Medical Ethics

In order for wireless body area networks to meet widespread adoption, a number of security implications must be explored to promote and maintain fundamental medical ethical principles and social expectations. As a result, integration of security functionality to sensor nodes is required. Integrating security functionality to a wireless sensor node increases the size of the stored software program in program memory, the required time that the sensor's microprocessor needs to process the data and the wireless network traffic which is exchanged among sensors. This security overhead has dominant impact on the energy dissipation which is strongly related to the lifetime of the sensor, a critical aspect in wireless sensor network (WSN) technology. Strict definition of the security functionality, complete hardware model (microprocessor and radio), WBAN topology and the structure of the medium access control (MAC) frame are required for an accurate estimation of the energy that security introduces into the WBAN. In this work, we define a lightweight security scheme for WBAN, we estimate the additional energy consumption that the security scheme introduces to WBAN based on commercial available off-the-shelf hardware components (microprocessor and radio), the network topology and the MAC frame. Furthermore, we propose a new micro-controller design in order to reduce the energy consumption of the system. Experimental results and comparisons with other works are given.

Objective: When a patient cannot make medical decisions for him or herself, and has not appointed a healthcare representative, default state healthcare consent laws determine who is able to make healthcare decisions for the patient. The narrow construction of some state laws leaves many patients in situations where the closest person to the patient does not qualify as a representative under the law, or where the patient has too many representatives and a consensus cannot be reached on the patient's medical care. Methods: In order to determine how state healthcare consent laws affect patient care in hospitals, a survey of 412 Indiana physicians was conducted. The data shows 53.8% of physicians experienced a delay in patient care because they were unable to identify a legally appropriate health care representative. Almost half (46.01%) of physicians experienced delay of patient care due to the inability to identify a final decision maker when disputes arose between multiple legal representatives. Conclusions: The results of this study have important implications for hospital administrators as a delay in patient care can be costly and unnecessarily utilizes hospital resources. Additionally, the results of this study have important implications for the status of state surrogate decision making laws. Amending state laws to include more potential surrogates, has the potential to minimize delays in patient care and ensure that appropriate surrogates are making medical care decisions for patients without the undue burden of court intervention.

The aim of this study is to explore whether specific ethical questions arise with the use of a shared electronic health record (EHR) system, based on the daily experience of primary care physicians (PCPs). Methods: In this qualitative research project, we conducted 14 in-depth semistructured interviews with PCPs in a tertiary hospital setting. Results: We identified 4 themes: 1) PCPs describe the EHR as a medicine with side effects, for which they provide suggestions for improvements; 2) A shared record raises ethical questions related to autonomy and trust; 3) Although use of the EHR often disturbs rapport with the patient, it can also support the patient-doctor interaction when it becomes an active part of the conversation; 4) A shared EHR may cause health care providers (and their relatives) to avoid seeking help for sensitive issues. Discussion: PCPs fear access to results could cause confusion and anxiety in patients, resulting in tensions between autonomy and beneficence. Improved efficiency and quality of care with a shared EHR relies on doctors trusting each other's input to avoid duplicate tests. However, this might compromise a fundamental skeptical attitude in practicing medicine, and we should be aware of a risk of increased confirmation and anchoring bias. The EHR is considered to be a work in progress-EHR design could be improved by examining physicians' coping strategies and implementing their suggestions for improvement. Ethical questions related to autonomy, trust, and the status of records that belong to doctor-patients need to be considered in future research and EHR development. (J Am Board Fam Med 2020;33:106 -117.

This Task Force document explores the ethical issues involved in the debate about the scope of genetic screening of gamete donors. Calls for expanded donor screening arise against the background of both occasional findings of serious but rare genetic conditions in donors or donor offspring that were not detected through present screening procedures and the advent of new genomic technologies promising affordable testing of donors for a wide range of conditions. Ethical principles require that all stakeholders' interests are taken into account, including those of candidate donors. The message of the profession should be that avoiding all risks is impossible and that testing should remain proportional.

Aim: Valid and reliable data are needed to gain insight into the decisions of paediatricians concerning the end of life of newborns and infants. Such data could throw light on the poorly documented aspects of medical practice regarding these end‐of‐life decisions (ELDs). In this article a classification of ELDs is developed. Methods: The classification is developed from knowledge generated from large‐scale epidemiological studies on ELDs. Results: This classification sets out from considerations of the various possible medical end‐of‐life procedures for newborns and infants and from important ethical aspects of the decision‐making process. From both ethical and legal viewpoints the life‐shortening intention of the physician is a significant factor for the qualification of ELDs. Furthermore, the consultation of the parents is an important factor in absence of the possibility of the patient's self‐determination. Conclusion: This classification has been devised with the aim of maki...

