Values-Based Medicine Is an Ethical Concept for Implementing the Ethical Principles in Daily Practice.

Values-based medicine (VsBM) is an ethical concept, and bioethical framework has been developed to ensure that medical ethics and values are implemented, pervasive, and powerful parameters influencing decisions about health, clinical practice, teaching, medical industry, career development, malpractice, and research. Neurosurgeons tend to adopt ethics according to their own values and to what they see and learn from teachers. Neurosurgeons, in general, are aware about ethical codes and the patient's rights. However, the philosophy, concept, and principles of medical ethics are rarely included in the training programs or in training courses. The impact of implementing, observing the medical ethics and the patients' value and culture on the course, and outcome of patients' management should not underestimate. The main principles of medical ethics are autonomy, beneficence, nonmaleficence, justice, dignity, and honesty, which should be strictly observed in every step of medical practice, research, teaching, and publication. Evidence-based medicine has been popularized in the last 40-50 years in order to raise up the standard of medical practice. Medical ethics and values have been associated with the medical practice for thousands of years since patients felt a need for treatment. There is no conflict between evidence-based medicine and values-based medicine, as a medical practice should always be performed within a frame of ethics and respect for patients' values. Observing the principles of values-based medicine became very relevant as multicultural societies are dominant in some countries and hospitals in different corners of the world.

Ethics of early detection of disease risk factors: A scoping review.

BACKGROUND: Scientific and technological advancements in mapping and understanding the interrelated pathways through which biological and environmental exposures affect disease development create new possibilities for detecting disease risk factors. Early detection of such risk factors may help prevent disease onset or moderate the disease course, thereby decreasing associated disease burden, morbidity, and mortality. However, the ethical implications of screening for disease risk factors are unclear and the current literature provides a fragmented and case-by-case picture. METHODS: To identify key ethical considerations arising from the early detection of disease risk factors, we performed a systematic scoping review. The Scopus, Embase, and Philosopher's Index databases were searched for peer-reviewed, academic records, which were included if they were written in English or Dutch and concerned the ethics of (1) early detection of (2) disease risk factors for (3) disease caused by environmental factors or gene-environment interactions. All records were reviewed independently by at least two researchers. RESULTS: After screening 2034 titles and abstracts, and 112 full papers, 55 articles were included in the thematic synthesis of the results. We identified eight common ethical themes: (1) Reliability and uncertainty in early detection, (2) autonomy, (3) privacy, (4) beneficence and non-maleficence, (5) downstream burdens on others, (6) responsibility, (7) justice, and (8) medicalization and conceptual disruption. We identified several gaps in the literature, including a relative scarcity of research on ethical considerations associated with environmental preventive health interventions, a dearth of practical suggestions on how to address expressed concerns about overestimating health capacities, and a lack of insights into preventing undue attribution of health responsibility to individuals. CONCLUSIONS: The ethical concerns arising with the early detection of risk factors are often interrelated and complex. Comprehensive ethical analyses are needed that are better embedded in normative frameworks and also assess and weigh the expected benefits of early risk factor detection. Such research is necessary for developing and implementing responsible and fair preventive health policies.

Brain Pioneers and Moral Entanglement: An Argument for Post-trial Responsibilities in Neural-Device Trials.

We argue that in implanted neurotechnology research, participants and researchers experience what Henry Richardson has called "moral entanglement." Participants partially entrust researchers with access to their brains and thus to information that would otherwise be private, leading to created intimacies and special obligations of beneficence for researchers and research funding agencies. One of these obligations, we argue, is about continued access to beneficial technology once a trial ends. We make the case for moral entanglement in this context through exploration of participants' vulnerability, uncompensated risks and burdens, depth of relationship with the research team, and dependence on researchers in implanted neurotechnology trials.

A critical take on procreative justice.

Herjeet Kaur Marway recently proposed the Principle of Procreative Justice, which says that reproducers have a strong moral obligation to avoid completing race and colour injustices through their selection choices. In this article, we analyze this principle and argue, appealing to a series of counterexamples, that some of the implications of Marway's Principle of Procreative Justice are difficult to accept. This casts doubt on whether the principle should be adopted. Also, we show that there are some more principled worries regarding Marway's idea of a strong pro tanto duty not to complete injustices through one's procreative choices. Nonetheless, we believe Marway's arguments point in the right general direction regarding duties and structural injustice. Thus, in the final part, we suggest a positive proposal on how it would be possible to respond to the cases we raise. More specifically, we explore the suggestion that agents have a pro tanto duty to participate in eliminating structural injustice. Importantly, this duty can be satisfied, not only in procreation choices but in multiple ways.

