Toward a new clinical pragmatism: method in clinical ethics consultation.

In this paper, I leverage the pragmatist tradition in philosophy, the collective wisdom of scholarship in clinical ethics consultation, and earlier attempts to apply pragmatism in clinical ethics to develop a new vision of clinical ethics practice called New Clinical Pragmatism. It argues that clinical ethics methodology, from the New Clinical Pragmatist's perspective, amounts to the recommendation that consultants should customize a methodological approach, drawing on the various available methods, depending on the demands of the specific case, and should avoid attempts to identify a 'true' methodology but to the incoherence and inevitable failure of those attempts. I argue that pragmatism's emphasis on practical wisdom and experimentation allow the New Clinical Pragmatist to do this while avoiding irrationality in choosing methods. I discuss how the New Clinical Pragmatist gives a unique, constructive perspective on key aspects of clinical ethics consultation such as the choice of common morality vs. internal morality of medicine approaches, process standards, bioethics mediation, and narrative ethics, and suggest how New Clinical Pragmatism's relaxed approach to choice of methodology encourages consultants to balance attention to the particulars of the case with knowledge of what the many insightful scholars of clinical ethics methodology have found useful in the past. I also argue that New Clinical Pragmatism is consistent with efforts to professionalize clinical ethics consultation.

The Value of Explicit, Deliberative, and Context-Specified Ethics Analysis for Health Technology Assessment: Evidence From a Novel Approach Piloted in South Africa.

OBJECTIVES: This article explores the perceived value, including associated strengths and challenges, of using a context-specified ethics framework to guide deliberative health technology appraisals. METHODS: The South African Values and Ethics for Universal Health Coverage (SAVE-UHC) approach, piloted in South Africa, consisted of 2 phases: (1) convening a national multistakeholder working group to develop a provisional ethics framework and (2) testing the provisional ethics framework through simulated health technology assessment appraisal committee meetings (SACs). Three SACs each reviewed 2 case studies of sample health interventions using the framework. Participants completed postappraisal questionnaires and engaged in focus group discussions. RESULTS: The SACs involved 27 participants across 3 provinces. Findings from the postappraisal questionnaires demonstrated general support for the SAVE-UHC approach and content of the framework, high levels of satisfaction with the recommendations produced, and general sentiment that participants were able to actively contribute to appraisals. Qualitative data showed participants perceived using a context-specified ethics framework in deliberative decision making: (1) supported wider consideration of and deliberation about morally relevant features of the health coverage decisions, thereby contributing to quality of appraisals; (2) could improve transparency; and (3) offered benefits to those directly involved in the priority-setting process. Participants also identified some challenges and concerns associated with the approach. CONCLUSIONS: The SAVE-UHC approach presents a novel way to develop and pilot a locally contextualized, explicit ethics framework for health priority setting. This work highlights how the combination of a context-specified ethics framework and structured deliberative appraisals can contribute to the quality of health technology appraisals and transparency of health priority setting.

Patients with severe mental illness and the ethical challenges related to confidentiality during family involvement: A scoping review.

Background: Despite evidence on the significant potential value of family involvement during the treatment of patients with severe mental illness, research has shown that family involvement is largely underused. The duty of confidentiality is reported to be a key barrier to family involvement. To develop more insight into this barrier, this scoping review focuses on the following question: What are the reported ethical challenges related to confidentiality when involving family in the treatment of patients with severe mental illness? Methods: A systematic search into primary studies was conducted using the following databases: Medline (Ovid), PsycINFO (Ovid), CINAHL (EBSCO), and Web of Science core collection (Clarivate). The PICO (Population, Intervention, Comparison, Outcome) scheme and qualitative content analysis were used to make the ethical challenges more explicit. Results: Twelve studies-both qualitative and quantitative-were included. We identified the following main categories of ethical challenges: (1) the best interest of family members vs. confidentiality, (2) the patient's best interest vs. the right to confidentiality, (3) patient trust and alliance as a reason not to involve the relatives or not to share information, and (4) using confidentiality as a smokescreen. We also identified several subcategories and illustrative and concrete examples of ethical challenges. Conclusions: Through a systematic examination, we discovered various types of ethical challenges related to confidentiality when involving the family in the treatment of patients with severe mental illness. However, research on these ethical challenges and the constituents of these challenges remains limited and often implicit. An ethical analysis will create knowledge which may facilitate a more balanced and nuanced approach to respecting the principle of confidentiality while also considering other moral principles. The duty of confidentiality does not always have to be a major barrier to family involvement; this insight and using this ethical analysis in the training of healthcare professionals may benefit the patient, the family, and the services.