Resumen: La clonación humana por transferencia nuclear ha sido propuesta como solución para que el tratamiento con células madre embrionarias no produzca rechazo. Sin embargo, desde el punto de vista científico hasta ahora no es posible llevarla a cabo por las dificultades que conlleva la reprogramación celular, como se demostró a consecuencia del fraude en Corea del Sur. A pesar de esto y de la aparición de las células iPS (induced pluripotent stem cells) (1), que abren otro camino para el estudio de las enfermedades y su posible curación, aunque también podrían ser mal utilizadas, y a pesar de los grandes avances con células madre adultas, la ley española apuesta por la mal llamada "clonación terapéutica". Después de revisar algunos documentos internacionales y las leyes españolas sobre el particular, en este trabajo se trata de exponer los fundamentos éticos y filosóficos que se esgrimen para justificar la clonación por transferencia nuclear, como vía para investigar y alcanzar tratamientos a partir de las células de la masa interna del embrión clónico. Posteriormente, se realiza un análisis crítico desde la ética general y la bioética personalista. Palabras clave: clonación humana, transferencia nuclear, embrión clónico, bioética personalista.

More than twenty-five years have elapsed since the first Do Not Resuscitate (DNR) policies were proposed. A historical review of the application of DNR policies is provided with its rationale and perceived effects. A viewpoint is presented, that acceptance of implied consent for cardiopulmonary resuscitation (CPR) in hospitalized patients was responsible for drawing up of DNR policies. Unfortunately, the principle of informed consent as related to CPR and DNR policies, has had unintended consequences. Practical results do not indicate that medical practices have become more humane. Abuses of the process go beyond matters of style and experience, in communicating with surrogate decision-makers. Instead of generating compassion and respect for the patient, policies may contribute to cynicism and lack of caring amongst physicians. Overly optimistic dependence on advance directives to reform medical practices, appears unjustified. The concept of futility to limit demands for non-beneficial care is examined. It is unlikely that physicians can routinely invoke futility, as an argument to limit treatments. A re-examination of DNR policies as a defense against technologic imperative is warranted.

A survey was performed on behalf of the European Respiratory Society to assess end-of-life practices in patients admitted to European respiratory intermediate care units and high dependency units over a 6-month period. A 33-item questionnaire was sent by e-mail to physicians throughout Europe and the response rate was 28 (29.5%) out of 95. A total of 6,008 patients were admitted and an end-of-life decision was taken in 1,292 (21.5%). The mortality rate in these patients was 68% (884 out of 1,292). The patients received similar proportions of withholding of treatment (298 (23%) out of 1292), do-not-resuscitate or do-not-intubate orders (442 (34%) out of 1,292) and noninvasive mechanical ventilation as the ceiling of ventilatory care (402 (31%) out of 1,292). Withdrawal of therapy was employed in 149 (11%) out of 1,292 patients and euthanasia in one. Do-not-intubate/do-notresuscitate orders were more frequently used in North compared with South Europe. All of the 473 competent patients directly participated in the decision, whereas, in 722 (56%) out of 1,292 cases, decision-making was reported to be shared with the nurses. In European respiratory intermediate care units and high dependency units, an end-of-life decision is taken for 21.5% of patients admitted. Withholding of treatment, do-not-intubate/do-notresuscitate orders and noninvasive mechanical ventilation as the ventilatory care ceiling are the most common procedures. Competent patients are often involved, together with nurses.

Background and aims: The base of any relation between patients and physician is patients' needs for medical services. By providing the most needed medical services, the control of patients' diseases could be improved. The goal of the current study is to investigate the effect of patient-doctor relation on the health information seeking behavior of the patients. Methods: This is an applied cross sectional study. 362 diabetic

The relationship between law and ethics is possibly one of the most controversial subjects in any country all over the world. Dr Frenkel looks at some of the problems raised and relates how they would be treated in Israel under the law and ethical guidelines of the present time. He concludes by stating that, in his opinion, where the patient's body and integrity are not touched upon then statutory law may possibly take precedence over the rules of medical ethics. However, where the patient becomes the victim because domestic statutory laws are in opposition with medical ethics, Dr Frenkel feels that medical practitioners should stand by their professional codes and persuade the legislators to adapt theirs to the laws of humanity and public conscience.

Cette étude, accompagnée d’un volume d’annexes, est une réflexion sur la manière d’aborder le sujet aphasique, dans les contextes médical et de réadaptation auxquels il est confronté, dès le diagnostic de son atteinte : l’aphasie, ou perte du langage acquis, touche généralement l’adulte. Puisant aux sources de la philosophie, la réflexion initiale évoque la problématique d’une éthique couvrant le parcours médical et paramédical complexe de ce type de patient, pointant aussi certains obstacles spécifiques à l’éthique médicale, psychologique ou de l’éducation. Ensuite, une définition succincte de la neuropsychologie du langage est suivie d’une présentation de l’aphasie, propos adossé à l’étude d’un cas d’aphasie mixte, comportant une anamnèse familiale (médecine narrative) et une anamnèse médicale, puis un bilan neuropsychologique, narratif également, centré sur le langage : il s’agit de montrer que, de façon plus ou moins diffuse, le sujet aphasique, dans un état de maladie chronique...

