Euthanasia and End-of-Life Decisions: From the Empirical Turn to Moral Intuitionism.

Most medical learned societies have endorsed both "equivalence" between all forms of withholding or withdrawing treatment and the "discontinuity" between euthanasia and practices to withhold or withdraw treatment. While the latter are morally acceptable insofar as they consist in letting the patient die, the former constitutes an illegitimate act of actively interfering with a patient's life. The moral distinction between killing and letting die has been hotly debated both conceptually and empirically, most notably by experimental philosophers, with inconclusive results. This article employs a "revisionary" intuititionist perspective to discuss the results of a clinical ethics study about intensivists' perceptions of withhold or withdraw decisions. The results show that practitioners' moral experience is at odds with both the discontinuity and equivalence theses. This outcome allows us to revisit certain concepts, such as intention and causal relationship, that are prominent in the conceptual debate. Intensivists also regard end-of-life decisions as being on a scale from least to most active, and whether they regard active forms of end-of-life decisions as ethically acceptable depends on the overarching professional values they endorse: the patient's best chances of survival, or the patient's quality of life.

Decision-Making for Hospitalized Incarcerated Patients Lacking Decisional Capacity.

Importance: Incarcerated patients admitted to the hospital face threats to their rights to privacy and self-determination in medical decision-making. Little is known about medical decision-making processes for hospitalized incarcerated persons who lack decisional capacity. Objective: To characterize the prevalence of incapacity among hospitalized incarcerated patients and describe the decision-making processes, including who served as surrogate decision-makers, involvement of prison employees in medical decisions, and ethical concerns emerging from the patients' care. Design, Setting, and Participants: Retrospective descriptive and qualitative study of medical records for all patients admitted from prison for at least 24 hours between January 1, 1999, and September 1, 2019, at a large Midwestern academic medical center. Data analysis was performed from March 15, 2021, to December 14, 2022. Main Outcomes and Measures: Prevalence of prison-to-hospital admissions for patients with a loss of capacity and characteristics of medical decision-making. Results: During the 20-year study period, 462 patients from the prison were admitted to the hospital, totaling 967 unique admissions. Of these, 131 admissions (14%) involved patients with a loss of capacity and 43 admissions (4%, representing 34 unique patients) required surrogate decision-making. Ten of these patients had advance directives. Surrogate decision-makers often faced decisions about end-of-life care (n = 17) or procedural consent (n = 23). A family member was identified as surrogate decision-maker in 23 admissions. In 6 cases with a kindred surrogate, additional consent was requested from a prison employee. In total, prison employees were documented as being present during or participating in major medical decisions for half of the admissions. Five themes emerged from thematic analysis: uncertainty and misinformation about patient rights and the role of prison employees in medical decision-making with respect to these two themes, privacy violations, deference to prison officials, and estrangement from family and friends outside of the prison. Conclusions and Relevance: In this first in-depth description, to date, of decision-making practices for hospitalized incarcerated patients lacking decisional capacity, admissions of these patients generated uncertainty about their rights, sometimes infringing on patients' privacy and autonomy. Clinicians will encounter incarcerated patients in both hospital and clinic settings and should receive education on how to support ethically and legally sound decision-making practices for this medically vulnerable population.

The Right to Be Childfree.

In this manuscript, we start with a real life account of an Ob/Gyn experience with a young patient from the childfree movement requesting permanent sterilization. A narrative ethics approach invites the reader to experience the encounter in an immersive way for this growing issue. This approach allows readers to reflect on their reaction to the patient and consider how that can affect other patient encounters. Additionally, it explores the stigma these young patients encounter making a permanent decision to never have children. In the commentary, we explore the ethical issues in this case including why we question the permanent decision to refrain from having children. We also discuss informed consent and patient education along with the various approaches to physician-patient relationships with an emphasis on shared decision making, which allows space for both patient and physician to question and reason through their health decisions.

What Do We Owe to Patients Who Leave Against Medical Advice? The Ethics of AMA Discharges.

Discharges against medical advice (AMA) make up a significant number of hospital discharges in the United States, and often involve vulnerable patients who struggle to obtain adequate medical care. Unfortunately, much of the AMA discharge process focuses on absolving the medical center of liability for what happens to these patients once they leave the acute setting. Comparatively little attention is paid to the ethical obligations of the medical team once an informed decision to leave the acute care setting AMA has been made. Via a case narrative, we offer an ethical framework that we believe can help guide an ethically defensible AMA discharge process. By emphasizing our duty to provide the best care possible under the circumstances, we contend, our ethical obligations to promote the patient's best interests can still be met despite their decision to leave the acute setting against medical advice.