Morally-Relevant Similarities and Differences Between Assisted Dying Practices in Paradigm and Non-Paradigm Circumstances: Could They Inform Regulatory Decisions?

There has been contentious debate over the years about whether there are morally relevant similarities and differences between the three practices of continuous deep sedation until death, physician-assisted suicide, and voluntary euthanasia. Surprisingly little academic attention has been paid to a comparison of the uses of these practices in the two types of circumstances in which they are typically performed. A comparative domains of ethics analysis methodological approach is used in the paper to compare 1) the use of the three practices in paradigm circumstances, and 2) the use of the practices in paradigm circumstances to their use in non-paradigm circumstances. The analytical outcomes suggest that a bright moral line cannot be demonstrated between any two of the practices in paradigm circumstances, and that there are significant, morally-relevant distinctions between their use in paradigm and non-paradigm circumstances. A thought experiment is employed to illustrate how these outcomes could possibly inform the decisions of hypothetical deliberators who are engaged in the collaborative development of assisted dying regulatory frameworks.

Q-SEA - a tool for quality assessment of ethics analyses conducted as part of health technology assessments.

Introduction: Assessment of ethics issues is an important part of health technology assessments (HTA). However, in terms of existence of quality assessment tools, ethics for HTA is methodologically underdeveloped in comparison to other areas of HTA, such as clinical or cost effectiveness. Objective: To methodologically advance ethics for HTA by: (1) proposing and elaborating Q-SEA, the first instrument for quality assessment of ethics analyses, and (2) applying Q-SEA to a sample systematic review of ethics for HTA, in order to illustrate and facilitate its use. Methods: To develop a list of items for the Q-SEA instrument, we systematically reviewed the literature on methodology in ethics for HTA, reviewed HTA organizations' websites, and solicited views from 32 experts in the field of ethics for HTA at two 2-day workshops. We subsequently refined Q-SEA through its application to an ethics analysis conducted for HTA. Results: Q-SEA instrument consists of two domains - the process domain and the output domain. The process domain consists of 5 elements: research question, literature search, inclusion/exclusion criteria, perspective, and ethics framework. The output domain consists of 5 elements: completeness, bias, implications, conceptual clarification, and conflicting values. Conclusion: Q-SEA is the first instrument for quality assessment of ethics analyses in HTA. Further refinements to the instrument to enhance its usability continue.

QUALITY ASSESSMENT OF ETHICS ANALYSES FOR HEALTH TECHNOLOGY ASSSESSMENT.

OBJECTIVES: Although consideration of ethical issues is recognized as a crucial part of health technology assessment, ethics analysis for HTA is generally perceived as methodologically underdeveloped in comparison to other HTA domains. The aim of our study is (i) to verify existing tools for quality assessment of ethics analyses for HTA, (ii) to consider some arguments for and against the need for quality assessment tools for ethics analyses for HTA, and (iii) to propose a preliminary set of criteria that could be used for assessing the quality of ethics analyses for HTA. METHODS: We systematically reviewed the literature, reviewed HTA organizations' Web sites, and solicited views from thirty-two experts in the field of ethics for HTA. RESULTS: The database and HTA agency Web site searches yielded 420 references (413 from databases, seven from HTA Web sites). No formal instruments for assessing the quality of ethics analyses for HTA purposes were identified. Thirty-two experts in the field of ethics for HTA from ten countries, who were brought together at two workshops held in Edmonton (Canada) and Cologne (Germany) confirmed the findings from the literature. CONCLUSIONS: Generating a quality assessment tool for ethics analyses in HTA would confer considerable benefits, including methodological alignment with other areas of HTA, increase in transparency and transferability of ethics analyses, and provision of common language between the various participants in the HTA process. We propose key characteristics of quality assessment tools for this purpose, which can be applied to ethics analyses for HTA purposes.

The Development of a Humanitarian Health Ethics Analysis Tool.

