Guidelines for conscientious objection in Spain: a proposal involving prerequisites and protocolized procedure.

Healthcare professionals often face ethical conflicts and challenges related to decision-making that have necessitated consideration of the use of conscientious objection (CO). No current guidelines exist within Spain's healthcare system regarding acceptable rationales for CO, the appropriate application of CO, or practical means to support healthcare professionals who wish to become conscientious objectors. As such, a procedural framework is needed that not only assures the appropriate use of CO by healthcare professionals but also demonstrates its ethical validity, legislative compliance through protection of moral freedoms and patients' rights to receive health care. Our proposal consists of prerequisites of eligibility for CO (individual reference, specific clinical context, ethical justification, assurance of non-discrimination, professional consistency, attitude of mutual respect, assurance of patient rights and safety) and a procedural process (notification and preparation, documentation and confidentiality, evaluation of prerequisites, non-abandonment, transparency, allowance for unforeseen objection, compensatory responsibilities, access to guidance and/or consultative advice, and organizational guarantee of professional substitution). We illustrate the real-world utility of the proposed framework through a case discussion in which our guidelines are applied.

Conscientious refusal or conscientious provision: We can't have both.

Some authors argue that it is permissible for clinicians to conscientiously provide abortion services because clinicians are already allowed to conscientiously refuse to provide certain services. Call this the symmetry thesis. We argue that on either of the two main understandings of the aim of the medical profession-what we will call "pathocentric" and "interest-centric" views-conscientious refusal and conscientious provision are mutually exclusive. On pathocentric views, refusing to provide a service that takes away from a patient's health is professionally justified because there are compelling reasons, based on professional standards, to refuse to provide that service (e.g., it does not heal, and it is contrary to the goals of medicine). However, providing that same service is not professionally justified when providing that service would be contrary to the goals of medicine. Likewise, the thesis turns out false on interest-centric views. Refusing to provide a service is not professionally justified when that service helps the patient fulfill her autonomous preferences because there are compelling reasons, based on professional standards, to provide that service (e.g., it helps her achieve her autonomous preferences, and it would be contrary to the goals of medicine to deny her that service). However, refusing to provide that same service is not professionally justified when refusing to provide that service would be contrary to the goals of medicine. As a result, on either of the two most plausible views on the goals of medicine, the symmetry thesis turns out false.

Perfil dos sobreviventes de violência sexual e factores associados ao abandono de seguimento de cuidados pós violência, nos centros integrados de atendimento do hospital geral josé macamo e hospital geral de mavalane entre 2019 e 2020 / Profile of survivors of sexual violence and factors associated with abandonment of follow-up of post-violence care, in the Integrated care centers of the José macamo general hospital and mavalane general hospital between 2019 and 2020

Introdução: A violência sexual afecta vários segmentos da sociedade e é um problema de saúde pública, que prejudica a saúde e o bem-estar de milhões de indivíduos no mundo. O seguimento pós violência sexual tem sido um dos maiores desafios enfrentados pelos profissionais de saúde, pois requer um cuidado, que não depende só do profissional, mas também dos sobreviventes. O estudo visa analisar o perfil dos sobreviventes de violência sexual e os factores associados ao abandono de cuidados pós violência sexual, no Hospital Geral José Macamo (HGJM) e Hospital Geral de Mavalane (HGM) entre 2019 e 2020. Métodos: Foi conduzido um estudo retrospectivo transversal, com uma abordagem quantitativa, no período entre Janeiro de 2019 à Dezembro 2020. Foram utilizados dados secundários colectados nas fichas de notificação e processos dos sobreviventes de violência sexual, atendidos nos Centros de Atendimento Integrado dos HGM e HGJM. Foram avaliados os casos de abandono e não abandono aos cuidados pós violência sexual com idade compreendida dos 2-56 anos. Para análise foi usado o pacote estatístico Stata 16.1, tendo se realizado análises de regressão logística e teste qui-quadrado. Resultados: No total foram revistas 318 fichas de notificação de sobreviventes de violência sexual, onde a maioria eram do sexo feminino 98% (313/318), com idades entre 2 a 56 anos, e mediana de idade de 15 anos (DP±8.3). Maior parte deles eram solteiros 97% (308/318) e residentes no distrito municipal Kamubukuane em 36% (114/318). Cerca de 55% (174/318) deles conheciam o seu agressor e a maior parte das agressões em 46% (147/318), ocorreram na casa do agressor…