Shared decision making in older people after severe stroke.

Stroke is a major cause of death and lifelong disability. Although stroke treatments have improved, many patients are left with life-changing deficits. Shared decision making and consent are fundamental to good medical practice. This is challenging because stroke often causes mental incapacity, prior views might not be known and prognosis early after stroke is often uncertain. There are no large trials of shared decision making after severe stroke, so we need to rely on observational data to inform practice. Core ethical principles of autonomy, beneficence, non-maleficence and justice must underpin our decision making. 'Surrogate' decision makers will need to be involved if a patient lacks capacity, and prior expressed views and values and beliefs need to be taken into account in decision making. Patients and surrogates often feel shocked at the sudden nature of stroke, and experience grief including anticipatory grief. Health care professionals need to acknowledge these feelings and provide support, be clear about what decisions need to be made and provide sufficient information about the stroke, and the risks and benefits of treatments being considered. Shared decision making can be emotionally difficult for health care professionals and so working in a supportive environment with compassionate leadership is important. Further research is needed to better understand the nature of grief and what sort of psychological support would be most helpful. Large randomised trials of shared decision making are also needed.

Proposing a Principle-Based Approach for Teaching AI Ethics in Medical Education.

The use of artificial intelligence (AI) in medicine, potentially leading to substantial advancements such as improved diagnostics, has been of increasing scientific and societal interest in recent years. However, the use of AI raises new ethical challenges, such as an increased risk of bias and potential discrimination against patients, as well as misdiagnoses potentially leading to over- or underdiagnosis with substantial consequences for patients. Recognizing these challenges, current research underscores the importance of integrating AI ethics into medical education. This viewpoint paper aims to introduce a comprehensive set of ethical principles for teaching AI ethics in medical education. This dynamic and principle-based approach is designed to be adaptive and comprehensive, addressing not only the current but also emerging ethical challenges associated with the use of AI in medicine. This study conducts a theoretical analysis of the current academic discourse on AI ethics in medical education, identifying potential gaps and limitations. The inherent interconnectivity and interdisciplinary nature of these anticipated challenges are illustrated through a focused discussion on "informed consent" in the context of AI in medicine and medical education. This paper proposes a principle-based approach to AI ethics education, building on the 4 principles of medical ethics-autonomy, beneficence, nonmaleficence, and justice-and extending them by integrating 3 public health ethics principles-efficiency, common good orientation, and proportionality. The principle-based approach to teaching AI ethics in medical education proposed in this study offers a foundational framework for addressing the anticipated ethical challenges of using AI in medicine, recommended in the current academic discourse. By incorporating the 3 principles of public health ethics, this principle-based approach ensures that medical ethics education remains relevant and responsive to the dynamic landscape of AI integration in medicine. As the advancement of AI technologies in medicine is expected to increase, medical ethics education must adapt and evolve accordingly. The proposed principle-based approach for teaching AI ethics in medical education provides an important foundation to ensure that future medical professionals are not only aware of the ethical dimensions of AI in medicine but also equipped to make informed ethical decisions in their practice. Future research is required to develop problem-based and competency-oriented learning objectives and educational content for the proposed principle-based approach to teaching AI ethics in medical education.

The ethicality of the COVID-19 response in children and adolescents.

Childhood and adolescence are critical periods of physiological growth as well as development in biological, emotional, and social domains. During the COVID-19 pandemic, children and adolescent's lives were drastically changed. Many countries including the United Kingdom and Ireland imposed strict universal lockdowns, which included the closing of creches, schools and universities as well as restricting peer interactions, social activities, and recreational pursuits. Evidence is emerging of a catastrophic impact on the younger generation, which leads the authors to explore the ethicality of the COVID-19 response in this population in relation to the four pillars of medical ethics: beneficence, nomaleficence, autonomy, and justice.

Challenges for Medical Students in Applying Ethical Principles to Allocate Life-Saving Medical Devices During the COVID-19 Pandemic: Content Analysis.

