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1.  The new Italian code of medical ethics. 
Journal of Medical Ethics  1997;23(4):239-244.
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.
PMCID: PMC1377273  PMID: 9279746
2.  How Many Principles for Public Health Ethics? 
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.
doi:10.2174/1874944500801010008
PMCID: PMC2804997  PMID: 20072707
3.  Bioethics Principles, Informed Consent, and Ethical Care for Special Populations: Curricular Needs Expressed by Men and Women Physicians-in-Training 
Psychosomatics  2005;46(5):440-450.
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.
doi:10.1176/appi.psy.46.5.440
PMCID: PMC1599853  PMID: 16145189
4.  To evaluate the effectiveness of health care ethics consultation based on the goals of health care ethics consultation: a prospective cohort study with randomization 
BMC Medical Ethics  2014;15:1.
Background
The growing prevalence of health care ethics consultation (HCEC) services in the U.S. has been accompanied by an increase in calls for accountability and quality assurance, and for the debates surrounding why and how HCEC is evaluated. The objective of this study was to evaluate the effectiveness of HCEC as indicated by several novel outcome measurements in East Asian medical encounters.
Methods
Patients with medical uncertainty or conflict regarding value-laden issues, and requests made by the attending physicians or nurses for HCEC from December 1, 2009 to April 30, 2012 were randomly assigned to the usual care group (UC group) and the intervention group (HCEC group). The patients in the HCEC group received HCEC conducted by an individual ethics consultant. Data analysis was based on the intention-to-treat principle. Mann–Whitney test and Chi-squared test were used depending on the scale of measurement.
Results
Thirty-three patients (53.23%) were randomly assigned to the HCEC group and 29 patients were randomly assigned to the UC group. Among the 33 patients in the HCEC group, two (6.06%) of them ultimately did not receive a HCEC service. Among the 29 patients in the UC group, four (13.79%) of them received a HCEC service. The survival rate at hospital discharge did not differ between the two groups. Patients in the HCEC group showed significant reductions in the entire ICU stay and entire hospital stay. HCEC significantly facilitated achieving the goal of medical care (p < .01). Furthermore, patients in the HCEC group had a shorter ICU stay and shorter hospital stay after the occurrence of medical uncertainty or conflict regarding value-laden issues than those in the UC group.
Conclusions
Our findings demonstrated that HCEC were associated with reduced consumption of medical resources as indicated by shorter entire ICU stay, entire hospital stay, and shorter ICU and hospital stay after the occurrence of the medical uncertainty or conflict regarding value-laden issues. This study also showed that HCEC facilitated achieving a consensus regarding the goal of medical care, which conforms to the goal of HCEC.
doi:10.1186/1472-6939-15-1
PMCID: PMC3898237  PMID: 24387594
Health care ethics consultation; Effectiveness; Randomization; Intention-to-treat
5.  The role of ethical principles in health care and the implications for ethical codes. 
Journal of Medical Ethics  1999;25(5):394-398.
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.
PMCID: PMC479265  PMID: 10536764
6.  The ethics of everyday practice in primary medical care: responding to social health inequities 
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.
doi:10.1186/1747-5341-5-6
PMCID: PMC2876986  PMID: 20438627
7.  In praise of unprincipled ethics 
Journal of Medical Ethics  2003;29(5):303-306.
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.
doi:10.1136/jme.29.5.303
PMCID: PMC1733790  PMID: 14519841
8.  Ethical psychiatry in an uncertain world: conversations and parallel truths 
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.
doi:10.1186/1747-5341-4-7
PMCID: PMC2714001  PMID: 19555473
9.  The ethical landscape: identifying the right way to think about the ethical and societal aspects of synthetic biology research and products 
Journal of the Royal Society Interface  2009;6(Suppl 4):S559-S564.
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.
doi:10.1098/rsif.2009.0055.focus
PMCID: PMC2843963  PMID: 19447816
ethics; science; technology
10.  Teaching clinical ethics as a professional skill: bridging the gap between knowledge about ethics and its use in clinical practice. 
Journal of Medical Ethics  1995;21(2):97-103.
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.
PMCID: PMC1376631  PMID: 7608948
11.  Pharmacy ethics: evaluation pharmacists’ ethical attitude 
Alterations in pharmacy practice from prescription dispensing to more patient-centered relationship intensifies the necessity of clinical decision-making. Pharmacists’ knowledge as well as ethical reasoning affects their clinical decision-making. Unfortunately in Iran pharmacy ethics did not develop along with medical ethics and special considerations are of major importance. The study was designed to evaluate pharmacists’ attitude toward some principles of bioethics.
