Ethics in a scientific approach: the importance of the biostatistician in research ethics committees

In medical practice and research it is necessary to consider the rights of the researcher or physician and of the subject or patient, to conform to scientific standards and to examine the appropriateness with respect to laws and moral values. Research ethics committees have an important role to play in ensuring the ethical standards and scientific merit of research on human subjects. Research of no scientific value is also against ethical principles. To obtain valid and reliable results from biomedical research, it is a scientific and ethical obligation to make use of the science of statistics. Therefore, for research to be evaluated using biostatistics intensively from ethical and scientific points of view, a biostatistics expert is necessary on research ethics committees. Developments in Turkey are used as examples.     

Confidentiality

The principle of medical confidentiality is described as a venerable moral obligation of medical ethics. It has been defended by utilitarians and deontologists alike, not as a moral end in itself, but as a means to a desirable end such as the general welfare, respect for autonomy, or respect for privacy. Neither philosophers nor codes of medical ethics consider confidentiality to be an "absolute" principle. Great Britain's General Medical Council recognizes eight legitimate exceptions to the rule of confidentiality, among them patient consent, the "best interests" of the patient, statutory obligations, and medical research that has been approved by a "recognized ethical committee." Gillon discusses the ethical justifications for these various exceptions, rejecting appeals to medical paternalism or the benefits of medical research as general grounds for not soliciting patient consent.     

医学伦理决策中的道德原则冲突及其排序

现代医学伦理学大多采用以原则为基础的伦理分析模式,这种分析模式具有清晰、明确、简单的特点,在一定程度上容纳了道德多元化且避免了道德相对主义。但是,在具体的医学伦理决策中,不同道德原则之间可能发生冲突,从而带来道德上难以解决的问题。通过安排并论证医学伦理四原则在道德优先性上的顺序,从而为由原则冲突所导致的道德难题提供一个较为明确的解决思路。     

医疗活动中的逐利行为对医患关系的影响及其伦理对策

社会转型带来的医德人格扭曲、医疗行政监管缺位和医疗行为中的诸多法律盲区等是医生医疗行为失范的主因。医疗市场经济的利益导向在医疗领域的扭曲体现,产生了医院管理伦理失范,医疗腐败更是对医院管理伦理产生极大的腐蚀作用。因此,反对医疗腐败,倡导文明行医,需要正本清源,从医院管理道德建设的源头抓起,注重医院管理道德人格的完整性;需要对医疗市场经济中的医院管理伦理建设进行方法论的思考,真正做到既要面对市场,又要超越市场。强化新伦理观教育实现医德建设的与时俱进、创新医疗行政管理制度是矫治医生医疗行为失范的对策。为病人最大利益着想是医护专业最根本的道德规范与责任,也是医患关系的伦理基石。     

A public health perspective on research ethics

Ethical guidelines for conducting clinical trials have historically been based on a perceived therapeutic obligation to treat and benefit the patient-participants. The origins of this ethical framework can be traced to the Hippocratic oath originally written to guide doctors in caring for their patients, where the overriding moral obligation of doctors is strictly to do what is best for the individual patient, irrespective of other social considerations. In contrast, although medicine focuses on the health of the person, public health is concerned with the health of the entire population, and thus, public health ethics is founded on the societal responsibility to protect and promote the health of the population as a whole. From a public health perspective, research ethics should be guided by giving due consideration to the risks and benefits to society in addition to the individual research participants. On the basis of a duty to protect the population as a whole, a fiduciary obligation to realise the social value of the research and the moral responsibility to distribute the benefits and burdens of research fairly across society, how a public health perspective on research ethics results in fundamental re-assessments of the proper course of action for two salient topical issues in research ethics is shown: stopping trials early for reasons of efficacy and the conduct of research on less expensive yet less effective interventions.     

Issues in bioethics. Teaching medical ethics to health professionals

New medical technologies, public concern about medical ethics, and the advent of numerous ethical dilemmas in healthcare have led many medical schools to increase their formal teaching of ethics. Ethical issues in healthcare may involve a complex mix of scientific, economic, social, cultural, religious, moral and legal issues. Education in medical ethics will therefore need to be on-going to accommodate changes that periodically occur in healthcare issues, policies, or the changing moral values of the society. This article proposes frameworks within which this process may occur.     

