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Background: Research on informed consent (IC) has traditionally focused on the documentation of the discussion with patients of potential complications. We sought to examine the completeness of documentation for all elements of IC for laparoscopic cholecystectomy (LC): potential complications, alternatives to LC and details of the procedure. Differences in the documentation of IC for elective and emergent LC were examined. Methods: A retrospective chart review of patients undergoing LC at our institution between 2015 and 2017 was performed. Completeness of documentation was defined as documentation of all 3 elements of IC in the clinic note, the operating room note or the consent form itself. Data were analyzed descriptively. We compared documention for emergent and elective cases as well as documentation by residents and attending physicians using t tests. Results: A total of 270 patients were included in the analysis. Only 5 (2%) had complete documentation of all elements of IC. Documentation of potential complications was noted in 232 cases (86%), of which 58 (25%) were elective and 174 (75%) were emergent. Details were noted in 28 (10%) cases, of which 21 (75%) were elective and 7 (25%) were emergent. Alternatives were documented the least frequently: they were documented in 23 cases (9%), of which 20 (87%) were elective and 3 (13%) were emergent. Residents performed better than attending physicians in documenting IC discussions in clinic notes and on consent forms, but not in operating room notes. Conclusion: Documentation of the elements of IC for LC was poor. Potential complications were the most frequently documented element of IC; alternatives and details were often omitted. Future studies comparing audiotaped IC conversations with the documentation of IC are warranted. The use of procedure-specific consent forms for LC may facilitate documentation. Contexte: La recherche sur le consentement eclaire (CE) s'est longtemps interessee surtout a la consignation du contenu des discussions avec les patients au sujet des complications potentielles. Nous avons voulu examiner l'exhaustivite de la consignation de tous les elements du CE pour la cholecystectomie laparoscopique (CL): complications potentielles, solutions de rechange a la CL et details de l'intervention. Nous avons observe des differences dans la consignation des elements du CE pour la CL urgente et non urgente. Methodes: Nous avons procede a un examen retrospectif des dossiers de patients soumis a une CL dans notre etablissement entre 2015 et 2017. La consignation au dossier etait jugee complete lorsque les 3 elements du CE etaient presents dans la note clinique, la note opera-toire ou le formulaire de consentement lui-meme. Nous avons effectue une analyse descriptive des donnees, et nous avons compare la consignation des elements pour les cas urgents et non urgents, effectuee par les residents et les medecins traitants au moyen de tests t. Resultats: Au total, 270 patients ont ete inclus dans l'analyse. Tous les elements du CE etaient adequatement consignes pour seulement 5 (2 %) d'entre eux. Les complications potentielles ont ete consignees dans 232 cas (86 %), dont 58 (25 %) etaient non urgents et 174 (75 %) etaient urgents. Les details de l'intervention ont ete notes dans 28 cas (10 %), dont 21 (75 %) etaient non urgents et 7 (25 %) etaient urgents. Ce sont les solutions de rechange qui ont ete le moins souvent consignees: elles ont ete notees dans 23 cas (9 %), dont 20 (87 %) etaient non urgents et 3 (13 %) etaient urgents. Les residents ont mieux fait que les medecins traitants pour ce qui est de consigner les discussions sur le CE dans les notes cliniques et les formulaires de CE, mais non dans les notes operatoires. Conclusion: La consignation des elements du CE pour la CL a ete faible. Les complications potentielles ont ete l'element du CE le plus souvent consigne au dossier; les solutions de rechange et les details de l'intervention ont souvent ete omis. Il faudra proceder a d'autres etudes pour comparer le contenu des discussions sur le CE enregistrees sur bande audio et sa consignation. L'utilisation de formulaires de CE specifiques aux interventions pourrait facili-ter la consignation de leurs elements., The concept of informed consent (IC) and its elements are well established, but little research has been devoted to examining the completeness of documentation of this critically important medical practice. [...]

This study is concerned with issues of dignity in dementia care, in situations where staff members handle potential or actual conflicts and interaction problems between residents. Based on empirical data consisting of observations and video recordings, various coping strategies are identified in regard to whether or not, as well as when and how to interfere. Microethical analysis is used in order to discuss these coping strategies in relation to contextual conditions and ways of understanding, and values or aspects of dignity are highlighted. In dialogue with empirical data, nuances of ethical considerations are approached that are otherwise difficult to access analytically -- thereby opening the door to a more reflective way of dealing with problematic situations in dementia care., Keywords: coping strategies; conflict solving; ethics; ethnography; microethics 507 ArticleDignity work in dementia careSketching a microethical analysis SAGE Publications, Inc.200710.1177/1471301207084368 LindaOrulv Linkoping University, Sweden, linda.orulv@tema.liu.se NinaNikku Linkoping University, Sweden, ninni@tema.liu.se [...]

