Psychotherapists' attitudes to intimate and informal behaviour towards clients.

BACKGROUND: To avoid harming or exploiting a client, sexual and non-sexual dual relationship is generally considered as unacceptable in the psychotherapeutic relationship. However, little is known about what therapists themselves constitute as (un)acceptable intimate and informal behaviour (IIB). METHODS: A survey among psychotherapists in Flanders (Belgium) was conducted. Opinions about the acceptability of IIB were asked. Based on these opinions attitude groups could be determined. RESULTS: In total, 786 therapists completed and returned the questionnaire (response rate: 39.8%). Therapists could be divided into three attitude groups. Almost half of the therapists belonged to the 'rather restrictive group', a third to the 'rather socially permissive group' and a fifth to the 'rather sexually permissive group'. Being categorised as 'rather sexually permissive' is predominantly related to being male and non-heterosexual, whereas being 'rather restrictive' or 'rather socially permissive' is mainly due to the type of psychotherapy training. The 'rather sexually permissive' therapists more often found a client sexually attractive during the last year and fantasised more often about a romantic relationship with a client, but they did not more often started a sexual relationship. CONCLUSIONS: Most therapists in Flanders are rather restrictive in their attitude to IIB, pointing to a high sense of morality. Having a rather sexually permissive attitude is predominantly related to more personal characteristics of the therapists, but these therapists did not start a sexual relationship more often.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study.

OBJECTIVE: To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time. DESIGN: Qualitative study. SETTING: Fetal medicine units in the Republic of Ireland. POPULATION: Ten fetal medicine specialists from five of the six fetal medicine units. METHODS: nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews. MAIN OUTCOME MEASURES: Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA. RESULTS: Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'. CONCLUSIONS: Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service. TWEETABLE ABSTRACT: The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

Respectful maternal and newborn care: measurement in one EN-BIRTH study hospital in Nepal.

BACKGROUND: Respectful maternal and newborn care (RMNC) is an important component of high-quality care but progress is impeded by critical measurement gaps for women and newborns. The Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study was an observational study with mixed methods assessing measurement validity for coverage and quality of maternal and newborn indicators. This paper reports results regarding the measurement of respectful care for women and newborns. METHODS: At one EN-BIRTH study site in Pokhara, Nepal, we included additional questions during exit-survey interviews with women about their experiences (July 2017-July 2018). The questionnaire was based on seven mistreatment typologies: Physical; Sexual; or Verbal abuse; Stigma/discrimination; Failure to meet professional standards of care; Poor rapport between women and providers; and Health care denied due to inability to pay. We calculated associations between these typologies and potential determinants of health - ethnicity, age, sex, mode of birth - as possible predictors for reporting poor care. RESULTS: Among 4296 women interviewed, none reported physical, sexual, or verbal abuse. 15.7% of women were dissatisfied with privacy, and 13.0% of women reported their birth experience did not meet their religious and cultural needs. In descriptive analysis, adjusted odds ratios and multivariate analysis showed primiparous women were less likely to report respectful care (ß = 0.23, p-value < 0.0001). Women from Madeshi (a disadvantaged ethnic group) were more likely to report poor care (ß = - 0.34; p-value 0.037) than women identifying as Chettri/Brahmin. Women who had caesarean section were less likely to report poor care during childbirth (ß = - 0.42; p-value < 0.0001) than women with a vaginal birth. However, babies born by caesarean had a 98% decrease in the odds (aOR = 0.02, 95% CI, 0.01-0.05) of receiving skin-to-skin contact than those with vaginal births. CONCLUSIONS: Measurement of respectful care at exit interview after hospital birth is challenging, and women generally reported 100% respectful care for themselves and their baby. Specific questions, with stratification by mode of birth, women's age and ethnicity, are important to identify those mistreated during care and to prioritise action. More research is needed to develop evidence-based measures to track experience of care, including zero separation for the mother-newborn pair, and to improve monitoring.

Psoriasis: The Skin I'm In. Development of a behaviour change tool to improve the care and lives of people with psoriasis.

