Restraint in somatic healthcare: how should it be regulated?

Restraint is regularly used in somatic healthcare settings, and countries have chosen different paths to regulate restraint in somatic healthcare. One overarching problem when regulating restraint is to ensure that patients with reduced decision-making capacity receive the care they need and at the same time ensure that patients with a sufficient degree of decision-making capacity are not forced into care that they do not want. Here, arguments of justice, trust in the healthcare system, minimising harm and respecting autonomy are contrasted with different national regulations. We conclude that a regulation that incorporates an assessment of patients' decision-making capacity and considers the patient's best interests is preferable, in contrast to regulations based on psychiatric diagnoses or regulations where there are no legal possibilities to exercise restraint at all in somatic care.

Rawlsian reasoning about fairness at the end of life

OBJECTIVES

The aim of this study was to discuss end-of-life care in the context of Rawls' and Daniels' philosophy of justice. The study is based on an empirical survey of Swedish physicians who were asked whether they would want the option of physician-assisted suicide (PAS) for themselves (hereafter called own preferences), what are their attitudes towards PAS in general and whether they were prepared to prescribe PAS drugs to eligible patients. The question is to what extent the physicians' answers are impartial and consistent in a Rawlsian sense.

METHODS

The underlying indicator was the physicians' own preferences. Kappa score inter-rater agreement was measured between that response and that same physician's general attitude towards allowing PAS and preparedness to prescribe PAS drugs. The coherence of provided comments and arguments were analysed using content analysis.

RESULTS

Palliative care physicians are the least willing to offer PAS, and surgeons and psychiatrist the most willing. There is a discrepancy between physicians' general attitudes about allowing PAS, their own wishes to be offered PAS at the end of life and the concrete action of prescribing PAS drugs. Arguments given for not prescribing PAS by those in favour of PAS are seemingly but not truly inconsistent.

CONCLUSIONS

Those supporting PAS provided impartial and consistent arguments for their stances in a Rawlsian sense, while those against PAS provided partial arguments. Two specialties, psychiatrists and palliative care physicians, were coherent in their reasoning about PAS for themselves and their willingness to prescribe the needed drugs.

Challenges regarding informed consent in recruitment to clinical research: a qualitative study of clinical research nurses' experiences

BACKGROUND

Clinical research nurses (CRNs) have first-hand experience with ethical challenges and play a crucial role in upholding ethical conduct and adherence to the principles of informed consent in clinical research. This study explores the ethical challenges encountered by CRNs in the process of obtaining informed consent for clinical research.

METHODS

A qualitative exploratory design. Semistructured interviews (n = 14) were conducted with diverse CRNs in Sweden. These CRNs covered a wide range of research fields, including pharmaceutical and academic studies, interventions, and observational research, spanning different trial phases, patient categories, and medical conditions. The interviews were analysed using inductive qualitative content analysis.

RESULTS

The analysis identified three main categories: (i) threats to voluntariness, (ii) measures to safeguard voluntariness, and (iii) questionable exclusion of certain groups. CRNs face challenges due to time constraints, rushed decisions, information overload, and excessive reliance on physicians' recommendations. Overestimating therapeutic benefits in stages of advanced illness emerged as a risk to voluntariness. CRNs outlined proactive solutions, such as allowing ample decision-making time and offering support, especially for terminally ill patients. Concerns were also voiced about excluding certain demographics, such as those with language barriers or cognitive impairments.

CONCLUSIONS

In conclusion, upholding ethical research standards requires recognising various factors affecting patient voluntariness. Researchers and CRNs should prioritise refining the informed consent process, overcoming participation challenges, and aligning scientific rigour with personalised care. Additionally, a concerted effort is vital to meet the diverse needs of patient populations, including equitable inclusion of individuals with language barriers or cognitive limitations in clinical studies. These findings have significant implications for enhancing the ethics of clinical research and advancing person-centred care.

"Being prevented from providing good care: a conceptual analysis of moral stress among health care workers during the COVID-19 pandemic"

BACKGROUND

Health care workers (HCWs) are susceptible to moral stress and distress when they are faced with morally challenging situations where it is difficult to act in line with their moral standards. In times of crisis, such as disasters and pandemics, morally challenging situations are more frequent, due to the increased imbalance between patient needs and resources. However, the concepts of moral stress and distress vary and there is unclarity regarding the definitions used in the literature. This study aims to map and analyze the descriptions used by HCWs regarding morally challenging situations (moral stress) and refine a definition through conceptual analysis.

METHODS

Qualitative data were collected in a survey of 16,044 Swedish HCWs who attended a COVID-19 online course in autumn 2020. In total, 643 free-text answers with descriptions of moral stress were analyzed through content analysis.

RESULTS

Three themes emerged from the content analysis (1) "Seeing, but being prevented to act; feeling insufficient/inadequate and constrained in the profession," (2) "Someone or something hindered me; organizational structures as an obstacle," and (3) "The pandemic hindered us; pandemic-related obstacles." The three themes correspond to the main theme, "Being prevented from providing good care."

DISCUSSION

The main theme describes moral stress as various obstacles to providing good care to patients in need and acting upon empathic ability within the professional role. The themes are discussed in relation to established definitions of moral stress and are assessed through conceptual analysis. A definition of moral stress was refined, based on one of the established definitions.

CONCLUSIONS

On the basis of the study results and conceptual analysis, it is argued that the presented definition fulfils certain conditions of adequacy. It is essential to frame the concept of moral stress, which has been defined in different ways in different disciplines, in order to know what we are talking about and move forward in developing prevention measures for the negative outcomes of this phenomenon.

Should relational effects be considered in health care priority setting?

It is uncontroversial to claim that the extent to which health care interventions benefit patients is a relevant consideration for health care priority setting. However, when effects accrue to the individual patient, effects of a more indirect kind may accrue to other individuals as well, such as the patient's children, friends, or partner. If, and if so how, such relational effects should be considered relevant in priority setting is contentious. In this paper, we illustrate this question by using disease-modifying drugs for Alzheimer's disease as a case in point. The ethical analysis begins by sketching the so-called prima facie case for ascribing moral weight to relational effects and then moves on to consider a number of objections to it. We argue that, whereas one set of objections may be dismissed, there is another set of arguments that poses more serious challenges for including relational effects in priority setting.

