Clinical Ethics Consultations and the Necessity of NOT Meeting Expectations: I Never Promised You a Rose Garden

Clinical ethics consultants (CECs) work in complex environments ripe with multiple types of expectations. Significantly, some are due to the perspectives of professional colleagues and the patients and families with whom CECs consult and concern how CECs can, do, or should function, thus adding to the moral complexity faced by CECs in those particular circumstances. We outline six such common expectations: Ethics Police, Ethics Equalizer, Ethics Superhero, Ethics Expediter, Ethics Healer or Ameliorator, and, finally, Ethics Expert. Framed by examples of requests for ethics consultation that illustrate each kind, along with brief descriptions, we argue that while these expectations ought to be resisted for clear and practical reasons, they also create opportunities for CECs to articulate, educate, and ultimately be responsible to the professional demands of clinical ethics work. Recognizing, acknowledging, and at times resisting those expectations thus become key activities and responsibilities in the performance of ethics consultation.

The Future Ethics of Artificial Intelligence in Medicine: Making Sense of Collaborative Models

This article examines the role of medical doctors, AI designers, and other stakeholders in making applied AI and machine learning ethically acceptable on the general premises of shared decision-making in medicine. Recent policy documents such as the EU strategy on trustworthy AI and the research literature have often suggested that AI could be made ethically acceptable by increased collaboration between developers and other stakeholders. The article articulates and examines four central alternative models of how AI can be designed and applied in patient care, which we call the ordinary evidence model, the ethical design model, the collaborative model, and the public deliberation model. We argue that the collaborative model is the most promising for covering most AI technology, while the public deliberation model is called for when the technology is recognized as fundamentally transforming the conditions for ethical shared decision-making.

Medical and Legal Aspects of the Practice of Teledermatology in Spain

Teledermatology is now fully incorporated into our clinical practice. However, after reviewing current legislation on the ethical aspects of teledermatology (data confidentiality, quality of care, patient autonomy, and privacy) as well as insurance and professional responsibility, we observed that a specific regulatory framework is still lacking and related legal aspects are still at a preliminary stage of development. Safeguarding confidentiality and patient autonomy and ensuring secure storage and transfer of data are essential aspects of telemedicine. One of the main topics of debate has been the responsibilities of the physicians involved in the process, with the concept of designating a single responsible clinician emerging as a determining factor in the allocation of responsibility in this setting. A specific legal and regulatory framework must be put in place to ensure the safe practice of teledermatology for medical professionals and their patients.

Emerging challenges in AI and the need for AI ethics education

Artificial Intelligence (AI) is reshaping the world in profound ways; some of its impacts are certainly beneficial but widespread and lasting harms can result from the technology as well. The integration of AI into various aspects of human life is underway, and the complex ethical concerns emerging from the design, deployment, and use of the technology serves as a reminder that it is time to revisit what future developers and designers, along with professionals, are learning when it comes to AI. It is of paramount importance to train future members of the AI community, and other stakeholders as well, to reflect on the ways in which AI might impact people's lives and to embrace their responsibilities to enhance its benefits while mitigating its potential harms. This could occur in part through the fuller and more systematic inclusion of AI ethics into the curriculum. In this paper, we briefly describe different approaches to AI ethics and offer a set of recommendations related to AI ethics pedagogy.

A balanced approach to decision-making in supporting people with IDD in extraordinarily challenging times

A balanced approach to decision-making during challenging times is necessary in order to avoid risks that jeopardize the lives and wellbeing of people with intellectual and developmental disabilities (IDD). The COVID-19 pandemic is the recent example of a crisis that places people with IDD at risk for lopsided societal reactions and threats to them or their wellbeing. Attention to decision-making is required to safeguard hard-earned achievements, including public policies and organization practices that emphasize human and legal rights, self-advocacy, individualized supports, inclusive environments, choices, and community inclusion. We suggest maintaining a holistic approach to understanding the lives and human functioning of people with IDD, a balanced approach to accountability and performance management, an understanding of the multidimensional properties of context, and a heightened vigilance in professional responsibility. A balanced approach will strengthen the likelihood of a return to high quality services and supports to people after the crisis, reduce loss of critical progress, and enhance stability across future social, political, and financial changes and challenges.

