What Role Should Resistance Play in Training Health Professionals?

The role that resistance plays in medicine and medical education is ill-defined. Although physicians and students have been involved in protests related to the COVID-19 pandemic, structural racism, police brutality, and gender inequity, resistance has not been prominent in medical education's discourses, and medical education has not supported students' role and responsibility in developing professional approaches to resistance. While learners should not pick and choose what aspects of medical education they engage with, neither should their moral agency and integrity be compromised. To that end, the authors argue for professional resistance to become a part of medical education. This article sets out a rationale for a more explicit and critical recognition of the role of resistance in medical education by exploring its conceptual basis, its place both in training and practice, and the ways in which medical education might more actively embrace and situate resistance as a core aspect of professional practice. The authors suggest different strategies that medical educators can employ to embrace resistance in medical education and propose a set of principles for resistance in medicine and medical education. Embracing resistance as part of medical education requires a shift in attention away from training physicians solely to replicate and sustain existing systems and practices and toward developing their ability and responsibility to resist situations, structures, and acts that are oppressive, harmful, or unjust.

Diversity Is Not Enough: Advancing a Framework for Antiracism in Medical Education.

Medical students, residents, and faculty have begun to examine and grapple with the legacy and persistence of structural racism in academic medicine in the United States. Until recently, the discourse and solutions have largely focused on augmenting diversity across the medical education continuum through increased numbers of learners from groups underrepresented in medicine (UIM). Despite deliberate measures implemented by medical schools, residency programs, academic institutions, and national organizations, meaningful growth in diversity has not been attained. To the contrary, the UIM representation among medical trainees has declined or remained below the representation in the general population. Inequities continue to be observed in multiple domains of medical education, including grading, admission to honor societies, and extracurricular obligations. These inequities, alongside learners' experiences and calls for action, led the authors to conclude that augmenting diversity is necessary but insufficient to achieve equity in the learning environment. In this article, the authors advance a 4-step framework, built on established principles and practices of antiracism, to dismantle structural racism in medical education. They ground each step of the framework in the concepts and skills familiar to medical educators. By drawing parallels with clinical reasoning, medical error, continuous quality improvement, the growth mindset, and adaptive expertise, the authors show how learners, faculty, and academic leaders can implement the framework's 4 steps-see, name, understand, and act-to shift the paradigm from a goal of diversity to a stance of antiracism in medical education.

Combating Health Care Fraud and Abuse: Conceptualization and Prototyping Study of a Blockchain Antifraud Framework.

BACKGROUND: An estimated US $2.6 billion loss is attributed to health care fraud and abuse. With traditional health care claims verification and reimbursement, the health care provider submits a claim after rendering services to a patient, which is then verified and reimbursed by the payer. However, this process leaves out a critical stakeholder: the patient for whom the services are actually rendered. This lack of patient participation introduces a risk of fraud and abuse. Blockchain technology enables secure data management with transparency, which could mitigate this risk of health care fraud and abuse. OBJECTIVE: The aim of this study is to develop a framework using blockchain to record claims data and transactions in an immutable format and to enable the patient to act as a validating node to help detect and prevent health care fraud and abuse. METHODS: We developed a health care fraud and abuse blockchain technical framework and prototype using key blockchain tools and application layers including consensus algorithms, smart contracts, tokens, and governance based on digital identity on the Ethereum platform (Ethereum Foundation). RESULTS: Our technical framework maps to the claims adjudication process and focuses on Medicare claims, with the US Centers for Medicare and Medicaid Services (CMS) as the central authority. A prototype of the framework system was developed using the blockchain platform Ethereum (Ethereum Foundation), with its design features, workflow, smart contract functions, system architecture, and software implementation outlined. The software stack used to build the system consisted of a front-end user interface framework, a back-end processing server, and a blockchain network. React was used for the user interface framework, and NodeJS and an Express server were used for the back-end processing server; Solidity was the smart contract language used to interact with a local Ethereum blockchain network. CONCLUSIONS: The proposed framework and the initial prototype have the potential to improve the health care claims process by using blockchain technology for secure data storage and consensus mechanisms, which make the claims adjudication process more patient-centric for the purposes of identifying and preventing health care fraud and abuse. Future work will focus on the use of synthetic or historic CMS claims data to assess the real-world viability of the framework.