BACKGROUND: Psoriasis is a long-term skin condition associated with considerable life impairment. Extensive literature regarding the needs of patients with psoriasis is not translated into clinical practice. AIM: To explore and communicate the experience of living with psoriasis and interacting with healthcare professionals (HCPs). METHODS: In total, 21 patients attending a tertiary adult psoriasis service were interviewed individually. Interviews were recorded and transcribed, then the transcripts were examined and thematic analyses and qualitative content analysis performed. The results were communicated via a short film. RESULTS: Three key themes were identified: comparison with cancer, misalignment of response with need and fear of social exclusion. Cancer comparison subthemes included poorer services, lack of awareness and trivialization of psoriasis compared with cancer. Misalignment subthemes related to lack of knowledge and inappropriate response of HCPs and society towards psoriasis. Fear of social exclusion subthemes included erroneous belief of psoriasis being contagious and the expectation of rejection. Consequent emotions of fear, shame and anxiety resulted in avoidant behaviours, which perpetuated social exclusion. Participants valued active listening, shared decision-making and communication of hope regarding treatment by HCPs. CONCLUSION: Despite extensive research into psoriasis and the availability of effective treatment for many patients, people with psoriasis live unnecessarily impaired lives and have unsatisfactory healthcare experiences. Storytelling techniques provide a method to communicate scientific information in a way that may drive change in delivery of healthcare and improve the lives of patients.

Professionally responsible management of the ethical and social challenges of antenatal screening and diagnosis of ß-thalassemia in a high-risk population.

Thalassemias are among the most frequent genetic disorders worldwide. They are an important social and economic strain in high-risk populations. The benefit of ß-thalassemia screening programs is growing evident but the capacity to diagnose fetal ß-thalassemia exceeds the treatment possibilities and even when treatment before birth becomes feasible, difficult decisions about the relative risks will remain. This paper can be of practical and ethically justified aid when counseling women about screening, diagnosis, and treatment of ß-thalassemia. It takes in consideration various social challenges, medical issues such as antenatal screening, preimplantation genetic diagnosis, prenatal diagnosis, non-invasive prenatal testing and prenatal therapy. We also describe the Sardinian experience in applying and promoting high-risk population screening and diagnosis programs and future trends in the management of ß-thalassemia.

Patient and Family Descriptions of Ethical Concerns.

Ethically challenging situations routinely arise in the course of illness and healthcare. However, very few studies have surveyed patients and family members about their experiences with ethically challenging situations. To address this gap in the literature, we surveyed patients and family members at three hospitals. We conducted a content analysis of their responses to open-ended questions about their most memorable experience with an ethical concern for them or their family member. Participants (N = 196) described 219 unique ethical experiences that spanned many of the prevailing themes of bioethics, including the patient-physician relationship, end-of-life care, decision-making capacity, healthcare costs, and genetic testing. Participants focused on relational issues in the course of experiencing illness and receiving medical care and concerns regarding the patient-physician encounters. Many concerns arose outside of a healthcare setting. These data indicate areas for improvement for healthcare providers but some concerns may be better addressed outside of the traditional healthcare setting.

Medicine's collision with false hope: The False Hope Harms (FHH) argument.

The goal of this paper is to introduce the false hope harms (FHH) argument, as a new concept in healthcare. The FHH argument embodies a conglomerate of specific harms that have not convinced providers to stop endorsing false hope. In this paper, it is submitted that the healthcare profession has an obligation to avoid collaborating or participating in, propagating or augmenting false hope in medicine. Although hope serves important functions-it can be 'therapeutic' and important for patients' 'self-identity as active agents'- the presentation of false hope along the hope continuum entails a misconstrued balancing act. By not speaking up against unrealistic patient and family requests-including some requests for rights to try, resuscitative efforts in terminally ill patients, or other demands for non-beneficial treatments-healthcare providers precipitate harms, i.e., the FHH. These harms arise on both individual and communal levels and cannot be ignored. The goal of this paper is not to offer a definition of false hope, because the phenomenon of false hope is too complex for any simple definition. Instead, this paper seeks to make four points while outlining the FHH argument: consumer medicine and false hope are connected; providers and patients are very vulnerable in the system of consumer medicine; providers have a responsibility to stand up against false hope; and how the FHH argument could perhaps offer a footing to resist giving in to false hope.

Promoting respectful maternity care for adolescents in Ghana: a quasi-experimental study protocol.

