Empirical Bioethics and the Health 'Brain-Drain': a qualitative study of the experiential and ethical landscape of compulsory community service for a group of South African doctors.

The health 'brain drain' (HBD) is an issue of significant global bioethical concern, resulting in severe maldistribution of healthcare workers (HCWs) and gross inequities in health service provision. The ethics of the HBD and its possible mitigation strategies are, however, complex and areas of active ongoing bioethical debate. South Africa faces a dire and worsening HBD crisis, and use a mitigation strategy of compulsory community service, or 'comserve', for most HCWs. While there is some literature on HCWs' comserve experiences and the various 'push and pull' factors affecting their migratory decisions, there is a notable gap regarding their personal values, beliefs and ethics regarding the HBD and comserve, which, as this research supports, play a prominent role in migratory decisions. This empirical bioethics research aims to explore this among a group of South African doctors who recently completed comserve, as well as how their experiences affected their situation on the individualist-collectivist continuum. This was done qualitatively using semistructured interviews with 11 participants and analysed using reflexive thematic analysis under a methodology of critical realism. Themes identified were 'Special Duties'; 'Freedom and Autonomy'; 'Justice and Accountability'; and 'The Individualist-Collectivist Continuum'. Participants use a variety of ethical theories to discuss the HBD and oppose or support comserve, which play a significant role in their migratory decisions. Most find the policy to be theoretically ethically justifiable but note that procedures undermine this. There are also several factors that appear to affect participants' position on the individualist-collectivist continuum, with some paradoxical effects on the HBD.

[Physicians' contribution in the creation and development of bioethics in Poland]. / Wklad lekarzy w powstanie i rozwój bioetyki w Polsce.

Bioethics was created in the 70s of the last century. From this period come works written by Van Resselaer Potter and André Hellegers, in which the authors raised the issue of the need to discuss the progress and to define a new reflection, they used for the first time in the scientific literature the term bioethics. In the United States of America, as well as in European countries, institutions began to emerge in which scientific bioethical reflection was realized. In Poland in the 1970s, the socio-political situation was not conducive to the integration of scientific circles or the freedom of exchange of views. Significant progress in the field of medicine, emerging new treatment options, posed questions that had to be answered. The questions were formulated in different environments, including by doctors who themselves participated in the progress of medical sciences, introducing, for example, new increasingly aggressive treatments, or saw new challenges emerging in the medical profession, which were not regulated by the hitherto applied principles of classical medical ethics. The article describes the achievements of prof. Jan Nielubowicz, prof. Józef Bogusz and prof. Tadeusz Kielanowski in the creation of Polish bioethical regulations in the field of experimental research in humans, the activity of prof. Kornel Gibinki in the formation of Bioethics Commisions, contribution of prof. Stefan Raszeja and prof. Marek Sych in bioethical education of the society and the role of prof. Krzysztof Szczygiel in the creation of the first Polish scientific bioethical unit.

What Nurse Bioethicists Bring to Bioethics: The Journey of a Nurse Bioethicist.

Nurses, one of the most trusted professional groups in our society, work with patients and their families at all stages of the illness trajectory. Nurse bioethicists are a small but special subset of the nursing profession and bioethics community, focusing on the moral complexities that arise in clinical care, research, and health policy. This article examines the career trajectory of a nurse bioethicist and the clinical, educational, and research experiences that shaped her career goals. It also addresses the uniqueness of nursing and the ethical challenges that nurse's encounter in their day-today interactions with diverse patient populations and calls for distinct conceptual and empirical bioethics inquiry. Training the next generation of nurse bioethicists requires a dialogue with nursing and bioethics scholars on the academic and philosophical skill set and mentorship requirements that will advance and contribute to the broader public good.

Why the history of nursing ethics matters.

Modern American nursing has an extensive ethical heritage literature that extends from the 1870s to 1965 when the American Nurses Association issued a policy paper that called for moving nursing education out of hospital diploma programs and into colleges and universities. One consequence of this move was the dispersion of nursing libraries and the loss of nursing ethics textbooks, as they were largely not brought over into the college libraries. In addition to approximately 100 nursing ethics textbooks, the nursing ethics heritage literature also includes hundreds of journal articles that are often made less accessible in modern databases that concentrate on the past 20 or 30 years. A second consequence of nursing's movement into colleges and universities is that ethics was no longer taught by nursing faculty, but becomes separated and placed as a discrete ethics (later bioethics) course in departments of philosophy or theology. These courses were medically identified and rarely incorporated authentic nursing content. This shift in nursing education occurs contemporaneously with the rise of the field of bioethics. Bioethics is rapidly embraced by nursing, and as it develops within nursing, it fails to incorporate the rich ethical heritage, history, and literature of nursing prior to the development of the field of bioethics. This creates a radical disjunction in nursing's ethics; a failure to more adequately explore the moral identity of nursing; the development of an ethics with a lack of fit with nursing's ethical history, literature, and theory; a neglect of nursing's ideal of service; a diminution of the scope and richness of nursing ethics as social ethics; and a loss of nursing ethical heritage of social justice activism and education. We must reclaim nursing's rich and capacious ethics heritage literature; the history of nursing ethics matters profoundly.