Conceptualising Surgical Innovation: An Eliminativist Proposal.

Improving surgical interventions is key to improving outcomes. Ensuring the safe and transparent translation of such improvements is essential. Evaluation and governance initiatives, including the IDEAL framework and the Macquarie Surgical Innovation Identification Tool have begun to address this. Yet without a definition of innovation that allows non-surgeons to identify when it is occurring, these initiatives are of limited value. A definition seems elusive, so we undertook a conceptual study of surgical innovation. This indicated common conceptual areas in discussions of (surgical) innovation, that we categorised alliteratively under the themes of "purpose" (about drivers of innovation), "place" (about contexts of innovation), "process" (about differentiating innovation), "product" (about tangible and intangible results of innovation) and "person" (about personal factors and viewpoint). These conceptual areas are used in varying-sometimes contradictory-ways in different discussions. Highlighting these conceptual areas of surgical innovation may be useful in clarifying what should be reported in registries of innovation. However our wider conclusion was that the term "innovation" carries too much conceptual baggage to inform normative inquiry about surgical practice. Instead, we propose elimination of the term "innovation" from serious discourse aimed at evaluation and regulation of surgery. In our view researchers, philosophers and policy-makers should consider what it is about surgical activity that needs attention and develop robust definitions to identify these areas: for our own focus on transparency and safety, this means finding criteria that can objectively identify certain risk profiles during the development of surgery.

Development of a national conceptual framework and measuring tool for Organisational Social Responsibility and Accountability for Health (OSRAH).

Organisations can have a significant impact (positive or negative) on society through their actions and decisions. Given this reality, it is important that they are held responsible and accountable for the consequences of their actions. This concept is often referred to as 'social responsibility'. However, 'social responsibility', as currently conceived in the literature, neglects a specific focus on health as a social goal. Additionally, there are no practical tools to capture this concept in a holistic way to facilitate implementation and monitoring of organisational improvement. This paper reports on the process of developing a more holistic conceptual framework and tool for assessing organisational social responsibility and accountability for health (OSRAH). We conducted a review of the published and grey literature and engaged in expert consultation and focus group discussions. The initial OSRAH framework and the self-assessment tool were finalised for implementation and used by 95 organisations at a national event in Iran in February 2017. The results of the assessment data collected at the event showed organisations scored lowest in the domain of community health and highest in the domain of employee health. The OSRAH framework and assessment tool represents a new understanding of health and its determinants in organisations outside the health sector. It integrates health within the existing Corporate Social Responsibility (CSR) culture of organisations. The process of creating the tool and implementing it at the national festival of OSRAH in Iran created momentum for intersectoral action. This experience can inspire researchers and practitioners in other countries, especially in developing countries, to develop their own local definition and practical assessment framework for responsibility and accountability.

Using the therapy and enhancement distinction in law and policy.

In a first major study, the UK's Royal Society found that 76% of people in the UK are in favour of therapeutic germline genomic editing to correct genetic diseases in human embryos, but found there was little appetite for germline genomic editing for non-therapeutic purposes. Assuming the UK and other governments acted on these findings, can lawmakers and policymakers coherently regulate the use of biomedical innovations by permitting their use for therapeutic purposes but prohibiting their use for enhancement purposes? This paper examines the very common claim in the enhancement literature that the therapy v enhancement distinction does little meaningful work in helping us think through the ethical issues, a claim that has significant implications for these lawmakers and policymakers who may wish to regulate genomic editing techniques to reflect the findings of this important study. The focus of this paper is on germline genomic editing as one of the main themes in this special issue.