[The responsibilities arising from the use of information and communication technologies in health professional practice]

The increasing use of Information and Communication Technologies (ICT) in the health setting has given rise to the current phenomenon of eHealth or eMedicine, terms equivalent to the cyberspace concept, but refer exclusively to health. Due to the appearance of Web 2.0 it can be stated that we are dealing with a phenomenon much greater than just using the technologies: we are facing a real social change, giving rise to that called Health 2.0. The legal regulation of this cyberspace requires two different types of rules. Some that regulate cyberspace itself, and others, the actions performed with its use and to those that appear applicable to conventional law. In this latter case, we are referring to the applying of already existing laws to actions performed using ICT, as is the case of medical actions. Within these latter situations, two clearly different ones have to be distinguished: the professional responsibilities arising from medical actions carried out within health organisation settings when the use of ICT is introduced, and those other actions carried out voluntarily, individually and privately, using personal media and devices. It is in these types of actions where the legality, as regards data protection and privacy of the patient, appears to be violated, and at the same time the professional may be held responsible.

Conflicts of interest in medicine. CETREMI recommendations

Conflicts of interest are situations in which judgment and integrity of medical decisions or actions are influenced by a secondary interest, often of an economic nature. The Committee of Ethics and Transparency in the Physician-Industry Relationship of the National Academy of Medicine of Mexico recognizes that these conflicts occur in health professionals' daily life, but also in public and private institutions that provide health services, as well as in the academy and in research activities. Therefore, it is necessary to identify conflicting situations and always act in accordance with the patient's interest.

Conflictos de intereses en medicina. Recomendaciones del CETREMI

Conflicts of interest are situations in which judgment and integrity of medical decisions or actions are influenced by a secondary interest, often of an economic nature. The Committee of Ethics and Transparency in the Physician-Industry Relationship of the National Academy of Medicine of Mexico recognizes that these conflicts occur in health professionals' daily life, but also in public and private institutions that provide health services, as well as in the academy and in research activities. Therefore, it is necessary to identify conflicting situations and always act in accordance with the patient's interest.

What is the Responsibility of Australian Medical Professionals Whose Patients Travel Abroad for Assisted Reproduction?

Australian medical professionals whose patients undertake assisted reproductive treatment abroad face a conflict: to try to provide optimal and on-going care for their patient at the same time as ensuring compliance with Australian legal, ethical, and professional rules which proscribe as unsafe or unethical key aspects of such treatment. A major suggestion from literature on medical travel is that risks to the patient can be mitigated through the involvement of the local professional. However, the force of legal regulation and ethical guidance in Australia strenuously directs clinicians away from involvement in overseas reproductive treatment. This article reports on 37 interviews with Australians travelling abroad for surrogacy, egg donation, and embryo donation, reflecting on patients' experiences with Australian medical professionals both before and after they travelled. Patient reports demonstrate a fragmented and bewildering medical landscape in Australia, in which the ability to access domestic care and expertise varied markedly depending upon the kind of treatment patients were seeking abroad, and the mode of practice of the Australian doctor. Doctors practicing within licensed IVF clinics were notably more constrained than those outside such a setting. Patients seeking egg donation were offered information and received a wide range of diagnostic and preparatory treatments, while those seeking surrogacy were shunned, chided and offered limited (and sometimes covert) assistance. While recent changes to national ethical guidance improve clarity on information giving, the ethical and legal propriety of Australian medical professionals providing diagnostic or preparatory treatment for cross border reproduction remains uncertain.

