War on healthcare services in Gaza.

This article looks at the October 2023 war on Gaza in the context of the effects of wars on healthcare systems. I will begin with a brief historical overview of the so-called Israeli-Palestinian conflict to clarify the special status of the Gaza Strip and the hostilities since October 7, 2023. This will be followed by a description of the major distinguishing characteristic of this war, namely, the systematic assault on the healthcare system. Finally, I will attempt to explain the conduct of this war using a necropolitical lens.

Concordance of International Regulation of Pediatric Health Research.

OBJECTIVE: To assess the comparability of international ethics principles and practices used in regulating pediatric research as a first step in determining whether reciprocal deference for international ethics review is feasible. Prior studies by the authors focused on other aspects of international health research, such as biobanks and direct-to-participant genomic research. The unique nature of pediatric research and its distinctive regulation by many countries warranted a separate study. STUDY DESIGN: A representative sample of 21 countries was selected, with geographical, ethnic, cultural, political, and economic diversity. A leading expert on pediatric research ethics and law was selected to summarize the ethics review of pediatric research in each country. To ensure the comparability of the responses, a 5-part summary of pediatric research ethics principles in the US was developed by the investigators and distributed to all country representatives. The international experts were asked to assess and describe whether principles in their country and the US were congruent. Results were obtained and compiled in the spring and summer of 2022. RESULTS: Some of the countries varied in their conceptualization or description of one or more ethical principles for pediatric research, but overall, the countries in the study demonstrated a fundamental concordance. CONCLUSIONS: Similar regulation of pediatric research in 21 countries suggests that international reciprocity is a viable strategy.

Healthcare Under Fire: Stories from Healthcare Workers During Armed Conflict.

This symposium includes twelve narratives from individuals or groups who have worked to help the sick and injured receive healthcare during armed conflict. Four commentaries on these narratives are also included, authored by experts and scholars in the fields of bioethics, human rights, sexual violence in armed conflict, the forced displacement of civilians, and policy development for resource constrained healthcare. The goal of this symposium is to call attention to the the difficulties and ethical dilemmas of providing healthcare during violent armed conflict.

Everyone Is Harmed When Clinicians Aren't Prepared.

War and conflict are now common, lingering like an endemic disease in most countries of the Global South. Population displacement, infectious disease outbreaks, food and water shortages, damage to infrastructure, anxiety, and posttraumatic stress are among the phenomena to which clinicians are expected to respond as professionals. Yet curricula in health professions do not prepare trainees to cultivate the skills needed to develop intervention pathways to meet the needs of populations in conflict zones. This article argues that decolonization of curricula in health professions is key to preparing clinicians to respond with care and competence to vulnerabilities and disease burden exacerbated by conflict.

Moral and Professional Values of Nurses in Lebanon.

BACKGROUND: Moral and professional values vary among cultures. The purpose of this study was to explore the moral and professional values of registered nurses at a university medical center in a Middle Eastern country and determine the relationship among formal ethics education, background variables (age, gender, nursing degree, regular daily prayer), and nurses' professional and moral values. METHOD: A cross-sectional survey method with 123 nurses was used. Data on background variables, moral and professional values, and confidence in ethical decision-making were assessed. RESULTS: Professional values were significantly higher among older nurses and nurses with master's degrees compared with younger nurses and nurses with bachelor's degrees. Daily prayer was related to higher mean scores for moral values. Nurses were confident in their ethical decision-making; however, formal education in ethics did not influence professional or moral values. CONCLUSION: Although formal education in ethics did not influence the professional or moral values of nurses in Lebanon, this finding does not negate the need for future studies to investigate the content and duration of ethics education that is likely to affect professional or moral values. [J Contin Educ Nurs. 2021;52(9):429-437.].

Top five ethical lessons of COVID-19 that the world must learn.

As the world reflects upon one year since the first cases of coronavirus disease 2019 (COVID-19) and prepare for and experience surges in cases, it is important to identify the most crucial ethical issues that might lie ahead so that countries are able to plan accordingly. Some ethical issues are rather obvious to predict, such as the ethical issues surrounding the use of immunity certificates, contact tracing, and the fair allocation of vaccines globally. Yet, the most significant ethical challenge that the world must address in the next year and beyond is to ensure that we learn the ethical lessons of the first year of this pandemic. Learning from our collective experiences thus far constitutes our greatest moral obligation. Appreciating that decision-making in the context of a pandemic is constrained by unprecedented complexity and uncertainty, beginning in June 2020, an international group of 17 experts in bioethics spanning 15 countries (including low-, middle-, and high-income countries) met virtually to identify what we considered to be the most significant ethical challenges and accompanying lessons faced thus far in the COVID-19 pandemic. Once collected, the group met over the course of several virtual meetings to identify challenges and lessons that are analytically distinct in order to identify common ethical themes under which different challenges and lessons could be grouped. The result, described in this paper, is what this expert group consider to be the top five ethical lessons from the initial experience with COVID-19 that must be learned.