BACKGROUND: Intra-partum mistreatment by healthcare providers remains a global public health and human rights challenge. Adolescents, who are typically younger, poorer and less educated have been found to be disproportionately exposed to intra-partum mistreatment. In Ghana, maternal mortality remains a leading cause of death among adolescent females, despite increasing patronage of skilled birth attendance in health facilities. In response to the the World Health Organisation Human Reproduction Programme (WHO-HRP) recommendations to address mistreatment with Respectful Maternity Care (RMC), this study aims to generate evidence on promoting respectful treatment of adolescents using an intervention that trains health providers on the concept of mistreatment, their professional roles in RMC and the rights of adolescents to RMC. METHODS: This study will employ a pre-test post-test quasi-experimental design. At pre-test and post-test, quantitative surveys will be conducted among adolescents who deliver at health facilities about their labour experience with mistreatment and RMC. A total target of 392 participants will be recruited across intervention and control facilities. Qualitative interviews will also be conducted with selected adolescents and health professionals for an in-depth understanding of the phenomenon. Following the pre-test, a facility-based training module will be implemented at intervention facilities for the facility midwives. The modules will be co-facilitated by the principal investigator and key resource persons from the district health directorate Quality of Care teams. Training will cover the rights of adolescents to quality healthcare, classifications of mistreatment, RMC as a concept and the role of professionals in providing RMC. No intervention will occur in the control facilities. Descriptive statistics, logistic regressions and difference in differences analyses will be computed. Qualitative data will be transcribed and thematically analysed. DISCUSSION: This study is designed to test the success of an intervention in promoting RMC and reducing intra-partum mistreatment towards adolescents. It is expected that the findings of this study will be beneficial in adding to the body of knowledge in improving maternal healthcare and reducing maternal mortality, especially for adolescents. TRIAL REGISTRATION: Name of the registry: Pan African Clinical Trials Registry. PACTR202008781392078 .

Moral Experiences of Crisis Management in a Child Mental Health Setting: A Participatory Hermeneutic Ethnographic Study.

Restraints and seclusion are routinely used in child mental health settings for conflict and crisis management, but raise significant ethical concerns. Using a participatory hermeneutic ethnographic framework, we studied conflict and crisis management in a child mental health setting offering care to children aged 6-12 years old in Quebec, Canada. The use of this framework allowed for an in-depth examination of the local imaginaries, of what is morally meaningful to the people in the setting, in addition to institutional norms, structures and practices. Data collection involved participant observation, interviews, and documentation review, with an interpretive framework for data analysis. We argue that the prevalent view of children shared by staff members as "incomplete human becomings" led to the adoption and legitimization of authoritative norms, structures and practices guided largely by a behavioral approach, which sometimes led to an increased use of control measures for reasons other than imminent harm. Children experienced these controlling practices as abusive and hindering the development of trusting relationships, which impeded the implementation of more collaborative approaches staff members sought to put in place to prevent the use of control measures. Study results are discussed in light of conceptions of children as moral agents.

Moral Features of the Therapeutic Relationship with Adults: Dignity, Trust, Autonomy, Vulnerability, and Resilience.

Using dignity as a foundational value of morality, this article defines trust, autonomy, vulnerability, and resilience in relational terms. A fictional narrative illustrates these attributes as well as solidarity and care, two core tenets of relational ethics. Medicine and rehabilitation are described as moral enterprises with respect for persons at the core of our professional obligations to patients-namely, duties of care, trustworthiness, and loyalty. Clinically, promoting autonomy, decreasing vulnerability, and fostering resilience are encouraged, with particular emphasis on avoiding words or actions (or inactions) that could cause patients to feel discouraged or depersonalized. In conclusion, the purpose of our work with persons with aphasia and other communication disorders is to help them live their lives as fully as possible, despite their life-changing losses. Viewing our therapeutic relationships with them in relational moral terms can enhance our work.

Ethical perspectives in communication in cancer care: An interpretative phenomenological study.

