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Journal of Medical Ethics

Adélaïde Doussau, Christine Grady
Ethical concerns about randomising persons to a no-treatment arm in the context of Ebola epidemic led to consideration of alternative designs. The stepped wedge (SW) design, in which participants or clusters are randomised to receive an intervention at different time points, gained popularity. Common arguments in favour of using this design are (1) when an intervention is likely to do more good than harm, (2) all participants should receive the experimental intervention at some time point during the study and (3) the design might be preferable for practical reasons...
October 17, 2016: Journal of Medical Ethics
Verina Wild, Bridget Pratt
The ethics of health incentive research-a form of public health research-are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. 'Long term harms' are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term basis, persisting even once an incentive research project ends...
October 13, 2016: Journal of Medical Ethics
Amanda van Beinum, Laura Hornby, Sonny Dhanani, Roxanne Ward, Jane Chambers-Evans, Kusum Menon
Studying patients during the end of life is important, as it has the potential to lead to improvements in care for the dying. For patients who die after a controlled withdrawal of life-sustaining therapies in the intensive care unit, information about the natural history of death and the process of removing life support has additionally led to advances in practice for deceased organ donation. However, this unique population of severely critically ill and imminently dying patients has been difficult to study, largely due to assumptions made by research teams and ethics boards alike about the logistical difficulties of obtaining consent and completing research procedures before or during the process of withdrawal of life-sustaining therapies...
October 13, 2016: Journal of Medical Ethics
Rebecca C H Brown
Financial incentives may provide a way of reducing the burden of chronic diseases by motivating people to adopt healthy behaviours. While it is still uncertain how effective such incentives could be for promoting health, some argue that, even if effective, there are ethical objections that preclude their use. One such argument is made by Michael Sandel, who suggests that monetary transactions can have a corrupting effect on the norms and values that ordinarily regulate exchange and behaviour in previously non-monetised contexts...
October 13, 2016: Journal of Medical Ethics
David Shaw
This brief report describes the contribution of the UK Donation Ethics Committee to organ donation and transplantation in the UK, and explains why the committee has met an early demise.
October 12, 2016: Journal of Medical Ethics
Rosalind McDougall, Dominique Martin, Lynn Gillam, Nina Hallowell, Alison Brookes, Marilys Guillemin
Ethical concerns about therapeutic misconception have been raised since the early 1980s. This concept was originally described as research participants' assumptions that decisions relating to research interventions are made on the basis of their individual therapeutic needs. The term has since been used to refer to a range of 'misunderstandings' that research participants may have. In this paper, we describe a new concept-therapeutic appropriation Therapeutic appropriation occurs when patients, or clinicians, actively reframe research participation as an opportunity to enhance patients' clinical care, while simultaneously acknowledging the generalised research aims...
October 12, 2016: Journal of Medical Ethics
Dominic Wilkinson
Decisions about allocation of limited healthcare resources are frequently controversial. These decisions are usually based on careful analysis of medical, scientific and health economic evidence. Yet, decisions are also necessarily based on value judgements. There may be differing views among health professionals about how to allocate resources or how to evaluate existing evidence. In specific cases, professionals may have strong personal views (contrary to professional or societal norms) that treatment should or should not be provided...
October 12, 2016: Journal of Medical Ethics
Kalle Grill
Health incentive schemes aim to produce healthier behaviours in target populations. They may do so both by making incentivised options more salient and by making them less costly. Changes in costs only result in healthier behaviour if the individual rationally assesses the cost change and acts accordingly. Not all people do this well. Those who fail to respond rationally to incentives will typically include those who are least able to make prudent choices more generally. This group will typically include the least advantaged more generally, since disadvantage inhibits one's effective ability to choose well and since poor choices tend to cause or aggravate disadvantage...
October 5, 2016: Journal of Medical Ethics
Carleigh B Krubiner, Maria W Merritt
Conditional cash transfers (CCTs) present a promising approach to simultaneously tackle chronic poverty and poor health. While these programmes clearly embody beneficent aims, questions remain regarding the ethical design of CCTs. Limited guidance exists for the ethical evaluation of the defining feature of these programmes: the conditionalities. Drawing upon prominent public health ethics frameworks and social justice theories, this paper outlines five categories of morally relevant considerations that CCT programme designers should consider when assessing which behaviours or outcomes they select as conditionalities for payment: (1) likelihood of yielding desired health outcomes, (2) risks and burdens, (3) receptivity, (4) attainability and (5) indirect impacts and externalities...
October 5, 2016: Journal of Medical Ethics
Benjamin Pojer
In his recent paper, Adam Cureton presents a compelling case in support of the right of parents with disabilities to conceive and raise children. Cureton argues that (a) caring for a parent with a disability may be beneficial for a child and (b) the creation of a child with the intention of him/her being a carer for his/her disabled parent is objectionable. This response to Cureton's paper will focus on the creation of children with the purpose of them being carers for their disabled parents. I will respond to Cureton on three counts...
October 5, 2016: Journal of Medical Ethics
Brent Michael Kious
Paternalistic interference in autonomous decisions is typically impermissible. This has several explanations, among which is a view I call the agent-constitution of the good: that the autonomous agent not only knows what is best for herself, but determines what is best for herself through her desires, goals and so on (her aims). For instance, it might seem that if an autonomous person does choose not to take insulin for her diabetes, then not only is it inappropriate to force treatment upon her, it is also not in her best interest to take insulin...
