ISSN / EISSN : 1477-7509 / 1758-101X
Published by: SAGE Publications (10.1177)
Total articles ≅ 673
Latest articles in this journal
Clinical Ethics; https://doi.org/10.1177/14777509221125340
In this article, we explore alternative conflict resolution strategies to assist families and clinicians in cases of intractable dissent in paediatric health care decision-making. We focus on the ethical and legal landscape using cases from the Australian jurisdiction in New South Wales, while referencing some global sentinel cases. We highlight a range of alternative means of addressing conflict, including clinical ethics support, and contrast and contextualise facilitative or interest-based mediation, concluding that legal intervention via the courts can be protracted and distressing and should be a ‘last resort’. We acknowledge many might view this as the current status quo, but we go further to recommend strategies optimal for all parties to recognise early signs of conflict and prevent its harmful escalation. While more empirical research is needed, we contend that interest-based mediation may be a valuable adjunctive method of conflict resolution. If judiciously distinguished from and utilised with clinical ethical support, it can be an effective tool to address dissent and its negative sequelae in paediatric healthcare decision-making.
Clinical Ethics; https://doi.org/10.1177/14777509221121107
The principle of clinical equipoise has been variously characterized by ethicists and clinicians as fundamentally flawed, a myth, and even a moral balm. Yet, the principle continues to be treated as the de facto gold standard for conducting randomized control trials in an ethical manner. Why do we hold on to clinical equipoise, despite its shortcomings being widely known and well-advertised? This paper reviews the most important arguments criticizing clinical equipoise as well as what the most prominent proposed alternatives are. In the process, it evaluates the justification for continuing to use clinical equipoise as the gold standard for randomized control trials.
Clinical Ethics, Volume 17, pp 221-224; https://doi.org/10.1177/14777509221113405
Clinical Ethics; https://doi.org/10.1177/14777509221117687
Introduction: Financial incentive schemes have been commonly used by the hearing aid industry as a way of encouraging device sales. These schemes can lead to a conflict of interest as the hearing device dispenser is torn between personal reward over the best interests of their client. This conflict of interest has the potential for the dispenser to develop “moral distress”, a negative state of mind when an individual’s ethical values contrast with those of the employing organization. The purpose of this study was to investigate if there was a relationship between financial incentives and moral distress in Australian audiologists and audiometrists. Methods: An online survey was distributed to all members of Audiology Australia and the Australian College of Audiology via email. Participants rated their perceived moral distress from 0 to 10 on the Moral Distress Thermometer and answered four questions about financial incentives in their respective workplace. Results: A total of 65 participants, 42 females and 23 males, completed the online survey. A quarter of participants rated their moral distress corresponding to levels of uncomfortable or above. A statistically significant association was found between financial incentives, sales target setting, and higher perceived moral distress in participants. Conclusions: For our sample, the implementation of financial incentives created ethical challenges for practicing audiologists and audiometrists. Modifications to employee rewards programs as well as a regulation of device sales are recommended.
Clinical Ethics; https://doi.org/10.1177/14777509221117683
Background: Doctors often deal with end-of-life issues other than assisted death, such as incompetent patients and treatment withdrawal, including food and fluids. Methods: A link to a questionnaire was sent by email three times, at one-week intervals, to the doctors registered in the Northern Section of the Portuguese Medical Association. Results: The questionnaire was returned by 1148 (9%) physicians. This study shows that only a minority of Portuguese doctors were willing to administer drugs in lethal doses to cognitively incompetent patients at the request of a family member or other close person, and even less would do it on their initiative. Most doctors favored the withdrawal of life support measures in advanced and progressive diseases at the patient’s request. Still, much fewer doctors agreed with the suspension of supportive life measures at the request of a family member, another close person, or by their own unilateral decision. However, fewer agreed with that action concerning the rest of the food and fluids. Portuguese doctors favor the administration of drugs for suffering control, even foreseeing they could shorten life. Conclusion: Most doctors in this study respect patients’ autonomy but disagree with measures decided by others that have an impact on patients’ survival. They also agree with the administration of drugs for suffering control, even considering the possibility of shortening life.
Clinical Ethics; https://doi.org/10.1177/14777509221117981
Minor-attracted persons raise multiple ethical and legal challenges. Sexual contact between adults and children is justly prohibited on child welfare grounds. Advances in technology raise the prospect of interventions for minor-attracted persons that have the potential to reduce harm to children by diverting would-be offenders to other endeavors that nonetheless may generate moral disgust This essay examines three of these potential harm reduction technologies (sex robots, haptic devices and synthetic child pornography) and raises the possibility that their use can be justified and their acceptance morally obligatory if doing so reduces harm to real children.
