Research ethics and Indigenous Peoples: Repercussions of returning Yanomami blood samples.

This work presents the case of the Yanomami indigenous people from Brazil that were the object of US ethnography initiated in the 1960s. The research brought harmful repercussions to the life of the Indigenous people of Brazil for several decades, and it took more than 40 years until the beginning of a process of reparation involving the Brazilian government and American universities. Objective: to discuss the meaning of the return of Yanomami blood samples, as well as contributions from the epistemologies of traditional Indigenous knowledge to the debate about research ethics and the structuring of means for the social control of researchers and the protection of participants in scientific studies, having as an example the Yanomami indigenous people from Brazil, subjected to noxious ethnography in the 1960s and the 1970s. This work used data reports recorded in secondary sources. In this article we argue that Bioethics needs to further diversify its epistemological foundations and to consider epistemologies and cosmologies beyond the frontiers of Western science, as the case of the abusive research involving the Yanomami indigenous people in Brazil reveals. We argue that traditional knowledge, such as those of indigenous and quilombolas, with their epistemologies and cosmologies, are fundamental for the election of less colonized and more efficient principles of research ethics, regarding the protection of the participants' rights in scientific studies. Traditional indigenous populations can teach us a great deal about doing research.

Ethics in cross-cultural encounters: a medical concern?

Modern medicine's investment in the disembodied, objective 'science' of biomedicine, where patients are transformed from suffering subjects to objects of investigation, calls for heightened ethical awareness. Around the world, ethical codes of conduct emphasise beneficence and non-maleficence. Lately, we have also seen a quest for autonomy and equitable healthcare for diverse populations. However, these tenets alone do not effectively address the problems which regularly occur in transcultural consultations. By developing a 'space for reflection' based on selected writings of the moral philosophers Axel Honneth, Emmanuel Levinas and Hans Jonas, my aim is to cast light on this issue. Given the differing aspects of the doctor-patient relationship, clearly there are no clear-cut rules to obey. However, a thematic analysis of a quote from a Somali, female refugee, supported by some other studies on medical practice, suggests that, metaphorically speaking, within the developed space for reflection, medical practice has worked itself into a corner. By neglecting the patient as a social being, lacking openness to alterity, and not conveying needed information, they make it very difficult for patients to take responsibility for their situation. In spite of doctors' benevolence, the result is alienation, increased suffering and thus, potential harm. Similar tendencies are reflected in a number of recent studies on medical consultations. Therefore, rather than blaming the single doctor for moral deceit, we should see these tendencies as a 'forgetfulness of recognition' that affects the medical profession, a disturbance which source probably is hidden in doctors training.

Sentidos de la formación bioética de enfermeros en un contexto intercultural / Meaning of the bioethical training of nurses in an intercultural context / Sentidos da formação bioética de enfermeiros em um contexto intercultural

Humanizar la educación se constituye en un pilar para la formación bioética de los profesionales de enfermería en contextos interculturales, lo que orienta el sentido transformador de la visión de cuidado disciplinar. Con este estudio se buscó comprender los sentidos que otorgan a la bioética los actores de formación desde las prácticas formativas en un contexto intercultural. Para ello se planteó una investigación cualitativa descriptiva con enfoque epistémico hermenéutico; el análisis de datos se realizó desde la teoría fundamentada. Se recolectaron datos a través de: revisión documental, entrevistas semiestructuradas, observación no participante, diarios de campo y grupos focales. Los participantes corresponden a los estudiantes, docentes y directivos del programa de enfermería de una universidad del suroccidente colombiano, tutores de práctica y sujetos de cuidado que fueron atendidos por los estudiantes. Los resultados permitieron concluir que el principal sinsentido en la formación radica en un problema de colonialidad del ser y saber, porque el currículo continúa privilegiando el saber técnico sobre una formación humana. Tejer la bioética intercultural desde la reflexión pedagógica en contextos interculturales permite desarrollar una formación con sentido crítico respecto aquello que no favorece la armonía del ser humano con el territorio y que conlleve al futuro profesional a ser consciente de su responsabilidad con el cuidado de salud

