Fatores clínicos do bem-estar de mulheres em parturição: perspectivas deontológicas e da bioética principialista / Clinical factors of women in labor well-being: deontological and bioethical principlism perspectives / Factores clínicos del bienestar de la mujer en trabajo de parto: perspectivas deontológicas y de la bioética principialista

Objetivo: avaliar os fatores clínicos associados ao bem-estar das mulheres durante o trabalho de parto e parto à luz da bioética principialista e da deontologia. Método: estudo transversal com abordagem quantitativa. Participaram 396 puérperas internadas em um hospital municipal do sudoeste da Bahia, e os dados foram coletados no período de janeiro a maio de 2023, após aprovação do comitê de ética em pesquisa. Os dados foram organizados no software Excel e analisados via SPSS v.25. a partir da regressão logística multinomial. Resultados: a maior parte da amostra apresentou bem-estar com assistência em saúde, mulheres que tiveram parto realizado por profissionais não médicos apresentaram mais chances de níveis de bem-estar "adequado". E mulheres que não tiveram a via de parto cesárea apresentaram aumento de chances de bem-estar. Conclusão: é necessário que os profissionais reflitam sobre suas ações, condicionando-as à humanização no parto, em observância aos princípios bioéticos.

Objective: to evaluate the clinical factors associated with women's well-being during labor and delivery in the light of bioethics principlism and deontology. Method: a cross-sectional study with a quantitative approach was conducted. It involved 396 postpartum women admitted to a municipal hospital in the southwest of Bahia. Data were collected from January to May 2023, after approval from the research ethics committee. The data were tabulated using Excel software and analyzed using SPSS v.25 through Multinomial Logistic Regression. Results: majority of the sample exhibited well-being with health care assistance. Women who underwent delivery performed by non-medical professionals showed higher chances of "adequate" levels of well-being. Additionally, women who did not undergo cesarean delivery showed increased chances of well-being. Conclusion: It is necessary for professionals to reflect on their actions, conditioning them to the humanization of childbirth, according to bioethical principles.

Objetivo: evaluar los factores clínicos asociados al bienestar de la mujer durante el trabajo de parto y parto a la luz de la bioética y la deontología principialista. Método: estudio transversal con enfoque cuantitativo. Incluyó 396 puérperas ingresadas en un hospital municipal del suroeste de Bahía. Recolección de datos de enero a mayo de 2023, con aprobación del comité de ética en investigación. Los datos se tabularon en el software Excel y se analizaron mediante SPSS v.25. utilizando regresión logística multinomial. Resultados: la mayoría de las participantes de la muestra presentó bienestar con la atención para la salud; las que tuvieron partos realizados por profesionales no médicos tenían más probabilidades de tener niveles "adecuados" de bienestar; las que no tuvieron parto por cesárea tenían mayores probabilidades de tener bienestar. Conclusión: es necesario que los profesionales reflexionen sobre sus acciones y las adecuen para humanizar el parto, respetando los principios bioéticos.

Open optimism as an "embodied-health" ethic for the information era.

This article forms part of a series on "openness," "non-linearity," and "embodied-health" in the post-physical, informational (virtual) era of society. This is vital given that the threats posed by advances in artificial intelligence call for a holistic, embodied approach. Typically, health is separated into different categories, for example, (psycho)mental health, biological/bodily health, genetic health, environmental health, or reproductive health. However, this separation only serves to undermine health; there can be no separation of health into subgroups (psychosomatics, for example). Embodied health contains no false divisions and relies on "optimism" as the key framing value. Optimism is only achieved through the mechanism/enabling condition of openness. Openness is vital to secure the embodied health for individuals and societies. Optimism demands that persons become active participants within their own lives and are not mere blank slates, painted in the colors of physical determinism (thus a move away from nihilism-which is the annihilation of freedom/autonomy/quality). To build an account of embodied health, the following themes/aims are analyzed, built, and validated: (1) a modern re-interpretation and validation of German idealism (the crux of many legal-ethical systems) and Freud; (2) ascertaining the bounded rationality and conceptual semantics of openness (which underlies thermodynamics, psychosocial relations, individual autonomy, ethics, and as being a central constitutional governmental value for many regulatory systems); (3) the link between openness and societal/individual embodied health, freedom, and autonomy; (4) securing the role of individualism/subjectivity in constituting openness; (5) the vital role of nonlinear dynamics in securing optimism and embodied health; (6) validation of arguments using the methodological scientific value of invariance (generalization value) by drawing evidence from (i) information and computer sciences, (ii) quantum theory, and (iii) bio-genetic evolutionary evidence; and (7) a validation and promotion of the inalienable role of theoretic philosophy in constituting embodied health, and how modern society denigrates embodied health, by misconstruing and undermining theoretics. Thus, this paper provides and defends an up-to-date non-physical account of embodied health by creating a psycho-physical-biological-computational-philosophical construction. Thus, this paper also brings invaluable coherence to legal and ethical debates on points of technicality from the empirical sciences, demonstrating that each field is saying the same thing.