Clinical Ethics; https://doi.org/10.1177/14777509221117979
Infant A was born at term with an antenatal diagnosis of gastroschisis. His parents were well informed about the condition and understood that he would require surgery. However, at delivery, his bowel was found to be severely compromised. Infant A returned from theatre with only four centimeters of small bowel. This is physiologically devastating and easily qualifies as ultrashort bowel syndrome (USBS). Whilst the prognosis from ultrashort bowel syndrome is greatly improving, the condition continues to carry a significant risk of mortality and morbidity, in part attributable to treatment itself. The cornerstone of management of USBS is provision of intravenous parenteral nutrition (PN). This is not a physiologically normal route of nutrition; it is a medical treatment. Infant A’s parents questioned whether continuation of active treatment was appropriate. If a treatment is not in the patient’s best interests, then it can be argued it is not justified to administer it. Decisions about quality of life are intensely personal. Where there is a significant burden of treatment, even when there is a potential for increased survival, whether the course of treatment is in the child’s best interests must be taken with huge emphasis on the parental perspective and their family values. For well-informed, realistic parents who are welcoming of the full picture of information and implications of their decision, I argue that parents are best placed to make the decision for their child. Long-term PN for USBS may well be a medically encouraged treatment. However, it should not be medically mandated.
Clinical Ethics; https://doi.org/10.1177/14777509221104703
The current legal status and medical ethics of routine or religious penile circumcision of minors is a matter of ongoing controversy in many countries. We focus on the United Kingdom as an illustrative example, giving a detailed analysis of the most recent British Medical Association guidance from 2019. We argue that the guidance paints a confused and conflicting portrait of the law and ethics of the procedure in the UK context, reflecting deeper, unresolved moral and legal tensions surrounding child genital cutting practices more generally. Of particular note is a lack of clarity around how to apply the “best interests” standard—ordinarily associated with time-sensitive proxy decision making regarding therapeutic options for a medically unwell patient—to a parental request for a medically unnecessary surgery to be carried out on the genitalia of a healthy child. Challenges arise in measuring and assigning weights to intended sociocultural or religious/spiritual benefits, and even to health-related prophylactic benefits, and in balancing these against potential physical, functional, and psychosexual risks or harms. Also of concern are apparently inconsistent safeguarding standards being applied to children based on their birth sex categorization or gender of rearing. We identify and discuss recent trends in British and international medical ethics and law, finding gradual movement toward a more unified standard for evaluating the permissibility of surgically modifying healthy children's genitals before they can meaningfully participate in the decision.
Clinical Ethics; https://doi.org/10.1177/14777509221105457
Disorders of sexual development are a heterogeneous group of disorders in which chromosomal, gonadal or anatomical sex development is atypical. The majority of these children are recognized at birth by ambiguous genitalia. Legal and societal pressures require the physician and parents to assign sex rapidly. Though sex assignment is undebated in several disorders of sexual development, many others need an individualized approach to gender-related concerns. Gender dysphoria is prevalent in disorders of sexual development, and early gender-defining surgeries have potentially lifelong consequences. We use two cases, one of partial androgen insensitivity and another of simple virilizing congenital adrenal hyperplasia to illustrate that in disorders of sexual development, the ethical management principles remain the same at their core despite the vast differences in phenotypes. Sex assignment should maximize functional, psychological and sexual needs. Sex assigned should coincide with gender identity. We propose that we manage such children with the mutual participation of the physician, parents and the child. Though the parents and the physician have the child's best interests when making a decision, the child's developing autonomy should be protected. The communication of the health provider to the parent must be honest if early sex assignment is difficult.
Clinical Ethics; https://doi.org/10.1177/14777509221105746
No laws or official guidelines govern medical assistance for dying in Japan. However, over the past several years, cases of assisted suicide or voluntary euthanasia, rarely disclosed until recently, have occurred in close succession. Inspired by these events, ethical, legal, and social debates on a patient’s right to die have arisen in Japan, as it has in many other countries. Several surveys of Japanese people’s attitudes towards voluntary assisted dying suggest that a certain number of Japanese prefer active euthanasia. Against this background, it is important to discuss voluntary assisted dying cases in Japan and the Japanese views on them and to consider their implications. We review three recent Japanese voluntary assisted dying cases and discuss the various objections to voluntary assisted dying that have been published in response to these in various media outlets. Our counterarguments include the double suffering of people who are unable to give up their desire to die, individuality of death, variability of culture, problem of being an annoyance to (burden on) others, a slippery slope argument supporting voluntary assisted dying, and unfair claims about responsibility and excessive burden on people who are unable to give up their desire to die. We also point out the psychocultural and social problems in Japanese society that these objections reflect, and argue that voluntary assisted dying can be ethically acceptable under certain conditions. We conclude that Japanese society must change in order to enable those who sincerely wish to die to do so in a better way.