Cost-equivalence and Pluralism in Publicly-funded Health-care Systems

Clinical guidelines summarise available evidence on medical treatment, and provide recommendations about the most effective and cost-effective options for patients with a given condition. However, sometimes patients do not desire the best available treatment. Should doctors in a publicly-funded healthcare system ever provide sub-optimal medical treatment? On one view, it would be wrong to do so, since this would violate the ethical principle of beneficence, and predictably lead to harm for patients. It would also, potentially, be a misuse of finite health resources. In this paper, we argue in favour of permitting sub-optimal choices on the basis of value pluralism, uncertainty, patient autonomy and responsibility. There are diverse views about how to evaluate treatment options, and patients' right to self-determination and taking responsibility for their own lives should be respected. We introduce the concept of cost-equivalence (CE), as a way of defining the boundaries of permissible pluralism in publicly-funded healthcare systems. As well as providing the most effective, available treatment for a given condition, publicly-funded healthcare systems should provide reasonable suboptimal medical treatments that are equivalent in cost to (or cheaper than) the optimal treatment. We identify four forms of cost-equivalence, and assess the implications of CE for decision-making. We evaluate and reject counterarguments to CE. Finally, we assess the relevance of CE for other treatment decisions including requests for potentially superior treatment.

Climate Change and Professional Responsibility: A Declaration of Helsinki for Engineers

In this paper, we argue that the professional engineering institutions ought to develop a Declaration of Climate Action. Climate change is a serious global problem, and the majority of greenhouse gas emissions come from industries that are enabled by engineers and represented by the engineering professional institutions. If the professional institutions take seriously the claim that a profession should be self-regulating, with codes of ethics that go beyond mere obedience to the law, and if they take their own ethical codes seriously, recognising their responsibility to the public and to future generations (and also recognising a duty of "responsible leadership"), the professional institutions ought to develop a declaration for engineers, addressing climate change. Our argument here is largely inspired by the history of the Declaration of Helsinki. The Declaration of Helsinki was created by the medical profession for the profession, and it held physicians to a higher standard of ethical conduct than was found in the legal framework of individual countries. Although it was not originally a legal document, the influence of the Declaration can be seen in the fact that it is now enshrined in law in a number of different countries. Thus, we argue that the engineering profession could, and should, play a significant role in the abatement of climate change by making changes within the profession. If the engineering profession sets strict standards for professional engineers, with sanctions for those who refuse to comply, this could have a significant impact in relation to our efforts to develop a coordinated response to climate change.

Care-managers' professional choices: ethical dilemmas and conflicting expectations

BACKGROUND

Care-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this.

METHODS

The study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project.

RESULTS

Two main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility.

CONCLUSIONS

Underlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.

Changes in the Social Responsibility Attitudes of Engineering Students Over Time

This research explored how engineering student views of their responsibility toward helping individuals and society through their profession, so-called social responsibility, change over time. A survey instrument was administered to students initially primarily in their first year, senior year, or graduate studies majoring in mechanical, civil, or environmental engineering at five institutions in September 2012, April 2013, and March 2014. The majority of the students (57 %) did not change significantly in their social responsibility attitudes, but 23 % decreased and 20 % increased. The students who increased, decreased, or remained the same in their social responsibility attitudes over time did not differ significantly in terms of gender, academic rank, or major. Some differences were found between institutions. Students who decreased in social responsibility initially possessed more positive social responsibility attitudes, were less likely to indicate that college courses impacted their views of social responsibility, and were more likely to have decreased in the frequency that they participated in volunteer activities, compared to students who did not change or increased their social responsibility. Although the large percentage of engineering students who decreased their social responsibility during college was disappointing, it is encouraging that courses and participation in volunteer activities may combat this trend.

Medical professional responsibility for postvasectomy pregnancy

BACKGROUND

The follow-up of patients postvasectomy is frequently limited to a seminogram at 3months if azoospermia is observed. This study evaluates a series of cases of complaints for postvasectomy pregnancy to establish follow-up recommendations that increase the clinical safety and reduce the risk of complaints.

MATERIAL AND METHODS

We reviewed the database of the Department of Professional Responsibility of the Council of the College of Physicians of Catalonia, finding 28 complaints for postvasectomy pregnancy between 1992 and 2011. We analysed the clinical and legal variables of the cases.