Humans are social beings, namely beings who are naturally living in society. As social beings, humans need other humans who live in society. Realize it or not to fulfill their life needs in exercising the rights and obligations to obtain health. Organizing effective and efficient health efforts requires health information, health information as referred to is carried out through an information system and through cross-sectors. In addition, further provisions regarding the information system as referred to are regulated by Government Regulation. it is emphasized that everyone has the right to health and even everyone has the same rights in obtaining access to resources in the health sector. Likewise, everyone has the right to obtain safe, quality, and affordable health services. The research method uses a normative legal method using an analysis method that is qualitative analysis with a statutory regulatory approach. 1. Legal framework regarding patient consultation using telemedicine in Indonesia. The use of telemedicine-based health services is stated in the Decree of the Minister of Health of the Republic of Indonesia concerning the benefits of telemedicine-based health services as an effort to achieve equitable health services, improve the quality of health services in remote areas and reduce referrals to hospitals, especially in handling emergency cases. Telemedicine can be said to be a solution for the community and medical personnel when faced with field situations that are not possible, so to provide a sense of security to medical personnel and patients, there are several legal bases related to the implementation of telemedicine in Indonesia which are regulated in laws and regulations. Telemedicine services have four obstacles, namely the Technological Environment, the Human Environment, the Economic Environment, and the Organizational Environment. The willingness of patients to use technology (45.7%) and the obstacles are limited infrastructure, Community Acceptance, and the Human Development Index (HDI). 2. Legal protection of the parties is associated with the application of the precautionary principle in diagnosing diseases through telemedicine. The legal basis for online consultation services or telemedicine still does not have concrete legal certainty at the national level. There are no national regulations that specifically regulate the implementation of telemedicine services and health workers who provide these services in Indonesia. Legal protection for related parties through telemedicine can be seen that related parties in this case medical service providers must comply with the rules governing human actions based on law, justice and morality.

A fundamental question in response-adaptive randomization is: What allocation proportion should we target to achieve required power while resulting in fewer treatment failures? For comparing two treatments, such optimal allocations are well studied in the literature. However, few authors address the question for multiple treatments and the generalization of optimal allocations is necessary in practice. We are interested in finding the optimal allocation proportion, which achieves a required power of a multivariate test of homogeneity in binary response experiments while minimizing expected treatment failures at the same time. We propose such an optimal allocation for three treatments by giving an analytical solution for the optimization problem. Numerical studies show that a response-adaptive randomization procedure that targets proposed optimal allocation is superior to complete randomization. We also discuss some future research topics and additional issues on optimal adaptive designs.

Patent-based intellectual property (IP) has come under progressively substantiative attack in the peer-reviewed literature as many studies have shown it retards innovation. In addition, the monopoly period no longer fits the innovation cycle. Although the vast majority of patents are not useful, patent proponents argue monopoly-based economic incentives are specifically necessary to fund medical technologies. Rather than use simple economics, quantifying human deaths has also been proposed as a means to guide public policies. Such an approach can be applied to patents by investigating the lives saved by patents as well as those lost in the current IP systems. This study is the first to provide such a theoretical approach to quantifying human mortality costs of patent-based IP systems. To illustrate the mechanism by which patents are responsible for premature deaths, a case study of the 100-year-old innovation of insulin is provided. The U.S. and Canada were selected to compare because the approach to drug costs in the two countries allows for a fraction of the additional costs of IP to be quantified. By comparing the different death rates of diabetics in U.S. and Canada, it was found that insulin-related patents result in over 94,000 American premature deaths annually (in 2021). The results also make it clear that many human deaths are related to price increases and lack of accessibility to needed medications due to the current monopolistic IP system. These findings require patent proponents to defend the continued existence of patents in the medical innovation space.

This paper describes the change ofemphasis that occurred in the teaching ofethics to smallgroups ofclinical students. Although the originalfocus ofthe course was on the analysis ofethical dilemmas associated with individual patients known to the students, it soon became evident that there were, for the students themselves, more fundamental ethical dilemmas in their new role as clinical students. These included worries about how to respond when patients asked questions which their consultants had previously deceived them about, worries about inflicting pain on patients, as with intravenous cannulation, and the role of the medical student in the clinical team. We emphasise the need to explore student experiences aspart oftheprocess of ethics teaching.