BACKGROUND: In cancer care, many clinical contexts still lack a good-quality patient-health professional communication about diagnosis and prognosis. Information transmission enables patients to make informed choices about their own healthcare. Nevertheless, disclosure is still an ethically challenging clinical problem in cancer care. High-quality care can be achieved by understanding the perspectives of others. The perspective of patients, their caregivers, physicians and nurses have seldom been simultaneously studied. OBJECTIVE: To investigate the phenomenon of diagnosis and prognosis-related communication as experienced by patients, their caregivers, and both their attending nurses and physicians, to enlighten meanings attached to communication by the four parties. METHODS: A qualitative study using interpretative phenomenological analysis was performed. PARTICIPANTS AND RESEARCH CONTEXT: Purposive sampling of six patients, six caregivers, seven nurses and five physicians was performed in two oncological hospitals in Italy. ETHICAL CONSIDERATIONS: Local Ethics Committee approved the study. It was guided by the ethical principles of voluntary enrolment, anonymity, privacy and confidentiality. RESULTS: Three main themes were identified: (a) the infinite range of possibilities in knowing and willing to know, (b) communication with the patient as a conflicting situation and (c) the bind of implicit and explicit meaning of communication. CONCLUSION: The interplay of meanings attached by patients, their caregivers, and their attending oncologist and nurse to communication about diagnosis and prognosis revealed complexities and ambiguities not yet settled. Physicians still need to solve the ethical tensions in their caring relationship with patients to really allow them 'to choose with dignity and being aware of it'. Nurses need to develop awareness about their role in diagnosis and prognosis-related communication. This cognizance is essential not just to assure consistency of communication within the multi-disciplinary team but mostly because it allows and enables the moral agent to take its own responsibilities and be accountable for them.

[Ethics: supporting the sexuality of people with a mental disability in an institution]. / Éthique : accompagner la sexualité des personnes atteintes de handicap en institution.

The question of the sexuality of people with a disability in an institution touches on two sensitive aspects: sexuality, between taboo and unknown, and disability-related particularities. Within the microsociety of an institution, the protocols, daily living rules and therapeutic framework guide institutional life, and caregivers are sometimes helpless. An ethical perspective can help professionals support people with a mental disability with regard to their emotional and sexual life.

A systematic review of reasons for and against asking patients about their socioeconomic contexts.

BACKGROUND: People's social and economic circumstances are important determinants of their health, health experiences, healthcare access, and healthcare outcomes. However, patients' socioeconomic circumstances are rarely asked about or documented in healthcare settings. We conducted a systematic review of published reasons for why patients' socioeconomic contexts (including education, employment, occupation, housing, income, or wealth) should, or should not, be enquired about. METHODS: Systematic review of literature published up to and including 2016. A structured literature search using databases of medicine and nursing (pubmed, embase, global health), ethics (Ethicsweb), social sciences (Web of Science), and psychology (PsychINFO) was followed by a 'snowball' search. Eligible publications contained one or more reasons for: asking patients about socioeconomic circumstances; collecting patients' socioeconomic information; 'screening' patients for adverse socioeconomic circumstances; or linking other sources of individual socioeconomic data to patients' healthcare records. Two authors conducted the screening: the first screened all references, the second author screened a 20% sample with inter-rater reliability statistically confirmed. 'Reason data' was extracted from eligible publications by two authors, then analysed and organised. RESULTS: We identified 138 eligible publications. Most offered reasons for why patients' should be asked about their socioeconomic circumstances. Reasons included potential improvements in: individual healthcare outcomes; healthcare service monitoring and provision; population health research and policies. Many authors also expressed concerns for improving equity in health. Eight publications suggested patients should not be asked about their socioeconomic circumstances, due to: potential harms; professional boundaries; and the information obtained being inaccurate or unnecessary. CONCLUSIONS: This first summary of literature on the subject found many published reasons for why patients' social and economic circumstances should be enquired about in healthcare settings. These reasons include potential benefits at the levels of individuals, health service provision, and population, as well as the potential to improve healthcare equity. Cautions and caveats include concerns about the clinician's role in responding to patients' social problems; the perceived importance of social health determinants compared with biomedical factors; the use of average population data from geographic areas to infer the socioeconomic experience of individuals. Actual evidence of outcomes is lacking: our review suggests hypotheses that can be tested in future research.

Disrespect and abuse during facility-based childbirth in southern Mozambique: a cross-sectional study.