Understanding nurses' justification of restraint in a neurosurgical setting: A qualitative interview study

BACKGROUND

Despite its negative impact on patients and nurses, the use of restraint in somatic health care continues in many settings. Understanding the reasons and justifications for the use of restraint among nurses is crucial in order to manage this challenge.

AIM

To understand nurses' justifications for restraint use in neurosurgical care.

RESEARCH DESIGN

A qualitative, descriptive design was used. Data were analysed with inductive qualitative content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden.

ETHICAL CONSIDERATIONS

Approved by The Regional Ethics Committee, Stockholm, Sweden.

FINDINGS

The analysis resulted in three categories. The category Patient factors influencing restraint use describes patient factors that trigger restraint, such as a diminished decision-making competence, restlessness, and need for invasive devices. The category Specific reasons for justifying restraint describes reasons for restraining patients, such as restraint being used for the sake of the patient or for the sake of others. The category General reasoning in justifying restraint describes how nurses reason when using restraint, and the decision to use restraint was often based on a consequentialist approach where the nurses' weighed the pros and cons of different alternatives.

DISCUSSION

Nurses with experience of restraint use were engaged in a constant process of justifying and balancing different options and actions. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse.

CONCLUSION

How nurses reason when justifying restraint, why they use restraint, and who they use restraint on must be considered when creating programs and guidelines to reduce the use of restraint and to ensure that when it is used it is used carefully, appropriately, and with respect.

Patients with borderline personality disorder and the effects of compulsory admissions on self-harm behaviour: a questionnaire study

BACKGROUND

Previous research on patients with borderline personality disorder (BPD) has indicated negative effects, including increased suicidality, from long hospital admissions and paternalism. Still, long-term compulsory admissions have been reported to occur regularly. Less is known about how healthcare personnel perceives these admissions and to what extent they think the use of compulsory care can be diminished. This study addresses those questions to make care more beneficial.

METHODS

A questionnaire study, the respondents being nurses and psychiatric aides employed at psychiatric hospital wards in Sweden. The questionnaire contained questions with fixed answers and room for comments. 422 questionnaires were distributed to 21 wards across Sweden, and the response rate was 66%. The data were analysed with descriptive statistics and qualitative descriptive content analysis.

RESULTS

Most respondents experienced that more than a week's compulsory admission either increased (68%) or had no effect (26%) on self-harm behaviour. A majority (69%) considered the compulsory admissions to be too long at their wards, with detrimental effects on the patients. They also recognized several reasons for compulsory admissions without medical indication, like doctors' fear of complaints and patients' lack of housing. Also, patients sometimes demand compulsory care. Respondents recommended goal-oriented care planning, around three-day-long voluntary admissions, and better outpatient care to reduce compulsory hospital admissions.

DISCUSSION

These findings imply that many BPD patients are regularly forced to receive psychiatric care that inadvertently can make them self-harm more. The respondents' comments can be used as a source when formulating clinical guidelines.

Misuse of co-authorship in Medical PhD Theses in Scandinavia: A Questionnaire Survey

Background

Several studies suggest that deviations from proper authorship practices are commonplace in medicine. The aim of this study was to explore experiences of and attitudes towards the handling of authorship in PhD theses at medical faculties in Denmark, Norway, and Sweden.

Methods

Those who defended their PhD thesis at a medical faculty in Scandinavia during the second half of 2020 were offered, by e-mail, to participate in an online survey. Survey questions dealt with experiences of violations of the first three of the ICMJE authorship criteria and misuse of authorship order in the thesis articles, as well as respondents’ attitudes to these matters. Both questions with fixed response alternatives and questions with free-text responses were used. Quantitative data were analysed statistically using the Table functions in SPSS 25 and Chi-2 tests. Free-text responses were analysed qualitatively using manifest content analysis.

Results

287 valid questionnaires were returned (response rate: 34.1%). Almost half (46.0%) of the respondents reported that the ICMJE authorship criteria were not fully respected in at least one of the papers in their thesis, while a vast majority (96.7%) found it important that authorship is handled according to the ICMJE authorship criteria. 24.4% reported inadequate handling of authorship order in at least one paper. The qualitative results provide a wide spectrum of examples of how the ICMJE authorship criteria are circumvented.

Conclusion

Despite increasing educational efforts to reduce deviations from good research practice at Scandinavian universities, the handling of authorship in medical papers remains problematic.

Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders

Background

Disasters are chaotic events with healthcare needs that overwhelm available capacities. Disaster healthcare responders must make difficult and swift choices, e.g., regarding who and what to prioritize. Responders dealing with such challenging choices are exposed to moral stress that might develop into moral distress and affect their wellbeing. We aimed to explore how deployed international disaster healthcare responders perceive, manage and are affected by moral challenges.

Methods

Focus groups discussions were conducted with 12 participants which were Swedish nurses and physicians with international disaster healthcare experience from three agencies. The transcribed discussions were analyzed using content analysis.

Results

We identified five interlinked themes on what influenced perceptions of moral challenges; and how these challenges were managed and affected responders’ wellbeing during and after the response. The themes were: “type of difficult situation”, “managing difficult situations”, “tools and support”, “engagement as a protective factor”, and “work environment stressors as a risk factor. Moral challenges were described as inevitable and predominant when working in disaster settings. The responders felt that their wellbeing was negatively affected depending on the type and length of their stay and further; severity, repetitiveness of encounters, and duration of the morally challenging situations. Responders had to be creative and constructive in resolving and finding their own support in such situations, as formal support was often either lacking or not considered appropriate.

Conclusion

The participating disaster healthcare responders were self-taught to cope with both moral challenges and moral distress. We found that the difficult experiences also had perceived positive effects such as personal and professional growth and a changed worldview, although at a personal cost. Support considered useful was foremost collegial support, while psychosocial support after deployment was considered useful provided that this person had knowledge of the working conditions and/or similar experiences. Our findings may be used to inform organizations’ support structures for responders before, during and after deployment.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13031-022-00456-y.

