Ethics Oral Answers PDF

1. Ethics and morality. Ethical theories and areas of ethics. -Ethics- is a branch of philosophy which represents a system of moral principles to be used as guidelines for human conduct. Ethics / Moral Philosophy is a study of morality -careful and systematic reflection on moral decisions and behavi...

1. Ethics and morality. Ethical theories and areas of ethics. -Ethics- is a branch of philosophy which represents a system of moral principles to be used as guidelines for human conduct. Ethics / Moral Philosophy is a study of morality -careful and systematic reflection on moral decisions and behavior. The role of ethics is to analyze and justify the moral value of human conduct, whether by an individual, group of people or whole society. (How? Why? , social system) -Morality is the value dimension of human decision-making and behavior differentiation of intentions, decisions, and actions between those that are good (or right) and those that are bad (or wrong). (Good or bad? , individual) Ethical theories: 1) UTILITARIANISM: decisions are chose based on the greatest amount of benefit obtained for the greatest number of individuals 2) DEONTOLOGY: ethics of duty where the morality of an action depends on the nature of the action; if the action is intrinsically wrong, then it doesn't matter how good its consequences, the act is forbidden 3) VIRTUE: what matters morally is not what we do at a time, but what we become over time. Areas of ethics are: 1) Descriptive ethics - observes, describes and explains the actions and behavior of individuals and groups 2) Normative ethics - determines what is right and what is wrong 3) Analytics ethics - studies the origin and meaning of ethical concepts 4) Applied ethics - attempts to apply ethical theory to real-life situations 2. Bioethics and its sub-disciplines. Goals and ethical aspects of health care. Bioethics – is philosophical science on principle of doing good for humans and the whole nature. Three main sub-disciplines of bioethics: ► Medical Ethics ► Animal Ethics ► Environmental Ethics After its creation, the term bioethics has been used mostly in relation to issues concerning medical ethics; therefore, in 1988 Potter suggested a new term "global bioethics" – the science of the balance between human and nature. Global bioethics is calling for the merging of environmental ethics and medical ethics on an international scale to preserve human survival it urges medical ethicists to also consider long term consequences of their day to-day clinical decisions and expand their thinking and actions to public health issues world-wide One of the organizations representing this idea is Global Bioethics Initiative (GBI) Goals of health care: Every human being as a part of society has 4 dimensions: biological (physical, somatic) mental (emotions) social (contact with society) spiritual / real "me" manifesting as: - the need of knowledge, - the need of thinking, - the need of values, - the need of relationships spiritual dimension in developing by contact with natural environment. → its beginning: relationships child – mother Requirement for existence of these dimensions is health. Health is a state of complete physical, mental and social well- being. (not just absence of disease) (definition of WHO) Basic postulates about health by WHO: 1. Health is one of the most important needs of every human being 2. Every human being is personally responsible for his/her health 3. Every person has a right to decide about their health 4. Every person must offer help to everyone, who’s health has been damaged Every person without difference has the right to: health, health care and social security. Society has to make it possible for everyone to: strengthen and regain back their health and handle the adverse health condition in the best way possible. 3. Basic principles of medical ethics. Areas of problems in medical ethics. 1. Beneficence – beneficialness (a requirement to do maximal good for the welfare of an ill or healthy (vaccination) person 2. Non maleficence – harmlessness (a requirement for exclusion of any, intentional or not intentional, damage of health) NIHIL NOCERE = NEVER DAMAGE! 3. Autonomy – autonomy (respectability of the patient) 4. Justice – justice (no discrimination of patients) + The informed consent of the patient or legal representative is a part of the mentioned four principles: a requirement of performing diagnostic, therapeutic as well as research interventions only on principle of free consent of the mentally competent patient on the basis of his/her previous understandable (intelligible) and full instruction (must be written). Areas of problems: - Selection and education of physicians and health care professionals - Patients' rights - Informed consent of the patient / guardian - Biomedical research involving human subjects - Organ and tissues donation - Highly infectious diseases / vaccination - Beginning-of-life issues (everything related to pregnancy) - End-of-life issues (DNR, assisted suicide, euthanasia and other) - Relationships and communication between the patients and health care providers - Relationship between the citizens and health care (health insurance) - Position of the complementary and alternative medicine 4. Informed consent of the patient. Previously expressed wishes of the patient. The informed consent of the patient or legal representative is a part of the mentioned four principles: a requirement of performing diagnostic, therapeutic as well as research interventions (clinical education and tissue banking, too) only on principle of free consent of the mentally competent patient on the basis of his/her previous understandable (intelligible) and full instruction (as a rule in a written form). Problems by informed consent: a) Consent of mentally incompetent persons (children, psychiatric and elderly patients) – the consent is given by the legal representatives b) Consent of patients in a life threatening state (unconsciousness, shock) – the consent is expected c) The problem of sufficiency of mental capacity of the patient and on the other side the ability of the physician to rich the full understanding of the information One of the main tasks of the physician by informed consent is to gain the patient for active cooperation. Previously expressed wishes relate to a medical intervention which the patient decided upon before being in the position