Conflictos éticos en los cuidados de Enfermería durante la pandemia por COVID-19 / Ethical conflicts in Nursing care during the COVID-19 pandemic

Objetivos: el objetivo principal fue identificar los conflictos éticos con los que se encontraron las/os enfermeras/os durante la pandemia por COVID-19 en España en el ámbito profesional.Método: se realizó un estudio cualitativo mediante etnografía para acercarse a la experiencia vivida por las/os enfermeras/os trabajando en España durante la primera ola de la pandemia COVID-19. Se empleó un muestreo intencional para seleccionar a 33 participantes, a quienes se contactó para llevar a cabo entrevistas no estructuradas por vía telemática. El análisis de los datos se efectuó mediante un enfoque temático que involucró la identificación de unidades de significado y la generación de códigos.Resultados: participaron 29 enfermeras/os, mayoritariamente mujeres trabajadoras en un hospital. Se identificaron tres conflictos éticos principales. El primero se relacionó con la “Priorización por edad: conflicto en el tratamiento equitativo”, que surgió debido a la limitación de recursos y la toma de decisiones difíciles. El segundo conflicto se denominó “Morir en soledad: conflicto con el trato humano del paciente”, ya que los familiares no podían acompañar a sus allegados al final de sus vidas por las restricciones de visita. El tercer conflicto fue “Cuidar con (in)seguridad: conflicto de poner al paciente, la enfermera y la familia en riesgo”, relacionado con la escasez de material de protección, lo que generó temor a posibles contagios tanto en el ámbito profesional como familiar.Conclusiones: la identificación de estos conflictos éticos subraya la necesidad de reorientar la ética del cuidado en salud para futuras pandemias por parte de los gestores de centros sanitarios. (AU)

Objective: the main objective was to identify the ethical conflicts faced by Nursing professionals during the COVID-19 pandemic in Spain in their professional setting.Method: a qualitative study was conducted through ethnography in order to approach the experience lived by Nursing professionals working in Spain during the first wave of the COVID-19 pandemic. Intentional sampling was used to select 33 participants, who were contacted to participate in non-structured online interviews. Data analysis was conducted with a thematic approach which involved the identification of units of meaning and the generation of codes.Results: the study included 29 Nursing professionals, mostly women, working at a hospital. Three main ethical conflicts were identified. The first was related to “Prioritization by age: conflict in equitable treatment”, which came up due to limited resources and difficult decision making. The second conflict was called “Dying alone: a conflict with the humane treatment of patients”, because relatives could not accompany patients at the end of their lives due to visiting restrictions. The third conflict was: “Care with (in)security: the conflict of putting patients, nurses and relatives at risk”, associated with the lack of protection materials, which generated fear of potential contagion both in the professional and the family setting.Conclusion: the identification of these ethical conflicts underlines the need to redirect the ethics of healthcare for future pandemics by health center managers. (AU)

Should Artificial Intelligence be used to support clinical ethical decision-making? A systematic review of reasons.

BACKGROUND: Healthcare providers have to make ethically complex clinical decisions which may be a source of stress. Researchers have recently introduced Artificial Intelligence (AI)-based applications to assist in clinical ethical decision-making. However, the use of such tools is controversial. This review aims to provide a comprehensive overview of the reasons given in the academic literature for and against their use. METHODS: PubMed, Web of Science, Philpapers.org and Google Scholar were searched for all relevant publications. The resulting set of publications was title and abstract screened according to defined inclusion and exclusion criteria, resulting in 44 papers whose full texts were analysed using the Kuckartz method of qualitative text analysis. RESULTS: Artificial Intelligence might increase patient autonomy by improving the accuracy of predictions and allowing patients to receive their preferred treatment. It is thought to increase beneficence by providing reliable information, thereby, supporting surrogate decision-making. Some authors fear that reducing ethical decision-making to statistical correlations may limit autonomy. Others argue that AI may not be able to replicate the process of ethical deliberation because it lacks human characteristics. Concerns have been raised about issues of justice, as AI may replicate existing biases in the decision-making process. CONCLUSIONS: The prospective benefits of using AI in clinical ethical decision-making are manifold, but its development and use should be undertaken carefully to avoid ethical pitfalls. Several issues that are central to the discussion of Clinical Decision Support Systems, such as justice, explicability or human-machine interaction, have been neglected in the debate on AI for clinical ethics so far. TRIAL REGISTRATION: This review is registered at Open Science Framework ( https://osf.io/wvcs9 ).