Introduction: Sexual violence affects various segments of the society and it is a public health problem, which harms the health and well-being of millions of people in the world. Post sexual violence follow-up has been one of the biggest challenges faced by health professionals, as it requires care, which does not depend only on the professional, but also on the survivors. The study aims to analazy the profile of sexual violence survivors and factors associated with abandonment of post sexual violence care, at Jose Macamo General Hospital (JMGH) and Mavalane General Hospital (MGH) between 2019 and 2020. Methodology: A retrospective cross-sectional study with a quantitative approach was conducted in the period from January 2019 to December 2020. Secondary data collected from the notification forms and files of survivors of sexual violence, assisted at the Integrated Care Centres of HGM and HGJM, were used. Abandonment and non-abandonment cases to post sexual violence care aged 2-56 years were assessed. The statistical package Stata 16.1 was used for analysis, and logistic regression analysis and chi square test were performed. Results: A total of 318 notification forms of sexual violence survivors were reviewed, where majority were female 98% (313/318), aged between 2-56 years, and average age of 17 years (SD±8.3). Most of them were single 97% (308/318) and residing in Kamubukuane municipal district 36% (114/318). About 55% (174/318) of them knew their abuser and most of the assaults 46% (147/318) occurred at the abuser's home…

Conscience and Vaccines: Lessons from Babylon 5 and COVID-19.

Babylon 5, like other great sci-fi franchises, touched on important ethical questions. Two ethical conundrums relating to the series' main characters included providing life-saving treatment to a child against their parents' wishes and potential involvement with a highly beneficial but morally dubious medication. I use these cases to discuss some aspects of the COVID-19 vaccines' development and roll-out, demonstrating that people (be it patients or clinicians) might object to some vaccines due to reasonable ethics and safety-based concerns rather than due to an anti-vaxxer mind-set. I highlight that it would be disingenuous to lump these two groups of objections together for not all objections to specific vaccines are objections to vaccination in general. Rather, governments and pharmaceutical companies should seriously engage with the concerns of reasonable objectors to provide citizens with the appropriate products and ensure large vaccination uptake - in the case of COVID-19 this should include giving patients the choice of the product they will be inoculated with.

Physician autonomy or discrimination: the risks and limits of saying "no".

Respect for patient autonomy is a critical concept in the training of all physicians. Most physicians will make clinical recommendations on a daily basis that reflect a marriage of evidence-based medical fact and the deeply felt aspirations and boundaries that patients share with them. While most physicians are well versed and comfortable managing issues of patient autonomy, many are less confident about ethical and legal guidelines for expressing their own autonomy in clinical decision-making. This paper will review the legal landscape surrounding the patient-physician relationship with a focus on when and how physicians can exercise their personal and professional autonomy in their clinical practice.

[Map of ethics conflicts in chronic patient's hospitalization]. / Mapa de conflictos éticos en hospitalización de pacientes crónicos.