Personal relationships are at the heart of providing care (Hatfield, 1987b). Relatives often depend on each other for informal caregiving activities, and physicians develop relationships to formally care for patients. [...]

Suicide and assisted suicide are not criminal acts in Germany. However, attempting suicide may create a legal duty for physicians to try to save a patient's life. This study presents data on medical students' legal knowledge and ethical views regarding physician assisted suicide (PAS). The majority of 85 respondents held PAS to be illegal. More than a third of the students viewed PAS in certain situations to be ethically acceptable whereas a smaller proportion thought that it should be legal. Compared with German physicians the medical students taking part in this study were less opposed to PAS. The majority perceived the undergraduate training concerning ethical aspect of assisted death as deficient.

In contemporary American medical practice, certain physicians are critical and wary of the current emphasis on patient autonomy in medicine, questioning whether it really serves the complex needs of severely ill patients. Physicians such as Eric Cassell and Thomas Duffy argue that the duty of beneficence should override the duty to respect autonomy when conflicts arise in clinical situations. After evaluating their claim that severe illness robs patients of their autonomy, I will argue that this perceived conflict between beneficence and autonomy is ill-conceived, resting on misperceptions about both the capacity for autonomy and the meaning of hope. Considering insights on hope from phenomenologist Gabriel Marcel and theologian William Lynch, as well as drawing upon a case study involving a bone marrow patient, I claim that respecting and nurturing patients' capacity for autonomy is a necessary condition for acting beneficently and fostering authentic hope.

Objectives: the purpose of this study is to explore laypersons' attitudes towards and experiences of medical research, and to compare them with those of physicians in Japan. Designs and Participants: fourteen Japanese adults from the general public and seven physicians participated in one of three focus interviews. Setting: Osaka, Japan. Results: trust and distrust in the physician by whom the participants were invited to participate in research played a considerable role in their decisions about participation. That the participants felt an obligation to participate was also expressed. The lay participants perceived medical research as something entirely outside of their world. A greater willingness to volunteer for research was expressed if there were direct benefits to themselves or their families. Research methods such as use of placebos, double blinds, and randomisations seemed to cause negative attitudes to medical research. All physicians were convinced of the need for medical research, including double-blinded randomised control trials, and its significant role in medical progress. Most physicians thought that the greater awareness of the need for medical research in the community and a better understanding of the psychology of potential research participants were necessary and urgent. Conclusions: there is a good possibility that the lay public and medical professionals have sharply different beliefs about and attitudes towards every aspect of medical research. Building up a better and equal patient-doctor relationship based on trust is a key issue in medical research, and it is mandatory to fill the gap in perception regarding medical research between them through fully informed debates.

When hope is discussed in bioethics' literature, it is most often in the context of 'false hopes' and/or how to maintain hope while breaking bad news to patients. Little or no time is generally devoted to the description of hope that supports these analyses. In this paper, I present a detailed description of hope, one designed primarily for the healthcare context. Noting that hope is an emotional attitude, four key aspects are explored. In particular, the function of imagination in hope is discussed in depth. Through an examination of the relationship between hope and vulnerability, I demonstrate how adequately describing hope can broaden the normative inquiry into the role of hope in healthcare. Three ways in which persons with hope can be vulnerable are illustrated, and the challenge of how healthcare providers can attend in moral ways to the hopes of patients is identified.

A major focus within the modern bioethics debate has been on reshaping power relationships within the doctorupatient relationship. Empowerment of the vulnerable has been achieved through an emphasis on human rights and respect for individual dignity. However, power imbalances remain pervasive within healthcare. To a considerable extent this relates to insufficient attention to social injustice. Such power imbalances together with the development of new forms of power, for example through new genetic biotechnology, raise the spectre of increasing social injustice. Attention will be drawn to the need to extend the bioethics debate to include ethical considerations regarding public health. Changes in political philosophy will also be required to reshape international power relations and improve population health.

The presence of truth and honesty is a permanent demand, and becomes vital the more committed and intimate a relationship is. Medical practice is relevant to this discussion when one questions whether or not a physician should always tell their patient the truth in the face of a progressive or potentially fatal disease, regarding the diagnosis, outcome, therapy and evolution of the specific disease. From this discussion we aim, with the present report, to look at the truth applicable to the patient-physician relationship, and its ethical and moral implications; and also to look at where the Brazilian Code of Medical Ethics (BCME) and the medical literature stand regarding this issue. One concludes that there are only two moments not to tell a patient the truth: when the patient does not want to be informed, and when the truth could be iatrogenic. The question now is, when would the truth be iatrogenic? Physicians, in our opinion, would not be able to judge solitarily when the truth might be deleterious to their patient. Alternatively, we propose the appointment of a multidisciplinary commission to help the doctor with such a decision.