[National Consultative Ethics Committee: forty years of bioethics in France!] / Comité consultatif national d'éthique : quarante ans de bioéthique en France.

NATIONAL ADVISORY COMMITTEE ON ETHICS: FORTY YEARS OF BIOETHICS IN France. The history of the National Advisory Committee on Ethics for Life Sciences and Health (CCNE) shows its specificity, the evolution of its competences and its role in the institutional landscape of ethics in France, between independence and openness to the City. While constantly reaffirming its adherence to fundamental ethical principles, the CCNE has been marked by forty years of movements, crises and upheavals in the fields of health, science and society. What about tomorrow?

COMITÉ CONSULTATIF NATIONAL D'ÉTHIQUE : QUARANTE ANS DE BIOÉTHIQUE EN France. La spécificité du Comité consultatif national d'éthique pour les sciences de la vie et de la santé (CCNE) apparaît à travers son histoire, qui est celle de l'évolution de ses compétences et de son rôle dans le paysage institutionnel de l'éthique en France, entre indépendance et ouverture sur la Cité. Tout en réaffirmant sans cesse son adhésion à des principes éthiques fondamentaux, le CCNE a été marqué par quarante ans de mouvements, de crises et de bouleversement dans le champ de la santé, des sciences et de la société. Et demain ?

Animating Clinical Ethics: A Structured Method to Teach Ethical Analysis Through Movies.

Movies can serve valuable didactic purposes teaching clinical ethics to medical students. However, using film sequences as means to develop critical thinking is not a straightforward task. There is a significant gap in the literature regarding how to analyse the ethical content embedded in these clips systematically, in a way that facilitates the students' transition from anecdotal reflections to abstract thinking. This article offers a pedagogical proposal to approach the ethical analysis of film sequences in a systematic fashion. This structured stepwise method encourages students to identify the main ethical problem of a selected scene and to reflect on the theoretical principles involved, emphasizing the application of these norms and values in a contextually situated analysis. We believe this method in film studies both reinforces the students' comprehension of the theoretical framework of an ethical topic, and casts light on its pertinence and limitations under the circumstances of the scene, thus proving a constructive tool to strengthen the bridge between the theoretical teaching of clinical ethics and clinical practice.

Racionalidad y sensibilidad ética en el cuidado enfermero al paciente internado en un hospital público peruano de Nivel II-2 / Rationality and ethical sensitivity in nursing care for patients admitted to a Peruvian public hospital of Level II-2

Introducción: En enfermería, la vivencia ética connota ser siempre afectivo-reflexiva, al ejercerse en contextos de fragilidad y vulnerabilidad de los pacientes, exigiendo a los profesionales del cuidado y la salud a actuar con tales criterios beneficiando a las personas cuidadas. Objetivo: Describir la racionalidad y sensibilidad ética en el cuidado de enfermería al paciente de un hospital público peruano de nivel II-2. Material y métodos: Se asumió el enfoque cualitativo, de tipo descriptivo bajo diseño de análisis hermenéutico. La muestra fue de 15 enfermeros, obtenido en muestreo no probabilístico por conveniencia, quienes trabajaron en el área de Medicina Interna del hospital público mencionado. Se recolectó la información mediante entrevista semiestructurada aplicada por medios digitales, previo consentimiento informado. Los datos se procesaron a través del análisis de contenido. Resultados: a) Disponibilidad y esfuerzo hacia un cuidado compasivo y solidario, b) Equilibrando deberes y afectos hacia el bien global del enfermo, c) Comprensión interactiva, confianza y buen trato hasta el final de la vida. Conclusión: Los resultados destacan la capacidad de la enfermera para aplicar la afectividad, la empatía, la comunicación afectiva, la mirada atenta y el contacto físico; así como la disponibilidad para oír e interpretar las necesidades, además de comprender la angustia, sufrimiento, miedos y dolor de la persona cuando está internada en un nosocomio.

Background: In nursing, the ethical experience connotes being always affective-reflexive, when exercised in contexts of fragility and vulnerability of patients, requiring care and health professionals to act with such criteria, benefiting the people cared for. Objective:To describe the rationality and ethical sensitivity in nursing care for patients in a level II-2 Peruvian public hospital. Material and methods: The qualitative, descriptive approach was assumed under hermeneutic analysis design. The sample consisted of 15 nurses, obtained through non-probabilistic convenience sampling, who worked in the Internal Medicine area of the aforementioned public hospital. Information was collected through a semi-structured interview applied by digital means, with prior informed consent. The data was processed through content analysis. Results: a) Availability and effort towards compassionate and supportive care, b) Balancing duties and affections towards the global good of the patient, c) Interactive understanding, trust and good treatment until the end of life. Conclusion: The results highlight the nurse's ability to apply affectivity, empathy, affective communication, attentive gaze and physical contact; as well as the availability to listen and interpret the needs, in addition to understanding the anguish, suffering, fears and pain of the person when they are admitted to a hospital.

