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1.
BMC Med Ethics ; 22(1): 28, 2021 03 22.
Artículo en Inglés | MEDLINE | ID: mdl-33752662

RESUMEN

BACKGROUND: The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. DISCUSSION: Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. CONCLUSION: We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.


Asunto(s)
Cuidados Críticos/ética , Toma de Decisiones/ética , Asignación de Recursos para la Atención de Salud/ética , Unidades de Cuidados Intensivos , Pandemias , Triaje/métodos , Conducta Cooperativa , Emociones , Ética Médica , Recursos en Salud , Humanos , Inutilidad Médica , Pronóstico , Sudáfrica , Triaje/ética
2.
J Med Internet Res ; 23(3): e24883, 2021 03 11.
Artículo en Inglés | MEDLINE | ID: mdl-33651705

RESUMEN

BACKGROUND: Effective communication during a health crisis can ease public concerns and promote the adoption of important risk-mitigating behaviors. Public health agencies and leaders have served as the primary communicators of information related to COVID-19, and a key part of their public outreach has taken place on social media platforms. OBJECTIVE: This study examined the content and engagement of COVID-19 tweets authored by Canadian public health agencies and decision makers. We propose ways for public health accounts to adjust their tweeting practices during public health crises to improve risk communication and maximize engagement. METHODS: We retrieved data from tweets by Canadian public health agencies and decision makers from January 1, 2020, to June 30, 2020. The Twitter accounts were categorized as belonging to either a public health agency, regional or local health department, provincial health authority, medical health officer, or minister of health. We analyzed trends in COVID-19 tweet engagement and conducted a content analysis on a stratified random sample of 485 tweets to examine the message functions and risk communication strategies used by each account type. RESULTS: We analyzed 32,737 tweets authored by 118 Canadian public health Twitter accounts, of which 6982 tweets were related to COVID-19. Medical health officers authored the largest percentage of COVID-19-related tweets (n=1337, 35%) relative to their total number of tweets and averaged the highest number of retweets per COVID-19 tweet (112 retweets per tweet). Public health agencies had the highest frequency of daily tweets about COVID-19 throughout the study period. Compared to tweets containing media and user mentions, hashtags and URLs were used in tweets more frequently by all account types, appearing in 69% (n=4798 tweets) and 68% (n=4781 tweets) of COVID-19-related tweets, respectively. Tweets containing hashtags also received the highest average retweets (47 retweets per tweet). Our content analysis revealed that of the three tweet message functions analyzed (information, action, community), tweets providing information were the most commonly used across most account types, constituting 39% (n=181) of all tweets; however, tweets promoting actions from users received higher than average retweets (55 retweets per tweet). When examining tweets that received one or more retweet (n=359), the difference between mean retweets across the message functions was statistically significant (P<.001). The risk communication strategies that we examined were not widely used by any account type, appearing in only 262 out of 485 tweets. However, when these strategies were used, these tweets received more retweets compared to tweets that did not use any risk communication strategies (P<.001) (61 retweets versus 13 retweets on average). CONCLUSIONS: Public health agencies and decision makers should examine what messaging best meets the needs of their Twitter audiences to maximize sharing of their communications. Public health accounts that do not currently employ risk communication strategies in their tweets may be missing an important opportunity to engage with users about the mitigation of health risks related to COVID-19.


Asunto(s)
/epidemiología , Toma de Decisiones/ética , Salud Pública , Medios de Comunicación Sociales/tendencias , Canadá/epidemiología , Humanos , /aislamiento & purificación
3.
J Clin Ethics ; 32(1): 61-68, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-33656457

RESUMEN

This article addresses a common yet rarely discussed aspect of hospital care-a pro-active approach to ethical dilemmas. Potential ethical conflicts often present warning signs to clinicians, analogous to the warning lights on a car's dashboard. Using a recent case study, a commonly encountered clinical decision-a conflict about whether to terminally extubate a critically ill patient versus whether to offer a tracheostomy-we describe a pro-active approach to ethical conflicts and outline three learning objectives: (1) the need for a robust understanding of the term "futility," (2) the need for an appreciation the various and often conflicting interpretations of "improved/improving," and (3) the need to understand the challenges of surrogate decision making.