Learning about Teaching.

There are three broad themes in this issue of the Hastings Center Report. First, a special report published as a supplement to the issue addresses the medical and health policy issues faced by lesbian, gay, bisexual, and transgender patients. Inside the issue, the two articles take up questions about how caregivers may justify a refusal to provide a medical service that a patient has requested. The issue also contains a set of essays that have emerged from a collaborative effort by The Hastings Center and the Presidential Commission for the Study of Bioethical Issues to promote scholarly engagement with the practical problem of teaching caregivers, researchers, scientists, and others to address bioethical problems. What appears here is the first installment of a series that will appear in the pages of the Report well into the 2015 volume.

Expected ethical competencies of public health professionals and graduate curricula in accredited schools of public health in North America.

OBJECTIVES: We assessed expected ethics competencies of public health professionals in codes and competencies, reviewed ethics instruction at schools of public health, and recommended ways to bridge the gap between them. METHODS: We reviewed the code of ethics and 3 sets of competencies, separating ethics-related competencies into 3 domains: professional, research, and public health. We reviewed ethics course requirements in 2010-2011 on the Internet sites of 46 graduate schools of public health and categorized courses as required, not required, or undetermined. RESULTS: Half of schools (n = 23) required an ethics course for graduation (master's or doctoral level), 21 did not, and 2 had no information. Sixteen of 23 required courses were 3-credit courses. Course content varied from 1 ethics topic to many topics addressing multiple ethics domains. CONCLUSIONS: Consistent ethics education and competency evaluation can be accomplished through a combination of a required course addressing the 3 domains, integration of ethics topics in other courses, and "booster" trainings. Enhancing ethics competence of public health professionals is important to address the ethical questions that arise in public health research, surveillance, practice, and policy.

Chapitre 7. Un regard de généticien.

Examined through the eyes of the geneticist, the modifications of the bioethics law seem relatively modest with regard to the supervision of the practices of his discipline. The introduction of rules concerning the use of algorithms in medical practice is the truly new point. It seemed beneficial to take into account “the interference of thinking machines” in medical decision-making and to initiate the outlines of a framework. We will debate the proposals and terms. Precisions made to the obligation to inform relatives of the existence of a genetic anomaly are defined around the concept of solidarity. Without neglecting this latter, we will recall other determinants, the complexity and the issues underlying the delivery of predictive genetic information as well as the risks that informed persons may incur. It seems appropriate to also consider the ethical tensions that can impose themselves on the physicians involved in the mandatory process of information..

Bioethics and War.

War has major health consequences and poses significant ethical dilemmas for health professionals. In caring for victims of armed conflicts, health providers are obliged to put medical ethics before military aims. While the normative framework of warfare is clear and accepted by almost all countries, in practice, restrictions on violence are continuously broken, and the safety and independence of health professionals are not ensured. In bioethics, the issue of war has not been treated as a major concern. The field can do more to articulate the responsibilities of health practitioners and scientists, arguing that Red Cross founder Henri Dunant's principle of humanity and the principles of professional and global ethics reject the idea of military necessity. Bioethics should focus on strategies to prevent war, encouraging the collective action of health professionals. Bioethics should also stress-as, so far, one national medical association has-that war is a man-made public health problem.

[A training course on bioethics for Family Health Strategy professionals in Santo André, SP]. / Capacitação em bioética para profissionais da Saúde da Família do município de Santo André, SP.

This case report presents the experience of a training course on bioethics for nurses and physicians of the Family Health Strategy in Santo André, SP. This study is based on problem-based learning and deliberative bioethics, and aimed at presenting the deliberation procedure as a means of handling ethical issues. Contents were addressed in a cross-section manner through five sequential activity sessions at two different moments of concentration with one dispersion interval. In the first moment of concentration, key concepts and deliberative bioethics contents were developed. The second involved deliberation sessions on moral conflicts, which were selected and prepared during the dispersion interval. Participants evaluated the deliberation as an appropriate instrument to deal with the ethical issues they are faced with. Problem-based learning was an effective educational strategy for continuing education in deliberative bioethics.

Medicine during the Nazi period and the Holocaust: what are the implications? An interview with Volker Roelcke.

In this interview, Volker Roelcke explains and analyzes historical evidence refuting erroneous assumptions about medical atrocities committed by physicians during the Nazi era, provides insight into the implications of medicine during the Nazi period and the Holocaust for medicine and bioethics today, analyzes the history of the term "genocide," and suggests formats for future teaching, among other topics.

