Gender, Pediatric Care, and Evidence.

This letter responds to the Other Voices commentaries "Troubling Trends in Health Misinformation Related to Gender-Affirming Care," by Stef M. Shuster and Meredithe McNamara; "Values and Evidence in Gender-Affirming Care," by Os Keyes and Elizabeth Dietz; "Breaking Binaries: The Critical Need for Feminist Bioethics in Pediatric Gender-Affirming Care," by Lisa Campo-Engelstein, Grayson Jackson, and Jacob Moses; and "Minors Lack the Autonomy to Consent to Gender-Affirming Care: Best Interests Must Be Primary," by John C. Bester, in the May-June 2024 issue of the Hastings Center Report.

On Normothermic Regional Perfusion.

This letter responds to the article "Neither Ethical nor Prudent: Why Not to Choose Normothermic Regional Perfusion," by Adam Omelianchuk et al., in the July-August 2024 issue of the Hastings Center Report.

Adam Omelianchuk, Alexander Morgan Capron, Lainie Friedman Ross, Arthur R. Derse, James L. Bernat, and David Magnus reply.

This letter responds to letters by Garson Leder and by Harrison Lee in the same issue, September-October 2024, of the Hastings Center Report.

Johan C. Bester replies.

This letter responds to a letter by Moti Gorin in the same issue, September-October 2024, of the Hastings Center Report.

The Expanding Role of United States Healthcare Chaplains in Clinical Ethics.

Healthcare chaplains in the United States increasingly report being tasked by their organizations to participate in the formal work of clinical ethics, by serving on ethics committees, performing clinical ethics consultations, or leading clinical ethics programs. This mapping study documents that professionally-trained chaplains possess a number of skills and attributes that enhance their capability for this work; however, they often lack certain knowledge specific to the discipline of clinical ethics that is needed for roles they are being asked to perform. The professional associations of both chaplaincy and clinical ethics are encouraged to address this educational gap for the benefit of both disciplines.

Moral challenges and understanding of clinical ethics in Tanzanian hospitals: Perspectives of healthcare professionals.

Healthcare professionals encounter many moral challenges in their daily clinical practice. However, there have been few studies on the subject matter in Tanzania. This study aims to provide an account of moral challenges faced by healthcare professionals in Tanzanian hospitals, their understanding of clinical ethics, and the ethics education they have received. Many participants reported receiving some kind of ethics training through formal education and on-the-job training. Some participants understood ethics in healthcare settings as adherence to established laws, regulations, guidelines, procedures, norms, and rules essential in clinical practice. Analysis of the data identified four themes of moral challenges. These challenges are related to 1) decision-making and communication in clinical practice, 2) scarcity of medical resources and prioritization in clinical practice, 3) withdrawal of curative treatment, and 4) conflicts between professional judgment, religious convictions and adherence to alternative treatments. Based on the findings, we suggest a context-sensitive form of clinical ethics training to prepare healthcare professionals to recognize and address these moral challenges.

Ethical concerns in caring for persons with anorexia nervosa: content analysis of a series of documentations from ethics consultations.

BACKGROUND: Caring for patients with anorexia nervosa (AN) is associated with high levels of moral distress among healthcare professionals. The main moral conflict has been posited to be between applying coercion to prevent serious complications such as premature death and accepting treatment refusals. However, empirical evidence on this topic is scarce. METHODS: We identified all 19 documentations of ethics consultations (ECs) in the context of AN from one clinical ethics support service in Switzerland. These documentations were coded with a sequential deductive-inductive approach and the code system was interpreted in a case-based manner. Here, we present findings on patient characteristics and ethical concerns. FINDINGS: The ECs typically concerned an intensely pretreated, extremely underweight AN patient endangering herself by refusing the proposed treatment. In addition to the justifiability of coercion, frequent ethical concerns were whether further coerced treatment aimed at weight gain would be ineffective or even harmful, evidencing uncertainty about beneficence and non-maleficence and a conflict between these principles. Discussed options included harm reduction (e.g. psychotherapy without weight gain requirements) and palliation (e.g. initiating end-of-life care), the appropriateness of which were ethical concerns in themselves. Overall, nine different types of conflicts between or uncertainties regarding ethical principles were identified with a median of eight per case. CONCLUSIONS: Ethical concerns in caring for persons with AN are diverse and complex. To deal with uncertainty about and conflict between respect for autonomy, beneficence and non-maleficence, healthcare professionals consider non-curative approaches. However, currently, uncertainty around general justifiability, eligibility criteria, and concrete protocols hinders their adoption.

[Evidence-based medicine and clinical ethics: toward shared decision making].