and therefor at the time of the intervention the physicians must take into account the patient’s previously expressed wishes. Example of these previously expressed wishes are: living will, declaration of desire for natural death, advanced directive and more. 5. Ethical requirements for medical profession. Codes of ethics for physicians. I. Physical and mental health: a) Corporeal fund (health care, condition, outward) b) Mental hygiene (ability to overcome stress and conflicts) II. Professional ability and efficiency of the personality: a) Mental powers and professional level (lifelong study) b) Socialness (help without discrimination, pity, self-sacrificing) c) Empathy (towards both patients and colleagues) d) Solidarity (with patients and relatives) e) Responsibility (towards patients and community) f) Conscience (inborn basis-coded demand of the protection of life and health developed lifelong) g) Self-confidence (competence to the medical rank) h) Communicability (with patients, relatives, colleagues -need to co- work and mutual help) i) Sympathetic, pleasant behavior j) Cultivation of rank virtues of physicians Code of ethics for p-hysicians is relied on the WMA international code of medical ethics. It contains many physicians’ duties in general or towards his patients and colleagues. It says that for example a physician must always use his professional judgment and always work according to the patient’s rights and never allow personal benefit or discrimination to influence his judgment or work. 6. Most important international conventions and declarations relevant to the health care professions. The oldest and the most quoted code is – Hippocratic Oath, which establishes based moral continuity of any subsequent codes of ethics. Most important international documents:  geneva protocol 1925: prohibition of the use of chemical and biological weapons in international armed conflicts.  nuremberg code 1947, universal declaration of human rights 1948: prohibition of experiments on humans without their consent.  WMA declaration of geneva 1948, 1968, 1983, 1994,2005, 2006: modern equivalent of hippocratic oath.  WMA international code of medical ethics 1949 1968 1983 2006: more detailed code ethics.  european convention on human rights 1950  declaration of helinski 1964-2013   WMA declaration of oslo 1970: statement on therapeutic abortion.  declaration on the rights of mentally retarded persons 1971: general and special rights of mentally handicapped persons.  the declaration of hawaii (world psychiatric association) 1977: prevention of the abuse of psychiatry for political purposes.  WMA declaration of lisbon on the rights of the patient 1982, 1995  the nurse’s role in safeguarding human rights 1983  european association for children in hospital each charter 1988  the declaration on the promotion of patient’s human rights in europe. 1994  the european charter of patient’s human rights 2002  declaration on tobacco control 2002  WMA declaration of taipei on ethical considerations regarding health databases and biobanks 7. The role of dignity in health care. Patients' rights. Doctor – patient relationship. Factors degrading the dignity of the sick person – patient: Physical Invasion of privacy during the examinations and procedures Invasion of privacy during participation of the patient in clinical teaching Influence of drugs Dependency on other people, complete subjection Psychological The very fact of the presence of disease Feeling of guilt for own disease, change of appearance Hopelessness, helplessness, feelings of worthlessness Social Informational isolation Social isolation Undignified conditions Unethical behavior of the doctor and nursing staff patients' rights: Human rights and individual freedom Tendency of patients for making decisions about their health Responsibility of patients for their own health condition Overall growth of medical knowledge in society Increase of chronical diseases – quality of life and problem of autonomy Patients have the right to be fully informed about their health status. Patients have the right to choose who, if any one, should be informed on their behalf. The informed consent of the patient is a prerequisite for any medical intervention. All information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind must be kept confidential, even after death. Possible models of doctor – patient relationship 1. Paternalistic (doctors are dominant) 2. Non-paternalistic → partnership (emphasizes patient’s autonomy and gives a possibility of informed consent) 3. Contract 8. Communication in medical care. The doctor must be able to communicate properly with his patient in order to maintain a successful doctor-patient relationship. Basic requirements for communication between doctor and patient: know, what we are going to say decide, when to provide the information choose an appropriate place to talk decide, how to best formulate the information remember, that information which is understandable for the doctor, might not be understandable for the patient talk clearly and do not try to complicate the communication in any way select the appropriate pace and corresponding tone language  watch and notice patient’s responses, notice in particular any signs of anger, confusion, take into consideration patient’s emotions enable the patient to sufficiently express him/herself do not trouble or irritate the patient by your speech verify that the patient received and understood the information 9. Communication with specific groups of patients (patients with disabilities, aggressive patients, etc.) Person (patient) with physical disability: hold the conversation in the same manner as with person without disability, abide by general rules of communication With patient in wheelchair communicate in sitting position ensure appropriate conditions: access for the disabled, enough space in the waiting room for mobility with the wheelchair, mobility aids always need to be within the reach of the patient During hospitalization, encourage the patient to be self-sufficient and to move as much as possible. Person (patient) with visual impairment: For communication use undamaged sense → verbal communication Patients can have guide dog with them Doctor is the first one who opens the door, introduces him/herself, offers the hand, and leads the patient inside Never move patient's personal belongings. Person (patient) with hearing impairment: For communication use undamaged sense → eyesight In the beginning of the conversation find out the degree of hearing damage (partial, complete, with speech disorder) communicate primarily with the patient, not the second person (guide) talk slowly, articulate properly. VIP (Very Important Person) – patient: Hospitalization under the media spotlight Presence of various accompanying persons (bodyguards, lawyers) Special requirements for environment, comfort, diet, visiting hours comply with the system of organization in the workplace, use standard diagnostic and therapeutic procedures. 