Search

While there is growing literature on experiences of healthcare workers and those providing unpaid care during COVID-19, little research considers the relationships between paid and unpaid care burdens and contributions. We administered a moral distress survey to healthcare workers in Canada, in 2022, collecting data on both paid and unpaid care. There were no significant differences in the proportion of participants providing unpaid care by gender, with both genders equally affected by certain responsibilities such as reduced contact with family/loved ones. However, men were significantly more distressed about specific unpaid care responsibilities. Unpaid care was not significantly associated with differences in intention to leave work. At work, women were significantly more concerned about patients unable to see family, while men were distressed by others mistreating COVID patients. This study enhances understanding of paid and unpaid care relationships, particularly during crises, and proposes an innovative method for assessing unpaid care burdens., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Smith et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Ethical conflict is embedded in healthcare and is common in critical care setting. However, there is a paucity of research on the nature of ethical conflict in China. Ethical conflict has cultural and context sensitivity. Therefore, evidence is needed from different backgrounds to help discuss this issue across borders., Aim: This study aimed to qualitatively identify the experience of ethical conflict in critical care professionals in China., Study Design: From December 2021 to February 2022, we performed semi-structured, face-to-face interviews with 21 critical care professionals from five intensive care units in a tertiary general hospital in China. A thematic analysis approach was used to analyse the data., Results: Five themes and 14 sub-themes emerged from the data. Critical care professionals probably felt unable to navigate uncertainty, torn by family issues, outraged by unprofessional behaviours of medical staff, being trapped in a socioeconomic dilemma when having experience of ethical conflict. In addition, they also perceived that they could turn struggle into growth., Conclusions: The experience of ethical conflict in critical care professionals involved a mixture of feelings. This study builds a comprehensive understanding of how ethical conflict affected their perceptions of themselves and their profession and provides implications to develop effective coping strategies., Relevance to Clinical Practice: The identification of critical care professionals' experience of ethical conflict would help identify what might trigger the ethical issues and what would be the potential target to optimize in critical practice., (© 2024 British Association of Critical Care Nurses.)

Evidence shows that during birth women frequently experience unconsented care, coercion, and a loss of autonomy. For many countries, this contradicts both the law and medical ethics guidelines, which emphasize that competent and fully informed women's autonomy must always be respected. To better understand this discordance, we empirically describe perinatal maternity care providers' and women's moral deliberation surrounding coercive measures during birth. Data were obtained from 1-on-1 interviews with providers (N = 15) and women (N = 14), and a survey of women (N = 118). Analyses focused on an in-depth exploration of responses to a question on the permissibility of coercion in birth whose wording was borrowed from a Swiss medical-ethical guideline. Reasons for and against a principle permissibility of coercive measures in birth were grouped into clusters of reasons to build a coherent explanatory framework. Factors considered morally relevant when deliberating on coercion included women's decisional capacity, beneficence/non-maleficence, authority through knowledge on the part of providers, flaws of the medical system, or the imperative to protect the most vulnerable. Also, we identified various misconceptions, such as the conviction that a pathological birth can justify coercion or that fetal rights can justifiably infringe on women's autonomy. Information and education on the issue of coercion in birth are urgently needed to enable women to fully exercise their reproductive autonomy, to prevent long-term adverse health outcomes of women and children, and to reconcile the medical vigilance which has lead to a reduction of perinatal morbidity and mortality with women's enfranchisement in their own care., (© 2024. The Author(s).)

A woman's right to a safe legal abortion in South Africa conflicts with a health care professional's freedom of conscience. Conscientious objection or treatment refusal on the basis of conscience may be protected by the constitution but its morality has not been explored. This study uses Kantian Deontology to elucidate the ethical duties of health care professionals based on the Physician's Pledge. It concludes that conscience is morally empty and that health care professionals have a duty to treat all patients equally irrespective of the condition they present. Drawing on Kantian promise keeping, the study also concludes that health care professionals should place patients health and wellbeing above all other considerations. Using the categorical imperative, the study shows that health care professionals have a perfect duty not to refuse treatment. The study recommends that conscientious objection be rejected in all circumstances except where the psychological wellbeing of the health care professional will be affected. This can be achieved through legislative and professional body regulation of conscientious objection., (© 2023 The Authors. Developing World Bioethics published by John Wiley & Sons Ltd.)

