Physicians' silent decisions: because patient autonomy does not always come first

Physicians make some medical decisions without disclosure to their patients. Nondisclosure is possible because these are silent decisions to refrain from screening, diagnostic or therapeutic interventions. Nondisclosure is ethically permissible when the usual presumption that the patient should be involved in decisions is defeated by considerations of clinical utility or patient emotional and physical well-being. Some silent decisions--not all--are ethically justified by this standard. Justified silent decisions are typically dependent on the physician's professional judgment, experience and knowledge, and are not likely to be changed by patient preferences. We condemn the inappropriate exclusion of the patient from the decision-making process. However, if a test or treatment is unlikely to yield a net benefit, disclosure and discussion are at times unnecessary. Appropriate silent decisions are ethically justified by such considerations as patient benefit or economy of time.     

Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force

Abstract

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing policies for pandemics differ by institution, health system, and applicable law. Most seem to agree that a patient’s ability to benefit from treatment and to survive are first-order considerations. However, there is debate about what clinical measures should be used to make that determination and about other factors that might be ethically appropriate to consider. In this paper, we discuss resource allocation and several related ethical challenges to the healthcare system and society, including how to define benefit, how to handle informed consent, the special needs of pediatric patients, how to engage communities in these difficult decisions, and how to mitigate concerns of discrimination and the effects of structural inequities.     

Applying the Ethical Principle of Social Benefits in Nursing Research in Developing Countries: the Case of Jordan

Journal of Academic Ethics - Research on human subjects is ethically justified when its anticipated results would ultimately benefit the society or public and not only the individuals participating...     

Gain-of-Function Research: Ethical Analysis

Gain-of-function (GOF) research involves experimentation that aims or is expected to (and/or, perhaps, actually does) increase the transmissibility and/or virulence of pathogens. Such research, when conducted by responsible scientists, usually aims to improve understanding of disease causing agents, their interaction with human hosts, and/or their potential to cause pandemics. The ultimate objective of such research is to better inform public health and preparedness efforts and/or development of medical countermeasures. Despite these important potential benefits, GOF research (GOFR) can pose risks regarding biosecurity and biosafety. In 2014 the administration of US President Barack Obama called for a “pause” on funding (and relevant research with existing US Government funding) of GOF experiments involving influenza, SARS, and MERS viruses in particular. With announcement of this pause, the US Government launched a “deliberative process” regarding risks and benefits of GOFR to inform future funding decisions—and the US National Science Advisory Board for Biosecurity (NSABB) was tasked with making recommendations to the US Government on this matter. As part of this deliberative process the National Institutes of Health commissioned this Ethical Analysis White Paper, requesting that it provide (1) review and summary of ethical literature on GOFR, (2) identification and analysis of existing ethical and decision-making frameworks relevant to (i) the evaluation of risks and benefits of GOFR, (ii) decision-making about the conduct of GOF studies, and (iii) the development of US policy regarding GOFR (especially with respect to funding of GOFR), and (3) development of an ethical and decision-making framework that may be considered by NSABB when analyzing information provided by GOFR risk-benefit assessment, and when crafting its final recommendations (especially regarding policy decisions about funding of GOFR in particular). The ethical and decision-making framework ultimately developed is based on the idea that there are numerous ethically relevant dimensions upon which any given case of GOFR can fare better or worse (as opposed to there being necessary conditions that are either satisfied or not satisfied, where all must be satisfied in order for a given case of GOFR to be considered ethically acceptable): research imperative, proportionality, minimization of risks, manageability of risks, justice, good governance (i.e., democracy), evidence, and international outlook and engagement. Rather than drawing a sharp bright line between GOFR studies that are ethically acceptable and those that are ethically unacceptable, this framework is designed to indicate where any given study would fall on an ethical spectrum—where imaginable cases of GOFR might range from those that are most ethically acceptable (perhaps even ethically praiseworthy or ethically obligatory), at one end of the spectrum, to those that are most ethically problematic or unacceptable (and thus should not be funded, or conducted), at the other. The aim should be that any GOFR pursued (and/or funded) should be as far as possible towards the former end of the spectrum.     

Extrapolating from Laboratory Behavioral Research on Nonhuman Primates Is Unjustified

Conducting research on animals is supposed to be valuable because it provides information on how human mechanisms work. But for the use of animal models to be ethically justified, it must be epistemically justified. The inference from an observation about an animal model to a conclusion about humans must be warranted for the use of animals to be moral. When researchers infer from animals to humans, it’s an extrapolation. Often nonhuman primates are used as animal models in laboratory behavioural research. The target populations are humans and other nonhuman primates. I argue that the epistemology of extrapolation renders the use of nonhuman primates in laboratory behavioural research unreliable. If the model is relevantly similar to the target, then the experimental conditions introduce confounding variables. If the model is not relevantly similar to the target, then the observations of the model cannot be extrapolated to the target. Since using nonhuman primates as animal models in laboratory behavioural research is not epistemically justified, using them as animal models in laboratory behavioural research is not ethically justified.     

