New treatment approaches and the dilemma of medical ethics and economics using haemoadsorption with Cytosorb

Avariety of medical professional societies have developed ethics practice guidelines or position statements regarding specific ethics issues (1–6). The Endocrine Society published its Code of Ethics for practice in 2001 (1); however, none of the practice guidelines are specific to thyroidology. In the field of thyroidology, specific clinical ethics issues arise in different clinical contexts. For example, autoimmune thyroid disease raises different clinical ethics issues compared with thyroid oncology. Within thyroid oncology, each type of thyroid cancer raises unique and distinct clinical ethics issues and dilemmas. For example, the clinical ethics dilemmas that present in hereditary medullary thyroid cancer surrounding genetic screening are not the same as in thyroid cancers that are not familial or do not yet have defined germline genetic markers. The dilemmas associated with poorly differentiated and aggressive thyroid cancers (such as anaplastic thyroid cancer) and raising end-of-life issues such as code status, existential suffering, and palliative care are not the same that present in well-differentiated thyroid cancers that respond well to treatment. In many cases, there is clinical disagreement over what constitutes beneficent care for patients. Additionally, new clinical ethics dilemmas are resulting from drug shortages (e.g., recombinant human thyrotropin), medical isotope shortages (e.g., I), as well as nuclear disasters where priority-setting guidelines for distributing potassium iodide are not in place or not identified. Despite the prevalence of clinical ethics dilemmas in thyroid disease, clinical ethics guidelines specific to the thyroid disease context have been notably absent. Clinical ethics expertise can provide morally sound frameworks for (i) the nuances and complexities of diagnosis and treatment, and (ii) allocation of resources in situations where the demand is greater than the supply. The field of thyroidology comprises both clinical ethics and research ethics issues; in both arenas, complex professional ethics and research integrity dilemmas may arise as funding for basic research shrinks, investigators move from clinical to corporate cultures, and competition for funding increases. Conflicts of interest are often poorly understood, which can range from financial to interprofessional conflicts of interest. The clinical and professional ethics guidelines presented here are intended to provide clear guidance about specific, yet common, ethics dilemmas and questions that arise in this unique subspecialty. These guidelines mainly address two groups of ethics dilemmas that are typically encountered by thyroidologists: clinical ethics dilemmas—those that arise in the patient care setting; and professional ethics dilemmas— those that revolve around disclosure of conflicts of interest and professional integrity. These guidelines also provide clear guidance on research ethics issues, such as when innovative therapy becomes ‘‘research,’’ the role of an institutional review board, as well as publication and data-sharing integrity issues. Finally, as enormous changes begin to take effect consequent to The Affordable Care Act (www.healthcare.gov/law/ index.html), thyroid practitioners find themselves in a new clinical landscape involving numerous resource allocation decisions. As aggressive, non-iodine-avid thyroid cancer continues to rise in incidence, more questions about end-oflife care, palliative care, or clinical trial candidacy have arisen. We offer these guidelines in recognition of this unique subspecialty that confronts wide clinical and research diversity.

Medical ethics and medical education.

IntroductionGlobally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESSs) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence about mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda.MethodsThis phenomenological qualitative study utilized in-depth interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook.ResultsThe study revealed there was no formal committee or mechanism dedicated to resolving ethical dilemmas at the UCI. Instead, ethical dilemmas were addressed in six forums: individual consultations, tumor board meetings, morbidity and mortality meetings (MMMs), core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas.ConclusionThe fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

IntroductionGlobally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESS) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence of mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda.MethodologyThis qualitative study utilized in-depth-interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers, who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook.ResultsThere was no formal committee nor mechanism utilized to resolve ethical dilemmas at the UCI. The study uncovered six fora where ethical dilemmas were addressed: individual consultations, tumor board meetings, morbidity and mortality meetings, core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas.ConclusionThe fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