BACKGROUND: The emergence of the COVID-19 pandemic has posed a significant ethical dilemma in the allocation of scarce, life-saving medical equipment to critically ill patients. It remains uncertain whether medical students are equipped to navigate this complex ethical process. OBJECTIVE: This study aimed to assess the ability and confidence of medical students to apply principles of medical ethics in allocating critical medical devices through the scenario of virtual patients. METHODS: The study recruited third- and fourth-year medical students during clinical rotation. We facilitated interactions between medical students and virtual patients experiencing respiratory failure due to COVID-19 infection. We assessed the students' ability to ethically allocate life-saving resources. Subsequently, we analyzed their written reports using thematic analysis to identify the ethical principles guiding their decision-making. RESULTS: We enrolled a cohort of 67 out of 71 medical students with a mean age of 34 (SD 4.7) years, 60% (n=40) of whom were female students. The principle of justice was cited by 73% (n=49) of students while analyzing this scenario. A majority of them expressed hesitancy in determining which patient should receive life-saving resources, with 46% (n=31) citing the principle of nonmaleficence, 31% (n=21) advocating for a first-come-first-served approach, and 25% (n=17) emphasizing respect for patient autonomy as key influencers in their decisions. Notably, medical students exhibited a lack of confidence in making ethical decisions concerning the distribution of medical resources. A minority, comprising 12% (n=8), proposed the exploration of legal alternatives, while 4% (n=3) suggested medical guidelines and collective decision-making as potential substitutes for individual ethical choices to alleviate the stress associated with personal decision-making. CONCLUSIONS: This study highlights the importance of improving ethical reasoning under time constraints using virtual platforms. More than 70% of medical students identified justice as the predominant principle in allocating limited medical resources to critically ill patients. However, they exhibited a lack of confidence in making ethical determinations and leaned toward principles such as nonmaleficence, patient autonomy, adherence to legal and medical standards, and collective decision-making to mitigate the pressure associated with such decisions.

Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence- and autonomy-based eligibility criteria?

According to the "discrimination argument," it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread "joint" approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy-based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence- and autonomy-based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS.

Ethical Issues Regarding Neurosurgical Management of Penetrating Brain Injury in the French Armed Forces.

Combat penetrating brain injury (PBI) differs significantly from PBI in civilian environments. Differences include technical factors such as the weapons involved, strained resource environments, and limited medical materials and human resources available. Ethical issues regarding the management of PBI in military settings may occur. This case study examines the case of a 20-year-old member of the French Armed Forces that suffered a penetrating brain injury in a combat situation. The four-quadrant method along with the four principles of medical ethics (respect for autonomy, beneficence, nonmaleficence, and justice) was used to analyze this case and to apply ethics to the practice of military medicine. Nowadays, we possess the medical and surgical resources as well as the aeromedical evacuation capability to save the life of a soldier with a penetrating craniocerebral wound. Nonetheless, the functional outcome of this type of wound places military doctors in an ethical dilemma. The line of conduct and clinical protocol established by the French Medical Health Service is to manage all PBIs when the patient's life can be saved and to provide all available financial and social support for the rehabilitation of patients and their family.

[The principles of bioethics in teaching: difficulties and proposal]. / Los principios de la bioética en la docencia: dificultades y propuesta.

It is common base the teaching of bioethics on the learning of the principles of autonomy, beneficence, non-maleficence and justice, widely used today. In terms of ethical practice, these principles suffer from a notable inadequacy, leaving aside their ambiguity and other problems. Nevertheless, as a teaching method, they show a special incongruity, for several reasons: a) little adequacy of the terms to the concepts that want to be expressed, b) formalism that hinders the approach to reality, c) little adaptation to the needs of the student and d) be specialized terms in a field that should be fundamentally informative. These four limitations, which advise another approach in the teaching of bioethics, are examined in detail; a final reflection is provided on the difference between the principles of bioethics and ethics.

Should Antipsychotics' Risks Be Accepted by Clinicians on Behalf of Patients to Achieve Benefits of Mitigating Older Adults' Behavioral Symptoms in Short-Staffed Units?

This commentary on a case considers risks and benefits of pharmacological and nonpharmacological management of agitation in patients with dementia. Specifically, it considers beneficence and nonmaleficence in treatment decisions that affect both patients and staff as well as autonomy and surrogate decision making.

Should Artificial Intelligence be used to support clinical ethical decision-making? A systematic review of reasons.

BACKGROUND: Healthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use. METHODS: PubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis. RESULTS: Artificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process. CONCLUSIONS: The prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human-machine interaction, have been neglected in the debate on AI for clinical ethics so far. TRIAL REGISTRATION: This review is registered at Open Science Framework ( https://osf.io/wvcs9 ).

Epistemic Injustice and Nonmaleficence.