Reflexiones ético-teológicas ante la edición genética / Genetic edition and theological ethics

El artículo busca anticipar los desafíos que se vislumbran hacia el futuro una vez que se perfeccione la técnica de la edición genética. En primer lugar, se encuadra la edición genética en el marco de la especificidad de la tecnología moderna. En segundo lugar, se plantea cómo el contraste de lo natural con lo artificial ilumina el problema que significa pretender sustituir lo natural, en el sentido de lo dado, con lo proyectado por la tecnología. Posteriormente, después de constatar el carácter incipiente de la reflexión teológica sobre la técnica, se plantea la convergencia de la idea de creación con un respeto por los equilibrios naturales, propios de la sensibilidad ecológica contemporánea. Se muestra así, que la propuesta cristiana no es la tecnofobia, sino la integración de la técnica -como elemento central de la cultura que desarrolla el ser humano- con la naturaleza y la asunción del carácter limitado de las realidades naturales, incluyendo al mismo ser humano. De este modo, la vulnerabilidad, como realización de esta finitud, es la característica que nos iguala y nos exige el reconocimiento de nuestra dignidad, mucho más que la realización de un ideal de perfección tecnológicamente mediado, aunque fuera accesible para todos

This paper tries to look forward to the incoming ethical challenges related with genetic editing. It begins with contextualizing genetic edition within the specific nature of modern technology. Afterwards it presents the contrast between natural beings and artifacts that sheds light for answering the question about the real possibility of replacing natural beings, as they are, with technologically projected living beings. In the third place, after acknowledging the scarce attention given by contemporary theology to technology, it shows the convergence of the Christian concept of creation with the respect for balance in nature, as most part of the contemporaty ecological sensibility upholds. Building on this common ground it shows that the Christian attitude towards technology is not technofobical but the integration of technology -a central element of contemporary culture- with nature, accepting the limitation of any natural being including mankind. In this way, vulnerability, as a visible consequence of this finitude, is the very attribute of human beings that makes ourselves equal and requieres recongnition of our common dignity, way over the idea of acquiring an ideal perfection through technology, even if it was accesible to all

Conflictos de interés en la profesión médica / Conflicts of interest in the medical profession

En las últimas décadas el mundo de la medicina se ha familiarizado con la valoración de los conflictos de interés (CDI). En las revistas científicas se ha generalizado el requisito de que los autores declaren sus CDI en relación con los artículos que proponen publicar; otros aspectos sensibles que merecen atención son los CDI en la toma de decisiones sobre prescripción y los CDI de quienes ocupan puestos de responsabilidad en instituciones científicas, asistenciales o de representación profesional. Estos debates son coherentes con la preocupación de las sociedades democráticas por la justicia y la ética social que exigen juego limpio en la toma de decisiones que afectan a terceros, particularmente a los pacientes. En el presente trabajo se analiza el concepto de los CDI, los tipos de conflictos que pueden abarcar y se reflexiona sobre propuestas para la gestión de los mismos en la profesión médica

In the last decades the world of medicine has become familiar with the disclosure of conflicts of interest (CDI). The requirement for authors to declare their CDIs concerning their publications is a common issue. Another topic for CDI is related to the medical decision making on prescription. Finally, professionals being in positions of responsibility in professional societies or associations and healthcare institutions are asked to show their disclosure of CDI. These debates show up the interest of democratic societies for justice and social ethics that demand fair play in making decisions that may affect third parties, particularly patients. In the present work, the concept and types of CDIs are analyzed, and authors make proposals for the management of CDI in the medical profession

Enriching the concept of vulnerability in research ethics: An integrative and functional account.

The concept of vulnerability is widely used in research ethics to signal attention to participants who require special protections in research. However, this concept is vague and under-theorized. There is also growing concern that the dominant categorical approach to vulnerability (as exemplified by research ethics regulations and guidelines delineating vulnerable groups) is ethically problematic because of its assumptions about groups of people and is, in fact, not very guiding. An agreed-upon strategy is to move from categorical towards analytical approaches (focused on analyzing types and sources of vulnerability) to vulnerability. Beyond this agreement, however, scholars have been advancing competing accounts of vulnerability without consensus about its appropriate operationalization in research ethics. Based on previous debates, we propose that a comprehensive account of vulnerability for research ethics must include four components: definition, normative justifications, application, and implications. Concluding that no existing accounts integrate these components in a functional (i.e., practically applicable) manner, we propose an integrative and functional account of vulnerability inspired by pragmatist theory and enriched by bioethics literature. Using an example of research on deep brain stimulation for treatment-resistant depression, we illustrate how the integrative-functional account can guide the analysis of vulnerability in research within a pragmatist, evidence-based approach to research ethics. While ultimately there are concerns to be addressed in existing research ethics guidelines on vulnerability, the integrative-functional account can serve as an analytic tool to help researchers, research ethics boards, and other relevant actors fill in the gaps in the current landscape of research ethics governance.

