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

General moral (ethical) principles play a prominent role in certain methods of moral reasoning and ethical decision-making in bioethics and public health. Examples include the principles of respect for autonomy, beneficence, nonmaleficence, and justice. Some accounts of ethics in public health have pointed to additional principles related to social and environmental concerns, such as the precautionary principle and principles of solidarity or social cohesion. This article provides an overview of principle-based methods of moral reasoning as they apply to public health ethics including a summary of advantages and disadvantages of methods of moral reasoning that rely upon general principles of moral reasoning. Drawing upon the literature on public health ethics, examples are provided of additional principles, obligations, and rules that may be useful for analyzing complex ethical issues in public health. A framework is outlined that takes into consideration the interplay of ethical principles and rules at individual, community, national, and global levels. Concepts such as the precautionary principle and solidarity are shown to be useful to public health ethics to the extent that they can be shown to provide worthwhile guidance and information above and beyond principles of beneficence, nonmaleficence, and justice, and the clusters of rules and maxims that are linked to these moral principles. Future directions likely to be productive include further work on areas of public health ethics such as public trust, community empowerment, the rights of individuals who are targeted (or not targeted) by public health interventions, individual and community resilience and wellbeing, and further clarification of principles, obligations, and rules in public health disciplines such as environmental science, prevention and control of chronic and infectious diseases, genomics, and global health.

Objective

Physicians-in-training today are learning in an ethical environment that is unprecedented in its complexity. There is a call for new approaches in preparing medical students and residents for the ethical and professional issues they will encounter. The perspectives of physicians-in-training at different levels regarding the level of curricular attention needed for emerging bioethics concepts, practical informed consent considerations, and the care of special populations are unknown.

Method

The authors performed a hypothesis-driven, confidential survey study to assess perceived needs and preferences among medical students and residents related to medical ethics education at the University of New Mexico School of Medicine.

Results

A total of 336 physicians-in-training volunteered (62% response rate). Overall, strong interest was expressed for increased curricular attention to the domains of bioethics principles, informed consent, and care of special populations. Women students expressed greater interest generally. For certain domains, clinical students expressed relatively less curricular need and psychiatry and primary care residents expressed relatively greater curricular need. Two of the four hypotheses were supported, a third received partial support, and a fourth was not supported by the findings.

Discussion

To be valuable and effective, new ethics curricular approaches must be responsive to the current complex ethical environment and attentive to the preferences of medical students and residents of both genders, at different stages of training, with different patient care responsibilities. This hypothesis-driven study provides guidance for the inclusion of novel and important ethics domains in training curricula across medical school and diverse residency programs.

A common ethical code for everybody involved in health care is desirable, but there are important limitations to the role such a code could play. In order to understand these limitations the approach to ethics using principles and their application to medicine is discussed, and in particular the implications of their being prima facie. The expectation of what an ethical code can do changes depending on how ethical properties in general are understood. The difficulties encountered when ethical values are applied reactively to an objective world can be avoided by seeing them as a more integral part of our understanding of the world. It is concluded that an ethical code can establish important values and describe a common ethical context for health care but is of limited use in solving new and complex ethical problems.

Background

Social and structural inequities shape health and illness; they are an everyday presence within the doctor-patient encounter yet, there is limited ethical guidance on what individual physicians should do. This paper draws on a study that explored how doctors and their professional associations ought to respond to the issue of social health inequities.

Results

Some see doctors as bound by a notion of care that is blind to a patient's social position, while others respond to this issue through invoking notions of justice and human rights where access to care is a prime focus. Both care and justice orientations however conceal important tensions linked to the presence of bioethical principles underpinning these. Other normative ethical theories like deontology, virtue ethics and utilitarianism do not provide adequate guidance on the problem of social health inequities either.

Conclusion

This paper explores if Bauman's notion of "forms of togetherness" provides the basis of a relational ethical theory that can help to develop a response to social health inequities of relevance to individual physicians. This theory goes beyond silence on the influence of social position of health and avoids amoral regulatory approaches to monitoring equity of care provision.

In this paper a plea is made for an unprincipled approach to biomedical ethics, unprincipled of course just in the sense that the four principles are neither the start nor the end of the process of ethical reflection. While the four principles constitute a useful "checklist" approach to bioethics for those new to the field, and possibly for ethics committees without substantial ethical expertise approaching new problems, it is an approach which if followed by the bioethics community as a whole would, the author believes, lead to sterility and uniformity of approach of a quite mindbogglingly boring kind. Moreover, much of bioethics is not concerned with identifying the principles or values appropriate to a particular issue, but rather involves analysing the arguments that are so often already in play and which present themselves as offering solutions in one direction or another. Here, as I try to show in discussion of these four scenarios, the principles allow massive scope in interpretation and are, frankly, not wonderful as a means of detecting errors and inconsistencies in argument.