Asunto(s)
Toma de Decisiones/ética , Inutilidad Médica , Principios Morales , Médicos , Humanos
6.
Clin J Oncol Nurs ; 25(1): 61-68, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: mdl-33480884

RESUMEN

BACKGROUND: The disruption in the supply chain of resources and interruptions in cancer treatments caused by the pandemic presented tremendous challenges to the healthcare system. OBJECTIVES: This article describes the National Academy of Medicine-defined states of medical and nursing care delivery for which local plans should be drawn and the shifting and evolving systems framework that can guide decisions to optimize the crisis standards of care. METHODS: A case study is presented to describe the process of shifting the state of medical and nursing care delivery and bioethical nursing considerations during the pandemic and beyond. FINDINGS: An evolving and shifting systems framework for crises rooted in deontology, principlism, and the ethics of care model provide meaningful guidance for establishing priorities for patient care.


Asunto(s)
/enfermería , Toma de Decisiones/ética , Prestación de Atención de Salud/ética , Neoplasias/enfermería , Enfermería Oncológica/ética , Enfermería Oncológica/normas , Pandemias/ética , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pandemias/prevención & control , Guías de Práctica Clínica como Asunto
7.
J Med Ethics ; 47(2): 108-112, 2021 02.
Artículo en Inglés | MEDLINE | ID: mdl-33335068

RESUMEN

One prominent view in recent literature on resource allocation is Persad, Emanuel and Wertheimer's complete lives framework for the rationing of lifesaving healthcare interventions (CLF). CLF states that we should prioritise the needs of individuals who have had less opportunity to experience the events that characterise a complete life. Persad et al argue that their system is the product of a successful process of reflective equilibrium-a philosophical methodology whereby theories, principles and considered judgements are balanced with each other and revised until we achieve an acceptable coherence between our various beliefs. Yet I argue that many of the principles and intuitions underpinning CLF conflict with each other, and that Persad et al have failed to achieve an acceptable coherence between them. I focus on three tensions in particular: the conflict between the youngest first principle and Persad et al's investment refinement; the conflict between current medical need and a concern for lifetime equality; and the tension between adopting an objective measure of complete lives and accommodating for differences in life narratives.


Asunto(s)
Toma de Decisiones/ética , Ética Clínica , Asignación de Recursos para la Atención de Salud/ética , Equidad en Salud/ética , Justicia Social , Triaje/ética , Prestación de Atención de Salud/ética , Análisis Ético , Prioridades en Salud/ética , Estado de Salud , Humanos , Principios Morales
8.
Rev. bioét. derecho ; (50): 189-203, nov. 2020.
Artículo en Español | IBECS | ID: ibc-191353

RESUMEN

La actual pandemia por la COVID-19 está ocasionado serias amenazas para la salud pública a nivel mundial, especialmente para los grupos de población más vulnerables. Los casos más graves de la enfermedad han sido primeramente atendidos por los profesionales de urgencias y emergencias, los cuales han tenido que tomar decisiones en contextos altamente complejos donde la priorización en la asignación de los recursos sanitarios disponibles les ha generado situaciones éticamente conflictivas. El objetivo del presente artículo es analizar la importancia de implantar la PDA en los servicios de urgencias y emergencias como herramienta de consulta en la resolución de los problemas éticos surgidos durante la pandemia por COVID-19, concretamente, en la atención al paciente crónico complejo o con enfermedad crónica avanzada


The events of the present CoVID-19 pandemic are causing serious threats to Public Health worldwide, specifically at the most vulnerable population groups. Emergency professionals have served as the first responders for the most serious cases of this disease. At the same time, they have made decisions in highly complex contexts where the prioritization of allocated care resources has generated ethically conflictive situations. The aim of this article is to analyze the importance of implementing the ACP as a tool in the emergency services to solve ethical problems that have arisen during the COVID-19 pandemic, particularly in the care of complex chronic patients or those with advanced chronic disease


L'actual pandèmia per la COVID-19 està ocasionat serioses amenaces a la salut pública a nivell mundial, especialment als grups de població més vulnerables. Els casos més greus de la malaltia han estat primerament atesos pels professionals d'urgències I emergències, els quals han hagut de prendre decisions en contextos altament complexos on la priorització en l'assignació dels recursos sanitaris disponibles els ha generat situacions èticament conflictives. L'objectiu d'aquest article va ser analitzar la importància d'implantar la PDA en els serveis d'urgències I emergències com a eina de consulta a la resolució dels problemes ètics sorgits durant la pandèmia per COVID-19, concretament, en l'atenció al pacient crònic complex o amb malaltia crònica avançada