Considerações éticas relacionadas às condutas terapêuticas de pacientes terminais / Ethical considerations related to the therapeutic management of terminally ill patients / Consideraciones éticas relacionadas con la conducta terapéutica de los pacientes terminales

Objetivo: Conhecer as considerações éticas relacionadas às condutas terapêuticas das equipes de saúde frente aos pacientes terminais. Metodologia: Trata-se de um estudo exploratório de natureza qualitativa. Realizado no período de dezembro de 2020, através do acesso ao Banco de Teses e Dissertações da CAPES, considerando que este, coordena o Sistema de Pós-graduação brasileiro. Resultados: Foram identificadas seis classes semânticas, de modo que a mesma formulou a seguinte distribuição de contextos temáticos: Classe 1 Paciente terminal; Classe 2 Condutas médicas; Classe 3 Manejo terapêutico; Classe 4 Protocolos clínicos e aspectos metodológicos dos estudos; Classe 5 Dependências metodológicas e Classe 6 Suporte clínico na terminalidade Dependências metodológicas. Discussão: A morte e a vida tornam-se um impasse enfrentado pelos profissionais de saúde, pois existem fatores decisivos na vida de cada paciente em situação terminal com nenhuma esperança de cura, envolvendo assim questões éticas. Conclusão: Portanto, torna-se necessário que as instâncias de saúde assegurem protocolos, treinamentos e aporte psicológicos para esses profissionais que atuam diretamente com pacientes em situações terminais de vida, para que possa haver uma ressignificação do processo de cuidado com pacientes e segurança na tomada de decisões por parte dos profissionais de saúde, e assim possa preservar a ética.

Objective: To know the ethical considerations related to the therapeutic behavior of health teams towards terminal patients. Methodology: This is an exploratory study of a qualitative nature. Carried out in January 2020, through access to the CAPES Theses and Dissertations Bank, considering that it coordinates the Brazilian Postgraduate System. Results: Six semantic classes were identified, so that it formulated the following distribution of thematic contexts: Class 1 Terminal patient; Class 2 Medical conducts; Class 3 Therapeutic management; Class 4 Clinical protocols and methodological aspects of the studies; Class 5 Methodological dependencies and Class 6 Clinical support in terminality Methodological dependencies. Discusson: Death and life become an impasse faced by health professionals, as decisive there are factors in the life of each patient in a terminal situation with no hope of cure, thus involving ethical issues. Conclusion: Therefore, it is necessary that health institutions ensure protocols, training and psychological support for these professionals who work directly with patients in terminal situations, so that there can be a new meaning for the process of patient care and safety in decision-making by health professionals, and thus can preserve ethics.

Objetivo: Conocer las consideraciones éticas relacionadas con las conductas terapéuticas de los equipos de salud frente a los pacientes terminales. Metodología: Se trata de un estudio exploratorio de carácter cualitativo. Realizado en el período de diciembre de 2020, a través del acceso al Banco de Tesis y Disertaciones de la CAPES, considerando que este, coordina el Sistema de Pós-graduación brasileño. Resultados: Se identificaron seis clases semánticas, por lo que se formuló la siguiente distribución de contextos temáticos: Clase 1 Paciente terminal; Clase 2 Conductas médicas; Clase 3 Manejo terapéutico; Clase 4 Protocolos clínicos y aspectos metodológicos de los estudios; Clase 5 Dependencias metodológicas y Clase 6 Apoyo clínico en la terminalidad Dependencias metodológicas. Discusión: La muerte y la vida se convierten en un impasse al que se enfrentan los profesionales de la salud, porque hay factores decisivos en la vida de cada paciente en situación terminal sin esperanza de curación, lo que implica cuestiones éticas. Conclusión: Por lo tanto, se hace necesario que las instancias de salud garanticen protocolos, capacitación y apoyo psicológico para estos profesionales que trabajan directamente con los pacientes en situaciones de vida terminal, para que pueda haber una resignificación del proceso de atención al paciente y seguridad en la toma de decisiones por parte de los profesionales de la salud, y así poder preservar la ética.

A theoretical framework for ethical decision-making during public health emergencies / Un marco teórico para la toma de decisiones éticas durante emergencias de salud pública / Um referencial teórico para tomada de decisão ética durante emergências de saúde pública

Abstract: The new theoretical ethical framework is a general frame or tool for ethical agents, developed to guide ethical reasoning during public health emergency preparedness and response. The TEF is based on the assumption that no existing ethical discourse in medical ethics alone is sufficient to address ethical issues of a PHE. The solutions suggested by existing approaches are limited in practicability and effectiveness, because they cannot address root problems and interplay among ethical problems. The reason for this insufficiency rests on the argument that ethical problems of PHEs have causal and reciprocal relationships, and any ethical decision-making framework should provide a wide enough perspective to consider relevant ethical norms and theories to suggest practical, implementable, coherent solutions compatible with the communal values and cultural norms. The TEF we suggest for PHEs embraces a holistic and integrated ethical perspective that enables us to comprehend that ethical problems that arise in various settings caused by PHE phenomena are in relationship with each other instead of addressing them as a standalone problem. The TEF provides decision-makers to achieve a coherent web of considered judgements compatible with ethical values and principles in various settings. This type of conceptualization offers a wide perspective to see causal and relational relationships among problems and produce outcomes that would not be possible by eclectic approaches.