Hospital staff at most psychiatric clinics in Stockholm experience that patients who self-harm have too long hospital stays, with ensuing detrimental effects

BACKGROUND

Previous research on patients who self-harm has indicated potential negative effects from long hospital stays. Yet, such care has been reported to occur regularly. We conducted this questionnaire study to investigate how hospital staff, who treat self-harming patients, experience the relation between lengths of stay and self-harm behaviour, and the motives for non-beneficial hospital stays.

METHODS

The respondents of the questionnaire were nurses and mental health workers employed at public inpatient wards in Stockholm, treating patients who self-harm. The questionnaire contained questions with fixed answers and room for comments. A total of 304 questionnaires were distributed to 13 wards at five clinics, and the response rate was 63%. The data were analysed with descriptive statistics and qualitative descriptive content analysis.

RESULTS

The results show that most staff experienced that more than a week's stay either increased (57%) or had no effect (33%) on self-harm behaviour. Most respondents at most clinics considered the stays to be too long at their wards, and that the stays could be reduced. The respondents recognized several reasons for non-beneficial hospital stays, like fear of suicidal behaviour and doctors' fear of complaints. Patients appearing as demanding or fragile were thought to be given more care than others. The respondents' comments confirmed the majority's experience of detrimental effects from longer hospital stays.

CONCLUSIONS

A majority of the health care staff experienced that patients who self-harm often receive too long hospital stays, with detrimental effects, and they had experienced several non-medical reasons for such care.

How to reveal disguised paternalism: version 2.0

Background

We aim to further develop an index for detecting disguised paternalism, which might influence physicians’ evaluations of whether or not a patient is decision-competent at the end of life. Disguised paternalism can be actualized when physicians transform hard paternalism into soft paternalism by questioning the patient’s decision-making competence.

Methods

A previously presented index, based on a cross-sectional study, was further developed to make it possible to distinguish between high and low degrees of disguised paternalism using the average index of the whole sample. We recalculated the results from a 2007 study for comparison to a new study conducted in 2020. Both studies are about physicians’ attitudes towards, and arguments for or against, physician-assisted suicide.

Results

The 2020 study showed that geriatricians, palliativists, and middle-aged physicians (46–60 years old) had indices indicating disguised paternalism, in contrast with the results from the 2007 study, which showed that all specialties (apart from GPs and surgeons) had indices indicating high degrees of disguised paternalism.

Conclusions

The proposed index for identifying disguised paternalism reflects the attitude of a group towards physician assisted suicide. The indices make it possible to compare the various medical specialties and age groups from the 2007 study with the 2020 study. Because disguised paternalism might have clinical consequences for the rights of competent patients to participate in decision-making, it is important to reveal disguised hard paternalism, which could masquerade as soft paternalism and thereby manifest in practice. Methods for improving measures of disguised paternalism are worthy of further development.

Nurses' experiences of using restraint in neurosurgical care - A qualitative interview study

AIM AND OBJECTIVES

To describe nurses' experiences of using restraint in neurosurgical care.

BACKGROUND

Despite reports of negative consequences, and conflicts with key values in healthcare, restraint measures are still practised in somatic healthcare worldwide. When using restraint, basic principles of nursing collide, creating dilemmas known to be perceived as difficult for many nurses. Patients in neurosurgical care are at high risk of being subjected to restraint, but research on nurses' experiences of using restraint in neurosurgical care are scarce.

DESIGN

A qualitative, descriptive design guided by a naturalistic inquiry was used.

METHODS

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden were analysed with inductive qualitative content analysis. COREQ reporting guidelines were used as reporting checklist.

RESULTS

The analysis resulted in one overarching theme, The struggling professional, and two categories. The category Internal struggle describes nurses' conflicting emotions and internal struggle when engaging in restraint. The category The struggle in clinical practice, describes how nurses struggle with handling restraint in clinical practice, and how the use of restraint is based on individual assessment rather than guidelines.

CONCLUSION

Nurses' experience restraint in neurosurgical care as a multi-layered struggle, ranging from inner doubts to practical issues. In order to enhance patient safety, there is a need for policies and guidelines regarding the use of restraint, as well as structured discussions and reflections for nurses engaged in the practice.

RELEVANCE TO CLINICAL PRACTICE

The results highlight the importance of clear guidelines, openness, support and teamwork for nurses working with patients at risk to be subjected to restraint, in order to create a safer care for patients as well as healthcare personnel. When developing guidelines and policies concerning restraint in somatic care, both practical issues such as the decision-making process, and the emotional effect on nurses should be considered.

Personal responsibility for health? A phenomenographic analysis of general practitioners' conceptions

OBJECTIVE

To analyse and describe general practitioners' perceptions of the notion of a 'personal responsibility for health'.

DESIGN

Interview study, phenomenographic analysis.

SETTING

Swedish primary health care.

SUBJECTS

General Practitioners (GPs).

MAIN OUTCOME MEASURES

Using the phenomenographic method, the different views of the phenomenon (here: personal responsibility for health) were presented in an outcome space to illustrate the range of perceptions.

RESULTS

The participants found the notion of personal responsibility for health relevant to their practice. There was a wide range of perceptions regarding the origins of this responsibility, which was seen as coming from within yourself; from your relationships to specific others; and/or from your relationship with the generalized other. Furthermore, the expressions of this responsibility were perceived as including owning your health problem; not offloading all responsibility onto the GP; taking active measures to keep and improve health; and/or accepting help in health. The GP was described as playing a key role in shaping and defining the patient's responsibility for his/her health. Some aspects of personal responsibility for health roused strong emotions in the participants, especially situations where the patient was seen as offloading all responsibility onto the GP.

