Ethical issues of organ donation after circulatory death: Considerations for a successful implementation in Chile.

Organ transplantation is a lifesaving procedure for end-organ damage and remains up to today as the most cost-effective alternative to treat these conditions. However, the main limitation to performing organ transplants is the availability of donor organs suitable for transplantation. To increase the donor pool, expanding organ donation from the conventional neurologic determination of death (NDD) to include circulatory determination of death (DCD) has been a well-established method of increasing donors in other countries. In this article, we discuss the clinical and ethical considerations for introducing DCD in Chile. The concepts we have used could very well be translatable to other similar countries which have not implemented this donation system yet. The most relevant issue to date is that DCD needs to alter the care of dying patients to obtain quality donor organs. In some countries, including Chile, there are some cultural barriers regarding withdrawal-of-care. These barriers include confusing withdrawal of care with acceleration of death, which leads to many practitioners refusing to remove artificial life support, and in turn only minimize ventilatory support or switch to a T-tube (without extubation). This cultural barrier could be overcome with careful consideration of the opinions of healthcare workers, family members, community and policy-based stakeholders. We also identified ethical issues related to informed consent of both donor and recipients, among other relevant ethical considerations. In conclusion, DCD donation in Chile can increase organ donation numbers in one of Latin America's countries with the lowest effective donor rate. However, this opportunity must be taken with caution to avoid the opposite effect if this policy is not well implemented, respecting the sound ethical principles mentioned in this paper.

[Medical teleconsultation. Analysis and recommendations from the ethics department of the Chilean medical association]. / Teleconsulta médica. Análisis y recomendaciones del Departamento de Ética del Colegio Médico de Chile.

The possibility of allowing patients access to health professionals, has been greatly facilitated by advances in technology. Indeed, nowadays it is possible not only direct contact between one health professional with another, but also the possibility of sending images and other tests to consult distant colleagues. This has undoubtedly enabled better health care for many patients. It is also possible for a patient to consult a doctor directly in a remote and synchronous way with oral and visual contact, thus establishing a new form of medical consultation. It is this last way of relationship, which has already spread as a practice in normal times, which arouses apprehensions about the ethical requirements that a consultation must meet. This work by the Ethics Department of the Chilean Medical Association seeks to reflect on the ethical demands of a medical consultation and on the shortcomings that teleconsultation has. It also aims to propose several recommendations, so that this new form of doctor-patient relationship serves as a complement to traditional care, without jeopardizing the objectives of a medical action.

[Decision making among older adults in hemodialysis. A qualitative assessment]. / Toma de decisiones en hemodiálisis crónica: estudio cualitativo en adultos mayores.

BACKGROUND: In Chile there are 22,310 people in Chronic Hemodialysis (CHD), 53% of them older adults (OA). Shared decision-making and advance directives (AD) are especially important in OA with end-stage chronic renal failure, since they have greater levels of disability, morbidity and mortality, raising doubts about the benefit of therapy. AIMS: To understand the experience in decision making and explore ways to express AD, in OA in CHD. MATERIAL AND METHODS: A qualitative phenomenological study, performing 12 in-depth interviews to OA who had been at CHD for at least one year. RESULTS: The analysis revealed four broad comprehensive categories, two related to participation in the decision to enter CHD, namely the experience of subjects as spectators and their lack of interest for decision support and two referred to the expression of AD, namely the difficulty in facing their own finitude and resistance to express AD. CONCLUSIONS: There is little participation of older adults in the decision about their admission to dialysis therapy, and once they enter the CHD program they are not prepared to discuss AD in general, nor an eventual suspension of dialysis in particular.

[Conscientious objectors in Chilean medical education]. / La objeción de conciencia en la educación médica. Una propuesta para Chile.

The Chilean Law regulating the voluntary interruption of pregnancy, contemplates the possibility that health personnel may refrain from doing the procedure if they have stated that they are conscientious objectors (CO). There are numerous articles on the subject. However, the impact on medical training centers when a student or resident abstain from performing certain clinical procedures invoking CO, has seldom been analyzed. In this article, we explore the rights and duties of the CO students to perform an abortion or other clinical procedures for either religious or cultural reasons. Based on international experience, we recommend that all health care centers should have established and publicly known policies on this matter. Finally, we honor CO invoked by students, based on three general principles. First, the autonomy and moral integrity of the students should be respected. Second, an adequate ethical sensitivity is promoted. Third, it contributes to the necessary heterogeneity and diversity of students, promoting a desirable pluralism. However, certain interests and values, such as the well-being of patients, must be considered over and above accepting the CO requests.

[Experience in the global forum of bioethics in research. Challenges for the ethical review in Chile]. / Experiencia en el Foro Global de Bioética en Investigación. Desafíos para la revisión ética en Chile.

