Developing a living lab in ethics: Initial issues and observations

Living labs are interdisciplinary and participatory initiatives aimed at bringing research closer to practice by involving stakeholders in all stages of research. Living labs align with the principles of participatory research methods as well as recent insights about how participatory ways of generating knowledge help to change practices in concrete settings with respect to specific problems. The participatory, open, and discussion-oriented nature of living labs could be ideally suited to accompany ethical reflection and changes ensuing from reflection. To our knowledge, living labs have not been explicitly trialed and reported in ethics literature. In this discussion paper, we report and discuss four initial issues that marked the process of setting up a living lab in ethics: (1) determining the goals and expected outcomes of an ethics living lab; (2) establishing operational procedures; (3) selecting communities and defining pilot projects; and (4) adopting a lens to tackle emerging questions and challenges. We explain these four issues and present the paths taken based on the novel and specific orientation, that is, living ethics, at the basis of this project. In alignment with living ethics and É-LABO, we approach challenges as learning opportunities to ask not only "how" questions but also "why" questions. We hope that this discussion paper informed by our experience helps to clarify the theoretical, methodological, and practical approaches necessary to successfully adopt and employ living labs in ethics.

Promise and peril-defining ethical telehealth practice from the clinician and patient perspective: A qualitative study

Objectives

We undertook a qualitative study to examine and compare the experience of ethical principles by telehealth practitioners and patients in relation to service delivery theory. The study was conducted prior to and during the recent global increase in the use of telehealth services due to the COVID-19 pandemic,

Methods

We conducted semi-structured interviews with 20 telehealth practitioners and patients using constructionist grounded theory methods to collect and analyse data. Twenty-five axial coded data categories were then unified and aligned through selective coding with the Beauchamp and Childress (2013) framework of biomedical ethics. The groups were then compared.

Results

Thirteen categories aligned to the ethical framework were identified for practitioners and 12 for patients. Variance existed between the groups. Practitioner results were non-maleficence 4/13 or (31%), beneficence 4/13 (31%), professional–patient relationships 3/12 (22%), autonomy 1/13 (8%) and justice 1/13 (8%). Patient data results were non-maleficence 4/12 (33%), professional–patient relationships 3/12 (33%), autonomy 2/12 (18%), beneficence 1/12 (8%) and justice 1/12 (8%).

Conclusions

Ethical principles are experienced differently between telehealth practitioners and patients. These differences can impact the quality and safety of care. Practitioners feel telehealth provides better care overall than patients do. Patients felt telehealth may force a greater share of costs and burdens onto them and reduce equity. Both patients and practitioners felt telehealth can be more harmful than face-to-face service delivery when it creates new or increased risk of harms. Building sufficient trust and mutual understanding are equally important to patients as privacy and confidentiality.

Confidential Care for Adolescents in the U.S. Health Care System

In providing care for adolescents, maintaining confidentiality should be considered a human right and an evidence-based component of quality care. Unfortunately, complexities in the U.S. legal and health care systems have created a setting in which confidential care is inaccessible to many adolescent patients. Federal laws provide a minimum standard for confidentiality protections, but variations in state legislation relating to minor consent, special health care services, and confidentiality exemptions create large variability in adolescent confidentiality rights across the country. In certain contexts, such as consensual sexual activity, legal provisions may not align with professional ethical standards in adolescent care. In addition, contemporary clinical and administrative issues related to the electronic health record and health care financing also threaten to breach confidentiality. Although further research is necessary, providers and institutions are already well positioned to broaden protections by implementing best practices in training and education, workflow, and medical records related to adolescent confidentiality.

Developments in euthanasia practice in the Netherlands: Balancing professional responsibility and the patient's autonomy

In 2015, euthanasia accounted for 4.5% of deaths in the Netherlands, of which 93% were performed by a GP. Historically, a conflict of physician’s duties—to alleviate unbearable suffering and at the same time preserve the patient’s life—is central to the justification of euthanasia practice in the Netherlands. However, there seems to be a shift towards a greater emphasis on the patient’s autonomous wish as the primary basis for euthanasia. This shift has consequences for the role and interpretation of the physician’s duties in end-of-life care. This paper aims to describe these developments in euthanasia practice and end-of-life decision-making. We describe important relevant developments and look into the role and the meaning of two dimensions of the concept of ‘patient autonomy’ regarding end-of-life decisions, in particular, the euthanasia request. We claim that the concept of autonomy ‘as a right,’ which can be distinguished from autonomy ‘as an ideal,’ narrows the physician’s window of opportunity to offer end-of-life care other than euthanasia.

Quaternary prevention: reviewing the concept

Background: According to the Wonca International Dictionary for General/Family Practice Quaternary Prevention is defined as: ‘Action taken to identify patient at risk of overmedicalization, to protect him from new medical invasion, and to suggest to him interventions, which are ethically acceptable.’ The concept of quaternary prevention was initially proposed by Marc Jamoulle and the targets were mainly patients with illness but without a disease.