The last low whispers of our dead: when is it ethically justifiable to render a patient unconscious until death?

A number of practices at the end of life can causally contribute to diminished consciousness in dying patients. Despite overlapping meanings and a confusing plethora of names in the published literature, this article distinguishes three types of clinically and ethically distinct practices: (1) double-effect sedation, (2) parsimonious direct sedation, and (3) sedation to unconsciousness and death. After exploring the concept of suffering, the value of consciousness, the philosophy of therapy, the ethical importance of intention, and the rule of double effect, these three practices are defined clearly and evaluated ethically. It is concluded that, if one is opposed to euthanasia and assisted suicide, double-effect sedation can frequently be ethically justified, that parsimonious direct sedation can be ethically justified only in extremely rare circumstances in which symptoms have already completely consumed the patient’s consciousness, and that sedation to unconsciousness and death is never justifiable. The special case of sedation for existential suffering is also considered and rejected.     

Early stopping of clinical trials: charting the ethical terrain

The decision to terminate a clinical trial earlier than planned is often described as ethically problematic, but it is rarely systematically analyzed as an ethical issue in its own right. This paper provides an overview of the main ethical considerations at stake in such decisions and of the main tensions between these considerations. Arguments about informed consent and the impact of early stopping on research and society are explored. We devote particular attention to a familiar conflict that arises with special urgency when early data suggest that the experimental treatment is superior. Should the trial be stopped so that participants in the control group will not be allocated a seemingly inferior treatment, or should it continue in pursuit of evidence conclusive enough to improve the care of future patients? We scrutinize three ways to address this problem. Rather than dissolving the tension, they represent different trade-offs between the respective welfare interests of subjects and future patients.     

Theism, Blame And Perfection

Blame and also punishment do not reach many agents in the sense that many agents are not motivated to ethically self-correct, and in fact, may be worsened by these practices. The main reasons agents may not be reached by them are that (on the most plausible secular or naturalistic ethical theory) (a) the agent's second nature may make inaccessible to him a sound appreciation of ethical considerations, and (b) the fixity of mature character may make ethical self-correction practically impossible. Still, when they are ethically rationalized, blame and punishment seem to be requirements. Even the most plausible secular or naturalistic ethics involves an important kind of incompleteness and unclarity concerning this issue. The Jewish and Christian traditions involve conceptions of the accessibility of ethical considerations and also the possibility of character change (both ultimately grounded in grace) in ways that enable us to overcome the perplexity about blame and punishment. They are not 'good for nothing' even when they fail to improve agents. The religious traditions' conceptions of moral agency and the possibility of perfection enable us to see why there are reasons not to ethically 'write off' even persistently vicious agents. Moreover, we can see that the fulfilling of ethical requirements is an enabling condition for perfection that is not merely ethical. To highlight the contrast between the naturalistic view and the theistic view, Aristotle's moral psychology and moral epistemology are contrasted with those of Maimonides and Aquinas, both of whom borrow heavily from Aristotle, but fundamentally transform what they borrow.     

Behavioral equipoise: a way to resolve ethical stalemates in clinical research

Randomized trials depend on clinicians feeling that they are morally justified in allowing their patients to be randomized across treatment arms. Typically such justification rides on what has been called "clinical equipoise"--when there is disagreement of opinion among the community of experts about whether one treatment is better than another, then physicians can ethically enter their patients into a clinical trial, even if individual physicians are not at equipoise. Recent debates over prominent studies, however, illustrate that controversy can be easily created rather than dispelled by trials, with many clinicians choosing not to use the proven therapy until they receive more convincing evidence of its superiority. In such situations, we propose that a new standard of equipoise be used to guide decisions about the ethical justifications for research trials--a standard of behavioral equipoise. Under behavioral equipoise, a trial is potentially justifiable if it addresses behavioral resistance to prior scientific evidence.     

