Journal scan: A review of 15 Ethics with clinical significance, harvested from a major international journal

From the desk of the Editor-in-Chief

Special Edition on Ethics: Healthcare Ethics and Communication| Volume 52, Issue 7, P403, July 2024

(1). Introduction

John Saunders Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.005

This edition of Medicine is with a focus on ethical issues, medical humanities and philosophy in medicine. It includes a wide range of current concerns to inform medical practice for all doctors.

(2). Transplantation and consent

John Saunders, Published: May 29, 2024DOI: https://doi.org/10.1016/j.mpmed.2024.04.015

Abstract

This is an overview of issues relating to consent in donation and transplantation, including the types of consent currently in use in organ donation.

There is a discussion of altruistic consent, opt-in, opt-out and deemed consent, and mandated choice. Donation of organs after cardiac death and after brain death is described.

(3). Informed consent, implications for clinical practice

Chantal Patel, Published May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.009

Abstract

Consent is central to the delivery of healthcare, and all healthcare professionals must obtain consent before proceeding with any interventions. The nature of informed consent allows the patient to fully participate in any proposed healthcare interventions.

Informed consent requires high-quality information to be given that enables the patient to fully understand all the benefits as well as the risks associated with proposed interventions.

This approach respects the right of the patient to self-determine what happens to their body provided they have the relevant capacity to understand the nature of the proposed intervention.

Although consent may be seen as a procedural ‘must’, the importance of the dialogue that takes place between the patient and the clinician is what determines the validity of the consent

(4). Medical ethical principles

Markus Frischhut et al, May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.012

Abstract

Medical ethics is a field of expertise that has developed alongside increasingly powerful technologies that have changed medical practice significantly over the past decades.

From artificial ventilation and the possibility of resuscitation after cardiac arrest in the 1960s to the big-data-driven medicine of today, increasingly supported by artificial intelligence (AI), modern medicine is loaded with ethical dilemmas and complex decisions.

Four principles, namely respect for autonomy, non-maleficence, beneficence and justice, were identified in the 1970s as guiding concepts of an ethics of biomedicine, the then emerging clinical practice that is informed by biological and physiological evidence from basic research.

However, as the cultural and historical context affects the understanding of these principles, their implementation in clinical practice and healthcare is not trivial.

Here, we highlight additional principles and values that back up these four core principles, particularly solidarity, human dignity, pluralism, tolerance, non-discrimination and gender equality.

We further summarize how law reflects such principles and values, and refer to existing instruments to support their implementation.

Focusing on solidarity, we highlight some challenges for its realization, particularly in the context of using AI in medicine and healthcare.

(5). The relevance of Kant’s philosophy for contemporary medical ethics

Andrew Jones Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.014

Abstract

In this article, I briefly consider the limitations of principlism, before considering how elements of Kant’s philosophy can support medical ethics.

I highlight the difference between the medical profession and other jobs, and consider how Kant’s political philosophy potentially offers support to universal healthcare. I then consider how science and technology studies are essential for a more robust approach toward biomedical ethics

(6). Religion, culture and conscience

Joshua Hordern, Published: June 05, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.05.002

Abstract

Religion, belief and culture should be recognized as potential sources of moral purpose and personal strength in healthcare, enhancing the welfare of both clinicians and patients amidst the experience of ill-health, healing, suffering and dying.

Communication between doctors and patients and between healthcare staff should be sensitive to the welfare benefits of religion, belief, and culture.

Doctors should respect personal religious and cultural commitments, taking into account of their significance for treatment and care preferences.

Good doctors understand their own beliefs and those of others. They hold that patient welfare is best served by understanding the importance of religion, belief and culture to patients and colleagues.

The sensitive navigation of differences between people’s religions, beliefs and cultures is part of doctors’ civic obligations.

In particular, apparent conflict between clinical judgment or normal practices and a patient’s culture, religion and belief should be considered carefully.

Doctors’ own religion or culture may play an important role in promoting adherence to this good practice, complementing the role of chaplaincy.

In all matters, the law and arrangements for conscientious objection that are in effect should govern doctors’ conduct.

The strongest ethical arguments in favour of conscientious objection provisions concern the moral integrity of professionals, the objectives and values of the medical profession, the nature of healthcare in liberal democracy and the welfare of patients. In practice, arguments mounted against conscientious objection have not been found persuasive.

(7). Confidentiality in medical practice

John Saunders Published: June 10, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.016

Abstract

A patient’s personal information can only be disclosed to those involved in their care if consent to such disclosure is given.

This consent normally extends implicitly beyond medical staff to other professionals who may also be involved in care.

It also commonly includes administrative, secretarial and managerial staff as well as healthcare professionals. This constitutes the duty of confidentiality.

In certain specified circumstances, a patient’s otherwise confidential information may be disclosed without consent to allow benefits to particular others.

The legal position is complex, and while doctors should be familiar with most routine situations (e.g. reporting of certain infectious diseases), advice should always be sought if doubt exists.

(8). Ethics at the end of life

John Idris Baker, Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.006

Abstract

End-of-life care has always been prominent in discussions of clinical ethics. Almost 30% of hospital inpatients are in their last year of life.

Doctors frequently encounter people with end-of-life care needs and should to be equipped to respond. However, what has been written about it leaves many doctors, other healthcare workers and the public uncertain and confused.

What key things should doctors know and understand?

