An ethically justified framework for clinical investigation to benefit pregnant and fetal patients

Research to improve the health of pregnant and fetal patients presents ethical challenges to clinical investigators, institutional review boards, funding agencies, and data safety and monitoring boards. The Common Rule sets out requirements that such research must satisfy but no ethical framework to guide their application. We provide such an ethical framework, based on the ethical concept of the fetus as a patient. We offer criteria for innovation and for Phase I and II and then for Phase III clinical trials to improve the health of pregnant patients and of fetal patients and also criteria to responsibly manage the transition from investigation to clinical practice. Basing ethical criteria for research involving pregnant women on the ethical concept of the fetus as a patient insulates the proposed ethical framework and therefore research on pregnant women from the divisive and politicized concepts and discourses of personhood, fetal rights, and unborn child.     

Human dignity and vulnerable agency: An ethical framework for forensic practice

In this paper, we present an integrated ethical framework that covers the different levels of ethical tasks inherent in forensic and correctional work. First, we briefly give an overview of the ethical framework and its component notion of human dignity. Second we analyze in depth the concept of dignity and its relationship to normative theories and ethical concepts that are particularly relevant for forensic practitioners. Third, we explore the capacity of the conceptions of human dignity and vulnerable agency to integrate principles typically contained in ethical codes and practice, such as beneficence, autonomy, and justice. Fourth, we discuss how conflict between ethical codes or duties of station adhered to by practitioners can be effectively addressed in light of the model of dignity and agency outlined earlier. Fifth, we explain how individuals' specific ethical judgments and actions should proceed in light of our framework model.     

Morality and parenting: An ethical framework for decisions about the treatment of imperiled newborns

This essay is written in the belief that questions relating to the treatment of impaired and imperiled newborns cannot be adequately resolved in the absence of a general moral theory of parent-child relations. The rationale for treatment decisions in these cases should be consistent with principles that ought to govern the normal work of parenting. The first section of this paper briefly examines the social contract theory elaborated by John Rawls in his renowned book A Theory of Justice and extracts from it normative principles that can guide us in our attempt to lay a rational foundation for parenthood. The second section clarifies the implications of a Rawlsian theory for the problem at hand by examining several standards that have been proposed for the treatment of impaired newborns: the strict right-to-life standard, the medical decision standard, and the quality-of-life standard. A Rawlsian standard, by contrast, is autonomy-based. That is, it would have us base our treatment decisions on consideration of the child's capacity for developing critical rationality in making decisions on his or her own. This standard, it is suggested, avoids morally objectionable features of the others.     

An analysis of the structure of justification of ethical decisions in medical intervention

The most important distinction in value theory is the subjective-objective distinction which determines the epistemological status of value judgments about medical intervention. Ethical decisions in medical intervention presuppose one of three structures of justification — namely, an inductive approach, a deductive approach which can be either consequentialist or non-consequentialist, and a uniquely ethical approach. Inductivism and deductivism have been discussed extensively in the literature and are only briefly described here. The uniquely ethical approach which presupposes value objectivism is analyzed in detail. This method involves a purely ethical inference which moves from facts to values directly with an emphasis on reason which involves a non-logical justification (as opposed to illogical). It involves the use of natural practical arguments which have an imperative conclusion but no imperative premise and exhibit a value-requiredness between two states of affairs.     

Toward a framework for defining and resolving ethical issues in the protection of communities involved in primary prevention projects

Ethical issues flow from and are embedded in contexts of practice. Contexts of practice refer to the diverse social settings where interventions occur. Primary prevention activities require new professional roles in these diverse social settings. These new roles engage the professional in new activities, which in turn allow new ethical issues to arise. This article takes an ecological perspective on ethical issues arising from the enactment of new preventive roles intended to affect groups or communities. Within this perspective, the concepts of context and culture take on special conceptual significance. Four ecological assumptions about preventive interventions intended to affect groups or communities are offered as a means of framing ethical issues in such interventions. Finally, several approaches to developing ecological knowledge about the contexts of practice are presented as ways of furthering our ability to conceptualize and cope with ethical issues in preventive interventions intended to affect groups or communities.     

Developing an informational tool for ethical engagement in medical tourism

Background

Medical tourism, the practice of persons intentionally travelling across international boundaries to access medical care, has drawn increasing attention from researchers, particularly in relation to potential ethical concerns of this practice. Researchers have expressed concern for potential negative impacts to individual safety, public health within both countries of origin for medical tourists and destination countries, and global health equity. However, these ethical concerns are not discussed within the sources of information commonly provided to medical tourists, and as such, medical tourists may not be aware of these concerns when engaging in medical tourism. This paper describes the methodology utilized to develop an information sheet intended to be disseminated to Canadian medical tourists to encourage contemplation and further public discussion of the ethical concerns in medical tourism.

Methods

The methodology for developing the information sheet drew on an iterative process to consider stakeholder feedback on the content and use of the information sheet as it might inform prospective medical tourists’ decision making. This methodology includes a literature review as well as formative research with Canadian public health professionals and former medical tourists.

Results

The final information sheet underwent numerous revisions throughout the formative research process according to feedback from medical tourism stakeholders. These revisions focused primarily on making the information sheet concise with points that encourage individuals considering travelling for medical tourism to do further research regarding their safety both within the destination country, while travelling, and once returning to Canada, and the potential impacts of their trip on third parties. This methodology may be replicated for the development of information sheets intending to communicate ethical concerns of other practices to providers or consumers of a certain service.

