The grey zone between freedom of belief and health risks: ethical and legal dilemmas of alternative therapeutic practices

Decisions in the Gray Zone: Evidence-Based or Culture-Based?

This paper argues for a preventative approach to ethical violations through developing and maintaining ethical awareness in training and in the group life of each society. Rather than teaching ethics as a theoretical subject, a method is proposed that encourages direct personal confrontation with ethical dilemmas through the consideration of key examples, in the Talmudic manner. This develops ethical 'muscles' and allows candidates to explore the dilemmas of what Primo Levi called the 'grey zone' where the boundaries between good and bad are unclear. Several illustrations of such ethical dilemmas are described, as used in workshops that the author has run in several societies and developing groups. In this way, ethical awareness becomes part of the group life of the society so that analysts become an ethical resource for each other.

This article analyses the representation of Jewish leaders in Holocaust fiction films, particularly in relation to the ethical dilemmas confronted by members of the Judenräte (Jewish councils) and similar figures in the ghettos of Eastern Europe. With growing interest in the immensely complex circumstances that so-called ‘privileged’ Jews found themselves in, the interventions of Holocaust screen culture in this space are only beginning to be understood. A close analysis of two feature films dealing with Jewish leaders reveals that Holocaust cinema also plays an important role in exploring difficult questions around moral judgment, coercion, and compromise that are at the heart of what Primo Levi called the ‘grey zone.’

The influence of Primo Levi’s writing on the ‘grey zone’ has only sharpened over the last decade, not only in terms of its broader application to human rights contexts beyond the Holocaust, but also through a greater focus on the question of how to understand the behaviour of so-called ‘privileged’ prisoners in the Nazi camps and ghettos. History has shown a court of law to be an inadequate setting for negotiating the complexities of the ethical dilemmas forced on victims in extremis, and substantial problems of judgement and representation have plagued efforts to understand these liminal figures elsewhere. This article examines the tensions within Levi’s writings and maps these onto attempts to represent the ‘grey zone’ in Holocaust films. Engaging in particular with Margarethe von Trotta’s critically acclaimed feature film Hannah Arendt (2012) and Tor Ben-Mayor’s lesser known documentary Kapo (1999), I highlight how these distinct approaches to depicting ‘privileged’ Jews expose the fraught nature of portraying victim complicity on screen.

Should prayer be allowed in public schools? Should biology be taught according to Darwin or to the book of Genesis? Why is polygamy against the law? These are just a few of the questions that touch our lives directly and emerge out of the separation of church and state. In this volume, one of the most distinguished scholars of American religious history traces the complicated relationship of church and state from the early colonial period, through the unique American experiment in religious liberty after the Revolution, to the ongoing debate over religious issues in our schools and communities. Edwin Gaustad relates entertaining and edifying accounts of headline-grabbing court trials involving polygamy, witchcraft, and church taxation. He quotes moving passages from the speeches and writings of American Presidents and Supreme Court justices to prove that, to paraphrase Michelangelo, ‘religious liberty is made up of a series of trifles, but religious liberty is no trifle’. General Editors: Jon Butler and Harry S. Stout, both at Yale University Religion in American Life explores the evolution, character, and dynamics of religion in America from 1500 to the present day. Written by distinguished religious historians, these books weave together the varying stories that compose the religious fabric of the United States, from Puritanism to alternative religious practices. Primary source material coupled with handsome illustrations and lucid text make these books essential in any exploration of Americas diverse nature. Each book includes a chronology, suggestions for further reading, and index.

