedical ethics.

RESULTS

Four main categories of critical incidents with ethical relevance were derived: (1) patient-related communication; (2) consent, autonomy, and patient interest; (3) conflicting economic and medical interests; (4) staff communication and corporate culture. Each category was refined with different subcategories and mapped with case examples and exemplary related ethical principles to demonstrate ethical relevance.

CONCLUSION

The developed framework for CIRS cases with its ethical dimensions demonstrates the relevance of integrating ethics into the concept of risk-, quality-, and organizational management. It may also support clinical ethics consultations' presence and effectiveness. The proposed enhancement could contribute to hospitals' ethical infrastructure and may increase ethical behavior, patient safety, and employee satisfaction.

Ethics Consultations at a Major Academic Medical Center: A Retrospective, Longitudinal Analysis

BACKGROUND

Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern.

METHODS

The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests.

RESULTS

Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (β = 0.7, 95% CI = 0.2-1.2, p = 0.008) and Discharge Planning (β = 2.2, 95% CI = 1.4-3.1, p < 0.001), and a trend toward increased number of consults for behavior-related consults from nurses (median 6.5% versus 2.3%, p = 0.07) were noted. Nurses were significantly more likely than physicians to request ethics consultation for Communication (yearly median 10.4% of cases vs 1.3% of cases, p = 0.01), whereas, physicians were significantly more likely to request ethics consultation for Proxy Decision-Making than nurses (yearly median 26.0% of cases vs 13.0%, p = 0.005) and for Decision-Making Capacity (yearly median 7.5% of cases vs 4.0%, p = 0.04).

CONCLUSIONS

This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.

Do you recommend cancer screening to your patients? A cross-sectional study of Norwegian doctors

OBJECTIVE

Guidelines for cancer screening have been debated and are followed to varying degrees. We wanted to study whether and why doctors recommend disease-specific cancer screening to their patients.

DESIGN

Our cross-sectional survey used a postal questionnaire. The data were examined with descriptive methods and binary logistic regression.

SETTING

We surveyed doctors working in all health services.

PARTICIPANTS

Our participants comprised a representative sample of Norwegian doctors in 2014/2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is whether doctors reported recommending their patients get screening for cancers of the breast, colorectum, lung, prostate, cervix and ovaries. We examined doctors' characteristics predicting adherence to the guidelines, including gender, age, and work in specialist or general practice. The secondary outcomes are reasons given for recommending or not recommending screening for breast and prostate cancer.

RESULTS

Our response rate was 75% (1158 of 1545). 94% recommended screening for cervical cancer, 89% for breast cancer (both established as national programmes), 42% for colorectal cancer (upcoming national programme), 41% for prostate cancer, 21% for ovarian cancer and 17% for lung cancer (not recommended by health authorities). General practitioners (GPs) adhered to guidelines more than other doctors. Early detection was the most frequent reason for recommending screening; false positives and needless intervention were the most frequent reasons for not recommending it.

CONCLUSIONS

A large majority of doctors claimed that they recommended cancer screening in accordance with national guidelines. Among doctors recommending screening contrary to the guidelines, GPs did so to a lesser degree than other specialties. Different expectations of doctors' roles could be a possible explanation for the variations in practice and justifications. The effectiveness of governing instruments, such as guidelines, incentives or reporting measures, can depend on which professional role(s) a doctor is loyal to, and policymakers should be aware of these different roles in clinical governance.