Asunto(s)
Humanos , Prioridades en Salud/ética , Prioridades en Salud/organización & administración , Planificación de Atención al Paciente , Toma de Decisiones/ética , Conflicto de Intereses , Servicios Médicos de Urgencia/ética , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Pandemias , Enfermedad Crónica
9.
Rev. bioét. derecho ; (50): 37-61, nov. 2020.
Artículo en Español | IBECS | ID: ibc-191345

RESUMEN

Este documento ofrece una propuesta desde la perspectiva de la bioética para la elaboración de un protocolo de triaje en el contexto de la pandemia de COVID-19. Dicha propuesta incluye recomendaciones sobre las normas procedimentales y normas sustantivas que deben regir la asignación y reasignación de recursos terapéuticos en condiciones de escasez extrema


This document offers a proposal for the elaboration of a triage guideline in the context of the COVID-19 pandemic. This proposal includes recommendations on the procedural norms and substantive norms that should govern the allocation and reallocation of therapeutic resources in conditions of extreme scarcity


Aquest document ofereix una proposta des de la perspectiva de la bioètica per a l'elaboració d'un protocol de triatge en el context de la pandèmia de COVID-19. L'esmentada proposta inclou recomanacions sobre les normes procedimentals I normes substantives que han de regir l'assignació I reassignació de recursos terapèutics en condicions d'escassetat extrema


Asunto(s)
Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Pandemias/ética , Protocolos Clínicos , Triaje/ética , Toma de Decisiones/ética
13.
J Med Ethics ; 46(11): 726-731, 2020 11.
Artículo en Inglés | MEDLINE | ID: mdl-32913116

RESUMEN

It has recently been reported that some hospitals in the UK have placed a blanket restriction on the provision of maternal request caesarean sections (MRCS) as a result of the COVID-19 pandemic. Pregnancy and birthing services are obviously facing challenges during the current emergency, but we argue that a blanket ban on MRCS is both inappropriate and disproportionate. In this paper, we highlight the importance of MRCS for pregnant people's health and autonomy in childbirth and argue that this remains crucial during the current emergency. We consider some potential arguments-based on pregnant people's health and resource allocation-that might be considered justification for the limitation of such services. We demonstrate, however, that these arguments are not as persuasive as they might appear because there is limited evidence to indicate either that provision of MRCS is always dangerous for pregnant people in the circumstances or would be a substantial burden on a hospital's ability to respond to the pandemic. Furthermore, we argue that even if MRCS was not a service that hospitals are equipped to offer to all pregnant persons who seek it, the current circumstances cannot justify a blanket ban on an important service and due attention must be paid to individual circumstances.


Asunto(s)
Cesárea/ética , Toma de Decisiones/ética , Asignación de Recursos para la Atención de Salud/ética , Derechos Humanos , Pandemias/ética , Complicaciones Infecciosas del Embarazo/prevención & control , Betacoronavirus , Cesárea/efectos adversos , Infecciones por Coronavirus/epidemiología , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/virología , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Quirúrgicos Electivos/ética , Femenino , Salud , Hospitales , Humanos , Madres , Pandemias/prevención & control , Autonomía Personal , Neumonía Viral/epidemiología , Neumonía Viral/prevención & control , Neumonía Viral/virología , Embarazo , Complicaciones Infecciosas del Embarazo/epidemiología , Complicaciones Infecciosas del Embarazo/etiología , Complicaciones Infecciosas del Embarazo/virología , Mujeres Embarazadas , Reino Unido
14.
Rev. esp. med. legal ; 46(3): 119-126, jul.-sept. 2020.
Artículo en Español | IBECS | ID: ibc-192313

RESUMEN

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


Asunto(s)
Humanos , Valor de la Vida , Manejo de Atención al Paciente/legislación & jurisprudencia , Selección de Paciente/ética , Infecciones por Coronavirus , Cuidados Paliativos al Final de la Vida/ética , Cuidados para Prolongación de la Vida/ética , Pandemias/legislación & jurisprudencia , Toma de Decisiones/ética , Discusiones Bioéticas , Revisión de Utilización de Recursos/legislación & jurisprudencia , Asignación de Recursos/legislación & jurisprudencia , Negativa al Tratamiento/ética , Negativa al Tratamiento/legislación & jurisprudencia
15.
Rev. bioét. (Impr.) ; 28(3): 410-417, jul.-set. 2020.
Artículo en Portugués | LILACS | ID: biblio-1137123

