The Ethical Dilemma of Balancing Confidentiality and Duty to Protect: A Case Report of Comorbid Schizophrenia and Cannabis Use Disorder with Homicidal Thoughts.

This is a report of a 29-year-old female with a history of Schizophrenia and Cannabis Use Disorder who presented with auditory hallucinations that asked her to kill her immediate supervisor. She presented the ethical dilemma many healthcare providers face in balancing the principles of patient confidentiality with the duty to protect and beneficence. The clinicians breached the patient's right to confidentiality to protect her supervisor by informing the supervisor, their manager, and the police. However, they also ensured her job security, which she risked in an environment where mental illness is highly stigmatized. This case highlights the importance of considering the ethical principles of disclosing confidential information, such as the Tarasoff I and II, and beneficence (as her job was protected) in making clinical decisions. It also summarizes the legal precedents established by the Tarasoff cases and the implications for clinical practice.

Management of Hypoplastic Left Heart Syndrome in Low-Resource Settings and the Ethics of Decision-Making.

Hypoplastic left heart syndrome (HLHS) is possibly the most challenging congenital heart defect to confront in any setting. The highly specialized infrastructure and resources needed to treat HLHS is not available in many low-resource settings. However, low-resource settings must not be assumed to be synonymous with low- and middle-income countries as national income is not necessarily indicative of a country's prioritization of healthcare resources. Besides, a low-resource setting may be institution-specific as well as country-specific. We have stratified institutional capabilities for addressing the requirements of treatment for HLHS into five levels based on the capacity for diagnosis, intervention, and post-discharge monitoring. Depending on institutional capabilities, children born with HLHS in low-resource settings experience a spectrum of outcomes ranging from death without diagnosis to the hybrid or Norwood stage 1 palliation. The decision-making is ethically challenging when resources are scarce and economic efficiency must be considered in the context of distributive justice. Even in settings that would be classified as resource-rich where survival after surgery and quality of life afterward keep improving, not every parent would choose surgical intervention for their hypothetical child with HLHS.

Coordination and Management of COVID-19 in Africa through Health Operations and Technical Expertise Pillar: A Case Study from WHO AFRO One Year into Response.

Background: following the importation of the first Coronavirus disease 2019 (COVID-19) case into Africa on 14 February 2020 in Egypt, the World Health Organisation (WHO) regional office for Africa (AFRO) activated a three-level incident management support team (IMST), with technical pillars, to coordinate planning, implementing, supervision, and monitoring of the situation and progress of implementation as well as response to the pandemic in the region. At WHO AFRO, one of the pillars was the health operations and technical expertise (HOTE) pillar with five sub-pillars: case management, infection prevention and control, risk communication and community engagement, laboratory, and emergency medical team (EMT). This paper documents the learnings (both positive and negative for consideration of change) from the activities of the HOTE pillar and recommends future actions for improving its coordination for future emergencies, especially for multi-country outbreaks or pandemic emergency responses. Method: we conducted a document review of the HOTE pillar coordination meetings' minutes, reports, policy and strategy documents of the activities, and outcomes and feedback on updates on the HOTE pillar given at regular intervals to the Regional IMST. In addition, key informant interviews were conducted with 14 members of the HOTE sub pillar. Key Learnings: the pandemic response revealed that shared decision making, collaborative coordination, and planning have been significant in the COVID-19 response in Africa. The HOTE pillar's response structure contributed to attaining the IMST objectives in the African region and translated to timely support for the WHO AFRO and the member states. However, while the coordination mechanism appeared robust, some challenges included duplication of coordination efforts, communication, documentation, and information management. Recommendations: we recommend streamlining the flow of information to better understand the challenges that countries face. There is a need to define the role and responsibilities of sub-pillar team members and provide new team members with information briefs to guide them on where and how to access internal information and work under the pillar. A unified documentation system is important and could help to strengthen intra-pillar collaboration and communication. Various indicators should be developed to constantly monitor the HOTE team's deliverables, performance and its members.

The willingness to participate in biomedical research involving human beings in low- and middle-income countries: a systematic review.

OBJECTIVES: To systematically review reasons for the willingness to participate in biomedical human subjects research in low- and middle-income countries (LMICs). METHODS: Five databases were systematically searched for articles published between 2000 and 2017 containing the domain of 'human subjects research' in 'LMICs' and determinant 'reasons for (non)participation'. Reasons mentioned were extracted, ranked and results narratively described. RESULTS: Ninety-four articles were included, 44 qualitative and 50 mixed-methods studies. Altruism, personal health benefits, access to health care, monetary benefit, knowledge, social support and trust were the most important reasons for participation. Primary reasons for non-participation were safety concerns, inconvenience, stigmatisation, lack of social support, confidentiality concerns, physical pain, efficacy concerns and distrust. Stigmatisation was a major concern in relation to HIV research. Reasons were similar across different regions, gender, non-patient or patient participants and real or hypothetical study designs. CONCLUSIONS: Addressing factors that affect (non-)participation in the planning process and during the conduct of research may enhance voluntary consent to participation and reduce barriers for potential participants.