10. Burnout syndrome in medical professions. Burnout syndrome: is defined as an emotional exhaustion and depersonalization, loss of personal or professional interest, which leads to a decrease in work efficiency. It occurs gradually and inconspicuously as a result of prolonged psychological exhaustion related mainly to intensive contact with the patients, sharing their illness and treatment with them, as well as the great responsibility for patients’ health and progress of their therapy. Physical symptoms: Fatigue, exhaustion. Apathy, weakness. Shortness of breath. Psychological symptoms: Irritability. Feelings of rage and anger. increased sadness. Depression. Uncontrollable verbal expressions of anger. Work related symptoms: “things have no meaning anymore” Loss of interest in patient or in medicine Negativity and increased irritability 11. Ethical and legal issues in pediatrics. The rights of hospitalized children. Child= person below the age of 18. Declaration of the Rights of the Child 20.11.1959: A) The right to equality, without distinction on account of race, religion or national origin. B) The right to special protection for the child’s physical, mental and social development C) The right to a name and a nationality. D) The right to special education and treatment when a child is physically or mentally handicapped. E) The right to protection against all forms of neglect, cruelty and exploitation. Charter for Children in Hospital / EACH Charter: *. Children in hospital have the right to have their parents constantly with them. *. Children and parents have the right to be informed. Under takings for diminishing the physical as well as emotional stress are necessary. *. The parents have the right to be informed about all decisions in health care of their children. Each child should be protected from needless treatment or research. *. Children should be nursed together with children of similar stage of development, not with adults. *. Children should have all conditions for games and relax as well as for education suitable for their age in an appropriate and stimulating environment. *. The nursing staff should be educated and experienced in optimal reactions to physical, emotional, and developmental requirements of children and their families. WMA (world medical association) Declaration of Ottawa (‫) בירת קנדה‬ on Child Health: general principles for promotion of child health: -. A place with a safe and secure environment * Clean water, air and soil * Protection from injury, exploitation, discrimination and from traditional practices prejudicial to the health of the child. -. A place where a child can have good health and development. * Prenatal and maternal care for the best possible health at birth. * Nutrition for proper growth, development and long-term health. -. A full range of health resources available to all means * The best interests of the child shall be the primary consideration in the provision of healthcare. * Basic health care including health promotion, recommended immunization, drugs & dental health. -. Research & monitoring for continual improvement * All children will be treated with dignity and respect. * All infants will be officially registered within one month of birth. Ethical issues in pediatrics : When children are hospitalized we there can be many psychological effects on the child due to separation from family or society or other problems. But the main fear a child feels is fear of pain. Therefore the pediatric health care must fight against the pain and prevent suppression of pain. And the doctor must achieve ethical standards by respecting the children rights and their psychological and emotional needs as well as their physiological needs. Ethical issues in pediatrics include problems with the child as the patient himself, the parents who sometimes might be aggressive, and also the siblings. When communicating with a child as a patient the doctor must respect the patient’s right to information and adjust to the state and needs of the child patient. Maintain professional standards and approach the patient with kind empathy. When communicating with the child’s parents some problems may arise for example: -aggressive parents in which case: a physician will not deal with the case in private and always try to keep a door open or having another doctor present. -announcing adverse information to a child’s parents must be held in private and only by a doctor and not any other medical staff. The doctor must use an understandable language and explain everything to the parents clearly. When communicating with the child’s siblings they have the right to be informed and accompany their parents in patient visit but must be fully aware of their sibling’s condition. 12. Communication with pediatric patients and their parents. Interaction doctor–child–parent: child as an equivalent participant in the conversation. the need to hold the conversation in a friendly and relaxed manner. Ethical issues in communication with the child: patient's right to information must be respected.  