Attitudes to End-of-Life Care and Voluntary Assisted Dying Amongst Members of the Australian Jewish community

The implementation of voluntary assisted dying (VAD) in the Australian State of Victoria in 2019 has stimulated discussions about end-of-life care and dying in many communities. Various attempts have been made to represent the attitudes of the Jewish community, a distinct culturally and linguistically diverse (CALD) group, in terms that suggest a unified set of opinions that opposes VAD policies. This research aimed to explore attitudes to VAD in the context of end-of-life care held by members of the Victorian Jewish community. A descriptive qualitative methodological design was employed. Ten Victorians who identify as Jewish were recruited and participated in in-depth, semi-structured interviews. Reflexive thematic analysis was carried out on the transcripts to identify key themes, attitudes and preferences in relation to end-of-life care, death and dying, and VAD. Three themes were identified: "complexity and variation", "similarities", and "factors influencing attitudes to VAD and end-of-life care". A significant degree of diversity was apparent, ranging from highly supportive of VAD to advocacy for a total repeal of the policy. The results indicate that images of how Victorian Jewish individuals feel towards VAD based on essentialised notions about the community and belief systems are not supported by the evidence. In reality, considerable diversity of attitudes exists towards VAD and end-of-life care. We conclude that it is important that policymakers and members of the broader society avoid stereotypes that falsely characterise this specific community and, by implication, other CALD groups, particularly in terms that ignore internal diversity regarding belief systems, social attitudes and ethical perspectives.

It is Not Too Late for Reconciliation Between Israel and Palestine, Even in the Darkest Hour

The conflict in Gaza and Israel that ignited on October 7, 2023 signals a catastrophic breakdown in the possibility of ethical dialogue in the region. The actions on both sides have revealed a dissolution of ethical restraints, with unimaginably cruel attacks on civilians, murder of children, destruction of health facilities, and denial of basic needs such as water, food, and shelter. There is a need both to understand the nature of the ethical singularity represented by this conflict and what, if any, options are available to allow the reconstruction of communication between the warring parties. This article seeks to address these tasks by analysing the conflict as inherently an ethical one, in the sense that it exposes a rupture in the fabric of communicative relationships that has evolved systematically out of the deep cultural structures from which all protagonists have emerged. Drawing on the work of Levinas, Habermas, Arendt, and others, and referring to the specific circumstances in the region, it examines the ethical sources of the crisis and tries to identify conditions for its resolution. The possibility of reconciliation-that is, of refiguring relationships to open up a space for dialogue to create pathways to heal the ruptures-is examined. The dark legacy of the Holocaust is identified as an abiding cultural vulnerability for both societies. It is concluded, however, that the rich history of partnerships and collaborations between Jews and Palestinians provides a robust infrastructure on the basis of which a sustainable peace might be built, providing a much-needed source of hope.

The Question of the Origins of COVID-19 and the Ends of Science

Intense public interest in scientific claims about COVID-19, concerning its origins, modes of spread, evolution, and preventive and therapeutic strategies, has focused attention on the values to which scientists are assumed to be committed and the relationship between science and other public discourses. A much discussed claim, which has stimulated several inquiries and generated far-reaching political and economic consequences, has been that SARS-CoV-2 was deliberately engineered at the Wuhan Institute of Virology and then, either inadvertently or otherwise, released to the public by a laboratory worker. This has been pursued despite a clear refutation, through comprehensive genomic analysis, of the hypothesis that the virus was deliberately engineered and the failure of detailed investigations to identify any evidence in support of a laboratory leak. At the same time a substantial, established body of knowledge about the many factors underlying the emergence of novel zoonotic diseases has been largely ignored-including climate change and other mechanisms of environmental destruction, tourism, patterns of trade, and cultural influences. The existence and conduct of these debates have raised questions about the vulnerability of science to manipulation for political purposes. Scientific discourses are vulnerable because: (i) claims can be made with no more than probabilistic force; (ii) alleged "facts" are always subject to interpretation, which depends on social, ethical, and epistemological assumptions; and (iii) science and scientists are not inherently committed to any single set of values and historically have served diverse, and sometimes perverse, social and political interests. In the face of this complexity, the COVID-19 experience highlights the need for processes of ethical scrutiny of the scientific enterprise and its strategic deployment. To ensure reliability of truth claims and protection from corrupting influences robust ethical discourses are required that are independent of, and at times even contrary to, those of science itself.

