The scientific and ethical feasibility of immunity passports

There is much debate about the use of immunity passports in the response to the COVID-19 pandemic. Some have argued that immunity passports are unethical and impractical, pointing to uncertainties relating to COVID-19 immunity, issues with testing, perverse incentives, doubtful economic benefits, privacy concerns, and the risk of discriminatory effects. We first review the scientific feasibility of immunity passports. Considerable hurdles remain, but increasing understanding of the neutralising antibody response to COVID-19 might make identifying members of the community at low risk of contracting and transmitting COVID-19 possible. We respond to the ethical arguments against immunity passports and give the positive ethical arguments. First, a strong presumption should be in favour of preserving people's free movement if at all feasible. Second, failing to recognise the reduced infection threat immune individuals pose risks punishing people for low-risk behaviour. Finally, further individual and social benefits are likely to accrue from allowing people to engage in free movement. Challenges relating to the implementation of immunity passports ought to be met with targeted solutions so as to maximise their benefit.

Off the Charts: Medical documentation and selective redaction in the age of transparency

A growing demand for transparency in medicine has the potential to strain the doctor-patient relationship. While information can empower patients, unrestricted patient access to the electronic medical record may have unintended consequences. Medical documentation is often written in language that is inaccessible to people without medical training, and without guidance, patients have no way to interpret the constellation of acronyms, diagnoses, treatments, impressions, and arguments that appear throughout their own chart. Additionally, full transparency may not allow physicians the intellectual or clinical freedom they need to authentically express questions, problematic impressions, and concerns about the patient's clinical and psychosocial issues. This article examines the ethical challenges of transparency in the digital era and suggests that selective redaction may serve as a means to maintain transparency, affirm physician's discretion, and uphold the core values of the doctor-patient relationship amidst disruptive technological change.

Analysis of Advance Directive Documentation to Support Palliative Care Activities in Nursing Homes

As part of an intervention to improve health care in nursing homes with the goal of reducing potentially avoidable hospital admissions, 1,877 resident records were reviewed for advance directive (AD) documentation. At the initial phases of the intervention, 50 percent of the records contained an AD. Of the ADs in the resident records, 55 percent designated a durable power of attorney for health care, most often a child (62 percent), other relative (14 percent), or spouse (13 percent). Financial power of attorney documents were sometimes found within the AD, even though these documents focused on financial decision making rather than health care decision making. Code status was the most prevalent health preference documented in the record at 97 percent of the records reviewed. The intervention used these initial findings and the philosophical framework of respect for autonomy to develop education programs and services on advance care planning. The role of the social worker within an interdisciplinary team is discussed.

Understanding Privacy in Occupational Health Services

The aim of this study was to gain a deeper understanding of privacy in occupational health services. Data were collected through in-depth theme interviews with occupational health professionals (n=15), employees (n=15) and employers (n=14). Our findings indicate that privacy, in this context, is a complex and multilayered concept, and that companies as well as individual employees have their own core secrets. Co-operation between the three groups proved challenging: occupational health professionals have to consider carefully in which situations and how much they are entitled to release private information on individual employees for the benefit of the whole company. Privacy is thus not an absolute right of an individual, but involves the idea of sharing responsibility. The findings open up useful new perspectives on ethical questions of privacy and on the development of occupational health practices.

Documentation of Individualized Patient Care: a qualitative metasynthesis

The aim of this study was to increase understanding of how individual patient care and the ethical principles prescribed for nursing care are implemented in nursing documentation. The method used was a metasynthesis of the results of 14 qualitative research reports. The results indicate that individualized patient care is not visible in nurses’ documentation of care. It seems that nurses describe their tasks more frequently than patients’ experiences of their care. The results also show that the structure of nursing documentation and the forms or manner of recording presupposed by the organization may prevent individual recording of patient care. In order to obtain visibility for good patient-centred and ethical nursing care, an effort should be made to influence how the content of nursing care is documented and made an essential part of individual patient care. If the content of this documentation does not give an accurate picture of care, patients’ right to receive good nursing care may not be realized.

Social work in a digital age: ethical and risk management challenges

Digital, online, and other electronic technology has transformed the nature of social work practice. Contemporary social workers can provide services to clients by using online counseling, telephone counseling, video counseling, cybertherapy (avatar therapy), self-guided Web-based interventions, electronic social networks, e-mail, and text messages. The introduction of diverse digital, online, and other forms of electronic social services has created a wide range of complex ethical and related risk management issues. This article provides an overview of current digital, online, and electronic social work services; identifies compelling ethical issues related to practitioner competence, client privacy and confidentiality, informed consent, conflicts of interest, boundaries and dual relationships, consultation and client referral, termination and interruption of services, documentation, and research evidence; and offers practical risk management strategies designed to protect clients and social workers. The author identifies relevant standards from the NASW Code of Ethics and other resources designed to guide practice.

