Journal of Medical Ethics

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Systems thinking in gender and medicine

Thu, 2020-04-09 09:43

If there is a single thread running through this issue of the journal, it may be the complex interplay between the individual and the system(s) of which they are apart, highlighting a need for systems thinking in medical ethics and public health.1 2 Such thinking raises at least three sorts of questions in this context: normative questions about the locus of moral responsibility for change when a system is unjust; practical questions about how to change systems in a way that is morally appropriate without triggering unintended, potentially harmful side-effects; and epistemic questions about how to predict the multidimensional consequences of a proposed change or set of changes to an intricate social system such as healthcare.3 These questions crop up throughout the issue, as I will discuss, but my focus is the target article and linked commentaries on gender bias in the surgical...

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Prescribing medical cannabis: ethical considerations for primary care providers

Thu, 2020-04-09 09:43

Medical cannabis is widely available in the USA and legalisation is likely to expand. Despite the increased accessibility and use of medical cannabis, physicians have significant knowledge gaps regarding evidence of clinical benefits and potential harms. We argue that primary care providers have an ethical obligation to develop competency to provide cannabis to appropriate patients. Furthermore, specific ethical considerations should guide the recommendation of medical cannabis. In many cases, these ethical considerations are extensions of well-established principles of beneficence and nonmaleficence, which indicate that providers should recommend cannabis only for conditions that have the strongest evidence base. Additionally, the contested status of cannabis in American culture raises specific issues related to shared decision-making and patient education, as well as continuing clinical education.

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Physician, heal thyself: a cross-sectional survey of doctors personal prescribing habits

Thu, 2020-04-09 09:43
Background

Self-prescribing and prescribing to personal contacts is explicitly discouraged by General Medical Council guidelines.

Aims

This study examines how widespread the practice of self-prescribing and prescribing to personal contacts is.

Methods

A 16-item questionnaire was distributed via an online forum comprising 4445 young medical doctors (representing 20% of all Irish registered doctors), which asked respondents about previous prescribing to themselves, their families, friends and colleagues, including the class of medication prescribed. Demographic details were collected including medical grade and specialty.

Results

A total of 729 responses were obtained, the majority of which were from young non-consultant hospital doctors from a range of specialties. Two-thirds of respondents had self-prescribed, over 70% had prescribed to family, and nearly 60% had prescribed to a friend or colleague. Older doctors were more likely to self-prescribe ( 2=17.51, p<0.001). Interns being less likely to self-prescribe was not unexpected ( 2=69.55, p<0.001), while general practitioners (GPs) and paediatricians were more likely to self-prescribe ( 2=13.33, p<0.001; 2=11.35, p<0.001). GPs, paediatricians and hospital medicine specialties were more likely to prescribe to family ( 2=5.19, p<0.05; 2=8.38, p<0.05; 2=6.17, p<0.05) and surgeons were more likely to prescribe to friends ( 2=15.87, p<0.001). Some 3% to 7% who had self-prescribed had prescribed an opiate, benzodiazepine or psychotropic medication. Male doctors, anaesthetists and surgeons were more likely to self-prescribe opioids ( 2=7.82, p<0.01; 2=7.31, p<0.01; 2=4.91, p<0.05), while those in hospital medicine were more likely to self-prescribe psychotropic medications ( 2=5.47, p<0.05).

Conclusion

Prescribing outside the traditional doctor-patient relationship is widespread despite clear professional guidance advising against it.

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Four types of gender bias affecting women surgeons and their cumulative impact

Thu, 2020-04-09 09:43

Women are under-represented in surgery, especially in leadership and academic roles, and face a gender pay gap. There has been little work on the role of implicit biases in women’s under-representation in surgery. Nor has the impact of epistemic injustice, whereby stereotyping influences knowledge or credibility judgements, been explored. This article reports findings of a qualitative in-depth interview study with women surgeons that investigates gender biases in surgery, including subtle types of bias. The study was conducted with 46 women surgeons and trainees of the Royal Australasian College of Surgeons. Maximum variance sampling strategies ensured a comprehensive set of perspectives. Data were analysed using iterative thematic analysis to document and classify forms of gender bias experienced by the participants, including implicit bias and epistemic injustice. It found four types of bias affecting women surgeons: (1) workplace factors such as access to parental leave and role models; (2) epistemic injustices—unfair assessments of women surgeons’ credibility by patients and colleagues; (3) stereotyped expectations that they will carry out more of surgery’s carework, such as meeting the emotional needs of patients and (4) objectification. Implicit biases arose in each category. Given that many of the biases identified in this study are small, are harmless on their own and are not necessarily under anyone’s conscious control, important questions arise regarding how they cause harm and how to address them. I draw on theoretical work on cumulative harm to answer these questions.