BACKGROUND: Evidence suggests that many women experience mistreatment during childbirth in health facilities across the world, but the magnitude of the problem is unknown. The occurrence of disrespect and abuse (D&A) in maternity care services affects the overall quality of care and may undermine women's trust in the health system. Studies about the occurrence of disrespect and abuse in Mozambican health facilities are scarce. The aim of this study was to explore the experience of women giving birth in hospital in different settings in Maputo City and Province, Mozambique. METHODS: A cross sectional descriptive survey was conducted between April and June 2018 in the Central Hospital of Maputo (HCM) and district hospitals of Manhiça and Marracuene, Maputo Province, Mozambique. Five hundred seventy-two exit interviews were conducted with women leaving the hospital after delivery. The questionnaire consisted of the following components: socio-demographic characteristics, the occurrence of disrespect and abuse, male involvement during labor and childbirth and intrapartum family planning counselling and provision. RESULTS: Prevalence of disrespect and abuse ranged from 24% in the central hospital to 80% in the district hospitals. The main types of D&A reported were lack of confidentiality/privacy, being left alone, being shouted at/scolded, and being given a treatment without permission. While very few women's partners attended the births, the majority of women (73-80%) were in favor of involving their partner as a birth companion. Intrapartum counseling of family planning was very low (9-17%). CONCLUSION: The occurrence of disrespect and abuse was much higher in the district hospitals compared to the central hospital, emphasizing the high need for interventions outside Maputo City. Allowing male partners as birth companions should be explored further, as women seem in favor of involving their partners. Investing in intrapartum counselling for family planning is currently a missed opportunity for improving the uptake of contraception in the country.

Humanizing birth in Tanzania: a qualitative study on the (mis) treatment of women during childbirth from the perspective of mothers and fathers.

BACKGROUND: While there has been a trend for greater number of women to deliver at health facilities across Tanzania, mothers and their family members continue to face mistreatment with respectful maternity care during childbirth being violated. The objective of this study was to describe the experience of mothers and fathers in relation to (mis) treatment during childbirth in Tanzania. METHODS: Using a qualitative descriptive design, 12 semi-structured interviews and four focus group discussions were held with mothers and fathers who were attending a postnatal clinic in the Lake Zone region of Tanzania. Mothers' age ranged from 20 to 45 years whereas fathers' age ranged from 25 to 60 years. Data were analyzed using a priori coding based on Bohren's et al. typology of the mistreatment of women during childbirth. RESULTS: Mothers reported facing mistreatment and disrespectful maternity care through verbal abuse (harsh or rude language and judgmental or accusatory comments), failure to meet professional standards of care (refused pain relief, unconsented surgical operations, neglect, abandonment or long delays, and skilled attendant absent at time of delivery), poor rapport between women and providers (poor communication, lack of supportive care, denied husbands presence at birth, denied mobility, denied safe traditional practices, no respect for their preferred birth positions), and health system conditions and constraints (poor physical condition of facilities, supply constraints, bribery and extortion, unclear fee structures). Despite some poor care, some mothers also reported positive birthing experiences and respectful maternity care by having a skilled attendant assistance at delivery, having good communication from nurses, receiving supportive care from nurses and privacy during delivery. CONCLUSION: Despite the increasing number of deliveries occurring in the hospital, there continue to be challenges in providing respectful maternity care. Humanizing birth care in Tanzania continues to have a long way to go, however, there is evidence that changes are occurring as mothers notice and report positive changes in delivery care practices.

Important outcomes of moral case deliberation: a Euro-MCD field survey of healthcare professionals' priorities.

BACKGROUND: There is a lack of empirical research regarding the outcomes of such clinical ethics support methods as moral case deliberation (MCD). Empirical research in how healthcare professionals perceive potential outcomes is needed in order to evaluate the value and effectiveness of ethics support; and help to design future outcomes research. The aim was to use the European Moral Case Deliberation Outcome Instrument (Euro-MCD) instrument to examine the importance of various MCD outcomes, according to healthcare professionals, prior to participation. METHODS: A North European field survey among healthcare professionals drawn from 73 workplaces in a variety of healthcare settings in the Netherlands, Norway and Sweden. The Euro-MCD instrument was used. RESULTS: All outcomes regarding the domains of moral reflexivity, moral attitude, emotional support, collaboration, impact at organisational level and concrete results, were perceived as very or quite important by 76%-97% of the 703 respondents. Outcomes regarding collaboration and concrete results were perceived as most important. Outcomes assessed as least important were mostly about moral attitude. 'Better interactions with patient/family' emerged as a new domain from the qualitative analysis. Dutch respondents perceived most of the outcomes as significantly less important than the Scandinavians, especially regarding emotional support. Furthermore, men, those who were younger, and physician-respondents scored most of the outcomes as statistically significantly less important compared with the other respondents. CONCLUSIONS: The findings indicate a need for a broad instrument such as the Euro-MCD. Outcomes related to better interactions between professionals and patients must also be included in the future. The empirical findings raise the normative question of whether outcomes that were perceived as less important, such as moral reflexivity and moral attitude outcomes, should still be included. In the future, a combination of empirical findings (practice) and normative reflection (theories) will contribute to the revision of the instrument.