Objective: To assess the level of bioethics awareness among healthcare professionals in Pakistan, focusing on the associations with sociodemographic characteristics, training and teaching of ethics, medical ethics practice and specific ethical issues., Design: Cross-sectional study., Setting: Public and private hospitals in Haripur, Pakistan., Participants: A total of 647 healthcare professionals participated in this study., Methods: This study was conducted between March and May 2023, following Strengthening the Reporting of Observational Studies in Epidemiology checklist criterion, involving healthcare professionals with at least 6 months of experience in patient care practice. Providers under close supervision are advised not to respond to the bioethics knowledge, attitudes and practices survey form due to potential ethical dilemmas., Results: Both physicians and non-physicians need to know more about bioethics. There was a significant difference (p<0.05) in ethical training and teaching based on job categories/designations, with ethical views differing greatly by job designation. Specific ethical issues, such as accepting gifts from patients and pharmaceutical companies, referral fees, advising specific products, disclosure of medical errors, patient confidentiality, not informing patients fully about treatment and performing tasks for financial gain, showed significant associations (p<0.05) with healthcare professional's designation. Ethical awareness scores also showed significant differences (p<0.05) based on age, ethnicity, place of posting, professional experience and the organisation's ethical guidelines., Conclusion: This study highlighted a notable gap in the understanding of certain ethical concerns among healthcare professionals, with nurses showing relatively lower awareness of healthcare practice compared with other professionals. Addressing these issues through targeted training and robust ethical guidelines is critical to improving patient care in Pakistan's healthcare system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Health professionals had difficulty choosing the right time to discuss life-sustaining treatments (LSTs) since the Korean Act was passed in 2018., Objective: This study aimed to understand how patients decide to undergo LSTs in clinical practice and to compare the perceptions of these decisions among health professionals, patients, and families with suggestions to support the self-directed decisions of patients., Research Design: A retrospective observational study with electronic medical records (EMRs) and a descriptive survey was used., Methods: The data obtained from the EMRs included all adult patients who died in end-of-life care at a university hospital in 2021. We also conducted a survey of 214 health professionals and 100 patients and their families (CNUH IRB approval no. 2022-07-006)., Results: Based on the EMR data of 916 patients in end-of-life care, 78.4% signed do-not-attempt-resuscitation consents, 5.6% completed the documents for LSTs, and 10.2% completed both forms. LST decisions were mostly made by family members (81.5%). Most survey participants agreed that meaningless LSTs should be suspended, and the decision should be made by patients. Patients and family members (42-56%) and health professionals (56-58%) recommended discussing LST suspension when the patient is still conscious but with predicted deterioration of their condition. The suffering experienced by the patient was considered to be a priority by most patients (58%) and families (54%) during the decision-making process, while health professionals considered "the possibility of the patient's recovery" to be the highest priority (43-55%)., Conclusions: There is still a significant discrepancy in the perceptions of LST decisions among health professionals, patients, and their families despite high awareness of the Act. This situation makes it challenging to implement the Act to ensure respect for the rights of patients to self-determination and dignified end-of-life. Further effort is needed to improve the awareness of LSTs and to clarify the ambiguity of document preparation timing., (© 2024. The Author(s).)

During pandemics, healthcare providers struggle with balancing obligations to self, family, and patients. While HIV/AIDS seemed to settle this issue, coronavirus disease 2019 (COVID-19) rekindled debates regarding treatment refusal. We searched MEDLINE, Embase, CINAHL Complete, and Web of Science using terms including obligation, refusal, HIV/AIDS, COVID-19, and pandemics. After duplicate removal and dual, independent screening, we analyzed 156 articles for quality, ethical position, reasons, and concepts. Diseases in our sample included HIV/AIDS (72.2%), severe acute respiratory syndrome (SARS) (10.2%), COVID-19 (10.2%), Ebola (7.0%), and influenza (7.0%). Most articles (81.9%, n = 128) indicated an obligation to treat. COVID-19 had the highest number of papers indicating ethical acceptability of refusal (60%, P < .001), while HIV had the least (13.3%, P = .026). Several reason domains were significantly different during COVID-19, including unreasonable risks to self/family (26.7%, P < .001) and labor rights/workers' protection (40%, P < .001). A surge in ethics literature during COVID-19 has advocated for permissibility of treatment refusal. Balancing healthcare provision with workforce protection is crucial in effectively responding to a global pandemic., Competing Interests: Potential conflicts of interest. The authors: No reported conflicts of interest. The authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Introduction: Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESSs) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence about mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda., Methods: This phenomenological qualitative study utilized in-depth interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook., Results: The study revealed there was no formal committee or mechanism dedicated to resolving ethical dilemmas at the UCI. Instead, ethical dilemmas were addressed in six forums: individual consultations, tumor board meetings, morbidity and mortality meetings (MMMs), core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas., Conclusion: The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics., (© 2024. The Author(s).)

Background: Previous studies have shown that the rapid transition to emergency remote teaching due to the COVID-19 pandemic was challenging for healthcare teachers in many ways. This sudden change made them face ethical dilemmas that challenged their values and ethical competence., Research Aim: This study aimed to explore and gain a deeper understanding of the ethical dilemmas healthcare teachers faced during the COVID-19 pandemic., Research Design: This was an inductive qualitative study using a hermeneutic approach. Semi-structured interviews were conducted and analysed thematically., Participants and Research Context: Healthcare teachers ( n = 20) from eight universities and universities of applied sciences in the Nordic and Baltic countries participated., Ethical Considerations: This study was based on the research ethics of the Norwegian National Research Ethics Committee for Medicine and Health Sciences and approved by the Norwegian Agency for Shared Services in Education and Research., Findings: Healthcare teachers faced several ethical dilemmas due to restrictions during the COVID-19 pandemic. The analysis revealed three main themes: How should I deal with students' ill-being, and what can I as a teacher do?; What can I demand from myself and my students, what is good teaching?; How do I manage the heavy workload and everyone's needs, and who gets my time?, Conclusions: This study highlights the importance of healthcare teachers' continuous need for pedagogic and didactic education, especially considering new technology and ethical issues. During the pandemic, the ethical consequences of remote teaching became evident. Ethical values and ethical dilemmas should be addressed in healthcare education programmes at different levels, especially in teacher education programmes. In the coming years, remote teaching will grow. Therefore, we need more research on this issue from an ethical perspective on its possible consequences for students and healthcare teachers., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To explore the ethical considerations and measures of quality assurance during data-collection for programme evaluation in health professional education., Methods: The qualitative case study was conducted at Bahria University of Health Sciences, Karachi, from August to November 2023, and comprised faculty members involved in programme evaluation for at least two years having done a minimum two audit cycles. System thinking philosophical framework was used during the data-collection phase. A diverse sample was selected to ensure representation from different sectors and roles within the teams. Data was collected through participant observation, semi-structured interviews and focus group discussions. Data was subjected to thematic analysis., Results: There were 7 faculty members who were interviewed individually twice in addition to 4 focus group discussion. Members of quality assurance team were experts in their respective fields, but were not found to be wellversed in terms of ethical considerations that should guide data-collection. This lack of knowledge may inadvertently lead to ethical lapses in the evaluation process. Another ethical challenge seen was bias in the data-collection phase., Conclusion: Faculty members integral to programme evaluation efforts were found to lack knowledge regarding ethical considerations in data-collection, which can pose significant risks.