Transparent entscheiden im moralischen Dilemma: Ethische Entscheidungsempfehlungen zu Besuchsregelungen im Krankenhaus während der COVID-19-Pandemie.

Visitation restrictions in hospitals during the COVID-19 (coronavirus disease 2019) pandemic led to great psychological burden for patients, their relatives and employees. For hospitals, they represent a complex organizational challenge with respect to ethics. The present recommendations are intended to support decision-making at the meso- and microlevels.

The Totalising Nature of Secure and Forensic Mental Health Services in England and Wales.

This evidence-based opinion piece explores the totalising risk averse nature of secure and forensic mental health services and associated iatrogenic harms in England and Wales. Drawing on the research literature I consider the various influences, both external and internal which impact on the provision of such services and how both the therapeutic alliance and recovery potential for patients may be improved. Especial attention is paid to the deployment of restrictive practise, practitioner attitudes, the potential for non-thinking, and how these may impact on decision-making and the care and treatment of mentally disordered offenders.

Percepción de médicos intensivistas de adultos sobre el aporte de la consultoría ético-clínica / Opinion about clinical ethics consultation among intensivist physicians

Background: Clinical ethics consultation services and their methods vary and they are seldom evaluated. Only one formal system of individual clinical ethics consultation has been reported in Chile, with a ten-year registry. Aim: To evaluate the opinion of intensivist physicians about the contribution of clinical ethics consultation. Material and Methods: An anonymous and voluntary questionnaire consulting their opinion about clinical ethics consultations was sent to 38 intensivist physicians. Results: The questionnaire was answered by 28 professionals. Eighty four percent of respondents considered that ethics consultation contributed to improve patients' quality of care, 92% responded that this practice helps in decisions about limitation of treatments or life support, and 96% expressed that it also was a positive support for patients and their relatives. Seventy two percent of respondents considered that ethics consultations enhanced their ethical sensibility, 76% that they improved their understanding of clinical ethics topics, and 72% declared that it decreased their stress in complex decision-making. Conclusions: Clinical ethics consultation provides a positive support for improvements in clinical decision-making and in the quality of patients' care.

[Recommendations for ethical decision making regarding hospital visitation during the COVID-19 pandemic]. / Ethische Entscheidungsempfehlungen zu Besuchsregelungen im Krankenhaus während der COVID-19-Pandemie.

Visitation restrictions in hospitals during the COVID-19 (coronavirus disease 2019) pandemic led to great psychological burden for patients, their relatives and employees. For hospitals, they represent a complex organizational challenge with respect to ethics. The present recommendations are intended to support decision-making at the meso- and microlevels.

Virtudes del médico: ¿qué importancia le atribuyen los pacientes?

Background: Theoretically, the exercise of good medicine requires physicians who possess and practice virtues. There are good reasons to believe that virtue ethics would be highly appreciated by patients. Aim: To determine the importance that patients attribute to the possession virtues among physicians. Material and Methods: Patients hospitalized in a private and a public hospital were invited to answer a three-question survey. The questions were: first, what do you expect of a good physician? Second, please evaluate, in a scale from 1 to 5, the importance of physician virtues to consider him a good doctor (fidelity to trust given by the patient, benevolence, postponement of self-interests, compassion, intellectual honesty, justice and prudence). Third, among the seven former virtues, select the three more important, and then the most important of all. Results: Most patients responded that they valued that a good physician should have good communication skills, a cordial relationship, commitment to the patient and knowledge. All virtues studied were considered important or very important by almost all patients. The virtues considered the most important were intellectual honesty and fidelity to trust given by the patient. Conclusions: These results support the theoretical argument that, for patients, the practice of virtue ethics is essential for a good medical practice.

Attitudes About Informed Consent: An Exploratory Qualitative Analysis of UK Psychotherapy Trainees.