CONCLUSION

The notion of personal responsibility for health is relevant to GPs. However, it is open to a broad range of interpretations and modulated by the patient-physician interaction. This may make it unsuitable for usage in health care priority settings. More research is mandated to further investigate how physicians work with patient responsibility, and how this affects the patient-physician relationship and the physician's own well-being.Key PointsThe notion of personal responsibility for health has relevance for discussions about priority setting and person-centred care.This study, using a phenomenographic approach, investigated the views of Swedish GPs about the notion of personal responsibility for health.The participants found the notion relevant to their practice. They expressed a broad range of views of what a personal responsibility for health entails and how it arises. The GP was described as playing a key role in shaping and defining the patient's responsibilities for his/her health.The notion was emotionally charged to the participants, and when patients were seen as offloading all responsibility onto the GP this gave rise to frustration.

Novel drug candidates targeting Alzheimer's disease: ethical challenges with identifying the relevant patient population

Intensive research is carried out to develop a disease-modifying drug for Alzheimer's disease (AD). The development of drug candidates that reduce Aß or tau in the brain seems particularly promising. However, these drugs target people at risk for AD, who must be identified before they have any, or only moderate, symptoms associated with the disease. There are different strategies that may be used to identify these individuals (eg, population screening, cascade screening, etc). Each of these strategies raises different ethical challenges. In this paper, we analyse these challenges in relation to the risk stratification for AD necessary for using these drugs. We conclude that the new drugs must generate large health benefits for people at risk of developing AD to justify the ethical costs associated with current risk stratification methods, benefits much larger than current drug candidates have. This conclusion raises a new set of ethical questions that should be further discussed.

Trends in Swedish physicians' attitudes towards physician-assisted suicide: a cross-sectional study

AIMS

To examine attitudes towards physician-assisted suicide (PAS) among physicians in Sweden and compare these with the results from a similar cross-sectional study performed in 2007.

PARTICIPANTS

A random selection of 250 physicians from each of six specialties (general practice, geriatrics, internal medicine, oncology, surgery and psychiatry) and all 127 palliative care physicians in Sweden were invited to participate in this study.

SETTING

A postal questionnaire commissioned by the Swedish Medical Society in collaboration with Karolinska Institute in Stockholm.

RESULTS

The total response rate was 59.2%. Slightly fewer than half [47.1% (95% CI 43.7-50.5)] of the respondents from the six specialties accepted PAS, which is significantly more than accepted PAS in the 2007 study [34.9% (95% CI 31.5-38.3)]. Thirty-three percent of respondents were prepared to prescribe the needed drugs. When asked what would happen to the respondent's own trust in healthcare, a majority [67.1% (95% CI 63.9-70.3)] stated that legalizing PAS would either not influence their own trust in healthcare, or that their trust would increase. This number is an increase compared to the 2007 survey, when just over half [51.9% (95% CI 48.0-55.2)] indicated that their own trust would either not be influenced, or would increase.

CONCLUSIONS

The study reveals a shift towards a more accepting attitude concerning PAS among physicians in Sweden. Only a minority of the respondents stated that they were against PAS, and a considerable proportion reported being prepared to prescribe the needed drugs for patient self-administration if PAS were legalized.

Who should be tested in a pandemic? Ethical considerations

BACKGROUND

In the initial phase of the Covid-19 pandemic, difficult decisions had to be made on the allocation of testing resources. Similar situations can arise in future pandemics. Therefore, careful consideration of who should be tested is an important part of pandemic preparedness. We focus on four ethical aspects of that problem: how to prioritize scarce testing resources, the regulation of commercial direct-to-consumer test services, testing of unauthorized immigrants, and obligatory testing.

MAIN TEXT

The distribution of scarce resources for testing: We emphasize the use of needs-based criteria, but also acknowledge the importance of choosing a testing strategy that contributes efficiently to stopping the overall spread of the disease. Commercial direct-to-consumer test services: Except in cases of acute scarcity, such services will in practice have to be allowed. We propose that they should be subject to regulation that ensures test quality and adequate information to users. Testing of unauthorized immigrants, their children and other people with unclear legal status: Like everyone else, these individuals may be in need of testing, and it is in society's interest to reach them with testing in order to stop the spread of the disease. A society that offers comprehensive medical services to unauthorized immigrants is in a much better position to reach them in a pandemic than a society that previously excluded them from healthcare. Obligatory testing: While there are often strong reasons for universal testing in residential areas or on workplaces, there are in most cases better ways to achieve testing coverage than to make testing mandatory.

CONCLUSION

In summary, we propose (1) decision-making primarily based on needs-based criteria, (2) strict regulation but not prohibition of direct-to-consumer test services, (3) test services offered to unauthorized immigrants, preferably as part of comprehensive medical services, and (4) broad outreach of testing services whenever possible, but in general not obligatory testing.

Should we accept a higher cost per health improvement for orphan drugs? A review and analysis of egalitarian arguments

In recent years, the issue of accepting a higher cost per health improvement for orphan drugs has been the subject of discussion in health care policy agencies and the academic literature. This article aims to provide an analysis of broadly egalitarian arguments for and against accepting higher costs per health improvement. More specifically, we aim to investigate which arguments one should agree upon putting aside and where further explorations are needed. We identify three kinds of arguments in the literature: considerations of substantial equality, formal equality, and opportunity cost. We argue that considerations of substantial equality do not support higher costs per health improvement orphan drugs, even if such considerations are considered valid. On the contrary, arguments of formal equality may support accepting a higher cost per health improvement for orphan drugs. However, in order to do so, a number of both normative and empirical issues must be resolved; these issues are identified in the article. For instance, it must be settled to what extent the opportunity cost in terms of foregone health for other patients is acceptable in order to uphold formal equality. We conclude that certain arguments can be set aside, and future focus should be put on the unresolved normative and empirical issues related to formal equality and opportunity cost.

Better in theory than in practise? Challenges when applying the luck egalitarian ethos in health care policy

Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals' imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, luck egalitarianism encounters several difficulties. We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of "imprudent actions" in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism's own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy.