There is a well-documented legacy of racial discrimination toward African Americans in medical research and clinical settings. Perhaps most notably, the 1932 U.S. Public Health Service Tuskegee Syphilis Study on […]

Every day, health care executives are faced with difficult decisions, which may impact the delivery of care in their organizations. Health care executives provide the leadership to foster their institutions' [...]

The futility debate may be considered as an effort to provide a clear and justified borderline between physician and patient decision-making authority. In this paper we argue that the search for a definition of futility that provides physicians with a final argument in discussions about life-prolonging treatment, is misplaced. An acceptable and meaningful criterion of futility that satisfies this effort, seems impossible. As a consequence, we reject a dichotomous domain of decision-making power as the starting point for definitions of futility. A good decision about withholding life-sustaining treatment should be justified from the perspectives of both physician and patient. In this light, a range of definitions of futility is still useful as it can clarify intuitions that a treatment is inappropriate.

An analysis of ethnic and racial disparities in health care administration based on factors such as bias, prejudice, clinical uncertainty and stereotyping is offered. Additional information on physician-patient relationship is included.

In this paper, I claim that the doctor-patient relationship can be viewed as a vessel of trust. Nonetheless, trust within the doctor-patient relationship has been impaired by managed care. When we conceive of trust as social capital, focusing on the role that it plays in individual and social well-being, trust can be viewed as a public good and a scarce medical resource. Given this, there is a moral obligation to protect the doctor-patient relationship from the cost-containment mechanisms that compromise its ability to produce trust. Keywords: doctor-patient relationship, managed care, social capital, trust.

After distinguishing two different meanings of the notion of a `morality internal to medicine' and considering a hypothetical case of a society that relied on its surgeons to `eunuchize' priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are `socially constructed', they may, nevertheless, be reflections, however imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. Keywords: ends of medicine, external morality, internal morality, social constructionism

What grounds and justifies conclusions in medical ethics? Is the source external or internal to medicine? Three influential types of answer have appeared in recent literature: an internal account, an external account, and a mixed internal/external account. The first defends an ethic derived from either the ends of medicine or professional practice standards. The second maintains that precepts in medical ethics rely upon and require justification by external standards such as those of public opinion, law, religious ethics, or philosophical ethics. The third claims that distinct medical ethics have emerged from distinct cultural frameworks, each with norms that govern physicians. There is merit in each perspective, but each overreaches its supporting arguments and fails to appreciate what is legitimate in the theses of its competitors. I propose a fourth account that offers a way to escape limitations of the other three, while retaining their most attractive features. Keywords: common morality, externalism, internalism, particular internal moralities, specification.

I begin this commentary with an expanded typology of theories that endorse an internal morality of medicine. I then subject these theories to a philosophical critique. I argue that the more robust claims for an internal morality fail to establish a stand-alone method for bioethics because they ignore crucial non-medical values, violate norms of justice and fail to establish the normativity of medical values. I then argue that weaker versions of internalism avoid such problems, but at the cost of failing to provide a clear sense in which their moral norms are internal or can ground a comprehensive approach to moral problems. Finally, I explore various functions that an internal morality might serve, concluding with the observation that, while there may be a core of good sense to the notion of an internal morality of medicine, our expectations for it must be drastically lowered. Keywords: external morality, internal morality, methods of ethics.

The moral authority for professional ethics in medicine customarily rests in some source `external' to medicine, i.e., a pre-existing philosophical system of ethics or some form of social construction, like consensus or dialogue. Rather, `internal' morality is grounded in the phenomena of medicine, i.e., in the nature of the clinical encounter between physician and patient. From this, a philosophy of medicine is derived which gives moral force to the duties, virtues and obligations of physicians qua physicians. Similarly, an ethic specific to the other healing professions, law, teaching or ministry, can be derived from the specific ends or telos of each of these professions, which like medicine, are focused on a special type of human relationship. Keywords: end, foundations for professional ethics, health professions, helping professions, internal morality, philosophy of medicine, teleology

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of `the common morality' to medicine or whether some of these norms are `internal' or `proper' to medicine. In this article we describe and defend an evolutionary perspective on `the internal morality of medicine' that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these goals. This perspective is developed by means of a critical examination of the `essentialist' conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp. Keywords: internal morality, medical ethics, professional integrity.