Religion is one of the most important social regulators influencing the relations in the society and the choice (action) of an individual in the concrete situation, sacralize definite behaviour and standards, or quite vice versa – disavow them (sin), regulate the relations among people and the relations between human and the highest power (God), in separate cases allowing to overcome legal and ethical dilemmas, to act or refrain from action. Each religion exists in a definite community (society), therefore, the religious norms affect the life of community members and thus also the state, culture, and rights. Nowadays the impact of rights on religion, religious organizations as communities of believing persons, their organization, administration and activity is impossible to deny. This study is an attempt to offer a review on the regulation of the relations betweens state and religious organizations in international and European legal acts. Analysis of the legal aspects of the relations between state and religious organizations allow the conclusion that the freedom of religion has a fundamental basis which today determines the relations/attitude of the state with/to religion and religious organizations. The principle of freedom of religion as an integral part of human rights is respected and implemented in states where the church is fully or partly separated (segregated) from the state as well as in states where there is state church. This principle has been acknowledged also by the European Union and the European Council leaving the implementation details to the Member States themselves. The principle of freedom of religion comprises two principal aspects: person’s individual choice to not/belong to some religion and to not/participate in religious activities, and state’s responsibility is to respect, within the framework of the law, the freedom of activities of religious organizations. Implementation of the principle of freedom of religion is burdened by manifold interpretation of the notions “religion” and “belief”; by the necessity to consider this principle commensurate with other human rights and freedoms; by the vagueness of the limits of this principle. In this context, the practice of the European Court of Human Rights is essential, in interpreting correspondingly the principle of freedom of religion provided for in Article 9 of the European Convention for the Protection of Human Rights and Fundamental Freedoms, particularizing the understanding of this principle in the relations between the state and religious organizations. Present-day practice, at least in the public sphere, facilitate a tolerant attitude and observance of the specific character of religious belonging in various social relations (work, contacts with state administration, military service) etc. Nevertheless, disregarding several implementation problems of the principle of freedom of religion, equality should be observed in the relations between the state and religious organizations, establishing precise limits of cooperation and supervision, which is a precondition for the existence of a legal secular state.

BACKGROUND AND PURPOSEAs the physical therapy profession moves toward increased professional autonomy, it is in the best interest of the public and the profession for physical therapists to continually develop the skills required to uphold legal and ethical standards in the workplace.1 With increased clinical autonomy, physical therapists (PTs) will need to navigate more complex ethical dilemmas. The foundation for developing clinical skills related to ethical decision making should occur in didactic coursework of physical therapist education programs. Physical therapist education must teach students to make ethical and legal clinical judgments in order to meet the challenges of clinical practice.2The specific aims of this research were to: (1) gain insight on students' ability to identify, address, and report legal issues, ethical issues, and dilemmas; (2) gather insight into barriers that prevent students from reporting these violations encountered in the clinic; and (3) collect student suggestions for the curriculum and clinical supervision that might assist students in identifying and reporting ethical and legal violations.Previous research has shown that many ethical conflicts arise from inappropriate use of resources,3'5 improper supervision,6 sexual harassment,7,8 lack of truth telling,4,5,9 respect,3'5,10 and blatant wrongdoing.6,9 In a fast-paced practice environment, it can be challenging to recognize ethical dilemmas and determine the appropriate course of action. Students in many health care professions are encountering an increased number of ethical dilemmas and conflicts when practicing in the clinical setting.10'12 The Code of Ethics for the Physical Therapist13 serves as a resource for physical therapists and physical therapist students to aid in recognition and resolution of ethical and legal dilemmas. Recent literature has provided some explanation and insight into the health care practitioner's ability to identify and resolve certain ethical and legal issues.4,6,12,14 For the purposes of this study, legal issues are defined as those explicit behaviors which violate the state practice act, state laws, or any of the federal laws governing the health care workforce, including but not limited to the Health Insurance Portability and Accountability Act (HIPAA) and Occupational Saftey and Health Administration (OSHA) or Medicare and Medicaid rules and regulations. Ethical issues are those areas such as respect for autonomy or beneficence that are essential to professional conduct but may not be required by law. Ethical dilemmas are defined as situations in which moral reasons come into conflict, and it is not immediately obvious what should be done.8(p3) In most cases we are concerned with both ethical issues and dilemmas. The following are domains of concern that appeared repeatedly in the literature relevant to clinical behaviors witnessed or performed by health care students in various health professions.Inappropriate Use of ResourcesThe Ethics and Judicial Committee of the American Physical Therapy Association (APTA) has identified the following as examples of improper use of resources: overutilization of services, billing fraud, improper use of personnel, false advertising, endorsement of products, and inappropriate fees.6 The literature supports that these issues are among the most common current ethical issues facing physical therapists.10,13,15,16Improper SupervisionState practice acts, as well as payers such as the Centers for Medicare and Medicaid Services, establish specific requirements for PTs regarding supervision of students, physical therapist assistants (PTAs), and physical therapy aides involved in patient care. Supervision also includes proper use of clinical time. In spite of these laws and regulations, improper supervision is a frequent theme experienced by students in many health professions, including medicine, nursing, occupational therapy, and physical therapy. …