Against Ulysses contracts for patients with borderline personality disorder

Patients with borderline personality disorder (BPD) sometimes request to be admitted to hospital under compulsory care, often under the argument that they cannot trust their suicidal impulses if treated voluntarily. Thus, compulsory care is practised as a form of Ulysses contract in such situations. In this normative study we scrutinize the arguments commonly used in favour of such Ulysses contracts: (1) the patient lacking free will, (2) Ulysses contracts as self-paternalism, (3) the patient lacking decision competence, (4) Ulysses contracts as a defence of the authentic self, and (5) Ulysses contracts as a practical solution in emergency situations. In our study, we have accepted consequentialist considerations as well as considerations of autonomy. We conclude that compulsory care is not justified when there is a significant uncertainty of beneficial effects or uncertainty regarding the patient's decision-making capacity. We have argued that such uncertainty is present regarding BPD patients. Hence, Ulysses contracts including compulsory care should not be used for this group of patients.

Severity as a Priority Setting Criterion: Setting a Challenging Research Agenda

Priority setting in health care is ubiquitous and health authorities are increasingly recognising the need for priority setting guidelines to ensure efficient, fair, and equitable resource allocation. While cost-effectiveness concerns seem to dominate many policies, the tension between utilitarian and deontological concerns is salient to many, and various severity criteria appear to fill this gap. Severity, then, must be subjected to rigorous ethical and philosophical analysis. Here we first give a brief history of the path to today’s severity criteria in Norway and Sweden. The Scandinavian perspective on severity might be conducive to the international discussion, given its long-standing use as a priority setting criterion, despite having reached rather different conclusions so far. We then argue that severity can be viewed as a multidimensional concept, drawing on accounts of need, urgency, fairness, duty to save lives, and human dignity. Such concerns will often be relative to local mores, and the weighting placed on the various dimensions cannot be expected to be fixed. Thirdly, we present what we think are the most pertinent questions to answer about severity in order to facilitate decision making in the coming years of increased scarcity, and to further the understanding of underlying assumptions and values that go into these decisions. We conclude that severity is poorly understood, and that the topic needs substantial further inquiry; thus we hope this article may set a challenging and important research agenda.

Genetic testing for breast cancer risk, from BRCA1/2 to a seven gene panel: an ethical analysis

Background

Genetic testing is moving from targeted investigations of monogenetic diseases to broader testing that may provide more information. For example, recent health economic studies of genetic testing for an increased risk of breast cancer suggest that it is associated with higher cost-effectiveness to screen for pathogenic variants in a seven gene panel rather than the usual two gene test for variants in BRCA1 and BRCA2. However, irrespective of the extent to which the screening of the panel is cost-effective, there may be ethical reasons to not screen for pathogenic variants in a panel, or to revise the way in which testing and disclosing of results are carried out.

Main text

In this paper we discuss the ethical aspects of genetic testing for an increased risk of breast cancer with a special focus on the ethical differences between screening for pathogenic variants in BRCA1/2 and a seven gene panel. The paper identifies that the panel increases the number of secondary findings as well as the number of variants of uncertain significance as two specific issues that call for ethical reflection.

Conclusions

We conclude that while the problem of handling secondary findings should not be overstated with regard to the panel, the fact that the panel also generate more variants of uncertain significance, give rise to a more complex set of problems that relate to the value of health as well as the value of autonomy. Therefore, it is insufficient to claim that the seven gene panel is preferable by only referring to the higher cost effectiveness of the panel.

From Child Protection to Paradigm Protection-The Genesis, Development, and Defense of a Scientific Paradigm

A scientific paradigm typically embraces research norms and values, such as truth-seeking, critical thinking, disinterestedness, and good scientific practice. These values should prevent a paradigm from introducing defective assumptions. But sometimes, scientists who are also physicians develop clinical norms that are in conflict with the scientific enterprise. As an example of such a conflict, we have analyzed the genesis and development of the shaken baby syndrome (SBS) paradigm. The point of departure of the analysis is a recently conducted systematic literature review, which concluded that there is very low scientific evidence for the basic assumption held by Child Protection Teams: when certain signs are present (and no other “acceptable” explanations are provided) the infant has been violently shaken. We suggest that such teams have developed more value-based than scientific-based criteria when classifying SBS cases. Further, we suggest that the teams are victims of “groupthink,” aggravating the difficulties in considering critics’ questioning the criteria established by the teams.

Do not despair about severity-yet

In a recent extended essay, philosopher Daniel Hausman goes a long way towards dismissing severity as a morally relevant attribute in the context of priority setting in healthcare. In this response, we argue that although Hausman certainly points to real problems with how severity is often interpreted and operationalised within the priority setting context, the conclusion that severity does not contain plausible ethical content is too hasty. Rather than abandonment, our proposal is to take severity seriously by carefully mapping the possibly multiple underlying accounts to well-established ethical theories, in a way that is both morally defensible and aligned with the term's colloquial uses.

Research Integrity Among PhD Students at the Faculty of Medicine: A Comparison of Three Scandinavian Universities

This study investigates research integrity among PhD students in health sciences at three universities in Scandinavia (Stockholm, Oslo, Odense). A questionnaire with questions on knowledge, attitudes, experiences, and behavior was distributed to PhD students and obtained a response rate of 77.7%. About 10% of the respondents agreed that research misconduct strictly defined (such as fabrication, falsification, and plagiarism, FFP) is common in their area of research, while slightly more agreed that other forms of misconduct is common. A nonnegligible segment of the respondents was willing to fabricate, falsify, or omit contradicting data if they believe that they are right in their overall conclusions. Up to one third reported to have added one or more authors unmerited. Results showed a negative correlation between “good attitudes” and self-reported misconduct and a positive correlation between how frequent respondents thought that misconduct occurs and whether they reported misconduct themselves. This reveals that existing educational and research systems partly fail to foster research integrity.

Justifying the Expansion of Neonatal Screening: Two Cases

During the last two decades, neonatal screening in Europe and North America has expanded substantially. This article examines two recent suggestions for expanding neonatal screening: severe combined immunodeficiency (SCID) and X-linked adrenoleukodystrophy (X-ALD). With reference to well-established risk-benefit based rationales for screening, it is argued that the case for introducing SCID in neonatal screening is considerably stronger than for introducing X-ALD. For instance, the majority of those screened for X-ALD most likely have a negative risk-benefit ratio of screening: they develop milder symptoms or perhaps no symptoms at all, while still being monitored for a long time. This argument is used as a vehicle for making some general points regarding justified expansions of neonatal screening. First, when considering the expansion of neonatal screening, we should look at a condition specific case-by-case basis. Moreover, future expansions of neonatal screening should stick to the well-established rationales for screening while avoiding risk-benefit slippage. Otherwise, more strict procedures of informed consent are warranted in neonatal screening, procedures that, in the end, risk undermining the benefits of current neonatal screening programmes.