The identification, priorization and anticipation of the ethics conflicts, allow the Healthcare Ethics Committees (HEC) a better approach to them, as well as the adoption of measures to prevent its appearance and/or its mitigation. For this purpose, we set ourselves the objective of knowing what they are in the present, how important they are, and what would be the future scenario to face. An qualitative structure research was made whit two focal groups whit the participation of nurses, nurse auxiliary and doctors from the hospitalization area, they also answer a future ethics conflicts Decalogue. The results were tested after by their importance level (Relevance-Frequency-Consistency). The medium age of the participants was 34,7 +- 15,4, whit a medium experience at work of 11,7 +- 15,4 years. A total of 40 ethics conflicts was identify grouped in 5 risk areas: professional, assistance, social, organizational and legal. From there 21 results the more important, between them we find patient abandonment, inexistence of internal performance protocols, patient and relatives false expectations waiting for non-assistance care, unnecessary care at the end of the life, lack of rules for family / caregivers, and ignorance of legality. The more important ethical dilemmas for the future identified by the personal will be patients in abandonment, the lack of sociohealth resources, conflicts with family / caregivers situation and lack of information for decision making at the end of the life. The ethical conflicts between the personal from a chronic patients hospital and the relatives/caregivers was identifying, the most important were prioritized, and futures were anticipated. In these scenarios, we highlight abandonment as the most important. A map of ethics conflicts is a good tool to identify risk areas for ethics conflicts, we see the difference between the ethics conflicts found in other kind of hospitals. The map of ethics conflicts need to be update periodically to keep the validity.

Impacto del COVID-19 en personas mayores en España: algunos resultados y reflexiones / No disponible

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A Duty to treat? A Right to refrain? Bangladeshi physicians in moral dilemma during COVID-19.

BACKGROUND: Normally, physicians understand they have a duty to treat patients, and they perform accordingly consistent with codes of medical practice, standards of care, and inner moral motivation. In the case of COVID-19 pandemic in a developing country such as Bangladesh, however, the fact is that some physicians decline either to report for duty or to treat patients presenting with COVID-19 symptoms. At issue ethically is whether such medical practitioners are to be automatically disciplined for dereliction of duty and gross negligence; or, on the contrary, such physicians may legitimately claim a professional right of autonomous judgment, on the basis of which professional right they may justifiably decline to treat patients. METHODS: This ethical issue is examined with a view to providing some guidance and recommendations, insofar as the conditions of medical practice in an under-resourced country such as Bangladesh are vastly different from medical practice in an industrialized nation such as the USA. The concept of moral dilemma as discussed by philosopher Michael Shaw Perry and philosopher Immanuel Kant's views on moral appeal to "emergency" are considered pertinent to sorting through the moral conundrum of medical care during pandemic. RESULTS: Our analysis allows for conditional physician discretion in the decision to treat COVID-19 patients, i.e., in the absence of personal protective equipment (PPE) combined with claim of duty to family. Physicians are nonetheless expected to provide a minimum of initial clinical assessment and stabilization of a patient before initiating transfer of a patient to a "designated" COVID-19 hospital. The latter is to be done in coordination with the national center control room that can assure admission of a patient to a referral hospital prior to ambulance transport. CONCLUSIONS: The presence of a moral dilemma (i.e., conflict of obligations) in the pandemic situation of clinical care requires institutional authorities to exercise tolerance of individual physician moral decision about the duty to care. Hospital or government authority should respond to such decisions without introducing immediate sanction, such as suspension from all clinical duties or termination of licensure, and instead arrange for alternative clinical duties consistent with routine medical care.

Consideraciones éticas y médico-legales sobre la limitación de recursos y decisiones clínicas en la pandemia del COVID-19 / Medico-legal and ethical considerations on resource limitation and clinical decisions during the COVID-19 pandemic

La pandemia por COVID-19 ha suscitado problemas éticos y médico-legales, entre los que destaca la asignación equitativa de recursos sanitarios, sobre todo en relación a la priorización de pacientes y el racionamiento de recursos. El establecimiento de prioridades está siempre presente en los sistemas sanitarios y depende de la teoría de justicia aplicable en cada sociedad. El racionamiento de recursos ha sido necesario en la pandemia por COVID-19, por lo que se han publicado documentos de consenso para la toma de decisiones sustentadas en cuatro valores éticos fundamentales: maximización de los beneficios, tratar a las personas igualmente, contribuir en la creación de valor social y dar prioridad a la situación más grave. De ellos derivan recomendaciones específicas: maximizar beneficios; priorizar a los trabajadores de la salud; no priorizar la asistencia por orden de llegada; ser sensible a la evidencia científica; reconocer la participación en la investigación y aplicar los mismos principios a los pacientes COVID-19 que a los no-COVID-19