always adjust to the state and needs of the child patient, as well as to the actual mental state, needs and abilities of the parents. cooperation between the pediatrician, clinical psychologist and social worker →in order to cover all of the child’s needs. Hospitalized child will cause many problems for the parents and thus ethical issues might arise. Adverse information about child’s health is announced to parents only by doctor (not nurse or other medical staff. *in private, without any interruption by other people or phones. *parents might start to blame themselves for not coming sooner. *enable parents contact with their child. Situation,when parents are angry ,accusatory and aggressive: *parents are trying to find a person to blame, they can be hysterical *do not deal with this situation in private, but in an open space (office with doors left open). *let the parents speak display the will to listen to them, answer in the calm voice. Ethical issues in communication with the siblings *should not be excluded from the situation, they need to be informed. *encourage them to communicate and touch their sick sibling. *they may feel abandoned and get angry with their sick sibling inform them about the death of their sibling, do not hide this information from them. 13. Elderly patients. Risks in hospital by elderly patients. Elderly persons which are usually 65 years and more can be classified as: - Positive personality- they are still active even during their retirement doing some free activities and hobbies. - Negative personality- with a more passive lifestyle, no dynamic activity. “just waiting for their time to come” Risks in hospital for elderly patients include: - Iatrogenic trauma –negative reaction to treatment, pills, etc.  - Dietetic trauma –different type of nutrition may cause obstipation or diarrhea, excessive eating during family visits. - Dehydration–patient’s don’t feel thirsty and thus don’t drink much water during the day. - Nosocomial infections –respiratory infections (flu, bacterial pneumonia) - Psychosocial trauma –as a consequence of separation from family and home environment, restrictions related to staying in hospital. - Physical trauma –mostly injuries from falling (subdural hematoma, femoral neck fracture) - Stay in bed –may worsen osteoporosis, lead to muscle atrophy, joint pain, orthostatic collapse, especially dangerous are pulmonary thromboembolism, bronchopneumonia, urinary infections and pressure ulcers. - Geriatric maladaptation syndrome – adaptation failure manifesting as depression, confusion, immobility, incontinence. 14. Terminal illness. Eschatology. Stages of dying. Intensity of the dying process. Terminal illness: A terminal phase of disease (terminal illness) – is a medical term to describe a disease that cannot be cured or adequately treated and is reasonably expected to result in the death of the patient within a short period of time. This term is more commonly used for progressive diseases such as cancer or advanced heart disease than for trauma.In popular use, it indicates a disease that eventually ends the life of suffering patient.  The duty of physicians is to heal, where possible, to relieve suffering and to protect the best interests of their patients.There shall be no exception to this principle even in the case of incurable disease.  In the care of terminal patients, the primary responsibilities of the physician are to assist the patient in maintaining an optimal quality of life.   The patient’s right to autonomy in decision making must be respected with regard to decisions in the terminal phase of life.This includes the right to refuse treatment and to request palliative measures to relieve suffering but which may have the additional effect of accelerating the dying process. However, physicians are ethically prohibited from actively assisting patients in suicide! This includes administering any treatments whose palliative benefits, in the opinion of the physician ,do not justify the additional effects.  Physicians should recognize the right of patients to develop written advance directives that describe their wishes regarding care in the event that they are unable to communicate and that designate a substitute decision - maker to make decisions that are not expressed in the advanced directive. Eschatology – science about the last things of human being.As the last things , we mean some specific physical and mental condition of human,in connection with situations, attitudes , and activities ,which are taking place in the final part of life ,during the dying of a human.It concerns the dying person as well as the people around him/her. *Kubler-Ross’s 5 stages of dying: 1.Denying “No, not me!” 2.Anger “Why me?” 3.Negotiation “Yes, me, but maybe…” 4.Depression “What does it mean for me?” 5.Acceptance “Yes, me. If it has to be, then I’m ready.” Intensity of dying: can be differentiated to 3 types depending on the time it lasts: - sudden death – ( e.g. heart attack ,heavy injuries ) in which realization of death lasts only a very short period of time or is absent.  - dying of chronic diseases of CNS – ( e.g. Alzheimer’s disease ) which don’t cause physical pain and realization of death is very limited or again absent.Taking care of these patients is a long term process ,which can be exhausting and lead to psychosocial problems. Death is then perceived more as a release for patient’s relatives. - very painful and slow dying – ( e.g. oncological diseases ) represents the biggest problem for the nursing staff. 15. Futile treatment. Resuscitation decisions. Legal aspects of end- of-life decisions. Futile treatment is considered to be an ineffective treatment that most likely cannot cure the patient or restore a quality of life that would be satisfactory to the patient. This includes any treatment in which the burdens greatly outweigh any chance of success or benefit to the patient. Discontinuation of futile treatment is following the interest of the patient, and aims to prevent violation of basic principles of medical ethics including dying with dignity. Resuscitation decisions: Decision regarding resuscitation is governed by two important principles: 1. The principle of patient autonomy:  Advanced directive (DNR, DNAR).  If patients’ preferences are uncertain, emergency conditions should be treated until those preferences are known. 2. The principle of futility:  If the purpose of the medical treatment cannot be achieved, the treatment is considered futile.  Key determinants: length and quality of life expected duration remaining in cardiac arrest. The judgment of quality of life is very difficult and subjective. It is  necessary to discuss it with the patients and their relatives. Legal aspect of end of life decision:  Informed consent and negative reverse.  Advance directive:  Living will: legal document in which a person specifies what actions should be taken for their health of they are no longer able to make decisions for themselves because of illness or incapacity.  Power of attorney: legal document in which the patient designates someone to be his/her representative, in the event where he/she is unable to make or communicate decisions about aspects of health care.  