Interfaces between electronic medical record (EMR/EHR) technology and people in American medicine: insight. imagination, and relationships in clinical practice

This paper explores the contexts and relationships in which EMR/EHR technology is used in healthcare settings. It approaches the EMR/EHR as an issue in clinical ethics. The author recognizes the immense contribution that healthcare informatics makes to coordinating and integrating medical care at the level of individual physician, nurse, and institutions. At the same time the author raises a cautionary note about some unrecognized dimensions of the use and experience of the EMR/EHR. The author argues that the EMR/EHR can consciously and unconsciously become an instrument of assembly line-like physician "productivity" and "production reports" that depersonalize patient and physician alike. Construed this way, the EMR/EHR can narrow the clinician's imagination, relationships, clinical decision-making, and documentation into oversimplified, and potentially distorting, clinical narratives and categories such as fit into CPT, ICD-9, DRG, DSM-IV and other codes, EBM protocols, and clinical algorithms. By contrast, the author uses a vignette and one of his own clinical poems to illustrate the rich weave of relationship and meaning that are foreground rather than background in clinical assessment, decision-making, treatment, outcome, and satisfaction. The author concludes with a call to imaginatively use the EMR/EHR as an instrument of physician-patient communication, and to include in it and make available vital narrative data (evidence) about patient, family, culture, occupation, socioeconomic status, physician, disease, and their relationships.

Ethical review of research protocols: experience of a research ethics committee

INTRODUCTION AND OBJECTIVES

Since the passing of the Law on Biomedical Research it has been the task of research ethics committees to assess the methodological, ethical and legal aspects of all research carried out on humans or human biological samples. The aim of the study is to analyze the experience of the Research Ethics Committee for the Carlos III Health Institute in the ethical assessment of research proposals involving human subjects.

METHODS

A descriptive study of the observations made on research projects registered between June 1, 2009 and June 30, 2010.

RESULTS

About two thirds of the projects evaluated in this period needed some type of amendment. Most of the comments were aimed at improving informed consent and procedures to ensure confidentiality (153 observations, 57.6%). Fifty (18.9%) observations related to the principles of beneficence and nonmaleficence. The remaining observations involved incomplete or incorrect documentation, or requests for additional information.

CONCLUSIONS

The largest number of observations related to the autonomy of research participants. It is important for researchers to be aware of the principle of autonomy in their interaction with study participants. Research ethics committees should therefore promote greater understanding of ethical issues on biomedical research.

A review of basic patient rights in psychiatric care

Although patient rights is a concept that all nurse managers need to be aware of, this concept often becomes confusing when applied to patients undergoing psychiatric treatment. It is important for the nurse manager to understand the basic rights that psychiatric patients are entitled to, to best be able to help staff nurses under his/her supervision to protect these rights. The nurse manager on a psychiatric unit often serves as a reference for staff nurses, and even for physicians, when questions regarding patient rights present themselves. The nurse manager should be certain to discuss these issues with the facility's legal and risk management team to be aware of particulars of the law of the state in which the facility is located, as state laws may differ somewhat in their treatment of psychiatric patients.

A bibliography concerning informed consent and biobanking: documents from national and international bodies

The article contains a list of national and international documents addressing the ethical aspects of biobanking, which were drafted by national bioethics committees; national ad hoc commissions; and national and international agencies, organizations, and societies. The greater part of the documents specifically focuses on questions involving the ethics of informed consent for biobanking. The documents are grouped according to the nature of the promulgating body, and are listed alphabetically within each group according to the promulgating body. Special attention is devoted to documents issued by the European Union and the Council of Europe.

Patient charting. Turning a routine activity into an opportunity for injury prevention

Injuries can be predicted and prevented. The first step in doing so is gathering data about who was injured and how. Because injury data is based on documentation in patients' medical charts, physicians play an important role in injury prevention. This article describes how to document all types of injuries, including those that are self-inflicted or caused by abuse.

Therapeutic risk management of clinical-legal dilemmas: should it be a core competency?

Therapeutic risk management of clinical-legal dilemmas achieves an optimal alignment between clinical competence and an understanding of legal concerns applicable to psychiatric practice. Understanding how psychiatry and law interact in frequently occurring clinical situations is essential for effective patient care. Successful management of clinical-legal dilemmas also avoids unnecessary, counterproductive defensive practices.

Obtaining informed consent and other ethical dilemmas

In the extracts from the discussion presented below, Prof Macklin (RM) and Dr Guerrero-Cohen (DG-C) respond to researchers' queries. Some of the dilemmas that the researchers describe were faced in their own work. Others, based on questions raised by the institutional ethics committee of the Anusandhan Trust, were summarised from the IEC's report.