RESULTS

A total of 13 extrajudicial complaints (46.43%), 13 civil lawsuits (46.43%) and 2 criminal lawsuits (7.14%) were recorded. Only 10 cases had a signed document of informed consent specific to vasectomy. In 26 cases, the data from the spermogram was available. A single spermogram was conducted in 20 cases (76.92%), 2 spermograms were conducted in 4 cases (15.38%) and none were performed in 2 cases (7.69%). For 9 of the cases (45%) where only a single spermogram was performed, the test was performed before 3months postvasectomy. In 17 cases (65.38%), the result of the last spermogram was azoospermia, and 3 cases had oligospermia (11.54%). There were 2 failures of interpretation of the spermogram (7.69%) and 2 of normospermia (7.69%). In 2 cases, a spermogram was not performed (7.69%). Pregnancy occurred between 4 and 50 months after the intervention. In 12 cases (42.86%), it was considered that the practitioner was responsible.

DISCUSSION

It is recommended that physicians emphasise (during the patient information stage) the possibility of spontaneous recanalisation and to request 2 spermograms, whose result should be azoospermia. Performing the test in the 3months after vasectomy is risky, as is basing the waiting time on the number of ejaculations.

Ethics in perinatal medicine: A global perspective

This article describes the professional responsibility model of perinatal ethics, which requires the perinatologist in all cases to identify and balance beneficence-based and autonomy-based obligations to the pregnant patient, beneficence-based obligations to the fetal patient, and beneficence-based obligations to the neonatal patient. We explain how this model avoids the clinical failure of both fetal and maternal rights-based reductionism, i.e., insistence either on unlimited fetal rights or on unlimited maternal rights, respectively. The professional responsibility model of perinatal ethics provides the basis for the transnational clinical ethical concept of healthcare justice, which requires that beneficence-based obligations to all patients be routinely fulfilled by providing them with an evidence-based standard of care. We then show how healthcare justice can be used to identify and address ethically unacceptable allocation of healthcare resources. The professional responsibility model of perinatal ethics creates an important role for the perinatologist as responsible advocate for pregnant, fetal, and neonatal patients.

Learning to attain an advanced level of professional responsibility

BACKGROUND

After graduation, nurse practitioner students are expected to be capable of providing complex, evidence-based nursing care independently, combined with standardized medical care. The students who follow work-study programs have to develop their competencies in a healthcare environment dominated by efficiency policies.

OBJECTIVE

This study aims to explore nurse practitioner students' perceptions of their professional responsibility for patient care.

METHOD

This qualitative interpretative study entails a content analysis of 46 reflective case studies written by nurse practitioner students.

FINDINGS

The students felt responsible for the monitoring of patients' health status, attending to psychosocial problems, emphasizing compliance, and optimizing the family's role as informal caregivers. At the same time, students struggled to understand the complexities of their patients' needs, and they had difficulty applying their knowledge and skills to complex medical, psychological, and social problems.

CONCLUSION

The students' perceptions of their new responsibility were characterized by a strong focus on curative care, while psychosocial components of health and illness concerns were often overlooked. The students experienced difficulties in meeting the criteria of advanced practice nursing described in the Dutch competency framework.

[Patient counseling in case of postoperative complication leading to emergency reintervention in plastic surgery. What is the current situation? How to improve? Retrospective study of counseling modalities and traceability in a series of 16 patients who needed emergency reintervention within a cohort of 402 patients]

AIM

Preoperative counseling is structured and well defined. Nevertheless, in the event of a complication leading to a new emergency surgical procedure, counseling is not well defined. We conducted a retrospective study of information delivered in this situation at our institution.

PATIENTS AND METHODS

We included all the patients who underwent emergency reintervention because of hematoma or operative site infection between November 2013 and October 2014. Sixteen patients were included over the 402 patients operated during this period.