Ethics Reporting Practices in Aging Research From the Arab Region.

Objectives: This study aims to assess the extent of ethics reporting practices in aging research from Arab countries. Methods: A systematic scoping review of research on aging in 22 Arab countries from seven databases (1994-2013) identified 637 publications warranting institutional ethical approval and 612 publications warranting informed consent. We used multivariable regression analysis to examine variations by time, place, and study characteristics. Results: Only 36.6% of articles reported approval from a Research Ethics Committee and 38.7% reported informed consent. Reporting of ethical research practices increased significantly over time and as research collaborations and journal impact factor increased, and when sampling frame included institutionalized participants. In contrast, failure to report ethical research practices was significantly more common in non-English articles and those that did not report a funding source. Discussion: Despite gains across time, reporting of ethical research practices remains suboptimal in the Arab region. Further guidelines and capacity building are needed.

Effect of Targeted Curricular Reform on the Learning Environment, Student Empathy, and Hidden Curriculum in a Medical School: A 7-Year Longitudinal Study.

OBJECTIVE: The American University of Beirut Faculty of Medicine follows the American model of medical education. In 2013-2014, a carefully designed new curriculum replaced the previous, largely traditional curriculum, and aimed to improve student wellbeing, upgrade the learning environment, enhance student empathy, and counter the negative influences of the hidden curriculum. This longitudinal study assessed the effectiveness of the new curriculum in those domains over a period of 7 years. METHODS: Three cohorts of medical students anonymously filled a paper-based survey at the end of years 1, 2, 3, and 4 of the 4-year curriculum. These included the Class of 2016, the last batch of students who followed the old curriculum, and 2 cohorts that followed the new curriculum (Class of 2017 and Class of 2019). The perceived learning environment was assessed by the Dundee Ready Education Environment Measurement survey; the student's empathy was assessed by the Jefferson Scale of Physician Empathy-Student version; and the hidden curriculum was examined using a locally developed survey. RESULTS: The scores on the learning environment survey were significantly higher among the cohorts following the new curriculum relative to those following the old curriculum. Similar significant results appeared when looking at each of the subscales for the learning environment. The students' empathy scores were also significantly higher in both cohorts of the new curriculum when compared with the old curriculum. Nevertheless, there was a significant decrease in empathy in both third and fourth years relative to second year. The new curriculum also improved aspects of the students' perceptions and responses to the hidden curriculum. CONCLUSION: In conclusion, a well-planned and well-researched curricular intervention, based on sound educational theories, practices, and standards can indeed transform the learning environment, as well as the attitudes, values, and experiences of medical students.

Disclosure of medical errors: physicians' knowledge, attitudes and practices (KAP) in an oncology center.

BACKGROUND: Between the need for transparency in healthcare, widely promoted by patient's safety campaigns, and the fear of negative consequences and malpractice threats, physicians face challenging decisions on whether or not disclosing medical errors to patients and families is a valid option. We aim to assess the knowledge, attitudes and practices (KAP) of physicians in our center regarding medical error disclosure. METHODS: This is a cross-sectional self-administered questionnaire study. The questionnaire was piloted and no major modifications were made. A day-long training workshop consisting of didactic lectures, short and long case scenarios with role playing and feedback from the instructors, were conducted. Physicians who attended these training workshops were invited to complete the questionnaire at the end of the training, and physicians who did not attend any training were sent a copy of the questionnaire to their offices to complete. To assure anonymity and transparency of responses, we did not query names or departments. Descriptive statistics were used to present demographics and KAP. The differences between response\s of physicians who received the training and those who did not were analyzed with t-test and descriptive statistics. The 0.05 level of significance was used as a cutoff measure for statistical significance. RESULTS: Eighty-eight physicians completed the questionnaire (55 attended training (62.50%), and 33 did not (37.50%)). Sixty Five percent of physicians were males and the mean number of years of experience was 16.5 years. Eighty-Seven percent (n = 73) of physicians were more likely to report major harm, compared to minor harm or no harm. Physicians who attended the workshop were more knowledgeable of articles of Jordan's Law on Medical and Health Liability (66.7% vs 45.5%, p-value = 0.017) and the Law was more likely to affect their decision on error disclosure (61.8% vs 36.4%, p-value = 0.024). CONCLUSION: Formal training workshops on disclosing medical errors have the power to positively influence physicians' KAP toward disclosing medical errors to patients and possibly promoting a culture of transparency in the health care system.

Bioethical Dilemmas in Conflict Zones: An Ethicist's Perspective Based on Lessons Learned from Gaza.

Health care practitioners practicing in conflict zones, more often than not, face ethical conundrums that are more urgent and extreme than those faced by their colleagues working in regular medical settings. Indeed, field physicians can attest to the fact that, oftentimes, medical ethics in war time is quite different, and that indeed they ought to be different. This strain is sensed only by those who have witnessed wars and practiced health care in times of conflict. Undeniably, physicians might recourse to what I call contrived medical ethics, which allows their medicine as well as moral compass to remain viable and moral. In this article, the challenges and dilemmas surrounding dialysis and renal transplants in war zones, particularly in the Middle East using Gaza as a model, are discussed.