'It's communication between people who are going through the same thing': experiences of informal interactions in hospital cancer treatment settings

PURPOSE

In hospital settings, patients, visitors, and staff engage in many interactions outside formal clinical encounters. Whilst many of these may be inconsequential, others contribute significantly to how patients and their carers experience cancer and its treatment. This article aims to explore the experiences and significance of interactions that occur outside formal clinical encounters in hospital cancer treatment settings.

METHODS

Semi-structured interviews were conducted with cancer patients, carers, and staff recruited from two hospital sites and cancer support groups. Hermeneutic phenomenology informed lines of questioning and data analysis.

RESULTS

Thirty-one people participated in the study: 18 cancer patients, four carers, and nine staff members. The experiences of informal interactions were grouped into three themes: connecting, making sense, and enacting care. The participants described how these encounters allowed connection with others in the hospital spaces, facilitating a sense of belonging, normality, and self-worth. Through these interactions, individuals participated in making sense of their experiences, to better anticipate the decisions and challenges that might lie ahead. By connecting with other individuals, they cared for others and felt cared for themselves, and were able to learn from, teach, and support each other.

CONCLUSIONS

Outside the confines of the clinical discourses participants negotiate terms of engagement, sharing of information, expertise, and their own personal stories that they may employ to contribute to the individuals around them. These interactions occur within a loose and evolving framework of social interactions, an 'informal community', in which cancer patients, carers, and staff members play active and meaningful roles.

Herman Boerhaave's Clinical Teaching: A Story of Partial Historiography

Gerrit Lindeboom's biography, Herman Boerhaave: The Man and His Work, presents a heroic account of Herman Boerhaave's life and his many contributions to medicine and medical education. He is portrayed as an outstanding eighteenth century educator who introduced into Leiden's Medical School a novel method of clinical teaching that was to be widely adopted and today remains at the centre of medical student instruction. Lindeboom's historiography induced a resurgence of interest in Boerhaave, a renewal of the myth concerning Boerhaave's innovative teaching and the publication of many acclamatory articles and false epithets, and several critical analyses. Such varying responses prompted this critical examination of the extant Boerhaavian literature, an appraisal of Lindeboom's objectivity and an assessment of his representations of Boerhaave's clinical teaching. In doing so, the moral nature of his historiography and that of those who were to sustain his assertions will be established, and the myth that surrounds the novelty and excellence of Boerhaave's clinical teaching will be evident.

Changing times in public health: The new wave of self-collection of invasive samples

Testing in public health programs has long been recognised as beneficial but has often been experienced by community members as intrusive and paternalistic. Cervical screening has been seen as even more threatening by women who have experienced sexual violence or come from culturally and linguistically diverse communities. A simple and natural solution to these formidable barriers, increasingly recognised in recent years, has been presented by the advent of self-testing. This article recounts the struggle to encourage medical practitioners to accept patient self-testing. It emphasises the importance of scrutinising our own personal prejudices, listening to the community, and being open to novel strategies that ensure inclusiveness and respect for those whose interests we are seeking to serve.

Response-The Multiple Understandings in the Clinic Do Not Always Need to be Resolved

This article reflects on the assumption underlying the argument of Little et al. that "contested understandings" in the clinic are susceptible to reconciliation within a liberal framework described as "pragmatic pluralism". It is argued that no such reconciliation is possible or desirable because it is of the nature of the clinic that it provides a forum for multiple voices, ethical and cultural perspectives, and conceptual frameworks, and this is the source of its fecundity and creativity. Medicine itself cannot be represented by a single discourse, precisely because it is itself an unruly collection of practices that, despite their heterogeneity, are able to engage in productive dialogues with each other. The heteroglossia of the clinic, therefore, is not a problem to be overcome. Rather, it is a rich resource to be mobilized in accordance with its multiple inherent purposes.