Restraint in a Neurosurgical Setting: A Mixed-Methods Study

OBJECTIVE

To investigate the extent to which restraint is used in neurosurgical care, under what circumstances, and how it is documented.

METHODS

A cross-sectional study with a mixed-methods approach was used to identify neurosurgical inpatients subjected to restraint. The data were collected in 2 phases: (1) a study-specific questionnaire was distributed to nurses in which they identified if restraints had occurred during their shifts, and if so, which restraint and to which patient; and (2) scrutinizing of electronic medical records of patients identified by the questionnaires. Numeric data were analyzed using descriptive and analytic statistical methods, and textual data were analyzed using qualitative content analysis. The findings from the different data sources were compared and merged.

RESULTS

Of the 517 patients admitted to the studied department during the study period, 58 (11%) were reported to have been subjected to restraint and most of the restraining events occurred in the neurointensive care unit. Most restraint measures were not documented in the electronic medical records. The identified patients were predominantly diagnosed with traumatic brain injury or subarachnoid hemorrhage. The qualitative content analysis showed the circumstances when restraints were used: when patients were considered a danger to self or others (theme) and which symptoms and behaviors (categories) were observed in relation to the use of restraint.

CONCLUSIONS

Restraint in neurosurgical care is mostly used to prevent patients from harming themselves or others. Because of the lack of documentation, restraint measures cannot be openly assessed, thus putting patients' safety at risk.

Principles of Need and the Aggregation Thesis

Principles of need are constantly referred to in health care priority setting. The common denominator for any principle of need is that it will ascribe some kind of special normative weight to people being worse off. However, this common ground does not answer the question how a plausible principle of need should relate to the aggregation of benefits across individuals. Principles of need are sometimes stated as being incompatible with aggregation and sometimes characterized as accepting aggregation in much the same way as utilitarians do. In this paper we argue that if one wants to take principles of need seriously both of these positions have unreasonable implications. We then characterize and defend a principle of need consisting of sufficientarian elements as well as prioritarian which avoids these unreasonable implications.

Challenges to patient centredness - a comparison of patient and doctor experiences from primary care

Background

We designed this observational study to investigate the level of patients’ and doctors’ ratings of patient-centred aspects of the primary care consultation.

Methods

Questionnaire study with patients and doctors. Consecutive patients in a primary care setting and 16 doctors responding post visit. Results are presented as proportions with 95% confidence intervals.

Results

411 questionnaires, 223 from patients and 188 from doctors, covered 251 consultations. Both patients and doctors gave the highest possible estimations on the aspects of patient-centred communication and satisfaction less frequently when the patient had other reasons for visit than purely somatic. Unlike the doctors’ estimations, the frequency of highest possible estimations in patient responses dropped if the patients had two to six reasons for visit rather than one. Among the six patient-centred aspects, both patients and doctors gave the highest possible estimation least frequently on the aspect of shared decision-making.

Conclusion

The results suggest that the nature of the reason, as well as the number of reasons for visit, interferes with the doctors’ level of patient-centred communication. Our results furthermore confirm the findings of previous studies that doctors insufficiently involve patients in their care.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0959-y) contains supplementary material, which is available to authorized users.

Targeting ethical considerations tied to image-based mobile health diagnostic support specific to clinicians in low-resource settings: the Brocher proposition

Background: mHealth applications assist workflow, help move towards equitable access to care, and facilitate care delivery. They have great potential to impact care in low-resource countries, but have significant ethical concerns pertaining to patient autonomy, safety, and justice. Objective: To achieve consensus among stakeholders on how to address concerns pertaining to autonomy, safety, and justice among mHealth developers and users in low-resource settings, in particular for the application of image-based consultation for diagnostic support. Methods: A consensus approach was taken during a three-day workshop using a purposive sample of global mHealth stakeholders (n = 27) professionally and geographically spread. Throughout a series of introductory talks, group brainstorming, plenary reviews, and synthesis by the moderators, lists of actions were generated that address the concerns engendered by mHealth applications on autonomy, justice and safety, taking into account the development, implementation, and scale-up phases of an mHealth application lifecycle. Results: Several types of actions were recommended; key ones among them included building in risk mitigation measures from the development stage, establishing inclusive consultation processes, using open sources platform whenever possible, training all clinical users, and bearing in mind that the gold standard of care is face-to-face consultation with the patient. Recommendations of patient, community and health system participation and of governance were identified as cutting across the mHealth lifecycle. Conclusion: Priorities agreed-upon at the meeting echo those put forward concerning other domains and locations of application of mHealth. Those more forcefully articulated are the need to adopt and maintain participatory processes as well as promoting self-governance. They are expected to cut across the mHealth lifecycle and are prerequisites to the safeguard of autonomy, safety and justice.

Value-impregnated factual claims may undermine medical decision-making

Clinical decisions are expected to be based on factual evidence and official values derived from healthcare law and soft laws such as regulations and guidelines. But sometimes personal values instead influence clinical decisions. One way in which personal values may influence medical decision-making is by their affecting factual claims or assumptions made by healthcare providers. Such influence, which we call 'value-impregnation,' may be concealed to all concerned stakeholders. We suggest as a hypothesis that healthcare providers' decision making is sometimes affected by value-impregnated factual claims or assumptions. If such claims influence e.g. doctor-patient encounters, this will likely have a negative impact on the provision of correct information to patients and on patients' influence on decision making regarding their own care. In this paper, we explore the idea that value-impregnated factual claims influence healthcare decisions through a series of medical examples. We suggest that more research is needed to further examine whether healthcare staff's personal values influence clinical decision-making.