RESUMEN

Resumo Este artigo busca identificar contribuições da bioética para enfrentar conflitos relacionados à tomada de decisão em tempos de pandemia. Trata-se de texto elaborado a partir de reflexões pessoais dos autores em diálogo com a literatura de diferentes perspectivas da bioética. Com fundamento em relatos históricos, argumenta-se que, durante epidemias, a sociedade passa a atuar em modo de excepcionalidade, o que exige argumentação mais apurada para se posicionar ante os conflitos que surgem. Analisam-se então diferentes vertentes teóricas - principialismo, personalismo, utilitarismo e bioética social -, recolhendo de cada uma elementos que podem nortear a tomada de decisão. Com base nessas contribuições, propõem-se parâmetros para a atuação dos profissionais da saúde, reconhecendo igual valor em cada vida humana, com o propósito de salvar o maior número de pessoas possível. Por fim, aponta-se para a responsabilidade de agentes políticos.


Abstract This article aims to identify the contribution of bioethics to resolve decision-making conflicts in healthcare in times of pandemic. The research was based on the authors' personal reflections in a dialogue with the literature and different bioethical perspectives. Historical accounts show that when a society is experiencing an epidemic it starts to function in a mode of social exceptionality, reinforcing the need for a more appropriate form of reasoning before the ethical conflicts that may arise from this situation. Some approaches to bioethics - principlism, personalism, utilitarianism and social bioethics - are briefly examined in order to obtain the elements for guiding the decision-making process. Finally, we suggest some parameters for health professionals, recognizing the value of all human lives, to save as many lives as possible.


Resumen Este artículo tiene como objetivo identificar la contribución de la bioética para hacer frente a los conflictos relacionados con la toma de decisiones en tiempos de pandemia. Se trata de un texto elaborado con base en las reflexiones personales de los autores en diálogo con la literatura de diferentes perspectivas de la bioética. Con base en los relatos históricos, se argumenta que, durante epidemias, la sociedad pasa a actuar en modo de excepcionalidad, lo que requiere una argumentación más precisa para posicionarse ante los conflictos que surgen. Se analizan entonces diferentes vertientes teóricas -el principialismo, el personalismo, el utilitarismo y la bioética social-, recogiendo de cada una los elementos que pueden orientar la toma de decisiones. Con base en dichas contribuciones, se proponen parámetros para la actuación de los profesionales de la salud, reconociendo el mismo valor en cada vida humana, con el propósito de salvar al mayor número posible de personas. Por fin, se apunta hacia la responsabilidad de los agentes políticos.


Asunto(s)
Grupos de Riesgo , Bioética , Infecciones por Coronavirus , Teoría Ética , Personeidad , Toma de Decisiones/ética , Pandemias
16.
PLoS One ; 15(8): e0237007, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32790699

RESUMEN

Although scientists agree that replications are critical to the debate on the validity of religious priming research, religious priming replications are scarce. This paper attempts to replicate and extend previously observed effects of religious priming on ethical behavior. We test the effect of religious instrumental music on individuals' ethical behavior with university participants (N = 408) in the Czech Republic, Japan, and the US. Participants were randomly assigned to listen to one of three musical tracks (religious, secular, or white noise) or to no music (control) for the duration of a decision-making game. Participants were asked to indicate which side of a vertically-bisected computer screen contained more dots and, in every trial, indicating that the right side of the screen had more dots earned participants the most money (irrespective of the number of dots). Therefore, participants were able to report dishonestly to earn more money. In agreement with previous research, we did not observe any main effects of condition. However, we were unable to replicate a moderating effect of self-reported religiosity on the effects of religious music on ethical behavior. Nevertheless, further analyses revealed moderating effects for ritual participation and declared religious affiliation congruent with the musical prime. That is, participants affiliated with a religious organization and taking part in rituals cheated significantly less than their peers when listening to religious music. We also observed significant differences in cheating behavior across samples. On average, US participants cheated the most and Czech participants cheated the least. We conclude that normative conduct is, in part, learned through active membership in religious communities and our findings provide further support for religious music as a subtle, moral cue.


