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Healthcare ethics committ challegne of change

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The lack of knowledge in clinical ethics has also been observed in an Ethiopian study that assessed the clinical ethics dilemmas faced by physicians working in public hospitals. One of the dilemmas concerned observed unethical or inappropriate care, and this was because the physicians lacked the skills for the procedures, did not know how to carry out the procedure or because no one had more advanced training [ 2 ].

These findings suggest the urgent need for educational interventions among bioethicists and HCPs in Africa to create awareness and improve decisions when deliberating on clinical ethics dilemmas. It is important for health professionals or bioethicists in Africa to establish the interest of professionals and to encourage interested individuals to pursue training in clinical ethics [ 20 ].

In a systematic review conducted by Ong et al. Furthermore, many CEC training programmes were not supported by host institutions which affected the sustainability of the programmes and long-term support of CEC trainees [ 1 ]. Therefore, it is important when such training programmes are established in Africa that they are supported by institutions to ensure uniformity and sustainability of training for their members to deliver their services effectively.

Another constraint mentioned was limited resources, which are also among the ethical challenges faced in South African healthcare [ 31 ]. Similarly, in a Tanzanian study, participants mentioned that they had few or no resources to assist them to resolve ethical issues when these arose [ 23 ]. There was a similar observation in an Ethiopian study, where resource scarcity influenced the physicians in numerous ways and forced them into ethically challenging situations [ 2 ].

This underscores the need for resources to establish CECs in Africa. The general lack of resources and poor awareness of CECs in African healthcare settings gives rise to clinical ethics dilemmas which would be best resolved by CECs.

Paradoxically, however, the lack of resources also mitigates against the training of staff in clinical ethics and the development of CECs. The majority of the participants mentioned that they were interested in establishing CECs in their institutions and countries. The participants in our study also indicated the kind of assistance which has previously been discussed, including financial assistance or funding in setting up CECs, capacity building and collaboration with other known CECs.

For example, for a CEC to be established members will require ethics education and this will need additional financial support for training [ 23 ]. In , the World Medical Association recommended that medical ethics should be included in all medical school curricula, including as a continuing professional development requirement [ 38 ].

Our findings suggest that a two-tiered approach might work well to encourage the establishment of CECs in Africa. While bioethicists are best placed to create interest in and to set up CECs, at the same time, health sciences education would benefit from bioethics training programs that include clinical ethics and research ethics.

We recommend that more studies are done to assess how CECs can be established in a sustainable manner in Africa. There are some limitations that must be taken into account when interpreting the results of this study.

There was a predominance of participants from countries such as Uganda, South Africa, Cameroon, etc. The reason for this could be that it was easier to obtain active email contacts from these countries. We aimed to get a minimum of one response per African country to include at least one representative from each country. In addition, it is possible that we could have missed HCPs or bioethicists that work within healthcare institutions or organizations that have CECs. Despite these limitations, this study demonstrates the need for future research on the use of established CECs among HCPs in African countries.

This study also investigated more detailed information using qualitative methodology research on awareness and perception of the participants regarding CECs in Africa. These findings will be published in a separate paper.

Expanding such funding opportunities to CECs is critical. A two-tiered approach to facilitate the establishment of CECs in Africa is recommended. This would involve the encouragement of bioethicists in Africa to stimulate CEC development in their institutions via conferences and networks while simultaneously increasing clinical ethics content in bioethics curricula at undergraduate and postgraduate levels in health sciences education.

The coronavirus pandemic has brought into sharp focus the pivotal role that CECs can play in hospitals. This may provide the impetus needed to create CECs in Africa.

The authors would like to thank all participants for their invaluable time in participating in the online survey.

KM was the principal investigator of the study and conceptualised, supervised the study, and contributed to writing the manuscript. SMK collected, analysed the data, and drafted the manuscript. LZ developed the protocol for REC submission and developing a survey. AK and SK participated in the reviewing and editing of the survey and the manuscript.

AEO reviewed, edited, and participated in the drafting of the manuscript. All authors read and approved the final manuscript. Participants gave written informed consent before they completed an online survey for the study. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Keymanthri Moodley, Email: az. Siti Mukaumbya Kabanda, Email: az. Leza Soldaat, Email: moc. Anita Kleinsmidt, Email: az.

Adetayo Emmanuel Obasa, Email: az. Sharon Kling, Email: az. Supplementary information accompanies this paper at BMC Med Ethics. Published online Nov Author information Article notes Copyright and License information Disclaimer.

Corresponding author. Received Jul 24; Accepted Nov 5. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material.

If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Associated Data Supplementary Materials Additional file 1. Survey instrument. Methods A descriptive study was undertaken using an online questionnaire via SunSurveys to survey healthcare professionals and bioethicists in Africa.

Results In total participants from 37 African countries completed the survey in December Keywords: Clinical ethics committees, Clinical ethics consultation service, Africa, Developing countries, Ethics, Clinical ethics, Dilemma.