Sudden infant death syndrome (SIDS) remains a leading cause of infant mortality. Medical science's failure to elucidate its cause is opprobrious. SIDS shares many epidemiological traits with infectious diseases. Autopsy findings show very consistent findings in ~90% of cases, and immunological investigations consistently reveal underlying activation of inflammatory pathways. Surprisingly, most mainstream researchers have largely ignored these key findings. The "Triple Risk Hypothesis" remains the mainstay for mainstream researchers. The hypothesis encompasses three main ideas: 1) a vulnerable infant, 2) a critical development period and 3) an exogenous stressor which combine lethally. Stressors include prone sleeping, smoke exposure, and overheating. Infections, though often overlooked, can trigger deadly immune responses. The COVID-19 pandemic and the use of parenterally administered SARS-Cov-2 vaccines provided an example of a lethal immunopathogenicity in elderly comorbid patients. During the pandemic, we reviewed papers on the impact of injected vaccines on infant mortality. The papers analysed vaccine adverse event reporting systems (VAERS) to conclude a possible causal relationship existed. It is of particular note that approximately 50% of cases in the VAERS dataset have been diagnosed as Sudden Infant Death Syndrome (SIDS). VAERS are known to capture a small minority of vaccine associated adverse events (estimated to be ~1%). Studies indicate that vaccination is preventative, but control groups often have more SIDS risk factors. The findings from the VAERS are of significant concern to the scientific, medical, public, and governmental communities. This review provides a scientific analysis of this apparent problem and proposes a case for vaccines that provide IgA-based mucosal immunity to replace (where appropriate) the potentially harmful parenterally administered vaccines currently in use. In addition to recommending the use of new safe vaccines, we highlight the role of breastfeeding in the prevention of sudden infant death syndrome (SIDS).

The prison environment for young prisoners can be accompanied by different changes. The current study aimed at comparing spiritual health, psychological well-being, and high-risk behaviors among young prisoners sentenced for drug, financial, and theft offences in Zanjan, Iran. The current descriptive-comparative study was conducted on the statistical population comprised of all prisoners within the age range of 18 to 35 years sentenced for theft, drug, and financial offences in Zanjan. Their number was 340. The sample size was calculated using the Cochran formula as 163 subjects. The subjects were selected by simple random sampling method and classified into three groups. The data collection instruments were high-risk behaviors, psychological well-being, and spiritual well-being questionnaires. The content validity and reliability of the questionnaires were assessed by Cronbach alpha. Data analysis was performed with SPSS version 24. Results: There was a significant difference in the religious indices among the studied groups, in such an extent that the average religious indices in the drug and theft groups were higher than those of the financial group (P < 0.05). Also, the mean aggressive behavior in the group of theft offences was higher than the financial group and the average cigarettes and hookah smoking in the two drug and theft groups was higher than the financial group (P < 0.05). Finally, the average high-risk behaviors of narcotic and psychotropic substances consumption in the drug offences group was significantly higher than the financial group (P < 0.05). Conclusions: Religious indices and high-risk behaviors were different in different individuals depending on the type of offences. Therefore, it is recommended to pay more attention to this issue in medical treatments and psychological counseling.

is moving around more she always says that she is, even though she ignores the prompts to come to the window and doesn't go to the kitchen with the robot. Frank is 89 years old and generally frail. He lives alone and needs assistance from a Care-O-bot® to live independently. He prefers the Care-O-bot® to having the neighbours or carers helping him because he thinks they are inclined to be intrusive and interfering. He uses his Care-O-bot® interface to talk about fishing with a friend he has known since childhood. Neither of them can go fishing anymore, but they enjoy talking about when they did and discussing items in a fishing magazine that they both subscribe to. They talk about once a month. Frank really looks forward to these conversations and they put him in a good mood for days afterwards. He becomes quite miserable if his friend is in hospital and unable to talk to him. Frank's daughter has suggested that the Care-O-bot® should be used to encourage Frank join a virtual fishing forum on the internet. She is worried that he only has one friend who is older and poorly and may die leaving Frank with no one else to talk to about fishing. Frank says that he is too old to be making new friends. Nina who is 70 years old had a stroke two years ago but has now recovered the use of her arm though one side of her face droops slightly. She is self-conscious about this, but it does not affect her physical functioning. She is supported at home by a Care-O-bot®. Since having the stroke she has become quite irritable and impatient. She often shouts at her daughter when she visits and complains angrily about her condition. Her daughter finds this very upsetting and has come to dread her visits. Nina has been so rude and demanding that two cleaners have already refused to work for her anymore. She is usually polite with her friends. Her Care-O-bot® has been programmed so that it will not do things for her if she asks sharply or in a demanding tone. It encourages her to say please and thank you and will withdraw help until she does so. Nina finds this infuriating and insists that the Care-O-bot® is reprogrammed to do what she asks no matter how she asks for help. Louis, who is 75 years old, is determined to continue to live in his own home, which is in a small town in which two of his sons live. He is regularly visited by his daughters-in-law, who bring him food, help with his cleaning and do his laundry. Louis was left with some weakness in one of his legs as a result of an accident in his 40's. He is becoming frail and is finding it increasingly difficult to get up from his chair and walk with his sticks. Louis is supported at home by a Care-O-bot®. The Care-O-bot® is programmed to help support him when he gets up from his chair and can be summoned to help if he falls. Louis has discovered that he can use the interface on the Care-O-bot® to visit online gambling sites and enjoys playing poker in the evening. He also uses the interface to give his doctor his blood pressure measurements, and sometimes his medication is adjusted as a result of the measurements he gives. Louis falls over about once a week on average. On the whole he is able to get up again with the help of the Care-O-bot®, but he recently was on the floor for several hours unable to get up and developed a bladder infection from lying in the cold unable to reach the toilet. He was in bed for several days as a result. This placed an additional burden on his daughters-in-law, who took turns to stay with him during the day until he was well enough to live alone. It was during this time that his daughters-in-law realised that he used the Care-O-bot® to play poker on line. They are very unhappy about this as he often loses money. They want access to the poker site to be blocked. They have taken away his sticks so that he has to use his walking frame, which means that he is less likely to fall. They want the Care-O-bot® to be programmed so that it alerts them as soon as he falls. Louis insists that it is up to him what he does with his own money and says that he doesn't want them to come rushing around every time he falls because he can usually get himself up.

