Slow codes, multiple layers of deception, and partial solutions.

It is not unusual for patients or families to disagree with healthcare professionals (HCPs) over best treatment options. Conversation typically results and mutually agreeable choices are implemented. Rarely, but increasingly, patients or families will request, even demand, interventions the treating team believes will be ineffective (they will not achieve the intended goal) or inappropriate (the medical or moral harms clearly outweigh any potential benefits). One's duty as an HCP requires one to refuse such interventions, but resulting patient or family conflict makes such refusals challenging, even traumatic, and HCPs often acquiesce. Some states have legal options that protect HCPs and their respective institutions when they make such unilateral choices, but the process is complex, time-consuming, and emotionally fraught. In this paper, We describe one especially difficult case, using it as a paradigmatic example of when, and why, a slow code is sometimes, if rarely, justified. We also discuss strategies HCPs can use to reduce the need for this, admittedly problematic, solution.

The First- and Second-Order Ethical Reasons Approach: The Case of Human Challenge Trials.

At the height of the Covid pandemic, there was much discussion in the literature about using human challenge trials (HCTs) to expedite the development of effective Covid-19 vaccines. Historically, reluctance to fully accept HCTs has largely been due to potential conflicts with the principle of nonmaleficence in bioethics. Only a few commentators have explored this topic in depth. In this paper, we claim that to address ethical concerns regarding HCTs, two types of ethical reasons should be identified and investigated: first-order reasons that can be given to claim that a practice in itself is in direct conflict with the principles of bioethics; and second-order reasons that take into consideration how a practice is carried out and its consequences. We argue that understanding these ethical reasons is crucial for guiding the implementation of HCTs. We investigate a first-order reason against HCTs when the practice is in conflict with the principle of nonmaleficence, and when it is not. Following this argument and assuming there is no first-order reason based on nonmaleficence that hinders using HCTs, we argue there may be second-order reasons to guide implementation of this practice, such as difficulty in obtaining informed consent; protection of the weaker party; and trust in the scientific enterprise.

[Ethical case discussions before compulsory medication in psychiatry]. / Ethische Fallbesprechungen vor Zwangsmedikation in der Psychiatrie.

BACKGROUND: Ethical case discussions in psychiatric hospitals are particularly useful when a moral conflict between respect for the patient's autonomy and well-being becomes apparent when considering the legitimacy of coercive treatment. To date, there is hardly any data on the procedure and the results of such case discussions. We therefore present data from a large psychiatric clinic. AIM OF THE STUDY: We retrospectively analyzed ethical case discussions prior to compulsory medication in a quantitative and qualitative manner. METHODS: The study analyzed the protocols of all ethical case discussions over a 2-year period. They used the method of principle-based ethical case discussion. The qualitative analysis of selected cases was supplemented by reference to case records. RESULTS: An advance care directive was not available in any of the cases, so that the presumed will was used generally to assess the autonomy perspective. It proved quite complex to address danger to third parties when assessing the beneficence and nonmaleficence perspective. In 5 out of 35 consultations, the compulsory medication was not recommended from an ethical perspective. DISCUSSION: Ethical case discussions enable a holistic individual examination of moral obligations. They contribute to well-founded decisions and can help to reduce the frequency of coercive medications, suggesting routine use of ethics counselling.

Non-Maleficence toward Young Kidney Donors: A Call for Stronger Ethical Standards and Associated Factors in Multidisciplinary Nephrology Teams.

BACKGROUND: The rising frequency of live kidney donations is accompanied by growing ethical concerns as to donor autonomy, the comprehensiveness of disclosure, and donors' understanding of long-term consequences. AIM: To explore donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding disclosure of donation consequences to live kidney donors. METHODS: A cross-sectional study was performed among Israeli live kidney donors who had donated a kidney in two hospitals that belonged to the Ministry of Health's Transplantation Center one year after the donation, from December 2018 to December 2020. Data collection was conducted online and through face-to-face interviews with the donors in their native language (Hebrew or Arabic). RESULTS: Overall, 91 live kidney donors aged 18-49 years were enrolled. Of those, 65.9% were males, and 54.9% were academic donors. Among the live kidney donors, 59.3% reported that the motivation behind the donation was a first-degree family member vs. 35.2% altruistic and 5.5% commercial. Only 13.2% reported that the provided disclosure adequately explained the possible consequences of living with a single kidney. Approximately 20% of the participants reported that the disclosure included information regarding their risk of developing ESRD, hypertension, and proteinuria. The donors reported a low mean of the index score that indicates a low follow-up by the physician after the donation (mean = 1.16, SD = 0.37). The mean GFR level was significantly lower in the post-donation period one year following a kidney donation (117.8 mL/min/1.73 m2) compared with the pre-donation period (84.0 mL/min/1.73 m2), p < 0.001. CONCLUSION: Our findings display that donors' satisfaction with the ethical competence of multi-professional nephrology teams regarding the disclosure of donation consequences to live kidney donors is low. This study indicates that donors are at an increased risk of worsening kidney functions (creatinine and GFR), and BMI. Our findings underscore the imperative to advise donors that their condition may worsen over time and can result in complications; thus, they should be monitored during short and long-term follow-up periods. This study was not registered.