Psychiatric practice is often faced with complex situations that seem to pose serious moral dilemmas for practitioners. Methods for solving these dilemmas have included the development of more objective rules to guide the practitioner such as utilitarianism and deontology. A more modern variant on this objective model has been 'Principlism' where 4 mid level rules are used to help solve these complex problems. In opposition to this, there has recently been a focus on more subjective criteria for resolving complex moral dilemmas. In particular, virtue ethics has been posited as a more sensitive method for helping doctors to reason their way through difficult ethical issues. Here the focus is on the character traits of the practitioner. Bloch and Green advocated another way whereby more objective methods such as Principlism and virtue ethics are combined to produce what they considered sound moral reasoning in psychiatrists. This paper points out some difficulties with this approach and instead suggests that a better model of ethical judgment could be developed through the use of narratives or stories. This idea puts equal prima facie value on the patient's and the psychiatrist's version of the dilemma they are faced with. It has the potential to lead to a more genuine empathy and reflective decision-making.

Synthetic biology promises to be highly innovative in its contribution to scientific understanding. But it offers other sorts of innovation too: in the variety of applications that could result and in the wide range of practitioners who could become involved. But directly corresponding to each of these is a kind of regulatory concern. If the entry barriers are low for a form of scientific practice with dramatic implications then the need for regulatory control over access is great since no one wants unlicensed operators releasing experimental organisms. If there are likely to be extensive opportunities for application within the human body and in the open environment (for energy production or novel forms of bioremediation) then the release and safety-testing implications are potentially enormous. Proponents of synthetic biology have been quick to realise that these challenges call for reviews of the societal and ethical aspects of synthetic biology. This paper shows that the template commonly adopted for such reviews draws on bioethics. It goes on to show that this template is far from ideal, both because of limitations in the way that bioethics has been institutionalized and because of key differences between the regulatory demands on synthetic biology and on bioethics. The paper concludes that broader models of societal and ethical review of synthetic biology are urgently required.

Ethical reasoning and decision-making may be thought of as 'professional skills', and in this sense are as relevant to efficient clinical practice as the biomedical and clinical sciences are to the diagnosis of a patient's problem. Despite this, however, undergraduate medical programmes in ethics tend to focus on the teaching of bioethical theories, concepts and/or prominent ethical issues such as IVF and euthanasia, rather than the use of such ethics knowledge (theories, principles, concepts, rules) to clinical practice. Not surprisingly, many students and clinicians experience considerable difficulty in using what they know about ethics to help them make competent ethical decisions in their day-to-day clinical practice. This paper describes the development of a seminar programme for teaching senior medical students a more systematic approach to ethical reasoning and analysis and clinical decision-making.

To incorporate medical ethics into clinical practice, it must first be understood and valued by health care professionals. The recognition of this principle led to an expanding and continuing educational effort by the ethics committee of the Vancouver General Hospital. This paper reviews this venture, including some pitfalls and failures, as well as successes. Although we began with consultants, it quickly became apparent that education in medical ethics must reach all health care professionals—and medical students as well. Our greatest successes came in the formative years of a medical career (ie, in medical school and residency training programmes), but other efforts were not wasted, particularly among nurses and other health care professionals.

Although this is a personal review of the experience in one institution, the lessons learnt in Vancouver are applicable to the further development of medical ethics in the UK.

Key Words: Medical ethics • ethics committees • continuing education

Background

Even though we are now well into the 21st century and notwithstanding all the abuse to individuals involved in clinical studies that has been documented throughout History, fundamental ethical principles continue to be violated in one way or another.

Discussion

Here are some of the main factors that contribute to the abuse of subjects participating in clinical trials: paternalism, improper use of informed consent, lack of strict ethical supervision, pressure exerted by health institutions to increase the production of scientific material, and the absence of legislation regarding ethics in terms of health care and research. Are researchers ready to respect fundamental ethical principles in light of the ample window of information provided by individual genomes, while defending the rights of the subjects participating in clinical studies as a major priority?

Summary

As one of the possible solutions to this problem, education regarding fundamental ethical principles is suggested for participants in research studies as an initial method of cognitive training in ethics, together with the promotion of ethical behavior in order to encourage the adoption of reasonable policies in the field of values, attitudes and behavior.

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications.

We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).

Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation.

Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Purpose: We propose an ethically justified policy for the number of embryos to transfer in an in vitro fertilization (IVF), by considering four factors: medical outcomes, patient's preferences, costs, and market forces of providers.