Understanding Complexity in Care: Opportunities for Ethnographic Research in Palliative Care

Background: Ethnography has been used to address a broad range of research questions in health care. With ethnographic research methods it is possible to gain access to the complex realities of health care practice as it occurs, through interpreting the nuances of individual and team behaviours, the roles and dynamics of care provision, and the social impacts and influences of illness. The provision of clinical palliative care is complex, involving multidisciplinary collaboration across different health systems, and is subject to a multitude of personal, cultural and environmental influences. This complexity demands creative methodological approaches to research in palliative care, of which ethnography plays an important, if infrequently utilised, role. Aim: This article aims to explore potential opportunities of ethnographic methods for palliative care research. Findings: Ethnographic methods focuses on behaviour in the 'natural' setting of participants, to create theoretical descriptions of events, cultures, interactions and experiences. In palliative care these methods may provide nuanced understandings of illness, relationships and teams, communication, medical education, complex care provision, and novel or changing health practices. Of particular importance is the potential of these methods to understand complex practices and processes, and engage with under-represented population groups who may be excluded from interview research. Conclusion: Ethnography offers important opportunities for future research in palliative care and should be considered as part of the 'research toolbox' to improve understanding of the complex nature of care provision and the experiences of illness and loss.

COVID-19 restrictions should only be lifted when it is safe to do so for Aboriginal communities

The NSW Government has proposed a blanket lifting of COVID‐19 restrictions when the proportion of fully vaccinated people rate reaches 70% of the adult population. If implemented, this would have devastating effects on Aboriginal populations. At the present time, vaccination rates in Aboriginal communities remain low. Once restrictions are lifted, unvaccinated people will be at high risk of infection. The risks of serious illness and death among Aboriginal people from a variety of medical conditions are significantly greater than for the wider population. This is also the case with COVID‐19 in First Nations populations around the world. The vulnerability of Aboriginal people is an enduring consequence of colonialism and is exacerbated by the fact that many live in overcrowded and poorly maintained houses in communities with under‐resourced health services. A current workforce crisis and the demographic structure of the population have further hindered the effectiveness of vaccination programmes. Aboriginal organisations have called on state and federal governments to delay any substantial easing of restrictions until full vaccination rates among Aboriginal and Torres Strait Islander populations aged 16 years and older reach 90–95%. They have also called for additional support in the form of supply of vaccines, enhancement of workforce capacity and appropriate incentives to address hesitancy. Australia remains burdened by the legacy of centuries of harm and damage to its First Nations people. Urgent steps must be taken to avoid a renewed assault on Aboriginal and Torres Strait Islander health.

Hidden in Plain Sight: The Moral Imperatives of Hippocrates' First Aphorism

This historiographic survey of extant English translations and interpretations of the renowned Hippocratic first aphorism has demonstrated a concerning acceptance and application of ancient deontological principles that have been used to justify a practice of medicine that has been both paternalistic and heteronomous. Such principles reflect an enduring Hippocratism that has perpetuated an insufficient appreciation of the moral nature of the aphorism's second sentence in the practice of the art of medicine. That oversight has been constrained by a philological discourse that has centred on the meanings of the aphorism's first sentence, while little consideration has been given to the more important ethical consideration within the second sentence's imperatives.

Clinical Ethics from the Islamic Perspective : A qualitative study exploring the views of Jordanian doctors