Resumen: El nuevo Marco Ético Teórico (MET) es una estructura general o herramienta para eticistas, desarrollada para guiar el razonamiento ético durante la preparación y respuesta a emergencias de salud pública (ESP). Supone que no existe un discurso ético en la ética médica que por sí solo sea suficiente para abordar temas éticos de ESP. Las soluciones sugeridas de aproximaciones existentes son limitadas en la práctica y en la efectividad, debido a que no pueden abordar problemas de raíz sin considerar las interacciones entre los problemas éticos. Esta insuficiencia es porque los problemas éticos de ESP tiene relaciones causales y recíprocas, y cualquier estructura de toma de decisiones éticas debería proporcionar una perspectiva suficientemente amplia como para considerar normas éticas y teorías relevantes, y sugerir soluciones prácticas que sean coherentes y compatibles con valores comunes y normas culturales. El MET que sugerimos para ESP abarca una perspectiva ética integral e integrada, que posibilita la comprensión de que los problemas éticos que surgen en varías situaciones causadas por fenómenos ESP se hallan en relación entre ellos, en vez de abordarlos como un problema aislado. El MET proporciona a los que toman decisiones el lograr una red coherente de juicios compatibles con los valores y principios éticos en varias situaciones. Este tipo de conceptualización ofrece una amplia perspectiva para ver relaciones causales y relacionales entre problemas y producir resultados que no serían posibles mediante aproximaciones eclécticas.

Resumo: O novo referencial ético teórico (NT: TEF, sigla em inglês) é um referencial geral ou instrumento para agentes éticos, desenvolvido para guiar o raciocínio ético durante o preparo e resposta a emergências de saúde pública (NT: PHE, sigla em inglês). O TEF é baseado na suposição de que nenhum discurso ético existente em ética médica sozinho é suficiente para abordar aspectos éticos de uma PHE. As soluções sugeridas pelas abordagens existentes são limitadas em praticabilidade e efetividade, porque elas não podem abordar problemas fundamentais e inter-relacionar problemas éticos. A razão para essa insuficiência repousa no argumento de que problemas éticos de PHEs têm relações causais e recíprocas, e qualquer referencial para tomada de decisão ética deve propiciar uma perspectiva ampla o suficiente para considerar normas e teorias éticas relevantes para sugerir soluções práticas, implementáveis e coerentes, compatíveis com valores comunitários e normas culturais. A TEF que sugerimos para PHEs abarca uma perspectiva ética holística e integrada que nos permite compreender que os problemas éticos que surgem em diversos ambientes causados pelo fenômeno da PHE estão em relação entre si, ao invés de abordá-los como um problema isolado. O TFE propicia a tomadores de decisões alcançar uma rede de julgamentos considerados compatíveis com valores e princípios éticos em ambientes diversos. Esse tipo de conceitualização oferece uma perspectiva ampla para observar relações causais e relacionais entre problemas e produzir desfechos que não seriam possíveis por abordagens ecléticas.

El efecto de las oportunidades en la salud / The effect of opportunity on health

Decidir por una u otra oportunidad tiene consecuencias frente a la salud. La realidad se torna caprichosa cuando lo que tenemos que hacer es tomar una decisión sobre la oportunidad que seleccionamos. Las decisiones relacionadas con nuestro desempeño ocupacional van a repercutir directamente sobre nuestra salud a corto, medio o largo plazo. ¿En que momento somos conscientes que hemos seleccionado la mejor de todas las oportunidades? (AU)

Deciding for one or another opportunity has consequences for health. Reality becomes capricious when what we have to do is make a decision about which opportunity we select. Decisions related to our occupational performance will have a direct impact on our health, in the short, medium or long term. At what point are we aware that we have selected the best of all opportunities?(AU)

Cuidados terminais: reflexão filosófica sob a ótica da ética e da moral / Cuidados terminales: reflexión filosófica desde la perspectiva de la ética y la moral / Terminal care: philosophical reflection from ethical and moral perspectives

RESUMO Objetivo Objetivou-se refletir sobre a prática assistencial do cuidado ao paciente com doença terminal sob a ótica da ética e da moral. Método Trata-se de estudo teórico-reflexivo realizado a partir da análise crítica de textos filosóficos sobre ética e moral no contexto do desenvolvimento moral humano e das práticas de saúde. Resultados Na época dos filósofos gregos, a ética se baseava na busca pela felicidade; contudo, com o advento do cristianismo, ela passou a ser vista como um dever. Pela ótica de Kant, a ética e a moral são também um dever, um imperativo categórico, e a questão da manutenção da vida deve ser perseguida, abrindo espaço para a ocorrência de práticas de distanásia. Já para Hans Jonas, o dever dos profissionais de saúde é considerar a qualidade de vida dos pacientes mais do que da quantidade de vida, introduzindo conceitos dos cuidados paliativos. Conclusão e implicações para a prática Tais conceitos se modificaram ao longo da história, sendo necessário conhecê-los, fazer uma reflexão crítica sobre a finitude humana e repensar as condutas nesse processo.