Background In medical care, ethical dilemmas abound, adding complexity to decision-making for healthcare professionals HCPs [ 1 ]. Methods Study design and sampling A descriptive survey was conducted with HCPs and bioethicists representing 37 African countries during September —December Yes 83 Open in a separate window. Results Demographic information A total of people were invited to the research study and completed the online survey, yielding an overall response rate of Description of clinical ethics committees Most of the participants Yes 79 Yes 16 Discussion To our knowledge, this is the first study to examine the presence or existence of established CECs in Africa.

Study limitations There are some limitations that must be taken into account when interpreting the results of this study. Supplementary information Additional file 1. Acknowledgements The authors would like to thank all participants for their invaluable time in participating in the online survey. Availability of data and materials Anonymised datasets used during the current study are available from the corresponding author. Consent for publication Not applicable.

Competing interests The authors declare that they have no competing interests. Footnotes Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Contributor Information Keymanthri Moodley, Email: az. Supplementary information Supplementary information accompanies this paper at References 1.

Training clinical ethics committee members between and systematic scoping review. J Med Ethics. Clinical ethics dilemmas in a low-income setting: a national survey among physicians in Ethiopia. Ethics Committee education: report on a Canadian project. HEC Forum. Ethics committees and consultants. Handbook of clinical neurology. Amsterdam: Elsevier; Zaidi D, Kesselheim JC. Assessment of orientation practices for ethics consultation at Harvard Medical School-affiliated hospitals. Pape D.

Manning S The educational ladder model for ethics committees: confidence and change flourishing through core competency development. Morgenstern T, Richter G.

Experiential learning in clinical ethics consultation. Camb Q Healthc Ethics. Toward a model that encourages the recruitment of ethics consultants with clinical experience. Am J Bioeth. Can clinical ethics committees be legitimate actors in bedside rationing? Catlin A. The hospital ethics committee and the nurse.

Adv Neonatal Care. American Society of Bioethics and Humanities. Core competencies for healthcare ethics consultation. Glenview: American Society of Bioethics; Slowther A-M, Hope T. Clinical ethics committees: they can change clinical practice but need evaluation.

Br Med J. Clinical ethics committee. Br Med. Geppert C, Shelton W. Health Care Ethics Committees as mediators of social values and the culture of medicine. AMA J Ethics. Development of clinical ethics committees. Roles and responsibilities of clinical ethics committees in priority setting. Clinical ethics consultation in the transition countries of central and eastern Europe. Sci Eng Ethics. Importance of systematic deliberation and stakeholder presence: a national study of clinical ethics committees.

J Med Ethics Hist Med. Practice of clinical ethics in developing countries: about time to revisit. J Med Biomed Sci. Nandi PL. Ethical aspects of clinical practice. Arch Surg. Clinical ethics revisited. Do Tanzanian hospitals need healthcare ethics committees? South African J Bioeth Law. Mapping research ethics committees in Africa: evidence of the growth of ethics review of health research in Africa.

Dev World Bioeth. Global and local forces shaping the research agenda and the governance of research ethics. S Afr J Sci. Medical ethics in sub-sahara africa: Closing the gaps. Afr Health Sci. Kapiriri L. Medical ethics and bedside rationing in low-income countries: challenges and opportunities.

In: Clark PA, editor. Bioethics-medical, ethical and legal perspectives. InTech: Croatia; Table 1 shows the supportive questions. The SME model strives to reach a decision or an overall assessment of how the different elements of the value conflict are to be weighed against each other. In the Clinical Ethics Committee of the Region of Southern Denmark, the analysis includes arguments both pro and con in response to the ethical question posed at the beginning of the process.

When an ethical challenge has been analysed in the Committee, a written case-report of 5—8 pages is made. The case-reports are anonymized, and they serve two purposes. The other purpose is to make it possible also for members of staff at other hospitals, to learn from the case discussion.

Therefore the case-reports are made available on the intranet to all clinicians working in mental healthcare in the Region of Southern Denmark. As is the case in the deliberation process, the case-reports always conclude with arguments both pro and con a concrete way of resolving the ethical challenge. An example of this is example 1.

The pros and cons stated to the ethical question asked in example 1 are presented in the result section of this paper. As in example 1, by far the most cases analysed in the Committee are retrospective. A rare example of a prospective case is case number 8. The consequences of the deliberation process in example 8 are also presented in the result section. The thorough case-reports give good insight into the ethical challenges experienced by clinicians.

To extract the overarching topics of the case-reports, we used a qualitative content analysis [ 18 , 19 , 20 ], which is a good method to use when straightforward descriptions of phenomena are desired [ 21 ]. In the period —, 66 case reports were made, of which 55 are included. Eleven case reports have been left out: six are fictitious cases used for training purposes, two are summaries of meetings with little written material available, one case was presented by the patient representative, and two case reports are shaped as a short reply letter only.

First all 55 case-reports were read individually by the first and the second author — a psychiatrist and a philosopher respectively. The reports were read in an open inductive way, focusing on the content of the case-report [ 22 ]. After the individual reading of all case-reports, the first and the second author had several face-to-face meetings in order to reach a consensus about the overarching topics of all the case-reports.