Misuse of Coauthorship in Medical Theses in Sweden

The aim of this study was to explore experiences of authorship issues among persons who have recently received their doctoral degree in medicine in Sweden. A survey was mailed to all who received their PhD at a medical faculty at a Swedish university the first half of 2016. Questions concerned experiences of violations of the first three authorship criteria in the Vancouver rules and of misuse of authorship order in the articles of their thesis, and the respondents' attitudes to these matters. The questionnaire was returned by 285 respondents (68%). According to the majority (53%), the Vancouver rules were not fully respected in the articles of their thesis. A vast majority (97%) found it important that authorship issues are handled correctly, but only 19% responded that their department has a clear and consistently applied policy. We conclude that authorship guidelines are frequently disrespected at medical faculties in Sweden. The universities seem to provide limited support on authorship issues.

[The ethical problems in limiting the role for cost-effectiveness]

In relation to the Swedish ethical platform for priority setting in health-care it is debated what role cost-effectiveness should play. In the article an ethical analysis is presented showing that a limited role risks leading to unequal priorities between similar needs in conflict with the human dignity and need-solidarity principles of the platform. It is also argued that resulting problems with effect comparability over different conditions and resulting equality problems with the current praxis can be mitigated through strategies like explicitly considering outcome measure and by adjusting the cost-effectiveness threshold under specific conditions.

Psychiatrists' motives for practising in-patient compulsory care of patients with borderline personality disorder (BPD)

INTRODUCTION

Patients with BPD are often subjected to compulsory care. However, as compulsory care restricts liberty and may have negative effects, it is recommended that it be used sparingly. In this study, we investigate psychiatrists' motives for practising compulsory care of BPD patients.

METHOD

Semi-structured interviews with twelve Swedish psychiatrists from Stockholm County. These interviews were analysed according to descriptive qualitative analysis.

RESULTS

The qualitative data from our study resulted in three themes: (1) BPD patients are perceived as difficult: interpersonally, in clinical and legal management, and due to suicide risk; (2) there are medical and non-medical motives for compulsory care of BPD patients, and its consequences can vary; and (3) BPD patients have decision competence and sometimes demand to be taken into compulsory care.

CONCLUSION

The interviewed psychiatrists' own judgements and values, rather than clinical and legal directions, were decisive in their practice of compulsory care. For the BPD patients, this can result in vast differences in the mental healthcare offered, depending on which individual psychiatrist they encounter. Socio-political expectations and psychiatrists' personal views seem to lead to more compulsory care of BPD patients than is clinically recommended and legally sanctioned.

Skepticism towards the Swedish vision zero for suicide: interviews with 12 psychiatrists

Background

The main causes of suicide and how suicide could and should be prevented are ongoing controversies in the scientific literature as well as in public media. In the bill on public health from 2008 (Prop 2007/08:110), the Swedish Parliament adopted an overarching “Vision Zero for Suicide” (VZ) and nine strategies for suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized both from a philosophical perspective and against the background of clinical experience and alleged empirical claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the normative discussion by investigating empirically how the VZ is perceived in healthcare.

Methods

Interviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists. The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the Vision Zero for Suicide as well as arguments for and against it.

Results

Though most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide, the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to be unachievable, while others focused more on its potential consequences and normative implications.

Conclusions

The VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive, and undesirable because of potential conflicts with other values and interests of patients as well as the general public. There were also important notions of the VZ having negative consequences for the working conditions of psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship.

Electronic supplementary material

The online version of this article (10.1186/s12910-018-0265-6) contains supplementary material, which is available to authorized users.

"Right to recommend, wrong to require"- an empirical and philosophical study of the views among physicians and the general public on smoking cessation as a condition for surgery

BACKGROUND

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as well as the reasons provided for this.

METHODS

A random sample of general practitioners and orthopaedic surgeons (n = 795) as well as members of the general public (n = 485) received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy.

RESULTS

Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains.

CONCLUSIONS

There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a "recommendation strategy" vis-à-vis smoking cessation prior to surgery rather than a "requirement strategy". The normative reasons speak in favour of the "recommendation strategy".

[NIPT – implentation, counselling and ethical issues]

NIPT - implentation, counselling and ethical issues It is today possible to analyze cell-free fetal DNA from a blood sample from the pregnant woman, i.e. non-invasive prenatal testing, NIPT. Thus, by a simple blood test from the mother you can detect trisomy 13, 18 and 21 in the fetus with high accuracy. However, NIPT is not a diagnostic test and a positive result should be confirmed by an invasive test, like chorionic villus sampling or amniocentesis. There are national guidelines from the Swedish Society of Obstetrics and Gynaecology (SFOG) on how to implement and use NIPT for trisomies in the Swedish health care. As NIPT is only a blood test there is a risk that it is seen by the expectant parents as a routine test or as a recommendation from the health care. Pre-test counselling is therefore of great importance to enable informed choice.

Is healthcare providers' value-neutrality depending on how controversial a medical intervention is? Analysis of 10 more or less controversial interventions

Background

Swedish healthcare providers are supposed to be value-neutral when making clinical decisions. Recent conducted studies among Swedish physicians have indicated that the proportion of those whose personal values influence decision-making (the value-influenced) vary depending on the framing and the nature of the issue.

Objective

To examine whether the proportions of value-influenced and value-neutral participants vary depending on the extent to which the intervention is considered controversial.

Methods

To discriminate between value-neutral and value-influenced healthcare providers, we have used the same methods in six vignette based studies including 10 more or less controversial interventions. To be controversial was understood as being an intervention where conscientious objections in healthcare have been proposed or an intervention that is against law and regulations.

Results

End of life decisions and female reproduction issues are associated with conscientious objection and more or less against regulations, and also resulted in the highest proportions of value-influenced participants. Following routines, which is not in conflict with official values, were associated with one of the lowest proportion of value-influenced participants. The difference between the highest and lowest proportions of value-influenced participants among the 10 examined interventions was significant (81.8% (95% confidence interval: 78.1–85.5) versus 34.7% (95% confidence interval: 29.2–40.2)).

Conclusion

The study indicates that the proportions of value-neutral participants decrease the more controversial an issue is, and vice versa. In some cases, however, framing effects may potentiate or obscure this association. As a bold hypothesis, we suggest the proportion of value-neutral or value-influenced might indicate how controversial an issue is.

