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Philos Ethics Humanit Med ; 15(1): 7, 2020 09 09.
Artigo em Inglês | MEDLINE | ID: mdl-32900388


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.

Betacoronavirus , Infecções por Coronavirus , Obrigações Morais , Pandemias , Médicos/ética , Pneumonia Viral , Recusa do Médico a Tratar/ética , Bangladesh , Humanos , Autonomia Profissional
Rev. esp. med. legal ; 46(3): 119-126, jul.-sept. 2020.
Artigo em Espanhol | IBECS | ID: ibc-192313


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

Humanos , Valor da Vida , Administração dos Cuidados ao Paciente/legislação & jurisprudência , Seleção de Pacientes/ética , Infecções por Coronavirus , Cuidados Paliativos na Terminalidade da Vida/ética , Cuidados para Prolongar a Vida/ética , Pandemias/legislação & jurisprudência , Tomada de Decisões/ética , Temas Bioéticos , Revisão da Utilização de Recursos de Saúde/legislação & jurisprudência , Alocação de Recursos/legislação & jurisprudência , Recusa do Médico a Tratar/ética , Recusa do Médico a Tratar/legislação & jurisprudência
Pediatrics ; 146(Suppl 1): S54-S59, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32737233


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.

Temas Bioéticos , Futilidade Médica/ética , Transferência de Pacientes/ética , Suspensão de Tratamento/ética , Dissidências e Disputas , História do Século XXI , Humanos , Internacionalidade , Malformações Arteriovenosas Intracranianas/terapia , Itália , Masculino , Futilidade Médica/legislação & jurisprudência , Turismo Médico/ética , Turismo Médico/legislação & jurisprudência , Pais , Transferência de Pacientes/legislação & jurisprudência , Recusa do Médico a Tratar/ética , Recusa do Médico a Tratar/legislação & jurisprudência , Texas , Traqueostomia/ética , Traqueostomia/legislação & jurisprudência , Reino Unido , Estados Unidos , Suspensão de Tratamento/legislação & jurisprudência
Cuad. bioét ; 31(102): 223-229, mayo-ago. 2020.
Artigo em Espanhol | IBECS | ID: ibc-194279


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

Humanos , Idoso , Instituição de Longa Permanência para Idosos/organização & administração , Direitos dos Idosos/legislação & jurisprudência , Pandemias/ética , Infecções por Coronavirus/epidemiologia , Recusa do Médico a Tratar/ética , Prioridades em Saúde/ética , Capacidade de Resposta ante Emergências/ética
Cuad. bioét ; 31(102): 231-243, mayo-ago. 2020.
Artigo em Espanhol | IBECS | ID: ibc-194280


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

Humanos , Idoso , Instituição de Longa Permanência para Idosos/organização & administração , Direitos dos Idosos/legislação & jurisprudência , Pandemias/ética , Infecções por Coronavirus/epidemiologia , Temas Bioéticos , Recusa do Médico a Tratar/ética , Prioridades em Saúde/ética , Capacidade de Resposta ante Emergências/ética , Ageismo/ética
J Clin Ethics ; 31(2): 146-153, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32585659


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.

Aborto Induzido , Consciência , Recusa do Médico a Tratar , Assistência à Saúde , Feminino , Pessoal de Saúde , Humanos , Masculino , Gravidez , Recusa do Médico a Tratar/ética , Recusa do Médico a Tratar/legislação & jurisprudência , Suicídio Assistido/ética
Anaesth Crit Care Pain Med ; 39(3): 333-339, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32426441


BACKGROUND: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources. RATIONALE: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients. PRIORITISATION STRATEGY: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount. PERSPECTIVE: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.

Betacoronavirus , Infecções por Coronavirus/terapia , Cuidados Críticos/organização & administração , Estado Terminal , Prioridades em Saúde/normas , Recursos em Saúde/provisão & distribução , Unidades de Terapia Intensiva/organização & administração , Pandemias , Pneumonia Viral/terapia , Triagem/normas , Canadá , Cuidadores , Continuidade da Assistência ao Paciente/organização & administração , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/ética , Cuidados Críticos/normas , França/epidemiologia , Pessoal de Saúde , Prioridades em Saúde/ética , Acesso aos Serviços de Saúde/ética , Humanos , Unidades de Terapia Intensiva/provisão & distribução , Transferência de Pacientes , Pneumonia Viral/epidemiologia , Guias de Prática Clínica como Assunto , Recusa do Médico a Tratar/ética , Alocação de Recursos/ética , Justiça Social , Suíça , Triagem/ética , Triagem/organização & administração
BMC Med Ethics ; 21(1): 5, 2020 01 10.
Artigo em Inglês | MEDLINE | ID: mdl-31924198