Objectives: The purpose of this opinion article is to open the debate around a new possible definition and a new conceptual model of quaternary prevention based on the belief that quaternary prevention should be present in physicians’ minds for every intervention they suggest to a patient.

Discussion: The debate around quaternary prevention is vital in the context of contemporary medicine and has expanded worldwide. The human being may suffer harm from medical interventions from conception, during their childhood, during their entire healthy lifetime as well as during a self-limited disease, a chronic disease, or a terminal disease. The current definition of quaternary prevention has limitations because it excludes patients and medical interventions where a quaternary prevention perspective would be needed and useful to protect patients from harm. In this context, a new definition and conceptual model of quaternary prevention is proposed.

Conclusion: In this new proposal, quaternary prevention is defined as an ‘action taken to protect individuals (persons/patients) from medical interventions that are likely to cause more harm than good.’

Adapting a community of practice model to design an innovative ethics curriculum in healthcare

The focus of healthcare ethics within the framework of ethical principles and philosophical foundations has always, in recent times, been the community, namely, the healthcare provider, the patient or, in research, the study participant. An initiative is thus described whereby a community of practice (CoP) model was developed around health ethics in health research, education and clinical care. The ethics curriculum was redesigned to include several components that are integrated and all embracing, namely, health research ethics, healthcare ethics, health personnel education in ethics and global and public health ethics. A CoP is a group who share a common interest and a desire to learn from and contribute to the community with their variety of experiences. The CoP is dynamic and organic, generating knowledge that can be translated into effective healthcare delivery and ethical research. It requires the collaboration and social presence of active participants such as community members, healthcare professionals and educators, ethicists and policy makers to benefit the community by developing approaches that adapt to and resonate with the community and its healthcare needs. Philosophical principles constitute the foundation or underpinning of this innovative curriculum. Recommendations are presented that will continue to guide the consolidation and sustainability of the CoP.

Interrogating scarcity: how to think about 'resource-scarce settings'

The idea of resource scarcity permeates health ethics and health policy analysis in various contexts. However, health ethics inquiry seldom asks-as it should-why some settings are 'resource-scarce' and others not. In this article I describe interrogating scarcity as a strategy for inquiry into questions of resource allocation within a single political jurisdiction and, in particular, as an approach to the issue of global health justice in an interconnected world. I demonstrate its relevance to the situation of low- and middle-income countries (LMICs) with brief descriptions of four elements of contemporary globalization: trade agreements; the worldwide financial marketplace and capital flight; structural adjustment; imperial geopolitics and foreign policy. This demonstration involves not only health care, but also social determinants of health. Finally, I argue that interrogating scarcity provides the basis for a new, critical approach to health policy at the interface of ethics and the social sciences, with specific reference to market fundamentalism as the value system underlying contemporary globalization.

Maximal care considerations when treating patients with end-stage heart failure: ethical and procedural quandaries in management of the very sick

Deciding who should receive maximal technological treatment options and who should not represents an ethical, moral, psychological and medico-legal challenge for health care providers. Especially in patients with chronic heart failure, the ethical and medico-legal issues associated with providing maximal possible care or withholding the same are coming to the forefront. Procedures, such as cardiac transplantation, have strict criteria for adequate candidacy. These criteria for subsequent listing are based on clinical outcome data but also reflect the reality of organ shortage. Lack of compliance and non-adherence to lifestyle changes represent relative contraindications to heart transplant candidacy. Mechanical circulatory support therapy using ventricular assist devices is becoming a more prominent therapeutic option for patients with end-stage heart failure who are not candidates for transplantation, which also requires strict criteria to enable beneficial outcome for the patient. Physicians need to critically reflect that in many cases, the patient's best interest might not always mean pursuing maximal technological options available. This article reflects on the multitude of critical issues that health care providers have to face while caring for patients with end-stage heart failure.

Shared health governance

Health and Social Justice (Ruger 2009a ) developed the "health capability paradigm," a conception of justice and health in domestic societies. This idea undergirds an alternative framework of social cooperation called "shared health governance" (SHG). SHG puts forth a set of moral responsibilities, motivational aspirations, and institutional arrangements, and apportions roles for implementation in striving for health justice. This article develops further the SHG framework and explains its importance and implications for governing health domestically.

[Public health ethics. Necessity and discourse in Germany]

The international discourse about public health ethics is becoming more intensive and complex. The starting point is bioethics. The debate about public health ethics is simultaneously a debate about an adequate identity of public health, its goals, tasks and standards. In Germany there is a tremendous need to take part in this discourse. German experiences within the traditions of social medicine, social hygiene and medical ethics could significantly contribute to the international discussion. Unfortunately the German speaking public health community has hardly acknowledged the topic of ethics. The reasons for this are not explicitly known. The Anglo-American discourse is much more developed, but the concepts, terms and paradigms should not simply be transferred. They should critically be proven.