Value-impregnated factual claims and slippery-slope arguments

Slippery-slope arguments typically question a course of action by estimating that it will end in misery once the first unfortunate step is taken. Previous studies indicate that estimations of the long-term consequences of certain debated actions, such as legalizing physician-assisted suicide, may be strongly influenced by tacit personal values. In this paper, we suggest that to the extent that slippery-slope arguments rest on estimations of future events, they may be mere rationalizations of personal values. This might explain why there are proponents even for strikingly poor slippery-slope arguments.

Challenges for principles of need in health care

What challenges must a principle of need for prioritisations in health care meet in order to be plausible and practically useful? Some progress in answering this question has recently been made by Hope, Østerdal and Hasman. This article continue their work by suggesting that the characteristic feature of principles of needs is that they are sufficientarian, saying that we have a right to a minimally acceptable or good life or health, but nothing more. Accordingly, principles of needs must answer two distributive questions: when do we have sufficient and how should we prioritise among those who do not yet have a sufficiency? Furthermore, it is argued that Roger Crisp's theory of need, which combines sufficientarianism with prioritarianism below the threshold of need, is better equipped than alternatives to answer these questions as well as meeting the challenges formulated by Hope, Østerdal and Hasman. However, Crisp's theory faces two major challenges. First, it has to say something about the currency of distribution: a principle of need must be complemented either with a theory on the human good or a theory about the proper goals of health care. Second, it has to say something about where the threshold should be set. However, any attempt to set a threshold seems morally arbitrary in the light of the sufficientarian idea that those just above the threshold never should be given priority over those just below the threshold.

Empirical and philosophical analysis of physicians' judgments of medical indications

Background

The aim of this study was to investigate whether physicians who felt strongly for or against a treatment, in this case a moderately life prolonging non-curative cancer treatment, differed in their estimation of medical indication for this treatment as compared to physicians who had no such sentiment. A further aim was to investigate how the notion of medical indication was conceptualised.

Methods

A random sample of GPs, oncologists and pulmonologists (n = 646) comprised the study group. Respondents were randomised to receive either version of a case presentation; in one version, the patient had smoked and in the other version she had never smoked. The physicians were labelled value-neutral (65%) and value-influenced (35%) on the basis of their attitude towards the treatment.

Results

In the ‘value-influenced’ group, there was a significant difference in the estimation of medical indication for treatment depending upon whether the patient had smoked (50% (95% CI: 41–59) or never smoked (67% (95% CI: 58–76) (Chi-2 = 5.8, df = 1; p = 0.016)). There was no such difference in the ‘value-neutral’ group.

Conclusion

This study shows that compared to value-neutral physicians, value-influenced physicians are more likely to base decisions of medical indication on medically irrelevant factors (in this case: the patient’s smoking status). Moreover, medical indication is used in an ambiguous manner. Hence, we recommend that the usage of ‘medical indication’ be disciplined.

Heed or disregard a cancer patient's critical blogging? An experimental study of two different framing strategies

Background

We have examined healthcare staff attitudes of toward a blogging cancer patient who publishes critical posts about her treatment and their possible effect on patient-staff relationships and treatment decisions.

Methods

We used two versions of a questionnaire containing a vignette based on a modified real case involving a 39-year-old cancer patient who complained on her blog about how she was encountered and the treatment she received. Initially she was not offered a new, and expensive treatment, which might have influenced her perception of further encounters. In one version of the vignette, the team decides to put extra effort into both encounters and offers the expensive new cancer treatment. In the other version, the team decides to follow the clinic’s routine to the letter. Subsequently, blog postings became either positive or negative in tone. We also divided participants into value-neutral and value-influenced groups (regarding personal values) by asking how their trust in healthcare would be affected if the team’s suggestion were followed.

Results

A total of 56 % (95 % CI: 51–61) of the respondents faced with a team decision to ‘do something-extra’ in encounters would act in accordance with this ambition. Concerning treatment, 32 % (95 % CI: 28–38) would follow the team’s decision to offer a new and expensive treatment. A large majority of those who received the “follow-routine” version agreed to do so in encountering [94 % (95 % CI: 91–97)]. Similar proportions were found regarding treatment [86 % (95 % CI: 82–90)].

A total of 83 % (95 % CI: 76–91) of the value-neutral participants who received the “do-something-extra” version stated that they would act as the team suggested regarding encounters, while 57 % (95 % CI: 47–67) would do so in regard to treatment. Among the value-influenced participants who received the “do-something-extra” version, 45 % (95 % CI: 38–51) stated that they would make an extra effort to accommodate the patient and her needs, while the proportion for treatment was 22 % (95 % CI: 16–27). Among those who had received the “follow-routine” version, a large majority agreed, and no difference was indicated between the value-neutral and the value-influenced participants.

Conclusion

The present study indicates that healthcare staff is indeed influenced by reading a patient’s critical blog entries, largely regarding encounters, but also concerning treatment is concerned. Value-neutral healthcare personnel seem to exhibit a pragmatic attitude and be more inclined to heed and respond to a patient whose criticism may well be warranted. The study also indicates that healthcare staff is partly positive or negative to future blogging patients depending on how the issue has been framed.

For future research we suggest as a bold hypothesis that the phrase “clinical routine” might conceal power aspects masquerading as adopted ethical principles.

Electronic supplementary material

The online version of this article (doi:10.1186/s12910-016-0115-3) contains supplementary material, which is available to authorized users.

Scientific Dishonesty

As we need knowledge about the prevalence of scientific dishonesty, this study investigates the knowledge of, experiences with, and attitudes toward various forms of scientific dishonesty among PhD students at the main medical faculties in Sweden and Norway. An anonymous questionnaire was distributed to all post-graduate research students attending basic PhD courses at the medical faculties in Stockholm and Oslo during the fall 2014. The responding doctoral students reported to know about various forms of scientific dishonesty from the literature, in their department, and for some also through their own experience. Some forms of scientific misconduct were considered to be acceptable by a significant minority. There was a high level of willingness to report misconduct but little awareness of relevant policies for scientific conduct.