Table 1 describes the abductive analytical process of condensing the original ten categories into the three overarching topics. During the dialogue at these meetings, a consensus was reached about the essence of the central ethical topic or question presented in each case. In this part of the process, the diverse professional and theoretical backgrounds of the two authors became evident; for example in the way that cases concerning the use of coercion were initially categorised differently by the two authors.

When are healthcare professionals obliged to intervene — using coercion — motivated by preventing neglect of care? These cases capture considerations about legitimacy of paternalistic interventions in the life of patients. When is it, for instance, indefensible not to use coercion? Despite the fact that a lot of the case-reports focused on the use of coercion, none of these cases were exclusively about the use of coercion.

A contributory means of identifying and naming the three overarching topics was reflections upon the understanding of ethical difficulties as happening in relations [ 23 , 24 ] both between individuals but also between individuals and the values existing within an institution or society.

Moreover, the analysis process was inspired by studies of the content of case-reports in other parts of the healthcare system [ 10 , 14 ]. Of special interest was a study presenting an overview of issues brought forward by participants in a moral case deliberation project in two elderly care organizations [ 25 ] Table 2. In the last part of the analysis, the first and the second author decided which case-reports best represented the typical ethical challenges and the diversity within the main topics; see Table 3 in the results section.

The diverse professional and educational backgrounds of both the first and the second author as well as the other three members of the research team was used to discuss the analytic process at various stages, to increase the validity by applying researcher triangulation [ 26 ]. In this section, the results of the qualitative content analysis will be presented. The results will be presented in three sections, each of which presents one of the three overarching topics: 1.

Clinicians and institutional aspects of mental healthcare. Table 3 shows the three overarching topics with typical examples of ethical challenges or case-reports within each of the main topics. It is important to remember, that the ethical challenges described are most often very complex, and may overlap with other ethical challenges, also among those categorized in another overarching topic. Example 7 is an illustrative example of multiple ethical challenges within one case-report.

The following presentation of the three overarching topics begins with a description of the main normative content of the overarching topic. Afterwards in each main topic, 4 case-reports are presented, illustrating the common ethical challenges within the each overarching topic. A characteristic of psychiatric disorders is that the capability of autonomous decision-making may be reduced.

This may result in actions that are potentially harmful — both to the health and quality of life of the patient and to other people. When clinicians witness and might prevent potentially harmful actions, they feel responsible. But what are the limits of their responsibility? But the risk of doing harm to the patient, by violating his integrity and his right of self-determination, is always present. The use of coercion may undermine their trust in the mental healthcare system.

As a consequence, a patient might be discouraged from turning to the mental healthcare system when needing help in the future. Example 1: Paternalism or respect for the way of life of a psychotic patient. A is a patient aged between 40 and 50 suffering from schizophrenia and alcohol abuse. A has been chronically ill for many years, hospitalised several times during the last years. Generally, when the condition deteriorates A unassisted contacts the mental hospital.

But once A is admitted, A wants to leave. Once treated at the hospital, A is discharged for follow-up treatment at the outpatient clinic. But A turns down their suggestions and initiatives, and for those reasons A is difficult to help. The municipality has refused to find A a group home where A could get care and support. Sometimes A shouts verbal threats, and some of the neighbours are scared of A. When it all gets too heated up, A vagabonds, also to neighbouring countries. The out-patient clinic wonders whether they are giving A the best possible treatment.

Is A suffering unnecessarily? The ethical question in the case-report is: Are clinicians in the out-patient clinic providing the best treatment for the patient? No, because A has psychotic symptoms, and therefore A is in no condition to make autonomous decisions. No, because A is a vulnerable person who needs help and the clinicians may be held liable for neglect of care if they refrain from treatment — if necessary they must use compulsory admission.

No, because A neighbours need protection against his threatening behaviour. This case — as many other cases — revolves implicitly around the possibility of using coercion. At the same time, the clinicians are deliberating on the possible harmful consequences of both using and refraining from using coercion. Sometimes clinicians are faced with patients afflicted in a serious way by mental illness and miserable social circumstances. Unavoidably they develop a relation to the patients.

They feel responsible for the patients and the possibilities the patients are given to live a life they find tolerable, and sometimes continued treatment may seem futile. The clinicians are afraid of contributing to neglect of care. Example 2: Powerlessness — when is further treatment futile? B is suffering from a severe personality disorder and has been admitted to the locked psychiatric ward for quite a while.

On a number of occasions, B has been physically restrained. Professionally, the clinicians are of the opinion that continued admission to their department does not constitute good treatment. But B refuses admission to the out-patient clinic. B also refuses to live in a group home.

The clinicians do not know what to do. B is suffering and doing a lot of harm, but the clinicians are unable to help B. The Committee reflects on the feeling of despair and powerlessness felt by the clinicians.