现代医院管理伦理的实践与探索

改革开放为我国的医疗卫生事业注入了生机,但随着医学模式的转变、和谐社会的创建,现代医院发展和管理中出现了各种伦理问题,本文以上海交通大学附属仁济医院多年来的探索与实践,试图论述应对这些问题的最佳方法之一就是管理伦理。它不仅具有社会价值、生态价值、道德价值,更具有经济价值。这是一门融管理学与伦理学为一体的新兴学科,应当成为管理科学发展的最高境界。     

影响医患关系的医方语言的伦理问题分析——基于B市五家医院的实地调查研究

针对医务职场语言所处的道德环境,分析了社会发展与转型中的医患交往语言所凸显的伦理问题及原因：卫生部门更多的关注规范制度建设而不同程度的忽视了医务人员道德信念的养成,媒体更多的关注医患纠纷的曝光而不同程度的忽视了道德楷模的宣传,这都使得医患关系失去了美德伦理的支持;患者因医院环境的陌生、医学知识的相对欠缺、维权意识的增强和医者因工作繁忙、诊疗更多的仰赖“器”,使得医患间不能实现平等主体的交往。     

新时期民族地区医学院校伦理道德建设探讨

加强民族地区医学院校伦理道德建设是落实科学发展观,振兴民族地区医药卫生事业的必然要求,其核心是建立完善的"育人为本、德育为先"的伦理道德教育体系,包括伦理道德教育内容、伦理道德教育途径等方面的建设。     

A legacy of Osler. Teaching clinical ethics at the bedside

The teaching of clinical medicine at the bedside is an enduring legacy of the Oslerian revolution in American education. The advantages of teaching clinical ethics at the bedside including dealing with actual cases to maximize personal accountability, reinforcing the relationship between technical competence and ethical decisions, involving the entire health care team, and possibly decreasing the resistance of the medical profession to formal medical ethics. The proposal to teach clinical ethics at the bedside is intended to indicate a primary role for ethicists and clinicians at different stages in the medical curriculum. During the preclinical years of medical school, ethicist-philosophers, assisted by clinicians, should assume primary responsibility for teaching medical ethics. During the clinical years, physicians, assisted by clinically informed ethicist-philosophers, should accept the primary obligation to teach clinical ethics at the bedside.     

医学伦理学教学模式探讨

医学伦理学是医学科学和伦理学科学交叉的边缘科学 ,是医学道德的科学 ,是一般伦理学原理在医学实践中的具体运用。培养合格医学生 ,不仅要注重医学知识的教育 ,而且要重视医学伦理道德的引导和培养。本文从教育的目的、原则、内容及教学方法等方面探讨医学伦理学的教学模式 ,旨在从理论到实践提高医学生的医德修养     

Ethical issues in funding orphan drug research and development

This essay outlines the moral dilemma of funding orphan drug research and development. To date, ethical aspects of priority setting for research funding have not been an issue of discussion in the bioethics debate. Conflicting moral obligations of beneficence and distributive justice appear to demand very different levels of funding for orphan drug research. The two types of orphan disease, rare diseases and tropical diseases, however, present very different ethical challenges to questions about allocation of research funds. The dilemma is analysed considering utilitarian and rights based theories of justice and moral obligations of non-abandonment and a professional obligation to advance medical science. The limitations of standard economic evaluation tools and other priority setting tools used to inform health policy decision makers on research funding decisions are outlined.     

Gaps, conflicts, and consensus in the ethics statements of professional associations, medical groups, and health plans

BACKGROUND: Patients today interact with physicians, physician groups, and health plans, each of which may follow distinct ethical guidelines. METHOD: We systematically compared physician codes of ethics with ethics policies at physician group practices and health plans, using the 1998-99 policies of 38 organisations-18 medical associations (associations), nine physician group practices (groups), and 12 health plans (plans)-selected using random and stratified purposive sampling. A clinician and a social scientist independently abstracted each document, using a 397-item health care ethics taxonomy; a reconciled abstraction form was used for analysis. This study focuses on ethics policies regarding professional obligation towards patients, resource allocation, and care for the vulnerable in society. RESULTS: A majority in all three groups mention "fiduciary obligations" of one sort or another, but associations generally address physician/patient relations but not health plan obligations, while plans rarely endorse physicians' obligations of advocacy, beneficence, and non-maleficence. Except for occasional mentions of cost effectiveness or efficiency, ethical considerations in resource allocation rarely arise in the ethics policies of all three organisational types. Very few associations, groups, or plans specifically endorse obligations to vulnerable populations. CONCLUSIONS: With some important exceptions, we found that the ethics policies of associations, groups, and plans are narrowly focused and often ignore important ethical concerns for society, such as resource allocation and care for vulnerable populations. More collaborative work is needed to build integrated sets of ethical standards that address the aims and responsibilities of the major stakeholders in health care delivery.     