Asunto(s)
Principios Morales , Música , Religión , Adolescente , Adulto , Comparación Transcultural , Señales (Psicología) , República Checa , Toma de Decisiones/ética , Femenino , Humanos , Japón , Masculino , Estados Unidos , Juegos de Video/ética , Adulto Joven
17.
J Med Ethics ; 46(10): 662-667, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32769094

RESUMEN

In March 2020, the Government produced a document entitled "Responding to COVID-19: The Ethical Framework for Adult Social Care" ('The Ethical Framework'). In this article, we summarise the key features of the proposed ethical framework and subject it to critical analysis. We highlight three primary issues. First, the emphasis placed on autonomy as the primary ethical principle. We argue if ever there was a context in which autonomy should dominate the ethical analysis, this is not it. Second, we examine the interface between ethics and law which is largely overlooked in the document. Finally, we explore the surprising lack of attention paid to the concept of responsibility and communal obligations within the framework.


Asunto(s)
Infecciones por Coronavirus/terapia , Toma de Decisiones/ética , Análisis Ético , Ética Médica , Legislación Médica/ética , Autonomía Personal , Neumonía Viral/terapia , Responsabilidad Social , Adulto , Betacoronavirus , Infecciones por Coronavirus/epidemiología , Teoría Ética , Humanos , Pandemias , Neumonía Viral/epidemiología , Medicina Estatal/ética , Medicina Estatal/legislación & jurisprudencia , Reino Unido
18.
J Med Ethics ; 46(10): 646-651, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32769095

RESUMEN

Tragic choices arise during the COVID-19 pandemic when the limited resources made available in acute medical settings cannot be accessed by all patients who need them. In these circumstances, healthcare rationing is unavoidable. It is important in any healthcare rationing process that the interests of the community are recognised, and that decision-making upholds these interests through a fair and consistent process of decision-making. Responding to recent calls (1) to safeguard individuals' legal rights in decision-making in intensive care, and (2) for new authoritative national guidance for decision-making, this paper seeks to clarify what consistency and fairness demand in healthcare rationing during the COVID-19 pandemic, from both a legal and ethical standpoint. The paper begins with a brief review of UK law concerning healthcare resource allocation, considering how community interests and individual rights have been marshalled in judicial deliberation about the use of limited health resources within the National Health Service (NHS). It is then argued that an important distinction needs to be drawn between procedural and outcome consistency, and that a procedurally consistent decision-making process ought to be favoured. Congruent with the position that UK courts have adopted for resource allocation decision-making in the NHS more generally, specific requirements for a procedural framework and substantive triage criteria to be applied within that framework during the COVID-19 pandemic are considered in detail.


Asunto(s)
Infecciones por Coronavirus/terapia , Cuidados Críticos/ética , Toma de Decisiones/ética , Asignación de Recursos para la Atención de Salud/ética , Neumonía Viral/terapia , Betacoronavirus , Infecciones por Coronavirus/epidemiología , Cuidados Críticos/legislación & jurisprudencia , Asignación de Recursos para la Atención de Salud/legislación & jurisprudencia , Humanos , Pandemias , Neumonía Viral/epidemiología , Medicina Estatal , Reino Unido
19.
Am J Bioeth ; 20(8): 54-64, 2020 08.
Artículo en Inglés | MEDLINE | ID: mdl-32757910

RESUMEN

Dementia patients in the moderate-late stage of the disease can, and often do, express different preferences than they did at the onset of their condition. The received view in the philosophical literature argues that advance directives which prioritize the patient's preferences at onset ought to be given decisive moral weight in medical decision-making. Clinical practice, on the other hand, favors giving moral weight to the preferences expressed by dementia patients after onset. The purpose of this article is to show that the received view in the philosophical literature is inadequate and is out of touch with real clinical practice. I argue that having dementia is a cognitive transformative experience and that preference changes which result from this are legitimate and ought to be given moral weight in medical decision-making. This argument ought to encourage us to reduce our confidence in the moral weight of advance directives for dementia patients.


Asunto(s)
Directivas Anticipadas/ética , Cognición , Demencia , Ética Médica , Competencia Mental , Prioridad del Paciente , Toma de Decisiones/ética , Disentimientos y Disputas , Humanos , Principios Morales
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