In Ethics in Rehabilitation: A Clinical Perspective, Kornblau and Burkhardt argue that funding structures, limited resources, and evolving practice requirements are common sources of ethical challenges for rehabilitation professionals. In a recent empirical study of rehabilitation nurses, the most frequently reported ethical conflicts were related to concerns about resource allocation, specifically disagreements about medical or institutional practice, patients' rights, and payment issues.1 It is thus worth asking which criteria or tools should be used to address these dilemmas. The authors draw our attention to this field of inquiry by providing an overview of some basic knowledge to approach ethical dilemmas in rehabilitation. The purpose of this very well organized and clearly written book is to give clinicians tools for analyzing ethical conflicts in their particular legal, social, and political contexts. The authors draw on their backgrounds in occupational therapy, public health, health care ethics, and law to present an approach that illuminates this important subject. They navigate with ease from discussions of political and social contexts and the key legal principles that affect ethical decision making to a presentation of useful clinical tools. The overview of ethical theory is rather thin, and somewhat simplistic, but nonetheless integrates pragmatic and helpful clinical illustrations. It should be noted that the socio-political context and the legal framework set out in the book are those of the United States; Canadian and international contexts are not discussed. While it covers many important topics that are relevant to rehabilitation professionals, this text will be of particular interest to clinical ethics educators, as the second section provides a catalogue of 140 ethical dilemmas related to a wide range of practice issues in rehabilitation. Taking the reader through a logical, step-by-step framework, Kornblau and Burkhardt present a structure for analyzing an ethical dilemma, built around questions that should be asked to ensure a complete and nuanced analysis. This tool, oddly enough, is called CELIBATE (Clinical Ethics and Legal Issues Bait All Therapists Equally); it consists of several steps: identifying the problem and the facts, the interested parties, and the nature of their interests; examining the potential ethical and legal dilemma; asking whether more information is needed; brainstorming action steps; analyzing them; and choosing a course of action. This structured and formal analytic grid is a strength, as the criteria are organized so that the reader learns practical rules of thumb with which to evaluate ethical dilemmas. Such a grid can help clinicians to carefully consider aspects of a dilemma and can have important pedagogical uses for clinicians seeking tools to sharpen their ethical analysis. An important limitation of the authors' ethical framework, at least for rehabilitation professionals, is that CELIBATE does not include any specific rehabilitation-oriented content. Moreover, a more societally focused language could be integrated; current codes of ethics in physical therapy, including that of the Canadian Physiotherapy Association, have been revised to move beyond focusing on the individual realm of ethical obligations and address the organizational and societal realms.2 Finally, CELIBATE would be strengthened by adding an additional step that encourages clinicians to reflect critically on the outcome of the situation and how the decision-making process was experienced by all involved.3 Another innovative tool from this book is a list of practical hints to help clinicians act in a legal and ethical manner (e.g., place the patient's interest above all, handle situations as they arise, yearn to learn); this list should be an essential desk reference for all clinicians! In Ethics in Rehabilitation: A Clinical Perspective, Kornblau and Burkhardt provide a rich and nuanced overview of rehabilitation ethics in the United States, with some useful ethical tools to address particular dilemmas. While not specifically aimed at a Canadian audience, the book provides a thorough guide to ethical thinking and practice in a clinical context, and should therefore be of interest to physiotherapists working in Canada, whether as practitioners or as educators. The authors offer pragmatic tools to empower rehabilitation professionals in their day-to-day ethical judgments, especially in a context of scarcity in which limited public health care resources create a need for fair and effective management of these services for the population.

An introduction to ethics.

Abstract:Standard health economics concentrates on the provision of care by medical professionals. Yet ‘care’ receives scant analysis; it is portrayed as a spillover effect or externality in the form of interdependent utility functions. In this context care can only be conceived as either acts of altruism or as social capital. Both conceptions are subject to considerable problems stemming from mainstream health economics’ reliance on a reductionist social model built around instrumental rationality and consequentialism. Subsequently, this implies a disregard for moral rules and duties and the compassionate aspects of behaviour. Care as an externality is a second-order concern relative to self-interested utility maximization, and is therefore crowded out by the parameters of the standard model. We outline an alternative relational approach to conceptualising care based on the social embeddedness of the individual that emphasises the ethical properties of care. The deontological dimension of care suggests that standard health economics is likely to undervalue the importance of care and caring in medicine.

With an increasingly complex healthcare environment, ethics is becoming a more critical part of medical education. We aimed to explore European paediatric trainees’ experiences of facing ethical dilemmas and their medical ethics education whilst assessing their perceptions of ethical dilemmas in current and future practice. The Young Sections of the European Academy of Paediatrics and European Society of Paediatric and Neonatal Intensive Care developed an explorative online survey covering demographics, ethical dilemmas faced and ethics training. The survey was made available in nine languages from November 2019 to January 2020 via newsletters and social media. Participants (n = 253) from 22 countries, predominantly female (82%) and residents (70%), with a median age of 29-years, completed the survey. The majority (58%) faced ethical dilemmas monthly or more frequently. Most ethics training was received by ethics lectures in medical school (81%) and on the job (60%). A disagreement between the healthcare team and patient/family was the most frequently faced moral dilemma (45%); the second was withholding/withdrawing life-prolonging measures (33%). The latter was considered the most challenging dilemma to resolve (50%). Respondents reported that ethical issues are not sufficiently addressed during their training and wished for more case-based teaching. Many have been personally affected by moral dilemmas, especially regarding withholding/withdrawing life-prolonging measures, and often felt inadequately supported.Conclusion: Paediatric trainees face many moral issues in daily practice and consider that training about managing current and future ethical dilemmas should be improved, such as by the provision of a core European paediatric ethics curriculum.What is Known:• Paediatric services are becoming more complex with an increase in ethical dilemmas asking for rigorous training in ethics.• Ethics training is often lacking or covered poorly in both pre- and postgraduate medical education curricula.• Existing ethics training for European paediatric trainees is haphazard and lacks standardisation.What is New:• The PaEdiatric Residents and Fellows Ethics (PERFEct) survey provides insight into the European paediatric trainees’ views regarding ethical dilemmas in their current and future practice.• European paediatric trainees report a lack of ethics training during paediatric residency and fellowship.• This study provides content suggestions for standardised medical ethics training for paediatric trainees in Europe.