The COVID-19 pandemic has raised ethical and medico-legal problems, which include the equitable allocation of health resources, especially in relation to the prioritization of patients and the rationing of resources. Priority setting is always present in healthcare systems and depends on the theory of justice applicable in each society. Resource rationing has been necessary in the COVID-19 pandemic, and therefore consensus documents have been published for decision-making based on four fundamental ethical values: maximization of benefits, treating people equally, contributing to creating social value and giving priority to the worst off, from which specific recommendations derive: maximize benefits; prioritize health workers; do not prioritize attendance on a first-come, first-served basis; be sensitive to scientific evidence; recognize participation in research and apply the same principles to COVID-19 patients as to non-COVID-19 patients

Understanding Ethical and Legal Obligations in a Pandemic: A Taxonomy of "Duty" for Health Practitioners.

From the ethics perspective, "duty of care" is a difficult and contested term, fraught with misconceptions and apparent misappropriations. However, it is a term that clinicians use frequently as they navigate COVID-19, somehow core to their understanding of themselves and their obligations, but with uncertainty as to how to translate or operationalize this in the context of a pandemic. This paper explores the "duty of care" from a legal perspective, distinguishes it from broader notions of duty on professional and personal levels, and proposes a working taxonomy for practitioners to better understand the concept of "duty" in their response to COVID-19.

The Charlie Gard Case, and the Ethics of Obstructing International Transfer of Seriously Ill Children.

In 2017, the court case over medical treatment of UK infant, Charlie Gard, reached global attention. In this article, I will analyze one of the more distinctive elements of the case. The UK courts concluded that treatment of Charlie Gard was not in his best interests and that it would be permissible to withdraw life-sustaining treatment. However, in addition, the court ruled that Charlie should not be transferred overseas for the treatment that his parents sought, even though specialists in Italy and the US were willing to provide that treatment. Is it ethical to prevent parents from pursuing life-prolonging treatment overseas for their children? If so, when is it ethical to do this? I will outline arguments in defense of obstructing transfer in some situations. I will argue, however, that this is only justified if there is good reason to think that the proposed treatment would cause harm.

Una respuesta ética en la atención a residencias de ancianos en la pandemia Covid-19 / An ethical response in the care of nursing homes in the covid-19 pandemic

La llegada de la pandemia COVID-19 puso en evidencia el riesgo de una posible falta de atención de los ancianos de las residencias de mayores. Aportamos la experiencia de un equipo multidisciplinar con profesionales voluntarios de diferentes especialidades que realizó una labor de apoyo a los profesionales sanitarios de las residencias. Este equipo se implementó desde las gerencias de atención primaria y de atención especializada. La sistemática de trabajo se inspiraba en el de hospitalización a domicilio e incluía la atención directa de los pacientes más complejos y el asesoramiento en las medidas de prevención, aislamiento e higiene dentro de la residencia. De este modo fue posible que los ancianos de las residencias con sospecha o diagnóstico de COVID-19 recibieran una atención adecuada por parte de un equipo interdisciplinar, que se descargara parte de la presión de los profesionales de las residencias y que los familiares percibieran que no existía abandono terapéutico. El compromiso desde diversos niveles asistenciales en una labor coordinada ha conseguido evitar que una población vulnerable pudiera quedar desatendido durante la pandemia

