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From ontological to relational: A scoping review of conceptions of dignity invoked in deliberations on medically assisted death

Dignity is omnipresent in Western ethics, but it also provokes dissension and controversy. One of the most striking examples is the debate on medically assisted death, where dignity is invoked to support antag...

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Putting patients first: when home-based care staff prioritise loyalty to patients above the system and themselves. An ethnographic study

The growing number of older people worldwide poses challenges for health policy, particularly in the Global North, where policymakers increasingly expect seniors to live and receive care at home. However, heal...

Encompassing trust in medical AI from the perspective of medical students: a quantitative comparative study

In the years to come, artificial intelligence will become an indispensable tool in medical practice. The digital transformation will undoubtedly affect today’s medical students. This study focuses on trust fro...

Impact of the life-sustaining treatment decision act on organ donation in out-of-hospital cardiac arrests in South Korea: a multi-centre retrospective study

The demand for organ transplants, both globally and in South Korea, substantially exceeds the supply, a situation that might have been aggravated by the enactment of the Life-Sustaining Treatment Decision Act ...

Opportunities and challenges of a dynamic consent-based application: personalized options for personal health data sharing and utilization

The principles of dynamic consent are based on the idea of safeguarding the autonomy of individuals by providing them with personalized options to choose from regarding the sharing and utilization of personal ...

Compromised informed consent due to functional health literacy challenges in Chinese hospitals

Medical informed consent stands as an ethical and legal requisite preceding any medical intervention. Hospitalized patients face functional health literacy (FHL) challenges when dealing with informed consent f...

Issues and implications of the life-sustaining treatment decision act: comparing the data from the survey and clinical data of inpatients at the end-of-life process

Health professionals had difficulty choosing the right time to discuss life-sustaining treatments (LSTs) since the Korean Act was passed in 2018.

Qualitative studies involving users of clinical neurotechnology: a scoping review

The rise of a new generation of intelligent neuroprostheses, brain-computer interfaces (BCI) and adaptive closed-loop brain stimulation devices hastens the clinical deployment of neurotechnologies to treat neu...

The ethical dimension of personal health monitoring in the armed forces: a scoping review

Personal Health Monitoring (PHM) has the potential to enhance soldier health outcomes. To promote morally responsible development, implementation, and use of PHM in the armed forces, it is important to be awar...

Exploration of clinical ethics consultation in Uganda: a case study of Uganda Cancer Institute

Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care....

Behind the scenes of research ethics committee oversight: a qualitative research study with committee chairs in the Middle East and North Africa region

Research cites shortcomings and challenges facing research ethics committees in many regions across the world including Arab countries. This paper presents findings from qualitative in-depth interviews with re...

The relationship professional commitment and ethics with patient rights: a cross-sectional descriptive study

Ethical behavior of health workers is an important part of health services. The aim of the present study was to determine the relationship between ethics and professional commitment and its relationship with t...

Ethics, design, and implementation criteria of digital assistive technologies for people with dementia from a multiple stakeholder perspective: a qualitative study

Dementia impairs the ability of people with dementia to be autonomous and independent. They need support from third parties, who should ideally respect their autonomy and independence as much as possible. Supp...

Acceptance of euthanasia by students of selected study disciplines at universities in Lublin, Poland

In the context of discussions between supporters and opponents of euthanasia, and legal regulations regarding this type of practices, the attitude of young people with respect to this phenomenon is a very inte...

The body as an obstacle and the “other”. How patients with chronic inflammatory bowel diseases view their body, self and the good life

Treatment of chronic inflammatory bowel disease (IBD) aims to improve patients’ quality of life and the extent of treatment success is measured via patient reported outcomes (PROs). However, questionnaires use...

Evaluation of an interactive education workshop on hospital pharmacists’ ethical reasoning: an observational study

Pharmacists are often faced with scenarios in practice that require application of ethical reasoning and decision-making skills. There is limited research on the ethical decision-making processes of hospital p...

‘It’s not making a decision, it’s prompting the discussions’: a qualitative study exploring stakeholders’ views on the acceptability and feasibility of advance research planning (CONSULT-ADVANCE)

Health and care research involving people who lack capacity to consent requires an alternative decision maker to decide whether they participate or not based on their ‘presumed will’. However, this is often un...

Ethical considerations during Mpox Outbreak: a scoping review

Historically, epidemics have been accompanied by the concurrent emergence of stigma, prejudice, and xenophobia. This scoping review aimed to describe and map published research targeting ethical values concern...

Artificial Intelligence to support ethical decision-making for incapacitated patients: a survey among German anesthesiologists and internists

Artificial intelligence (AI) has revolutionized various healthcare domains, where AI algorithms sometimes even outperform human specialists. However, the field of clinical ethics has remained largely untouched...

Ethical requirements of instructions for authors of complementary and alternative medicine journals: a cross-sectional study

Medical research in complementary and alternative medicine (CAM) has increased recently, raising ethical concerns about the moral status of CAM. Medical academic journals are responsible for conducting ethical...

Medical ethics in childbirth: a structural equation modeling approach in south of Iran

The existence of a valid instrument to evaluate the attitude of mothers towards compliance with medical ethics during childbirth can lead to appropriate interventions to create a positive attitude. The purpose...

Children’s voices on their values and moral dilemmas when being cared and treated for cancer– a qualitative interview study

Childhood cancers affect about 350 children every year in Sweden and are life-threatening diseases. During the treatment period, situations arise that can become morally challenging for the child. When knowing...

Public perceptions of artificial intelligence in healthcare: ethical concerns and opportunities for patient-centered care

In an effort to improve the quality of medical care, the philosophy of patient-centered care has become integrated into almost every aspect of the medical community. Despite its widespread acceptance, among pa...

Exploring moral competence regression: a narrative approach in medical ethics education for medical students

Studies from different countries report a stagnation or regression of moral competence in medical students between the first and the last year of their studies, and the value of various educational interventio...

“I feel like I’m walking on eggshells”: a qualitative study of moral distress among Chinese emergency doctors

While the number of emergency patients worldwide continues to increase, emergency doctors often face moral distress. It hampers the overall efficiency of the emergency department, even leading to a reduction i...

Telling the truth to patients before hip fracture surgery

Hip fracture repair surgery carries a certain mortality risk, yet evidence suggests that orthopedic surgeons often refrain from discussing this issue with patients prior to surgery.

Concept analysis of conscience-based nursing care: a hybrid approach of Schwartz-Barcott and Kim’s hybrid model

The nursing profession considers conscience as the foundation and cornerstone of clinical practice, which significantly influences professional decision-making and elevates the level of patient care. However, ...

For, against, and beyond: healthcare professionals’ positions on Medical Assistance in Dying in Spain

In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access th...

Ethical regulation of biomedical research in Brazil: a quality improvement initiative

Q-CEP ( Qualificação dos Comitês de Ética em Pesquisa que compõem o Sistema CEP/Conep ) is a nationwide project resulting from a partnership between the Brazilian National Research Ethics Commission (Conep), the Mi...

Perspectives of researchers, science policy makers and research ethics committee members on the feedback of individual genetic research findings in African genomics research

Genetic research can yield information that is unrelated to the study’s objectives but may be of clinical or personal interest to study participants. There is an emerging but controversial responsibility to re...

Using symbiotic empirical ethics to explore the significance of relationships to clinical ethics: findings from the Reset Ethics research project

At the beginning of the coronavirus (Covid-19) pandemic, many non-Covid healthcare services were suspended. In April 2020, the Department of Health in England mandated that non-Covid services should resume, al...

Determining capacity of people with dementia to take part in research: an electronic survey study of researcher confidence, competence and training needs

Researchers are required to determine whether a person has capacity to consent to a research study before they are able to participate. The Mental Capacity Act and accompanying Code of Practice for England and...

The concept of intersectionality in bioethics: a systematic review

Intersectionality is a concept that originated in Black feminist movements in the US-American context of the 1970s and 1980s, particularly in the work of feminist scholar and lawyer Kimberlé W. Crenshaw. Inter...

A scoping review of ethics review processes during public health emergencies in Africa

The COVID-19 pandemic forced governments, multilateral public health organisations and research institutions to undertake research quickly to inform their responses to the pandemic. Most COVID-19-related studi...

Respect for bioethical principles and human rights in prisons: a systematic review on the state of the art

Respect for human rights and bioethical principles in prisons is a crucial aspect of society and is proportional to the well-being of the general population. To date, these ethical principles have been lacking...

Cardiac organoids do not warrant additional moral scrutiny

Certain organoid subtypes are particularly sensitive. We explore whether moral intuitions about the heartbeat warrant unique moral consideration for newly advanced contracting cardiac organoids. Despite the he...