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Commentary on 'Four types of gender bias affecting women surgeons, and their cumulative impact by Hutchison

Thu, 2020-04-09 09:43

The central concerns of Hutchison’s1 paper are the under-representation and unequal pay of women in surgery and the role that subtle gender biases play in explaining these phenomena. My comments will focus on how well executed and important this work is and also why we need more of it to fully understand the gravity of the situation for women in surgery and how it compares with similar situations for women in other fields.

Hutchison argues that women in surgery experience many subtle inequities that together help to explain their unequal representation and pay relative to men. She conducted a qualitative study that involved in-depth interviews of 46 women surgeons: fellows or trainees of the Royal Australasian College of Surgeons (RACS). Effort was taken to recruit participants who were diverse in various ways, including in their perspectives on sexual harassment in surgery. They were asked about barriers they...

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Stop the bleeding: we must combat explicit as well as implicit biases affecting women surgeons

Thu, 2020-04-09 09:43

When I was a 7 months pregnant medical student, an attending surgeon asked me to which specialty I would be applying. When I replied that I was hoping to match in general surgery, he touched my pregnant abdomen and said, "Not with that you’re not."

I am not alone. Gender bias and discrimination have been shown to negatively impact women surgeons throughout their careers and deter women from even applying in surgical fields.1 Bias against female surgical trainees leads to less operative autonomy and higher dropout rates.2 3 Once faculty, women surgeons are less likely to reach leadership roles.4 Recent studies confirm the author’s assertion that implicit biases create substantial harm.

The author has undertaken an important study, conducting in-depth interviews with 46 women surgeons in Australia that identifies four distinct types of bias causing cumulative harm. In all four types...

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Implicit bias, women surgeons and institutional solutions: commentary

Thu, 2020-04-09 09:43

This paper argues that a major contribution to women’s under-representation and the gender pay gap in surgery is the interaction and aggregation of many small wrongs, or as they have come to be called in the literature, microinequities. Further, the paper argues that existing strategies do not adequately address the problems faced by women surgeons and cannot do so without an understanding of those wrongs as microinequities. Insights from the literature on ethics and microinequities are thought to be able to inform new strategies.1

The study identifies four different kinds of gender bias: workplace discrimination, epistemic injustice, stereotyped roles and objectification. The different kinds of gender bias interact with one another and add up in ways that pose serious setbacks to the careers of women surgeons. In addition to being small wrongs, microinequities share other features. They are cumulative; they interact with one other; they are often...

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Wrongdoing and responsibility in the context of cumulative harms: a response to commentators

Thu, 2020-04-09 09:43

Let me first thank Samantha Brennan, Carolyn McLeod and Brandi Braud Scully for their detailed and constructive commentaries. In this brief response I wish to highlight and engage with three main points they raise. First, I will address McLeod’s argument that female surgeons are not merely harmed, but also wronged by the forms of bias found in the study. Second, I will discuss a concern voiced by both Scully and Brennan that my emphasis on small and implicit biases fails to acknowledge the ongoing, significant problem of explicit bias. Third, and finally, I will engage with Brennan’s argument that institutional responses are the best way of addressing cumulative harms caused by microinequities. These concerns all connect with the difficult question of responsibility, a feature I draw out below.

Carolyn McLeod argues that female surgeons’ interests in receiving equal treatment and opportunity are morally significant interests. As such, when these...

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Arrogance of 'but all you need is a good index finger: A narrative ethics exploration of lack of universal funding of PSA screening in Canada

Thu, 2020-04-09 09:43

This narrative ethics exploration stems from my happy prostate-specific antigen (PSA) story, though it should not have been, as I annually refuse my family physician’s recommendation to purchase PSA screening. The reason for my refusal is I teach ethics to medical students and of course must walk the talk, and PSA screening is not publicly funded in the province of Ontario, Canada. In addition, I might have taken false comfort in ‘but all you need is a good index finger’ to detect prostate cancer, expounded by a senior physician at a national medical conference in 2010, and applauded by the large audience of physicians. I was compelled to begin this exploration out of survivor guilt, although I will not be a survivor for long, and as a mea culpa to the men similarly situated to me in having late diagnosis of prostate cancer, aggressive tumours and multiple metastases, but who unlike me are dead because they did not experience the physician–educator-based exceptionisms and coincidences that permit me to still be alive. Although my PSA story will always be a happy story, even when my life ends in a few years, the initiation of public funding of PSA screening for all men over 50 would make my PSA story an even happier story.