The insanity defense has been described as a symbol of the relationship between law and psychiatry (Stone, 1984b). As such, it has always been the subject of intense legal and public scrutiny, despite the fact that it is infrequently raised and seldom successful. Forensic psychiatrists are often depended upon by the criminal justice system to provide these evaluations, which require a high degree of training and expertise. In 2002, the American Academy of Psychiatry and the Law published it's Practice Guideline for Forensic Psychiatric Evaluation of Defendants Raising the Insanity Defense (AAPL, 2002). While noting that any attempt to promulgate guidelines will be limited by evolving legal doctrine and psychiatric science, the intent of the guidelines was to describe ''acceptable forensic psychiatric practices.''

Twee visies op menswaardig leven en sterven 67 Maarten den Dulk Rondetafelgesprek over leven en dood Aan de wieg van het leven 74 Petruschka Schaafsma Je weet niet waar je voor kiest: over kinderen krijgen en levensvertrouwen 80 INTERMEZZO: Eduard Verhagen 'Niet alles wat kan, moet altijd gedaan worden' 82 Bart-Jan Heine & Bart Koopman Christendemocratische grenzen aan de technologische beheersing van het nieuwe leven Het leven als bouwpakket? Naar een ethiek van vitaliserende zorg 92 Theo Boer Mensverbetering en ethiek 100 Maarten Verkerk Eindeloze zorg en de dood als natuurlijke grens 108 Joachim Duyndam Autonomie, keuzestress en zelfoverschatting 116 Egbert Schroten De keerzijde van zwart: gedachten over vitaliserende zorg Over het regelen en op afstand houden van de dood 124 James Kennedy Het euthanasiedebat in de kerken in historisch perspectief 129 Jean-Jacques Suurmond Ouder worden als roeping 136 INTERMEZZO: Annemarie van Veldhuizen 'Gesprekken kunnen helend en bevrijdend werken * * * Dit cdv-lentenummer, getiteld Biopolitiek: over de beheersing van leven en dood, is een poging om het debat te verbreden. Het gaat niet om een mate-Ter introductie Christen Democratische Verkenningen | Lente 2014 ter introductie heeft de mens bestaansrecht als hij een rationeel handelend wezen is. Dan blijft er inderdaad weinig van zijn dementerende moeder over. In het christendemocratische gedachtegoed wordt de mens vanaf het vroegste begin tot het einde niet gezien als een opzichzelfstaande en in zichzelf gekeerde entiteit, maar als een persoon die is opgenomen in een netwerk van relaties. Vanuit dat perspectief herinnert de kwetsbare moeder van Jansen ons aan wat ware menselijkheid is, hoe moeilijk het ook zal zijn om dat zo te ervaren. Juist die kwetsbaarheid maakt zorg, toewijding en liefde mogelijk. Dat is een ogenschijnlijk moeilijk te overbruggen verschil in mensbeeld. Godfried Bomans vatte dat verschil eens kernachtig samen: 'Vroeger was een oud mens iemand die er bijna was. Nu is het iemand die er bijna geweest is.' Dat verschil in mensbeeld hoeft niet te lopen langs de lijnen van christelijk versus seculier. Iedereen zal de ervaring hebben dat we ons leven leiden, maar soms ook geleid worden. Die erkenning dat we deel kunnen uitmaken van een krachtenveld waarin we zelf niet altijd subject zijn, zou weleens ontspannend kunnen werken op onze totale beheersingsdrift. Het articuleren van het mensbeeld zou al kunnen helpen. Het vocabulaire van 'zelfbeschikking' en 'zelfsturing' is echt niet de enige taal waarin we ons leven ter sprake kunnen brengen. In de zorgpraktijk van alledag wordt dat voortdurend bewezen. De zogenoemde intermezzo's in dit nummer, onder het motto 'groot denken, klein kijken', getuigen ervan. Zorg is geen medische handeling of een product, maar een betekenisvolle relatie, weet Annemarie van Veldhuizen, werkzaam in een hospice, en dat is veel meer dan een gratuite vaststelling.