Humanizing education constitutes a pillar for bioethical formation of nursing professionals in intercultural contexts, which guides the transformative sense of the vision of disciplinary care. It was sought to understand the senses that the training actors grant bioethics from the training practices in an intercultural context. For this, a descriptive qualitative investigation with a hermeneutical epistemic approach is proposed, the data analysis was carried out from the grounded theory. Data were collected through: documentary review, semi-structured interviews, non-participant observation, field diaries and focus groups. Participants correspond to students, teachers and directors of the nursing program of a university in southwestern Colombia, practice tutors and care subjects who were attended by the students. The results allow us to conclude that the main nonsense in formation lies in a problem of coloniality of being and knowing, because the curriculum continues to privilege technical knowledge over a human formation. Weaving intercultural bioethics from pedagogical reflection in intercultural contexts allows developing a critical training regarding what does not favor the harmony of human being with territory and that leads the professional future to be aware of their responsibility with health care

A educação humanizada constitui um pilar para a formação bioética dos profissionais de enfermagem em contextos interculturais, que norteiam o sentido transformador da visão do cuidado disciplinar. Buscou-se compreender os sentidos que os atores treinadores conferem bioética a partir das práticas de treinamento em um contexto intercultural. Para isso, propõe-se uma investigação qualitativa descritiva, com abordagem epistêmica hermenêutica, e a análise dos dados foi realizada a partir da teoria fundamentada. Os dados foram coletados por meio de: revisão documental, entrevistas semiestruturadas, observação não participante, diários de campo e grupos focais. Os participantes correspondem a estudantes, professores e diretores do programa de enfermagem de uma universidade no sudoeste da Colômbia, tutores de prática e assuntos de atendimento que foram atendidos pelos alunos. Os resultados permitem concluir que o principal absurdo da formação está em um problema de colonialidade do ser e do saber, porque o currículo continua privilegiando o conhecimento técnico sobre a formação humana. A tecer a bioética intercultural da reflexão pedagógica em contextos interculturais permite desenvolver um treinamento crítico sobre o que não favorece a harmonia do ser humano com o território e que leva o futuro profissional a ter consciência de sua responsabilidade com os cuidados em saúde

Refugee women's experience of the resettlement process: a qualitative study.

BACKGROUND: Resettlement can be particularly challenging for women as having a lower socioeconomic status and language barriers, may impede women's access to education, employment opportunities, health-care services, as well as the cultural, social, material and resilience factors that facilitate adjustment and adaption. Thus, the aim of this study is to further explore the perception of refugee women in Sweden concerning their situation during active participation in the resettlement process in the country. METHODS: Qualitative interview study with 11 recently arrived refugee women who had received their residence permits and were enrolled in the resettlement process. The interviews were conducted in Swedish with the support of an authorized Arabic translator present by telephone. RESULTS: Refugee women suffered from being separated from their loved ones and felt compelled to achieve something of value in the host country. All experienced both physical and mental anguish. CONCLUSIONS: Stakeholders in societies that receive refugee women should stress the importance of finding opportunities for and fast entrance into employment in the host countries. This would be beneficial for the integration and well-being of refugee women after migration.

Personal Faith and Professional Ethics: Best Practice with the Families of Sexual and Gender Minority Youths.

Religious mental health practitioners who hold traditional views of gender and sexuality may face moral and ethical dilemmas when working with sexual and gender minority (SGM) clients. Typical responses to this dilemma include selective positioning, values-based referrals, and attempted objectivity. Grounded in social work ethics and values, this article examines the evidence base, viability, and repercussions of these approaches. This article demonstrates the importance of cultural competence and affirmative therapeutic practices for religious mental health practitioners, whether or not they expect to work with gender and sexual minority clients or their families. In addition, the author tackles the difficult issue of providing ethical, evidence-based therapeutic services for religiously conservative parents of SGM children and adolescents. SGM people exist in every community, in every faith, and in every kind of family. The ethical treatment of SGM clients is relevant to all mental health practitioners, regardless of personal values or the type of practice they maintain.