This article reports the results of a survey, by mailed questionnaire, of the attitudes, values and practices of doctors in Singapore with respect to the doctor-patient relationship. Questionnaires were sent to a random sample of 475 doctors (261 general practitioners and 214 medical specialists), out of which 249 (52. 4%) valid responses were completed and returned. The survey is the first of its kind in Singapore. Questions were framed around issues of medical paternalism, consent and patient autonomy. As the doctors were exposed to Western ethical concepts in their training, we were not surprised to find that they would mostly allow patients some say in decision-making and keep patients reasonably informed. In respecting patient autonomy, they would usually seek to influence patient choice by persuasion. However, the residual 'Asian-ness' of doctors in Singapore gives rise to some inconsistencies between values and practices. Many doctors still believe that a number of their patients are incapable of rational choice. There is some lack of openness in telling patients the whole truth. When patients choose to refuse treatment, many doctors are prepared to involve family members in making a consensus decision. Doctors were also asked how they made ethical judgements in the face of dilemmas, and how they would like disputes with patients to be resolved. By and large, the doctors prefer to make their own judgements rather than to rely on rules. They also wish to keep the law courts out of disputes with patients, preferring less public ways of settling disputes.

No viable conception of equipoise for clinical trials is available and ethical problems of clinical trials have not been resolved. Clinical trials are generally thought to be ethical if some form of equipoise exists between the treatments compared and used on different groups, that is, if neither of the two treatments is actually known to be better than the other and if those given one or the other are chosen randomly. Judgement of equipoise can end up being managed socially, but it is supposedly cognitive in significance. A clinician may not be in equipoise once data are partially accumulated. Recent reconstructions of equipoise-like concepts in epistemology give some hints on how to understand it in a cognitive way. The reconstructions and success thereof are discussed.

Compassionate interference is being considered in the Netherlands as coercion and autonomy for psychiatric patients or potential psychiatric patients is discussed. It is thought that professional carers might do better to adopt a more active and committed attitude. Some call this modern paternalism and other say that the mentally ill and drug addicts in some cases are desperately in need of flourishing viable relationships, part of their problem being that they do not relate well to others. The views of a nurse specializing in social psychiatric care in Rotterdam are considered.

Hope is thought to have therapeutic value, so physicians, with help from friends or family, often give them false hope, a practice which bioethicists claim is paternalistic and may violate the patient's right to autonomy. A collective Project Hope might pursue deeper philosophical and psychological studies and help to guide the giving of hope. What is possible and what is probable are not necessarily the same and patients often base hopes of what is only possible.

Third-trimester abortions for fetal abnormality are now more often requested because medical technology is now capable of diagnosing server structural abnormality of the fetus. Serious ethical and legal questions arise relative to physicians and whether they should be allowed to fulfill such a request and if so, what safeguards they should have in place. The situation in the Netherlands, where a commission has been established and has reported on these issues, is discussed in particular.

This paper tells the story of events that led up to a septoplasty and the consequences that followed it. The patient is a medical ethicist. After scratching the inside of a nostril in 1976, he suffered with occasional bleeding and irritation for almost two decades. He tried topical treatment. As this failed, he sought help from an ENT specialist. The paper relates the conduct of the patient and others (friends in the medical field, the patient's spouse, nurses and anesthesiologists) vis-a-vis informed consent. Key words: anesthesia, friend, informed consent, nurses, septoplasty.

What is available to psychologists to assist them in identifying or minimizing the damage that can result from inappropriate professional boundary crossings? Frequency data of both sexual and nonsexual boundary violations by psychologists are provided as they occurred with clients, supervisees, and students. The impact of engaging in such relationships on subsequent professional practice is also reported. Data on 18 nonsexual boundary crossings are described, and guidelines for making decisions about crossing accepted professional boundaries are provided.

Ever-increasing technological innovations surrounding birth are creating new challenges in biomedical ethics in U.S. obstetrics. The politicization of abortion has augmented these challenges and led to increased conflict between physicians' personal morality and professional responsibility. This paper focuses on some of the problems generated by abortion policies and procedures in an obstetric/ gynecology residency program. Examples of conflicts among residents are presented to demonstrate the effect of pluralistic moral perspectives. A system is described where some residents will do abortions and some will not. Patients seeking abortion are often treated in an unprofessional manner when it appears that a conflict exists between the values of patients and those of residents. Unless the socialization of residents includes ethical training, defined educational policy and institutional direction, ethical dilemmas will lead to increased resident stress, an inadequate doctor-patient relationship and a continued shortage of physicians willing to perform abortions despite new policies called for in graduate medical education. Key words - bioethics, abortion, doctor-patient relationship, medical education