Genetic Enhancement, Human Rights, and Regioglobal Bioethics.

This article examines the cross-cultural bioethical concerns stemming from the potential use of CRISPR-Cas9 for genetic enhancement projects. It emphasizes the need to differentiate between basic and non-basic human rights when considering genetic enhancement, as recent international declarations lack this distinction. Basic rights possess a universal nature and are applicable across cultures, while non-basic rights are culturally specific and should be determined within respective regions. To illustrate this, the study explores the acceptance or rejection of non-basic rights related to genetic enhancement in two distinct cultural categories: Type-A and Type-B cultures. Type-A cultures predominantly adhere to a liberal moral framework, while Type-B cultures are rooted in Confucian morality. Additionally, the article argues for two basic rights in genetic enhancement: the right to be free from bodily harm and the right to be free from deception. These rights differ from non-basic rights and should be universally upheld in all cultures. By analyzing a hypothetical case and drawing parallels with the He Jiankui incident, the article investigates the violation of these two basic rights in each scenario, regardless of cultural context. Consequently, both cases should be unequivocally rejected in both Type-A and Type-B cultures.

Black bodies in phenomenological bioethics: cultural othering, 'Corporeal Uncanny' and ethical quandaries of black nurses in Take My Hand and Small Great Things.

The aims of the present article are twofold. First, it attempts to theorise the thematic and ontological intersection between phenomenological and black bioethics and proposes 'Ontic-Black Bioethics', a neologism to evince how the corporeal misconceptions (such as race construct, bodily othering and colourism) become the cultural impediment for black women healthcare professionals. The article draws specific insights from the philosophical anthropology of race, ranging from Richard Polt to Sarah Ahmed, to understand the epistemic structures of scientific racism. Second, it investigates how the racial attitudes of white healthcare professionals and supremacist patients towards black nurses can be potential triggers of cultural othering, corporeal burden and ethical quandaries by closely reading Take My Hand by Dolen Perkins-Valdez (2022) and Small Great Things by Jodi Picoult (2016). For this, the article relies on the theoretical frameworks of cultural phenomenology and somatic attention postulated by Thomas Csordas, Philipa Rothfield and other theoreticians of varying importance. While the corporeality of black nurses is replete with the images of biological misconception and racial-cultural constructs, the epistemic perspectives and literary representations underscoring their bodily and experiential agony have been scarcely examined through the lenses of bioethics. Thus, the article construes the corporeality of black nurses as the confluence of biological and cultural discourses under phenomenological bioethics.

[Do not resuscitate orders and limitation of therapeutic effort: Ethical challenges in healthcare teams in Chile]. / Orden de no reanimar y limitación del esfuerzo terapéutico: desafíos éticos en equipos sanitarios en Chile.

The purpose of this paper is to delve into the ethical aspects experienced by the healthcare team when they receive the directive to limit therapeutic effort or a do-not-resuscitate order. From an interpretative, qualitative paradigm with a content analysis approach, a process based on three phases was conducted: pre-analysis in which categories were identified, the projection of the analysis, and inductive analysis. During 2023, interviews were conducted in the clinical setting of a high-complexity hospital in Chile with 56 members of the healthcare teams from critical and emergency units, from which four categories emerged: a) the risk of violating patients' rights by using do-not-resuscitate orders and limiting therapeutic effort; b) the gap in the interpretation of the legal framework addressing the care and attention of patients at the end of life or with terminal illnesses by the healthcare team; c) ethical conflicts in end-of-life care; and d) efficient care versus holistic care in patients with terminal illness. There are significant gaps in bioethics training and aspects of a good death in healthcare teams facing the directive to limit therapeutic effort and not resuscitate. It is suggested to train personnel and work on a consensus guide to address the ethical aspects of a good death.