DEI Is Not Enough.

The movement under way to increase diversity, equity, and inclusion (DEI) in every workplace, including academia, medicine, and science, is an essential step toward health justice, but only a first step. Bioethics, health care, and health-related research all need more professionals from minoritized groups, but all of us need to do more to address justice at every level. From inclusive workplace policies and practices to research into structural injustices and health disparities, bioethics can and must lead the way in collaborative efforts. The work belongs to all of us, and DEI is only the beginning.

The Case for Ethical Efficiency: A System That Has Run Out of Time.

The American health care system increasingly conflates physician "productivity" with true clinical efficiency. In reality, inordinate time pressure on physicians compromises quality of care, decreases patient satisfaction, increases clinician burnout, and costs the health care system a great deal in the long term even if it is financially expedient in the short term. Inadequate time to deliver care thereby conflicts with the core principles of biomedical ethics, including autonomy, beneficence, nonmaleficence, and justice. We propose that the health care system adjust its focus to recognize the nonmonetary value of physician time while still realizing the need to deploy resources as effectively as possible, a concept we describe as "ethical efficiency."

[Divergent approaches to medicine: a bioethical reflection]. / Enfoques divergentes de la medicina: una reflexión bioética.

Based on the elements that constitute the bases of Western Medicine and a distinction made by Pedro Laín Entralgo from Homeric work, two possible approaches to medical practice are reflected, which could be characterized as ″palliative″ medicine and ″medicine without palliative″. The relationships that these two approaches may have with Philosophy, Ethics and Bioethics are mentioned; the main characteristics and some of the dangers of each one. It shows how the presence, in clinical practice, of palliative care in itself leaves several lessons on the two approaches. It concludes by showing the importance of person-centered medical education with humanistic components. Some ideas are given so that the curricular contents lead to the training of doctors capable of acting with humanism and professionalism, being agents of a cultural change in favor of life.

Teaching Health Professions Students About the Holocaust.

The legacy of health professionals' roles in the Holocaust is fundamental to understanding modern health care ethics, but teaching it is difficult. The University of Colorado Center for Bioethics and Humanities has developed a program that addresses 4 main pedagogical challenges of this content. This article identifies 3 core lessons and proposes 5 specific learning objectives related to health professionals' involvement in the Holocaust for any health professional training program.

How do we care for our future caregivers? Rethinking education in bioethics with regard to professionalism and institutions.

BACKGROUND: Bioethics is an integral part of most medical curricula. It complements medical skills training to help future caregivers make morally good decisions in their encounters with patients. Principle-based concepts are commonly regarded as the mainstream approach to bioethics in today's world. However, despite its clear merits, principlism alone is not sufficient for educating future caregivers. Hence, additional perspectives of health care education are required and will be taken into account in this paper. OBJECTIVES: Two shortcomings of typical health care training must be addressed: insufficient consideration of the nature of the health care profession and of institutional requirements. Notions and relevance of professionalism in health care have been intensively discussed in recent years. In this paper, I argue that a caring understanding of professionalism is essential for good quality care for the patient and for the physicians themselves. With reference to the ethics of care, the scope of caring professionalism and its implications for health care education are considered and placed within an analytical framework that combines the individual and the institutional context of health care. CONCLUSIONS: To educate our future caregivers, we must address aspects of professionalism more intensively in medical and nursing schools, and even more so during residencies. This is not just a task of training in knowledge or competencies, but also involves the character formation of the individual and the whole organization. Rethinking health care education from this perspective will allow us to answer the question 'How do we care for our future caregivers?' with an easier conscience.

Expanding ethics curriculum resources: American College of Epidemiology's syllabus collection project.

This commentary provides an update on the evolution of the American College of Epidemiology's online and open-source collection of ethics syllabi in epidemiology and public health. Begun in 2011, the syllabus-collection project anticipated the Council on Education for Public Health's accreditation requirement calling for "the development of ethical practice" and identifying a need to "demonstrate our commitment to ethical dealings." The Ethics Committee of the American College of Epidemiology continued the project in 2018 seeking to acquire as many syllabi as possible for the repository; all 180 Council on Education for Public Health-accredited schools and programs were contacted and asked to share syllabi that addressed ethical and related issues. The overarching goal was to support institutions that have not yet introduced ethics into public health and epidemiology curricula. In total, 45 new syllabi were collected in 2018 and collated with the 38 acquired in 2011; 83 syllabi have been compiled from 52 accredited entities. Having a readily available on-line resource to support institutions and faculty seeking to introduce or improve the presentation of ethics in public health and epidemiology curricula is believed to be an important contribution to public health science and pedagogy.

Equitable Health Care and Low-Density Living in the United States.

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.