Artificial intelligence (AI) has garnered tremendous attention in health care, and many hope that AI can enhance our health system's ability to care for people with chronic and degenerative conditions, including Parkinson's Disease (PD). This paper reports the themes and lessons derived from a qualitative study with people living with PD, family caregivers, and health care providers regarding the ethical dimensions of using AI to monitor, assess, and predict PD symptoms and progression. Thematic analysis identified ethical concerns at four intersecting levels: personal, interpersonal, professional/institutional, and societal levels. Reflecting on potential benefits of predictive algorithms that can continuously collect and process longitudinal data, participants expressed a desire for more timely, ongoing, and accurate information that could enhance management of day-to-day fluctuations and facilitate clinical and personal care as their disease progresses. Nonetheless, they voiced concerns about intersecting ethical questions around evolving illness identities, familial and professional care relationships, privacy, and data ownership/governance. The multi-layer analysis provides a helpful way to understand the ethics of using AI in monitoring and managing PD and other chronic/degenerative conditions.

With the introduction of artificial intelligence (AI) to healthcare, there is also a need for professional guidance to support its use. New (2022) reports from National Health Service AI Lab & Health Education England focus on healthcare workers' understanding and confidence in AI clinical decision support systems (AI-CDDSs), and are concerned with developing trust in, and the trustworthiness of these systems. While they offer guidance to aid developers and purchasers of such systems, they offer little specific guidance for the clinical users who will be required to use them in patient care.This paper argues that clinical, professional and reputational safety will be risked if this deficit of professional guidance for clinical users of AI-CDDSs is not redressed. We argue it is not enough to develop training for clinical users without first establishing professional guidance regarding the rights and expectations of clinical users.We conclude with a call to action for clinical regulators: to unite to draft guidance for users of AI-CDDS that helps manage clinical, professional and reputational risks. We further suggest that this exercise offers an opportunity to address fundamental issues in the use of AI-CDDSs; regarding, for example, the fair burden of responsibility for outcomes., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation., Methods: We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model., Results: We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy., Conclusions: There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID., (© 2024. The Author(s).)

Healthcare practitioners have access to a range of ethical guidance. However, the normative role of this guidance in ethical decision-making is underexplored. This paper considers two ways that healthcare practitioners could approach ethics guidance. We first outline the idea of deference to ethics guidance, showing how an attitude of deference raises three key problems: moral value; moral understanding; and moral error. Drawing on philosophical literature, we then advocate an alternative framing of ethics guidance as a form of moral testimony by colleagues and suggest that a more promising attitude to ethics guidance is to approach it in the spirit of 'critical engagement' rather than deference., (© 2024. The Author(s).)

Civility is an essential feature of health care, as it is in so many other areas of human interaction. The article examines the meaning of civility, reviews its origins, and provides reasons for its moral significance in health care. It describes common types of uncivil behavior by health care professionals, patients, and visitors in hospitals and other health care settings, and it suggests strategies to prevent and respond to uncivil behavior, including institutional codes of conduct and disciplinary procedures. The article concludes that uncivil behavior toward health care professionals, patients, and others subverts the moral goals of health care and is therefore unacceptable. Civility is a basic professional duty that health care professionals should embrace, model, and teach., (© 2022. The Author(s).)

Resistance to acknowledging and curbing cheating should be seen as expressing academic organizations' dereliction of their tacit early career health professional self-regulatory duties. Cheating among students and trainees deserves ethical attention, scrutiny, and self-regulatory responses because cheating behaviors express characterological vices that undermine trust and trustworthiness, which, among other virtues, are key to good stewardship and other duties of health professionals., (Copyright 2024 American Medical Association. All Rights Reserved.)

