Strengthen the doctor-patient relationship and avoid administrative stifling.

The acquisition of private medical practices by large health-care corporations is transforming clinical practice in many Western countries. The growing influence of health administration on medical practice is increasingly perceived as a danger by the public and health professionals. Health-care administrators should not replace doctors or invade their competencies. Back to principles, the patient-doctor relationship must be funded in trust. Representing society, governments must try to ensure health care to all citizens, serving one of the fundamental human rights. Using the principle of subsidiarity, administrators should fill gaps in the provision of health care to all patients by doctors.

Reassessing reverse triage in future conflict.

Future warfare will likely involve near-peer or peer-peer conflict in which there is a great risk of mass casualty scenarios. Because of anti-access and area denial, air superiority will not be guaranteed, which will hamper rapid evacuation of casualties as well as resupply. Under such circumstances, military medical personnel may be forced, due to the constraints of the battlefield and tactical necessity to return servicemembers to duty, to implement reverse triage in which servicemembers with less severe injuries are treated first. However, reverse triage is potentially incongruent with international humanitarian law. Furthermore, should reverse triage need to be implemented, from the extant military doctrine it is not certain when this would be appropriate or the steps that might be followed, which highlight the gaps that exist before reverse triage should be considered as military doctrine on the battlefield. Lastly, we question the psychological impact that reverse triage could portend on military medical personnel, unit morale and unit cohesion. While there have been recent recommendations that reverse triage might need to be implemented in a near-term future conflict, these issues linger. It is time for Western militaries to assess the merits of reverse triage and the potential drawbacks.

Legal and Ethics Considerations in Capacity Evaluation for Medical Aid in Dying.

Evaluating decisional capacity for patients seeking medical aid in dying (MAID) raises challenging legal, logistical, and ethics questions. The existing literature on the subject has been shaped largely by early disagreements over whether effective capacity assessment for such patients is ever possible, which in turn stemmed from debates over the ethics of MAID itself. In attempting to establish meaningful criteria for assessments, many jurisdictions have sought either to apply or to adapt models of capacity evaluation designed for other forms of medical decision-making, such as the widely used "four skills" model, failing to account for the fundamental differences in kind between these other decisions and MAID. This article seeks to reexamine these questions with a focus on two logistical matters (the appropriate credentialing for the evaluator and the potential liability of the evaluator) and three clinical matters (level of understanding, clinical scrutiny and certainty, and impairment) in an effort to raise legal and ethics concerns that remain unresolved, even as MAID is permitted in an increasing number of jurisdictions.

Ethical requirements of instructions for authors of complementary and alternative medicine journals: a cross-sectional study.

BACKGROUND: Medical research in complementary and alternative medicine (CAM) has increased recently, raising ethical concerns about the moral status of CAM. Medical academic journals are responsible for conducting ethical review (ER) of manuscripts to protect the interests of human subjects and to make ethical results available before deciding to publish. However, there has been no systematic analysis of the ER in CAM journals. This study is aim to evaluate the current status of ethical requirements and compliance in CAM journals. METHODS: This is a cross-sectional study. We reviewed instructions for authors (IFAs) of CAM journals included in the Journal Citation Reports (2021) ( https://jcr.clarivate.com ) for general information and requirements for ER. We also browsed the manuscripts regarding randomized controlled trials published by CAM journals in Q1 and Q2 section from January to June, 2023, to check the actual situation of ethical requirement. Descriptive statistics and Fisher's exact test were used for statistical analysis. RESULTS: 27 journals and 68 manuscripts were ultimately included. 92.6% (25/27) IFAs included keywords of ER, indicating the presence of ethical considerations. However, no specific ER was required for CAM (n = 0). We categorized journals by Geographic origin, JCR section, Year of electronic JCR, Types of studies, % of OA Gold to explore the factors that could influence CAM journals to have certain ethical review policies. The results showed there was no statistical significance in certain ethical review policy in any classification of journals (p > 0.05). All RCT manuscripts included in the study generally met the requirements of the published journals for ethical review. CONCLUSIONS: All IFAs discussed ER, but the content was scattered, unfocused, and there were no specific ER requirements regarding CAM. Although the manuscripts basically met the requirements of the journal, it was not possible to get closer to the process of ER in the manuscript. To ensure full implementation of these policies in the future, CAM journals should require authors to provide more details, or to form a list of items necessary for CAM ethical review.