On the reconceptualization of Alzheimer's disease.

In the hope of future treatments to prevent or slow down the disease, there is a strong movement towards an ever-earlier detection of Alzheimer's disease (AD). In conjunction with scientific developments, this has prompted a reconceptualization of AD, as a slowly progressive pathological process with a long asymptomatic phase. New concepts such as 'preclinical' and 'prodromal' AD have been introduced, raising a number of conceptual and ethical questions. We evaluate whether these new concepts are theoretically defensible, in light of theories of health and disease, and whether they should be understood as disease or as an at-risk state. We introduce a pragmatic view on disease concepts and argue that an evaluation of the reconceptualization of AD should also take its aims and effects into account, and assess their ethical acceptability. The reconceptualization of AD is useful to coordinate research into preventive strategies, and may potentially benefit future patients. However, in the short term, early detection and labelling of 'preclinical AD' can potentially harm people. Since there is no treatment available and the predictive value is unclear, it may only create a group of 'patients-in-waiting' who may suffer from anxiety, uncertainty and stigmatization, but will never actually develop dementia. We conclude that only if the promise of preventive medication materializes, will the reconceptualization of AD turn out unequivocally to be for the better. Otherwise, the reconceptualization may do more harm than good.

Formación en Valores. Conceptos éticos y tecnológicos, métodos y estrategias / Values formation. Ethical and technologic concepts, methods and strategies

Introducción: para el sector de la salud, reviste especial importancia que sus profesionales, técnicos y trabajadores en general, compartan no solo la esencia político ideológica de la sociedad cubana en cuanto a los principios y valores que la rigen, sino que interioricen que la ética en la atención para con aquellos que reciben el servicio, adquiere un significado especial en el comportamiento de la persona. El nuevo siglo trae consigo la integración de las Tecnologías en todas las esferas de la vida. Es importante preparar a cada uno de los profesionales y técnicos de la salud en el "SABER HACER", y en el "SABER SER". Integrar los conceptos éticos y tecnológicos, a través de métodos y estrategias adecuadas para la formación en valores de manera coherente y orgánica.Objetivo: identificar los conceptos, métodos y estrategias generales para la formación en valores y su integración en el trabajo de desarrollo estratégico del sector de la salud.Desarrollo: se presentan los conceptos, métodos, estrategias y mecanismos para la formación en valores en el Sistema Nacional de Salud, en entornos docentes presenciales, virtuales y laborales, haciendo énfasis en los valores deseados y compartidos en la organización. Se concluye la importancia de estos conceptos en el proceso docente-educativo de las diferentes carreras de las Universidades de Ciencias Médicas y en el desarrollo estratégico del Sistema Nacional de Salud, donde los entornos virtuales de enseñanza-aprendizaje juegan un rol integrador en el proceso de formación de valores deseados y compartidos(AU)

Introduction: In the health sector, it is very important for the professionals, technicians and workers in general share not only the political and ideological essence of the Cuban society, but also that they interiorize that health care ethics towards those who receive the service acquires a special meaning in the person's behavior. The new century brings technology integration into all the life spheres. It is important to prepare each health professional and technician to "KNOW HOW TO DO" and to "KNOW HOW TO BE", in order to coherently and organically integrate the ethical and technological concepts by proper methods and strategies in view of values formation.Objective: Identify the general concepts, methods and strategies for values formation and its integration to the strategic work development in the health sector.Development: This paper presents the concepts, methods, strategies and mechanisms for values formation in the national health system, in working, virtual and on-site teaching environments, making an emphasis in the values desired and shared in the organization. The importance is concluded regarding these concepts in the teaching-educational process of the medical university majors and the strategic development of the national health system, where virtual teaching-learning environments play an integrating role within the desired and shared values formation process(AU)

What Do the Various Principles of Justice Mean Within the Concept of Benefit Sharing?