Like other Arab countries, Jordan must find ways of responding to the rapid processes of change affecting many aspects of social life. This is particularly urgent in healthcare, where social and technical change is often manifested in tensions about ethical decision-making in the clinic. To explore the attitudes, beliefs and concerns relating to ethical decision-making among health professionals in Jordanian hospitals, a qualitative study was conducted involving face-to-face interviews with medical personnel in four hospitals in Amman, the capital of Jordan. Data were analysed thematically in relation to a pre-existing set of ethical categories. Interviews were conducted with thirty-eight doctors covering most medical specialities. Five major themes emerged from the interviews: ethical awareness, ethical issues, the impact of religion on ethical decision-making, practical and theoretical resources for ethical decision-making, and challenges. While uncertainty was expressed about some aspects of Western approaches to ethics, participants strongly supported adoption of a range of Western bioethical principles, including cultural and ethical diversity, along with adherence to Islamic religious norms. A range of serious ethical challenges facing the Jordanian health system were identified, covering social, legal, managerial, and technical issues. Ethical decision-making in Jordan is complex, having to accommodate the needs of patients, the opinions of doctors and their families, the views of religious authorities, managerial considerations, and both local norms and international standards. Health professionals struggle with three sets of tensions that emerge out of the struggle between traditional, community-embedded forms of social organization and the demands generated by globalization and the influence of Western culture: the tensions between tradition and modernity, conservatism and pragmatism, and religion and secularism. Doctors in Jordan prefer approaches to ethical decision-making that realize a balance between the extremes, although the exact nature of where that balance should lie remains uncertain.

Not all Bad: Sparks of Hope in a Global Disaster

The focus of discussion about the ethical issues associated with the COVID-19 pandemic has been on the great suffering to which it has given rise. However, there may be some unexpected positive outcomes that also emerge from the global disaster. The rupturing of entrenched systems and processes, the challenging of certainties that seemed beyond question, and the disruption of the assumed consensus of modernity may contribute to a rediscovery of the challenges that compose an ethical life. Elements of such a process are evident in the surge of community support and mutual caring, of spontaneous acts of joyous solidarity, of suspension of past conflicts, and exploration of new forms of reconciliation. The experiences are tentative and the outcomes uncertain, but at least for a moment the hope of a new way forward has been raised.

COVID-19-Extending Surveillance and the Panopticon

Surveillance is a core function of all public health systems. Responses to the COVID-19 pandemic have deployed traditional public health surveillance responses, such as contact tracing and quarantine, and extended these responses with the use of varied technologies, such as the use of smartphone location data, data networks, ankle bracelets, drones, and big data analysis. Applying Foucault's (1979) notion of the panopticon, with its twin focus on surveillance and self-regulation, as the preeminent form of social control in modern societies, we examine the increasing levels of surveillance enacted during this pandemic and how people have participated in, and extended, this surveillance, self-regulation, and social control through the use of digital media. Consideration is given to how such surveillance may serve public health needs and/or political interests and whether the rapid deployment of these extensive surveillance mechanisms risks normalizing these measures so that they become more acceptable and then entrenched post-COVID-19.

Promoting ethics across the healthcare sector: what can codes achieve?

Over the course of the twentieth century, numerous national and international ethics 'codes' have been developed. While such codes serve important substantive and symbolic functions, they can also pose challenges. In this article, we discuss these challenges, noting that they fall into four main categories relating to conceptual tensions, power imbalances, organisational barriers, and threats of exploitation. We illustrate these challenges using examples provided from the United Nations Educational Scientific and Cultural Organization (UNESCO) Universal Declaration on Bioethics and Human Rights. We emphasise the importance of accountability in the development and maintenance of national and international codes and argue that, despite all their challenges, codes provide an important common language among otherwise disparate and sometimes adversarial groups, and provide visible and explicit sets of standards that may be invoked by community members to criticise and hold powerful bodies to account. This is particularly important for practitioners and researchers who belong to organisations that are signatories to codes, who can use these codes to both guide and justify ethical behaviour in the face of competing organisational, professional and political imperatives.

The struggle for gender diversity

INTRODUCTION

Contradictory social policies and attitudes about gender diversity raise questions about how we should understand the current status of the historical 'heterosexual' gender regime.

CONCLUSION

Drawing on the work of the feminist philosopher and psychoanalyst Luce Irigaray, this essay argues that sexual difference is the irreducible starting point for all meaning, sense, morality and affect.

Communal responsibility: a history of health collectives in Australia

Healthcare encompasses multiple discourses to which health professionals, researchers, patients, carers and lay individuals contribute. Networks of patients and non-professionals often act collectively to build capacity, enhance access to resources, develop understanding and improve provision of care. This article explores the concept of health collectives and three notable examples that have had an enduring and profound impact in the Australian context.