BACKGROUND: Ritual circumcision of infant boys is controversial in Norway, as in many other countries. The procedure became a part of Norwegian public health services in 2015. A new law opened for conscientious objection to the procedure. We have studied physicians' refusals to perform ritual circumcision as an issue of professional ethics. METHOD: Qualitative interview study with 10 urologists who refused to perform ritual circumcision from six Norwegian public hospitals. Interviews were recorded and transcribed, then analysed with systematic text condensation, a qualitative analysis framework. RESULTS: The physicians are unanimous in grounding their opposition to the procedure in professional standards and norms, based on fundamental tenets of professional ethics. While there is homogeneity in the group when it comes to this reasoning, there are significant variations as to how deeply the matter touches the urologists on a personal level. About half of them connect their stance to their personal integrity, and state that performing the procedure would go against their conscience and lead to pangs of conscience. CONCLUSIONS: It is argued that professional moral norms sometimes might become more or less 'integrated' in the professional's core moral values and moral identity. If this is the case, then the distinction between conscience-based and professional refusals to certain healthcare services cannot be drawn as sharply as it has been.

Comportamento Ritualístico , Circuncisão Masculina/ética , Médicos/ética , Padrões de Prática Médica/ética , Recusa do Médico a Tratar/ética , Ética Profissional , Hospitais Públicos , Humanos , Recém-Nascido , Masculino , Noruega , Pesquisa Qualitativa
J Relig Health ; 59(2): 639-650, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31925633


Conscientious objection remains a very heated topic with strong opinions arguing for and against its utilization in contemporary health care. This paper summarizes and analyzes various arguments in the bioethical literature, favoring and opposing conscientious objection, as well as some of the proposed solutions and compromises. I then present a paradigm shifting compromise approach that arises out of very recent Jewish bioethical thought that refocuses the discussion and can minimize the frequency with which conscientious objection is required.

Temas Bioéticos , Consciência , Assistência à Saúde/ética , Pessoal de Saúde/psicologia , Recusa do Médico a Tratar/ética , Bioética , Dissidências e Disputas , Humanos
Int J Gynaecol Obstet ; 148(1): 127-132, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31677270


This article celebrates the remarkable changes which have occurred in the provision of abortion care in Ireland following the vote to remove the restrictive Eighth Amendment to the Constitution of Ireland in May 2018. However, it also identifies ways in which the emerging legal, ethical and clinical landscape is still impeding the conscientious provision of abortion care. It argues that in order to address these impediments, more attention needs to be paid to the ethical context for conscientious provision. This requires political leadership as well as ongoing leadership by professional bodies to develop both the clinical and the ethical guidance for conscientious provision.

Aborto Legal/ética , Aborto Legal/psicologia , Atitude do Pessoal de Saúde , Feminino , Política de Saúde , Humanos , Irlanda , Masculino , Gravidez , Recusa do Médico a Tratar/ética
Theor Med Bioeth ; 40(6): 539-564, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31797214


A US Department of Health and Human Services Final Rule, Protecting Statutory Conscience Rights in Health Care (2019), and a proposed bill in the British House of Lords, the Conscientious Objection (Medical Activities) Bill (2017), may well warrant a concern that-to borrow a phrase Daniel Callahan applied to self-determination-conscientious objection in health care has "run amok." Insofar as there are no significant constraints or limitations on accommodation, both rules endorse an approach that is aptly designated "conscience absolutism." There are two common strategies to counter conscience absolutism and prevent conscientious objection in medicine from running amok. One, non-toleration, is to decline to accommodate physicians who refuse to provide legal, professionally accepted, clinically appropriate medical services within the scope of their clinical competence. The other, compromise or reasonable accommodation, is to impose constraints on accommodation. Several arguments for non-toleration are critically analyzed, and I argue that none warrants its acceptance. I maintain that non-toleration is an excessively blunt instrument to prevent conscientious objection in medicine from running amok. Instead, I defend a more nuanced contextual approach that includes constraints on accommodation.