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Just caring: screening needs limits

Thu, 2020-04-09 09:43

This personal narrative tugs at the heart strings. However, personal narratives are not sufficient to justify public funding for any screening policy. We have to take seriously the ‘just caring’ problem. We have only limited resources to meet virtually unlimited health care needs. No doubt, screening tests often save lives. The author wants public funding for prostate-specific antigen screening for prostate cancer. However, why only prostate cancer? Numerous cancers at various stages can be screened for. Are all of them equally deserving of public funding? What about screening for a very long list of other life-threatening medical disorders? There is nothing ethically special about cancer. Where does the money come from to pay for all these screening tests? Do we reduce expensive life-prolonging care for patients in late-stage diseases? Ultimately, a balance must be struck between saving statistical lives through screening and saving identifiable lives in the intensive care unit. Achieving a just balance requires rational democratic deliberation as justification for these choices, not personal narratives.

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Have ignorance and abuse of authorship criteria decreased over the past 15 years?

Thu, 2020-04-09 09:43
Objective

A high prevalence of authorship problems can have a severe impact on the integrity of the research process. We evaluated the authorship practices of clinicians from the same university hospital in 2019 to compare them with our 2003 data and to find out if the practices had changed.

Methods

Practitioners were randomly selected from the hospital database (Hospices Civils de Lyon, France). The telephone interviews were conducted by a single researcher (HM) using a simplified interview guide compared with the one used in 2003. The doctors were informed that their answers would be aggregated without the possibility of identifying the respondents. During the interviews, the researcher ticked the boxes with the answers on a paper file.

Results

We interviewed 26 clinicians (mean age 49±8 years) from various medical specialties. They were unfamiliar with the ICMJE (International Committee of Medical Journal Editors) criteria for writing medical articles and felt that these criteria were not well met in general. With regard to ways of reducing the practice of honorary authors, the participants clearly felt that asking for a signature was hypocritical and of little use. The ghost authors were well known; this practice was considered as rather rare. The ‘publish or perish’ has always been cited as being responsible for bad practices (26/26: 100%). We compared these results with those observed in 2003 and no improvement has been observed in the past 15 years.

Conclusion

For the second time in France, within a 15-year interval, we have shown that the ICMJE criteria were ignored and that honorary authorship was frequent.

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Prioritarian principles for digital health in low resource settings

Thu, 2020-04-09 09:43

This theoretical paper argues for prioritarianism as an ethical underpinning for digital health in contexts of extreme disadvantage. In support of this claim, the paper develops three prioritarian principles for making ethical decisions for digital health programme design, grounded in the normative position that the greater the need (of the marginalised), the stronger the moral claim. The principles are positioned as an alternative view to the prevailing utilitarian approach to digital health, which the paper argues is not sufficient to address the needs of the worst off. As researchers of digital health, we must ensure that the most globally marginalised are not overlooked by overtly technocentric implementation practices. Consequently, the paper concludes by advocating for use of the three principles to support stronger critical reflection on the ethics involved in the design and implementation of digital health programmes.

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Decolonising ideas of healing in medical education

Thu, 2020-04-09 09:43

The legacy of colonial rule has permeated into all aspects of life and contributed to healthcare inequity. In response to the increased interest in social justice, medical educators are thinking of ways to decolonise education and produce doctors who can meet the complex needs of diverse populations. This paper aims to explore decolonising ideas of healing within medical education following recent events including the University College London Medical School’s Decolonising the Medical Curriculum public engagement event, the Wellcome Collection’s Ayurvedic Man: Encounters with Indian Medicine exhibition and its symposium on Decolonising Health, SOAS University of London’s Applying a Decolonial Lens to Research Structures, Norms and Practices in Higher Education Institutions and University College London Anthropology Department’s Flourishing Diversity Series. We investigate implications of ‘recentring’ displaced indigenous healing systems, medical pluralism and highlight the concept of cultural humility in medical training, which while challenging, may benefit patients. From a global health perspective, climate change debates and associated civil protests around the issues resonate with indigenous ideas of planetary health, which focus on the harmonious interconnection of the planet, the environment and human beings. Finally, we look further at its implications in clinical practice, addressing the background of inequality in healthcare among the BAME (Black, Asian and minority ethnic) populations, intersectionality and an increasing recognition of the role of inter-generational trauma originating from the legacy of slavery. By analysing these theories and conversations that challenge the biomedical view of health, we conclude that encouraging healthcare educators and professionals to adopt a ‘decolonising attitude’ can address the complex power imbalances in health and further improve person-centred care.