     

Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals

Periodic and unexpected shortages of drugs, biologics, and even medical devices have become commonplace in the United States. When shortages occur, hospitals and clinics need to decide how to ration their available stock. When such situations arise, institutions can choose from several different allocation schemes, such as first-come, first-served, a lottery, or a more rational and calculated approach. While the first two approaches sound reasonable at first glance, there are a number of problems associated with them, including the inability to make fine, individual patient-centered decisions. They also do not discriminate between what kinds of patients and what types of uses may be more deserving or reasonable than others. In this article I outline an ethically acceptable procedure for rationing drugs during a shortage in which demand outstrips supply.     

The ethics of distress: Toward a framework for determining the ethical acceptability of distressing health promotion advertising

Distressing health promotion advertising involves the elicitation of negative emotion to increase the likelihood that health messages will stimulate audience members to adopt healthier behaviors. Irrespective of its effectiveness, distressing advertising risks harming audience members who do not consent to the intervention and are unable to withdraw from it. Further, the use of these approaches may increase the potential for unfairness or stigmatization toward those targeted, or be considered unacceptable by some sections of the public. We acknowledge and discuss these concerns, but, using the public health ethics literature as a guide, argue that distressing advertising can be ethically defensible if conditions of effectiveness, proportionality necessity, least infringement, and public accountability are satisfied. We do not take a broad view as to whether distressing advertising is ethical or unethical, because we see the evidence for both the effectiveness of distressing approaches and their potential to generate iatrogenic effects to be inconclusive. However, we believe it possible to use the current evidence base to make informed estimates of the likely consequences of specific message presentations. Messages can be pre‐tested and monitored to identify and deal with potential problems. We discuss how advertisers can approach the problems of deciding on the appropriate intensity of ethical review, and evaluating prospective distressing advertising campaigns against the conditions outlined.     

An investigation of the cues responsible for figure impossibility

Two different perceptual confrontations produced by two different cues (sides that seem to twist and apparent levels of depth), which were thought to influence the perception of the degree of possibility of impossible torus figures, were examined in two experiments. In Experiment 1 it was found that net change in depth experienced with one scan around the figure was inversely related to magnitude estimates of possibility, whereas the number of apparently twisted sides was not. These results were verified in Experiment 2, a replication of Experiment 1 using stereograms of the figures, in which an interpretation of multiple levels of depth was more difficult.     

Development of a medical management system for psychiatric patients in Prussia in the 1st half of the 19th century

In recent years, som noted authors have been reappraising the distinctive features of the history of psychiatry, setting out its relationship to social history. Trends and models, and the legal basic of psychiatric care are demonstrated, taking the early days of psychiatry in Prussia as an example. In the first half of the 19th century there was in Prussia an especially coherent development from the dual-purpose mental hospital/mental home arrangement (Neuruppin), through total separation of asylum from hospital from home for incurables (Siegburg, Leubus) inaugurated by Langermann, to the more or less linking of asylum with hospital with home for incurables (Nietleben) under Damerow.     

Six domains of research ethics. A heuristic framework for the responsible conduct of research

The purpose of this paper is to provide a simple yet comprehensive organizing scheme for the responsible conduct of research (RCR). The heuristic offered here should prove helpful in research ethics education, where the many and heterogeneous elements of RCR can be bewildering, as well as research into research integrity and efforts to form RCR policy and regulations. The six domains are scientific integrity, collegiality, protection of human subjects, animal welfare, institutional integrity, and social responsibility.     

A proposed ethical framework for vaccine mandates: competing values and the case of HPV

Debates over vaccine mandates raise intense emotions, as reflected in the current controversy over whether to mandate the vaccine against human papilloma virus (HPV), the virus that can cause cervical cancer. Public health ethics so far has failed to facilitate meaningful dialogue between the opposing sides. When stripped of its emotional charge, the debate can be framed as a contest between competing ethical values. This framework can be conceptualized graphically as a conflict between autonomy on the one hand, which militates against government intrusion, and beneficence, utilitarianism, justice, and nonmaleficence on the other, which may lend support to intervention. When applied to the HPV vaccine, this framework would support a mandate based on utilitarianism, if certain conditions are met and if herd immunity is a realistic objective.     

An ethical perspective on caregiving in the family

The emphasis on intra-family caregiving that prevailed from ancient until relatively recent times, in both philosophy and practice, was substantially displaced under the influence of the Eighteenth Century Enlightenment by an emphasis on individual independence. The ethics of familial relationships ceased to be at the center of philosophical interest. A consequence was growing inattention to the social conditions and practical arrangements needed to support family efforts to take care of the very young, the very old, the physically or mentally ill or disabled, and others in need of care. The myth of the self-sufficient family must be exploded to permit the development of a public policy that will make such support possible.     

An analysis of letter expertise in a levels-of-categorization framework

While there has been increasing effort in dissociating the neural substrates recruited by perception of different objects, the theoretical and behavioural work needed to understand such dissociation lags behind. In an attempt to compare expertise in letter and face perception, we outline a theoretical framework that characterizes different types of object expertise based on the task demand (level of abstraction) required in object categorization. Face perception requires categorization at a subordinate level, whereas letter perception involves mainly basic-level categorization. Accordingly face and letter perception should represent two different types of expertise and display different neural and behavioural markers. Results from three behavioural experiments supported the predictions of the framework in that letter expertise is characterized by an enhancement of the basic-level advantage, instead of its attenuation as typically found for face perception. We compare this framework with Farah's taxonomy of visual abilities based on cooccurrence of deficits in visual agnosias.