This paper explores the problems of judgement and representation in relation to Jewish victims of the Holocaust who occupied so-called privileged positions in the camps and ghettos. Such figures, forced to act in ways that have proven controversial both during and after the war, faced unprecedented ethical dilemmas under Nazi persecution. Taking Auschwitz survivor Primo Levi’s highly influential essay on the ‘grey zone’ as a point of departure, I examine the extreme situations confronted by prisoner doctors, an important — though little discussed — category of ‘privileged’ Jews. Investigating the synergies between history, memory and film, I focus particularly on the case of Gisella Perl, a prisoner doctor whose experiences in Auschwitz-Birkenau are represented in her memoir and a recent fiction film. The emotionally and morally fraught circumstances of prisoner doctors can never be fully understood, yet reflecting on the double binds they faced, and acknowledging the inherent problems involved in representing and judging them, enables a nuanced approach to the moral complexities of the Holocaust.This article has been peer-reviewed

Physicians experience scary cases in the course of usual medical practice. Cases of near misses, legal and ethical dilemmas, or unique clinical challenges are great sources of education. However, there is no format for presentation and dissemination of cases that do not meet criteria for morbidity and mortality (M&M) conferences. The Scary Cases Conference is an innovative educational forum for scrutiny and analysis of these challenging clinical cases. Scary Cases differs from traditional Morbidity and Mortality conferences as it explores outcomes beyond the scope of medical or surgical errors. From 2011 to 2021: 11 regional and 10 national "Otolaryngology Scary Cases" conferences and mini-seminars were held. The cases presented were analyzed for case specialty, area of management deemed troublesome, and compared to M&M conference criteria. 187 cases were presented. 62% percent of cases included traditional medical problems, whereas 21% involved legal issues, and 17% focused on ethical dilemmas. For the cases with medical problems, 31% involved airway obstruction, 17% nerve injuries, and 17% malignancy. 49% of cases would have met criteria for presentation at traditional M&M conferences. Of all the "scary cases," 25% were near misses and 26% represented ethical or legal dilemmas which would not be classified as morbitidy, mortality, or near miss. The Scary Cases provides a forum conducive to learning amongst peers and experts. It allows medical and surgical specialties to share the cases deemed most impactful. The M&M conference would only include half of such cases, but could be expanded beyond the traditional scope in the future.

Undergraduate social work students are exposed to ethical and legal dilemmas during their fieldwork training. This article presents a study that examined these ethical dilemmas in an Israeli sample of undergraduate social work students. 117 students who participated in a course in ethics submitted 31 written presentations of ethical-dilemma analysis. Their oral presentations were recorded and transcribed. Using a qualitative analysis, three major themes emerged: 1. The tension between the duty to maintain client's confidentiality and its violation under certain conditions; 2. The students’ conflict of loyalty toward the client vs. the organization; 3. The question of the clients’ right to self-determination when, in the student's view, this is against their best interests. Our findings point to the vital role of an ethics course in the social work undergraduate curriculum that can enhance students’ knowledge of specific laws relevant to the limits of confidentiality in social work and their ability to analyze ethical dilemmas as future professionals. Furthermore, it is essential to raise awareness in educators and supervisors concerning moral distress that may afflict students coping with ethical dilemmas at this early professional developmental phase.

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.