Background: At the beginning of the coronavirus (Covid-19) pandemic, many non-Covid healthcare services were suspended. In April 2020, the Department of Health in England mandated that non-Covid services should resume, alongside the continuing pandemic response. This 'resetting' of healthcare services created a unique context in which it became critical to consider how ethical considerations did (and should) underpin decisions about integrating infection control measures into routine healthcare practices. We draw on data collected as part of the 'NHS Reset Ethics' project, which explored the everyday ethical challenges of resetting England's NHS maternity and paediatrics services during the pandemic., Methods: Healthcare professionals and members of the public participated in interviews and focus group discussions. The qualitative methods are reported in detail elsewhere. The focus of this article is our use of Frith's symbiotic empirical ethics methodology to work from our empirical findings towards the normative suggestion that clinical ethics should explicitly attend to the importance of relationships in clinical practice. This methodology uses a five-step approach to refine and develop ethical theory based on a naturalist account of ethics that sees practice and theory as symbiotically related., Results: The Reset project data showed that changed working practices caused ethical challenges for healthcare professionals, and that infection prevention and control measures represented harmful barriers to the experience of receiving and offering care. For healthcare professionals, offering care as part of a relational interaction was an ethically important dimension of healthcare delivery., Conclusions: Our findings suggest that foregrounding the importance of relationships across a hospital community will better promote the ethically important multi-directional expression of caring between healthcare professionals, patients, and their families. We offer two suggestions for making progress towards such a relational approach. First, that there is a change of emphasis in clinical ethics practice to explicitly acknowledge the importance of the relationships (including with their healthcare team) within which the patient is held. Second, that organisational decision-making should take into account the moral significance afforded to caring relationships by healthcare professionals, and the role such relationships can play in the negotiation of ethical challenges., (© 2024. The Author(s).)

Competing Interests: Competing interests: None declared.

Introduction: Previous research has explored euthanasia's ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap exists in understanding the comprehensive value-based perspectives of other professionals involved in both somatic and psychiatric euthanasia. This paper aims to analyze the interplay among legal, medical, and ethical factors to clarify how foundational values shape the ethical discourse surrounding euthanasia in both somatic and psychiatric contexts. It seeks to explore these dynamics among all healthcare professionals and volunteers in Belgium., Methods: Semi-structured interviews were conducted with 30 Dutch-speaking healthcare workers who had encountered patients requesting euthanasia for psychiatric conditions, in Belgium, from August 2019 to August 2020. Qualitative thematic analysis was applied to the interview transcripts., Findings: Participants identified three pivotal values and virtues: religious values, professional values, and fundamental medical values encompassing autonomy, beneficence, and non-maleficence, linked to compassion, quality care, and justice. These values interwove across four tiers: the patient, the patient's inner circle, the medical realm, and society at large. Irrespective of their euthanasia stance, participants generally displayed a blend of ethical values across these tiers. Their euthanasia perspective was primarily shaped by value interpretation, significance allocation to key components, and tier weighting. Explicit mention of varying ethical values, potentially indicating distinct stances in favor of or against euthanasia, was infrequent., Conclusion: The study underscores ethical discourse's central role in navigating euthanasia's intricate landscape. Fostering inclusive dialogue, bridging diverse values, supports informed decision-making, nurturing justice, and empathy. Tailored end-of-life healthcare in psychiatry is essential, acknowledging all involved actors' needs. The study calls for interdisciplinary research to comprehensively grasp euthanasia's multifaceted dimensions, and guiding policy evolution. While contextualized in Belgium, the implications extend to the broader euthanasia discourse, suggesting avenues for further inquiry and cross-cultural exploration., (© 2024. The Author(s).)

Background: Professional care workers face ethical issues in long-term care settings (LTCS) for older adults. They need to be independent and responsible, despite limited resources, a shortage of skilled professionals, global and societal changes, and the negative reputation of LTCS work., Research Aim: Our aim was to describe the care workers' lived experiences of ethical issues. The findings can be used to gain new perspectives and to guide decision-making to improve the quality of care, occupational well-being and nursing education., Research Design: Focus group interviews were analyzed using a hermeneutic-phenomenological method. The analysis comprised three steps: naïve reading, structural analysis, and comprehensive understanding., Participants and Research Context: We randomly sampled LTCS service providers in Finland and 53 care workers with different educational backgrounds from seven organizations participated in focus group interviews in 2021., Ethical Considerations: This was a sensitive study, which was connected to the participants' individual views of the world, professional ethics and social and health care legislation. The participants' provided informed consent and their anonymity was guaranteed., Findings: Care workers spoke about their lived experiences of ethical issues in an emotional way, using practical examples. They talked about how they were experts at caring and advocating for residents, balanced the responsibilities of their different roles, and defended their work to the wider society. The care workers said that ethical aspects of their work were too difficult to solve on their own. There were elements of their working environment and practices that caused unnecessary strain and they needed the commitment of managers, organizations, and society to solve ethical issues in LTCS., Conclusions: Ethical issues were related to the well-being of both residents and care workers and reflected both internal and external pressures. Some issues could not be resolved by individuals and needed input from managers, organizations, and society., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This symposium includes twelve personal narratives from those who have received clinical ethics consultation (CEC) services as a healthcare provider, patient, family member, or patient advocate. Three commentaries on these narratives are also included, authored by experts and scholars in bioethics, healthcare ethics consultation and certification, narrative medicine, and policy. The goal of this symposium is to call attention to the experiences of people who have received clinical ethics consultation (CEC) services as a healthcare provider, patient, family member, or patient advocate.