Evidence-based medicine (EBM) is "decision-making for better patient care that integrates current evidence, and clinical expertise with patients' preferences, values and circumstances." It is important to distinguish research evidence from EBM, which is comprehensive decision-making that takes into account the diversity and individuality of clinical situations while respecting evidence as a general theory. Clinical practice guidelines are "a document that evaluates the total body of evidence through systematic review and presents recommendations that are considered optimal, taking into account the balance of benefits and harms, in order to support decision-making on important health-related issues by healthcare users and providers," and is useful in the practice of EBM. Shared decision making (SDM), which has been attracting attention in recent years, is "a process in which the patient and the health care provider, through dialogue, decide on a treatment plan that is acceptable to the patient, based on the patient's own preferences and values, research evidence, and clinical expertise" and must be understood in relation to the above definition of EBM and from the perspective of clinical ethics.

Clinicians' Perspectives and an Ethical Analysis of Safer Supply Opioid Prescribing.

In British Columbia, Canada, many physicians providing care to individuals with high-risk opioid use disorder adopted safer supply (SS) opioid prescribing in the spring of 2020 with the goal of facilitating public health measures for COVID-19. This prescribing practice continued after measures were lifted. This study aimed to explore prescribers' perspectives following several years of local experience in prescribing SS opioids, primarily in the form of hydromorphone tablets, and to apply ethical concepts to explore current challenges and ongoing sources of provider distress. Addiction medicine SS prescribers participated in individual or small group semi-structured interviews. Each interview was transcribed and analysed for recurrent themes. Themes were then integrated into a narrative ethics discussion. Eleven addiction medicine physicians practicing in various settings within Vancouver participated in this study. Six themes were identified: clinical assessment, clinician distress, gaps in care, models of safer supply, research, and special populations. Ethical dilemmas in prescribing SS are identified and explored through a discussion of biomedical ethics principles and the physician role.

Incarceration Postpartum: Is There a Right to Prison Nurseries?

Rising rates of female incarceration within the United States are incompatible with the lack of federal standards outlining the rights of incarcerated mothers and their children. A robust body of evidence demonstrates that prison nurseries, programmes designed for mothers to keep their infants under their care during detainment or incarceration, provide essential and beneficial care that could not otherwise be achieved within the current carceral infrastructure. These benefits include facilitation of breastfeeding, bonding during a critical period of child development, and decreased recidivism rates for participants. Legal precedent exists to support the rights of the mother to continue to parent their child but remains in stark opposition to current prison infrastructure that could allow them to do so. Existing state policies also have inconsistent mechanisms for determining child eligibility and should move to centre decision-making on a case-by-case basis. This work will demonstrate that a just society, supported by law and ensuring maternal-child welfare supports the establishment of prison nursery programmes as a part of the existing right to healthcare for incarcerated individuals.

The Effectiveness of a Hospital Ethics Committee in a Non-Western Country: Lessons from a Ten-Year Experience.

Hospital ethics committees (HECs) are relatively new in non-Western countries. This article examines the effectiveness of a HEC established in Bursa/Turkey over ten years, aiming to contribute insights for the wider implementation and enhancement of HECs. The evaluative methodology combines quantitative and qualitative approaches to assess its effectiveness. Patients are the primary users of the HEC, although applications from physicians, hospital managers, and the Patient Rights Board are also observed. Surgical specialities account for the majority of applications, particularly from obstetrics and gynecology, anesthesiology, and emergency medicine. The study identifies the types of applications, with malpractice claims, ethical inquiries, and access-related complaints being the most common. Despite many healthcare professionals encountering ethical dilemmas, the HEC was underutilized for consultations due to factors such as low awareness, perceived autonomy challenges, and skepticism regarding its efficacy. Additionally, the study describes how HEC recommendations contribute to policy development, addressing organizational issues and promoting ethical practices. The decision-making process within the HEC was also scrutinized, emphasizing the necessity of a structured methodology for moral deliberation. Concerns are raised about committee members lacking specific training in ethical analysis, potentially resulting in biases and suboptimal decisions. Contextual factors, including institutional culture and economic considerations, are also recognized for their influence on decision-making. This analysis highlights the multifaceted nature of HECs and the challenges they face in achieving effectiveness. It underscores the need for standardized measures, improved training for committee members, and contextual awareness to enhance the impact and functionality of HECs in healthcare institutions.

The Impact of Clinical Ethics Consultations on Physicians in a Latin American Context.