Medical directive: do not resuscitate (DNR) order do not attempt resuscitation (DNAR) order. In countries where there is no DNR orders available, the decision not to resuscitate is solely in the hands of the physician and health care team. 16. Thanatology. Euthanasia, dysthanasia, and assisted suicide. Thanatology is an interdisciplinary field of medicine dealing with processes of death and dying and with problems of terminal care. The three basic problems of thanatology: *. Determination of the moment of death after injuries with an irreparable damage of vital functions *. Identification of terminal phase of disease. *. Ethical problems connected with death and dying process and terminal care. Which one is more important? The sanctity of life (in the Christian religion) or quality of life. Euthanasia – activity or inactivity leading to death carried out with the intention to cause death or accelerate its coming in order to stop the suffering of the terminally ill patient; further, done on the demand of the patient or with high probability that he or she would demand it or with agreement of his or her guardian. Dysthanasia – withholding the inevitable end of life with assistance of medical equipment and pills (like case of President Tito – kept alive for political reasons). Euthanasia is classified into 3 types depending on person’s will: *Voluntary euthanasia – the person wants to die * Non-voluntary euthanasia – the person cannot make a decision or cannot make their wishes known, *Involuntary euthanasia – the person who dies chooses life and is killed anyway (is usually considered murder).  Active euthanasia - occurs when the medical professional or another person besides the patient, deliberately does something that leads to the death of the patient or accelerates the dying process. For example, when a medical practitioner administers the lethal dose of a drug, medication or chemicals, this is active euthanasia.  Passive euthanasia - discontinuing care with life sustaining measures with the intention of causing death or accelerating it, in the patients’ interest. This is because there is a negative expectation of prognosis. Withdrawing or withholding of life- prolonging treatment, the main purpose is to bring about the patient’s death, the reason for hastening death is that dying is in the patient’s own best interest. For example turning off respirators, halting medications, discontinuing food and water supply to allow person to dehydrate or starve to death, or failure to resuscitate. Assisted suicide- Main difference between euthanasia and assisted suicide: the doctor is not assisting during the final step of suicide, he/she can help the patient just with the preparation of the act (prescription of the drugs use for the suicide, explanation of how to use the drugs, etc...). Assisted suicide has the potential to be more accepted than euthanasia. It is legally allowed in: Switzerland, Colombia, Netherlands, Luxembourg, Canada, USA (Oregon, Washington, Vermont, California, Montana {only via court ruling}). 17. Ethical issues in organ transplantations. Legal approach to organ donation. Based on the ethical principle that the art ought to improve the nature, the physician can interfere with the integrity of the human body by removing the defects and failures even by organ transplantation under one condition: The natural essence and creative intelligence of human should not be suppressed! One of the ethical issues of organ transplantation is disproportion between demand and supply of organs for transplantation, especially kidneys. Health care institutions are poorly motivated and not every possible donor is used. No one can seek or receive financial or material reward for any human organ. Therefore organ trafficking is also considered to be unethical in organ transplantation. Legal approach to organ donation: OPT-IN – only those who have given explicit consent are donors. It is used in USA and UK. You can register online and sometimes you are forced to answer the question regarding organ transplantation after registering for a driving license. OPT-OUT – anyone who has not refused consent to donate is a donor (presumed consent). It is used in many European countries. Like here in Slovakia, people can write their refusal of organ procurement for the purpose of transplantation. In some legislation systems family members are allowed to give consent or refusal, if the deceased neither allowed nor refused donation while alive. 18. Conditions for organ donation from living donors. The basic conditions for organ transplantations from living donor (declaration of WMA, madrid 1986):  1. urgency for the acceptor: who cannot be successfully treated in any other way. 2. to insure that the donation does not violate the principles of integrity of donor’s organism. ( the corresponding function must be preserved, e.g, kidney). 3. minimization of risk for the donor. 4. favourable prognosis of transplantation for the acceptor for a long time, (bas health condition and elderly age is a contra- indication). 5. voluntary and spontaneous informed consent of both, donor and acceptor (the donor needs sufficient time for decision, withholding of consent because of interest in own health is ethically correct too). 6. exclusion of commercial interests, discrimination, exploitation (pressure of relatives on potential donor). 19. Conditions for organ donation from dead donors. Two types of dead donors. Brain death. There are two types of dead donor, depending on determination of their death: a. Beating heart donor - brain death b. Non - beating heart donor: respiratory and cardiac arrest. The basic conditions of organ transplantation from dead donors: 1. Urgency 2. Favorable prognosis for living acceptor 3. Informed consent of the acceptor 4. Absence of legal barriers (presumed consent of the donor - it assumes the person has chosen to do so in the absence of evidence to the contrary - some argue its unethical because it may deny patient autonomy) 5. Reliable diagnosis of brain death (independence towards the transplantation team) 6. Exclusion of commercial interests. 7. Protection of the acceptor from the risk of HIV infection and malignant tumor. 8. Anonymity  9. Selection of acceptor exclusively based on medical (immunological) criteria. 10. Disposition of organs for other countries. 