Ethical perspectives regarding Euthanasia, including in the context of adult psychiatry: a qualitative interview study among healthcare workers in Belgium

Previous research has explored euthanasia’s ethical dimensions, primarily focusing on general practice and, to a lesser extent, psychiatry, mainly from the viewpoints of physicians and nurses. However, a gap e...

Urban people’s preferences for life-sustaining treatment or artificial nutrition and hydration in advance decisions

The Patient Right to Autonomy Act (PRAA), implemented in Taiwan in 2019, enables the creation of advance decisions (AD) through advance care planning (ACP). This legal framework allows for the withholding and ...

How prehospital emergency personnel manage ethical challenges: the importance of confidence, trust, and safety

Ethical challenges constitute an inseparable part of daily decision-making processes in all areas of healthcare. Ethical challenges are associated with moral distress that can lead to burnout. Clinical ethics ...

Exploring the consent process among pregnant and breastfeeding women taking part in a maternal vaccine clinical trial in Kampala, Uganda: a qualitative study

The involvement of pregnant women in vaccine clinical trials presents unique challenges for the informed consent process. We explored the expectations and experiences of the pregnant women, spouses/partners, h...

Refusal of patients: care for people without health insurance in German emergency departments

In case of an emergency, health insurance in Germany provides easy access to medical care in emergency departments. Over 100,000 people do not have health insurance for various reasons. They are repeatedly ref...

Ethical considerations and concerns in the implementation of AI in pharmacy practice: a cross-sectional study

Integrating artificial intelligence (AI) into healthcare has raised significant ethical concerns. In pharmacy practice, AI offers promising advances but also poses ethical challenges.

Who to engage in HIV vaccine trial benefit-sharing negotiations? An empirical proposition of a framework

A morally sound framework for benefit-sharing is crucial to minimize research exploitation for research conducted in developing countries. However, in practice, it remains uncertain which stakeholders should b...

Correction: Ethical use of artificial intelligence to prevent sudden cardiac death: an interview study of patient perspectives

The original article was published in BMC Medical Ethics 2024 25 :42

Navigating the ethical landscape of artificial intelligence in radiography: a cross-sectional study of radiographers’ perspectives

The integration of artificial intelligence (AI) in radiography presents transformative opportunities for diagnostic imaging and introduces complex ethical considerations. The aim of this cross-sectional study ...

A qualitative interview study to determine barriers and facilitators of implementing automated decision support tools for genomic data access

Data access committees (DAC) gatekeep access to secured genomic and related health datasets yet are challenged to keep pace with the rising volume and complexity of data generation. Automated decision support ...

Facing a request for assisted death - views of Finnish physicians, a mixed method study

Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians’ attitudes toward assisted death vary...

Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation

Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed d...

A comparative ethical analysis of the Egyptian clinical research law

In this study, we examined the ethical implications of Egypt’s new clinical trial law, employing the ethical framework proposed by Emanuel et al. and comparing it to various national and supranational laws. Th...

“I am in favour of organ donation, but I feel you should opt-in”—qualitative analysis of the #options 2020 survey free-text responses from NHS staff toward opt-out organ donation legislation in England

In May 2020, England moved to an opt-out organ donation system, meaning adults are presumed to be an organ donor unless within an excluded group or have opted-out. This change aims to improve organ donation ra...

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• Published: 13 September 2024

Research ethics matter

Nature Methods volume  21 ,  page 1569 ( 2024 ) Cite this article

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All life sciences research is potentially subject to ethical considerations. Institutions should support collaborations with professional ethicists and philosophers to help life scientists navigate ethical crossroads.

For scientists working with animals, human data or stem cells, or collecting ecological data in resource-poor settings, the ethical considerations of their research are something they must grapple with regularly. For those working at the molecular or cellular level or purely in silico, however, their experiences with ethics may be limited to a brief training course mainly covering issues of data manipulation and plagiarism.

Many molecular, cellular and computational biologists may think that research ethics — that is, whether the scientific questions being explored are ethical to pursue, whether the approaches used to pursue such questions are ethical, and whether the communication of that research is ethical — just do not apply to their work. But in this issue of Nature Methods , a Comment from Jeantine Lunshof and Julia Rijssenbeek 1 implores life scientists of all stripes to integrate discussions with professional ethicists and philosophers into the research planning process.

For some research fields, ethical guidelines are readily available. Research on human subjects — for example, the use of fMRI to study alterations to brain connectivity networks in disease — must be approved by ethics committees (in accordance with the Declaration of Helsinki ), and such subjects must provide informed consent. Experiments with lab mice must also be preapproved by an ethics committee, and researchers should follow the ARRIVE reporting guidelines 2 , as well as the American Veterinary Medical Association guidelines for animal euthanasia. Developmental biologists working with human embryos should abide by ethics guidelines set by the International Society for Stem Cell Research . Ecologists collecting data in the global South are encouraged to follow the TRUST Code recommendations — in particular, by including local researchers in the work.

There are many areas of life sciences research, however, where research does not require ethics oversight and ethics guidelines are not readily available, but where ethical considerations may yet be important. There are likely several examples of methodologies and tools that, in the wrong hands, may lead to harmful gain-of-function experiments or dual-use threats to public health or national security. A molecular biologist tinkering to improve genome editing tools would be wise to ponder the implications of the unethical use of the technology for human germline editing, as in the ‘CRISPR babies’ case 3 . Computational biologists using AI technology for drug discovery need to be aware that such models could be misused to design biochemical weapons 4 .

In their Comment, Lunshof and Rijssenbeek describe a model called ‘collaborative ethics’, which calls for life sciences researchers to work closely with professional ethicists or philosophers starting at the earliest stages of research planning. As they write, collaboration can “improve the efficiency and robustness of outcomes” for the research team and also “prepare a team for a formal ethics review and criticism after publication.” Such collaborations also benefit the field of philosophy, “as direct involvement with the sciences allows long-held assumptions and arguments to be put to the test.”

In the collaborative ethics model, a research team will discuss their ideas and concepts with a professional ethicist or philosopher, who may ask probing questions about the nature of the work. The ethicist will help the researchers understand whether there are any ethical considerations and whether the potential harms of sharing the resulting new knowledge with society outweigh the potential benefits of advancing science. Lunshof and Rijssenbeek highlight how the collaborative ethics model played a role in three different projects: the engineering of synthetic human entities with embryo-like features, the development of brain organoids and the programming of computer-designed ‘biobots’. They note that collaborative ethics may also have a role to play in many other fields, such as protein engineering, systems biology, aging research and computational biology.

As described in our journal policy , performing ethical research is the responsibility of all scientists. Professional ethicists are not the police; their role is not to punish or curb scientific progress. Rather, ethicists can serve as a ‘conscience’ and help scientists understand the ethical implications of their work. Without such collaborations, the after-the-fact consequences could be much worse — yes, papers can be retracted, but reputations are already damaged and harmful gain-of-function work may be out there for the world to see.

For scientists used to dealing with quantitative measures and statistical significance, the concept of research ethics can feel a bit vague or murky, at best an afterthought to their work. This is even more a reason for breaking down the walls between science and ethics, especially in this age of rapid technology development and especially with swift advances in AI. We strongly encourage institutions to go beyond minimal ethics training courses and do much more to support close collaborations between scientists and professional ethicists.

Lunshof, J. E. & Rijssenbeek, J. https://doi.org/10.1038/s41592-024-02320-8 (2024).

Kilkenny, C., Browne, W. J., Cuthill, I. C., Emerson, M. & Altman, D. G. PLoS Biol. 8 , e1000412 (2010).

Article   PubMed   PubMed Central   Google Scholar  

Cyranoski, D. & Ledford, H. Nature 563 , 607–608 (2018).

Article   CAS   PubMed   Google Scholar  

Urbina, F., Lentzos, F., Invernizzi, C. & Ekins, S. Nat. Mach. Intell. 4 , 189–191 (2022).