UNLABELLED: Introduction Health care workers (HCWs) who participate in humanitarian aid work experience a range of ethical challenges in providing care and assistance to communities affected by war, disaster, or extreme poverty. Although there is increasing discussion of ethics in humanitarian health care practice and policy, there are very few resources available for humanitarian workers seeking ethical guidance in the field. To address this knowledge gap, a Humanitarian Health Ethics Analysis Tool (HHEAT) was developed and tested as an action-oriented resource to support humanitarian workers in ethical decision making. While ethical analysis tools increasingly have become prevalent in a variety of practice contexts over the past two decades, very few of these tools have undergone a process of empirical validation to assess their usefulness for practitioners. METHODS: A qualitative study consisting of a series of six case-analysis sessions with 16 humanitarian HCWs was conducted to evaluate and refine the HHEAT. RESULTS: Participant feedback inspired the creation of a simplified and shortened version of the tool and prompted the development of an accompanying handbook. CONCLUSION: The study generated preliminary insight into the ethical deliberation processes of humanitarian health workers and highlighted different types of ethics support that humanitarian workers might find helpful in supporting the decision-making process.

Uma nova metodologia docente em bioética: experiência da aplicação do portfólio com estudantes de medicina / Una nueva metodología docente en bioética: experiencia de la aplicación del portafolio con alumnos de medicina / A new teaching methodology in bioethics: experience of the application of portfolios with medical students

Hoje em dia não se pode negar a necessidade de dedicar tempo na formação curricular em bioética nas escolas médicas. O espaço curricular que se abre para o aprendizado da Bioética nas faculdades de medicina deveria impregnar toda a formação técnica e de habilidades do aluno, sem limitar-se às aulas teóricas. O sistema de portfólio aplicado à bioética consiste em metodologia simples, útil tanto para o aprendizado como para a avaliação do aluno, e oferece a possibilidade de discutir os questionamentos éticos que o estudante enfrente no seu dia a dia. Por este motivo, é passível de ser aplicado ao longo de todo o curso médico. Através de exemplos coletados com a utilização do portfólio num projeto com 64 alunos de 8 faculdades de Medicina do Brasil , foi possível observar como os alunos captam as questões éticas, e passam a estudá-las e refletir sobre elas, construindo assim seu próprio conhecimento.

Nowadays the necessity of dedicating time to curricular education in bioethics in medical schools is undeniable. Curricula that opens for Bioethics teaching in medical schools should impregnate the whole technical education and the development of skills by students, going thus beyond theoretical aspects. A portfolio system applied to bioethics is a simple, useful methodology both for teaching and for evaluating students, and makes possible to discuss ethical questions students face in their daily lives. For this reason, it may be applied during the entire medical education program. By means of examples collected using the portfolio in a project with 64 students of 8 Brazilian medical schools, it was possible to see how the students become aware of thical questions and begin to study and reflect about them, building this way their own knowledge.

No se puede negar hoy la necesidad de dedicar tiempo a la formación curricular en bioética en las escuelas médicas. El espacio curricular que se abre al aprendizaje de la Bioética en las facultades de medicina debería impregnar toda la formación técnica y de habilidades del alumno, sin limitarse a las aulas teóricas. El sistema de portafolio aplicado a la bioética consiste en una metodología simple, útil tanto para el aprendizaje como para la evaluación del alumno, y ofrece la posibilidad de discutir los cuestionamientos éticos del estudiante en su cotidiano. Por ese motivo, el sistema de portafolio puede ser aplicado a lo largo de todo el curso médico. Por medio de ejemplos recolectados con la utilización del portafolio en un proyecto con 64 alumnos de 8 facultades de Medicina brasileñas, fue posible observar como los alumnos captan las cuestiones éticas y pasan a estudiarlas y reflexionar acerca de ellas, construyendo así su propio conocimiento.

Ethical Anglysis for Tissue Engineering / 中国医学伦理学

Objective To explore the medical ethical problens in the research of tissue engineering and their clinical application.Methods According to the technical route of tissue engineering ,including seeding cells.scaffold materials,implantation in body,ethical problems and their disposal were dissussed.Results Patient's rights to know the facts of test,efficacy and security of clinical application must be fully ensured during implantation of seeding cells and scaffold materials to human body.Conclusion In needs to formulate related standard of tissue engineered products and perfect politics and regulations.