The struggle for clinical ethics in Jordanian Hospitals

The Arab and Islamic world is in cultural, political and ethical flux. Pressures of globalisation contend with ancient ideas and concepts that permeate cultural frameworks. Health professionals are among the many groups battling to accommodate the rapidly changing conditions. In many predominantly Muslim countries intense debates are underway among clinicians about the impact of the forces of change on their practices. To help understand these forces we conducted a study of the experiences of clinicians in the Hashemite Kingdom of Jordan, a Middle Eastern nation state where the overwhelming majority of the population is Muslim. The sample contained 508 doctors and doctors-in-training, of whom 63% were male and 80% were younger than 40 years of age. It included both a quantitative survey, covering a wide range of issues, and qualitative, free-text written responses. Our results demonstrated high levels of disquiet related to the overall organisation and administration of the health care system, the specific content of ethical decisionmaking, and the impact of changing social, cultural and religious factors. Concerns included overcrowding, widespread corruption and hierarchical, non- democratic, management practices, and tensions relating to traditional and modern approaches to ethics, especially in relation to consent, organ donation, confidentiality, privacy, abortion, and the role of women. The roles of religion and religious authorities, the relative importance of the family, and community and tribal obligations were also areas of contention. The study exposes profound divisions and widely differing perspectives among Jordanian doctors and an abiding sense of uncertainty and instability within the profession. Many doctors express ambivalence in relation to both modern trends and traditional precepts. Three main axes of ethical contention were demonstrated, relating to the tensions between: "conservative" and "pragmatic" styles of decision-making; "traditional" approaches and internationalised standards of ethics; and the role of Islam and pressures to disengage ethical decision- making from religious authority. We speculate that these issues and divisions, and the deep sense of disquiet revealed by our data reflect large-scale forces to which Jordanian society is exposed and to a substantial degree may provide a way to understand the ethical predicament of many other countries in the contemporary Arab world.

Complementary medicine use among people living with HIV/AIDS in Victoria, Australia: practices, attitudes and perceptions

There is limited evidence suggesting the underlying reasons for the use of complementary and alternative medicines (CAMs) by people with HIV/AIDS, or individual attitudes and beliefs about the use of CAMs. Using focus groups and a survey with 151 individuals attending the HIV Clinics at The Alfred Hospital, Melbourne, we aimed to provide insights into factors that influence the use of CAMs among people living with HIV/AIDS. Roughly half (49%) of the participants had used CAMs to manage their HIV/AIDs. Users of CAMs utilized a wide range of treatments in managing their condition, but costs of the CAMs meant that users were not necessarily able to use them as much as they might have liked. Use of CAMs was based on a desire to find something beneficial rather than on being dissatisfied with conventional medicine. Further research is needed into (a) the effects of CAMs and (b) the enhancement of communication and collaboration between patients, doctors and complementary medicine practitioners.

Chinese Medicine in Australia

OBJECTIVES

Chinese medicine is a complex domain of theoretical and practical approaches that is being increasingly put under the research spotlight. The "Chinese Medicine in Australia" research project attempted to capture the clinical features of practitioners of Chinese medicine.

PARTICIPANTS AND INTERVENTIONS

The project involved a national survey of Chinese medicine professional association members and registered practitioners in the state of Victoria, Australia (n = 655; response rate, 42%-55%) completed in 2012-2013.

DESIGN

The content and face validated survey was developed using new and previous workforce survey questions.

RESULTS

This paper reports on the workforce and practice characteristics of the survey respondents. Chinese medicine practitioners are highly educated, come from diverse backgrounds, and have chosen to practice predominantly in sole or multipractitioner private practice settings. An interest in the philosophy of Chinese medicine and previous experiences contributed to practitioners' decisions to study and practice Chinese medicine. Incorporating a variety of techniques, practitioners describe themselves as practicing predominantly Chinese acupuncture and herbal medicine.

CONCLUSIONS

The results from this survey contribute to the understanding of the nature and description of Chinese medicine practice in Australia.