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• http://orcid.org/0000-0002-4609-9179 Melanie Jansen 1 , 2 ,
• Peter Ellerton 3
• 1 Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law , Children’s Health Queensland Hospital and Health Service , South Brisbane , Queensland , Australia
• 2 Faculty of Medicine , University of Queensland , Herston , Queensland , Australia
• 3 Faculty of Humanities and Social Sciences , University of Queensland , Brisbane , Queensland , Australia
• Correspondence to Dr Melanie Jansen, Paediatric Intensive Care Unit & Centre for Children’s Health Ethics and Law, Children’s Health Queensland Hospital and Health Service, Brisbane, QLD 4101, Australia; doctormjansen{at}gmail.com

In recent decades, evidence-based medicine has become one of the foundations of clinical practice, making it necessary that healthcare practitioners develop keen critical appraisal skills for scientific papers. Worksheets to guide clinicians through this critical appraisal are often used in journal clubs, a key part of continuing medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of medical ethics papers. Medicine is increasingly ethically complex, and there is a growing medical ethics literature that modern practitioners need to be able to use in their practice. In addition, clinical ethics services are commonplace in healthcare institutions, and the lion’s share of the work done by these services is done by clinicians in addition to their usual roles. Education to support this work is important. In this paper, we present a worksheet designed to help busy healthcare practitioners critically appraise ethics papers relevant to clinical practice. In the first section, we explain what is different about ethics papers. We then describe how to work through the steps in our critical appraisal worksheet: identifying the point at issue; scrutinising definitions; dissecting the arguments presented; considering counterarguments; and finally deciding on relevance. Working through this reflective worksheet will help healthcare practitioners to use the ethics literature effectively in clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. Practising these critical reasoning skills will also increase practitioners’ capacity to think through difficult ethical decisions in daily clinical practice.

• clinical ethics
• education for health care professionals

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/medethics-2018-104997

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Evidence-based medicine is a foundation of clinical practice, necessitating that healthcare practitioners develop keen critical appraisal skills for scientific papers. Many excellent resources exist, including the paper by Sackett  et al 1 and a reference book by Greenhalgh. 2 In 1992, the Medical Journal of Australia published a paper titled ‘How to read a journal article’ . 3 The authors’ goal was to give a step-by-step guide to critically appraising scientific papers. Journal clubs using this worksheet, or similar, are now commonplace in teaching hospitals and are a key part of medical education. A similar need is arising for health professionals to develop skills in the critical appraisal of ethics papers. The reasons for this are twofold. First, healthcare grows increasingly ethically complex. Just as clinicians must keep abreast of the scientific literature, they should also keep up to date with the ethics literature relevant to their practice. Second, clinical ethics services (CES) have become commonplace in hospitals in developed nations. The lion’s share of the work of these services is done by healthcare professionals in addition to their clinical roles 4–6 and who have highly variable levels of training. 4–8 There is an urgent need to equip these and other clinical staff with skills to appraise papers relevant to these aspects of practice.

In this paper, we present the critical appraisal worksheet developed at the Centre for Children’s Health Ethics and Law (CCHEL), Children’s Health Queensland, Brisbane, Australia ( table 1 ). The worksheet was developed for our ethics journal club and has proved useful both for the critical appraisal of ethics papers and for the development of critical thinking skills that can be applied in clinical practice and in clinical ethics consultation work. The goal of this paper is to provide a tool for clinicians without extensive philosophical training to critically appraise ethics papers relevant to clinical practice. We also intend it to be a shared evaluative tool that can form the basis of professional discussion such as at ethics journal clubs. In the first section, we explain what is different about ethics papers. We then describe the steps in our critical appraisal worksheet.

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Ethics critical appraisal worksheet

What is different about ethics papers? A discussion of arguments, facts and values

It is important to recognise that ethics is a philosophical, not a scientific, discipline. Healthcare professionals are accustomed to critically appraising scientific data, and to constructing an argument based on that data for why a particular clinical decision is justified. Note that we use the word argument in the philosophical sense, meaning a set of reasons that justify a position. For example, if a patient presents with clinical signs consistent with bacterial pneumonia, the doctor will prescribe an antibiotic regimen based on their knowledge of the likely pathogens and the efficacy of particular antibiotics against these. That oral amoxicillin is an effective treatment for mild community-acquired pneumonia is a factual claim supported by scientific evidence. In contrast, ethical claims are claims of value and must be justified with an ethical argument. For example, the claim that life-sustaining therapy (LST) should be withdrawn from a patient with end-stage cancer is a value claim. Prescriptive words such as ‘should’ and ‘ought’ are useful signposts for value claims. An argument that may justify the claim that LST should be withdrawn is that the patient had previously stated that they did not want to be maintained on LST, and therefore to respect their autonomy the treatment should be withdrawn.

Note that matters of fact and matters of value coexist in clinical medicine (as they do in life) and that rationales for ethical and medical decisions are usually made up of both fact and value claims. Take the example just given of the argument that therapy should be stopped to respect the patient’s autonomy. That the patient had previously expressed wishes not to be maintained on life support is a factual claim. The claim that we should respect autonomy is a value claim. Likewise, when deciding on antibiotics for the patient with pneumonia, the claim that amoxicillin is effective is a factual claim. That we should treat the patient with amoxicillin is a value claim—the implicit argument for which is that the right thing to do is to treat patients with the most effective therapy for their disease. This seems so plainly reasonable that it does not need to be stated; however, it is important to recognise implicit value judgements in clinical decisions, as these are often at issue when there is conflict. The important skill is to be able to differentiate fact and value claims and to understand how the two can interact to form a set of reasons that support a particular conclusion. To do this, it is important to understand how arguments are constructed.

Understanding arguments is important for clinical practice, because ethical decision making threads through everything healthcare practitioners do. High-level skills in this area are especially important for those providing clinical ethics consultation. The UK Clinical Ethics Network and the American Society for Bioethics and Humanities have each published core competencies for clinical ethics consultation. 9 10 Both specify the need for consultants to understand ethical theory and reasoning, to analyse ethical conflicts, and to be able to elicit values and assumptions. Understanding argumentation is fundamental to these skills. The ethics critical appraisal worksheet provides a framework through which to appraise arguments and, by guiding practitioners to read ethics papers actively, aims to deepen understanding of ethical argumentation. We acknowledge that there is a growing literature in empirical ethics—this critical appraisal worksheet is not intended for these papers, as they are scientific papers and can be appraised as such. This worksheet is intended for papers that discuss ethical issues, not those that present scientific data relevant to an ethical issue.

The ethics critical appraisal worksheet

We have structured the worksheet in a similar way to the one by Darzins et al , 3 as a matrix of questions arranged in three columns ( table 1 ). In the first column are questions that prompt the reader to look for important types of information in the article. The second column contains questions that help the reader to decide whether there are problems with these. The third column poses questions to help the reader decide if any problems identified threaten the quality of the paper. Using this worksheet should assist clinicians to more rapidly identify problems with the paper, making the reading of ethics papers more time-efficient.

Critical appraisal questions

What is the point at issue.

The point at issue is the ethical question that the paper is addressing. Well-written ethics papers will explicitly state the point, or points, at issue in the introduction and will go on to address them. Poorly written ethics papers will shift between points at issue, which clouds reasoning and precludes systematic appraisal of all the relevant arguments. Shifting the point at issue happens often in ethical discussions. For example, we may be discussing the issue of whether we should continue providing LST to a child with a very poor prognosis. One person believes that the LST is causing suffering to the child, another person questions the truth of this. A third person points out that we cannot over-ride the parents’ autonomy. This third person is shifting the point at issue. The ethicality of over-riding parental autonomy is important, but concerns a different point at issue. Whether the LST is causing suffering or not is a point that needs to be explored and clarified before moving onto the question of whether it is of a magnitude that makes it reasonable to interfere with parental autonomy.

Has the author defined all of the terms they use?

Defining key terms is critical to avoid confusion. For example, in a paper discussing the rights of adolescents to autonomy in medical decision making, the author needs to define what persons they are referring to with the word ‘adolescent’; exactly what range of decisions they are referring to within the phrase ‘medical decision making’; and exactly how autonomy is conceived in this context. Failing to define key terms used in an argument sacrifices clarity, and defining key terms in an unusual or unreasonable way may have implications for the generalisability of the argument.

Dissect the argument: What are the premises of the author’s argument? What is/are the author’s conclusion/s?

This section of the worksheet requires explanation of the anatomy of an argument and clarification of the difference between truth and validity.

Arguments consist of premises and a conclusion, for example:

Premise 1: Human suffering is undesirable.

Premise 2: Medically extending life in case X prolongs human suffering.

Conclusion: Medically extending life in case X is undesirable.

This is a valid argument because the conclusion follows logically from the premises; that is, it is impossible for the premises to be true and the conclusion false. Whether the conclusion (or a premise) is true or not is a separate issue. Refuting this argument requires proving one or both of the premises to be false—finding evidence that suffering is not always undesirable, or making a case that this particular medical intervention does not prolong suffering. There are no errors of reasoning in this argument, but there may be factual errors which will prove the argument to be a bad one. Consider another argument:

Premise 1: Lucy has a chronic cough.