Developing culturally competent physicians: Empathy, inclusivity, moral distress training and ethical reflections during the Medicine Clerkship.

PURPOSE: We aimed to develop a tool that would allow assessment of ethics competency and moral distress during the Internal Medicine Clerkship and to introduce curricular changes that could empower students to better address ethical dilemmas and challenges encountered during the clerkship. MATERIALS AND METHODS: A structured ethics assignment was introduced where students could reflect on impactful stressful scenarios and address questions related to emotional responses, identified ethical issues, management themes, and professional obligations. A 4-tiered grading rubric and individual narrative feedback was provided for each assignment, and small-group debriefing sessions were introduced for reflective thought and future planning. De-identified assignments were analyzed and classified into subgroups according to 5 main ethical issue subgroups and 10 specific management themes. Assignments were also analyzed for the presence of moral distress. RESULTS: 357 students completed the reflective ethics activities. The most commonly identified ethical issues were related to Shared Medical Decision Making (>40%), Primary of Patient Welfare challenges, (>20%), and Social/Organizational dilemmas. Management themes often pertained to Patient Wishes/Legal Obligations, Professional Behaviors, and Limited Resources. 87% of assignments demonstrated moral distress. CONCLUSION: Medical school is a stressful time and challenges are augmented during clinical years. Our reflective activity demonstrated significant exposures to ethical dilemmas, reviewed earlier principles of ethics training, and provided a safe forum in which to discuss these important aspects of healthcare. We captured powerful images of challenging situations eliciting moral distress, and students greatly appreciated the activity. We encourage future investigations that support student well-being and enable smooth transitions into residency training.

Germline genome editing of human IVF embryos should not be subject to overly stringent restrictions.

This paper critiques the restrictive criteria for germline genome editing recently proposed by Chin, Nguma, and Ahmad in this journal. While praising the authors for resisting fervent calls for an outright ban on clinical applications of the technology, this paper argues that their approach is nevertheless unduly restrictive, and may thus hinder technological progress. This response advocates for weighing potential benefits against risks without succumbing to excessive caution, proposing that ethical oversight combined with genetic scrutiny at the embryo stage post-editing can enable responsible use of the technology, ultimately reducing the burden of genetic diseases and enhancing human health, akin to how IVF transformed reproductive medicine despite strong initial opposition.

Ethical Implications of Artificial Intelligence in Gastroenterology: The Co-pilot or the Captain?

Though artificial intelligence (AI) is being widely implemented in gastroenterology (GI) and hepatology and has the potential to be paradigm shifting for clinical practice, its pitfalls must be considered along with its advantages. Currently, although the use of AI is limited in practice to supporting clinical judgment, medicine is rapidly heading toward a global environment where AI will be increasingly autonomous. Broader implementation of AI will require careful ethical considerations, specifically related to bias, privacy, and consent. Widespread use of AI raises concerns related to increasing rates of systematic errors, potentially due to bias introduced in training datasets. We propose that a central repository for collection and analysis for training and validation datasets is essential to overcoming potential biases. Since AI does not have built-in concepts of bias and equality, humans involved in AI development and implementation must ensure its ethical use and development. Moreover, ethical concerns regarding data ownership and health information privacy are likely to emerge, obviating traditional methods of obtaining patient consent that cover all possible uses of patient data. The question of liability in case of adverse events related to use of AI in GI must be addressed among the physician, the healthcare institution, and the AI developer. Though the future of AI in GI is very promising, herein we review the ethical considerations in need of additional guidance informed by community experience and collective expertise.

Teaching Moral Courage & Rights-Based Leadership in Medicine: A Cross-Disciplinary Exploration.

Clinical medicine's complexities and demands often surpass the scope of formal ethics and leadership training that medical schools and residency programs provide. The discrepancy between medical education and the realities of clinical work may contribute to ethical erosion among learners, namely, medical students and residents. Unlike traditional approaches to teaching professional ethics and leadership in medicine, rights-based (aspirational) pedagogies approach trainees as autonomous moral agents, whose work has moral value to themselves and others, who live with the ethical consequences of their professional choices, and whose work shapes their individual moral character. By incorporating teaching strategies that intentionally build learners' rights-based leadership through the development of moral courage, medical educators may counter important aspects of ethical erosion while promoting learner preparedness, outcomes, and well-being. Military teaching approaches offer a valuable example to medical educators seeking to create structured curricula that foster moral courage to promote rights-based leadership, given the high level of moral and managerial complexity present in both medicine and the military. Through a comparative analysis of professional ethics in the medical and military disciplines, this Observation article explores the validity of applying precedents from military ethics and leadership education to medical training. Through arguments rooted in moral philosophy, military history, and military organizational research, we explore the expansion of rights-based teaching methods within the predominantly traditional and rules-based norms of medical education. In relating these findings to real-life clinical scenarios, we offer six specific, rights-based modifications to medical ethics curricula that have potential to promote morally courageous leadership and counteract the ethical erosion medical students and residents face.