This symposium collection of twelve narratives from individuals who experienced clinical ethics consultations provides perspectives from a group that has not been adequately explored in the bioethics literature. The authors represent a variety of stakeholders who received ethics consultations: healthcare providers and family members. This commentary will focus on three themes addressed in the different narrative accounts: the reasons for requesting an ethics consultation; the expectations of the narrators from the consultation; and the conclusions the authors drew from their experience of the ethics consultation.

This study aimed to explore ethical dilemmas and challenges faced by young mental healthcare researchers and professionals working with survivors of suicide (hereinafter suicide survivors). Two focus group discussions (FGDs) Researcher FGD (with those engaged in suicide research) and Clinician FGD (with those providing treatment to suicide survivors) - consisting of open-ended questions and lasting for 70-90 minutes were conducted and analysed using Thematic Analysis. Five themes were identified: i) struggling with the incongruity of harm within benefit, ii) difficulty in delineating boundaries, iii) self-doubt in one's professional competence, iv) nature of suicide straining the limits of confidentiality, and v) working with structural limitations. The study helps to understand the obstacles and dilemmas encountered in adhering to ethical principles while working with vulnerable individuals.

Abstract: It's usually considered a violation of professional ethics for health care workers, including nurses, to refuse to work during mass medical emergencies, especially if their refusal is over concerns like compensation. Strikes and other forms of work stoppage may result in harm to patients and, therefore, violate professional obligations of beneficence. However, in rare circumstances a health care worker's choice to remain on the job despite risk or potential harm to themselves or even their family may be considered beyond their professional obligation. During a pandemic such as COVID-19, the ethical calculus (that is, finding the right balance between beneficence and harm before deciding on a course of action) must take account of a confluence of factors, including the risks to present patients, future patients, and health care workers; the severity and duration of the risks; and the availability of ameliorative or protective steps that reduce risk and harm. The principle of beneficence to both future patients and health care workers may be thwarted if the risk analysis is confined only to short-term concerns (that is, to concerns occurring within a narrow temporal window). If a significantly elevated risk has been demonstrated to affect nurses and other health care workers of color disproportionately, racial justice must also be considered. The purpose of this article is to assess the moral framework of a work stoppage by nurses during a pandemic., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: Competing interests: none declared

Background: Research is urgently needed to understand health care workers' (HCWs') experiences of moral-ethical dilemmas encountered throughout the COVID-19 pandemic, and their associations with organizational perceptions and personal well-being. This research is important to prevent long-term moral and psychological distress and to ensure that workers can optimally provide health services., Objective: Evaluate associations between workplace experiences during COVID-19, moral distress, and the psychological well-being of Canadian HCWs., Method: A total of 1362 French- and English-speaking Canadian HCWs employed during the COVID-19 pandemic were recruited to participate in an online survey. Participants completed measures reflecting moral distress, perceptions of organizational response to the pandemic, burnout, and symptoms of psychological disorders, including depression, anxiety, and posttraumatic stress disorder (PTSD)., Results: Structural equation modelling showed that when organizational predictors were considered together, resource adequacy, positive work life impact, and ethical work environment negatively predicted severity of moral distress, whereas COVID-19 risk perception positively predicted severity of moral distress. Moral distress also significantly and positively predicted symptoms of depression, anxiety, PTSD, and burnout., Conclusions: Our findings highlight an urgent need for HCW organizations to implement strategies designed to prevent long-term moral and psychological distress within the workplace. Ensuring availability of adequate resources, reducing HCW risk of contracting COVID-19, providing organizational support regarding individual priorities, and upholding ethical considerations are crucial to reducing severity of moral distress in HCWs., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Mark Wicclair's defense of conscientious objection is grounded in an effort to respect the core moral beliefs of health care providers. While such a theoretical schema has merit, this paper argues that core moral beliefs should not serve as the basis of conscientious objection in health care because we, as a community, lack reliable access to a person's core moral beliefs and because individuals are prone to be confused about the scope and extent of their core moral beliefs. Furthermore, a person's confusion over their core moral beliefs is likely to be exacerbated when they lack time to investigate those beliefs and are under heightened external pressure to do so-both conditions frequently encountered by health care providers. Finally, the paper considers whether grounding conscientious objection in core moral beliefs might have the unintended consequence of further entrenching the practical problems that the move is aiming to solve., (© 2020. Springer Nature B.V.)

The literature on conscientious objection in medicine presents two key problems that remain unresolved: (a) Which conscientious objections in medicine are justified, if it is not feasible for individual medical practitioners to conclusively demonstrate the genuineness or reasonableness of their objections ("the justification problem")? (b) How does one respect both medical practitioners' claims of conscience and patients' interests, without leaving practitioners complicit in perceived or actual wrongdoing ("the complicity problem")? My aim in this paper is to offer a new framework for conscientious objections in medicine, which, by bringing medical professionals' conscientious objection into the public realm, solves the justification and complicity problems. In particular, I will argue that: (a) an "Uber Conscientious Objection in Medicine Committee" ("UCOM Committee")-which includes representatives from the medical community and from other professions, as well as from various religions and from the patient population-should assess various well-known conscientious objections in medicine in terms of public reason and decide which conscientious objections should be permitted, without hearing out individual conscientious objectors; (b) medical practitioners should advertise their (UCOM Committee preapproved) conscientious objections, ahead of time, in an online database that would be easily accessible to the public, without being required, in most cases, to refer patients to non-objecting practitioners., (© 2020. Springer Nature B.V.)