Where is the limit of their responsibility? What are the responsibilities of the patient, who is mentally ill but seldom psychotic? The clinicians are caught in a vicious circle, as they have a relation to this suffering patient. They feel obliged to help and to prevent neglect of care.

Together with example 9, this case illustrates that sometimes it may not be possible to help. Or the damage done by trying to help might outweigh the benefits. But when is it all right to conclude that all treatment possibilities have been exhausted? When is it best to conclude that for the time being treatment is futile? Is it possible to reverse such a decision? Sometimes the involvement of relatives or other third parties makes the cases even more difficult.

Example 3: Involvement of relatives: violation of patient autonomy in order to protect the relation with a son. C is a patient aged between 45 and 55 suffering from schizophrenia. C is committed to a mental hospital because C is psychotic suffering from persecutory delusions. C has an adult child D. C is sure that D is about to be killed by a terrorist attack because of C. C is also bothering the dentist, asking for consultations because of dental pain, which C believes to be caused by poisoning.

The clinicians are contacted by D. D is troubled by frequent telephone calls from C. D has in numerous years been safeguarding and helping C, but now D is asking the department to prevent the frequent telephone calls from C. But the patient is — although on psychotic grounds — worried about D. So confiscation might most likely lead to an increased use of sedatives and possibly psychical restraint.

Is the harm done to C worth the effort of trying to save the important relation to D? The Committee wonders whether the guidelines of the institution concerning reducing the use of physical restraint may have an influence on the decision of the health-care professionals in this situation. The next case raises an important question about the responsibility of clinicians when they experience actions performed by colleagues, which are questionable or criticisable.

Out of solidarity with the patient, when and how are clinicians obliged to intervene? And when are they bound by loyalty to defend the actions of a colleague or the mental healthcare institution? Example 4: Solidarity with the patient or respect for a decision made by a colleague. A nurse, with years of experience from an outpatient clinic, serves as a substitute in a locked psychiatric ward during a period of staff shortage.

Together with a colleague from the locked ward, she is called to perform an obligatory inspection of a patient in physical restraint. The patient needs to go to the bathroom. When entering the room, it immediately comes to the attention of the colleague that the leather belt used for physical restraint is far too slack. The colleague walks straight up to the bed and tightens the leather belt. But in the situation, she is disregarding the need of the patient to go to the bathroom.

In the view of the nurse, the colleague talks to the patient in a harsh way. The nurse is feeling uncomfortable about the tone of voice used by the colleague. The situation intensifies, and as a result the patient gives up wishing to go the bathroom. The nurse is stunned by the situation, and her own lack of intervention. The Committee reflects on the course of the action of the colleague. The environment in a locked ward may give rise to an increased focus on security.

But it still does not justify violation of the integrity of a patient already in a vulnerable and powerless situation. They discuss the challenge of the nurse balancing her feeling of solidarity with the patient against her feeling of loyalty to the colleague, who is a permanent staff member in the locked ward. What about the institutional conditions under which clinicians are expected to treat and care for their patients?

Ethical challenges may arise when clinicians must apply and balance various general conditions and rules in specific situations concerning an individual patient. Sometimes they experience the conditions of care as a barrier to treating patients in the best possible way.

The mental healthcare institutions are seen to be responsible for the conditions of care, even though these conditions may be a result of many different elements — some of them beyond the control of the mental healthcare institutions, such as legislation, allocation of financial resources or formulation of national clinical guidelines. Still, mental healthcare institutions are distinct organisations in society, with specific purposes and responsibilities.

A mental healthcare institution creates the organisational framework around the daily work and is responsible for local management of wards and clinics. On a day-to-day basis, the mental healthcare institutions provide the main operating conditions for the clinicians, and thus influence the quality of care.

Clinicians are expected to be loyal to the mental healthcare institutions and the conditions of care — for example physical conditions, but also written policies and guidelines, routines, budgets, and more informal local practices. Over the last decades, there has been a decrease in the number of beds in mental healthcare. At the same time, there has been rise in the number of patients in forensic psychiatry. In case of an exacerbation of mental illness in this group, and considering the risk of renewed criminal activity, these patients must be admitted to a locked psychiatric ward.

As a result of an overload of patients in the wards of forensic psychiatry, the general psychiatric hospitals receive increasing numbers of patients who should have been admitted to forensic psychiatry. In a locked ward in a general psychiatric hospital, the clinicians have experienced that three patients from forensic psychiatry have caused a serious change in the environment.

They are aggressive in speech and behaviour. One patient in particular has made it necessary to call the police to assist the clinicians several times. Another patient tricks a fellow patient into giving away personal belongings. The clinicians experience the situation as getting out of hand. They know staff levels are higher in forensic wards, and that the staff is better skilled to deal with this group of patients.

In this situation, the clinicians feel that the three patients are disrupting the ward, but they are afraid of stigmatising them. The clinicians feel unable to treat both the patients in the general psychiatric hospital and the three patients from the forensic ward in a good way.

The Committee reflects on the conditions of care that the clinicians have to work under. The clinicians feel unable to meet their duty to help their patients, and that is felt as a violation of their professional ethical standards.