Who Is Served Best by Health Professions Service Learning Trips?

Service learning trips can be a powerful means of fostering cultural competency as well as an opportunity for students to expand their clinical skill set. However, if not planned and executed thoughtfully, they might not provide lasting benefit to the communities they seek to serve. Through analysis of a case in which participants question the value of their short-term international service learning trip, we argue that such trips should be designed with the community's needs in mind, preferably as identified by the community. Ideally, both the service group and the community should seek opportunities for teaching and exchange in order to expand the community's ability to provide care to the local population long after the service learning group has left.

Perceptions of intercultural competence and institutional intercultural inclusiveness among first year medical students: a 4-year study.

BACKGROUND: This study sought to examine the awareness/perception of intercultural competence and institutional intercultural inclusiveness among first year students at an Australian medical school over four consecutive years (2014-2017); to identify existing gaps in the curriculum and proffer recommendations. METHODS: The study employed an adapted 20-item questionnaire for data collection. The reliability and interrelations of the survey items were examined. Descriptive statistics was used to examine students' perceptions, while Mann-U Whitney and Kruskal-Wallis tests were used to assess items scores in relation to participant characteristics. RESULTS: Over the 4 years of study, there were 520 respondents with between 53 to 69% response rates per year. Cronbach's alpha for the instrument was 0.88 and factor analysis showed all items loading strongly on two components. Participants' mean score on self-reported intercultural competence levels ranged from 3.8-4.6 out of 5; indicating relatively high awareness, valuing and understanding of cultural differences among this group of students. However, their mean scores (3.4-4.2) for institutional intercultural inclusiveness were slightly lower. CONCLUSION: The instrument used in this study is effective in assessing level of intercultural competence among medical students. However, the results highlight the need for increased institutional support and professional development for faculty members to foster institutional intercultural inclusiveness.

Getting it Right: validating a culturally specific screening tool for depression (aPHQ-9) in Aboriginal and Torres Strait Islander Australians.

OBJECTIVES: To determine the validity, sensitivity, specificity and acceptability of the culturally adapted nine-item Patient Health Questionnaire (aPHQ-9) as a screening tool for depression in Aboriginal and Torres Strait Islander people. DESIGN: Prospective observational validation study, 25 March 2015 - 2 November 2016. SETTING, PARTICIPANTS: 500 adults (18 years or older) who identified as Aboriginal or Torres Strait Islander people and attended one of ten primary health care services or service events in urban, rural and remote Australia that predominantly serve Indigenous Australians, and were able to communicate sufficiently to respond to questionnaire and interview questions. MAIN OUTCOME MEASURES: Criterion validity of the aPHQ-9, with the depression module of the Mini-International Neuropsychiatric Interview (MINI) 6.0.0 as the criterion standard. RESULTS: 108 of 500 participants (22%; 95% CI, 18-25%) had a current episode of major depression according to the MINI criterion. The sensitivity of the aPHQ-9 algorithm for diagnosing a current major depressive episode was 54% (95% CI, 40-68%), its specificity was 91% (95% CI, 88-94%), with a positive predictive value of 64%. For screening for a current major depressive episode, the area under the receiver operator characteristic curve was 0.88 (95% CI, 0.85-0.92); with a cut-point of 10 points its sensitivity was 84% (95% CI, 74-91%) and its specificity 77% (95% CI, 71-83%). The aPHQ-9 was deemed acceptable by more than 80% of participants. CONCLUSIONS: Indigenous Australians found the aPHQ-9 acceptable as a screening tool for depression. Applying a cut-point of 10 points, the performance characteristics of the aPHQ were good.