El propósito de este trabajo es profundizar en los aspectos éticos que experimenta el equipo de salud cuando reciben la indicación de limitar el esfuerzo terapéutico o la orden de no reanimar. Desde un paradigma interpretativo, cualitativo y con un enfoque de análisis de contenido, se realizó un proceso basado en tres fases: preanálisis en el que se identificaron las categorías, la proyección del análisis y el análisis inductivo. Durante 2023, se realizaron entrevistas en el entorno clínico de un hospital de alta complejidad en Chile a 56 miembros de equipos de salud de unidades críticas y urgencias, de las que emergieron cuatro categorías: a) riesgo de vulnerar los derechos de los pacientes al utilizar la orden de no reanimar, y limitación del esfuerzo terapéutico; b) brecha en la interpretación del marco legal que aborda la atención y cuidado de pacientes al final de la vida, o con enfermedades terminales por parte del equipo de salud; c) conflictos éticos de la atención al final de la vida; y d) el cuidado eficiente o el cuidado holístico en pacientes con enfermedad terminal. Existen brechas importantes en la formación en bioética y aspectos del buen morir en los equipos de salud que se enfrentan a la orden de limitar el esfuerzo terapéutico y no reanimar. Se sugiere capacitar al personal, y trabajar una guía de consenso para abordar los aspectos éticos del buen morir.

Refining research on access to gynecologic cancer care: The DIMeS framework.

BACKGROUND: Despite its importance, there is no consensus definition of access to care, and several fundamental philosophical questions about access remain unanswered. Lack of clarity impedes interventional research designed to develop and test methods of correcting barriers to access. To help remedy this problem, we propose a conceptual framework to help guide empirical research about access to gynecologic cancer care. METHODS: Relevant philosophical and empirical literature was reviewed and analyzed to highlight key elements needed to refine research on access to care. RESULTS: The DIMeS framework involves 1) choice and justification of a Definition of access to cancer care that will guide research; 2) Identification of essential gynecologic cancer care services for which access disparities are ethically unacceptable; 3) quantitative MEasurement of specific parameters that affect access to care; and 4) Selection of a target threshold on measured parameters above which access is acceptable. CONCLUSIONS: The DIMeS framework provides clarity and reproducibility for investigators seeking to develop and test interventions to improve cancer health equity. This framework should be considered for use in research on access to gynecologic cancer care.

The ethics of artificial intelligence systems in healthcare and medicine: from a local to a global perspective, and back.

Artificial intelligence systems (ai-systems) (e.g. machine learning, generative artificial intelligence), in healthcare and medicine, have been received with hopes of better care quality, more efficiency, lower care costs, etc. Simultaneously, these systems have been met with reservations regarding their impacts on stakeholders' privacy, on changing power dynamics, on systemic biases, etc. Fortunately, healthcare and medicine have been guided by a multitude of ethical principles, frameworks, or approaches, which also guide the use of ai-systems in healthcare and medicine, in one form or another. Nevertheless, in this article, I argue that most of these approaches are inspired by a local isolationist view on ai-systems, here exemplified by the principlist approach. Despite positive contributions to laying out the ethical landscape of ai-systems in healthcare and medicine, such ethics approaches are too focused on a specific local healthcare and medical setting, be it a particular care relationship, a particular care organisation, or a particular society or region. By doing so, they lose sight of the global impacts ai-systems have, especially environmental impacts and related social impacts, such as increased health risks. To meet this gap, this article presents a global approach to the ethics of ai-systems in healthcare and medicine which consists of five levels of ethical impacts and analysis: individual-relational, organisational, societal, global, and historical. As such, this global approach incorporates the local isolationist view by integrating it in a wider landscape of ethical consideration so to ensure ai-systems meet the needs of everyone everywhere.

Consideraciones bioéticas en el manejo de la esclerosis lateral amiotrófica: Una aproximación al quehacer fonoaudiológico

Introducción: La esclerosis lateral amiotrófica (ELA) es la forma más común de enfermedad degenerativa de motoneurona en la edad adulta y es considerada una enfermedad terminal. Por lo mismo, el accionar del fonoaudiólogo debe considerar el respeto a los principios bioéticos básicos para garantizar una asistencia adecuada. Objetivo: Conocer aquellas consideraciones bioéticas relacionadas al manejo y estudio de personas con ELA para luego brindar una aproximación hacia el quehacer fonoaudiológico. Método: Se efectuó una búsqueda bibliográfica en las bases de datos PubMed, Scopus y SciELO. Se filtraron artículos publicados desde 2000 hasta junio de 2023 y fueron seleccionados aquellos que abordaban algún componente bioético en población con ELA. Resultados: Aspectos relacionados al uso del consentimiento informado y a la toma de decisiones compartidas destacaron como elementos esenciales para apoyar la autonomía de las personas. Conclusión: Una correcta comunicación y una toma de decisiones compartida son claves para respetar la autonomía de las personas. A su vez, la estandarización de procedimientos mediante la investigación clínica permitirá aportar al cumplimiento de los principios bioéticos de beneficencia y no maleficencia, indispensables para la práctica profesional.