Health legislation and written policies and guidelines also form part of the conditions of care, because they govern and direct the actions of the clinicians. Ethical challenges arise when the clinicians assess a specific clinical situation and find a way to act that differs from the one described in the guidelines.

They may experience that they are at risk of being criminalised for not following the guidelines. Laws or guidelines might be seen as an obstruction to choosing the best possible action. Sometimes the guidelines are self-contradictory and difficult to convert into specific action. In other situations, clinicians may find an individual judgement so difficult to make that they ask for a generalised practice — and more guidelines.

Example 6: When an action performed in the best interest of the patient might escalate and be contrary to health legislation. A clinician F employed in an out-patient clinic of child and adolescent psychiatry is treating E. E is a child with a hyperkinetic conduct disorder and Aspergers syndrome, and aged between 9 and The behavior of E is socially unacceptable. That is a part of the reason why E is admitted to the outpatient clinic. One day E is entering the neighboring out-patient clinic.

The waiting room is full of people. E enters and takes a cup of coffee. Then E walks around sprinkling coffee at the people in the waiting room. F discovers the incident, and tries to talk E into stopping. But E goes on, and F is in doubt what to do. Professionally the F is encouraged to use a playful physical intervention, motivated by the fact, that the E needs clear correction of his behavior.

But at the same time F knows, that the situation might escalate and get out of hand. F also knows that it is prohibited to use any kind of restraint in an outpatient clinic. In contrast the law may deprive E the good of learning more socially acceptable behavior. Is the harm done proportional to the good gained in the long run? The clinician is afraid of being criminalized. But what alternative possibilities of action are provided both professionally and organizationally to handle situations like this?

In other situations, clinicians see the guidelines as self-contradictory and preventing them from acting in accordance with their professional judgment. Example 7: How to act in the best interest of the patient in a context of conflicting guidelines. Patients admitted to the locked psychiatric ward as an emergency are sometimes unable to buy their cigarettes themselves. To what extent is the psychiatric ward responsible for making cigarettes available?

One ward was situated a long distance from the kiosk, and therefore had a box containing cigarettes. Patients could borrow cigarettes from the box, on the condition that they refilled the box when discharged.

That did not always happen. Controversies about the funding of the cigarettes arose, and the arrangement with the cigarette box stopped. The head of the department could not defend providing the patients with cigarettes due to a general guideline stating that smoking in public areas must decrease or stop. Moreover, psychiatric patients have an excess mortality rate from illnesses related to smoking. But clinicians felt that the timing of motivating patients to quit smoking was not right.

They experienced a rise in the use of sedatives, and potentially dangerous situations when patients dependent on nicotine for instance tried to steal cigarettes from their fellow patients. To prevent escalation of a potentially violent situation, a clinician chose to solve a specific situation by offering a patient one of her own cigarettes.

The Committee discussed the conflict between two conflicting guidelines. The clinicians found it difficult to convert the good intentions of diverging guidelines into real life actions. In other situations, clinicians ask the mental healthcare institutions for a generalised way of action in complex situations. Example 8: Generalised guidelines are asked for when individual professional judgement is too difficult.

In a clinic treating young people suffering from psychotic disorders, the clinicians often meet young women who are pregnant. It is difficult to build up a treatment alliance with them. But at the same time the clinicians feel as a burden the responsibility of the future child.

They are aware of their obligation to notify the municipality if they are worried about the wellbeing of the child. But at the same time, they perceive their treatment relation as important for both the young woman and for her unborn child.

They are afraid that a notification to the municipality may be seen as an act of disloyalty. The patients may lose all trust in the clinicians, putting the best possible treatment for their severe mental illness at risk.

To secure the treatment alliance, the clinicians may prefer not to inform the municipality, unless the reduced ability to take care of the baby is obvious. But this action may deprive patients of the help they are entitled to, leaving the clinicians with a great responsibility.

To avoid that the clinicians refrain from notifying the municipality, the team considers introducing a new practice. They want to tell all pregnant women that the clinicians will always inform the municipality.

In that way they disclaim their responsibility of assessing each case individually. The Committee reflects on the fact that the clinicians feel they are snitching on patients when they notify the municipality.

The Committee also deliberates on the wish of the clinicians to introduce a general guideline motivated by a wish to avoid this difficult individual clinical judgment. The Mental Health Act specifies that every patient must be seen as an individual person.

But the clinicians find it so difficult to make this individual judgment that they have asked for a generalised practice.

However, to ask for a general practice is to violate the Act, to avoid their own responsibility and pass on the problem to the municipality. As a result of the deliberations in the Committee, the clinicians became aware that by generalising all pregnant women with severe mental illness, they were violating the Act and the right of the patient to get an individual evaluation.

In the process, the clinicians gained a better understanding of the difficult ethical elements of cases involving pregnant women. As a consequence, they reflected on and became aware of the legitimacy of involving other clinicians more before deciding whether to notify the municipality or not. Patients often have important relations to other institutions as well, for instance somatic healthcare departments, the municipality or the police.