Beyond the Belmont Principles: A Community-Based Approach to Developing an Indigenous Ethics Model and Curriculum for Training Health Researchers Working with American Indian and Alaska Native Communities.

Individuals responsible for carrying out research within their diverse communities experience a critical need for research ethics training materials that align with community values. To improve the capacity to meet local human subject protections, we created the research Ethics Training for Health in Indigenous Communities (rETHICS), a training curriculum aligned within American Indian and Alaska Native (AI/AN) context, culture, and community-level ethical values and principles. Beginning with the Belmont Report and the Common Rule that defines research with human subjects (46 CFR 45), the authors convened three different expert panels (N = 37) to identify Indigenous research values and principles common across tribal communities. The resulting culturally grounded curriculum was then tested with 48 AI/AN individuals, 39 who also had recorded debriefing interviews. Using a thematic analysis, we coded the qualitative feedback from the expert panel discussions and the participant debriefings to assess content validity. Participants identified five foundational constructs needed to ensure cultural-grounding of the AI/AN-specific research training curriculum. These included ensuring that the module was: (a) framed within an AI/AN historical context; (b) reflected Indigenous moral values; (c) specifically linked AI/AN cultural considerations to ethical procedures; (d) contributed to a growing Indigenous ethics; and (e) provided Indigenous-based ethics tools for decision making. Using community-based consultation and feedback from participants led to a culturally grounded training curriculum that teaches research ethical principles and procedures for conducting research with AI/ANs. The curriculum is available for free and the community-based process used can be adapted for other cultural groups.

El idioma inglés como lengua de la medicina / English as the language of medicine

No disponible

Ethical Dilemmas in Neonatology - Four Theoretical Cases and Three Monotheistic Approaches: A Pilot Study.

BACKGROUND: Israel's population is diverse, with people of different religions, many of whom seek spiritual guidance during ethical dilemmas. It is paramount for healthcare providers to be familiar with different religious approaches. OBJECTIVES: To describe the attitudes of the three major monotheistic religions when encountering four complex neonatal situations. METHODS: A questionnaire related to four simulated cases was presented to each participant: a non-viable extremely premature infant (case 1), a severely asphyxiated term infant with extensive brain damage (case 2), a small preterm infant with severe brain hemorrhage and likely extensive brain damage (case 3), and a term infant with trisomy 21 syndrome and a severe cardiac malformation (case 4). RESULTS: Major differences among the three religious opinions were found in the definition of viability and in the approach towards quality of life. CONCLUSIONS: Neonatologists must be sensitive to culture and religion when dealing with major ethical issues in the neonatal intensive care unit.

Empathy and cultural competence in clinical nurses: A structural equation modelling approach.

BACKGROUND: Forgiveness has the potential to resolve painful feelings arising from nurse-patient conflicts. It would be useful to evaluate direct and indirect important factors which are related to forgiveness in order to design interventions that try to facilitate forgiveness. AIM/OBJECTIVE: The purpose of this study was to evaluate the intermediating role of empathy in the cultural competence-forgiveness association among nurses using structural equation modeling. RESEARCH DESIGN: The research applied a cross-sectional correlational design. PARTICIPANTS AND RESEARCH CONTEXT: The study included 380 nurses eight hospitals in southern Iran. ETHICAL CONSIDERATIONS: The Ethics and Research Committee of Birjand University of Medical Sciences approved the study protocol. The voluntary nature of participation was explained consent was obtained from participants, and anonymity was guaranteed. FINDINGS: Most of the participants were married and female and fell in the 20- to 30-year-old category. Most of them (89.5%) had a working experience of 1-10 years. The proposed model showed that nurses' empathy intermediated the association between nurses' cultural competence and forgiveness which has fitted the data acceptably (root mean square error approximation = 0.070; comparative fit index = 0.993; goodness-of-fit index = 0.983; and χ2/df = 2.85). CONCLUSION: Empathy skills and cultural competence training were essential for interventions aimed at increasing the tendency to forgive patients. In such interventions, planners should aim at increasing nurses' cultural competence in order to enhance their empathy toward patients, which can, in turn, lead to a greater wish to forgive patients.