Methods: We develop an ethical framework that incorporates three ethical principles: beneficence, respect for autonomy, and justice; and three professional virtues: integrity, compassion, and self-sacrifice.

Results: This ethical framework calls for an informed consent process for IVF that provides: information about medical outcomes; information about the risks of multiple gestation; the opportunity to weigh the goal of pregnancy and live birth against the medical and moral risks of multiple gestation; evidence-based recommendations; protection of the woman from potentially coercive influences; and discussion of living with infertility and going to better centers.

Conclusion: The number of embryos to be transferred in IVF should mainly be a function of the pregnant women's informed decision. Limiting the number of transferred embryos to two in all cases is not ethically justified at this time.

The practice of occupational medicine has been portrayed as being fraught with ethical conflict and yet this problem has received little systematic study. A question and case study survey of a randomly selected cohort of members of the American Occupational Medical Association has been performed to examine the extent and nature of this problem in occupational medicine practice in the United States. The results indicate a strong reliance on traditional medical role models in responding to ethical conflict but with significant underlying tension between more deontological physician-patient approaches and more teleological public health approaches. These results have significant implications for the synthesis of bioethical theories based on a perceived complementarity of ethical reality, as well as suggesting important improvements in future occupational medicine training.

The death of Jesse Gelsinger in 1999 during a gene therapy trial raised many questions about the ethical review of medical research. Here, the author argues that the principle of justice is interpreted too narrowly and receives insufficient emphasis and that what we permit in terms of bodily invasion affects the value we place on individuals. Medical research is a societally supported activity. As such, the author contends that justice requires that invasive medical research demonstrates sufficiently compelling societal benefit. Many consider this societal benefit to be self evident. However, medical research is a complex activity; it yields new treatments but also creates financial rewards and affects health resource allocation. As research evolves into a multibillion pound, multinational enterprise, justice requires a much broader analysis of societal benefit. Without such evaluation we risk undermining the value of bodily integrity and of research participants.

In this paper we develop an ethical perspective for public and environmental health practice in consideration of the "right to know" by contrasting consequential and deontological perspectives with relational ethics grounded in the concept of fostering autonomy. From the consequential perspective, disclosure of public and environmental health risks to the public depends on the expected or possible consequences. We discuss three major concerns with this perspective: respect for persons, justice, and ignorance. From a deontological perspective, the "right to know" means that there is a "duty" to communicate about all public health risks and consideration of the principles of prevention, precaution, and environmental justice. Relational ethics develops from consideration of a mutual limitation of the traditional perspectives. Relational ethics is grounded in the relationship between the public and public/environmental health providers. In this paper we develop a model for this relationship, which we call "fostering autonomy through mutually respectful relationships." Fostering autonomy is both an end in public health practice and a means to promote the principles of prevention, precaution, and environmental justice. We discuss these principles as they relate to practical issues of major disasters and contaminants in food, such as DDT, toxaphene, chlordane, and mercury.

The controversy about the use of data from human volunteer studies involving experimental exposure to pesticides as part of regulatory risk assessment has been widely discussed, but the complex and interrelated scientific and ethical issues remain largely unresolved. This discussion paper, generated by authors who comprised a workgroup of the ICOH Scientific Committee on Rural Health, reviews the use of human experimental studies in regulatory risk assessment for pesticides with a view to advancing the debate as to when, if ever, such studies might be ethically justifiable. The discussion is based on three elements: (a) a review of discussion papers on the topic of human testing of pesticides and the positions adopted by regulatory agencies in developed countries; (b) an analysis of published and unpublished studies involving human testing with pesticides, both in the peer-reviewed literature and in the JMPR database; and (c) application of an ethical analysis to the problem. The paper identifies areas of agreement which include general principles that may provide a starting point on which to base criteria for judgements as to the ethical acceptability of such studies. However, the paper also highlights ongoing unresolved differences of opinion inherent in ethical analysis of contentious issues, which we propose should form a starting point for further debate and the development of guidelines to achieve better resolution of this matter.

Progress in medical diagnosis and therapy has raised new problems with far-reaching ethical implications. Medicine must remain a profession and not become a business. Textbooks must address ethical problems in the context of health care decisions and not restrict themselves to pathophysiology and practical therapeutics alone. The relative roles of the principles of autonomy, non-maleficence, beneficence, and justice must be balanced and appropriately applied to individual situations in biomedical ethics. When therapy becomes futile and the suffering of the patient does not justify any anticipated benefit, the patient (and/or patient surrogate) may request withholding or even withdrawing life-prolonging interventions. In the persistent vegetative state, even nutritional support by an unnatural (tube) route may ethically be denied at the patient's (or surrogate's) informed decision. New areas of ethical evaluation have been raised by the desire of some individuals to prolongation of their lives at high expense to the society such that other individuals are denied services because of limitation of available resources. There has been a long-standing conflict of interest between the acceptance by physicians and/or medical institutions of money or gifts from pharmaceutical companies whose drugs they prescribe, stock, or sell. This practice increases the cost of the drugs and is, in effect, a "sick tax," which is morally wrong.