The principles are the same as in any area of medicine, but they have to be applied in a different context. Some goals (e.g. long-term survival) can no longer be achieved, but new ones (e.g. new ways to improve quality of life) become available. By clearly understanding the ethics, we can learn how to do good end-of-life care.

This article addresses key areas including why ethics matters in end-of-life care, how to apply familiar principles, how we can overcome barriers to respect for autonomy, applying the doctrine of double effect and understanding the application of ethics in the last days of life.

(9). ‘Do Not Attempt CPR’: how the pandemic changed perceptions and practice

Mark Taubert et al, Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.008

Abstract

In this article, the authors look at the current literature and studies around ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) discussions and decisions, and how the global coronavirus disease (COVID-19) pandemic brought increased focus on this area of practice.

For patients with incurable, advancing illness, having discussions to ascertain their views about CPR, and suggesting and instituting advance care planning measures such as ‘Do Not Attempt CPR’ forms, is becoming part of normal practice in medical settings.

Yet all decisions must be individualized to each patient. There was evidence of increased decision-making regarding DNACPR during the pandemic, with concerns raised in the press and on social media.

Here, we discuss how this has changed with the global COVID-19 pandemic, where concerns about blanket decision-making and lack of candor in discussing DNACPR decisions with patients and those close to them were raised.

(10). Ethical aspects of risk communication

Jill Gordon, Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.010

Abstract

The essence of risk communication is to provide patients with a clear understanding of the benefits, harms, trade-offs and uncertainties of any proposed treatment.

Doctors often assume that they do this well but can overestimate the comprehension of even well-educated patients.

We all make complex decisions using intuitive and deliberative thinking and there are hidden sources of bias in decision-making that apply to both doctor and patient.

Recent research suggests that patients are best equipped to understand risk when they are simply able to ‘get the gist’ of the risks involved in their treatment as accurately as possible.

This can be achieved by a process of thinking out loud in which the doctor outlines the nature of the problem and the factors they think might be important to the individual patient, while checking carefully for shared understanding along the way.

We have an ethical obligation to keep on developing skills in how to convey knowledge with honesty, empathy and respect.

(11). Working in partnership with patients – what does it mean in clinical practice?

Jill Gordon, Published: May 29, 2024DOI: https://doi.org/10.1016/j.mpmed.2024.04.011

Abstract

Working in partnership with patients is not a new idea but neither is it a simple one.

It holds benefits for both the patient and the doctor.

Benefits for the treating doctor include better self-care and a reduced risk of burnout.

The UK General Medical Council has provided guidelines for practitioners and patients that provide a useful template for personal reflection. There are also formal programmes dedicated to this end.

(12). Clinical uncertainty and the consequent ethical responsibilities for today’s doctors

Hugh Davies, Published:May 30, 2024DOI:https://doi.org/10.1016/j.mpmed.2024.05.003

Abstract

Clinical uncertainty continues to matter today, causing harm and waste in healthcare.

Managing and resolving this through the empirical findings of research are the foundations of modern medicine’s successes.

Doctors therefore have an ethical duty to help contribute to the identification and resolution of clinical uncertainty through facilitating and contributing to research, a point clearly put in sharp perspective by the recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

Ethical codes support this, but endorsement is far from emphatic given its clinical importance and future revisions should urgently address this omission.

(13). Intentionally terminating life (ITL) and doctors’ direct involvement

Rob George et al, Published: May 28, 2024DOI: https://doi.org/10.1016/j.mpmed.2024.05.001

Abstract

Intentionally terminating life (ITL) is usually assumed to require a doctor to perform it.

However, it does not.

Two questions have been conflated.

First, is it a moral good for society to facilitate people ending their lives, and if so, in what circumstances?

Second, how and by whom is it to be done?

If ITL becomes a medical responsibility, the profession changes to incorporate a new duty to end some people’s lives. This is the most significant moral question in medicine.

Because the political movement to legalize assisted suicide and euthanasia is vocal, organized and well-funded, the first question may become redundant soon. The second will then be upon us without due consideration.

This article clarifies several ethical confusions that could derail your analysis. You may favor the legalization of ITL without compunction, oppose it in any form, or you may favor ITL but see it as safe only if implemented separately from medicine.

We intend that you engage with the moral reasoning and not the emotional polemic of this postmodern debate.

(14). Ethics of genomic technologies in medicine

Amanda Court right-Lim, Published May 30, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.007

Abstract

This article explores the rapid shift of genomic technologies from biomedical research to medical applications.

This has led to the development of precision medicine, which can use genetic testing, gene therapy and gene editing for targeted care based on genetic information.

The evolution of this targeted approach has advanced from using genetic information to inform care to developing care tailored to individual genomic information.

Physicians are compelled to integrate genomic technologies for optimal patient care.

Through multiple case studies, the authors highlight ethical considerations that physicians face when incorporating these technologies, emphasizing informed consent for transparent integration.

Subsequently, addressing broader societal concerns, the article underscores the importance of equitable access. This exploration aims to provide physicians with a foundation to ethically facilitate access to these technologies that meet the needs of all patients.

(15). Ethico-legal considerations in the assessment of capacity

Kate EA. Saunders et al, Published: May 28, 2024 DOI: https://doi.org/10.1016/j.mpmed.2024.04.013

Abstract

The right of an autonomous person to make decisions about their care is central to the practice of medicine.

However, we are often faced with situations where someone is unable to make those decisions because of their medical status, mental health or intellectual ability. Here we consider the legal framework for the treatment of individuals who lack the capacity to decide for themselves, and some of the ethical issues that inform how such decisions are made.

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