Global Ethical Principles in Healthcare Networks, Including Debates on Euthanasia and Abortion.

In today's ever-evolving healthcare landscape, the focus is shifting towards integrated care, inter-organizational cooperation, and healthcare networks (HCNs) as alternatives to traditional healthcare institutions. This transformation is driven by factors such as an aging population and increasing healthcare costs, necessitating a reevaluation of ethical considerations to ensure the well-being of patients remains central. This review provides a narrative overview of ethics within HCNs, with a focus on patient-centered medical ethics. It elaborates on the four fundamental ethical principles, namely justice, beneficence, nonmaleficence, and autonomy. The principle of justice underscores HCNs' ethical obligation to provide equitable and transparent access to all patients, ensuring fairness in resource allocation. The principle of nonmaleficence underscores the responsibility to prioritize patient safety, while beneficence obliges HCNs to ensure continuity of care across all dimensions. Furthermore, the principle of autonomy is redefined as a commitment to actively promote and respect patient choices. HCNs that do not adhere to these ethical principles raise concerns and lack ethical justification. Additionally, the review delves into the legal aspects of euthanasia and abortion, both of which present complex ethical challenges in healthcare systems globally. A comparative analysis is provided, examining their legal status in Islamic countries, European nations, and the United States. This study sheds light on the evolving ethical landscape in HCNs and the diverse global perspectives on contentious issues. Therefore, harmonizing legislation and defining appropriate boundaries are crucial steps toward upholding ethical standards in healthcare practices on a global scale.

Ethical and moral principles for oncology healthcare workers: A brief report from a Bioethics consortium emphasizing on need for education.

The medical sub-specialty of Oncology presents diverse ethical dilemmas, often challenging cancer healthcare workers with difficult-to-handle clinical scenarios that are tough from a personal and professional perspective. Making decisions on patient care in various circumstances is a defining obligation of an oncologist and those duty-based judgments entail more than just selecting the best treatment or solution. Ethics is an essential and inseparable aspect of clinical medicine and the oncologists as well as the allied health care workers are ethically committed to helping the patient, avoiding or minimizing harm, and respecting the patient's values and choices. This review provides an overview of ethics and clinical ethics and the four main ethical principles of autonomy, beneficence, non-maleficence, and justice are stated and explained. At times there are frequently contradictions between ethical principles in patient care scenarios, especially between beneficence and autonomy. In addition, truth-telling, professionalism, empathy, and cultural competence; which are recently considered important in cancer care, are also addressed from an Indian perspective.

Ethical Considerations in Pediatric Surgery.

Pediatric surgeons need to learn to give as much importance to the ethical approach as they have been giving to the systemic methodology in their clinical approach all along. The law of the land and the governmental rules also need to be kept in mind before deciding the final solution. They need to always put medical problems in the background of ethical context, reach a few solutions keeping in mind the available resources, and apply the best solution in the interest of their pediatric patients.

An Ethical Framework for Allergy and Immunology.

Ethical dilemmas routinely occur in the clinical practice of allergy and immunology. These ethical questions stem from the range of conditions and the different populations cared for by Allergists/Immunologists. Hence, medical ethics is not an esoteric concept, but a practical skill physicians exercise regularly. Moreover, an ethics-centered approach may improve patient safety and outcomes. This article describes key principles of bioethics and illustrates an ethical framework that physicians can use in their conversations with patients. Utilization of this ethical framework is demonstrated through applying it to 4 unique clinical scenarios encountered by Allergists/Immunologists from different practice settings. The ethical framework for allergy and immunology is a technique to navigate ethically complex decisions that arise in routine clinical practice.