The Covid-19 effect on medical students' perceptions of their profession: A mixed methods study from South India.

Covid-19 has devastated human lives and stretched the limits of the medical profession and health systems. Using the mixed methods of online survey and online focus group discussions, we assessed how medical students and interns of two medical colleges in South India viewed the profession they had chosen. Of the 900 participants, 571(63.4%) had a positive perception of the medical profession, 77(8.6%) a negative perception and 252(28%) were undecided. The year of study in medical school was significantly associated with their perception of the medical profession, with interns more likely to have a negative perception. An overwhelming 823(91.4%) participants remained confident of their career choice, but a higher proportion of interns were less confident or regretful about their choice of profession compared to first to fourth year students. Most participants experienced moral distress; they acknowledged a duty to care but were troubled by personal risk, inadequate protection, and limited resources. Gaps were identified in medical and ethics training particularly regarding uncertainties and coping with deficiencies of the health system as encountered in the pandemic. The essential role played by doctors with its required competence, care and ethics cannot be assumed or expected without investment in the making of the future doctor through more socially embedded medical education imparting the skills of understanding the public, responding to them and being the advocate for their equitable and optimal care. An ethics of responsiveness emerges as important for healthcare, also for medical education in preparation for future health crises.

Managing feeding needs in advanced dementia: perspectives from ethics of care and ubuntu philosophy.

The response to feeding needs in advanced dementia patients is a subject of ethical inquiry. Advanced dementia is the debilitating result of a range of neurodegenerative diseases. As this terminal illness progresses, patients develop mild to severe dysphagia that can make swallowing difficult. Of the two available options, artificial tube feeding or oral hand feeding, an estimated one-third of these patients will receive artificial tube feeding. However, observational studies have failed to validate the clinical benefits of tube feeding. Ethics of care, the feminist philosophical perspective, and Ubuntu philosophy offer arguments for the choice of oral hand-feeding as a preferrable first option by caregivers as far as possible. These moral theories acknowledge that human beings can be dependent for long periods, mostly early and later years of life. Both views reflect an approach that draws people into a system of interdependent caring relationships. They encourage hand feeding as a way of exhibiting solidarity and respecting human dignity even at the end of life.

Perceptions about controlled human infection model (CHIM) studies among members of ethics committees of Indian medical institutions: A qualitative exploration.

Introduction: Controlled Human Infection Model (CHIM) studies provide a unique platform for studying the pathophysiology of infectious diseases and accelerated testing of vaccines and drugs in controlled settings. However, ethical issues shroud them as the disease-causing pathogen is intentionally inoculated into healthy consenting volunteers, and effective treatment may or may not be available. We explored the perceptions of the members of institutional ethics committees (IECs) in India about CHIM studies. Methods: This qualitative exploratory study, conducted across seven sites in India, included 11 focused group discussions (FGD) and 31 in-depth interviews (IDI). A flexible approach was used with the aid of a topic guide. The data were thematically analyzed using grounded theory and an inductive approach. Emerging themes and sub-themes were analyzed, and major emergent themes were elucidated. Results: Seventy-two IEC members participated in the study including 21 basic medical scientists, 29 clinicians, 9 lay people, 6 legal experts and 7 social scientists. Three major themes emerged from this analysis-apprehensions about conduct of CHIM studies in India, a perceived need for CHIM studies in India and risk mitigation measures needed to protect research participants and minimize the associated risks. Conclusion: Development of a specific regulatory and ethical framework, training of research staff and ethics committee members, and ensuring specialized research infrastructure along with adequate community sensitization were considered essential before initiation of CHIM studies in India.

Public perceptions on Controlled Human Infection Model (CHIM) studies-a qualitative pilot study from South India.

Research using Controlled Human Infection Models is yet to be attempted in India. This study was conducted to understand the perceptions of the lay public and key opinion makers prior to the possible introduction of such studies in the country. 110 respondents from urban and rural Bangalore district were interviewed using qualitative research methods of Focus Group Discussions and In-depth Interviews. The data was analyzed using grounded theory. Safety was a key concern of the lay public, expressed in terms of fear of death. The notion of infecting a healthy volunteer, the possibility of continued effects beyond the study duration and the likelihood of vulnerable populations volunteering solely for monetary benefit, were ethical concerns. Public good outcomes such as effective treatments, targeted vaccines and prevention of diseases was necessary justification for such studies. However, the comprehension of this benefit was not clear among non-medical, non-technical respondents and suggestions to seek alternatives to CHIMs repeatedly arose. There was a great deal of deflection-with each constituency feeling that people other than themselves may be ideally suited as participants. Risk takers, those without dependents, the more health and research literate, financially sound and those with an altruistic bent of mind emerged as possible CHIM volunteers. While widespread awareness and advocacy about CHIM is essential, listening to plural voices is the first step in public engagement in ethically contentious areas. Continued engagement and inclusive deliberative processes are required to redeem the mistrust of the public in research and rebuild faith in regulatory systems.

DNAR Guidelines: Supporting end-of-life decisions.

The Indian Council of Medical Research Consensus Guidelines on 'Do Not Attempt Resuscitation' (DNAR) were published in the April 2020 issue of the Indian Journal of Medical Research (1), and simultaneously in the National Medical Journal of India (2). It is a timely effort at resolving a long-standing clinical dilemma.

Keywords: DNAR, end of life decisions, surrogate decisions, patient autonomy

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The Student's Pledge - an oath of initiation for modern times.