Black bodies in phenomenological bioethics: cultural othering, 'Corporeal Uncanny' and ethical quandaries of black nurses in Take My Hand and Small Great Things.

The aims of the present article are twofold. First, it attempts to theorise the thematic and ontological intersection between phenomenological and black bioethics and proposes 'Ontic-Black Bioethics', a neologism to evince how the corporeal misconceptions (such as race construct, bodily othering and colourism) become the cultural impediment for black women healthcare professionals. The article draws specific insights from the philosophical anthropology of race, ranging from Richard Polt to Sarah Ahmed, to understand the epistemic structures of scientific racism. Second, it investigates how the racial attitudes of white healthcare professionals and supremacist patients towards black nurses can be potential triggers of cultural othering, corporeal burden and ethical quandaries by closely reading Take My Hand by Dolen Perkins-Valdez (2022) and Small Great Things by Jodi Picoult (2016). For this, the article relies on the theoretical frameworks of cultural phenomenology and somatic attention postulated by Thomas Csordas, Philipa Rothfield and other theoreticians of varying importance. While the corporeality of black nurses is replete with the images of biological misconception and racial-cultural constructs, the epistemic perspectives and literary representations underscoring their bodily and experiential agony have been scarcely examined through the lenses of bioethics. Thus, the article construes the corporeality of black nurses as the confluence of biological and cultural discourses under phenomenological bioethics.

Age-related hearing loss and "hearables": An agenda for moral considerations.

Rapid advances in digital hearing technologies, also known as hearables, are expected to disrupt the direct-to-consumer health market. For older adults with higher incidence of hearing loss, such disruption could reduce hearing problems, increase accessibility to hearing aids, and mitigate related stigmas. This paper delves into the intersection of disruptive innovation and hearables within the realm of biomedical ethics. Through a comprehensive exploration, we shed light on the ethical implications surrounding hearables. By critically evaluating the key ethical advantages and drawbacks, we find that no single concern presents an insurmountable a priori objection to hearables. We conclude with some ideas to maximize the benefits of hearables and further promote opportunities for equitable hearing health.

The Hippocratic principle "to help or at least to do no harm".

Hippocrates' teaching on the ethical and moral values of medicine have captivated physicians, scholars, and historians for over twenty-five centuries, enduring despite the challenges of applying moral guidance across diverse cultures. At the core of Hippocratic ethics is the human relationship between the physician and the patient, with an emphasis on the physician's responsibility to assess potential harm involved in any attempt to heal. The Hippocratic principle "to help, or at least to do no harm" remains as relevant today as it was 2,500 years ago. In the modern context, it serves as a deontological imperative, reminding physicians to evaluate the risks of harm associated with any healing attempt. This concept aligns with the ethical principles of beneficence and non-maleficence, which are at the heart of Hippocratic medical ethics with timeless significance.

Ethical issues in the application of genome-wide association studies to US military recruitment and personnel assignments.

Genome-wide association studies seek to associate an organism's genotypes with phenotypes. The goal of such research is to identify specific genetic variants that may be used to predict an individual's risk for a specific physical or mental disease. Recently, it has been recommended that policymakers in the USA should employ genomic surveillance so that it can be used for initial military personnel selection and personnel assignments. However, such a proposal highlights the necessity of subjecting such recommendations to rigorous ethical analysis, including concerns regarding recruitment, transparency and the return of genetic results.

An ethical assessment of professional opinions on concerns, chances, and limitations of the implementation of an artificial intelligence-based technology into the geriatric patient treatment and continuity of care.