The Global Forum on Bioethics in Research annually convenes a number of researchers, bioethicists and stakeholders with a shared interest in the ethics of conducting research in low and middle-income countries (LMIC). It provides a useful platform to discuss ethical issues that affect research practice in different scenarios, promoting ethically conducted research, global development for health research ethics and partnerships between the global north and south. As participant of the last three meetings, in this article the author analyzes the main ethical issues that were discussed in this forum, namely "Emerging epidemic infections and experimental medical treatments" (Annecy, France, 2015); "Ethics of research in pregnancy" (Buenos Aires, Argentina, 2016), and "The ethics of alternative clinical trial designs and methods in LMIC research" (Bangkok, Thailand, 2017). Local research ethics committees are not well prepared to face the new ethical challenges associated with research conducted in emergency situations or in pregnant women, or to evaluate new methods, such as alternative clinical trial designs (cluster randomized trials, adaptive platforms, or controlled human infection models, among others). According to this scenario, research ethics committees should be trained to carefully assess the risks and benefits of approving this type of research. In this context, it is necessary to harmonize local regulations with the new international standards in research ethics.

[Ethical aspects of the doctors' behavior towards people on hunger strike: position paper from the Ethics Department of the Chilean Medical Association]. / Aspectos éticos de la conducta del médico ante personas en huelga de hambre: opinión del Departamento de Ética del Colegio Médico de Chile.

Every so often, in Chile there is a discussion about the role of physicians in the care of people on hunger strike (HS). In this document, we review the ethical aspects of health care for persons in HS, aiming to provide guidelines to medical doctors who are required to attend them. First, we make an important distinction between HS and suicide, since the former is used as a protest and denunciation tool, while suicide seeks deliberately to end a life. Then we describe the three roles that the health professional can fulfill: as a treating doctor, as an expert or as an official of a prison. The respect for the autonomy and dignity of the person in HS must prevail whatever the role of the physician. Therefore, we maintain that under no circumstances, people who have autonomously decided to be in HS should be fed by force. Due to the complexity of the issue, we make special considerations about the management of minors and the non-competent persons in HS. In conclusion, we adhere to the principles that inspire the Declaration of Malta, which indicate that it would be preferable to "allow a person on hunger strike to die in dignity, rather than subjecting them to repeated interventions against their will".

Ethical challenges posed by clinical trials in preterm labor: a case study.

This paper explores the ethical implications of a randomized double-blind clinical trial aimed to determine effectiveness and safety of an oxytocin receptor antagonist versus a betamimetic in the treatment of preterm labor, presented to a teaching hospital affiliated with a private university in Santiago, Chile. Though this trial protocol fulfills one of the conditions under which pregnant women could be enrolled in a clinical trial-the intervention has the potential to benefit the pregnant woman (by reducing adverse effects associated to salbutamol administration) and her fetus (if the new drug prolongs pregnancy)-there are some specific ethical issues raised. First, when to obtain consent is an important issue for clinical trials involving acute and unforeseen conditions that affect pregnant woman, e.g. preterm labor. Second, research must address the risk/benefit ratio for these two interdependent individuals, providing a good prospect of low risk and adequate benefit for both of them. Thirdly, specifically when a study is sponsored by a high-income country and conducted in a low- or middle-income country, decisions regarding ancillary care provisions for research participants should be made in advance. Lastly, researchers must consider the requirements for paternal consent based on cultural contexts.

[Differentiated review of biomedical research projects by ethics committees]. / Formas de Revisión Ética de Proyectos de Investigación Biomédica.

Ten years after the approval of the Chilean bill that regulates scientific research in humans (Law Nº 20.120), and considering the current status of accreditation and training of many Research Ethics Committee (REC), it is necessary to analyze their performance. We analyzed the Chilean experience with REC aiming to propose a differential type of review, considering the risks to research participants. To improve the quality of the review and the efficiency of these committees, we propose to differentiate the revisions depending on the type of project, its methods and its risks. Initially, the types of review should be classified as exempt from review, expedited review and full review by the committee. In this proposal the type of review is confirmed or can be modified by a designated member of the committee after an initial review of the project. Thus, the deliberation and review times of the committee could be optimized avoiding delays in their revision.

[Ethical and health issues posed by the recent Ebola epidemic: What should we learn?]. / Problemas éticos y de salud planteados por la reciente epidemia de Ébola: ¿Qué debemos aprender?

The recent Ebola epidemic that affected several countries in Africa, with very high mortality and a pandemic threat, posed problems of justice, public health, prevention, treatment and research, each of which has relevant ethical issues. Despite severe initial difficulties, an effective international response was achieved, whose outcome has left significant teachings to be considered in order to deal with future epidemics or pandemics. In this article, the authors analyze the main problems faced during the Ebola epidemic, including the unequal distribution of health resources between countries, the need for international collaboration, the requirement for a review of the ethical standards of clinical trials in emergencies, and the necessity of an organized global system of prevention and timely response to these outbreaks. Authors conclude that at the present time health is a global issue without borders, that insufficient healthcare resources in some countries poses risks and affects all countries and that the confrontation of the threats of epidemics requires a solution based in universal solidarity. At the same time, a moral duty to investigate should be acknowledged, seeking a balance between sense of urgency, scientific rigor and involvement of local communities.