Physicians' empathy levels in a primary care setting: perceptions of patients and their physicians, a qualitative study.

BACKGROUND: The physician-patient relationship is a crucial element in successful medical care. Empathy is the ability to understand an individual's subjective experience yet remain as an observer. It plays a major role in establishing a good physician-patient relationship. OBJECTIVE: The aim of this study was to evaluate the perspectives of patients and their corresponding emergency physicians regarding physicians' empathy levels and to extract themes that both patients and their doctors considered as important for an empathic encounter. METHODS: This is a qualitative study conducted at a Middle Eastern tertiary care centre Emergency Department (ED) using in-depth semi-structured interviews administered to each participating patient and his/her corresponding ED physician. Empathy-related themes were identified using inductive thematic analysis. RESULTS: This study shows that both patients and physicians believe in the importance of empathy in the ED based on four major themes: emotions, interpersonal skills, time and chief complaint. Time and the chief complaint were perceived as barriers by physicians, but not by their patients. CONCLUSIONS: A gap lies in the expressive communication phase of empathy between the two groups. The four major themes retrieved could form the basis of an empathy measure in the medical encounter in Lebanese and similar settings.

Fair, just and compassionate: A pilot for making allocation decisions for patients requesting experimental drugs outside of clinical trials.

Patients have received experimental pharmaceuticals outside of clinical trials for decades. There are no industry-wide best practices, and many companies that have granted compassionate use, or 'preapproval', access to their investigational products have done so without fanfare and without divulging the process or grounds on which decisions were made. The number of compassionate use requests has increased over time. Driving the demand are new treatments for serious unmet medical needs; patient advocacy groups pressing for access to emerging treatments; internet platforms enabling broad awareness of compelling cases or novel drugs and a lack of trust among some that the pharmaceutical industry and/or the FDA have patients' best interests in mind. High-profile cases in the media have highlighted the gap between patient expectations for compassionate use and company utilisation of fair processes to adjudicate requests. With many pharmaceutical manufacturers, patient groups, healthcare providers and policy analysts unhappy with the inequities of the status quo, fairer and more ethical management of compassionate use requests was needed. This paper reports on a novel collaboration between a pharmaceutical company and an academic medical ethics department that led to the formation of the Compassionate Use Advisory Committee (CompAC). Comprising medical experts, bioethicists and patient representatives, CompAC established an ethical framework for the allocation of a scarce investigational oncology agent to single patients requesting non-trial access. This is the first account of how the committee was formed and how it built an ethical framework and put it into practice.

When a physician and a clinical ethicist collaborate for better patient care.

Bioethics is a relatively new addition to bedside medical care in Arab world which is characterized by a special culture that often makes blind adaptation of western ethics codes and principles; a challenge that has to be faced. To date, the American University of Beirut Medical Center is the only hospital that offers bedside ethics consultations in the Arab Region aiming towards better patient-centered care. This article tackles the role of the bedside clinical ethics consultant as an active member of the medical team and the impact of such consultations on decision-making and patient-centered care. Using the case of a child with multiple medical problems and a futile medical condition, we describe how the collaboration of the medical team and the clinical ethics consultant took a comprehensive approach to accompany and lead the parents and the medical team in their decision-making process and how the consultations allowed several salient issues to be addressed. This approach proved to be effective in the Arab cultural setting and indeed did lead to better patientcentered care.

Respecting patient choices: using the 'Go Wish' cards as a teaching tool.

BACKGROUND: Individuals have different values and priorities that can have an important impact on their medical management. Understanding this concept can help physicians provide medical care that is in line with the goals of their patients. Communicating this message effectively to students is challenging. OBJECTIVE: To report our experience with using Go Wish cards in the medical education setting. DESIGN: A thematic analysis of student reflection papers using grounded theory. SETTING/SUBJECTS: Second-year medical students participated in an activity using the Go Wish cards as part of a course module on palliative care. The activity aimed to encourage students to reflect on their own choices at the end of life and to highlight that different people have different priorities. RESULTS: Forty-two students (42%) mentioned the Go Wish activity in their reflections on the module. They reported that the activity demonstrated the different priorities at the end of life, it illustrated the importance of providing personalised care, it promoted self-discovery, it transformed their view of death and dying, and it increased their appreciation of the importance of palliative care. CONCLUSION: Go Wish cards can be used to help illustrate the variability in priorities of patients. They can be used as an effective to teach medical students about the importance of considering patient preferences when illness progresses.

Bioethicsing.

This article describes the components of a unique 9 month required course in bioethics for 3rd year medical students at the American University of Beirut. The blended (hybrid) learning format emphasizes three innovative learning activities: the bioethics documentary, edutainment games, and the bioethics log book. Sample student responses are included as well as an outline of limitations.