With the introduction of an artificial intelligence-based dashboard into the clinic, the project SURGE-Ahead responds to the importance of improving perioperative geriatric patient treatment and continuity of care. The use of artificial intelligence to process and analyze data automatically, aims at an evidence-based evaluation of the patient's health condition and recommending treatment options. However, its development and introduction raise ethical questions. To ascertain professional perspectives on the clinical use of the dashboard, we have conducted 19 semi-structured qualitative interviews with head physicians, computer scientists, jurists, and ethicists. The application of a qualitative content analysis and thematic analysis enabled the detection of main ethical concerns, chances, and limitations. These ethical considerations were categorized: changes of the patient-physician relationship and the current social reality are expected, causing de-skilling and an active participation of the artificial intelligence. The interviewees anticipated a redistribution of human resources, time, knowledge, and experiences as well as expenses and financing. Concerns of privacy, accuracy, transparency, and explainability were stated, and an insufficient data basis, an intensifying of existing inequalities and systematic discrimination considering a fair access emphasized. Concluding, the patient-physician relationship, social reality, redistribution of resources, fair access, as well as data-related aspects of the artificial intelligence-based system could conflict with the ethical principles of autonomy, non-maleficence, beneficence, and social justice. To respond to these ethical concerns, a responsible use of the dashboard and a critical verification of therapy suggestions is mandatory, and the application limited by questions at the end of life and taking life-changing decisions.

The rise of medical influencers: The pros and the cons.

In the past few years, the online influencer industry has exponentially expanded, fuelled by the COVID pandemic lockdown, increased social media platforms and lifestyle appeal of influencership. This phenomenon has likewise infiltrated the medical field, where many healthcare practitioners have taken to social media platforms for content creation and influencer marketing. There are many reasons that underlie medical influencership - some may use it to improve public health literacy and correct medical misinformation, engage in medical advocacy or use the platform simply as a means of humanistic expression of the medical career, while others may seek to advertise private practice/medical products, boost personal reputation, and gain popularity and monetary benefits. Regardless of the underlying motivations of the medical influencers, some have fallen afoul of professionally accepted practices and ethical boundaries in their use of social media platforms, leading to serious consequences such as professional sanctioning or termination of employment. In this article, we hope to provide a comprehensive review of the 'good' (positive practices), the 'bad' (practices with possible unintended negative consequences) and the outright unprofessional or unethical behaviours aspects of social media use by medical influencers and offer practical strategies to ensure responsible and meaningful use of influencer platforms at both the physician and health systems level.

Consent and Educational Sensitive Exams on Anesthetized Patients: Experiences of Medical Students Across Canada.

OBJECTIVES: This study investigates experiences of medical students across Canada related to consent for educational sensitive (i.e., pelvic, rectal) exams under anesthesia (EUAs). METHODS: A bilingual online questionnaire was developed and distributed to medical students across Canada. RESULTS: Of 134 respondents, 63% had performed a pelvic EUA, 35% a rectal EUA, and 11% another sensitive EUA during their training. For those who had performed pelvic EUA, 28% were unsure if consent had taken place, 26% reported no specific consent, 20% reported specific consent, and 25% had mixed experiences of consent. For rectal EUAs, 48% reported no specific consent, 37% were unsure if consent had taken place, 13% reported that there had been specific consent, and 2% reported mixed experiences. Most respondents were uncomfortable (36%) or not sure if they were comfortable (32%) with how the consent process was handled for student pelvic EUAs; 31% were comfortable. In open-ended responses, respondents described experiences related to variability, discomfort, and authority. CONCLUSIONS: Non-consensual educational sensitive EUAs continue to take place in medical training across Canada, although practices of consent are highly variable. The majority of respondents reported being uncomfortable or unsure if they were comfortable with how consent for educational sensitive EUAs was practised during their training, and some respondents struggled to express their discomfort given the power dynamics at play.

When medical assistance in dying is not a last resort option: survey of the Canadian public.