The Practice of Respect in the ICU.

Although "respect" and "dignity" are intuitive concepts, little formal work has addressed their systematic application in the ICU setting. After convening a multidisciplinary group of relevant experts, we undertook a review of relevant literature and collaborative discussions focused on the practice of respect in the ICU. We report the output of this process, including a summary of current knowledge, a conceptual framework, and a research program for understanding and improving the practice of respect and dignity in the ICU. We separate our report into findings and proposals. Findings include the following: 1) dignity and respect are interrelated; 2) ICU patients and families are vulnerable to disrespect; 3) violations of respect and dignity appear to be common in the ICU and overlap substantially with dehumanization; 4) disrespect may be associated with both primary and secondary harms; and 5) systemic barriers complicate understanding and the reliable practice of respect in the ICU. Proposals include: 1) initiating and/or expanding a field of research on the practice of respect in the ICU; 2) treating "failures of respect" as analogous to patient safety events and using existing quality and safety mechanisms for improvement; and 3) identifying both benefits and potential unintended consequences of efforts to improve the practice of respect. Respect and dignity are important considerations in the ICU, even as substantial additional research remains to be done.

Patient-targeted googling and psychiatric professionals.

OBJECTIVE: This is a pilot study which assesses the beliefs of psychiatric professionals regarding obtaining patient information via the Internet as well as the frequency with which they do it in a variety of clinical settings. METHODS: Psychiatry faculty and residents were asked to participate in an anonymous online survey about their use of the search engine Google to find information about their patients. Data were analyzed with Microsoft Excel. RESULTS: The participants included 48 faculty and 34 residents (118 faculty and 44 residents were surveyed) with response rates of 41% and 77%, respectively. Majority of attending physicians and residents reported engaging in patient-targeted googling with no significant difference between the groups. Residents were most likely to search for patient information online in the psychiatric emergency room (45%). Psychiatric emergency room (36.8%) and private practice (31.6%) were notable clinical settings for obtaining further patient information on the Internet for the faculty. When describing reasons for engaging in patient-targeted googling, "patient care" was cited about twice as often as "curiosity" in the psychiatric emergency room, whereas "curiosity" and "patient care" were reasons mentioned in other clinical settings. In general, neither faculty nor residents report informing their patients of their Internet searches either before or after engaging in patient-targeted googling. CONCLUSION: This study raises important questions about education for trainees and faculty regarding patient-targeted googling.

Compulsory treatment in eating disorders: Control, provocation, and the coercion paradox.

In eating disorders, the denial of the illness is a central phenomenon. In the most severe forms of anorexia, compulsory treatment may be necessary. The professional acceptance of involuntary treatment is controversial due to the fact that the autonomy of the patient is juxtaposed with the obligation of the health care practitioner to save lives. This paper discusses the major practical and ethical considerations surrounding this controversy. In addition, case vignettes are used to illustrate various strategies to diminish client resistance and enhance motivation toward treatment. Involving the family is nearly always essential for the treatment of patients with eating disorders. In some cases, parental consultation (i.e., treatment without the client) can also be an option. Home visits, though rarely used, can reframe the therapeutic relationship and provide information about family functioning. In general, a lower level of treatment coercion can be achieved through transparent client-parent and client-therapist communication.

Healthcare professionals as gatekeepers in research involving refugee survivors of sexual torture: An examination of the ethical issues.

This paper examines the ethical issues that arise when healthcare providers act as gatekeepers to research involving vulnerable populations. Traumatised refugees serve as an example of this subset of research participants. Highlighting the particular vulnerabilities of this group, we argue that specific ethical considerations are required that go beyond the conventional research approaches. While gatekeeping responds to some of those vulnerabilities, it risks wronging through unwarranted paternalism. Instead, we will propose that a relational ethics of justice and care serves as a more appropriate framework for responding to the challenges of research involving traumatised refugees. Specifically, such a framework allows us to reflect more deeply on the role of the gatekeeper. In conclusion, we recommend that clinicians and researchers collaborate with survivors' advisory groups in the development of specific research ethical guidelines.