Purpose: There is robust research examining the negative impact of racial and socioeconomic implicit bias on healthcare provider clinical decision-making. However, other under-studied important biases are likely to impact clinical care as well. The goal of this study was to explore the presence of bias against people with physical disability among a heterogeneous group of healthcare workers and trainees and to evaluate the effect of implicit association testing and an educational module on this bias., Method: The study was composed of a one-hour web-based survey and educational module. The survey included an explicit disability bias assessment, disability Implicit Association Tests (IATs), demographic collection, and pre- and post- module clinical vignettes of prenatal patient scenarios. In addition to providing counseling to hypothetical patients, participants also indicated their personal preferences on genetic testing and termination. The educational module focused on the principles of patient-centered counseling., Results: The collected data reflects responses from 335 participants. Within this sample, there were both explicit and implicit biases towards individuals with physical disabilities. Prior to the IAT and educational module, when respondents were tasked with providing genetic testing recommendations, implicit biases and personal preferences for genetic testing and termination influenced respondents' clinical recommendations. Importantly, having previous professional experience with individuals with disabilities diminished biased clinical recommendations prior to the intervention. In response to the IAT and educational intervention, the effect of implicit bias and personal preferences on clinical recommendations decreased., Conclusions: This study demonstrates how bias against a marginalized group exists within the medical community and that personal opinions can impact clinical counseling. Importantly, our findings suggest that there are strategies that can be easily implemented into curricula to address disability bias, including formal educational interventions and the addition of professional experiences into healthcare professional training programs., Competing Interests: The authors have declared that no competing interests exist.

Objectives: To investigate the perspectives of doctors involved with voluntary assisted dying in Victoria regarding the Voluntary Assisted Dying Act 2017 (Vic) and its operation., Design, Setting, Participants: Qualitative study; semi-structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation (commenced 19 June 2019). Doctors were interviewed during April-July 2020., Results: Three major themes related to problems during the first year of operation of the Act were identified: the statutory prohibition of health professionals initiating discussions with their patients about voluntary assisted dying; the Department of Health and Human Services guidance requirement that all doctor-patient, doctor-pharmacist, and pharmacist-patient interactions be face-to-face; and aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service., Conclusions: Doctors reported only limited concerns about the Victorian voluntary assisted dying legislation, but have had some problems with its operation, including implications for the accessibility of voluntary assisted dying to eligible patients. While legislative change may resolve some of these concerns, most can be ameliorated by improving the processes and systems., (© 2021 AMPCo Pty Ltd.)

Purpose: Compassion is central to health care. Efforts to promote compassion through educational interventions for health professionals show promise, yet such education has not gained widespread dissemination. Adapting compassion education through technology-enhanced learning may provide an opportunity to enhance the scale and spread of compassion education. However, challenges are inherent in translating such curricula for online delivery. In this study, the authors explored how technology influences the delivery of compassion education for health professionals., Method: Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 13 participants from across Ontario, Canada, from March to October 2019. The sample consisted of individuals who had experience with the design and evaluation of compassion education for health professionals. The interviews were coded and inductively analyzed to identify pertinent themes using constant comparative analysis. The study originated at the Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada., Results: Participants provided a range of responses regarding technology and compassion education. While participants revealed concerns about the constraints of technology on human interaction, they also described technology as both inevitable and necessary for the delivery of future compassionate care curricula. Participants also shared ways in which technology may enhance compassion education for health professionals by increasing accessibility and learner comfort with vulnerability. Addressing technological ambivalence, improving facilitation, and maintaining a balance between face-to-face instruction and technology-enhanced learning were identified as elements that could advance compassion education into the future., Conclusions: Compassion education can be enhanced by technology; however, evidence-informed adaptation may require deliberate efforts to maintain some level of face-to-face interaction to ensure that technology does not erode human connection. Further research is required to address the uncertainties surrounding technology and compassion education as identified by participants. These findings provide educators with guidance for adapting compassionate care curricula into a digital domain., (Copyright © 2021 by the Association of American Medical Colleges.)

In this single centre cohort study we assessed BNT162B2 vaccine uptake and effectiveness among UK healthcare workers (HCWs) during a time of high community COVID-19 prevalence. Early uptake among HCWs was 62.3% (1409/2260), however there were significant differences in uptake between age groups, ethnic origins, and job roles. Uptake increased to 72.9% after a vaccine hesitancy working group implemented specific measures. In the 42 days after vaccination, 49 new cases of COVID-19 were identified, of which 7 (14.3%) occurred in HCWs who were beyond 10 days of vaccination. Kaplan-Meier curves for partially vaccinated and unvaccinated groups were congruent until day 14 and continued to diverge up to 42 days. Cox regression analysis showed a 70.0% (95%CI 6.0-91.0; p=0.04) risk reduction for COVID-19 infection in partially vaccinated HCWs. Here we report early vaccination rates among HCWs are generally high although uptake is lower in certain groups. It is possible to improve vaccine uptake and efforts should focus on this, however, significant resource is required. The BNT162B2 vaccine is effective from 14 days post-vaccination in a frontline clinical setting and protection continues beyond 21 days post 1st dose without a 2nd dose, being given.