RESULTS

Information before initial surgery: all patients had at least two preoperative consultations, and all preoperative informed consents were obtained. Complications leading to reintervention were mentioned in the consultation record in 31% of cases, and in a letter to another practitioner in 19% of cases. SofCPRE information card was delivered in 63% of cases. Information before reintervention: reintervention indication was mentioned in the hospitalization report in 81% of cases, and in the operative report in 88% of cases. Blood count results were mentioned in 55% of cases when it had been done. Patients were orally informed of reintervention in 100% of cases, and this new information was mentioned in 50% of cases. A new informed consent was signed in 31% of cases and postoperative letter was written in 25% of cases.

CONCLUSION

Information delivery traceability is mandatory. In case of complication leading to emergency reintervention, traceability should be done in the same way as prior to initial surgery.

Foreign bodies ingestion: what responsibility?

The ingestion of foreign bodies is one of the most important and difficult emergencies for a physician to diagnose. Accidental ingestion is more common in children, in patients with dental implants, in individuals with mental disability and in drug users. Voluntary ingestion is found in patients who are psychologically unstable, in prisoners or those who attempt suicide. Foreign bodies may be divided into food as fish bones, chicken bones, food bolus, meat, etc. or real foreign bodies such as orthodontic implants, needles, pins, glass, coins, etc. The authors present a case of management, from the medicolegal point of view, of a female patient age 80, who complained, for some weeks of modest pain in the left iliac fossa, and afterwards the endoscopy showed a toothpick into the wall of the sigmoid colon. Assessed of the clinical status of the patient presented severe cardiac comorbidities so that before processing the patient to a second resolutive endoscopy, it was necessary to obtain the hemodynamic stability. However the management of cases of accidental ingestion of foreign bodies is particularly difficult. Medical errors can arise from the very first contact with the patient resulting in delays in appropriate treatment. The doctor to avoid compromising its position on medical liability, must use all the knowledge and diligence known by the art and science of medicine.

Becoming a nurse faculty leader: taking risks by doing the right thing

Risk taking is a key aspect of academic leadership essential to meeting the challenges and opportunities in higher education. What are the practices of risk taking in nurse faculty leaders? This interpretive phenomenological study examines the experience and meaning of risk taking among nurse leaders. The theme of doing the right thing is brought forth through in-depth hermeneutic analysis of 14 individual interviews and two focus group narratives. The practice of doing the right thing is propelled and captured by leaders through a sense professional responsibility, visioning the future, and being true to self and follow one's core values. This study develops an evidence base for incorporating ways of doing the right thing in leadership development activities at a time when there is tremendous need for highly effective leaders in academic settings. Examining the practices of doing the right thing as a part of leadership development lays a foundation for building the next generation of nursing leaders prepared to navigate the ever-changing and complex academic and health care environments.

Ethical issues in periviable birth

Ethics is an essential dimension of the management of periviable birth in both clinical practice and research. The goal of clinical care in periviable birth is to improve outcomes for current pregnant and fetal patients. The goal of research in periviable birth is to improve outcomes for future pregnant patients and fetal patients. This paper provides an ethical framework for professionally responsible clinical management and research to improve the outcomes of periviable birth. The ethical framework is based on the professional responsibility model of obstetric ethics, which rejects rights-based reductionism. This model elaborates the ethical concept of the fetus as a patient in terms of beneficence-based and autonomy-based obligations to the pregnant woman and beneficence-based obligations to the fetus and emphasizes that the fetus is not a separate patient. Guidance is provided for counseling pregnant women about the management of pregnancies at 22 weeks of well-documented gestation, for which directive counseling in the form recommending non-aggressive obstetric management is ethically justified. At 24 weeks and later of gestation, directive counseling in the form of recommending aggressive obstetric management is ethically justified. For the period between 22 and 24 weeks gestation, non-directive counseling is ethically justified. Guidance is also provided for counseling pregnant women about participation in clinical trials and in innovative intervention for fetal benefit. Non-directive counseling should be strictly followed for both.