Medical detection and management through Artificial Intelligence (AI) constitutes a transformative healthcare force which identifies and handles health threats including infectious diseases combined with chronic conditions and new worldwide health challenges. Worldwide healthcare systems reveal extensive problems that the fast-evolving AI technologies encompassing ML, DL and NLP demonstrate ability to resolve. AI stands as a promising solution to minimize both health threats' mortality rates and morbidity through diagnostic process automation as well as surveillance capabilities improvement and enhanced decision support systems. The journal evaluates how AI detects health threats through its analysis of large datasets while identifying discreet patterns to create predictive models that help with early detections. We review the multiple obstacles encountered during traditional health threat detection through complex datasets combined with human resource restrictions and diagnosis scheduling problems. At the same time, we demonstrate how AI-based systems have produced effective solutions. The review presents actual projects where AI technology enhances healthcare by detecting cancer and forecasting disease spread along with monitoring antimicrobial resistance and mental health evaluation. The journal analyzes both ethical dilemmas and privacy issues tangled with AI implementation together with its integration capability in current healthcare infrastructure. The journal highlights how AI has substantial power to transform healthcare threat detection and requires proper execution and continuous oversight and interdisciplinary team effort to optimize performance while handling risks effectively.

Medical detection and management through Artificial Intelligence (AI) constitutes a transformative healthcare force which identifies and handles health threats including infectious diseases combined with chronic conditions and new worldwide health challenges. Worldwide healthcare systems reveal extensive problems that the fast-evolving AI technologies encompassing ML, DL and NLP demonstrate ability to resolve. AI stands as a promising solution to minimize both health threats' mortality rates and morbidity through diagnostic process automation as well as surveillance capabilities improvement and enhanced decision support systems. The journal evaluates how AI detects health threats through its analysis of large datasets while identifying discreet patterns to create predictive models that help with early detections. We review the multiple obstacles encountered during traditional health threat detection through complex datasets combined with human resource restrictions and diagnosis scheduling problems. At the same time, we demonstrate how AI-based systems have produced effective solutions. The review presents actual projects where AI technology enhances healthcare by detecting cancer and forecasting disease spread along with monitoring antimicrobial resistance and mental health evaluation. The journal analyzes both ethical dilemmas and privacy issues tangled with AI implementation together with its integration capability in current healthcare infrastructure. The journal highlights how AI has substantial power to transform healthcare threat detection and requires proper execution and continuous oversight and interdisciplinary team effort to optimize performance while handling risks effectively.

Electronic health records (EHRs) facilitate several innovations capable of reforming health care. Despite their promise, many currently unanswered legal, ethical, and financial questions threaten the widespread adoption and use of EHRs. Key legal dilemmas that must be addressed in the near-term pertain to the extent of clinicians' responsibilities for reviewing the entire computer-accessible clinical synopsis from multiple clinicians and institutions, the liabilities posed by overriding clinical decision support warnings and alerts, and mechanisms for clinicians to publically report potential EHR safety issues. Ethical dilemmas that need additional discussion relate to opt-out provisions that exclude patients from electronic record storage, sale of deidentified patient data by EHR vendors, adolescent control of access to their data, and use of electronic data repositories to redesign the nation's health care delivery and payment mechanisms on the basis of statistical analyses. Finally, one overwhelming financial question is who should pay for EHR implementation because most users and current owners of these systems will not receive the majority of benefits. The authors recommend that key stakeholders begin discussing these issues in a national forum. These actions can help identify and prioritize solutions to the key legal, ethical, and financial dilemmas discussed, so that widespread, safe, effective, interoperable EHRs can help transform health care.

Advances in neonatology have led to improved survival for periviable infants. Immaturity still carries a high risk of short- and long-term harms, and uncertainty turns provision of life support into an ethical dilemma. Shared decision-making with parents has gained ground. However, the need to start immediate life support and the ensuing difficulty of withdrawing treatment stands in tension with the possibility of a fair decision-making process. Both the parental “instinct of saving” and “withdrawal resistance” involved can preclude shared decision-making. To help health care personnel and empower parents, we propose a novel approach labeled “postponed withholding.” In the absence of a prenatal advance directive, life support is started at birth, followed by planned redirection to palliative care after one week, unless parents, after a thorough counseling process, actively ask for continued life support. Despite the emotional challenges, this approach can facilitate ethically balanced decision-making processes in the gray zone.