Clinicians may experience ethical challenges when they have to weigh such considerations against providing mental healthcare for their patients. New technology has entailed new ways of living and new ways of working — important examples being social media and electronic patient records.

These new technologies are motivated by values like openness, involvement of patients and quick and easy communication, which may challenge traditional values within mental healthcare like privacy and patient confidentiality. Example 9: When easy and quick access to electronic patient records might harm the patient. The process of making a diagnosis involves many clinicians working together. They depend on written facts and considerations documented in the hospital medical records.

A clinician who was responsible for the initial diagnostic tests and communication with a patient experienced an ethical challenge when the patient read about the diagnostic considerations in her electronic patient record before the clinician had had a chance to communicate the results to the patient herself. The Committee reflected upon the risk of violating the integrity of the patient, increasing the vulnerability of the patient and decreasing the trust in the healthcare system. The committee also discussed the risk of the clinicians censoring themselves when documenting in electronic medical records.

Likewise the committee reflected on the potential responsibility of patients not to read their medical record before the content had been communicated to them by a clinician.

Open access to medical records requires that patients know how to read the record and understand its multiple uses. If patients are to be asked not to read certain parts of their records, it will require adequate information from clinicians, and possibly also some technological changes limiting access to various parts of the electronic patient record. When using the electronic patient record, clinicians experience ethical challenges because they may unintendedly break patient confidentiality and their obligation to protect patient privacy and integrity.

Example To secure privacy of the patient, a psychiatrist refrains from documenting in the electronic patient record. A pregnant woman sees her psychiatrist G on a regularly basis. During a conversation, G reveals concerns regarding her reduced ability to take care of her future child. G also says that a psychiatrist has an obligation to notify the child protection services in the municipality if there are worries about the wellbeing of a child.

At present G is not sure about the graveness of the worries. At the end of their meeting, they agree to postpone the subject to a later meeting, and G agrees not to involve the municipality or anyone else at the moment. After the consultation, G documents in the electronic patient record. Among other things, G briefly writes down the concern that the patient may not have sufficient ability to take care of her future child.

Later the pregnant woman sees her midwife. During the preparation for the meeting, the midwife reads the electronic patient record.

At the consultation, the midwife mentions the worries of G, and agrees that involving the municipality is the right thing to do. When seeing G again, the woman is disappointed and feels her confidentiality has been violated, and that her privacy and integrity have not been protected. G thinks the accusation is unreasonable since G was just doing what G was supposed to do, documenting relevant matters in the medical record.

The Committee reflected on the risk of self-censorship by clinicians, and the potentially negative consequences for both patients and clinicians. The patients risk reduced quality of care. If the clinicians refrain from documenting important knowledge, they become vulnerable because they violate the laws and may be accused of negligence — all to secure the confidentiality of their patients. The Committee also reflected on the conflict of protecting the therapeutic relation for benefit the woman versus the responsibility of the midwife to safeguard the wellbeing of the unborn child.

Social media is another element of the surrounding society that poses ethical challenges to clinicians. The information existing on social media is in a way both private and public. Example Is the privacy of the patient violated when the social worker uses Facebook to obtain information?

H is a psychologist in the process of diagnosing a patient who has consulted H to discuss difficulties that may be interpreted as symptoms of a personality disorder. H is working on gaining the trust of the patient. Then H is contacted by a social worker from the municipality. The social worker suggests that there is a disproportion between the level of function presented by the patient in the Facebook profile and in the consultations with the psychologist. Thereby the social worker raises suspicions about the patient — maybe the patient is not as ill as pretends to be.

If that is the case, the patient must take part in a work ability testing programme, from which the patient has been exempted because of assumed mental vulnerability. H is dependent on gaining the trust of the patient if H is to succeed in finding the correct diagnosis. Usually H does not look up the Facebook profiles of patients. H thinks that it violates the privacy, integrity and autonomy of her patients. The interaction with the social worker causes a sense of mistrust against the patient to increase even though H does not find it well-founded.

That is not in the best interest of the patient. The Committee reflects that the parties involved use the Facebook profile for different purposes. The patient may give a false picture of a good life and a high level of functioning because the patient wants to avoid stigmatisation by friends.

The social worker uses it to discover if the patient is cheating the social services. The primary concern of the psychologist is the health of the patient, and the psychologist has doubts about the applicability of Facebook information. The psychologist is balancing the risk of undermining the trust of the patient and the interest of society to make sure that no one gets away with social welfare fraud.

As described above in examples 10 and 11, and below in example 12, different institutions have different tasks to perform in society.

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Such analysis promises more accurate diagnostic and therapeutic assessments, but assessments based purely on technology and data, no matter how accurate, lack an essential human touch. As healthcare data collection technology advances, the industry faces questions about how to handle automatically collected data.

For example, digital pills, also known as smart pills, are pharmaceuticals that contain an ingestible sensor that transmits data after the pill is consumed. The first digital pill to be approved in the United States was a form of the antipsychotic medication aripiprazole sold under the trade name Abilify in The technology offers a promising benefit for treating patients who struggle with medication adherence, but critics cite concerns about who should have access to such data and how it can be protected.