Purpose: The overall aim of this study was to describe perceptions of the decision-making process in relation to participation/non-participation in ethics discussions among healthcare professionals in paediatric oncology., Methods: Healthcare professionals, working at three paediatric units where ethics discussions where performed answered a study-specific questionnaire focusing on perceptions of involvement, influence, responsibility and understanding of ethics decision-making. Statistical analyses included descriptive statistics, non-parametric paired t-tests and correlation tests., Results: Participation in ethics discussions was related to perceptions of greater involvement and the possibility of influencing decisions, as well as formal/shared responsibility for the ethics decisions related to patient care. Medical doctors and registered nurses perception of involvement in decisions, possibility to influence and responsibility decreased when they were not present during the ethics discussion or when no ethics discussion was conducted at all. Healthcare professionals had a generally good understanding of the ethical issues and the ethics decisions. The whole group considered medical doctors to be the most important participants in the ethics discussions, followed by patients/family. Healthcare professionals wanted more teamwork and viewed ethics discussions as very helpful for teamwork when dealing with ethical issues in paediatric oncology., Conclusions: Ethics discussions in paediatric oncology practice increases the involvement within and the understanding of the decision-making process about ethical decisions. The understanding is not always dependent on participation, indicating a great trust in team members. Based on these findings the implementation of a structure for ethics support in paediatric oncology where patients/families are integrated is recommended., (Copyright © 2021. Published by Elsevier Ltd.)

The impact of host genomics on an individual's susceptibility, immune response, and risk of severe outcomes for a given infectious pathogen is increasingly recognized. As we uncover the links between host genomics and infectious disease, a number of ethical, legal, and social issues need to be considered when using that information in clinical practice or workforce decisions. We conducted a survey of the clinical staff at 10 federally funded Regional Ebola and Other Special Pathogen Treatment Centers to understand their views regarding the ethical, legal, and social issues related to host genomics and the administrative and clinical functions of high-level isolation units. Respondents overwhelmingly agreed that genomics could provide valuable information to identify patients and employees at higher risk for poor outcomes from highly infectious diseases. However, there was considerable disagreement about whether such data should inform the allocation of scarce resources or determine treatment decisions. While most respondents supported a confidential employer-based genomic testing system to inform individual employees about risk, respondents disagreed about whether such information should be used in staffing models. Respondents who thought genomic information would be valuable for patient treatment were more willing to undergo genetic testing for staffing purposes. Most respondents felt they would benefit from additional training to better interpret results from genetic testing. Although this study was completed before the COVID-19 pandemic, the responses provide a baseline assessment of provider attitudes that can inform policy during the current pandemic and in future infectious disease outbreaks.

Urging the government to exercise a complete border closure to inhibit the spread of the novel coronavirus from Mainland China, about 8,000 health care workers participated in a 5-day strike in early February 2020 in Hong Kong. Despite gaining 61% support from the public, dissenters criticised that the participants violated professional ethics and abandoned their accountabilities, which led to moral distress. However, the participants were guided by the four fundamental medical principles (autonomy, beneficence, non-maleficence, and justice) for public interest and health equity. Their concerns for occupational safety should not be ignored to maintain an effective health care system. In short, the strike adopted a bottom-up initiative and adhered to a public-centered perspective and community-driven ethical behaviors, through which the participants deliberated over professionalism, humanism and the imminence of public health, and the balance between them. Strikers showed care and concern for the safety of the community, sustainability of the health care system, and well-being of all people in Hong Kong., (© 2021 Wiley Periodicals LLC.)

Suicide occurs in people of all ages and backgrounds, which negatively affects families, communities, and the health care providers (HCPs) who care for them. The objective of this study was to better understand HCPs' perspectives of everyday ethical issues related to caring for suicidal patients, and their perceived needs for training and/or support to address these issues. We conducted a mixed methods survey among HCPs working in mental health in Québec, Canada. Survey questions addressed their perspectives and experiences of everyday ethical challenges they encounter in their practice with people who are suicidal, and their perceived needs for training and/or support therein. 477 HCPs completed the survey. Most participants mentioned encountering ethical issues when caring for people who are suicidal. The challenges HCPs encounter in their practice with people who are suicidal are numerous, including issues related to maintaining privacy, confidentiality, freedom and the therapeutic relationship. The lack of time, resources and professional support to address these issues was emphasized. Most HCPs reported that the training or education they have received does not allow them to address everyday ethical issues related to suicide care. In sum, there is a clear reported need for better training and support for HCPs who are offering care to people who are suicidal in relation to everyday ethical issues they encounter. Implications for practice include providing greater access to training, including access to specialists in ethics to address specific issues. This additional support could alleviate morally distressing situations for HCPs., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Moral distress occurs when professionals cannot carry out what they believe to be ethically appropriate actions because of constraints or barriers. We aimed to assess the validity and reliability of the Japanese translation of the Measure of Moral Distress for Healthcare Professionals (MMD-HP)., Methods: We translated the questionnaire into Japanese according to the instructions of EORTC Quality of Life group translation manual. All physicians and nurses who were directly involved in patient care at nine departments of four tertiary hospitals in Japan were invited to a survey to assess the construct validity, reliability and factor structure. Construct validity was assessed with the relation to the intention to leave the clinical position, and internal consistency was assessed with Cronbach's alpha. Confirmatory factor analysis was conducted., Results: 308 responses were eligible for the analysis. The mean total score of MMD-HP (range, 0-432) was 98.2 (SD, 59.9). The score was higher in those who have or had the intention to leave their clinical role due to moral distress than in those who do not or did not have the intention of leaving (mean 113.7 [SD, 61.3] vs. 86.1 [56.6], t-test p < 0.001). The confirmatory factor analysis and Cronbach's alpha confirmed the validity (chi-square, 661.9; CMIN/df, 2.14; GFI, 0.86; CFI, 0.88; CFI/TLI, 1.02; RMSEA, 0.061 [90%CI, 0.055-0.067]) and reliability (0.91 [95%CI, 0.89-0.92]) of the instrument., Conclusions: The translated Japanese version of the MMD-HP is a reliable and valid instrument to assess moral distress among physicians and nurses.