OBJECTIVES: What are the Canadian public's understanding of and views toward medical assistance in dying (MAID) in persons refusing recommended treatment or lacking access to standard treatment or resources? DESIGN/SETTING: An online survey assessed knowledge of and support for Canadian MAID law, and views about four specific scenarios in a two (medical or psychiatric) by two (treatment refusal or lack of access) design. PARTICIPANTS: A quota sample (N=2140) matched to the 2021 Canadian census by age, gender, income, education and province. MAIN OUTCOMES: Participants' level of support for MAID in general and in the four specific scenarios. RESULTS: Only 12.1% correctly answered ≥4 of 5 knowledge questions about the MAID law; only 19.2% knew terminal illness is not required and 20.2% knew treatment refusal is compatible with eligibility. 73.3% of participants expressed support for the MAID law in general, matching a nationally representative poll that used the same question. 40.4% of respondents supported MAID for mental illnesses. Support for MAID in the scenarios depicting refusal or lack of access to treatment ranged from 23.2% (lack of access in medical condition) to 32.0% (treatment refusal in medical illness). Older age, more education, higher income, lower religious attendance or being white was associated with greater support for MAID in general but was either negatively associated or not associated with support for MAID in the four refusal or lack of access scenarios. CONCLUSIONS: Most Canadians support the current MAID law but appear unaware that MAID cases they do not support are compatible with that law. The lower support for MAID in the four scenarios cuts across sociodemographics. The gap between current policy and public opinion warrants further study. For jurisdictions debating MAID, opinion surveys may need to go beyond assessing general attitudes, and target knowledge and views regarding implications of legalisation.

Medical ethics in childbirth: a structural equation modeling approach in south of Iran.

BACKGROUND: The existence of a valid instrument to evaluate the attitude of mothers towards compliance with medical ethics during childbirth can lead to appropriate interventions to create a positive attitude. The purpose of this study is to determine the construct validity of the MEAVDQ (Medical Ethics Attitude in Vaginal Delivery Questionnaire). METHODS: The study was carried out with 350 women. The main research instrument was MEAVDQ. This 59-item questionnaire comprises three parts A, B, J. Part A is concerned with the first principles. Part B deals with the second and third principles and part J addresses the fourth principle of medical ethics. Structural Equations Modeling (SEM) was used to determine the construct validity of MEAVDQ. RESULTS: The results of SEM revealed that there was a positive correlation between structures A and B. The relationship between structures B and J was also positive and significant. On the other hand, there was a direct and indirect relationship between structures A and J. One-unit increase in structure A led to 0.16 (95% CI: 0.01, 0.33) direct increase in structure J. Also, one-unit increase score increases in structure A caused 0.39 indirect rise (95% CI: 0.26, 0.53) in structure J with the mediating role of the structure B. CONCLUSIONS: It can be suggested to midwifery policy maker and midwives that respect for the first principle of medical ethics and autonomy is the most important principle of medical ethics in childbirth. By respecting the autonomy of mothers, a positive birth experience can be created for them.

Cross-sectional analysis of pharmaceutical industry payments to authors of clinical practice guidelines for bipolar disorder and major depressive disorder in Japan.

OBJECTIVE: Clinical practice guidelines (CPGs) are essential for standardising patient care based on evidence-based medicine. However, the presence of financial conflicts of interest (COIs) among CPG authors can undermine their credibility. This study aimed to examine the extent and size of COIs among authors of psychiatry CPGs in Japan. METHODS: This cross-sectional analysis of disclosed payments from pharmaceutical companies assesses the prevalence and magnitude of personal payments for lecturing, consulting and writing to CPGs for bipolar disorder and major depressive disorder in Japan between 2016 and 2020. RESULTS: This study found that 93.3% of authors received payments over a 5-year period, with total payments exceeding US$4 million. The median payment per author was US$51 403 (IQR: US$9982-US$111 567), with a notable concentration of payments among a small number of authors, including the CPG chairperson. Despite these extensive financial relationships, only a fraction of authors disclosed their COIs in the CPGs. These large amounts of personal payments were made by pharmaceutical companies manufacturing new antidepressants and sleeping aids listed in the CPGs. CONCLUSIONS: This study found that more than 93% of authors of CPGs for major depressive disorder and bipolar disorder in Japan received considerable amounts of personal payments from the pharmaceutical industry. The findings highlight deviations from international COI management standards and suggest a need for more stringent COI policies for psychiatry CPGs in Japan.

Take five? A coherentist argument why medical AI does not require a new ethical principle.

With the growing application of machine learning models in medicine, principlist bioethics has been put forward as needing revision. This paper reflects on the dominant trope in AI ethics to include a new 'principle of explicability' alongside the traditional four principles of bioethics that make up the theory of principlism. It specifically suggests that these four principles are sufficient and challenges the relevance of explicability as a separate ethical principle by emphasizing the coherentist affinity of principlism. We argue that, through specification, the properties of explicability are already covered by the four bioethical principles. The paper finishes by anticipating an objection that coherent principles could not facilitate technology induced change and are not well-suited to tackle moral differences.