A gentle ethical defence of homeopathy

Recent discourses about the legitimacy of homeopathy have focused on its scientific plausibility, mechanism of action, and evidence base. These, frequently, conclude not only that homeopathy is scientifically baseless, but that it is "unethical." They have also diminished patients' perspectives, values, and preferences. We contend that these critics confuse epistemic questions with questions of ethics, misconstrue the moral status of homeopaths, and have an impoverished idea of ethics-one that fails to account either for the moral worth of care and of relationships or for the perspectives, values, and preferences of patients. Utilitarian critics, in particular, endeavour to present an objective evaluation-a type of moral calculus-quantifying the utilities and disutilities of homeopathy as a justification for the exclusion of homeopathy from research and health care. But these critiques are built upon a narrow formulation of evidence and care and a diminished episteme that excludes the values and preferences of researchers, homeopaths, and patients engaged in the practice of homeopathy. We suggest that homeopathy is ethical as it fulfils the needs and expectations of many patients; may be practiced safely and prudentially; values care and the virtues of the therapeutic relationship; and provides important benefits for patients.

A minimalist legislative solution to the problem of euthanasia

Intense debate has continued for many years about whether voluntary euthanasia or assisted suicide should be permitted by law. The community is bitterly divided and there has been vigorous opposition from medical practitioners and the Australian Medical Association. Despite differences of religious and philosophical convictions and ethical values, there is widespread community agreement that people with terminal illnesses are entitled to adequate treatment, and should also be allowed to make basic choices about when and how they die. A problem with the current law is that doctors who follow current best practice cannot be confident that they will be protected from criminal prosecution. We propose simple changes to Commonwealth and state legislation that recognise community concerns and protect doctors acting in accordance with best current practice. This minimalist solution should be widely acceptable to the community, including both the medical profession and those who object to euthanasia for religious reasons. Important areas of disagreement will persist that can be addressed in future debates.

Practical aspects of telehealth: doctor-patient relationship and communication

The fourth in a series of articles about the practical aspects of telehealth, this paper provides advice and information for specialists to communicate effectively with patients during a telehealth video consultation.

Practical aspects of telehealth: set-up and preparation for video consultations

The third in a series of articles about the practical aspects of telehealth, this paper gives guidance on suitable setup for video consultations, including layout of rooms, managing sound and image quality, scheduling, testing and best practice in telehealth videoconferencing.

Medicine and the task of healing

To understand the traditional description of medicine as a practice of healing, it is necessary to examine its relationships with both science and ethics. The "scientific" component of medicine includes an acknowledgment of the influence of social, cultural and environmental factors on the functioning of the organism. The "ethical" component is often presented as merely supplementary but actually provides the conditions of possibility of knowledge. "Healing" then appears as what joins the two together: the site where science is applied in the service of ethics and where ethics encounters science. This perspective allows us to reconsider medicine as a project to healing complex wounds that manifest themselves at the physical, psychological, emotional and cultural levels.

Practical aspects of telehealth: are my patients suited to telehealth?

The first in a series of articles that demonstrate the practical aspects of telehealth, this paper provides three case studies that examine the suitability of telehealth for patients living in rural and remote areas who require ongoing specialist care.

A case study approach to investigating end-of-life decision making in an acute health service

Aim. To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital. Methods. A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning. Results. Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66–99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24 h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care. Conclusion. This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment. What is known about the topic? End of life (EOL) care planning has been widely discussed in some countries but research into outcomes of such programs has produced variable results both in real outcomes for patients and in satisfaction and ease of application for health professionals. Programs of advance care planning have been introduced in some Australian health services but are yet to produce definitive results. What does this paper add? This paper identifies some of the factors that appear to impact on EOL decision making processes in a major Australian metropolitan hospital for patients suffering non-cancer life-limiting illnesses. These data will facilitate the development of more effective EOL care processes in this and other similar healthcare services. What are the implications for practitioners? Clear effective processes for making EOL decisions are likely to result in better outcomes for patients, family members and practitioners. A distinctive cluster of patient circumstances may identify risk for poor advance care planning.