Premise 2: Lung cancer can present with a chronic cough.

Conclusion: Lucy has lung cancer.

In this case, the argument is invalid. The premises are true but the reasoning is flawed. It is true that Lucy has a chronic cough, and that lung cancer can present with a chronic cough, but it does not follow that Lucy necessarily has lung cancer. Her chronic cough may be from asthma or chronic bronchitis. Lucy may even have lung cancer, although it could be of a type that would not usually cause coughing. So, even if all the information given is true, the conclusion that she must have lung cancer does not necessarily follow.

Another important phenomenon to be aware of is the ‘hidden assumption’. A hidden assumption is a premise that is not explicitly stated. For example, a person may claim that homosexuality is morally wrong because it is unnatural. The hidden premise here is that things that are unnatural are morally wrong, as follows:

Premise 1: (Hidden) Things that are unnatural are morally wrong.

Premise 2: Homosexuality is unnatural.

Conclusion: Homosexuality is morally wrong.

To refute this argument one needs to either show the premises are false or that the reasoning is invalid. The reasoning is valid because it is impossible for the premises to be true and the conclusion false. However, even if one were to accept premise 2—in ignorance of the natural occurrence of homosexuality in many animals—the hidden premise 1 ignores that many things that are unnatural are considered morally good (or at least morally neutral), such as medicines, clothing or the telephone. Identifying the hidden premise is necessary to fully represent the argument, and hence to properly evaluate it.

In ethics papers, deciding whether premises are true will often require recourse to the scientific literature. Good ethics papers have well-researched references for factual premises. Appraising the validity of reasoning can be more difficult and requires practice. A full and rich account of logical fallacies is outside the scope of this paper; however, there are excellent, accessible resources available to hone these skills. 11 It is also worth noting that the overall position of an ethics paper is likely to be made up of a complex argument, with the conclusions of initial arguments making up the premises of further arguments. For example, some may claim that premise 1 (above) is a claim about the existence of ethical laws of nature. To support this claim, the person must develop an argument for the existence of ethical laws of nature and the definition of ‘unnatural’, ending with premise 1—things that are unnatural are morally wrong—as the conclusion. The analytical framework we present here is applicable to each constituent argument of a complex argument.

Does the author address all relevant counterarguments?

When making a case for an ethical position, it is imperative that authors address counterarguments to their position. If an author has not addressed relevant counterarguments, or has done so unconvincingly, this significantly decreases the strength of their case, or at least suggests a shallow investigation of the issue.

Is the argument or exploration of the issue relevant to your practice?

Some ethics papers will address a specific ethical question arising in the reader’s own practice and assist them in navigating this scenario. Other papers will change the way practitioners think, affecting practice in myriad but subtle ways. There will be papers that, while of good internal quality, are not relevant to the reader’s practice. Explicitly deciding on the relevance of a paper prompts practitioners to contextualise new ethical information within their own practice.

Working through this reflective worksheet will aid healthcare practitioners in actively reading and critically appraising ethics papers, enabling them to use the ethics literature more effectively. Developing these critical reasoning skills will also increase capacity to think through difficult ethical decisions in day-to-day practice. It is of particular importance that clinicians working within CES develop these skills to a high level. In the future, we hope to empirically evaluate the ethics critical appraisal worksheet.

Key messages

Healthcare is increasingly ethically complex, and so there is a growing need for clinicians to keep up to date with the ethics literature relevant to clinical practice.

Clinical ethics services have become commonplace, and the majority of the work of these services is done by clinicians in addition to their clinical roles.

Ethics papers differ in important ways from scientific papers, requiring a different set of critical appraisal skills.

We have developed a worksheet to assist clinicians in the critical appraisal of ethics papers, which can also be used as a shared evaluative tool, such as at ethics journal clubs.

Acknowledgments

The authors would like to acknowledge all CCHEL Clinical Ethics Response Pool members who have participated in the ethics journal club, and in so doing have helped to refine this critical appraisal worksheet.

• Sackett DL ,
• Rosenberg WM ,
• Gray JA , et al
• Greenhalgh T
• Darzins PJ ,
• Pearlman RA
• Slowther AM ,
• McClimans L ,
• Irving H , et al
• Godkin MD ,
• Upshur RE , et al
• Kesselheim JC ,
• Johnson J ,
• Larcher V ,
• Richardson J ,
• Meaden S , et al

Contributors MJ conceived the idea of the critical appraisal worksheet for clinicians. PE assisted in developing the idea and refining the worksheet. MJ wrote the initial draft of the manuscript. PE and MJ were both involved in draft review and development of the final version of the manuscript. MJ is the guarantor of this article.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Disclaimer The views expressed in this paper are the authors’ own and do not necessarily reflect the views of their institutions.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Author note MJ is a medical doctor in intensive care medicine and has additional qualifications and experience in clinical ethics. She co-led the working group to establish the Centre for Children’s Health Ethics and Law at Children’s Health Queensland, and was the centre’s inaugural Clinical Ethics Fellow. MJ recently completed a Churchill Fellowship in clinical ethics. She has published both empirical research and analysis pieces on healthcare ethics issues. PE is a science educator and philosopher, and is the Curriculum Director of the University of Queensland Critical Thinking Project. He is an expert in critical thinking and argumentation and has published on these topics in a number of contexts.

Correction notice This article has been made Open Access since it was published Online First.

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Defining ethical challenge(s) in healthcare research: a rapid review

Guy schofield.

1 Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK

3 Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK

Mariana Dittborn

2 Paediatric Bioethics Centre, Great Ormond Street Hospital, London, WC1N 3JH UK

Lucy Ellen Selman

Richard huxtable, associated data.

All data is presented in this manuscript.

Despite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature.

Rapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.

Conclusions

Only 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Methodological rigour within research is a cornerstone in the production of high-quality findings and recommendations. Across the range of empirical methodologies, a broad collection of protocol development tools, methodology guidelines, and reporting guidelines have been developed and evidence of their use is increasingly required by journals [ 1 – 6 ]. Within both empirical bioethics and descriptive ethics, there has been an accompanying increase in the acknowledgment of the importance of methodological rigour in the empirical elements, including within the recent consensus statement on quality standards in empirical bioethics research by Ives et al. [ 7 – 9 ]. Aligned with this aim for rigour, definitional clarity of key terms used within a research project is a component of research quality [ 10 , 11 ]. Improving the quality of empirical bioethics is also itself an ethical imperative [ 9 ].

We recently conducted a systematic review examining ‘ethical challenges’ as reported by specialist palliative care practitioners [ 12 ]. Our review, alongside our initial scoping search findings and reading of the literature, suggested that, although many authors use the term ‘ethical challenge(s)’ in empirical ethics research, there appeared to be no commonly described or accepted definition. Furthermore, papers retrieved rarely defined ‘ethical challenge(s)’ explicitly , which has also been noted by other researchers examining other topic areas [ 13 – 15 ]. Our review further suggested that authors frequently use terms closely related to ‘ethical challenge(s)’—such as ‘moral dilemmas’ or ‘ethical issues’—interchangeably with ‘ethical challenge(s)’ throughout manuscripts, rather than staying with the original term. Research shows that non-philosophers may understand these related terms in heterogeneous ways which may additionally affect understanding of texts across different readerships [ 16 , 17 ].

Without a clear definition of an ethical challenge, each researcher must use individual judgement to ascertain whether they have identified an instance of one within their dataset. This potentially generates an unnecessary source of bias, particularly if multiple researchers are involved in data collection, extraction, or analysis. This risks generating misleading ethical analyses, evaluations, or recommendations. Additionally, and more broadly, if primary studies do not define the term, then work based on these—such as systematic reviews of individual studies or those undertaking secondary data analysis—may unknowingly compare different phenomena without a mechanism for mitigating the effects this introduces.

In the hope of prompting a debate on this topic, we therefore undertook a rapid review, which aimed to explore existing definitions of “ethical challenge(s)” and the use of other closely related terms within recent empirical healthcare ethics literature.

We conducted a rapid review examining the usage of the term ‘ethical challenge(s)’ over the last 5 years in published research articles, in order to identify and summarise if, and how, the term was defined. As a secondary aim, we examined authors’ uses of closely related alternative terms within the included article texts separate to their use within any explicit definitions that may be present.