[Ethical dilemmas about disclosure of errors in medicine]. / Dilemas éticos acerca de la revelación de errores médicos a los pacientes.

Since the publication of the Institute of Medicine’s report “To Err is Human: Building a Safer Health System” awareness of the importance of medical errors has increased. These are a major cause of morbidity and mortality and recent studies suggest that they can be the third leading cause of death in the United States. Difficulties have been identified by health personnel to prevent, detect and disclose to patients the occurrence of a medical error, an also to report them to the appropriate authorities. Although human error cannot be eliminated, it is possible to design safety systems to mitigate their frequency and consequences. Our goal is to provide an update on the major concepts related to medical errors, a review of Chilean legislation on the subject, and a bioethical analysis on the principles involved, along with a management proposal. We propose mandatory reporting of errors to the health institution where they occur, to serve as a measure of personal and team learning, and to disclose the error to patients, depending on their own preferences.

[Ethical conflicts in the authorship of scientific papers]. / Conflictos éticos en las autorías de trabajos científicos.

The frequency of conflicts about authorship of publications has increased along with the increase in the number of people involved in scientific work. Some of the factors that strongly influence the generation of conflicts and malpractices in authorship definition of scientific publications are the pressure of academia, economic incentives from the pharmaceutical industry in the field of biomedicine and authors’ wishes and expectations of recognition, among other factors. The article analyzes this problem, increasingly common in the field of medicine and related areas. Special attention is devoted to the prevailing laws in our country and international guidelines related to intellectual property and authorship of scientific publications, respectively. However, the ethical commitment, intellectual honesty and truthfulness of each of the authors about what is reported seems to be the decisive factor for the solution to these authorship conflicts.

[Conflicts of interest in nephrology]. / Conflictos de intereses en nefrología.

Since doctors disposed of effective tools to serve their patients, they had to worry about the proper management of available resources and how to deal with the relationship with the industry that provides such resources. In this relation-ship, health professionals may be involved in conflicts of interest that they need to acknowledge and learn how to handle. This article discusses the conflicts of interest in nephrology. Its objectives are to identify those areas where such conflicts could occur; to help to solve them, always considering the best interest of patients; and to help health workers to keep in mind that they have to preserve their autonomy and professional integrity. Conflicts of interest of professionals in the renal area and related scientific societies, with the industry producing equipment, supplies and drugs are reviewed. Dichotomy, payment for referral, self-referral of patients and incentives for cost control are analyzed. Finally, recommendations to help preserve a good practice in nephrology are made.

[Ethical issues perceived by health care professionals working in chronic hemodialysis centers]. / Problemas ético-clínicos en hemodiálisis crónica: percepción de médicos y enfermeras.

BACKGROUND: Clinical teams working at chronic hemodialysis centers (CHC) frequently have to face ethical problems, but there is no systematic approach to deal with them. AIM: To study the ethical problems perceived by health professionals at CHC. MATERIAL AND METHODS: Eighty randomly selected physicians and 139 nurses from 23 CHC, answered a structured questionnaire, devised by the research team. RESULTS: Twenty-six percent of respondents had postgraduate studies in clinical ethics. The ethical problems mentioned by respondents were therapeutic disproportion in 66.7%, lack of communication between patients, their families and the clinical team in 25.9%, personal conflicts of interests related with hemodialysis prescription in 14.6% and conflicts of interests of other members of the clinical team in 30.6%. The percentage of respondents that experienced not starting or discontinuing hemodialysis treatment due to decision of patients’ relatives was 86.8%. Only 45.2% of health professionals had the opportunity to take part in decision-making meetings. Eighty seven percent of respondents supported the use of advanced directives in the event of a cardio respiratory arrest during treatment. CONCLUSIONS: To improve the approach to ethical problems in CHC, it is necessary to improve training in clinical ethics, promote an effective dialogue between the patients, their families and health professionals, and follow their advance directives in case of cardiac arrest during treatment.

[Position paper from the Department of Ethics of the Chilean College of Physicians about conscientious objection]. / El médico y la objeción de conciencia: Opinión del Departamento de Ética del Colegio Médico de Chile A. G.

The Chilean bill that regulates abortion for three cases (Bulletin Nº 9895-11) includes the possibility that health professionals may manifest their conscientious objection (CO) to perform this procedure. Due to the broad impact that the issue of C O had, the Ethics Department of the Chilean College of Physicians considered important to review this concept and its ethical and legal basis, especially in the field of sexual and reproductive health. In the present document, we define the practical limit s of CO, both for the proper fulfillment of the medical profession obligations, and for the due respect and non-discrimination that the professional objector deserves. We analyze the denial of some health institutions to perform abortions if it is legalize d, and we end with recommendations adjusted to the Chilean reality. Specifically, we recognize the right to conscientious objection that all physicians who directly participate in a professional act have. But we a lso recognize that physicians have ineludib le obligations towards their patients, including the obligation to inform about the existence of this service, how to access to it and -as set out in our code of ethics- to ensure that another colleague will continue attending the patient.