Spanish Language Concordance in U.S. Medical Care: A Multifaceted Challenge and Call to Action.

Patient-physician language discordance within the growing Spanish-speaking patient population in the United States presents a significant challenge for health systems. The Civil Rights Act, an Executive Order, and federal standards establish legal requirements regarding patients' legal right to access medical care in their language of origin and to culturally and linguistically appropriate services, and national competency standards for undergraduate and graduate medical education and licensing examinations support the importance of patient-physician communication. However, no requirements or guidelines currently exist for medical Spanish educational resources, and there is no standardized process to assess the competency of medical students and physicians who use Spanish in patient care. Relatedly, existing data regarding current medical Spanish educational resources are limited, and Spanish proficiency evaluations are often based on self-assessments. Future efforts should use a multifaceted approach to address this complex challenge. A standardized process for Spanish-language-concordant medical care education and quality assurance should incorporate the validation of medical Spanish educational resources, competency requirements for medical usage of Spanish, an incentivized certification process for physicians who achieve medical Spanish competency, and health system updates that include routine collection of language concordance data and designation of Hispanic-serving health centers.

Ethical learning on international medical electives: a case-based analysis of medical student learning experiences.

BACKGROUND: Students on international medical electives face complex ethical issues when undertaking clinical work. The variety of elective destinations and the culturally specific nature of clinical ethical issues suggest that pre-elective preparation could be supplemented by in-elective support. METHODS: An online, asynchronous, case-based discussion was piloted to support ethical learning on medical student electives. We developed six scenarios from elective diaries to stimulate peer-facilitated discussions during electives. We evaluated the transcripts to assess whether transformative, experiential learning took place, assessing specifically for indications that 1) critical reflection, 2) reflective action and 3) reflective learning were taking place. We also completed a qualitative thematic content analysis of the discussions. RESULTS: Of forty-one extended comments, nine responses showed evidence of transformative learning (Mezirow stage three). The thematic analysis identified five themes: adopting a position on ethical issues without overt analysis; presenting issues in terms of their effects on students' ability to complete tasks; describing local contexts and colleagues as "other"; difficulty navigating between individual and structural issues, and overestimation of the impact of individual action on structures and processes. CONCLUSION: Results suggest a need to: frame ethical learning on elective so that it builds on earlier ethical programmes in the curriculum, and encourages students to adopt structured approaches to complex ethical issues including cross-cultural negotiation and to enhance global health training within the curriculum.

From Paternalistic to Patronizing: How Cultural Competence Can Be Ethically Problematic.

Cultural competence literature and training aim to equip healthcare workers to better understand patients of different cultures and value systems, in an effort to ensure effective and equitable healthcare services for diverse patient populations. However, without nuanced awareness and contextual knowledge, the values embedded within cultural competence practice may cripple rather than empower the very people they mean to respect. A narrow cultural view can lessen cultural understanding rather than grow it. In its first part, this paper argues that a hasty, unrestrained, and uneducated willingness to accept something as a cultural good, despite being well intentioned, can still cause significant harms-particularly when based on false, misinformed, and stereotypical conceptions-including the minimization of issues, the reinforcement of stereotypes, and the impediment of cultural change. The second part of this paper examines medical autonomy within the context of Saudi Arabian women. It pushes back on the common perception that Saudi women, by virtue of culture and religion, view dependency on and deference to male relatives as a cultural good. Through a historical examination and a presentation of the current women's movement in Saudi Arabia, it is argued that the continued assumption that personal agency is a value external to Saudi women is false, misguided, and ethically problematic. Lastly, this paper considers some approaches to help providers navigate the narrow grounds between paternalism and patronization when caring for patients.

Does Doctor Know Best? Cultural competence is patient-centered care.

[Full article available at http://rimed.org/rimedicaljournal-2017-10.asp].