A cross-sectional survey was performed on a sample of Iranian pharmacists attended in continuous education programs in 2010. Based on the pharmacists’ attitude toward common ethical problems, 9 Likert-type scale scenarios were designed. A thousand pharmacists were surveyed and 505 questionnaires were filled. For the whole questionnaire the strongly disagree answer was the most ethical answer. On a scale from 1–5 on which 5=strongly disagree, the total score of pharmacists ethical attitude was 17.69 ± 3.57. For easier analysis we considered the score of 1 for agree and strongly agree answers, score of 2 for neutral answers and score of 3 for disagree and strongly disagree answers. The total score in confidentiality for all participants was 4.15 ± 1.45 out of 9, in autonomy 6.25 ± 1.85 out of 9, in non-maleficence 5.14 ± 1.17 out of 6 and in justice was 2.27 ± 0.89 out of 3, however there was no significant difference between men and women in the total score and the score of each theme. The older participants (> 40 years) significantly had lower total score (P< 0.05) as well as the score of each theme (P< 0.05), except for non-maleficence. The work experience showed impact on the pharmacists’ attitude toward autonomy and the participants with more than 5 years work experience significantly obtained lower score in this theme.
Compiling ethical guidelines and improving pharmacy ethics curriculum is highly critical to provide the best pharmaceutical care and to make clinical decisions in critical situations. Therefore further quantitative and qualitative investigations into finding pitfalls and challenges in this issue are highly recommended.
PMCID: PMC3714006  PMID: 23908747
Pharmacy ethics; Ethical attitude; Confidentiality; Autonomy
12.  Teaching old dogs new tricks—a personal perspective on a decade of efforts by a clinical ethics committee to promote awareness of medical ethics 
Journal of Medical Ethics  2001;27(Suppl 1):i41-i43.
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
doi:10.1136/jme.27.suppl_1.i41
PMCID: PMC1765536  PMID: 11314612
13.  Comparison of ethical judgments exhibited by clients and ethics consultants in Japan 
BMC Medical Ethics  2014;15:19.
Background
Healthcare professionals must make decisions for patients based on ethical considerations. However, they rely on clinical ethics consultations (CEC) to review ethical justifications of their decisions. CEC consultants support the cases reviewed and guide medical care. When both healthcare professionals and CEC consultants face ethical problems in medical care, how is their judgment derived? How do medical judgments differ from the ethical considerations of CECs? This study examines CECs in Japan to identify differences in the ethical judgment of clients and CEC consultants.
Methods
The CEC request and response documents of all 60 cases reviewed across Japan between October 2006 and the end of October 2011 were classified in terms of the presence of decisional capacity in the patient. We conducted a qualitative content analysis of the differences in reasoning between client and CEC consultants. Reasoned judgments were verified in individual cases to classify the similarities or differences of opinion between CEC clients and teams.
Results
As the result of classification of the decisional capacity and the difference of opinion regarding medical care, the most frequent category was 25 cases (41.7%) of “uncertain decisional capacity,” and 23 cases (38.3%) of “withholding of decision-making.” A chi-square analysis was performed on presence of decisional capacity and agreement in decision-making, yielding a statistically significant difference (p < 0.05). The CEC consultants’ reasoning was based on “patient’s preference was ambiguous,” “validity of family as a surrogate,” “estimation of patient preference,” and “patient’s best interest,” whereas the CEC client’s reasoning was based on “consistent family preference was shown/not shown” and “appropriate therapeutic methods to manage patient safety.”
Conclusion
Differences in opinions were found in cases classified according to decisional capacity. Furthermore, the reasoning behind judgments differed between CEC clients and CEC consultants. The reasoning of CEC consultants was critical and reflective, while for clients it was situational and pragmatic.