Medicine and the Holocaust: a visit to the Nazi death camps as a means of teaching medical ethics in the Israel Defense Forces Medical Corps

A novel method of teaching military medical ethics, medical ethics and military ethics in the Israel Defense Force (IDF) Medical Corps, essential topics for all military medical personnel, is discussed. Very little time is devoted to medical ethics in medical curricula, and even less to military medical ethics. Ninety-five per cent of American students in eight medical schools had less than 1 h of military medical ethics teaching and few knew the basic tenets of the Geneva Convention. Medical ethics differs from military medical ethics: the former deals with the relationship between medical professional and patient, while in the latter military physicians have to balance between military necessity and their traditional priorities to their patients. The underlying principles, however, are the same in both: the right to life, autonomy, dignity and utility. The IDF maintains high moral and ethical standards. This stems from the preciousness of human life in Jewish history, tradition and religious law. Emphasis is placed on these qualities within the Israeli education system; the IDF teaches and enforces moral and ethical standards in all of its training programmes and units. One such programme is 'Witnesses in Uniform' in which the IDF takes groups of officers to visit Holocaust memorial sites and Nazi death camps. During these visits daily discussions touch on intricate medical and military ethical issues, and contemporary ethical dilemmas relevant to IDF officers during active missions.     

Risk and supervised exercise: the example of anorexia to illustrate a new ethical issue in the traditional debates of medical ethics

Sport and physical activity is an area that remains relatively unexplored by contemporary bioethics. It is, however, an area in which important ethical issues arise. This paper explores the case of the participation of people with anorexia nervosa in exercise. Exercise is one of the central features of anorexia. The presence of anorexics in exercise classes is becoming an increasingly sensitive issue for instructors and fitness professionals. The ethics of teaching exercise to anorexics has, however, seldom, if ever, been addressed. Codes of ethics and legislation do not offer guidelines pertinent to the case and it is left unclear whether anorexics should be allowed to participate in exercise classes. It is shown by this paper that there are strong ethical reasons to let anorexics participate in exercise classes. However, the paper also explains why, despite these apparently cogent ethical reasons, there is no moral obligation to allow a person with anorexia to take part in exercise/sports activities.     

Ethical problems in the medical office

The majority of health care in this country is provided to patients in the office setting. This study, conducted in an internal medicine office practice, describes the ethical problems encountered in medical offices. Two hundred eighty consecutive patients, a total of 562 office visits, were prospectively evaluated. Ethical problems were defined as being present when specific ethical issues came into conflict with the physician's moral obligation to benefit the patient. The majority of the patients studied were white (214) and were women (212). The mean age of the patients was 49 years, with a range from 17 to 98 years. Ethical problems were present in 84 (30%) of the patients and in 119 (21%) of the office visits. The most common ethical problems for the patients were costs of care (11.1%), psychological factors that influence preferences (9.6%), competence and capacity to choose (7.1%), refusal of treatment (6.4%), informed consent (5.7%), and confidentiality (3.2%). Ethical problems were more common in patients over 60 years of age. This study establishes an educational as well as a research base for a broad study of biomedical ethics that looks beyond the problems encountered in the hospital.     

The new Italian code of medical ethics.

In June 1995, the Italian code of medical ethics was revised in order that its principles should reflect the ever-changing relationship between the medical profession and society and between physicians and patients. The updated code is also a response to new ethical problems created by scientific progress; the discussion of such problems often shows up a need for better understanding on the part of the medical profession itself. Medical deontology is defined as the discipline for the study of norms of conduct for the health care professions, including moral and legal norms as well as those pertaining more strictly to professional performance. The aim of deontology is therefore, the in-depth investigation and revision of the code of medical ethics. It is in the light of this conceptual definition that one should interpret a review of the different codes which have attempted, throughout the various periods of Italy's recent history, to adapt ethical norms to particular social and health care climates.     

心理咨询与干预中的道德冲突与伦理原则——写在庆祝中国医学伦理学研究30周年之际

在庆祝中国医学伦理学与生命伦理学研究30周年之际,回顾了在活动筹办之初所阐述的文化背景在医学伦理研究中的重要意义,提出了在现代科学技术视域下对我国医学伦理学发展的思考,并结合自身长期从事心理咨询工作的实践,介绍了心理咨询与干预中的若干道德冲突,并提出了应该把握的伦理原则.     

“守经达权”思路下护理伦理的告知义务问题探析

在护理伦理领域,告知义务的道德要求表现为尊重病人的知情权,但对于一些心理承受能力差的患者,护理人员在履行告知义务时却要面临伦理困境。借鉴中国传统观念"守经达权"的思路,主张护理人员在履行告知义务时依循程序伦理选择应有的价值取向,同时采取变通的方式,根据实际价值需要决定是否向病人告知其真实病情以及告知的程度,从而使护理人员能够既坚守道义,又不失灵活。     

"The patient's interests always come first"? Doctors and society

In one of a series of articles on philosophical medical ethics, Gillon considers the implications for medical ethics of the social context in which doctors practice. Such implications often contradict a common and absolutist medico-moral cliché that "the patient's interests always come first." He notes that moral obligations to a particular patient may at times be superseded by the social obligation to allocate health care resources justly; to pursue research to benefit future patients; and to engage in preventive medicine to benefit potential patients. Gillon also reflects on three more hidden aspects of medicine's relation with society that may conflict with the interests of the individual patient--the contribution of social factors to disease and health, social determinants of physician's attitudes, and the struggle for power between the medical profession and other social groups