The taking of oaths by medical students at graduation or other times during training have become common practice globally, particularly in the last century. While some use the modern versions of the Hippocratic Oath, other colleges encourage students to frame their own. Inspired by the Oath of Initiation of Caraka, a student oath at the start of medical education, when idealism is high, can be formative as it introduces the values of the profession. The proposed student pledge could find a place in the foundation course and white coat ceremony of the new MBBS curriculum. Keywords: student's pledge, initiation ceremony, orientation, medical curriculum, fraternity.

Encounter with a legend: Dr James F Drane.

Dr James F Drane is a living legend in the field of Bioethics. In 2002, he was named one of the Founders of the Discipline of Bioethics at the International Bioethics Conference in Brasilia, Brazil. It was a privilege to meet Dr Drane at Edinboro University Pennsylvania and uncover his journey as a pioneer and leader in this field.

Centring patient autonomy in DNAR decisions.

The Response from the ICMR team of Dr Mani et al (1) to the IJME Editorial (2) on the ICMR DNAR Guidelines (3) provides some answers to the gaps and questions raised, and it is hoped that these will find a place in revised versions of the document. The document Disclaimer said "further revisions" were planned, based on perceptions and experiences of clinicians and the public; an early revision will allow for better acceptance of the Guidelines.

The Parallel Arts Festival at the 14th World Congress of Bioethics and the 7th National Bioethics Conference, Bengaluru.

The theme of the 14th World Congress of Bioethics (WCB) was "Health for All in an Unequal World; Obligations of Global Bioethics". The Parallel Arts Festival was embedded within the programme of the Congress and curated to reflect its theme.

Consultation on the feasibility and ethics of specific, probable Controlled Human Infection Model study scenarios in India: A report.

On March 6, 2019, a workshop was held as part of a larger public consultation exercise to evaluate the perceptions of participants from diverse backgrounds of studies involving Controlled Human Infection Models (CHIMs) (1,2) in India, through three specific case scenarios. This workshop was organised by the Health and Humanities Division of the St. John's Research Institute, Bangalore with funding from the Translational Health Science and Technology Institute (TSHTI), Faridabad (www.thsti.res.in), an autonomous institute of the Department of Biotechnology, Government of India This was an on-going effort of the Division to bring public discourse centre stage in the discussion on the use, ethics and regulations related to CHIM studies, and the introduction of such studies in India. Participants included epidemiologists, community/public health experts, microbiologists, infectious disease specialists, basic and translational scientists, ethicists, journalists and lawyers.

Ending commercial surrogacy in India: significance of the Surrogacy (Regulation) Bill, 2016.

The introduction of the Surrogacy (Regulation) Bill, 2016 into Parliament, in August 2016, was a much-awaited response to citizen voices and human rights groups calling for action in the unregulated area of commercial surrogacy arrangements. Both houses of Parliament have reviewed the Bill, and its fate was to be decided in the Winter Session of Parliament, 2017. It is still unclear whether the Bill will come up for decision in the Budget Session that will reconvene on March 5, 2018. The market for infertility treatments has attracted to India global clients seeking access to surrogates and procedures at lower costs. The Bill seeks to protect the rights of women and children at risk of exploitation and commodification as third parties in infertility treatments that use assisted reproductive technologies. Can commercial surrogacy be allowed in a country where injustice, inequalities, and poorly implemented laws place vulnerable women and children at risk? The proposed Bill could shut the door on commercial surrogacy arrangements in India and bring regulation into this sector of medical services.

Report of the Parliamentary Standing Committee on the Surrogacy (Regulation) Bill, 2016: A commentary.

Soon after the Surrogacy (Regulation) Bill, 2016 was approved by the Cabinet for introduction into Parliament in 2016, it was submitted for review to a Parliamentary Standing Committee on Health and Family Welfare. The report of this committee, The 102nd Report on the Surrogacy (Regulation) Bill, 2016 was laid on the table of the Lok Sabha and presented to the Rajya Sabha on August 10, 2017. It contains hearings with stakeholders and witnesses and a review of relevant documents and related legislation. The comments of the Parliamentary Standing Committee are wide ranging and pertinent, seeking to fill the gaps and explain and rationalise the statute and includes responses from the Department of Health Research. This commentary seeks to analyse the recommendations of the Committee, exploring some of the ethical, legal, and social implications of surrogacy arrangements in our country, where diverse viewpoints and strong sentiments can encounter difficult ground realities.

Protecting challenge study participants in low and middle income settings.

With India only just emerging out of a period of extreme concern and apprehension over clinical trials, the introduction of Controlled Human Infection Model (CHIM) studies calls for the need to proceed with caution, particularly with regard to protection of participants; especially vulnerable populations. In the Indian context, persons can be vulnerable due to circumstances of poverty, ignorance about clinical research and lack of access to education and healthcare. This paper will look at possible ways to provide protection to participants, starting with review and selection, through the trial period and after it is completed.

On the integration of Ethics into the Physiology curriculum.

A one-day state-level workshop was organised in Karnataka to share the experience of a programme implemented earlier, in 2015-16, at St John's Medical College, Bengaluru that integrated the teaching of ethics into the physiology curriculum. The aim was to develop the programme further, list the challenges likely to be faced while scaling it up, and identify other colleges which could participate in the scaling up. Twenty-eight participants, representing 13 medical colleges, and five resource persons attended the workshop. There was a consensus that the integration of ethics into the physiology course was relevant and desirable, although the participants identified several critical challenges which might arise. These included the lack of institutional support, a possible lack of student "buy-in" since it was beyond the requirements of the examinations, and time constraints. Specific areas of integration were identified. Three medical colleges, including the host institution, opted to implement the programme and refine it further.