Ethics education based upon everyday ethical dilemmas can help trainees place themselves within the situation and encourage them to reflect on their role and responsibility in reaching its resolution.• Three elements can help augment the bioethics teaching experience: (a) identifying the ethical dilemma, (b) employing methods of ethical analysis, and(c) having knowledge of additional bioethics resources.An increasing number of bioethics resources are available to clinicians, including clinical ethics consultation (CEC) and print and Web-based resources.

This paper was written in the framework of my internship at the National Commission for Bioethics and Technoethics of the Hellenic Republic. It constitutes an attempt at exploring the ethical and legal dilemmas of the medical practice of telepsychiatry. Telepsychiatry, as well as other forms of telemedicine, has become a prevalent way through which patients gain access to healthcare and with many research papers reporting on its effectiveness and advantages, telepsychiatry has gained a lot of proponents in the scientific and healthcare community. However, several questions regarding the ethical and legal nature of the practice remain unanswered and this can put patients and other users of telemental health services under risk for basic rights violations. In this paper, at first the scientific data supporting the use of telepsychiatry will be cited. In addition to that, there will be discussion of several ethical dilemmas that have been reported concerning the use of telemedicine in psychiatry during the past few years and there will be reference to the medical code of ethics. Following that, there will be reference to the existing legislation for telepsychiatry in Greece and the legal issues that can arise will be analyzed. In spite of the fact that the advantages and ethical pitfalls of telepsychiatry are common in many countries, the focus of this paper will be on Greece’s code of medical ethics and legislation due to the lack of relevant bibliography on the matter, even though telepsychiatry is widely used by Greek patients. Finally some suggestions will be made on what ought to be ameliorated in regards to the current conditions, so as to make sure telepsychiatry is in line with the basic principles of bioethics.

BackgroundHaving reliable information to make decisions about the allocation of healthcare resources is needed to improve well-being and quality-of-life of individuals with eating disorders (EDs). EDs are a main concern for healthcare administrators globally, particularly due to the severity of health effects, urgent and complex healthcare needs, and relatively high and long-term healthcare costs. A rigorous assessment of up-to-date health economic evidence on interventions for EDs is essential for informing decision-making in this area. To date, health economic reviews on this topic lack a comprehensive assessment of the underlying clinical utility, type and amount of resources used, and methodological quality of included economic evaluations. The current review aims to (1) detail the type of costs (direct and indirect), costing approaches, health effects, and cost-effectiveness of interventions for EDs; (2) assess the nature and quality of available evidence to provide meaningful insights into the health economics associated with EDs.MethodsAll interventions for screening, prevention, treatment, and policy-based approaches for all Diagnostic and Statistics Manual (DSM-IV and DSM-5) listed EDs among children, adolescents, and adults will be included. A range of study designs will be considered, including randomised controlled trials, panel studies, cohort studies, and quasi-experimental trials. Economic evaluations will consider key outcomes, including type of resources used (time and valued in a currency), costs (direct and indirect), costing approach, health effects (clinical and quality-of-life), cost-effectiveness, economic summaries used, and reporting and quality assessments. Fifteen general academic and field-specific (psychology and economics) databases will be searched using subject headings and keywords that consolidate costs, health effects, cost-effectiveness and EDs. Quality of included clinical studies will be assessed using risk-of-bias tools. Reporting and quality of the economic studies will be assessed using the widely accepted Consolidated Health Economic Evaluation Reporting Standards and Quality of Health Economic Studies frameworks, with findings of the review presented in tables and narratively.DiscussionResults emanating from this systematic review are expected to highlight gaps in healthcare interventions/policy-focused approaches, under-estimates of the economic costs and disease-burden, potential under-utilisation of ED-related resources, and a pressing need for more complete health economic evaluations.