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Abortion and the Epicurean challenge

Thu, 2020-04-09 09:43

In a recent article in this journal, Anna Christensen raises an ‘Epicurean challenge’ to Don Marquis’ much-discussed argument for the immorality of abortion. According to Marquis’ argument, abortion is pro tanto morally wrong because it deprives the fetus of ‘a future like ours’. Drawing on the Epicurean idea that death cannot harm its victim because there is no subject to be harmed, Christensen argues that neither fetuses nor anyone else can be deprived of a future like ours by dying. Thus, Christensen suggests, the moral wrongness of abortion (and other killings) cannot be grounded in the relevant individual’s being deprived of a future like ours. In this reply, I argue that on no interpretation of Christensen’s Epicurean challenge does it succeed.

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Continuing conversations about abortion and deprivation

Thu, 2020-04-09 09:43

In ‘Abortion and deprivation: a reply to Marquis’, I argued that Marquis’ argument about abortion encounters the Epicurean Challenge. In this essay, I continue the conversation begun there. I aim to motivate the Challenge further by examining Marquis’ argument on his own terms and responding to objections about whom death deprives, whether we should focus on the action of killing or the result of death, and how harms suffered before existence compare to harms suffered after death. Finally, I suggest that perhaps the solution to the ethics of killing lies in considering another account of harm entirely—one that does not rely on deprivation.

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Understanding choice, pressure and markets in kidneys

Thu, 2020-04-09 09:43

Here, I briefly respond to a recent paper by Julian Koplin, in which he criticises my earlier work in this journal. I show that Koplin has misunderstood the distinction I have made between pressure to vend and pressure with the option to vend. I also show that his pessimism about the market regulations I favour is unwarranted.

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Ethics briefing

Thu, 2020-04-09 09:43
Assisted dyingBritish Medical association survey on physician-assisted dying closes

Previous Ethics briefings have highlighted the survey of members on physician-assisted dying being carried out by the British Medical Association.1 This survey closed at midnight on Thursday 27 February.

In total, 29 011 members responded – 20.1% of all members who received an invitation to participate – making this one of the largest surveys of medical opinion carried out on this issue, ever.

The results of the survey will not make BMA policy, but will inform a debate and discussion at the organisation’s main policy-making conference, the annual representative meeting (ARM) in June this year. You can find out more about the survey and how it was carried out at www.bma.org.uk/PAD This page will continue to be updated when more information about the survey results is available.

Royal College of General Practitioners remains...
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Design thinking in medical ethics education

Thu, 2020-04-09 09:43
Background

Design thinking (DT) is a tool for generating and exploring ideas from multiple stakeholders. We used DT principles to introduce students to the ethical implications of organ transplantation. Students applied DT principles to propose solutions to maximise social justice in liver transplant allocation.

Methods

A 150 min interactive workshop was integrated into the longitudinal ethics curriculum. Following a group didactic on challenges of organ donation in the USA supplemented by patient stories, teams of students considered alternative solutions to optimise fairness of organ distribution and ethical implications of changing the current model. Facilitators led students through DT steps of empathy, defining the team’s point of view, ideating on potential solutions, prototyping a specific idea and testing the idea through oral presentation, with questions and answers by peers and faculty. The curriculum was evaluated with presurveys and postsurveys including quantitative and open-ended items.

Results

100 first year medical students participated. Before the session, 75.3% of students had no practical experience with DT. Following participation, students reported an increased understanding of the current liver transplant allocation system (p<0.01) and an increased appreciation of shortcomings of the current organ allocation system (p<0.01). After the session, 73.8% of students felt that DT could be used to approach complex health system problems.

Discussion

Students participating in a DT workshop displayed improved knowledge and attitudes toward organ transplantation and DT. In this pilot study, DT showed promise as a student-led approach emphasising collaboration and creativity in ethics curricula in medical education.

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