October 5, 2016: Journal of Medical Ethics
Domnita O Badarau, Eva De Clercq, Tenzin Wangmo, Monica Dragomir, Ingrid Miron, Thomas Kühne, Bernice S Elger
Communication about diagnosis and medical treatment for children suffering from life-threatening illnesses is complex. It is a primary step in involving underage patients and families in care and lays the foundation for obtaining parental permission and patient assent for treatment. In practice child participation in care is often difficult to obtain due to patients' different and sometimes fluctuating preferences, but also parents' protective strategies. Physicians may be susceptible to parental wishes to limit information and feel uncomfortable discussing issues related to uncertainty of cure with patients...
October 3, 2016: Journal of Medical Ethics
Euzebiusz Jamrozik, Toby Handfield, Michael J Selgelid
Mass vaccination has been a successful public health strategy for many contagious diseases. The immunity of the vaccinated also protects others who cannot be safely or effectively vaccinated-including infants and the immunosuppressed. When vaccination rates fall, diseases like measles can rapidly resurge in a population. Those who cannot be vaccinated for medical reasons are at the highest risk of severe disease and death. They thus may bear the burden of others' freedom to opt out of vaccination. It is often asked whether it is legitimate for states to adopt and enforce mandatory universal vaccination...
October 3, 2016: Journal of Medical Ethics
David S Oderberg
I explore the increasingly important issue of cooperation in immoral actions, particularly in connection with healthcare. Conscientious objection, especially as pertains to religious freedom in healthcare, has become a pressing issue in the light of the US Supreme Court judgement in Hobby Lobby Section 'Moral evaluation using the basic principles of cooperation' outlines a theory of cooperation inspired by Catholic moral theologians such as those cited by the court. The theory has independent plausibility and is at least worthy of serious consideration-in part because it is an instance of double-effect reasoning, which is also independently plausible despite its association with moral theology...
October 3, 2016: Journal of Medical Ethics
Tom O'Shea
This article develops a civic republican approach to medical ethics. It outlines civic republican concerns about the domination that arises from subjection to an arbitrary power of interference, while suggesting republican remedies to such domination in healthcare. These include proposals for greater review, challenge and pre-authorisation of medical power. It extends this analysis by providing a civic republican account of assistive arbitrary power, showing how it can create similar problems within both formal and informal relationships of care, and offering strategies for tackling it...
September 29, 2016: Journal of Medical Ethics
Steve Clarke
An analogy is sometimes drawn between the proper treatment of conscientious objectors in healthcare and in military contexts. In this paper, I consider an aspect of this analogy that has not, to my knowledge, been considered in debates about conscientious objection in healthcare. In the USA and elsewhere, tribunals have been tasked with the responsibility of recommending particular forms of alternative service for conscientious objectors. Military conscripts who have a conscientious objection to active military service, and whose objections are deemed acceptable, are required either to serve the military in a non-combat role, or assigned some form of community service that does not contribute to the effectiveness of the military...
September 29, 2016: Journal of Medical Ethics
Robert F Card
This paper builds upon previous work in which I argue that we should assess a provider's reasons for his or her objection before granting a conscientious exemption. For instance, if the medical professional's reasoned basis involves an empirical mistake, an accommodation is not warranted. This article poses and begins to address several deep questions about the workings of what I call a reason-giving view: What standard should we use to assess reasons? What policy should we adopt in order to evaluate the reasons offered by medical practitioners in support of their objections? I argue for a reasonability standard to perform the essential function of assessing reasons, and I offer considerations in support of a policy establishing conscientious objector status in medicine...
September 28, 2016: Journal of Medical Ethics
Jocelyn Maclure, Isabelle Dumont
In a thought-provoking paper, Schuklenk and Smalling argue that no right to conscientious objection should be granted to medical professionals. First, they hold that it is impossible to assess either the truth of conscience-based claims or the sincerity of the objectors. Second, even a fettered right to conscientious refusal inevitably has adverse effects on the rights of patients. We argue that the main problem with their position is that it is not derived from a broader reflection on the meaning and implications of freedom of conscience and reasonable accommodation...
September 28, 2016: Journal of Medical Ethics
D Carrieri, C Bewshea, G Walker, T Ahmad, W Bowen, A Hall, S Kelly
Current guidelines on consenting individuals to participate in genomic research are diverse. This creates problems for participants and also for researchers, particularly for clinicians who provide both clinical care and research to their patients. A group of 14 stakeholders met on 7 October 2015 in Exeter to discuss the ethical issues and the best practice arising in clinically based genomic research, with particular emphasis on the issue of returning results to study participants/patients in light of research findings affecting research and clinical practices...
September 27, 2016: Journal of Medical Ethics
Caspar Hare
How much risk can we expose our research subjects to? There is a special challenge answering this question when the evidence on which we base our assessments of risk is fragmentary, conflicting or sparse. Such evidence does not support precise assignments of risk (eg, there is a 24.8% chance that this patient will develop AIDS in the next year if she participates in my study). At best it supports imprecise assignments of risk (eg, there is between a 5% and 35% chance that this patient will develop AIDS in the next year if she participates in my study)...
September 26, 2016: Journal of Medical Ethics
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