OBJECTIFS: Analyser systématiquement les raisons de la volonté de participer à la recherche biomédicale sur les sujets humains dans les PRFI. MÉTHODES: Cinq bases de données ont été systématiquement recherchées pour des articles publiés entre 2000 et 2017 contenant le domaine de la «recherche sur des sujets humains¼ dans les «PRFI¼ et les déterminantes «raisons de la (non) participation¼. Les raisons mentionnées ont été extraites, classées et les résultats décrits de manière narrative. RÉSULTATS: 94 articles ont été inclus, 44 études qualitatives et 51 études à méthodes mixtes. L'altruisme, les avantages pour la santé personnelle, l'accès aux soins de santé, les avantages pécuniaires, les connaissances, le soutien social et la confiance étaient les principales raisons de la participation. Les principales raisons de la non-participation étaient les problèmes de sécurité, les inconvénients, la stigmatisation, le manque de soutien social, les soucis de confidentialité, la douleur physique, les soucis d'efficacité et la méfiance. La stigmatisation était une préoccupation majeure dans le cadre de la recherche sur le VIH. Les raisons étaient similaires dans les différentes régions, le sexe, les participants patients ou non-patients et les modèles d'étude réels ou hypothétiques. CONCLUSIONS: La prise en compte des facteurs qui affectent la (non) participation au processus de planification et au cours de la recherche peut renforcer le consentement volontaire à la participation et réduire les obstacles pour les participants potentiels.

Hidden dangers-prevalence of blood borne pathogens, hepatitis B, C, HIV and syphilis, among blood donors in Sierra Leone in 2016: opportunities for improvement: a retrospective, cross-sectional study.

INTRODUCTION: Transmissible blood-borne infections are a serious threat to blood transfusion safety in West African countries; and yet blood remains a key therapeutic product in the clinical management of patients. Sierra Leone screens blood donors for blood-borne infections but has not implemented prevention of mother-to-child transmission for hepatitis B. This study aimed to describe the overall prevalence of hepatitis B and C, HIV and syphilis among blood donors in Sierra Leone in 2016 and to compare the differences between volunteer versus family replacement donors, as well as urban versus rural donors. METHODS: Retrospective, cross-sectional study from January-December 2016 in five blood bank laboratories across the country. Routinely-collected programme data were analyzed; blood donors were tested with rapid diagnostic tests-HBsAg for HBV, anti-HCV antibody for HCV, antibodies HIV1&2 for HIV and TPHA for syphilis. RESULTS: There were 16807 blood samples analysed, with 80% from males; 2285 (13.6%) tested positive for at least one of the four pathogens. Overall prevalence was: 9.7% hepatitis B; 1.0% hepatitis C; 2.8% HIV; 0.8% syphilis. Prevalence was higher among samples from rural blood banks, the difference most marked for hepatitis C. The proportion of voluntary donors was 12%. Family replacement donors had a higher prevalence of hepatitis B, C and HIV than volunteers. CONCLUSION: A high prevalence of blood-borne pathogens, particularly hepatitis B, was revealed in Sierra Leone blood donors. The study suggests the country should implement the prevention of mother-to-child transmission of hepatitis B and push to recruit more volunteer, non-remunerated blood donors.

Evidence-based guidelines for supportive care of patients with Ebola virus disease.

The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.

A Structured Approach to End-of-Life Decision Making Improves Quality of Care for Patients With Terminal Illness in a Teaching Hospital in Ghana.

PURPOSE: To determine whether a structured approach to end-of-life decision-making directed by a compassionate interdisciplinary team would improve the quality of care for patients with terminal illness in a teaching hospital in Ghana. FINDINGS: A retrospective analysis was done for 20 patients who consented to participate in the structured approach to end-of-life decision-making. Twenty patients whose care did not follow the structured approach were selected as controls. Outcome measures were nociceptive pain control, completing relationships, and emotional response towards dying. These measures were statistically superior in the study group compared to the control group. CONCLUSIONS: A structured approach to end-of-life decision-making significantly improves the quality of care for patients with terminal illness in the domains of pain control, completing relationships and emotional responses towards dying.

Ethical Dilemmas Relating to the Management of a Newborn with Down Syndrome and Severe Congenital Heart Disease in a Resource-Poor Setting.

Decision-making regarding treatment for newborns with disabilities in resource-poor settings is a difficult process that can put parents and caregivers in conflict. Despite several guidelines that have helped to clarify some of the medical decision-making in Ghana, there is still no clear consensus on the specific moral criteria to be used. This article presents the case of a mother who expressed her wish that her child with Down syndrome should not have been resuscitated at birth. It explores the ethical issues at stake in both her misgivings about the resuscitation and her unwillingness to consider surgical repair of an atrioventricular (AV) canal defect. Knowing that children born with Down syndrome are able to pursue life's goals, should our treatment of complete AV canal defect in such children be considered morally obligatory, even in resource-poor settings like Ghana?

Controlling Sickle Cell Disease in Ghana--ethics and options.

Sickle Cell Disease (SCD) is a significant public health burden in Ghana. Recent studies indicate that 2% of Ghanaian newborns are affected by SCD; one in three Ghanaians has the hemoglobin S and/or C gene. As a means of controlling the disease, some authorities have recommended prenatal diagnosis (PND) and selective abortion. In the current era, SCD has a good prognosis and fairly reasonable quality of life. Advances in bone marrow transplantation have shown the disease is curable in selected patients. PND and selective abortion therefore raises a myriad of ethical dilemmas which are considered in this review. In the light of the demonstration of improved prognosis in recent times, PND and selective abortion appears to be applying capital punishment to the unborn child for "crimes" only the parents can be responsible for. In this review, we recommend control of SCD on three levels--preconception genetic testing and strategic reproductive choices, PND and education for carrier parents, and holistic management of persons with SCD. We emphasize the critical importance of self-management, especially self-awareness, in assuring a good quality of life for persons with SCD. We believe such an approach is cost-effective, and consistent with sound ethical principles and good conscience.