Clinical Ethics current issue

Focusing clinicians on ethics

Slowther, A. — Mon, 16 Nov 2009 17:45:09 PST

Ethics in collaborative global health research networks

Parker, M., Bull, S. — Mon, 16 Nov 2009 17:45:09 PST

Clinical Ethics Committee Case 8: Should we carry out a predictive genetic test in our young patient?

Newson, A. J — Mon, 16 Nov 2009 17:45:09 PST

Truth-telling in health care

Slowther, A. — Mon, 16 Nov 2009 17:45:09 PST

Competent minors and health-care research: autonomy does not rule, okay?

Biggs, H. — Mon, 16 Nov 2009 17:45:09 PST

A dearth of clinical research involving children has resulted in off-licence and sometimes inappropriate medications being prescribed to the paediatric population. In this environment, recent years have seen the introduction of a raft of regulation aimed at increasing the involvement of children in clinical trials research and generating evidence-based medicinal preparations for their use. However, this regulation pays scant attention to the autonomy of competent minors. In particular, it makes no provision for the ability of competent minors to consent to participate in medical research and is therefore at odds with best ethical practice. This article explores the tensions between law and ethics in relation to clinical research involving minors and concludes that greater respect should be given to the autonomy of those minors who are competent to decide for themselves.

Cutting through red tape: non-therapeutic circumcision and unethical guidelines

Shaw, D. — Mon, 16 Nov 2009 17:45:09 PST

Current General Medical Council (GMC) guidelines state that any doctor who does not wish to carry out a non-therapeutic circumcision (NTC) on a boy must invoke conscientious objection. This paper argues that this is illogical, as it is clear that an ethical doctor will object to conducting a clinically unnecessary operation on a child who cannot consent simply because of the parents’ religious beliefs. Comparison of the GMC guidelines with the more sensible British Medical Association guidance reveals that both are biased in favour of NTC and subvert standard consent procedures. It is further argued that any doctor who does participate in NTC of a minor may be guilty of negligence and in breach of the Human Rights Act. In fact, the GMC guidance implies that doctors must claim conscientious objection if they do not wish to be negligent. Both sets of guidelines should be changed to ensure an objective consent process and avoid confusion over the ethics of NTC.

Subject positions in research ethics committee letters: a discursive analysis

O'Reilly, M., Armstrong, N., Dixon-Woods, M. — Mon, 16 Nov 2009 17:45:09 PST

Ethical review of applications to conduct research projects continues to be a focus of scrutiny and controversy. We argue that attention to the actual practices of ethical review has the potential to inform debate. We explore how research ethics committees (RECs) establish their position and authority through the texts they use in their correspondence with applicants. Using a discursive analysis applied to 260 letters, we identify four positions of particular interest: RECs positioned as disinterested and responsible; as representing the interests of potential participants; as facilitating ethically sound, high-quality research; and as engaged in dialogue. These positions are used strategically to deflect criticism or complaint. This analysis has implications for reducing contestation between researchers and RECs, suggesting that more dialogic rather than hierarchical approaches to positioning might be helpful.

Experiencing bad treatment: qualitative study of patient complaints concerning their treatment by public health-care practitioners in the County of Stockholm

Wessel, M, Helgesson, G, Lynoe, N — Mon, 16 Nov 2009 17:45:09 PST

The aim of this study was to investigate patients' experiences of not being treated well in medical health care in Stockholm County, Sweden. The study was conducted by implementing qualitative content analysis using categorization of empirical material for 2006 and 2007 provided by the Patients' Advisory Committee (Patientnämnden) in Stockholm. Complaints about not being treated well accounted for 13% of all complaints to the Patients' Advisory Committee. A sample of those who complained about their medical treatment shows that about 30% of these complaints also involved experiences of being badly received. Categorization of the complaints about being badly treated resulted in the following 11 categories: (1) rude, aggressive or arrogant behaviour; (2) being ignored; (3) being denied examinations or treatments; (4) lack of empathy among personnel; (5) lack of respect for personal integrity; (6) lack of time/waiting time; (7) personnel not separating private issues from their professional role; (8) injustice and discrimination; (9) sexual harassment; (10) coercion and violence and (11) unspecified bad treatment. In relation to the total number of patients, women were over-represented in all categories. In conclusion, what patients react most strongly against is when health-care personnel treat them disrespectfully by not abiding by established social norms. The results indicate that the combination of failure in medical treatment and not receiving an apology often leads patients to complain to the Patients' Advisory Committee.

Confidentiality and consent in living kidney transplantation: is it essential for a donor to know that their recipient has HIV disease?

Elias, R. — Mon, 16 Nov 2009 17:45:09 PST

It is now possible for someone with HIV disease to receive a kidney transplant from a living donor, although there is evidence only about the short-term outcomes of such a procedure. A person with HIV disease may not wish to disclose their diagnosis to a potential kidney donor. This paper argues that disclosure of the diagnosis of HIV to the donor is not necessary for informed consent. Concerns about the relationship of trust between the clinical team and the donor hold weight in deciding whether disclosure is essential, though openness about the limited nature of informed consent may facilitate a trusting relationship in the absence of disclosure. In general, the recipient's medical information should be treated as confidential, thereby avoiding any need to distinguish between HIV and other medical conditions.

Substituted misjudgement

Woo, J. A, Prager, K. M — Mon, 16 Nov 2009 17:45:09 PST

Substituted judgement is often used in the absence of advanced directives to guide decision-making when patients lack decisional capacity. We present a remarkable case of family members exercising substituted misjudgement for a 42-year-old man hospitalized with multiorgan failure on life support. Feeling that their loved one would rather die than face severe disability, they elected to withdraw life support. Although this was done, the patient remained alive and recovered enough to clearly indicate his preference for life, even with severe disability. This case suggests that in instances of unusual quality-of-life judgements where the patient's wishes cannot be known with reasonable certainty, families and physicians should be very wary using substituted judgement to refuse life support. Unless there are strong considerations based on the patient's prior statements, actions and values to decline life support, it would seem ethically appropriate to continue treatment, even with substantial disability the likely outcome.

Splitting hairs over the definition of murder: Thomas Aquinas and the doctrine of double effect

Papanikitas, A. — Mon, 16 Nov 2009 17:45:09 PST

A recent article in the March 2009 edition of Clinical Ethics stated that, ‘In the Summa Theologica, Thomas Aquinas discusses how murder may be justified in self defence’, provided that killing is not intended. This statement is open to challenge on historical and semantic grounds, with respect to the writings of the 13th Century Roman Catholic philosopher Thomas Aquinas (1225–1274). A better appreciation of Aquinas' writings on this topic could inform the debate relating to medical end-of-life decisions. The normatively loaded word ‘murder’ is not applicable to Aquinas' conclusion on unintended homicide, nor is it applicable to unintended homicide in current law, which is by definition not murder.

Why I Wrote ... Holding On? Vacant Possession, Paternity, Double Trouble, Right to Die - novels addressing key medical ethical dilemmas

McHaffie, H. — Mon, 16 Nov 2009 17:45:09 PST