doi:10.1186/1472-6939-15-19
PMCID: PMC3975850  PMID: 24592932
Clinical ethics consultation; Ethical judgment; Ethical reasoning; Clinical ethics; Quality of healthcare
14.  Organ Transplantation: Legal, Ethical and Islamic Perspective in Nigeria 
Organ transplantation dates back to the ancient times and since then it has become one of the important developments in modern medicine; saving the lives, as well as improving the quality of life of many patients. As the demand for organ transplantation far exceeds the organ availability, the transplant program is often saddled with complex legal and ethical issues. This review article highlights the legal and ethical issues that might arise regarding organ transplantation and appraises the existing legal frame work governing organ transplantation in Nigeria. Information on legal, cultural, religious and medical ethical issues regarding organ transplantation in Nigeria was obtained by searching the PubMed and Google Scholar, conference proceedings, seminar paper presentations, law library and other related publications were collated and analyzed. In decision making for organ transplantation, the bioethical principles like autonomy, beneficence and justice must be employed. It was believed by Catholic theologians that to mutilate one living person to benefit another violates the principle of Totality. Among Muslim scholars and researchers, there are those who throw legal support as to its permissibility while the other group sees it as illegal. Organ/tissues transplantation is considered a medical intervention that touches on the fundamental rights of the donor or the recipient. Where there is an unlawful infringement of the right of such persons in any way may be regarded as against Section 34 of the 1999 Nigerian Constitution dealing with right to dignity of the human person. Worldwide, the researchers and government bodies have agreed on informed consent for organ/tissue donation and for recipient should be obtained without coercion before embarking on such medical treatment Worldwide organ transplantation has become the best medical treatment for patients with end stage organ failure. However, there is no law/legislation backing organ/tissues transplantation in Nigeria. The government should take measures to combat transplantation tourism and the problem of national and international trafficking in human tissues and organs, ethics commission and National Transplant registry should be established in order to monitor and regulate the programme in the country.
doi:10.4103/1117-6806.103103
PMCID: PMC3762001  PMID: 24027394
Ethical; Islamic perspective; legal; Nigeria; organ transplantation
15.  Violation of ethical principles in clinical research. Influences and possible solutions for Latin America 
BMC Medical Ethics  2012;13:35.
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.
doi:10.1186/1472-6939-13-35
PMCID: PMC3543192  PMID: 23241478
Informed consent; Autonomy; Genomics; Ethical; Justice; Nonmaleficence; Beneficence
16.  Cesarean delivery on maternal request: Can the ethical problem be solved by the principlist approach? 
BMC Medical Ethics  2008;9:11.
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.
doi:10.1186/1472-6939-9-11
PMCID: PMC2446392  PMID: 18559083
17.  Ethical Dimensions of the Number of Embryos to be Transferred in In Vitro Fertilization 
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.
doi:10.1023/A:1013104820518
PMCID: PMC3455696  PMID: 11804425
ethics; in vitro fertilization; embryo transfer; informed consent
18.  Ethical conflict in the practice of occupational medicine. 
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.
PMCID: PMC1009726  PMID: 2920145
19.  Legitimate requests and indecent proposals: matters of justice in the ethical assessment of phase I trials involving competent patients 
Journal of Medical Ethics  2005;31(4):205-208.
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.
doi:10.1136/jme.2003.006684
PMCID: PMC1734133  PMID: 15800360
20.  The ethics of human volunteer studies involving experimental exposure to pesticides: unanswered dilemmas 
Environmental Health  2010;9:50.
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.
doi:10.1186/1476-069X-9-50
PMCID: PMC2931486  PMID: 20718963
21.  Observations on ethical problems and terminal care. 
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.
PMCID: PMC2589514  PMID: 1519374
22.  Ethical Dilemmas in Disaster Medicine 
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.
PMCID: PMC3518976  PMID: 23285411
Disasters; Ethics; Bioethics; Disaster medicine; Public health
23.  Ethical perspectives for public and environmental health: fostering autonomy and the right to know. 
Environmental Health Perspectives  2003;111(2):133-137.
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.
PMCID: PMC1241339  PMID: 12573894
24.  Preconception care and genetic risk: ethical issues 
Journal of Community Genetics  2011;3(3):221-228.
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.
doi:10.1007/s12687-011-0074-9
PMCID: PMC3419287  PMID: 22205578
25.  How can ethics relate to science? The case of stem cell research 
We live in an era of an important turning point in the relationship between ethics (or, more accurately, bioethics) and science, notably due to both public interest and the gradual tightening of the gap in time between scientific discoveries and ethical reflection. The current bioethics debates of emerging situations (pluripotent stem cells, gene therapy, nanotechnology) have undoubtedly contributed to this change. Today, science happens and bioethics reflects on the possibilities, considers the risks, and advances proposals, which, without being scientific, can also imprint a mark on the path of scientific development. In this article, through the narrative of stem cell research, we will try to illustrate how bringing a bioethical viewpoint to the scientific debate can become a healthy exercise in both ethics and science, especially as narratives shift, as was the case in this field due to the introduction of induced pluripotent stem cells, the advent of which is not easily dissociated from the controversies related to embryo research. We should perhaps welcome this trend as promising for the future relationship between ethics and scientific research, providing a stimulus (and not a block) to the ever-evolving scientific discourse.
doi:10.1038/ejhg.2012.232
PMCID: PMC3658189  PMID: 23150079
bioethics; ethics; science; stem cells; embryo; induced pluripotent stem cells

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