The advent of predictive and prescriptive algorithms that can analyze large amounts of data also increases the potential privacy risks associated with stored medical specimens. Medical researchers have long collected and stored blood and tissue samples for future research, but the value of biological samples has increased as advances have been made in genetics, genomics, and biotechnology.

Reusing stored biological samples and data collected from research participants in past studies, as well as samples collected from patients for clinical or diagnostic purposes, raises new issues about the responsibility of healthcare providers to obtain informed consent.

A patient may give permission to a healthcare provider or clinical researcher to use a tissue sample for one test, for example, but have no control over its use in future projects. The digitization of patient information provides enormous benefits. Because they hold large amounts of very personal data, they also carry the risk of privacy violation. Protecting patient data is a core responsibility of healthcare providers, and the federal law restricting release of medical information strictly regulates the handling of sensitive patient health information, but the field of population health complicates issues of patient privacy.

Population health is the analysis of health outcomes of large groups of people. The use and effectiveness of population health is increasing in the era of big data, which can be used to find links between diseases and specific environments or socioeconomic groups. Population health can discover widespread health problems or locate segments of the population that have a particularly high occurrence of a disease, for example.

Sharing patient data for secondary purposes, such as population health programs, requires either consent from the patient or anonymization of the data. However, even anonymized data can be misused. Through the practice of de-anonymization, or data re-identification, anonymous data can be compared with publicly available information and matched to an individual.

The same information that public health officials use to diagnose, treat, and promote public policies could potentially be used by insurance companies, lenders, marketers, landlords, and employers.

An analysis that reveals a high rate of a disease in a given population could be used to focus education and treatment efforts; it could also be used to adjust insurance coverage. Customized medicine refers to the creation of bioidentical limbs and organs to replace injured or missing ones. The related field of precision medicine, or personalized medicine, also uses genomic data.

Enabled by advances in the understanding of how unique molecular and genetic profiles make an individual susceptible to a particular disease, personalized medicine has applications in risk assessment, prevention, detection, diagnosis, treatment, and management of diseases. Customized medicine and other advanced treatments raise issues of income inequality and equal access to healthcare.

Advances such as DNA mapping and bioidentical organs hold the potential to lengthen lives dramatically, but treatments that are prohibitively expensive for many or most patients violate the tenets of health equity. Health administrators responsible for healthcare finance management decisions may be put in a position to question, for example, whether a drug needs to be prescribed or an imaging test needs to be done.

The risk of moral injury can be particularly high in a profit-driven healthcare environment where multiple factors other than patient care influence treatment decisions. The growing use of AI and robotics also raises issues of healthcare technology ethics. AI refers to the ability of computers to mimic human intelligence and learning. Potential medical applications include analysis of radiologic images. AI used for health-related predictive analysis relies on large, diverse datasets, including EHRs.

However, the ability of AI-powered tools to analyze virtually any dataset, from income data to criminal records, raises concerns about its potential for abuse. The Genetic Information Nondiscrimination Act of prohibits employers and health insurers from considering genetic information when making decisions such as hiring and firing or health insurance eligibility.

Robotics are already heavily used in healthcare; robot-assisted surgeries are now commonplace, and robotic prosthetics are advancing rapidly. However, some see a future where robots care for the sick and elderly and robotic enhancements provide patients with superhuman capabilities — applications with more problematic implications.

The evolution of robotics in healthcare beyond compensatory measures and into human enhancements raises issues of access and fairness for patients and challenges the definition of a healthcare provider. The outbreak of the COVID virus provides a grim illustration of ethical issues in pandemic planning and response. The daily loss of life caused by the virus created an immediate healthcare crisis, prompting a rush to develop a vaccine and the enactment of social distancing measures in countries around the world.

A rapid response during pandemics is crucial, but rushing healthcare efforts can add risk to processes such as drug trials. Deciding how much risk is justified under the circumstances is an ongoing debate. Lacking a vaccine, public health officials have fought the outbreak with social distancing measures that slow the spread of the disease, helping to mitigate outbreak spikes that overwhelm medical facilities and ultimately result in more lives lost.

When determining how strict such measures should be, lawmakers and public health officials must balance the good of communities against individual liberties, a literal life-and-death decision with substantial financial, political, and social ramifications.

However, despite its best intentions, PCC may not always be effective. This is where an ethics review can be helpful. In and , researchers in the Netherlands studied patients with two or more chronic conditions from seven primary care practices. The study looked at the following areas:. During the year of the study, the patients reported that their overall healthcare experience and satisfaction improved.

In the UK, two studies in and published in the Clinical Journal of the American Society of Nephrology investigated the impact of patient-centered care on patients who required dialysis.

Doctors offered different options to patients based on their needs and requirements. They offered advanced directive planning for patients as they needed it, rather than forcing it on them due to a health crisis. Doctors treating young adult kidney patients, on the other hand, after consulting with families and patients, offered personalized care, career counseling, and benefits counseling, which the clinic added to its services long-term.