Rapid reviews use abridged systematic review methodology to understand the evidence base on a particular topic in a time and resource efficient manner [ 18 – 22 ]. Comparative reviews of topics in which both a rapid review and a systematic review had been undertaken demonstrated that the overall conclusions were similar, although rapid reviews were less likely to contain social and economic data, and systematic reviews contained more detailed recommendations [ 18 – 20 , 23 , 24 ]. The Cochrane Rapid Review Methods Group has recently released interim methodological guidelines for undertaking rapid reviews [ 6 ], advising authors to describe where their protocol deviates from a systematic review and detail any biases that these deviations may introduce [ 18 , 19 , 21 ]. We have followed the Cochrane recommended methodology [ 6 ]. A rapid review reporting guideline is currently under development [ 25 ] and this review is therefore reported based on the PRISMA 2020 statement for systematic reviews, with justifications provided where our approach deviated [ 26 ].

Prospective review protocol registration on the PROSPERO database is the current gold standard, but, at the time of writing, PROSPERO does not accept records for rapid reviews [ 27 ]. The protocol was therefore not published in advance.

Eligibility criteria

The inclusion and exclusion criteria are summarised in Table ​ Table1. 1 . We used Strech et al.’s Methodology, Issues, Participants (MIP) structure for our eligibility criteria, which is recommended for systematic reviews in ‘empirical bioethics’ [ 28 ]. The criteria reflect three assumptions. First, that the inclusion of ‘ethical challenge(s)’ in the title would increase the likelihood that this was the authors’ preferred term for the concept under investigation, and therefore increase the probability of a definition being provided. Second, that studies aiming to describe empirical data and identify ethical challenges in real-world contexts are most likely to contain a definition to guide researchers in identifying these challenges as they collect and analyse data. Third, that structured reviews of studies of ethical challenges are likely to include a definition to allow researchers to reliably recognise an ethical challenge in retrieved records. We used a 5-year timeframe as a date restriction. This reflected a balance between adequately covering recent use of the term and time and resource restrictions of the rapid review.

Inclusion and exclusion criteria

Information sources

The search strategy was as follows:

‘ethical challenge’.ti OR ‘ethical challenges’.ti.

We searched Medline (Ovid interface), Philosopher’s Index (OVID interface), EMBASE (OVID interface), and CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCO interface) for studies indexed over a five-year period between April 2016 and April 2021. These resources cover the breadth of healthcare research. Including Philosopher’s Index increased coverage of the bioethics literature. We did not search the grey literature [ 6 ]. The search strategy was tested by successfully retrieving three sentinel studies known to the research team.

Study selection

Retrieved studies were imported into Endnote X9.2 [ 29 ]. Records unavailable through institutional subscriptions were requested from corresponding authors. If unavailable 14 days after the request, the record was excluded. A random sample of 20% of records were dual screened at the title/abstract level by GS/MD. After discussion, the remainder were screened by GS. At full-text screening, a further 20% were dual screened by GS/MD and, again after discussion, the remaining studies were screened by GS.

Data extraction and analysis

Data extraction was undertaken using a pre-piloted form, with the first 5 records dually extracted by GS and MD. Data from the remaining included studies was then extracted by GS, with correctness and completeness checked by MD. We collected data on date of publication, authors, journal, country (for primary studies), methodology, definition of ‘ethical challenge(s)’ (present (yes/no)) and (where offered) the definition provided, and any closely related terms used, with counts of all terms used in each article. For closely related terms, data was extracted from the authors’ text, but not from direct quotations from qualitative research. Where definitions of ‘ethical challenge(s)’ were offered and/or related terms were identified, these were categorised and counted following the principles of summative content analysis [ 30 ]. Summative content analysis combines both the quantitative counting of specific content or words/terms with latent content analysis to identify and categorise their meanings. We identified keywords (‘ethical challenge(s)’ and closely related terms) deployed by the authors of the included papers, both prior to and during data analysis, and analysed the retrieved definitions. This approach allowed for exploration of both the content of definitions and development of insights into the use of related terms.

Risk of bias assessment

The focus of the rapid review was the definition of the term ‘ethical challenge(s)’ within retrieved records. We therefore did not undertake quality assessment for the included studies and reviews.

831 records were retrieved, reduced to 393 after de-duplication. 238 records were excluded after reviewing the title and/or abstract. 157 records were identified for full text screening, with 3 unavailable [ 31 – 33 ]. 82 records were excluded at full text stage and 72 records were included for analysis. See Fig.  1 for the PRISMA flowchart.

PRISMA flow diagram of record identification

Record characteristics

Of the 72 included records, 53 were empirical studies [ 34 – 86 ], 10 non-systematic reviews [ 87 – 96 ], 7 systematic reviews [ 12 – 14 , 97 – 100 ], 1 systematic review protocol [ 101 ], and 1 non-systematic review protocol [ 102 ]. Of the 53 empirical studies, 42 (79%) were qualitative studies [ 34 – 36 , 38 – 44 , 47 , 48 , 50 – 52 , 54 – 58 , 60 , 62 – 67 , 69 , 71 – 77 , 79 – 81 , 83 – 86 ], 6 (12%) used a mixed methods approach [ 45 , 46 , 53 , 59 , 61 , 68 ], and 5 (10%) were quantitative [ 37 , 49 , 70 , 78 , 82 ]. 7/56 empirical studies, all qualitative interview studies, recruited participants internationally with no specific location stated [ 40 , 54 , 55 , 58 , 60 , 63 , 73 ]. Of the remaining studies, all but one were single-country studies: Botswana [ 75 ], Canada [ 41 , 65 ], China [ 57 ], Denmark [ 39 , 43 ], Dominican Republic [ 44 ], Germany [ 51 , 84 ], India [ 61 ], Iran [ 38 , 46 , 49 , 68 , 70 – 72 , 78 , 82 , 98 ], Italy [ 45 ], Mexico [ 87 ], the Netherlands [ 76 ], New Zealand [ 47 ], Norway [ 42 , 52 , 56 , 64 , 80 , 81 , 83 ], Saudi Arabia [ 34 – 37 ], Tanzania [ 69 , 74 ], Uganda [ 67 ], UK [ 86 ], and USA [ 50 , 53 , 59 , 62 , 66 , 77 , 79 , 85 , 85 ]. The remaining study was undertaken in both Sierra Leone and the UK [ 48 ]. See Table ​ Table2 2 for a summary.

Included study details

12/72 (17%) of retrieved studies offered an explicit definition for ‘ethical challenge(s)’ [ 12 – 14 , 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 , 101 ]. Definitions were more likely to be found in more recent publications, with 4/12 included studies published in 2016–2018 [ 14 , 48 , 56 , 81 ], and 8/12 published in 2019–2021 [ 12 , 13 , 50 , 57 , 66 , 69 , 98 , 101 ]. The included study locations were evenly distributed, matching the overall pattern of retrieved studies, with studies from high- [ 48 , 50 , 56 , 66 , 81 ], middle- [ 57 , 98 ], and low-income settings [ 48 , 69 ]. The identified studies included eight qualitative studies [ 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 ], 3 systematic reviews [ 12 – 14 ], and 1 systematic review protocol [ 101 ]. Two of these records were the systematic review protocol and the report from our group, which accordingly contained the same definition [ 12 , 101 ], leaving 11 unique definitions. Definitions of ‘ethical challenge(s)’ identified in included studies are provided in Table ​ Table3. 3 . Additionally, 68/72 (94%) reports used closely related terms synonymously in place of ‘ethical challenge(s)’ throughout their manuscript text, with between 1 and 8 different terms used within each report, and 32 different terms were identified. This occurred in both those reports that contained a definition and those that did not. See Table ​ Table4 4 for terms and frequencies.

Details of studies that contained an explicit definition of ‘ethical challenges’

Use of terms closely related to ‘ethical challenge’

Those records that offered explicit definitions used four approaches: (1) definition through concepts [ 12 , 57 , 66 ]; (2) reference to moral conflict, moral uncertainty or difficult choices [ 13 , 14 , 48 , 57 , 69 , 98 ]; (3) definition by study participants [ 12 , 48 , 50 , 56 ]; or (4) challenges as linked to their ability to generate emotional or moral distress within healthcare practitioners [ 14 , 14 , 66 , 81 ]. Each definition was associated with one or more of the identified elements, although none covered all four approaches. We describe these approaches below.