The concept of benefit sharing pertains to the act of giving something in return to the participants, communities, and the country that have participated in global health research or bioprospecting activities. One of the key concerns of benefit sharing is the ethical justifications or reasons to support the practice of the concept in global health research and bioprospecting. This article evaluates one of such ethical justifications and its meaning to benefit sharing, namely justice. We conducted a systematic review to map the various principles of justice that are linked to benefit sharing and analysed their meaning to the concept of benefit sharing. Five principles of justice (commutative, distributive, global, procedural, and compensatory) have been shown to be relevant in the nuances of benefit sharing in both global health research and bioprospecting. The review findings indicate that each of these principles of justice provides a different perspective for a different benefit sharing rationale. For example, commutative justice provides a benefit sharing rationale that is focused on fair exchange of benefits between research sponsors and communities. Distributive justice produces a benefit sharing rationale that is focused on improving the health needs of the vulnerable research communities. We have suggested that a good benefit sharing framework particularly in global health research would be more beneficial if it combines all the principles of justice in its formulation. Nonetheless, there is a need for empirical studies to examine the various principles of justice and their nuances in benefit sharing among stakeholders in global health research.

Stumbled, fumbled, bumbled, grumbled, and humbled: looking back at the future history of clinical ethics.

This retrospective of the last quarter century of clinical ethics offers an examination of some of the areas in which it should focus, and refocus, attention in the next.

[Legal debate about the definition of medical device and of medicinal drug for human use]. / Jogvita az orvostechnikai eszköz és a gyógyszer fogalmának értelmezésérol.

On 3 October 2013 the European Court of Justice made a decision regarding the interpretation of definitions of medical devices (Directive 93/42/EC) and medicinal product for human use (Directive 2001/83/EC), based on the Article 267 TFEU preliminary ruling. Orv. Hetil., 2014, 155(11), 429-433.

The definition of mental disorder: evolving but dysfunctional?

Extensive and diverse conceptual work towards developing a definition of 'mental disorder' was motivated by the declassification of homosexuality from the Diagnostic and Statistical Manual in 1973. This highly politicised event was understood as a call for psychiatry to provide assurances against further misclassification on the basis of discrimination or socio-political deviance. Today, if a definition of mental disorder fails to exclude homosexuality, then it fails to provide this safeguard against potential abuses and therefore fails to do an important part of the work it was intended to do. We argue that fact-based definitions of mental disorder, relying on scientific theory, fail to offer a robust definition of mental disorder that excludes homosexuality. Definitions of mental disorder based on values do not fare better: these definitions are silent on questions about the diagnostic status of individuals in oppressive societies and over-inclusive of mental or behavioural states that happen to be negatively valued in the individual's social context. We consider the latest definition proposed for the Diagnostic and Statistical Manual-5 (DSM-5) in light of these observations. We argue that definition fails to improve on these earlier deficiencies. Its inclusion in the manual may offer false reassurance against repetition of past misclassifications. We conclude with a provocation that if candidate definitions of mental disorder are unable to exclude homosexuality, it might perhaps be preferable not to attempt a definition at all.

Social categories as markers of intrinsic interpersonal obligations.

Social categorization is an early-developing feature of human social cognition, yet the role that social categories play in children's understanding of and predictions about human behavior has been unclear. In the studies reported here, we tested whether a foundational functional role of social categories is to mark people as intrinsically obligated to one another (e.g., obligated to protect rather than harm). In three studies, children (aged 3-9, N = 124) viewed only within-category harm as violating intrinsic obligations; in contrast, they viewed between-category harm as violating extrinsic obligations defined by explicit rules. These data indicate that children view social categories as marking patterns of intrinsic interpersonal obligations, suggesting that a key function of social categories is to support inferences about how people will relate to members of their own and other groups.