BACKGROUND: Ethics of medical care are global health concerns. It is universally acknowledged that medical practice should be guided by ethical principles which serve as yardsticks for regulation of professional conduct and discipline. AIM: The study was aimed at describing the awareness, attitude, practice, violations of ethical principles, and ethical dilemmas experienced by medical professionals in Abia State, Nigeria. MATERIALS AND METHODS: A descriptive study was carried out on a cross-section of 210 medical practitioners in Abia State, Nigeria. Data were collected using pretested, self-administered questionnaire that elicited information on awareness, attitude, practice, violations of ethical principles, and ethical dilemmas. Attitude and practice of principles of medical ethic (ME) were assessed in the previous 1 year. Violations and ethical dilemmas were assessed over lifetime practice as a medical doctor. RESULTS: The age of the participants ranged from 26 to 77 years. There were 173 (82.4%) males and 37 (17.6%) females. The participants were most commonly aware of principles of autonomy (100%) and nonmaleficence (100%), while the least was justice (91.9%). The positive attitude to principles of ME was predominantly oriented toward autonomy (92.4%) and the least was justice (76.2%). The most adequately practiced principle was autonomy (78.1%) and the least was justice (71.4%). The most violated ethical principle was autonomy while the most common ethical dilemma was issues related to rights of patients. The attitude (P = 0.042) and practice (P = 0.034) of principle of autonomy were significantly associated with >10 years of medical practice. CONCLUSION: Awareness of principles of ME was very high but did not translate to appropriate positive attitude and adequate practice orientations. The most violated principle was patients' autonomy and most common ethical dilemma was issues related to the rights of the patients.

The article provides an overview of important topics in contemporary medical ethics. Methodologically, it is a literature review. The article addresses only a limited selection of the problematic areas, which are, however, related to each other: digitisation of medicine, genome editing, personalised medicine as well as ethical problems and dilemmas of allocation in healthcare. The global COVID-19 pandemic has emerged as a focus and trigger. Reflections on human rights and justice in medicine are fundamental not only on the individual and social level but also on a global scale. The fundamental question is how society as a whole can be involved in the complex biopolitical and bioethical debate. The social and cultural consequences of life increasingly being understood as a technical product rather than a gift are serious.Contribution: The article also reflects on the specific contribution that Christian theology, and in particular the reformed heritage, can make to bioethical debates in modern society. The distinction between instrumental knowledge [Verfügungswissen] and orientational knowledge [Orientierungswissen] is helpful for its better understanding. A crucial result of this article is that medical treatment is repeatedly faced with ethical dilemmas. Moreover, medical progress not only creates new and better solutions to medical problems, it also raises new ethical questions that did not exist before. The purpose of medical ethics lies in identifying such dilemmas and developing ethical decision-making processes that help us to deal with such dilemmas to some extent.

Coming together to care for the dying in India

BackgroundDepression is a common condition that typically has a relapsing course. Effective interventions targeting relapse have the potential to dramatically reduce the point prevalence of the condition. Mindfulness-based cognitive therapy (MBCT) is a group-based intervention that has shown efficacy in reducing depressive relapse. While trials of MBCT to date have met the core requirements of phase 1 translational research, there is a need now to move to phase 2 translational research - the application of MBCT within real-world settings with a view to informing policy and clinical practice. The aim of this trial is to examine the clinical impact and health economics of MBCT under real-world conditions and where efforts have been made to assess for and prevent resentful demoralization among the control group. Secondary aims of the project involve extending the phase 1 agenda to an examination of the effects of co-morbidity and mechanisms of action.Methods/DesignThis study is designed as a prospective, multi-site, single-blind, randomised controlled trial using a group comparison design between involving the intervention, MBCT, and a self-monitoring comparison condition, Depression Relapse Active Monitoring (DRAM). Follow-up is over 2 years. The design of the study indicates recruitment from primary and secondary care of 204 participants who have a history of 3 or more episodes of Major Depression but who are currently well. Measures assessing depressive relapse/recurrence, time to first clinical intervention, treatment expectancy and a range of secondary outcomes and process variables are included. A health economics evaluation will be undertaken to assess the incremental cost of MBCT.DiscussionThe results of this trial, including an examination of clinical, functional and health economic outcomes, will be used to assess the role that this treatment approach may have in recommendations for treatment of depression in Australia and elsewhere. If the findings are positive, we expect that this research will consolidate the evidence base to guide the decision to fund MBCT and to seek to promote its availability to those who have experienced at least 3 episodes of depression.Trial RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12607000166471