Approach 1: definition through concepts

This approach involves primarily defining ‘ethical challenge(s)’ in terms of related concepts. All three definitions using this approach defined ‘ethical challenge(s)’ as a summative collection of related concepts, including ‘ethical dilemmas’, ‘moral dilemmas’, ‘moral challenges’, ‘ethical issues’, and ‘ethical conflicts’ [ 12 , 57 , 66 ], for example:

‘The expression “ethical challenges” mainly refers to ethical dilemmas and ethical conflicts as well as other scenarios where difficult choices have to be made’ [ 57 ] p34

Only one went on to define the other concepts they utilised, ‘ethical dilemmas’ and ‘ethical conflicts’:

‘Ethical dilemmas are described as situations that cannot be solved; decisions made between two options may be morally plausible but are equally problematic due to the circumstances. Ethical conflicts, on the contrary, arise when one is aware of the necessity of proper actions but he or she may have trouble exercising these actions because of certain internal or external factors.’ [ 57 ] p34

Approach 2: moral conflict, moral uncertainty or difficult choices

This approach anchors an ethical challenge to the requirement for an agent to make a (difficult) choice in a situation where moral principles conflict, or there is moral uncertainty as to the ‘right’ way forward.

‘In this context, ethical challenge refers to the situation whereby every alternative is morally wrong and still one has to make a choice’ [ 69 ] p676 ‘An ethical challenge occurs when one does not know how to behave and act in the best way…’ [ 14 ] p93

Approach 3: definition by study participants

Four of the definitions involved research participants themselves defining something as an ‘ethical challenge’ [ 12 , 48 , 50 , 56 ], with three studies explicitly stating that participants would lead this definitional work [ 48 , 50 , 56 ]. Draper & Jenkins offer a starting definition, adopted from Schwartz et al. [ 103 ] with which to prime participants, while Forbes and Phillips [ 50 ] and Jakobsen and Sørlie [ 56 ] left the definition fully with their participants (Table ​ (Table3). 3 ). Finally, Schofield et al. proposed a very broad definition (Table ​ (Table3), 3 ), alongside the specific statement that either participants or researchers could nominate something as an ‘ethical challenge’ [ 12 ].

Approach 4: emotional or moral distress

This final approach was to tie ethical challenges to situations where participants feel ‘discomfort’, emotional distress or more specifically moral distress or moral residue [ 14 , 66 , 81 ]. Larkin et al. are clear that this distress must be tied to moral causes, but Hem et al. and Storaker et al. also refer more broadly to ‘discomfort’ [ 14 ] and ‘emotional stress’ [ 81 ] respectively. For example:

‘In this article, ethical challenges refer to values that entail emotional and moral stress in healthcare personnel.’ [ 81 ] p557

To the authors’ knowledge, this is the first rapid review to examine the use of the term ‘ethical challenge(s)’ in empirical healthcare research literature. Notably, only 12/72 (17%) of included studies published in the last 5 years contained a definition for ‘ethical challenge(s)’, despite this being the focus of the research being reported. The definitions identified were found in qualitative studies and systematic reviews and were evenly distributed geographically across high-, middle- and low-income settings. Definitions contained one or more of the identified approaches, although none contained elements from all four. Taken together, these findings suggest that a clear definition of ‘ethical challenge(s)’, and consistent use thereof, is currently lacking.

The four approaches indicate the diverse approaches to understanding ‘ethical challenge(s)’. Approaches 1 and 2 explore the concept from opposite viewpoints, with approach 1 looking from the conceptual perspective, through terms such as ‘dilemmas’ and ‘conflict’, and approach 2 from a participant perspective, specifically in those situations in which someone is trying to make a decision in circumstances where the preferred option is not possible or when they perceive there to be clash in values they feel are important. Within the concept-led definitions (approach 1), the use of a plurality of terms highlights a potential risk of bias, as different readers may interpret these differently. For example, some terms, such as ‘moral dilemma’, have relatively well understood specific meanings for some readers, particularly those with philosophical training [ 104 – 106 ]. The presence in the literature of specific and multiple meanings for some related terms highlights the importance of empirical studies providing a definition of these additional terms alongside their primary definition for ‘ethical challenge(s)’. This is more likely to be relevant where an a priori definition is used, but may be relevant to any prompting text for studies using a participant-led process, as in the study by Draper and Jenkins [ 48 ]. This clarity is important for both readers and future researchers who may undertake a secondary analysis of the data.

Approach 3 involves facilitating participants to nominate something as an ethical challenge [ 12 , 48 , 50 , 56 ]. This speaks to an important question about who, in a research context, is permitted to define or describe the object of interest, in this case ‘ethical challenge(s)’. Restricting the identification of ‘ethical challenge(s)’ to researchers alone may introduce bias by excluding input from those without bioethical ‘expertise’, but with important lived experience of the context under investigation. There is evidence that although clinicians can be sensitive to major ethical dilemmas, they can be less sensitive to small everyday ethical elements in clinical practice, and that ethical awareness varies between individuals [ 107 , 108 ]. Additionally, there is evidence in healthcare ethics research that patients and carers identify ethical challenges in situations that healthcare workers do not [ 109 ]. Therefore, relying entirely on a particular stakeholders’ perspectives (such as clinicians’) may risk missing important ethical challenges present in a scenario (assuming, of course, that we can settle what counts as an ‘ethical challenge(s)’).

In Approach 4, ethical challenges were linked to situations in which participants felt discomfort [ 14 ], emotional stress [ 81 ], moral distress or moral residue [ 66 ]. These concepts are themselves defined in quite varied ways (see, for example, definitions of ‘moral distress’ in a systematic review by Morley et al. [ 110 ]), potentially leading to additional conceptual confusion. Identifying triggers for moral distress is important, as high levels of moral distress are known to have negative impacts on work environments and lead to increased levels of compassion fatigue, increased staff turnover rates and poorer patient outcomes [ 110 – 112 ]. However, it is also possible that the requirement that, to be identified as an ethical challenge, the situation must invoke stress or distress might result in the under-identification of ethical challenges. We anticipate that many practitioners will daily manage multiple low-level ethical challenges, many of which will not generate moral distress or leave a moral residue. As such, the presence of moral distress may not be sufficient or even necessary in order to label a moral event an ‘ethical challenge’. However, the relationship between ‘ethical challenge(s)’ and moral distress is complex, and some might argue that the latter has an important relationship to the former. For example, moral distress, as conceived by Jameton and others [ 110 , 113 , 114 ], is linked to the after-effects of having to handle ethical challenge(s), so some researchers might view the generation of moral distress as relevant to identifying ethical challenges.

Although our review revealed these four approaches, the wider literature indicates there may be alternative approaches available. For example, other potential approaches would define ethical challenges as events that interact with moral principles, such as autonomy, beneficence, non-maleficence or justice, as proposed by Beauchamp and Childress [ 115 ], or as events in which those principles clash, for example as used by Klingler et al. in their research focusing on ethical issues in health surveillance [ 116 ]. However, these approaches were not seen amongst our included papers.

Returning to our included papers, the high rates of use of closely related terms within included manuscript texts may add to difficulties in understanding the exact object of interest if these terms are being used as synonyms for ‘ethical challenge(s)’. This may be particularly the case if terms used include those such as ‘moral dilemma’, which (as shown above) will have specific meanings for some readers. Interchangeable, undefined usage of these terms by study authors within study texts risks further exacerbating the problems caused by a lack of definitional clarity.

Strengths and limitations

This rapid review is the first systematic attempt to describe the definitions of ‘ethical challenge(s)’ available within the recent published literature.

There are, however, five limitations to note. First, the review only includes results from the past 5 years, which inevitably means that older publications, which may have contained further definitions of ‘ethical challenge(s)’, were excluded. The focus on the previous 5 years does, however, allow for an assessment of the term’s use(s) within a reasonable period of time and was felt to be appropriate given the aims and resources available to this project.

Second, our three assumptions listed in the methodology section may have excluded some records that contained a relevant definition. However, these assumptions, and the resulting focus on two search terms, allowed for a balance between retrieved record numbers and team resources.

Third, the four databases searched were chosen for their focus on the healthcare ethics literature; we may therefore may have missed relevant usage in other fields or disciplines. Similarly, we did not search the grey literature, which might have excluded relevant research.

Fourth, for resource reasons, the assessment as to whether a related term was being used interchangeably in the text was undertaken by a single researcher (GS). This subjective assessment risks miscalculating both the number of interchangeable terms identified and the frequency counts.

Finally, we did not review the theoretical literature for conceptual definitions of ‘ethical challenge(s)’, hence the definitions we identified might not match completely conceptual understandings of the term. However, our review shows how the term is currently being used in the research literature. Indeed, if there are strong conceptual definitions within the theoretical literature, then it is clear that they are currently not reaching the researchers whose work was identified by our review.