TOWARD A MULTIDIMENSIONAL APPROACH TO THE STUDY OF SELF-DISCLOSURE

In an effort to develop a multidimensional theory of self-disclosure, the present research considered two dimensions of disclosure content—degree of personalness (intimacy) and valence (positiveness or negativeness)—as well as gender of the discloser, timing of disclosure in relationship development, and the recipient of disclosure. In Study I, the variables of personalness and valence were manipulated through the use of prototypical disclosure statements with subjects blocked by sex. Subjects were asked to use a scale indicating phases of relationship development to rate when they would likely disclose statements. The analysis revealed significant main effects for all three factors: personal-ness, valence, and gender, as well as a significant interaction between personalness and valence. In Study II, personalness and valence were again manipulated, along with blocking for sex. The variable of disclosure recipient (target) was manipulated by asking subjects to separately indicate whether or not they would disclose each statement to five targets: stranger, acquaintance, parent, friend, and spouse. The analysis revealed significant main effects for three factors: personalness, valence, and target. All possible interactions of these variables were also significant. Due to the many consistencies between the findings of these two studies and the many highly significant interactions, it was concluded that a multidimensional approach to the study of self-disclosure is both justified and required.     

Feeling grateful to God: A qualitative inquiry

There is an expanding literature on the psychological and relationship effects of positive disclosure, whereby people who disclose about good things that happen to them benefit from this disclosure. Extending this research, we focused on what people identify as positive information about themselves and why they disclose this content to others. College students (190 men and 219 women) described what they considered to be a positive experience, feeling, or private aspect of themselves and whether or not they had disclosed this information to close others (mother, father, same-sex friend, and dating/intimate partner). They also described their reasons for disclosing and/or not disclosing to these relationship targets. Based on participants’ open-ended responses, we constructed taxonomies of positive information about the self and the reasons for and against disclosing this content. The research documents how different relationship contexts affect the disclosure of positive information and the reasons for these disclosure decisions.     

Temporal experience as metaphysically lightweight

Experience is the most primitive kind of intentional contact with reality. Metaphysical inquiry is one of the heights of human thought. It would not be surprising if experience was often silent on metaphysics, failing to offer support to one metaphysical disputant over the other, forcing them to fall back on nonexperiential considerations. I argue that the dispute between A- and B-theorists about time is a dispute about which experience is silent. B-theorists have typically conceded that the manifest image of time conflicts with how time turns out to be, on their own view of time. They have offered an array of accounts of why that conflict should not worry us. I argue here that these accounts are unconvincing. I also argue that they are unnecessary. Nothing about how time is experienced conflicts with B-theory. An independently plausible method for discovering what properties experience represents—the method of phenomenal contrast—implies that experience does not favor A-theory over B-theory.     

Ethics and public health emergencies: restrictions on liberty

Responses to public health emergencies can entail difficult decisions about restricting individual liberties to prevent the spread of disease. The quintessential example is quarantine. While isolating sick patients tends not to provoke much concern, quarantine of healthy people who only might be infected often is controversial. In fact, as the experience with severe acute respiratory syndrome (SARS) shows, the vast majority of those placed under quarantine typically don't become ill. Efforts to enforce involuntary quarantine through military or police powers also can backfire, stoking both panic and disease spread. Yet quarantine is part of a limited arsenal of options when effective treatment or prophylaxis is not available, and some evidence suggests it can be effective, especially when it is voluntary, home-based and accompanied by extensive outreach, communication and education efforts. Even assuming that quarantine is medically effective, however, it still must be ethically justified because it creates harms for many of those affected. Moreover, ethical principles of reciprocity, transparency, non-discrimination and accountability should guide any implementation of quarantine.     

Toward a better understanding of the process of disclosure events among people who stutter

PurposeThe purpose of this study was to identify components of disclosure events among people who stutter, and identify possible relations between these components in order to understand how disclosure events unfold.MethodTwelve adults who stutter participated in semi-structured interviews focused on disclosure of stuttering. Participants were purposefully selected due to their self-reported history of disclosing stuttering. Qualitative content analysis using a grounded theory approach helped to identify relevant themes and subthemes related to the process of disclosure of stuttering.ResultsThe findings describe the complex process of disclosure as being comprised of antecedents (including considerations about when and why to disclose), the disclosure event itself (including the content and form of the disclosure, most and least helpful methods of disclosure, as well as immediate listener reactions), and the perceived outcomes of the disclosure at individual, dyadic, and societal/contextual levels. These components of the process are linked and affect one another, resulting in a feedback loop. Disclosure methods are context-dependent and not mutually exclusive within individuals who stutter.ConclusionProfessionals and advocates gaining a more nuanced understanding of the process of disclosure events can increase their ability to help people who stutter make optimal decisions about disclosure. Making good disclosure decisions can help PWS improve their quality of life and reduce a variety of environmental communicative barriers.     