Clinical bioethics plays a significant role in hospital settings through bioethics consultations, which focus on providing ongoing assistance in complex situations within the doctor-patient dynamic. These consultations entail regular interaction between physicians and clinical bioethicists. This situation prompts an exploration into how bioethics consultations affect physicians. The current research aims to understand the influence of bioethics consultations on physicians' bioethical knowledge by analyzing the lexical content in their patients' medical records. Medical records are a synthesis carried out by physicians, often reflecting collaborative efforts, and capturing verbal statements indicative of thought processes suggestive of learning. The study is a sequential mixed-methods design with a retrospective descriptive approach, comparing medical records from the early years of the Department of Humanism and Bioethics' operation (2013-2015) to the more recent ones (2019). Technical bioethical terminology such as "therapeutic effort limitation," "futility," "beneficence," and "respect for autonomy" is more prevalent in recent medical records. This trend may stem from the positive impact of bioethics consultations conducted by the Department, with haptic communication serving as a particularly effective form of interaction with others during experiences of moral distress. This appears to be characteristic of cultures like those in Latin America.

Capacity to consent: a scoping review of youth decision-making capacity for gender-affirming care.

BACKGROUND: Transgender and gender expansive (TGE) youth often seek a variety of gender-affirming healthcare services, including pubertal suppression and hormone therapy requiring that TGE youth and their parents participate in informed consent and decision making. While youth must demonstrate the ability to understand and appreciate treatment options, risks, benefits, and alternatives as well as make and express a treatment choice, standardized approaches to assess the capacity of TGE youth to consent or assent in clinical practice are not routinely used. This scoping review identified the currently available data regarding adolescent capacity to consent to gender-affirming medical treatments. METHODS: Articles relevant to assessing adolescent capacity for clinical decision-making were identified using OVID Medline, Web of Science, and PubMed. Articles were reviewed and thematically analyzed. RESULTS: Eight relevant articles were identified using three tools for measuring adolescent clinical decision-making capacity: Measure of Understanding, Measure of Competence, and MacArthur Competence Assessment Tool (MacCAT). These studies explored hypothetical treatment decisions, mental health treatment decisions, HIV treatment decisions, genetic testing decisions, and gender-affirming medical decisions. Only one study specifically examines the capacity of TGE youth to consent to medical treatments. Age was correlated with capacity in most, but not all studies. Other studies found cognitive measures (IQ, literacy, numeracy) may impact important aspects of capacity (understanding and reasoning). CONCLUSIONS: For clinicians caring for TGE youth, tools such as the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) may prove useful, in conjunction with consideration of youth developmental abilities and utilization of shared decision-making practices. A standardized, collaborative approach to assessing TGE youth capacity would benefit TGE youth and their parents, and allow clinicians to more easily resolve ethical concerns.

Complex Decision-Making in Paediatric Intensive Care: A Discussion Paper and Suggested Model.

Paediatric Intensive Care Units (PICU) are complex interdisciplinary environments where challenging, high stakes decisions are frequently encountered. We assert that appropriate decisions are more likely to be made if the decision-making process is comprehensive, reasoned, and grounded in thoughtful deliberation. Strategies to overcome barriers to high quality decision-making including, cognitive and implicit bias, group think, inadequate information gathering, and poor quality deliberation should be incorporated. Several general frameworks for decision-making exist, but specific guidance is scarce. In this paper, we provide specific guidance on collaborative complex decision-making for PICUs. The proposed approach is on principles of procedural justice and pragmatic hermeneutics. The process encompasses set-up/planning, information gathering, question formulation, analysis (perspectives, values, and principles), action plan development, decision documentation, and a review and appeal mechanism. The process can be adapted to suit other clinical contexts. Research evaluating the process, exploring how best to develop education for clinicians, and how to build a culture that values high quality deliberation, is worthwhile.

Charity Scott, Bioethics, and Health Law.

As Steve Kaminshine said in his comments at the symposium honoring Charity Scott, I was recruited to come to Georgia State University as a "Law and Bioethics" scholar who had spent more than sixteen years shuttling between an office in a hospital and another in a law school. But when I first visited Georgia State Law, I did not know that more than ten years earlier Charity Scott had spent the better part of an academic year living and breathing clinical ethics at Grady Memorial Hospital.1 Because of her usual habit of immersion in all learning experiences, in that year Charity gained more insight into how hospitals work and how physicians behave when they are knee deep in their professional milieu of life and death decision-making than many full-time bioethics academics do in a career. For the rest of her career Charity kept one foot well planted in the medical context, as an advisor in problems of research ethics, as a teacher in her own medical-legal partnership structured around real-life clinical problems, and as an ethical analyst who could never be accused of mouthing a mantra of phrases, the "vacuous incantation of abstract principles"2 that might pass for bioethics discourse in some circles.

"Moral spaces": A feasibility study to build nurses' ethical confidence and competence.