This review is the first, to our knowledge, to identify and describe definitions (and uses) of the widely-utilised concept of ‘ethical challenge(s)’ within healthcare research. Only 17% (12/72) of retrieved papers presented an explicit definition of ‘ethical challenge(s)’ before beginning to investigate this concept in context. The definitions found contained one or more of four identified approaches, with significant cross-reference to related terms and concepts which themselves have variation in their accepted meanings. We recommend that researchers define the phenomenon of interest—in this case, ‘ethical challenge(s)’—to help ensure clarity. This should either be a priori, or, if using an approach that includes participant participation in the generation of the definition, reporting their final working definition a posteriori. The choice of definition should be justified, including the decision as to whether to include participants in this process. Additionally, if a definition references other conceptual terms, then consideration should be given to defining these as well.

The results of this rapid review suggest that a common conceptual understanding of the term ‘ethical challenge(s)’ is lacking within empirical bioethical research and that there is a need for researchers in this area to consider what conceptual formulations might be most useful. Again, failure to use definitions of crucial research concepts within empirical bioethics research potentially generates confusion and avoidable bias within research outputs, risking misleading ethical analyses, evaluations, and resulting recommendations. We therefore hope this review will help stimulate debate amongst empirical bioethics researchers on possible definitional content for such a commonly used term and prompt further discussion and research. Additionally, given the central role of patient and public partnership and involvement in research, further thought should be given to who should be involved in nominating something as a challenge worthy of study.

Following on from this work, there would be value in conducting an empirical bioethical project combining a full systematic review of definitions of ‘ethical challenge(s)’ (and related terms) integrated with an exploration of the conceptual literature to generate recommendations for approaches towards the content of potential definitions, perhaps related to the identified approaches above. Such a project could also ask authors who currently use the term ‘ethical challenge(s)’ in their research how they conceptualise this. Furthermore, work to better understand the benefits of including study participants in the definition process is also important. Finally, whilst researchers should justify whatever approach they choose to take, there may be merit in examining whether anything is lost if studies lack a robust or agreed definition, or whether doing so affords a flexibility and openness that allows for a broader range of ethical challenges to be identified.

Acknowledgements

Not applicable.

Authors' contributions

GS, MD and RH conceived of the idea for the review; LES, GS, MD and RH designed the review protocol; GS and MD conducted the literature searching, screening, data extraction and led on data interpretation but all authors were involved; GS led on drafting the manuscript; all authors critically revised the manuscript for content and approved the version to be published. All authors read and approved the final manuscript.

GS is supported by a Wellcome Trust Research Award for Health Professionals (208129/Z/17/Z). LES is funded by a Career Development Fellowship from the National Institute for Health Research. RH is part-funded by the Wellcome Trust (209841/Z/17/Z) and the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. He serves on various local, regional, and national ethics committees and related groups. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health, or any of the other organisations with and for whom the authors work.

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Declarations.

The authors declare that there are no conflicts of interests.

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• Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. (Chest. 2022;162(2):288-90)
• Rebuttal From Dr. DeCamp et al. (Chest. 2022;162(2):292-3)
• ACP Letter Regarding Discrimination on Basis of Disability in Health and Human Service Programs Proposed Rule 2023 (November 13, 2023)

Electronic and Online Professionalism

Ethics manual, electronic patient-physician communication, electronic health records, telemedicine, and online professionalism.

• Initiating and Discontinuing the Patient–Physician Relationship
• The Medical Record
• Boundaries and Privacy

Case Studies

• Lab Results Reporting, Ethics, and the 21st Century Cures Act Rule on Information Blocking CME/MOC

Ethics, Electronic Health Record Integrity and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2021)

Ethics, Professionalism, and the Physician Social Media Influencer CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

”Doctor, Can’t You Just Phone a Prescription In?” and Other Ethical Challenges of Telemedicine Encounters CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2019)

Maintaining Medical Professionalism Online: Posting of Patient Information CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Addressing a Colleague's Sexually Explicit Facebook Post CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Copied and Pasted and Misdiagnosed (or Cloned Notes and Blind Alleys) CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

American College of Physicians Ethical Guidance for Electronic Patient-Physician Communication: Aligning Expectations (J Gen Intern Med. published online 22 June 2020)

Ethical Implications of the Electronic Health Record: In the Service of the Patient (J Gen Intern Med. 2017;32:935-9)

Policy Recommendations to Guide the Use of Telemedicine in Primary Care Settings (Ann Intern Med. 2015;163:787-9)

Online Medical Professionalism: Patient and Public Relationships (Ann Intern Med. 2013;158:620-7)

End-of-Life Care

• Care of Patients Near the End of Life
• Show Codes, Slow Codes, Full Codes, or No Codes: What Is a Doctor to Do? CME/MOC (ACP Ethic Case Studies Series, MOC and CME by Medscape. 2023)

2011 Letter and 2009 letter to Congressman Blumenauer regarding ACP’s support for legislation to pay for voluntary end-of-life care consultations (see H.R. 1898, the Life Sustaining Treatment Preferences Act of 2009).

• Ethics, Determination of Death, and Organ Transplantation in Normothermic Regional Perfusion (NRP) with Controlled Donation after Circulatory Determination of Death (cDCD): American College of Physicians Statement of Concern

End-of-Life (PEACE) Brochures (ACP. 2014) The PEACE brochures were developed by the Patient Education Work Group, which was convened in conjunction with the Consensus Panel project. Order copies of printed brochures

• Improving Your End-of-Life Care Practice
• Living with a Serious Illness: Talking with Your Doctor When the Future is Uncertain
• When You Have Pain at the End of Life
• Making Medical Decisions for a Loved One at the End of Life

ACP-ASIM End-of-Life Care Consensus Panel Papers (1999-2001) ACP convened this Greenwall Foundation supported consensus panel to develop ethical, policy, and clinical recommendations for physicians and other clinicians on end-of-life decisions.

Physician's Guide to End-of-Life Care Edited by Lois Snyder, JD, and Timothy Quill, MD, FACP (ACP Books. 2001)

Advance Directive Forms for Your State Contact Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO).

National Healthcare Decisions Day, April 16 Details and resources on NHDD and the importance of advance care planning.

• Expert Witnesses

To Be or Not to Be: Should I Serve as an Expert Witness? CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Guidelines for the Physician Expert Witness (Ann Intern Med. 1990;113:789)

Family Caregivers

Ethical Guidance on Family Caregiving, Support, and Visitation in Hospitals and Residential Health Care Facilities, Including During Public Health Emergencies (J Gen Intern Med. 2023 Mar 20:1–8)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (J Gen Intern Med. 2010;25:255-60)

Family Caregivers, Patients and Physicians: Ethical Guidance to Optimize Relationships (ACP. 2009) (This publication is a longer version of the position paper above.)

Information Resources for Physicians Supporting Family Caregivers (ACP. 2010) This appendix of resources was developed in conjunction with the ACP position paper to help physicians manage relationships with patients and caregivers.

When the Family Caregiver Is a Physician: Negotiating the Ethical Boundaries CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Genetic Testing and Precision Medicine

• Precision Medicine, Genetic Testing, Privacy, and Confidentiality

ACP Comments on privacy protection and human genome sequencing (May 24, 2012) ACP provided comments to the Presidential Commission for the Study of Bioethical Issues regarding the ethical implications of evolving notions of privacy and access in relation to the integration of large-scale human genome sequencing into research and clinical care.

Position Papers and Statements

Ethical Considerations in Precision Medicine and Genetic Testing in Internal Medicine Practice Ann Intern Med.2022;175:1322-1323

Genetic Testing and Reuniting Families (July 10, 2018)

Global Health Clinical Experiences

• Cultural Humility and Volunteerism

Ethical Obligations Regarding Short-Term Global Health Clinical Experiences (Ann Intern Med. 2018;168:651-7)

Health and Human Rights

"Health and human rights are interrelated. When human rights are promoted, health is promoted ... Physicians have important roles in promoting health and human rights and addressing social inequities." (Ethics Manual, seventh edition).

• Obligations of the Physician to Society

Health as a Human Right (Ann Intern Med. doi:10.7326/M23-1900)

ACP's Human Rights Page : ACP policy statements and letters of support, as well as documents related to College advocacy for the humane treatment of prisoners and detainees.

Health Information Privacy, Protection, and Use

• Confidentiality
• Research Sections within the Research chapter include “Use of Human Biological Materials in Research” and “Internet and Social Media Research”.

Maintaining Medical Professionalism Online: Posting of Patient Information (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Ethical Guidance for Physicians and Health Care Institutions on Grateful Patient Fundraising: A Position Paper From the American College of Physicians (Ann Intern Med.doi:10.7326/M23-1691)

Health Information Privacy, Protection, and Use in the Expanding Digital Health Ecosystem: A Position Paper of the American College of Physicians (Ann Intern Med.2021;174:994-998)

Pandemics and Ethics -->

Health care system catastrophes.