Epistemic injustice has undergone a steady growth in the medical ethics literature throughout the last decade as many ethicists have found it to be a powerful tool for describing and assessing morally problematic situations in healthcare. However, surprisingly scarce attention has been devoted to how epistemic injustice relates to physicians' professional duties on a conceptual level. I argue that epistemic injustice, specifically testimonial, collides with physicians' duty of nonmaleficence and should thus be actively fought against in healthcare encounters on the ground of professional conduct. I do so by fleshing out how Fricker's conception of testimonial injustice conflicts with the duty of nonmaleficence as defined in Beauchamp and Childress on theoretical grounds. From there, I argue that testimonial injustice produces two distinct types of harm, epistemic and non-epistemic. Epistemic harms are harms inflicted by the physician to the patient qua knower, whereas non-epistemic harms are inflicted to the patient qua patient. This latter case holds serious clinical implications and represent a failure of the process of due care on the part of the physician. I illustrate this through examples taken from the literature on fibromyalgia syndrome and show how testimonial injustice causes wrongful harm to patients, making it maleficent practice. Finally, I conclude on why nonmaleficence as a principle will not be normatively enough to fully address the problem of epistemic injustice in healthcare but nevertheless may serve as a good starting point in attempting to do so.

Socially optimal dosing for scarce vaccines: Ethical analysis through the principlism framework.

RATIONALE, AIMS, AND OBJECTIVES: Under conditions of vaccine scarcity, the socially optimal dosing (SOD) strategy administers a lower dose of vaccine to a larger number of people than the individually optimal dosing (IOD) strategy, which administers a higher dose of vaccine to a smaller number of people. In the context of vaccines that generate diminishing returns of effectiveness with each additional dose beyond the first, SOD therefore generates a greater total amount of vaccine-induced protection than IOD and, as such, constitutes the socially optimal strategy. While the clinical and public health arguments in favour of SOD have previously been outlined, this article conducts an ethical analysis of SOD for scarce vaccines through the ethical framework of principlism. METHODS: SOD is examined with regard to each principle within the principlism framework-nonmaleficence, beneficence, autonomy, and justice. RESULTS: SOD is found to satisfy each of the ethical requirements under examination. Regarding nonmaleficence, SOD induces less iatrogenic harm than IOD since the dose of vaccine administered to each individual is lower in the former than the latter. Furthermore, both the good and bad effects of SOD are foreseen while only the good effects are intended, meaning this strategy simultaneously satisfies the doctrine of double effect. Regarding autonomy, SOD makes vaccine-induced protection available to a greater number of individuals who wish to receive it, thereby respecting their capacity for self-determination and to make independent decisions. Regarding beneficence, SOD renders the good-namely the protection of health-more widely available to the individuals that constitute the population in question. Finally, SOD promotes theories of justice that treat individuals equally and is unlikely to reduce the effectiveness of other distribution policies that allocate scarce vaccines in a just manner. CONCLUSION: In conditions of vaccine scarcity, SOD favourably satisfies the ethical framework of principlism.

Drilling down into ethics: A thematic review of ethical considerations for the creation and use of 3D printed human remains in crime reconstruction.

The existing literature contains some exploration of the ethics concerning human remains in forensic and virtual anthropology. However, previous work has stopped short of interrogating the underlying ethical concepts. The question of how people understand and apply these concepts in practice, and what it means to act ethically, remain underexplored. This thematic review explores the ethical considerations that contribute to the creation and use of 3D printed human remains for forensic purposes. The three main branches of ethical theory are outlined to explore how they may apply to forensic practice. Key themes relating to 3D printing human remains in forensic contexts were explored to better understand the ethics landscape, ethical challenges, and the current guidelines in place. Through this thematic review, nine ethics principles were identified as key principles for guiding best practice: anonymity, autonomy, beneficence, consent, context, justice, non-maleficence, proportionality, and transparency. It is suggested that these principles could be incorporated into adaptable guidelines going forward to support ethical practice. The findings also suggest that holistic ethics cognition training may have value in supporting forensic scientists in ethical decision-making, together with procedural and structural design that may promote best practice and reduce cognitive load.

Co-production as a resolution to authoritarian attitudes in healthcare.

Healthcare services should be provided according to contemporary ethical norms that require patients' active engagement in all the relevant processes. However, authoritarian attitudes and behaviors in healthcare, one of which is paternalism, put patients in a passive role. But, as Avedis Donabedian emphasizes, patients are co-producers of care, reformers of healthcare, informants, and definers and evaluators of quality. Overlooking these significant functions and merely focusing on physicians' benevolence due to their medical knowledge and skills in the production of healthcare services would leave the fate of patients in the hands of clinicians and impose physicians' hegemony on patients and their choices. Nevertheless, the concept of co-production is a practical and effective mechanism to redefine the language used in healthcare by recognizing patients as co-producers and equal partners. The application of co-production in healthcare would improve the therapeutic relationship, decrease ethical violations, and promote the patient's dignity.