With the arrival of the COVID-19 pandemic, the risk of a possible lack of care for the elderly in nursing homes became evident. We summarize the experience of a multidisciplinary team with volunteer professionals from different specialties who carried out support for healthcare professionals in nursing homes. This team was implemented from both Primary and Specialty Care managements. Its work paradigm was proposed by our home hospitalization team, which included direct care of the most complex patients and general counselling on isolation, hygiene and preventive measures within the nursing homes. Thanks to this support, the elderly population placed there, with suspected or diagnosed COVID-19, received adequate care from an interdisciplinary team, which led part of the pressure to be released from their professional workers, and many family members were aware that there was no neglect of the elderly. Commitment from various levels of care in a coordinated effort has prevented a vulnerable population from being left unattended during the pandemic

Reflexiones éticas en torno a las medidas tomadas en las residencias durante la pandemia / Ethical reflections on the measures taken in nursing homes during pandemic

La pandemia por Covid-19 ha afectado especialmente a los mayores que viven en residencias desde su aparición. Para frenar sus efectos devastadores las autoridades sanitarias pusieron en marcha numerosos protocolos y medidas que han podido vulnerar la debida ética asistencial. El asilamiento social de los ancianos de las residencias, el confinamiento en las habitaciones, el cribado en la derivación de los pacientes mayores a los hospitales, y a las unidades de cuidados intensivos han hecho tanto daño como beneficio. En el presente trabajo se plantean diversas líneas reflexivas en torno a la eticidad de cada una de las medidas adoptadas. También acerca del papel de los comités de ética en la vigilancia y supervisión de todos los procesos asistenciales en las residencias

The Covid-19 pandemic has particularly affected older people living in nursing homes since its onset. To curb its devastating effects, the health authorities have put in place numerous protocols and measures that have been able to violate the proper ethics of care. The social isolation of the elderly from the nursing homes, the confinement in the rooms, the screening in the referral of the elderly patients to the hospitals, and to intensives cares units have done both harm and benefit. In the present work, several reflexive lines are proposed around the ethicity of each of the measures adopted. Also about the role of ethics commit-tees in the monitoring and supervision of all care processes in residences

Valoración del documento: "Recomendaciones generales relacionadas con las decisiones éticas difíciles y la adecuación de la intensidad asistencial/ingreso en las Unidades de Cuidados Intensivos en situaciones excepcionales de crisis" por parte del Consejo Asesor Regional de Ética Asistencial –Dr. D. Juan Gómez Rubí– (carea) / Evaluation of the document: "General recommendations related to difficult ethical decisions and the adequacy of the health care/admission in the Intensive Care Units in exceptional crisis situations" by the Regional Advisory Council of Health Care Ethics. –D. Juan Gómez Rubí- (carea)

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COVID-19, adulto mayor y edadismo: errores que nunca han de volver a ocurrir / COVID-19, older adults and ageism: Mistakes that should never happen again

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Conscientious Objection in Healthcare: Neither a Negative Nor a Positive Right.

Conscientious objection in healthcare is often granted by many legislations regulating morally controversial medical procedures, such as abortion or medical assistance in dying. However, there is virtually no protection of positive claims of conscience, that is, of requests by healthcare professionals to provide certain services that they conscientiously believe ought to be provided, but that are ruled out by institutional policies. Positive claims of conscience have received comparatively little attention in academic debates. Some think that negative and positive claims of conscience deserve equal protection in terms of measures that institutions ought to take to accommodate them. However, in this issue of The Journal of Clinical Ethics (JCE), Abram Brummett argues against this symmetry thesis.1 He suggests that the relevant distinction is not between negative and positive claims of conscience, but between negative and positive rights of conscience. He argues that conscientious refusals and positive claims of conscience are both already protected as negative rights of conscience, but that this does not require institutions to accommodate positive claims of conscience. In this article I will argue that both Brummett and the authors he criticizes share a wrong view about the existence of conscience rights in healthcare. I will argue that there is no right to conscientious objection in healthcare, whether positive or negative. Thus, contra Brummett, I argue that the question whether such rights are positive or negative is as irrelevant as the question whether the claims of conscience are positive or negative.