Doctors diagnosed Mrs. Z with lymphoma. Z spoke limited English, so her grown son translated for her. In research, published in the Journal of Personalized Medicine , analysis was conducted of the literature dating back decades regarding person-centered care for patients with depression or anxiety. Researchers determined that PCC is more effective than traditional treatments for patients with these emotional disorders. In particular, the studies showed that patients who were given care that included personalized treatment and care planning, patient education, family involvement, and other aspects of PCC had more successful outcomes when compared to those who had traditional treatment programs.

When patients are treated under the guiding principles of PCC, they tend to have better outcomes. It can mean higher satisfaction levels with received care, which in turn can make patients more likely to return for follow-up care, annual appointments, and immunizations, improving their overall health. Patient-centered care is in line with the shift toward value-added care. Health experts have pointed out a number of potential ethical concerns with PCC. These can arise out of the personal connections that PCC fosters as well as the principle of shared decision-making.

Data security: The move toward electronic health records EHRs can put patient data at risk of data breaches. Shared decision-making: Ethical concerns include patients making uninformed decisions, and doctors having to negotiate treatment. Despite the potential conflict between healthcare ethics and PCC, ethical policies can be used to improve the patient-centered care model.

For example, the core principles of healthcare ethics are a match for the key principles of PCC: autonomy, beneficence, nonmaleficence, and justice.

Like healthcare itself, strategies for improving patient-centered care are not one-size-fits-all solutions. Treat patients with respect and thank them for their trust. Begin with empathy and establish open communication. Something as simple as making eye contact can go a long way.. Patients are at their most vulnerable when seeking healthcare. Including families and friends and welcoming their support can help patients through medical procedures. Enlisting family support has been shown to have a positive effect on reducing intensive care unit ICU delirium.

Stay open to questions from patients and their families. Keep patients aware of their care plan and involved in making decisions about their care.

Let patients know that feedback is welcome. Many hospitals use patient surveys to improve protocols. Patients may have come to doctors due to a physical illness, but they are vulnerable to mental and emotional health issues as a result. Using healthcare technology can help with care management and coordination.

Telehealth, scheduling, and EHRs can all be used to make care easier to access. Automated reminders can help patients remember their medications. Ethics in healthcare starts with leaders who understand the need for ethical decision-making throughout the industry. The online Master of Business Administration in Healthcare offered by Northern Arizona University in partnership with Dignity Health Global Education prepares future healthcare leaders with a strong curriculum that focuses on ethical policy in all of its coursework.

With courses covering accounting and financial management, strategy and leadership, and healthcare decision-making; an applied practicum; and direct engagement with healthcare professionals, students receive a holistic educational experience.

Find out how NAU can help you advance your career in healthcare leadership today. The healthcare industry continues to undergo a massive transition to value-based care, prioritizing health outcomes and patient experience in a way that has never been seen before.

This has opened the door for new care delivery models, payment models and technologies that put a greater emphasis on patient outcomes, engagement, adherence and empowerment. Sign up to receive monthly newsletters to learn all things DHGE, such as webinars, program launches and updates, scholarship information, and more!

By entering your mobile number you agree to receive notifications from DHGE Updates short code Message and data rates. Most Popular. Share on Study With Us. What is ethics in healthcare? Guiding principles Providing the appropriate care, treatment, and safety of patients is the guiding principle of the code of ethics in healthcare. Why is ethics important in the healthcare profession? For example: Ethical guidance can help doctors communicate with patients and their families on end-of-life decisions.

They can inform care considerations, especially in fast-paced emergency situations. When combined with patient-centered care, they can help create an environment of compassionate care that works for patients, their families, and providers. Some benefits of a code of ethics include:. What codes of ethics exist in healthcare? American Nurses Association The nine provisions of the nursing code of ethics require compassion and respect for patients, and call for nurses to make patients their first priority.

American College of Healthcare Executives The code of ethics for healthcare executives covers both management considerations and patient care concerns. What is the role of ethics committees in healthcare? Some of the issues that may be brought before an ethics committee include:. Emergency procedures:.

Human research:. Care rationing:. How do ethics impact the concept of patient-centered care? Principles of PCC include:. Coordination : Providers coordinate medical treatments and support services, as well as post-discharge care. Communication : Nurses keep patients informed of their clinical status, including post-discharge instructions. Emotional support : Illness and medical treatments can be frightening. Family involvement : Providers take the needs of families and caregivers into account.

Care access : Healthcare facilities make access to care as simple as possible, including access to scheduling, referrals, and transportation. Examples — and failures — of patient-centered care The benefits of patient-centered care are well-documented. Patients with multimorbidity In and , researchers in the Netherlands studied patients with two or more chronic conditions from seven primary care practices.

Dialysis patients In the UK, two studies in and published in the Clinical Journal of the American Society of Nephrology investigated the impact of patient-centered care on patients who required dialysis.