Introduction: Amyotrophic lateral sclerosis (ALS) is the most common form of degenerative motor neuron disease in adulthood and is considered a terminal disease. For this reason, the actions of the speech therapist must consider respect for basic bioethical principles to guarantee adequate assistance. Objective: To know those bioethical considerations related to the management and study of people with ALS to then provide an approach to speech therapy. Methodology: A bibliographic search was carried out in the PubMed, Scopus, and SciELO databases. Articles published from 2000 to June 2023 were filtered and those that addressed a bioethical component in the population with ALS were selected. Results: Aspects related to the use of informed consent and shared decision-making stood out as essential elements to support people's autonomy. Conclusion: Proper communication and shared decision-making are key to respecting people's autonomy. In turn, the standardization of procedures through clinical research will contribute to compliance with the bioethical principles of beneficence and non-maleficence, essential for professional practice.

Translational Bioethical Decision-Making: Human Brain Organoids as a Case Study.

In an earlier essay, I advocated that translational bioethics uses the public's values, determined through social science, in its analysis of translational science technologies. It may be unclear what those values might be, and whether such a translational ethics would necessarily conclude that cutting edge technologies should not be developed. In this essay, I show the public's values relevant to human brain organoids and argue that a translational bioethics analysis using these values would support continued organoid research.

Troubling Trends in Health Misinformation Related to Gender-Affirming Care.

Amidst the misinformation climate about trans people and their health care that dominates policy and social discourse, autonomy-based rationales for gender-affirming care for trans and nonbinary youth are being called into question. In this commentary, which responds to "What Is the Aim of Pediatric 'Gender-Affirming' Care?," by Moti Gorin, we contextualize the virulent ideas circulating in misinformation campaigns that have become weaponized for unprecedented legal interference into standard health care. We conclude that the current legal justifications for upending gender-affirming care gloss over how this health care field meets conventional evidentiary standards and aligns protocols with most other fields of medicine. Refusal to offer gender-affirming care is more harmful than centralizing trans and nonbinary people's health autonomy.

Beneath the Sword of Damocles: Moral Obligations of Physicians in a Post-Dobbs Landscape.

Since the U.S. Supreme Court's decision in Dobbs vs. Jackson Women's Health Organization, a growing web of state laws restricts access to abortion. Here we consider how, ethically, doctors should respond when terminating a pregnancy is clinically indicated but state law imposes restrictions on doing so. We offer a typology of cases in which the dilemma emerges and a brief sketch of the current state of legal prohibitions against providing such care. We examine the issue from the standpoints of conscience, professional ethics, and civil disobedience and conclude that it is almost always morally permissible and praiseworthy to break the law and that, in a subset of cases, it is morally obligatory to do so. We further argue that health care institutions that employ or credential physicians to provide reproductive health care have an ethical duty to provide a basic suite of practical supports for them as they work to ethically resolve the dilemmas before them.

Anti-obesity Medications: Ethical, Policy, and Public Health Concerns.

New anti-obesity medications (AOMs) have received widespread acclaim in medical journals and the media, but they also raise critical ethical, public health, and public policy concerns that have largely been ignored. AOMs are very costly, need to be taken by a patient in perpetuity (since significant rebound weight gain otherwise occurs), and threaten to shift resources and focus away from other crucial efforts at obesity treatment and prevention. Many people may feel less motivated to exercise or reduce their caloric consumption, if they assume that obesity is now medically treatable. Policy-makers may similarly come to feel that the solution to the obesity pandemic is simply to prescribe medications and that prevention efforts are far less necessary. These drugs raise concerns about justice (since AOMs will disproportionately benefit the wealthy), medicalization, and marketing. Policy-makers, clinicians, and others need to engage in multipronged educational and policy efforts to address these challenges.

Nancy S. Jecker, Zohar Lederman, and Anita Ho reply.

This letter replies to the letter "Colonial and Neocolonial Barriers to Companion Digital Humans in Africa," by Luís Cordeiro-Rodrigues, in the same, May-June 2024, issue of the Hastings Center Report.

Better Conversations for Better Informed Consent: Talking with Surgical Patients.