Background: Ethical informed consent to psychotherapy has recently been the subject of in-depth analysis among healthcare ethicists. Objective: This study aimed to explore counseling and psychotherapy students' views and understanding about informed consent to psychological treatments. Methods: Two focus groups were conducted with a total of 10 students enrolled in a Masters course in counseling and psychotherapy at a British university. Questions concerned participants' understanding of informed consent including judgments about client capacity; the kinds of information that should be disclosed; how consent might be obtained; and their experiences of informed consent, both as a client and as a therapist. Focus groups were audio-recorded, transcribed, and analyzed using qualitative content analysis. Coding was conducted independently by three authors. Results: Comments were classified into three main themes: (1) the reasons and justifications for informed consent; (2) informed consent processes; and (3) the hidden ethics curriculum. Some trainees expressed significant doubts about the importance of informed consent. However, participants also identified the need to establish the clients' voluntariness and their right to be informed about confidentiality issues. In general, the format and processes pertaining to informed consent raised considerable questions and uncertainties. Participants were unsure about rules surrounding client capacity; expressed misgivings about describing treatment techniques; and strikingly, most trainees were skeptical about the clinical relevance of the evidence-base in psychotherapy. Finally, trainees' experiences as clients within obligatory psychotherapy sessions were suggestive of a "hidden ethics curriculum"-referring to the unintended transmission of norms and practices within training that undermine the explicit guidance expressed in formal professional ethics codes. Some students felt coerced into therapy, and some reported not undergoing informed consent processes. Reflecting on work placements, trainees expressed mixed views, with some unclear about who was responsible for informed consent. Conclusions: This qualitative study presents timely information on psychotherapy students' views about informed consent to psychotherapy. Major gaps in students' ethical, conceptual, and procedural knowledge were identified, and comments suggested the influence of a hidden curriculum in shaping norms of practice. Implications: This exploratory study raises important questions about the preparedness of psychotherapy students to fulfill their ethical obligations.

Orientaciones éticas para la toma de decisiones médicas en el contexto de la pandemia de COVID-19 en Chile / Ethical guidelines for medical decision-making during COVID-19 pandemic in Chile

The catastrophic emergency experienced by many countries with the COVID-19 pandemic emphasized the importance of bioethics for decision-making, both at the public health (equitable and effective policies) and at the clinical level. At the clinical level, the issues are the fulfillment of medical care demand with adequate health care teams, infrastructure, and supplies, and to cover critical care demands that surpass the available resources. Therefore, ethically correct approaches are required for the allocation of life sustaining resources. There are recommendations for the allocating life support during disasters based on multiple considerations, including ethical ones. However, the ethical criteria of existing guidelines are variable. Ethical principles usually considered are saving the greatest number of lives, saving the greatest number of years of life and the principle of the life cycle or the goal to give each individual equal opportunity to live through the various phases of life. However, the centrality of the human being and the search for the common good should be considered. Knowledge of public perspectives and moral benchmarks on these issues is essential. A successful assignment effort will require everyone's trust and cooperation. Decision making should be planned and discussed in advance, since in-depth deliberation will be extremely complex during the disaster. Our goal is to help the health care teams to wisely allocate resources in shortage periods.

Live-case demonstrations in pediatric urology: Ethics, patient safety, and clinical outcomes from an 8-year institutional experience.

Purpose: Live case demonstrations have become a common occurrence at surgical meetings around the world. These demonstrations are meant to serve as an educational medium for teaching techniques, promote discussion, improve interventions and outcomes. Despite the valuable educational benefits, many authors still question the ethics of this approach. We present our 8-year experience in live surgery, discuss the ethical issues, and provide recommendations. Materials and Methods: We reviewed records of patients who underwent live robotic surgery during broadcasting events. Procedures performed were robot-assisted laparoscopic pyeloplasty (RAL-P), ureteral reimplantation (RALUR), and hemi-nephrectomy (RAL-HN). Peri- and post-operative outcomes were compared to our previously published case series. Results: From October 2011 to May 2019, the senior author (MSG) performed all live surgery demonstrations on 22 patients: 9 RAL-P, 9 RALUR, and 4 RAL-HN. Live RAL-Ps had a 100% success rate and lower 30-day Clavien-Dindo grade (CDG) III complications when compared to our previous case series (11.1% vs. 21.2%). RALURs performed during live demonstrations had a higher success rate than our previously published cohort (100% vs. 82%). RAL-HN operative time and length of stay were comparable to our non-live control group. Conclusions: Live surgery is a valuable didactic tool, but even experienced surgeons may be adversely affected by inappropriate case selection, technical difficulty, and anxiety associated with particular settings, such as operating at different institutions or working with unfamiliar surgical teams. We suggest consultation of an ethics review board and formulation of standard guidelines for patient selection, surgical equipment, and operative team.