Altruistic Discourse in the Informed Consent Process for Childhood Cancer Clinical Trials

Scholars have debated the role that altruistic considerations play—and should play—in recruitment and decision-making processes for clinical trials. Little empirical data are available to support their various perspectives. We analyzed 140 audiotaped pediatric informed consent sessions, of which 95 (68%) included at least one discussion of how participation in a cancer clinical trial might benefit: 1) the pursuit of scientific knowledge generally; 2) other children with cancer specifically; and 3) “the future” and other vaguely defined recipients. Clinicians initiated most (80%) of these discussions of altruism. The enrollment rate of children in the clinical trial was high (83%) overall, but not higher among children whose parents were involved in an altruism-oriented discussion. These findings suggest that: (1) clinicians invoke a spectrum of altruistic considerations rather than a single monothematic notion of altruism, and (2) the effect of altruistic considerations on subsequent enrollment decisions is marginal. While further research on this topic is warranted, bioethical debate should strive to reflect the diversity of altruistic discourse in clinical research encounters and to place this discourse in the context of other, including nonaltruistic, considerations.     

Ethical Dilemmas of Confidentiality With Adolescent Clients: Case Studies From Psychologists

Navigating limits to confidentiality with adolescent clients can be ethically and professionally challenging. This study follows on from a previous quantitative survey of psychologists about confidentiality dilemmas with adolescents. The current study used qualitative methods to explore such dilemmas in greater depth. Twenty Australian psychologists were interviewed and asked to describe an ethically challenging past case. Cases were then used to facilitate discussion about the decision-making process and outcomes. Interviews were transcribed and analyzed using interpretive content and thematic analysis. Three key findings are discussed. First, it is of little use to perceive confidentiality dilemmas as binary choices (breach/don’t breach) because psychologists described 5 distinct options. These can be conceptualized on a spectrum of varying degrees of client autonomy, ranging from “no disclosure” (highest client autonomy) to “disclosure without the client’s knowledge or consent” (lowest client autonomy). Second, confidentiality dilemmas often involve balancing multiple and conflicting risks regarding both immediate and future harm. Third, a range of strategies are employed by psychologists to minimize potential harms when disclosing information. These are primarily aimed at maintaining the therapeutic relationship and empowering clients. These findings and the case studies described provide a valuable resource for teaching and professional development.     

For an indeterministic ethics. The emptiness of the rule in dubio pro vita and life cessation decisions

It is generally claimed that there exist exceptional circumstances when taking human life may be approved and when such actions may be justified on moral grounds. Precise guidelines in the medical field for making such decisions concerning patients who are terminally ill or have irreparable injuries incompatible with a bearable life, are difficult to establish. Recommendations that take the particular logical form of a rule, such as "in dubio pro vita", "when in doubt favour life") have been suggested and in some countries incorporated into legal texts (Germany). We claim here that such a rule is of no value since it is open-ended and always allows for doubt, and a decision to employ measures that would support human life could always be argued to be a valid choice. Preservation of this rule could be encouraged, but giving it the force of law may put physicians at risk, as they may be challenged for choosing to terminate life in otherwise ethically and medically uncontroversial circumstances.     

Ethical Considerations in Social Psychological Research: Is the Bogus Pipeline a Special Case?

The ethics of using deception in research are discussed, and Aguinis and Handelsman's (1997) arguments that research using the bogus pipeline (BPL), in particular, is unethical are reviewed and critiqued. Stances that view any deception research as unethical may be reasonable, and lead to the conclusion that BPL research is unethical. However, if the position taken is that deception research may be ethically acceptable, then there is no basis for concluding that BPL research is intrinsically unethical. The same considerations that are taken into account when deciding whether any deception in research is ethical apply to decisions about the ethical appropriateness of using the BPL.     

Healthcare,Responsibility and Golden Opportunities

When it comes to determining how healthcare resources should be allocated, there are many factors that could—and perhaps should—be taken into account. One such factor is a patient’s responsibility for his or her illness, or for the behavior that caused it. Policies that take responsibility for the unhealthy lifestyle or its outcomes into account—responsibility-sensitive policies—have faced a series of criticisms. One holds that agents often fail to meet either the control or epistemic conditions on responsibility with regard to their unhealthy lifestyles or their outcomes. Another holds that even if patients sometimes are responsible for these items, we cannot know whether a particular patient is responsible for them. In this article, we propose a type of responsibility-sensitive policy that may be able to surmount these difficulties. Under this type of policy, patients are empowered to change to a healthier lifestyle by being given what we call a ‘Golden Opportunity’ to change. Such a policy would not only avoid concerns about patients’ fulfilment of conditions on responsibility for their lifestyles, it would also allow healthcare authorities to be justified in believing that a patient who does not change her lifestyle is responsible for the unhealthy lifestyle. We conclude with a discussion of avenues for further work, and place this policy in the broader context of the debate on responsibility for health.