Background

Disasters may lead to ethical challenges that are different from usual medical practices. In addition, disaster situations are related with public health ethics more than medical ethics, and accordingly may require stronger effort to achieve a balance between individual and collective rights. This paper aims to review some ethical dilemmas that arise in disasters and mainly focuses on health services. Disasters vary considerably with respect to their time, place and extent; therefore, ethical questions may not always have `one-size-fits-all` answers. On the other hand, embedding ethical values and principles in every aspect of health-care is of vital importance. Reviewing legal and organizational regulations, developing health-care related guidelines, and disaster recovery plans, establishing on-call ethics committees as well as adequate in-service training of health-care workers for ethical competence are among the most critical steps. It is only by making efforts before disasters, that ethical challenges can be minimized in disaster responses.

Preconception care to address genetic risks in reproduction may be offered either individually to couples with a known or suspected increased risk of having a child with a genetic disorder, or systematically to couples or individuals of reproductive age. The identification of couples at risk of transmitting a (serious) genetic disorder allows those couples to refrain from having children or to adapt their reproductive plans (using prenatal or preimplantation diagnosis, donor gametes, or adoption). Ethical issues concern the possible objectives of providing these options through preconception genetic counseling or screening, objections to abortion and embryo-selection, concerns about eugenics and medicalization, and issues arising in the professional–client relationship and/or in the light of the normative framework for population screening. Although enhancing reproductive autonomy rather than prevention should be regarded as the primary aim of preconception care for genetic risks, directive counseling may well be acceptable in exceptional cases, and prevention in the sense of avoiding serious suffering may be an appropriate objective of specific community-based preconception screening programmes. The seemingly unavoidable prospect of comprehensive preconception screening raises further ethical issues.

Ethics in biomedical research cannot be defined by etymology, and need a semantic definition based on national and contemporary values. In a Nordic cultural and historic context, key values are solidarity with one’s fellow man, equality, truth, justice, responsibility, freedom, and professionalism. In contemporary medical research, such ethics are further subgrouped into research ethics, researcher ethics, societal ethics, and distributive ethics. Lately, public and academic debates have addressed the necessary strengthening of the ethical concerns and interests of patients and society. Despite considerable progress, common ethical definitions and control systems still lack uniformity or indeed do not exist. Among the cooperative partners involved, the pharmaceutical industry have preserved an important role. The same is true for the overall judgments reflected by the European Forum for Good Clinical Practice, leading peer-reviewed journals, the Nuffield Council on Bioethics for developing nations, and the latest global initiative, the Singapore Statement on Research Integrity. To help both institutions and countries, it will be valuable to include the following information in academia–industry protocols before starting a project: international authorship names; fixed agendas and time schedules for project meetings; chairperson shifts, meeting reports, and project plan changes; future author memberships; equal blinding and data distribution from disciplinary groups; an equal plan for exchange of project manuscripts at the proofing stage; contractual descriptions of all procedures, disagreements, publishing rights, prevention, and controls for suspected dishonesty; and a detailed description of who is doing what in the working process.

Life is risky, and insurance provides one of the best developed ways of controlling risks. By pooling, and so transferring risks, those who turn out to suffer antecedently uncertain harms can be assured in advance that they will be helped if those harms arise; they can then plan their lives and activities with confidence that they are less at the mercy of ill fortune. Both publicly organized and commercial insurance can organize the pooling of risk in ways that are beneficial for all concerned. They provide standard ways of securing fundamental ethical values such as solidarity and mutuality. Although policy holders do not know or contract with one another, each benefits from the contribution of others to a shared scheme for pooling and so controlling risk. Although there is a limit to the degree to which commercially-based insurance, where premiums depend on risk level, can go beyond mutuality towards solidarity, in practice it too often achieves a measure of solidarity by taking a broad brush approach to pooling risk. However, the ordinary practices of insurance, and in particular of commercial insurance, also raise ethical questions. These may be put in simple terms by contrasting the way in which an insurance market discriminates between different people, on the basis of characteristics that (supposedly) determine their risk level, and our frequent abhorrence of discrimination, in particular on the basis on religious, racial and gender characteristics. Are the discriminations on which insurance practice relies upon as standard acceptable or not? The increasing availability of genetic information, which testing (of individuals) and screening (of populations) may provide, could lend urgency to these questions. Genetic information may provide a way of obtaining more accurate assessment of individual risks to health and life. This information could be used to discriminate more finely between the risk levels of different individuals, and then to alter the availability and the costs of health, life and unemployment insurance to them. Since all of these forms of insurance bear very directly on the way most people live, it will matter to them how (if at all) insurers take account of genetic information. Will use of this information improve or damage the capacity of insurance to provide confidence in the face of uncertain harms, and help if they happen? Will it discriminate in acceptable or in unacceptable ways? Will it support or damage the sorts of mutuality and solidarity various sorts of insurance schemes have successfully institutionalized?