RESUMEN Objetivo El objetivo fue reflexionar sobre la práctica del cuidado al paciente con enfermedad terminal desde una perspectiva de la ética y la moral. Método Se trata de un estudio teórico-reflexivo, basado en el análisis crítico de textos filosóficos sobre ética y moral en el contexto del desarrollo moral humano y las prácticas de salud. Resultados La ética, en la época de los filósofos griegos, se basaba en la búsqueda de la felicidad, sin embargo, con el advenimiento del cristianismo, ésta pasó a ser vista como un deber. Desde el punto de vista de Kant, la ética y la moral también son un deber, un imperativo categórico y la cuestión del mantenimiento de la vida debe ser perseguida, abriendo espacio para la ocurrencia de prácticas distanásicas. Para Hans Jonas, el deber de los profesionales de la salud es considerar la calidad de vida de los pacientes por encima de la cantidad de vida, introduciendo conceptos de cuidados paliativos. Conclusión e implicaciones para la práctica Tales conceptos han cambiado con la historia, requiriendo conocimiento y reflexión crítica sobre la finitud humana y repensar el comportamiento en este proceso.

ABSTRACT Objective To reflect on the care practice for patients with a terminal illness from ethical and moral perspectives. Method This is a theoretical-reflective study carried out from the critical analysis of philosophical texts on ethics and morals in the context of human moral development and health practices. Results At the time of Greek philosophers, ethics was based on the search for happiness. However, with the advent of Christianity, this came to be seen as a duty. According to Kant, ethics and morals are duties as well — a categorical imperative — and the life maintenance issue must be pursued, opening space for the occurrence of dysthanasia practices. From Hans Jonas' point of view, otherwise, health professionals must consider the quality of life of the patient over their life span, introducing concepts of palliative care. Conclusion and implications for the practice The above-mentioned concepts changed over time, and knowing them is necessary for critically reflecting on human finitude and rethinking practices that revolve around this process.

Trust and shared decision-making among individuals with multiple myeloma: A qualitative study.

BACKGROUND: Multiple myeloma (MM) is an incurable cancer with complex treatment options. Trusting patient-clinician relationships are essential to promote effective shared decision-making that aligns best clinical practices with patient values and preferences. This study sought to shed light on the development of trust between MM patients and clinicians. METHODS: Nineteen individual semi-structured interviews were conducted with MM patients within 2 years of initial diagnosis or relapse for this qualitative study. Interviews were recorded and transcripts were coded thematically. RESULTS: We identified three main themes: (1) externally validated trust describes patients' predisposition to trust or distrust clinicians based on factors outside of patient-clinician interactions; (2) internally validated trust describes how patients develop trust based on interactions with specific clinicians. Internally validated trust is driven primarily by clinician communication practices that demonstrate competence, responsiveness, listening, honesty, and empathy; and (3) trust in relation to shared decision-making describes how patients relate the feeling of trust, or lack thereof, to the process of shared decision-making. CONCLUSION: Many factors contribute to the development of trust between MM patients and clinicians. While some are outside of clinicians' control, others derive from clinician behaviors and interpersonal communication skills. These findings suggest the possibility that trust can be enhanced through communication training or shared decision-making tools that emphasize relational communication. Given the important role trust plays in shared decision-making, clinicians working with MM patients should prioritize establishing positive, trusting relationships.

Do-not-resuscitate order in COVID-19 times: bioethics and professional ethics.

OBJECTIVE: To reflect about the do-not-resuscitation order at COVID-19 in Brazil, under bioethical focus and medical and nursing professional ethics. METHOD: Reflection study based on the principlist bioethics of Beauchamps and Childress and in professional ethics, problematizing actions, and decisions of non-resuscitation in the pandemic. RESULTS: It is important to consider the patient's clinic, appropriation of treatment goals for people with comorbidities, elderly people, with less chance of surviving to resuscitation, or less quality of life, with the palliative care team, to avoid dysthanasia, use of scarce resources and greater exposure of professionals to contamination. CONCLUSION: COVID-19 increased the vulnerabilities of professionals and patients, impacting professional decisions and conduct more widely than important values ​​such as the restriction of freedom. It propelled the population in general to rethink ethical and bioethical values ​​regarding life and death, interfering in decisions about them, supported by human dignity.