20. Ethics of autopsy and exhumation. Autopsy is an indispensable source of information about the cause and mechanism of death, represents the most important examination method of current forensic medicine. It is a full post mortem external and internal examination of the dead body for medical or legal purpose. It must always be complete. Autopsy is very important for gaining more information. Thus we must maintain ethical principles when it comes to autopsy. In addition the human body still does not lose its moral and ethical values even after death therefore we must maintain dignity and respect of the body. - Autopsy must be carried in a way that will get the dead body back to a state closest to that before autopsy and will leave no signs on the face or exposed areas. - During autopsy we must maintain confidentiality and reputation of the dead person. Therefore it’s considered to be unethical to take pictures or videos of the dead body during autopsy. - Usage of dead bodies for science and learning is acceptable but must be only according to ethical principles. Ethics of exhumation: Exhumation is usually not very preferable but in some cases are unfortunate necessity. Because as it was mentioned before, the human body still has its ethical and moral values even after death we still must maintain dignity of the body. Therefore “dead bodies should not be exhumed unless reason of substance is brought forward for disturbing their repose”. In order to grant permission for this process, a very substantial purpose (such as murder investigation) is needed. But in all cases this process must be granted by local government and religious authorities. 21. Ethical issues in reproductive medicine: sterilization, abortion. Sterilization is a surgical method of obtaining permanent contraception by occluding the fallopian tubes in women and occluding vas deferens in men. Ethical recommendations to sterilization: -Informed consent, written only + time to change the mind! -The woman be interviewed without family members present. -Socialization training, sexual abuse avoidance training, family therapy and sex education be considered as alternatives to sterilization. -A reversible long-term form of contraception, such as the intrauterine device or other implants be considered as they may be preferable to sterilization. Sterilization may be problematic because it’s sometimes carried with no informed consent (in some countries). And also because it can cause many psychological problems in the family. Abortion- premature expulsion of the fetus from the womb before pregnancy reaches full term (40 weeks). It can be as a miscarriage (spontaneous) because it happens naturally. Or it could be produced (induced) by deliberately ending the pregnancy. - An ethical problem is whether the mother has the right to decide about the life of a conceived child. - Another ethical problem is when the fetus considered to be “alive” 22. Ethical issues in reproductive medicine: assisted reproduction, surrogacy. Assisted reproductive technologies- all treatments and procedures that are used for the purpose of achieving pregnancy. 1. Artificial insemination (AI) - The process of injecting washed sperm directly into the uterus with the use of a very thin flexible catheter placed in the cervix. There are two types of artificial insemination: by husband or by a donor. (The donor must be over 18 years and mustn’t be a relative. 2. In vitro fertilization / embryo transfer - In the process of IVF mature eggs are collected from woman’s ovaries and fertilized by sperm in a lab. Then the fertilized egg (embryo) or eggs are then implanted in your uterus. 3. Gamete / zygote intrafallopian transfer - GIFT is when gametes (both eggs and sperm) are injected into the fallopian tubes using laparoscopic surgical technique. ZIFT is when zygotes (fertilized eggs) are then laparoscopically injected into the fallopian tubes (combination with IVF). 4. Gamete and embryo cryopreservation- used for leftover embryos after a cycle of IVF. 5. Oocyte and embryo donation- rapid development in the field of ART, need for legislation, continuous ethical dilemmas. Ethical issues: -risk of alteration in genetic pedigree -financial gain -exploitation -reproductive tourism -donor anonymity *the right of autonomy and privacy of the parents *the right of privacy of the donor *the right of the child to know his/her origins Surrogacy („womb renting“) is when another woman carries and gives birth to a baby for the couple who want to have a child – intended parents. Types of surrogacy: Gestational (GS) → the child is not genetically related to the surrogate mother. - Embryo from both intended parents - Egg donation (embryo from intended father's sperm and a donor egg where the donor is not the surrogate). - Donor sperm (intended mother's egg and donor sperm) - Donor embryo (leftover embryos from IVF of other people)  Traditional - naturally or artificially inseminating a surrogate with intended father's sperm / donor sperm. Gainful / commercial Altruistic (surrogate does not receive any financial compensation) Ethical problems: - A question concerning who is the “real mother” of the child. - The citizenship status of the child. - Babies with disabilities might not be accepted by the parents. - Commercial surrogacy is also an ethical issue because some woman take advantage of surrogacy to make money. 23. Ethical issues of genetic testing and gene therapy. Ethics of human cloning. GENETIC TESTING - The ownership of genetic information- the information is revealed only to the patient himself. But in some cases the information might be useful for other family members but the patient refuses to reveal the results. - Patient’s right of privacy- the patient has the right to genetic privacy and to informational self-determination. Meaning the patient can decide whether or not to know the risks involved. - Limitations of genetic testing- since genetic testing could be inaccurate in some cases, problems might arise in patient’s decision making regarding some preventive treatment. - Genetic discrimination- sometimes information revealed in genetic testing might limit person’s ability to obtain employment in certain professions or get a life insurance. GENE THERAPY - Therapy vs. enhancement- an ethical problem occurs when it’s hard to distinguish the line between therapy and enhancement. Because gene therapy could be used for changing of human traits in purpose of enhancement. - Accessibility- because gene therapy is expensive it’s not accessible to all people. Thus it’s problematic if it’s only accessible to the wealthy.  - In germ line gene therapy a genetic defect can be corrected, but might also create a new mutation which will be passed on to a new generation. Ethics of human cloning: Cloning means creating the exact replica, artificial and identical genetic copy, of an existing life form. There are 2 types of cloning: -Reproductive cloning- performed with the express intent of creating another organism (like creating sheep dolly) -Therapeutic cloning- performed not to produce another organism but to harvest embryonic stem cells with the same DNA as the donor cells for the use in medical treatment and research. It includes destruction if the generated embryos in order to collect stem cells which arises questions regarding moral status of human embryo. 24. Ethical issues in selected medical divisions: neonatal and fetal medicine, gynecology and obstetrics. NEONATAL AND FETAL MEDICINE Neonatal medicine is the branch of medicine that is concerned with the diagnosis and treatment of ill newborn babies (28 days after delivery). Fetal medicine is the branch of medicine that is concerned with the health and development of the unborn baby. Problems: - The moral status of the fetus is an ethical problem because different opinions are found. Thus it is hard to decide exactly what the moral status of the fetus is. And relying on that to make medical decisions regarding treatment. - The principle of “best interest” could also be an ethical problem because it is hard to define what kind of pain the fetus will feel or mental distress. Therefore it is hard to choose a treatment that will be of best interest of the fetus. - Decision making by the parents who are the legal representative of the fetus and thus they have the moral authority to make the decision regarding the treatment. GYNECOLOGY AND OBSTETRICS Problems: - termination of pregnancy (legalized health and social indications, the right of the woman against the right of the unborn baby to life and free development, consequences in the national population politics – negative reproduction, predominance of old people, complications can cause sterility, feeling of fault, question what and when is the beginning of human life, the obstetrician has the right to refuse the execution) - Birth control – contraception, fertility control (The role of the state and society is to create well conditions for functioning of families. If there are health or social reasons, using of allowed contraception method is available. - sterilization (a commission decides on basis of legal indications – life threatening, genetic indications) - artificial insemination (sterility is a social problem, too – disintegration of marriage – should be treated, homologous [own husband] and heterologous insemination [unknown donor of semen], problem: the donor cannot know the fate of his child, he reproduce himself without responsibility against child, alternative – adoption) - in vitro fertilization and embryo transfer (the basic subject: human embryo; if the embryo is considered as a non-repeatable biological and spiritual base of human individuality, then IVF and ET are ethically doubtful: devaluation of superfluous embryos, donation of eggs, possibility of damage through cryopreservation, surrogate mother etc.) 25. Ethical issues in selected medical divisions: surgery, nephrology. SURGERY In the center of interest is the operation – damage of the integrity of human body bound to the patient’s consent – responsibility for the result. Three basic requirements: high professionality, knowledge of legal regulations and norms, acceptation of principles of medical ethics. Problems:  - Paternalism – the right of the surgeon to decide about treatment without consent of the patient (anesthesia, unconsciousness, vital indication etc.) - Dehumanization of medicine (patient is identified by the procedure) - Communication with the family - “One day surgery” - Indication of a surgical way of treatment - Control of the patient after operation - Team-work, co-operation among surgeons and hospitals - Introduction of new diagnostic and therapeutic methods (lasers, stents, mini invasive surgery etc.) NEPHROLOGY - treatment by dialysis Two main contradictions: a) providing with expensive care in limited economic possibilities (The society is guilty) b) contradiction between life maintenance and source of suffering (breach of harmlessness) Ad a) Selection of patients in consequence of insufficient capacity (Slovakia 180 patients/1 million inhabitants, western Europe 300-400, Japan 700). There are absolute and relative contraindications (malignity with bad prognosis, severe general atherosclerosis, stroke, lack of possibility of arteriovenous cannulation, progressed cachexia, chronic ethylism, liver cirrhosis, blind diabetics, inability to co-operate, immobility). Ad b) Restriction of life (dialysis about 5 hours 3 times weekly, inability to work, development of the system man – machine). Different adaptation from hope for successful transplantation to depression and danger of suicide. 26. Ethical issues in selected medical divisions: psychiatry, prehospital emergency care. PSYCHIATRY Psychiatric treatment might sometimes be misused for the purpose of controlling the behavior of some people. And also some problems might arise due to the close relationship between the patient and therapist. Problems: - Psychiatric diagnosis: One should not equate psychiatric diagnosis with legal insanity or it should not be used as a defense for reduced responsibility Large number of psychiatric diagnoses do not fulfill the legal conditions required for insanity. - Informed consent: sometimes informing the patient about his diagnosis causes a distress. Also it’s hard for the patient to fully understand the treatment methods and to give proper consent to all the procedures - Confidentiality: sometimes information given by the patient might be dangerous (for example threatening of murder) and the problem of protective privilege vs. public peril arises. PREHOSPITAL EMERGENCY CARE Prehospital care is delivered by emergency physicians and by emergency medical technicians, paramedics or nurses. Problems: - Justice (so many calls but not enough ambulances) - Triage (sorting people based on their need for immediate treatment to