Diversity in the lines of public institutions, such as hospitals, schools, and police forces, is thought to improve provision for minority group members. Nonetheless, whether and how diversity in public institutions shapes majority citizens' prejudice toward minorities are unclear. Building on insights from the intergroup contact literature, I suggest that diversity in public institutions can facilitate positive intergroup contact between majority group members and minorities in elevated social positions. Such unique interactions, which exceed the equal status condition for effective intergroup contact, can serve to reduce prejudice and facilitate more inclusive attitudes among majority group members. To test this expectation, I focus on health care provision-a leading sector with regard to minority representation. Leveraging a natural experiment unfolding in 21 Israeli medical clinics where Jewish patients are haphazardly assigned to receive care from Jewish or Arab doctors and embedding prejudice-related questions in a routine evaluation survey, I demonstrate that brief contact with an Arab doctor reduces prejudice. Specifically, contact with an Arab doctor reduces Jewish patients' exclusionary preferences toward Arabs by one-sixth of an SD and increases Jewish patients' optimism about peace by a 10th of an SD. The modest magnitude of these effects is similar to the impact of well-powered interventions recently reviewed in a meta-analysis of prejudice reduction experiments. These findings emphasize how the demographic makeup of public institutions can reduce mass prejudice, even in a context of intractable conflict., Competing Interests: The author declares no competing interest.

Responsibly determining whether and when to use potentially lifesaving force when caring for patients who are acutely mentally ill typically requires carefully applying 2 key ethical standards. First, short-term morbidity or mortality risk must be minimized. Second, potential long-term harm to a patient who is traumatized during a forcibly performed intervention and potential long-term consequences to a patient's trust in clinicians must be seriously considered. This article suggests these minimum standards in mental health care decision making are necessary but insufficient. It is proposed that clinicians' intentions and motivations should not be grounded merely in harm minimization; rather, they should be grounded in compassion maximization. The article then proposes criteria for what compassion maximization would look like in response to a case., (© 2021 American Medical Association. All Rights Reserved.)

Abstract: Fundamental quandaries of clinical and biomedical ethics for health care professionals, committees, and systems have been raised into stark relief by the COVID-19 pandemic. The nature and extent of critical issues raised by this ongoing crisis, including challenging ethical dilemmas for the health care profession, is likely to have an indelible impact on the professional identity formation (PIF) of learners and practitioners across the trajectory of the professional lifecycle. The lifelong process of PIF for health care practitioners, from learner through independent practice, is supported in medical education by intentional reflection, relationships within community of practice include guidance from mentoring, as well as resilience, both emotional and moral. We consider how grappling with ethical dilemmas related to the COVID-19 pandemic can challenge, inform, and even potentially transform the PIF process, thereby supporting development of a morally resilient, humanistic professional identity in health care trainees and health care professionals., Competing Interests: Disclosures: The authors declare no conflict of interest., (Copyright © 2021 The Alliance for Continuing Education in the Health Professions, the Association for Hospital Medical Education, and the Society for Academic Continuing Medical Education.)

As endocrinologists we have focused on biological contributors to disparities in diabetes, obesity and other endocrine disorders. Given that diabetes is an exemplar health disparity condition, we, as a specialty, are also positioned to view the contributing factors and solutions more broadly. This will give us agency in contributing to health system, public health, and policy-level interventions to address the structural and institutional racism embedded in our medical and social systems. A history of unconsented medical and research experimentation on vulnerable groups and perpetuation of eugenics theory in the early 20th century have resulted in residual health care provider biases toward minority patients and patient distrust of medical systems, leading to poor quality of care. Historical discriminatory housing and lending policies resulted in racial residential segregation and neighborhoods with inadequate housing, healthy food access, and educational resources, setting the foundation for the social determinants of health (SDOH) contributing to present-day disparities. To reduce these disparities we need to ensure our health systems are implementing the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care to promote health equity. Because of racial biases inherent in our medical systems due to historical unethical practices in minority communities, health care provider training should incorporate awareness of unconscious bias, antiracism, and the value of diversity. Finally, we must also address poverty-related SDOH (eg, food and housing insecurity) by integrating social needs into medical care and using our voices to advocate for social policies that redress SDOH and restore environmental justice., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)