The objective of the study was to assess the current status of ethics education in obstetrics-gynecology residency programs. STUDY DESIGN: A cross-sectional, web-based survey was designed in conjunction with a professional survey laboratory at the University of Chicago. The survey was piloted with a convenience sample of clinical medical ethics fellows to assess question content and clarity. The survey was deployed by e-mail to all obstetrics-gynecology residency program directors. Descriptive statistics were used to analyze participant responses. The University of Chicago's Institutional Review Board deemed this study exempt from institutional review board formal review. Of 242 eligible obstetrics-gynecology residency program directors, 118 (49%) completed the survey. Most respondents were from university-based programs (n ¼ 78, 66%) that were not religiously affiliated (n ¼ 98, 83%) and trained 4-6 residents per postgraduate year (n ¼ 64, 70%). Although 50% of program directors (n ¼ 60) reported having ethics as part of their core curriculum, most programs teach ethics in an unstructured manner. Fifty-seven percent of respondents (n ¼ 66) stated their program dedicated 5 or fewer hours per year to ethics. The majority of program directors (n ¼ 80, 73%) responded they would like more to a lot more ethics education and believed that ethics education should be required (n ¼ 93, 85%) for residents to complete their training. Respondents identified that crowding in the curriculum was a significant barrier to increased ethics training (n ¼ 50, 45%) and two-thirds (n ¼ 74, 67%) reported a lack of faculty expertise as a moderate barrier to providing ethics education in the residency curriculum. CONCLUSION: This study found that a lack of structured curricula, inadequate faculty expertise, and limited time were important barriers for ethics education in obstetrics-gynecology programs across the nation. Despite these existing challenges, program directors have a strong interest in increasing ethics education in residency training. Therefore, additional resources are needed to assist program directors in enhancing resident ethics education.

Background: The high disease burden of Africa, the emergence of new diseases and efforts to address the 10/90 gap have led to an unprecedented increase in health research activities in Africa. Consequently, there is an increase in the volume and complexity of protocols that ethics review committees in Africa have to review. Methods: With a grant from the Bill and Melinda Gates Foundation, the African Malaria Network Trust (AMANET) undertook a survey of 31 ethics review committees (ERCs) across sub-Saharan Africa as an initial step to a comprehensive capacity-strengthening programme. The number of members per committee ranged from 3 to 21, with an average of 11. Members of 10 institutional committees were all from the institution where the committees were based, raising prima facie questions as to whether independence and objectivity could be guaranteed in the review work of such committees. Results: The majority of the committees (92%) cited scientific design of clinical trials as the area needing the most attention in terms of training, followed by determination of risks and benefits and monitoring of research. The survey showed that 38% of the ERC members did not receive any form of training. In the light of the increasing complexity and numbers of health research studies being conducted in Africa, this deficit requires immediate attention. Outcome: The survey identified areas of weakness in the operations of ERCs in Africa. Consequently, AMANET is addressing the identified needs and weaknesses through a 4-year capacity-building project.

The degree and nature ofpatient involvement in consultations with health professionals influences problem and needs recognition and management, and public accountability. This paper suggests a framework for understanding the scope for patient involvement in such consultations. Patients are defined as co-producers offormal health services, whose potentialfor involvement in consultations depends on their personal rights, responsibilities and preferences. Patients'rights in consultations are poorly defined and, in the National Health Service (NHS), not legally enforceable. The responsibilities ofpatients are also undefined. I suggest that these are not to deny, of their own volition, the rights of others, which in consultations necessitate mutuality of involvement through information-exchange and shared decisionmaking Preferences should be met insofar as they do not militate against responsibilities and rights.

Background: A different ethos with respect to the perception of medical ethics prevails in societies in transition such as those in the Arabian Peninsula, which makes it difficult to apply international principles of bioethics in medical practice. This study aimed to develop and psychometrically test an instrument that measures physicians' awareness of bioethics and medical law and their attitudes towards the practice of medical ethics. Additionally, it examined physician correlates influencing the awareness of bioethics. Methods: Following a rigorous review of relevant literature by a panel of experts, a 13-item instrument, the Omani physicians' bioethics and medical law awareness (OBMLA) questionnaire was developed with the aim of assessing physicians' awareness of bioethics and medical law. The study tool's construct validity and internal consistency reliability were examined by exploratory factor analysis (EFA) and Cronbach's alpha. In a cross-sectional study, the questionnaire was distributed among a random sample of 200 physicians at a tertiary hospital in Muscat, Oman. Participant characteristics that may influence awareness of bioethics and medical law were explored. The EFA of the OBMLA questionnaire resulted in three well-loading factors: (1) Physicians' bioethics practice subscale (2) incentive related bioethics subscale and (3) medical law awareness subscale. Internal consistency reliability ranged between Cronbach's α: 0.73-0.8. Of the total 200 participants, 52% reported that teaching medical ethics during medical school was inadequate. The overall mean (standard deviation, SD) of the bioethics awareness score and Omani medical law awareness were 27.6 (3.5) and 10.1 (2.1) respectively. The majority of physicians (73%) reported that they frequently encountered ethical dilemmas in their practice and 24.5% endorsed the view that unethical decisions tended to occur in their practice. The study provides an insight into the practice of bioethics, and the awareness of bioethics and medical law among physicians in a teaching hospital in Oman. The OBMLA questionnaire appears to be a valid and reliable tool to assess a physician's awareness of bioethics and medical law. In this preliminary study, it appears that participants have suboptimal scores on the indices which measure practice and awareness of bioethics and medical law.

