Equity in Clinical Care and Research Involving Persons with Disorders of Consciousness.

People with disorders of consciousness (DoC) are characteristically unable to synchronously participate in decision-making about clinical care or research. The inability to self-advocate exacerbates preexisting socioeconomic and geographic disparities, which include the wide variability observed across individuals, hospitals, and countries in access to acute care, expertise, and sophisticated diagnostic, prognostic, and therapeutic interventions. Concerns about equity for people with DoC are particularly notable when they lack a surrogate decision-maker (legally referred to as "unrepresented" or "unbefriended"). Decisions about both short-term and long-term life-sustaining treatment typically rely on neuroprognostication and individual patient preferences that carry additional ethical considerations for people with DoC, as even individuals with well thought out advance directives cannot anticipate every possible situation to guide such decisions. Further challenges exist with the inclusion of people with DoC in research because consent must be completed (in most circumstances) through a surrogate, which excludes those who are unrepresented and may discourage investigators from exploring questions related to this population. In this article, the Curing Coma Campaign Ethics Working Group reviews equity considerations in clinical care and research involving persons with DoC in the following domains: (1) access to acute care and expertise, (2) access to diagnostics and therapeutics, (3) neuroprognostication, (4) medical decision-making for unrepresented people, (5) end-of-life decision-making, (6) access to postacute rehabilitative care, (7) access to research, (8) inclusion of unrepresented people in research, and (9) remuneration and reciprocity for research participation. The goal of this discussion is to advance equitable, harmonized, guideline-directed, and goal-concordant care for people with DoC of all backgrounds worldwide, prioritizing the ethical standards of respect for autonomy, beneficence, and justice. Although the focus of this evaluation is on people with DoC, much of the discussion can be extrapolated to other critically ill persons worldwide.

Neuromodulation and Opioid Use Disorder: Ethical Opportunities for Canada.

Despite increased efforts of government and non-government organisations to intervene via harm reduction and education initiatives, the opioid crisis has continued to worsen and has been exacerbated by the COVID-19 pandemic. In British Columbia, Canada, opioid overdose deaths in 2021 are the highest ever recorded. Neuromodulation procedures such as deep brain stimulation and repetitive transcranial magnetic stimulation have gained traction as treatments for opioid use disorder in various countries such as Germany, the Netherlands, the United States and China. However, these treatment options have been met with apprehension from both clinicians and patients, likely owing to fear, stigma and reluctance to label addiction as a brain disorder. Further complicating this landscape are socio-demographic factors, as marginalised communities are disproportionately burdened by addiction, while having poor access to care and a history of distrust in the health system. This multifactorial challenge involving many sociocultural factors requires culturally sensitive, interdisciplinary approaches to ensure direct-to-brain innovations are implemented ethically and equitably. This review summarises the state of the science for using neuromodulation to treat opioid use disorder, as well as the available ethical discourse surrounding the expansion of clinical trials and eventual widespread clinical implementation. Additional ethics discussions highlight opportunities for the engineering and clinical evolution of neuromodulation for opioid use disorder trials.

Ethicolegal considerations of screening for brain injury in women who have experienced intimate partner violence.

The vast majority of women who experience physical intimate partner violence (IPV) will likely suffer a brain injury (BI) as a result of the abuse. Accurate screening of IPV-BI can ensure survivors have access to appropriate health care and other supports, but screening results may also impact them receiving fair and equitable treatment in the legal system, and the justice they deserve. We used semi-structured interviews, combined with a contrastive vignette that described a realistic but hypothetical scenario involving IPV with or without BI, to explore the impact of BI on parenting disputes. Participants were lawyers (n = 12) whose focus is family law. Results highlight the potential adverse consequences of a positive BI screen that are influenced by the legal responsibility of counsel, the legal aid status of the woman, ongoing family dynamics, and the expectations of society while the focus on the best interests of the child is retained. Taken together, the findings reflect the legal vulnerability of women in decision-making about their capacity to parent after a BI. We conclude with recommendations for the future of IPV-BI screening aimed at mitigating risk and equipping women to navigate a legal system that has disadvantaged them, both historically and in the current context.