Background: Pre-licensure ethics nursing education does not adequately prepare and instill confidence in nurses to address ethical issues, and yet ethics education provides nurses with greater confidence to take moral action, which can mitigate the negative effects of moral distress. Objectives: To assess the feasibility and acceptability of a nursing ethics education program that included simulated case-based ethics competencies as a form of evaluation. The program aimed at building nurses' ethical knowledge and confidence to respond to ethical challenges in practice. Research design: A prospective, longitudinal, correlational, single-cohort feasibility study using an investigator-developed survey and intervention field data. Participants and research context: Registered nurses were recruited from an academic quaternary-care medical center and 9 small- to mid-sized regional hospitals within one health system in the Midwest United States. Ethical considerations: IRB approval was obtained. Participants could complete the educational program regardless of research process participation. Findings: Of 20 participants, 19 (95%) provided post-program surveys and 18 completed competencies. Median (IQR) scores with quartiles for scheduling, timing, and length of sessions were all 10.0 [9.0, 10.0], and participants perceived that the content was interesting, increased knowledge and confidence in ethics, increased skills in providing ethical care, and would recommend the program to colleagues. Of factors, an increase in ethics knowledge had the highest "always agree" (17, 89.5%) response. Most participants reported that ethics competencies were appropriate 9.0 [9.0, 10.0] and sufficiently challenging 10.0 [9.0, 10.0]. Discussion: The education program developed nurses' ethics knowledge and confidence. The single-cohort feasibility design provided early-stage intervention outcomes; however, a larger randomized controlled trial would substantiate program value. Conclusion: This novel ethics education program was highly feasible and acceptable to hospital-based nurses who reported increased knowledge and confidence in providing ethical care. Simulated case-based ethics competencies were an appropriate evaluation method.

Adolescents' healthcare decisional capacity in the clinical context: a theoretical study and model.

OBJECTIVE: To provide a theoretical study and model for the bioethical foundations of the factors that influence adolescents' healthcare decisional capacity. SOURCES: Materials from diverse sources, including indexed articles in recognized databases and official government documents, were examined for a purposefully selected sample. The research consisted of two stages: selection of documents and reflective thematic analysis, followed by the preparation of a report. The analysis adopted a phenomenological stance and a reflective view compatible with human rights. To reduce bias and ensure the robustness of the results, measures such as data triangulation were employed. Ethical measures were taken to ensure data integrity, including considerations of anonymity and conflicts of interest in the selected studies. SUMMARY OF THE FINDINGS: It was possible to list intrinsic and extrinsic factors of the adolescent patient that influence their decisional capacity regarding health. A theoretical model was developed to discuss these factors for evaluation by means of an infographic. CONCLUSIONS: It seems clear that the evaluation of healthcare decisional capacity of adolescents must position itself ethically regarding the tension between the moral duty to respect the self-determination of the able subject and the need to protect adolescents decidedly unable to make a specific health decision at a given time.

[Theoretical foundations of clinical ethics consultation in psychiatry]. / Theoretische Grundlagen der klinischen Ethikberatung in der Psychiatrie.

BACKGROUND: Clinical ethics consultants support mental health professionals in identifying and analyzing moral problems in clinical practice. OBJECTIVE: Presentation of key ethical concepts and normative theories that are relevant for clinical ethics consultation in mental healthcare. MATERIAL AND METHODS: Conceptual and ethical analyses. RESULTS: After distinguishing between morality, ethics and law, moral problems are differentiated from other types of problems encountered in clinical practice. Subsequently, key ethical concepts and the concept of moral distress are clarified. In relation to the normative framework a distinction is made between philosophical ethical theories and medical ethical theories, such as principlism and the ethics of care. Finally, justification tests for ethical decision-making in situations of danger to self or others based on the harm principle and soft paternalism are proposed. CONCLUSION: Knowledge of key ethical concepts and normative theories is important for the identification and analysis of moral problems in mental healthcare and should be given greater weight in the training of clinical ethics consultants.

Exploration of clinical ethics consultation in Uganda: a case study of Uganda Cancer Institute.

INTRODUCTION: Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESSs) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence about mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda. METHODS: This phenomenological qualitative study utilized in-depth interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook. RESULTS: The study revealed there was no formal committee or mechanism dedicated to resolving ethical dilemmas at the UCI. Instead, ethical dilemmas were addressed in six forums: individual consultations, tumor board meetings, morbidity and mortality meetings (MMMs), core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas. CONCLUSION: The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

Conscience, Disobedience, and Standard of Care.

In the article "Principled Conscientious Provision: Referral Symmetry and Its Implications for Protecting Secular Conscience," Abram L. Brummett, Tanner Hafen, and Mark C. Navin reject what they call the "referral asymmetry" in U.S. conscientious objection law in medicine, which recognizes rights of conscientiously objecting physicians to withhold referrals for medical interventions but does not (yet) recognize rights of physicians to make referrals for medical interventions to which they are morally committed but to which their health care institutions are morally opposed. This commentary concentrates on a second asymmetry, namely, the relationship of a health care provider's referral or nonreferral to the medical standard of care. The commentary argues that this second asymmetry seems to require action more appropriately recognized as civil disobedience than conscientious provision of referral.