Receiving feedback on one's work from colleagues is an essential part of clinical and forensic psychiatric practice. Often the material on which feedback is sought concerns past cases. When the material relates to current cases, particular safeguards are needed to protect important interests. This paper lists the interests that must be protected when feedback is provided through clinical consultation and supervision meetings in a forensic psychiatric training program. These are the interests of the person being evaluated, the attorneys, the people providing feedback to the evaluator, and the employers of the people providing feedback. The principles that the training program applies in determining attendance at, and participation in, these meetings are described. Finally, scenarios are presented that illustrate the application of these principles. Such application has allowed trainees and others to receive the benefits of consultation and supervision in the course of developing their opinions while protecting the interests of those involved.

Si dejamos morir lo gratuito, si renunciamos a la fuerza generadora de lo inútil, si escuchamos únicamente el mortífero canto de sirenas que nos impele a perseguir el beneficio, sólo seremos capaces de producir una colectividad enferma y sin memoria que, extraviada, acabará por perder el sentido de sí misma y de la vida. Y en ese momento, cuando la desertificación del espiritu nos haya ya agostado, será en verdad difícil imaginar que el ignorante homo sapiens pueda desempeñar todavía un papel en la tarea de hacer más humana la humanidad.

To investigate the relationship between psychological constructs related to professional and research integrity and moral reasoning among medical students. METHODS Medical students, 2nd-year (n ¼ 208, 85.6% of 243 enrolled students), answered the moral reasoning test-defining issues test 2 (DIT2) and the Machiavellianism and Paulhus socially desirable responding (SDR) scales. Students had the highest score on the post-conventional schema of moral reasoning (mean ± standard deviation, 35.2 ± 11.6 of a possible 95) compared with personal interest (27.2 ± 12.3) and maintaining norms schemae (29.2 ± 11.5; P < 0.001, repeated-measures ANOVA). Female students scored higher than their male collegues on post-conventional moral reasoning (37.6 ± 11.0 versus 31.2 ± 22.4, P < 0.001, independent-sample t-test). Of all 4 Machiavellianism subscales students scored highest on deceiving, where female students scored higher than their male colleagues (24.5 ± 4.2 versus 22.9 ± 5.1 of a possible 30; P ¼ 0.037, independent-sample t-test). Female students also scored higher on the impression management subscale, whereas their male colleagues scored higher on the self-deception subscale of the Paulhus SDR scale. Moral reasoning scores were associated with cynicism, deceiving and flattering Machiavellianism scores, but not with Paulhus SDR scores. Multiple regression analysis showed the Machiavellianism amorality score as a significant negative predictor (b ¼ )0.183, P ¼ 0.017) and female sex as a positive predictor (b ¼ 0.291, P < 0.001) for the post-conventional schema score on the DIT2. The Machiavellianism flattering score was a significant negative predictor for the personal interest schema score (b ¼ )0.215, P ¼ 0.006). CONCLUSIONS Although moral reasoning is generally seen as independent of variables related to personality, our study indicated that Machiavellianism, especially its amorality and flattering subscales, were associated with moral reasoning. These results have important implications for teaching ethics and the responsible conduct of research in different cultural and socio-economic settings. KEYWORDS EDUCATION, medical, undergraduate ⁄ *methods; teaching ⁄ *methods; *ethics, medical ⁄ *psychology; *morals; *thinking; male; female; women ⁄ *psychology; men ⁄ *psychology.

Non-collateralised, good-intentioned, African Promoters of Infrastructural Investment Programs are challenged by a gamut of obstacles, not least, the Cost of Feasibilities Studies, Cost of Land Acquisition and requisite Technical Competencies. Whilst some Ethical Infrastructural Investment Firms i.e. Beyond

Ethical debates about liberal eugenics frequently focus on the supposed unnaturalness of its means and possible harm to autonomy. I present a Nietzsche-inspired critique focusing on intention rather than means and harm to abilities rather than to autonomy. I first critique subjective eugenics, the selection of extrinsically valuable traits, drawing on Nietzsche’s notion of ‘slavish’ values reducible to the negation of another’s good. Subjective eugenics slavishly evaluates traits relative to a negatively evaluated norm (eg, above-average intelligence), disguising a harmful intention to diminish the relative value of that norm. I then argue there is no objective form of eugenics on the Nietzschean ground that abilities are not valuable intrinsically; they are valuable only if one possesses the relative power to exercise them. Abilities frustrated by conflict with other abilities or environment are harmful, while disabilities that empower one’s other abilities are beneficial. Conseque...