Toma de decisiones y consideraciones éticas en el soporte ventilatorio en áreas críticas hospitalarias en el contexto de pandemia COVID-19 / Decision-making and ethical considerations in ventilatory support in critical hospital areas in the context of the COVID-19 pandemic

Objetivo. Los recursos hospitalarios resultan insuficientes ante la demanda de pacientes graves con COVID-19. La adecuada gestión de recursos es esencial para brindar la mejor atención posible. Se revisaron criterios que ayuden a tomar decisiones adecuadas y oportunas, siguiendo principios éticos. La priorización del soporte ventilatorio invasivo debe hacerse de manera transparente y objetiva, evaluando integralmente al paciente y basado en criterios objetivos como escalas de pronóstico, ciclo de vida o compromiso clínico. El tratamiento sintomático (incluyendo cuidados paliativos) es indispensable en esta pandemia y la comunicación con el aciente o la familia permiten humanizar la atención del personal de salud.

Objetive. Hospital resources are insufficient given the demand for seriously ill patients with COVID-19. Proper resource management is essential to provide the best possible care. Criteria to help make appropriate and timely decisions were reviewed, following ethical principles. The prioritization of invasive ventilatory support must be done in a transparent and objective manner, comprehensively evaluating the patient and based on objective criteria such as prognostic scales, life cycle or clinical commitment. Symptomatic treatment (including palliative care) is essential in this pandemic and communication with the patient or family makes it possible to humanize the care of health personnel.

[Clinical management of intersex conditions in France]. / Prise en charge de l'intersexuation en France.

Clinical management of intersex conditions in france. Although a better understanding of the nuances of the spectrum linking the normal to the pathological seems to be acquired today, some situations such as intersexuality remain problematic and impose legitimate questions about intervention modalities by medical profession. It is characterized by variations in sexual development both in the genital organs and overall sexual characteristics. Since the 1950s, its clinical management has been based on heavy medical procedures in the first years of life and throughout childhood and adolescence. These procedures such as repeated surgical operations, hormonal treatments and vaginal dilations are often not agreed by the child. In the early 2000s, there was an emergence of associations promoting interests of intersex people and a dissemination of intersex testimonies. They aiming to alert the public opinion by showing consequences and limitations of early systematic sexual conformation. These procedures, practiced and defended today by some specialists, are a subject of debate. Therefore, we propose an analysis of ethical stakes of this situation, which is part of the current debate on patient care modalities. A reorganisation of care pathway based on a well-reasoned and supervised bio-psycho-social approach would therefore emerge. This approach avoids systematic interventionism and allows patients to make free choices.

Prise en charge de l'intersexuation en france. Si une meilleure appréhension des nuances du spectre reliant le normal au pathologique semble acquise aujourd'hui, certaines situations comme celles de l'intersexuation demeurent problématiques et imposent des interrogations légitimes sur les modalités d'intervention du corps médical. Elle se caractérise par des variations du développement sexuel tant au niveau des organes génitaux que des caractéristiques sexuelles globales. Depuis les années 1950, sa prise en charge repose sur des actes médicaux lourds dans les premières années de vie et tout au long de l'enfance et l'adolescence, souvent non consentis par l'enfant, tels que des opérations chirurgicales répétées, des traitements hormonaux et des dilatations vaginales. Au début des années 2000, la naissance d'associations portant les intérêts de personnes intersexes et la diffusion de témoignages visant à alerter l'opinion publique ont mis en lumière les conséquences et limites de ce paradigme de conformation sexuée précoce systématique. Ces actes, pratiqués et défendus par certains spécialistes aujourd'hui, font donc l'objet de débats. C'est pourquoi nous proposons une analyse des enjeux éthiques de la situation s'inscrivant dans le débat actuel sur les modalités de prise en charge. Se dessinerait donc une réorganisation du parcours de soin fondé sur une approche bio-psycho-sociale raisonnée et encadrée permettant d'éviter l'interventionnisme systématique et de permettre un réel libre choix des patients.

Is presumed consent an ethically acceptable way of obtaining organs for transplant?

The near-universal acceptance of cadaveric organ donation has been based on the provision of explicit consent by the donor while alive, either in the form of a formal opt-in or informal discussion of wishes with next of kin. Despite the success of transplantation programmes based on explicit consent, the ongoing imbalance between demand and supply of organs for transplantation has prompted calls for more widespread introduction of laws validating presumed consent with facility for opt-out as a means of increasing organ availability. The Department of Health (UK) has recently concluded a consultation on the introduction of such a law for England. This article explores the debate on presumed consent from an ethical point of view and summarises the key arguments on both sides of the ethical divide.