red yellow green and black) - Interventions in dangerous situations - Informed consent (the patient has to be content which might be a problem in emergency care and not enough time to get the proper consent) - Refusal of treatment (sometimes patients refuse treatment due to distress) - Dealing with difficult patients (like drunk patients of aggressive or stubborn) - Withholding or withdrawal of CPR 27. Biomedical research involving human subjects: conditions, ethical and legal regulations. Clinical and non-clinical research. Conditions for biomedical research include: Novelty of medical hypothesis, benefit of the society, approval by an authority, presence of voluntary signed informed consent. Ethical and legal regulations in biomedical research represent universally recognized need. Regulation by international and national codes of conduct: o Nuremberg code, 1947 o Declaration of Helsinki (WMA), 1964 –2013 o Convention on Human Rights and Biomedicine (Council of Europe), 1997, Oviedo o Good Clinical Practice–international ethical and scientific quality standard for designing, recording and reporting trials that involve the participation of human subjects. Biomedical research can be classified into: 1) Clinical (therapeutic): is undertaken together with patient’s care and has direct benefit for the subject. 2) Non-clinical (non-therapeutic): undertaken on other subject and contribute to general knowledge so has no direct benefit for the subject. 28. Ethical issues in animal experimentation. 4R principle. Animal experiments is every use of animal for scientific purposes. Animal experiments are very important and its aim should be scientific and exactly described. It should be performed with no torture of the animals and with the minimal number of animals and with connection with the human health. Animal experiments research must be approved by an ethics committee. Ethical issues: - Maintaining freedoms of laboratory animals (freedom hunger or thirst, discomfort, pain and injury, fear and distress) - Maintaining the right conditions for laboratory animals (convenience, safety, hygiene, training) - Selection of right experimental animal *The 4 Rs: are a set of ethical principles that scientists are encouraged to follow in order to reduce the negative impact of research on animals. (by Perry, 2007) 1- Reduction: reducing the number of animals used in experiments (by ways like improving techniques or other) 2- Refinement: refining the experiment to reduce animals’ suffering by the usage of less invasive techniques and better conditions. 3- Replacement: replacing experiments on animals with other techniques (like using cell cultures and instead of an animal or using computer models…) 4- Responsibility: professional liability and competence of the personnel providing experiments on animals. A scientific fraud must be excluded. 29. Ethics committees. Ethics committees: Ethics committees are independent multidisciplinary groups of experts and people without medical or scientific qualification, which play an important role in solving ethical problems concerning biomedical research and health care. They include professional members (with knowledge in medicine or science) and also laymen (people without any specific qualifications) to represent the view of the public and the patient, all equally represented in the process of the assessment. The number of the members of ethics committee must be an odd number with no less than 5 members. In solving ethical problems ethics committees rely on main principles of medical ethics (beneficence, harmlessness, autonomy, justice, and informed consent), bioethics, country’s legislation and internationally recognized documents. *Ethics committees are constituted on three levels: local, regional and nationwide. *The main roles of Ethics Committees: Evaluation and review of ethical-legal aspects of biomedical research concerning animal or human subjects Assessment of ethical dilemmas in the process of providing healthcare Assessment of ethical legitimacy of new diagnostic, therapeutic, prophylactic and preventive procedures, including cell and tissue banking  Evaluation of publications of clinical research results for editorial councils of international medical journals. Promotion of patient’s rights and suggestion of new legislation forms, which would provide better alignment of ethics and law They are the representation of the positive image of accepted reforms concerning biomedical research and healthcare Participation in educational process 30. Publication ethics. In research processing of publications using the results obtained in the experiment and their subsequent dissemination is very important and therefore the publication ethics are important for researchers when it comes to publishing their results. However, researches are sometimes influenced by some factors and thus interpret their results. Some of these factors include public influence, moral and ethical qualities and personal scale of value. There are two basic principles of publication ethics: -fair reporting (truthful content) -fair publishing (correct format) But the International Committee of Medical Journals Editors (ICMJE) has formulated the principles of publication ethics: - Recommendations for the Conduct - Reporting - Editing -Publication of Scholarly Work in Medical Journals. Sometimes breaches of ethics occur in biomedical research. For the following reasons: Bad management of researchers, pressure to publish, conflict of interests or direct financial gain. These breaches of publication ethics include: Plagiarism, falsification of data, intentional distortion of facts or concealment of data, redundant (duplicate) publication. The most important breaches are: *Plagiarism: illegal use of any published or unpublished ideas, formulations, results, photos, illustrations, tables, etc. without mentioning the source of the document (references) and representation of them as one's own original work. *Redundant publication: when a published work is published more than once (possibly in a different language) without adequate acknowledgment of the source (or cross-referencing or justification) when the same data is presented in more than one publication without adequate cross-referencing (or justification) particularly when this is done in such a way that readers are unlikely to realize that most or all the findings have been published before.