Context: Doctors have been known to treat or give consultation to patients informally, with none of the usual record keeping or follow up. They may wish to know whether this practice is ethical.

Objective: To determine whether this practice meets criteria of medical ethics.

Design: Informal medicine is analysed according to standard ethical principles: autonomy, beneficence and non-maleficence, distributive and procedural justice, and caring.

Setting: Hospital, medical school, and other settings where patients may turn to physicians for informal help.

Conclusion: No generalisation can be made to the effect that informal medicine is or is not ethical. Each request for informal consultation must be considered on its own merits.

Guidelines: Informal medicine may be ethical if no payment is involved, and when the patient is fully aware of the benefits and risks of a lack of record keeping. When an informal consultation does not entail any danger to the patient or others, the physician may agree to the request. If, however, any danger to the patient or others is foreseen, then the physician must insist on professional autonomy, and consider refusing the request and persuading the patient to accept formal consultation. If a reportable infectious disease, or other serious danger to the community, is involved, the physician should refuse informal consultation or treatment, or at least make a proper report even if the consultation was informal. If agreeing to the request will result in an unfair drain on the physician's time or energy, he or she should refuse politely.

Futile cardiopulmonary resuscitation (CPR) may prevent humane care of the dying child and deprive parents of the opportunity to express their love, grief, and dedication at a critical moment, while appropriate and successful CPR may restore intact their child. Attempted resuscitation of corpses or children with terminal illness indicates inadequate knowledge, discrimination, and decision making. CPR is a medical procedure applicable to certain medical problems; weighing up the risks and benefits in each individual case is a medical function that is constrained by the law and must take full note of patient and family preferences, but cannot be governed by them and should not be over-ruled by laws based on complex but different cases. Time limits on occasions may curtail the full process of consultation and decision making. Applications of skills and resources in the right time and place requires understanding of the medical logistics and study of the potential for good outcome.

Background

This study presents an empirical investigation of the ethical reasoning and ethical issues at stake in the daily work of physicians and molecular biologists in Denmark. The aim of this study was to test empirically whether there is a difference in ethical considerations and principles between Danish physicians and Danish molecular biologists, and whether the bioethical principles of the American bioethicists Tom L. Beauchamp and James F. Childress are applicable to these groups.

Method

This study is based on 12 semi-structured interviews with three groups of respondents: a group of oncology physicians working in a clinic at a public hospital and two groups of molecular biologists conducting basic research, one group employed at a public university and the other in a private biopharmaceutical company.

Results

In this sample, the authors found that oncology physicians and molecular biologists employed in a private biopharmaceutical company have the specific principle of beneficence in mind in their daily work. Both groups are motivated to help sick patients. According to the study, molecular biologists explicitly consider nonmaleficence in relation to the environment, the researchers' own health, and animal models; and only implicitly in relation to patients or human subjects. In contrast, considerations of nonmaleficence by oncology physicians relate to patients or human subjects. Physicians and molecular biologists both consider the principle of respect for autonomy as a negative obligation in the sense that informed consent of patients should be respected. However, in contrast to molecular biologists, physicians experience the principle of respect for autonomy as a positive obligation as the physician, in dialogue with the patient, offers a medical prognosis based upon the patients wishes and ideas, mutual understanding, and respect. Finally, this study discloses utilitarian characteristics in the overall conception of justice as conceived by oncology physicians and molecular biologists from the private biopharmaceutical company. Molecular biologists employed at a public university are, in this study, concerned with allocation, however, they do not propose a specific theory of justice.

Conclusion

This study demonstrates that each of the four bioethical principles of the American bioethicists Tom L. Beauchamp & James F. Childress – respect for autonomy, beneficence, nonmaleficence and justice – are reflected in the daily work of physicians and molecular biologists in Denmark. Consequently, these principles are applicable in the Danish biomedical setting.