For more than sixty years, surgeons have used bioethical strategies to promote patient self-determination, many of these now collectively described as "informed consent." Yet the core framework-understanding, risks, benefits, and alternatives-fails to support patients in deliberation about treatment. We find that surgeons translate this framework into an overly complicated technical explanation of disease and treatment and an overly simplified narrative that surgery will "fix" the problem. They omit critical information about the goals and downsides of surgery and present untenable options as a matter of patient choice. We propose a novel framework called "better conversations." Herein, surgeons provide context about clinical norms, establish the goals of surgery, and comprehensively delineate the downsides of surgery to generate a deliberative space for patients to consider whether surgery is right for them. This paradigm shift meets the standards for informed consent, supports deliberation, and allows patients to anticipate and prepare for the experience of treatment.

Colonial and Neocolonial Barriers to Companion Digital Humans in Africa.

This letter responds to the essay "Digital Humans to Combat Loneliness and Social Isolation: Ethics Concerns and Policy Recommendation," by Nancy S. Jecker, Robert Sparrow, Zohar Lederman, and Anita Ho, in the January-February 2024 issue of the Hastings Center Report.

Digital pathology implementation in cancer diagnostics: towards informed decision-making.

Digital pathology (DP) has become a part of the cancer healthcare system, creating additional value for cancer patients. DP implementation in clinical practice provides plenty of benefits but also harbors hidden ethical challenges affecting physician-patient relationships. This paper addresses the ethical obligation to transform the physician-patient relationship for informed and responsible decision-making when using artificial intelligence (AI)-based tools for cancer diagnostics. DP application allows to improve the performance of the Human-AI Team shifting focus from AI challenges towards the Augmented Human Intelligence (AHI) benefits. AHI enhances analytical sensitivity and empowers pathologists to deliver accurate diagnoses and assess predictive biomarkers for further personalized treatment of cancer patients. At the same time, patients' right to know about using AI tools, their accuracy, strengths and limitations, measures for privacy protection, acceptance of privacy concerns and legal protection defines the duty of physicians to provide the relevant information about AHI-based solutions to patients and the community for building transparency, understanding and trust, respecting patients' autonomy and empowering informed decision-making in oncology.

Another "turn" in bioethics? A plea for methodological continuity.

A growing trend in bioethics highlights the importance of using big data science methods to advance normative insight. This has been called the "digital turn" in bioethics by Salloch and Ursin. Automated data processing can, for example, detect significant patterns of correlation that have escaped the attention of human scholars. Although we agree that such technological innovations could bolster existing methods in empirical bioethics (EB), we argue that it should not be conceptualized as a new turn but rather as a revivification, and possibly an amplification of entrenched debates in EB. We begin by highlighting some convergences between EB and digital bioethics that Salloch and Ursin seem to categorize as fundamental differences and end up with elaborating on some risks related to the integration of empirical findings with normative (philosophical) analysis in the digitalization trend.

For, against, and beyond: healthcare professionals' positions on Medical Assistance in Dying in Spain.

BACKGROUND: In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation. METHODS: We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model. RESULTS: We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy. CONCLUSIONS: There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

Another Defense of Abortion: What Transplant Ethics Tells Us about the Ethics of Abortion after Dobbs.

In 1971, two years before Roe v. Wade affirmed federal protection for abortion, Judith Jarvis Thomson attempted to demonstrate the wrongs of forced gestation through analogy: you awake to find that the world's most esteemed violinist is wholly, physically dependent on you for life support. Here, the authors suggest that Thomson's intuition, that there is a relevant similarity between providing living kidney support and forced gestation, is realized in the contemporary practice of living organ donation. After detailing the robust analogy between living kidney donation and gestation, we turn to current ethical guidelines incorporated in the United Network for Organ Sharing's requirements for legally authorized organ donation and transplantation. We conclude that if, as we-and Thomson-suggest, organ donation and gestation are relevantly similar, then the ethical framework supporting donation may aid in articulating ethical grounds that will be compelling in informing the legal grounds for a defense of abortion.

Minors Lack the Autonomy to Consent to Gender-Affirming Care: Best Interests Must Be Primary.

What ethically justifies the provision of invasive and irreversible treatments to minors? In this commentary, I examine this question in response to Moti Gorin's article "What Is the Aim of Pediatric 'Gender-Affirming' Care?," which critiques autonomy-based arguments for justification of gender-affirming care in minors. Minors generally lack sufficient autonomy to make significant medical decisions or major life decisions. For this reason, parents are generally their decision-makers, working with medical professionals to choose treatments that serve the best interests of the minor. Medical care in minors is justified by beneficence, not autonomy, and this should be no different for gender-affirming care. This severely undermines autonomy-based arguments for provision of gender-affirming care to minors. Given the lack of conclusive evidence for benefit, the nature of the treatment, and the fact that gender dysphoria in minors resolves spontaneously in most cases, there is presently insufficient justification for provision of such care to minors.