Interest in the retrieval of organs from non-heart-beating cadaver donors has been rekindled by the success of transplantation ofsolid organs and the insufficient supply of donor organs currently obtainedfrom heart-beating cadaver donors. There are currently two retrieval techniques being evaluated, the in situ cold perfusion approach and the controlled death approach. Both, however, raise ethical concerns. Reanimation is a new method which has been used successfully in animals. We believe this new approach overcomes the ethical objections raised to these other methods. in most countries to retrieving organs from heart- beating cadaver donors (HBCD's). Non-heart- beating cadaver donors were largely abandoned for copyright.

Medical Humanities in the Recent Medical Education Literature Medical humanities is an educational approach based on the creative and intellectual forces of various humanistic disciplines. The educational setting offered by medical humanities based on small groups discussion, or reflective activities, allows students to discover, share and compare their values and in this way internalize and construct the doctor they wish to be. The article presents an overview of the recent literature on medical humanities in medical education, describing four rationales to guide its implementation in medical education.

Values and attitudes are strongly influenced by the subjective elements of the organizational culture of the medical school. The objective of this research was to better understand the medical school environment and the difficulties in training doctors in humanism in clinical practice. Qualitative research focused on subjective aspects of the teacher-student relationship, such as ethics and respect for differences, was conducted in a traditional Brazilian medical school. We used the technique of ethnographic observation and interviews with students and teachers. The data were analysed according to three categories: 1. self and other, 2. misuse of technology, and 3. models of teacher-student interactions. Over 12 months, we observed 22 teachers and 128 students (8 groups of 14-18 students), and we interviewed 9 teachers and 19 students, who were recognized as key-interviewees. Our analyses revealed that the medical school environment enables doctors and medical students' feelings of intellectual superiority, selfish and excessive competitiveness; inability to see the patient as a whole; overvaluation and excessive use of technology; role modelling of nonempathic behaviours; and behaviours showing disrespect, discrimination, and violence. These findings reveal attitudes that hamper the doctor-patient relationship, and some underlying issues of critical importance to the humanistic training of medical students. This study shows the need for institutional humanistic values to be adopted and applied to everyone. Perhaps an educational process that uses ethics more than academic disciplines should be used as a method of thinking and acting, which may encourage institutional changes that improve medical education as a whole.

Values and attitudes are strongly influenced by the subjective elements of the organizational culture of the medical school. The objective of this research was to better understand the medical school environment and the difficulties in training doctors in humanism in clinical practice. Qualitative research focused on subjective aspects of the teacher-student relationship, such as ethics and respect for differences, was conducted in a traditional Brazilian medical school. We used the technique of ethnographic observation and interviews with students and teachers. The data were analysed according to three categories: 1. self and other, 2. misuse of technology, and 3. models of teacher-student interactions. Over 12 months, we observed 22 teachers and 128 students (8 groups of 14-18 students), and we interviewed 9 teachers and 19 students, who were recognized as key-interviewees. Our analyses revealed that the medical school environment enables doctors and medical students' feelings of intellectual superiority, selfish and excessive competitiveness; inability to see the patient as a whole; overvaluation and excessive use of technology; role modelling of nonempathic behaviours; and behaviours showing disrespect, discrimination, and violence. These findings reveal attitudes that hamper the doctor-patient relationship, and some underlying issues of critical importance to the humanistic training of medical students. This study shows the need for institutional humanistic values to be adopted and applied to everyone. Perhaps an educational process that uses ethics more than academic disciplines should be used as a method of thinking and acting, which may encourage institutional changes that improve medical education as a whole.

Key Points
• Medical ethics and professionalism are interdependent constructs that co-
developed over the course of medicine's evolution.
• The essential touchstone of medicine is caring for the patient, predicated on com-
petence in skills and knowledge, the recognition that patient interests supersede
physician self-interest, and that the collective medical enterprise is an implicit so-
cial contract founded on patient-directed trust.
• The history of medical professionalism is a relatively new concept, introduced by
John Gregory and Thomas Percival, founded on precepts from Bacon and Hume.
• The concept of the medical contract is minimalist in its construction and is better
described by a covenant, with an initial promise, sustained by a trusting relation-
ship, and with aspirations to excellence and fidelity.

According to these two reasons, the patient will be always a dependant of the practitioner: First, the patient has no knowledge about the issue although patient's life, limb or organ is at risk; or second, the practitioner is a member of the occupational group that can solve his or her problem. In addition, the practitioner has always superiority over the patient. However, ideally, this relationship should depend on confidence. The first condition of this situation would be the practitioner's clarification about the patient's health problem, therapy and the results of this therapy, moreover the patient's consent about the way of therapy and the results.