Advance directives: prerequisites and usefulness

Advance directives allow competent persons to extend their right of self-determination into the future, by recording choices that are intended to influence their future care should they become unable to make choices. They are considered tools to facilitate end-of-life decision making. Advance directives are a form of anticipatory decision-making. This article will focus on instruction directives against a certain treatment, so-called advance refusals. The most important legal requirement is the acknowledgement of patient autonomy. This condition is met in all European countries. The legal uncertainties surrounding advance refusals are focused on practical modalities rather than on the validity of the general principle. According to leading ethics the underlying moral rule of advanced directives is that all truly autonomous refusals of treatment must be respected, no matter what the consequences. Physicians find it hard to adhere to the wishes and choices of patients as expressed in directives. They find the text ambiguous. Another weakness is that directives give little information about what in the patient's view constitutes a good quality of life. Some health professionals lack the willingness to step outside their own value systems and fully embrace that of the patient. Empathic skills are required. Very few persons create an advance directive. Furthermore, of the created directives only some are accessible when patients are admitted to hospital. However, when directives are available they usually influence medical treatment decisions.

Informed consent: views from Karachi

Little is known about the public's perceptions about the process of obtaining informed consent for participation in medical research. A study was made of the views of patients, their attendants, parents, schoolteachers and office workers living in Karachi, Pakistan. Participants felt that informed consent was an important step in recruiting research participants but many felt that it was a trust-based process not requiring proper documentation. For recruiting women, both men and women believed it was important to approach women through their husbands and fathers. When there was a conflict with the opinions of family leaders, it was clear that the male participants' opinion was valued more than that of the female participants by both men and women.

Implementation of informed consent for a cystic fibrosis newborn screening program in France: low refusal rates for optional testing

OBJECTIVES

The French Association for Neonatal Screening implemented cystic fibrosis neonatal screening (CF NBS) region by region in France, from the beginning of the year 2002 to early 2003. The program uses an immunoreactive trypsinogen/DNA testing algorithm on dried blood samples obtained at 3 days of age. Incorporation of DNA testing necessitated compliance with official regulations and French "bioethics" laws: the need for a written consent from the patient/guardian and specific circulation of the prescription, sample, and results. To fulfill these obligations, the Ethics and Genetics committee of the French Association for Neonatal Screening recommended that informed consent should be obtained for all neonates at birth by having the parents sign directly on the sampling paper. This study was designed to evaluate the effect of the educational efforts used to obtain informed consent on acceptance of CF NBS.

STUDY DESIGN

Data from the screening center in Lille, France, were analyzed to determine the rate of refusal of CF NBS in the 18 months after initiation of the informed consent process.

RESULTS

The number of refusals for CF NBS declined from 0.8% at the start of the program to 0.2% at the end of the first year of the new process for obtaining written consent.

CONCLUSIONS

Efforts to inform parents and professionals resulted in a significant decrease in the number of refusals for CF NBS.

Modes of rationality in nursing documentation: biology, biography and the 'voice of nursing'

This article is based on a discourse analysis of the complete nursing records of 45 patients, and concerns the modes of rationality that mediated text-based accounts relating to patient care that nurses recorded. The analysis draws on the work of the critical theorist, Jurgen Habermas, who conceptualised rationality in the context of modernity according to two types: purposive rationality based on an instrumental logic, and value rationality based on ethical considerations and moral reasoning. Our analysis revealed that purposive rationality dominated the content of nursing documentation, as evidenced by a particularly bio-centric and modernist construction of the workings of the body within the texts. There was little reference in the documentation to central themes of contemporary nursing discourses, such as notions of partnership, autonomy, and self-determination, which are associated with value rationality. Drawing on Habermas, we argue that this nursing documentation depicted the colonisation of the sociocultural lifeworld by the bio-technocratic system. Where nurses recorded disagreements that patients had with medical regimes, the central struggle inherent in the project of modernity became transparent--the tension between the rational and instrumental control of people through scientific regulation and the autonomy of the subject. The article concludes by problematising communicative action within the context of nursing practice.

Review of current authorship guidelines and the controversy regarding publication of clinical trial data

Publication of clinical trial data is the final step in the scientific method and an important method by which pharmaceutical and biotechnology companies, i.e., drug sponsors, disseminate information about their products. Because of the nature of large, multicenter trials, multiple investigators from many institutions may be considered as authors of these papers. Controversy concerning the rights of academic institutions and the rights of drug sponsors has been widely debated. This chapter summarizes the controversy and the current policies.

Informed consent

It is essential that nurses are familiar with the principles and requirements of informed consent. This article examines the rationale and principles behind it and encourages nurses to reflect on how it affects their everyday practice.