Consciência , Recusa do Médico a Tratar/ética , Atitude do Pessoal de Saúde , Humanos , Obrigações Morais , Assistência Centrada no Paciente/ética , Assistência Centrada no Paciente/legislação & jurisprudência , Médicos/ética , Médicos/psicologia , Recusa do Médico a Tratar/legislação & jurisprudência
Theor Med Bioeth ; 40(6): 487-506, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31797215


To inform the ongoing discussion of whether claims of conscientious objection allow medical professionals to refuse to perform tasks that would otherwise be their duty, this paper begins with a review of the philosophical literature that describes conscience as either a moral sense or the dictate of reason. Even though authors have starkly different views on what conscience is, advocates of both approaches agree that conscience should be obeyed and that keeping promises is a conscience-given moral imperative. The paper then considers exemplars of conscientious objection-Henry David Thoreau, Mohandas Gandhi, and Martin Luther King Jr.-to identify the critical feature of conscientious objection as willingness to bear the burdens of one's convictions. It concludes by showing that medical professionals who put their own interests before their patients' welfare violate their previous commitments and misappropriate the title "conscientious objector" because they are unwilling to bear the burdens of their choices and instead impose burdens on their patients and colleagues.

Consciência , Pessoal de Saúde/psicologia , Recusa do Médico a Tratar/ética , Assistência à Saúde/ética , Assistência à Saúde/métodos , Assistência à Saúde/tendências , Pessoal de Saúde/ética , Humanos
Sex., salud soc. (Rio J.) ; (33): 137-157, set.-dez. 2019.
Artigo em Espanhol | LILACS | ID: biblio-1059085


Resumen Este artículo examina el fenómeno de la objeción de conciencia (OC) a los servicios de aborto legal en Argentina, Uruguay y Colombia. Basado en relatos obtenidos a través de entrevistas, el análisis toma distancia de aquellos enfocados en diferenciar entre OC y barreras al servicio, o en identificar si las razones de objeción son verdaderas o válidas. Partiendo del hecho de que en muy pocos casos las/los objetoras/es están al tanto de las definiciones legales de la OC, se busca entender los significados que las/los entrevistadas/os le atribuyeron, y desde los cuales organizan su práctica médica, y justifican su negación a prestar servicios de aborto. En los tres países las/los entrevistadas/os se oponían principalmente a que fueran las mujeres quienes tomaran la decisión de qué embarazos interrumpir, y cómo y cuándo hacerlo. Los discursos contingentes a través de los cuales las/os médicas/os construyen las racionalidades de su OC están hechos, sobre todo, de un incuestionado apego al control de los cuerpos con capacidad de gestar; y de entendidos médico-sociales de las mujeres como inexorablemente madres, máquinas de reproducción o soportes vitales de fetos.

Resumo Este artigo examina o fenômeno da objeção de consciência (OC) nos serviços de aborto legal na Argentina, Uruguai e Colômbia. Com base nas narrativas obtidas por meio de entrevistas, a análise se distancia daquelas focadas na diferenciação entre OC e barreiras ao serviço, ou na interrogação sobre a verdade ou validade das razões para a objeção. Partindo do fato de que, em poucos casos, os objetores conhecem as definições legais da OC, procura-se compreender os significados que as/os entrevistadas/os lhe atribuíram e a partir dos quais organizam a sua prática médica e justificam a sua recusa em prestar serviços de aborto. Em todos os três países, os/as entrevistados/as se opuseram principalmente a que as mulheres decidissem por si mesmas quais gravidezes interromper, como e quando o fazem. Os discursos contingentes através dos quais os/as médicos/as constroem as racionalidades da sua OC são feitos, sobretudo, através de um apego inquestionável ao controle dos corpos capazes de gestação; e de compreensões médico-sociais das mulheres como inexoravelmente mães, máquinas de reprodução ou suportes vitais dos fetos.

Abstract This article examines conscientious objection (CO) to legal abortion services in Argentina, Uruguay and Colombia. Based on interviews, the analysis offers an alternative from studies focusing on differentiating between CO and access barriers, or in identifying if the reasons for the objections are true or valid. Considering the fact that it is only in very few cases that the objectors knew the legal definition of CO, the article seeks to understand the meanings that the interviewees attribute to their objection, how they organize their medical practices and how they justify their denial to provide abortion services. In all three countries, the interviewees' main opposition was to women themselves making the decision to interrupt a pregnancy, and how and when to do it. The contingent and variable discourses through which the doctors construct the logic of their CO are made of an unquestioning attachment to controlling gestating bodies; and a default socio-medical understanding of women as mothers, reproductive machines or as fetal life support systems.

Humanos , Feminino , Gravidez , Médicos , Bioética , Recusa do Médico a Tratar/ética , Aborto Legal , Consciência , Argentina , Uruguai , Atitude do Pessoal de Saúde , Entrevistas como Assunto , Colômbia , Direitos Sexuais e Reprodutivos , Violência contra a Mulher , Narrativa Pessoal , Barreiras ao Acesso aos Cuidados de Saúde , Ginecologia