• The Patient-Physician Relationship and Health Care System Catastrophes
• Medical Risk to Physician and Patient

When Resources Are Limited During a Public Health Catastrophe: Nondiscrimination and Ethical Allocation Guidance CME/MOC (ACP Ethics Case Studies Series. MOC and CME by Medscape. 2023)

Pandemic Treatment Resource Allocation Ethics and Nondiscrimination (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza (ACP Ethics Case Studies Series. 2017)

ACP supports ACIP recommendation for additional mRNA COVID-19 vaccine dose and WHO call for equitable global vaccine distribution (August 17, 2021)

ACP Statement on Global COVID-19 Vaccine Distribution and Allocation: On Being Ethical and Practical (June 8, 2021)

ACP's Policy Statement on the Ethical Allocation of Vaccines During Pandemics Including COVID-19 (November 23, 2020)

A Wake-up Call for Healthcare Emerging Ethical Lessons from Covid-19 (Modern Healthcare, June 16, 2020)

Non-Discrimination in the Stewardship of Healthcare Resources in Health System Catastrophes, including COVID-19 Pandemic (March 26, 2020)

Internists Say Harassment Based on Race or Ethnic Origin is Never Okay (March 31, 2020)

Universal Do-Not-Resuscitate Orders, Social Worth, and Life-Years: Opposing Discriminatory Approaches to the Allocation of Resources During the COVID-19 Pandemic and Other Health System Catastrophes (Ann Intern Med.2020;173:230-232)

Patient–Physician Relationship

Patient-physician relationship.

• The Physician and the Patient
• Initiating and Discontinuing the Patient-Physician Relationship
• Third-Party Evaluations
• Providing Medical Care to One’s Self; Persons With Whom the Physician has a Preexisting Close Nonprofessional Relationship or a Reporting Relationship; and VIPs
• Sexual Contact between Physician and Patient
• Gifts from Patients

Confidentiality and privacy, disclosure of medical errors, and informed and surrogate decision making

• Informed Decision Making and Consent
• Making Decisions Near the End of Life

The Doctor Will See You Shortly. The Ethical Significance of Time for the Patient–Physician Relationship (J Gen Intern Med. 2005;20:1057-62)

Ethics and Time, Time Perception, and the Patient–Physician Relationship (ACP. March 2003) (This publication is a longer version of the position paper above.)

• Patient Prejudice? The Patient Said What?... and What Comes Next CME (ACP Ethics Case Studies Series. CME by Medscape. 2022)

Confidentiality and Privacy: Beyond HIPAA to Honey, Can We Talk? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Preventive Health Screening, Ethics, and the Cognitively Impaired Patient CME (ACP Ethics Case Studies Series. CME by Medscape. 2015)

The Difficult Patient: Should You End the Relationship? What Now? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Must You Disclose Mistakes Made by Other Physicians? CME (ACP Observer. November 2003)

Physicians and Society

• Relation of the Physician to Government
• Strikes and Other Joint Actions by Physicians

Physician Work Stoppages and Political Demonstrations—Economic Self-Interest or Patient Advocacy? Where Is the Line? CME (ACP Ethics Case Studies Series. CME by Medscape. 2010)

• Physician-Assisted Suicide and Euthanasia
• Toolkit on Issues in Delivering Patient-Centered End-of-Life Care and Responding to a Request for Physician-Assisted Suicide (Member login)

Ethics and the Legalization of Physician-Assisted Suicide (Ann Intern Med. 2017;167:576-8)

Physician–Industry Relations

• Conflicts of Interest
• Sponsored Research

Physician Open Payments (Sunshine Rule) This ACP webpage provides guidance and related tools for physicians on the Physician Payment Sunshine Rule (also referred to as the National Physician Payment Transparency Program, or Open Payments). The Open Payments system, implemented by the Centers for Medicare and Medicaid Services (CMS) in 2015, provides a mechanism for the public reporting of physician and teaching hospital financial relationships with industry.

Physician–Industry Relations. Part 1: Individual Physicians (Ann Intern Med. 2002;136:396-402)

Physician–Industry Relations. Part 2: Organizational Issues (Ann Intern Med. 2002;136:403-6)

Practice Models, the Business of Medicine and the Changing Practice Environment

• The Changing Practice Environment
• Financial Arrangements

Ethics, Professionalism, Physician Employment and Health Care Business Practices CME/MOC

Banning Harmful Health Behaviors as a Condition of Employment: Where There's Smoke There's Fired? CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Wellness Programs and Patient Goals of Care CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Obligations and Opportunities: The Role of Clinical Societies in the Ethics of Managed Care (J Am Geriatr Soc. 1998;46:378-80)

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices CME (Ann Intern Med. published online 15 March 2021)

Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices (Ann Intern Med. 2015;163:949-52)

The Patient-Centered Medical Home: An Ethical Analysis of Principles and Practice (J Gen Intern Med. 2013;28:141-6)

Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond (ACP. 2010)

Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto (Ann Intern Med. 2007;147:792-4)

Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care—An Ethics Manifesto (ACP. 2007) (This publication is a longer version of the position paper above.)

Medical Professionalism in the Changing Health Care Environment: Revitalizing Internal Medicine by Focusing on the Patient–Physician Relationship (ACP. 2005)

Ethics in Practice: Managed Care and the Changing Health Care Environment (Ann Intern Med. 2004;141:131-6)

Selling Products Out of the Office (Ann Intern Med. 1999;131:863-4)

Prescription Drug Abuse

Prescription Drug Abuse (Ann Intern Med. 2014;160:198-200)

• Professionalism

American College of Physicians Pledge (ACP. 1982 [updated; original 1924]) The ACP Pledge is taken by new Fellows at Convocation at each Internal Medicine annual meeting. The Pledge affirms the physician’s membership in an ethical and moral community dedicated to healing, comfort, and altruism.

Physician Charter on Professionalism

Medical Professionalism in the New Millennium: A Physician Charter (Ann Intern Med. 2002;136:243-6)

Ethical and Professionalism Implications of Physician Employment and Health Care Business Practices (Ann Intern Med. published online 15 March 2021)

• ACP Professional Accountability Principles (ACP. March 2018)

Professional Attire and the Patient-Physician Relationship CME/MOC (ACP Ethics Case Studies Series. CME and MOC by Medscape. 2020)

Addressing a Colleague's Unprofessional Behavior During Sign-Out CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Dealing with the "Disruptive" Physician Colleague CME (ACP Ethics Case Studies Series. CME by Medscape. 2009)

Professional Well-being and Ethics

• The Impaired Physician

Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community CME/MOC

When an Aging Colleague Seems Impaired CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Physician Suicide Prevention and the Ethics and Role of a Healing Community: An American College of Physicians Policy Paper (J Gen Intern Med. 2021 Sep;36(9):2829-2835)

Physician Impairment and Rehabilitation: Reintegration Into Medical Practice While Ensuring Patient Safety (Ann Intern Med. 2019;170(12):871-879.)

ACP’s Physician Well-being and Professional Satisfaction initiative aims to foster a culture of wellness, reduce administrative burdens on physicians, improve practice efficiency and enhance individual physician well-being. The project website includes tools and programs for individual members, their practices, and ACP Chapters.

Research Ethics and Human Subjects

Research Sections within the chapter include “Protection of Human Subjects,” “Use of Human Biological Materials in Research,” “Placebo Controls,” “Innovative Medical Therapies,” “Scientific Publication,” “Sponsored Research” and “Public Announcement of Research Discoveries.”

Responsible Conduct of Research (RCR) Project

Under a grant from the Association of American Medical Colleges and the DHHS Office of Research Integrity, ACP Ethics staff has implemented member education and support programs on the responsible conduct of office-based research. Workshops have been presented at ACP's annual meeting as well as at several ACP chapter meetings.

Research in the Physician's Office: Navigating the Ethical Minefield (Hastings Cent Rep. 2008)

Volunteering for a Research Study? Talk with Your Doctor About What You Should Know This patient education brochure provides information and guidance to patients who are considering volunteering for a research study. The brochures are designed to facilitate conversations between doctors and their patients. They are intended for distribution in doctors’ offices and come in packages of 50. Access the brochure order form .

Author! Author! Who Should Be Named in a Published Study? An Ethics Case Study CME (ACP Ethics Case Studies Series. CME by Medscape. 2014)

When are Industry-Sponsored Trials a Good Match for Community Doctors? CME (ACP-ASIM Observer. 2001)

Research Ethics Training Resources

• Revised Common Rule Educational Materials , Department of Health and Human Services
• The Research Clinic , Office of Research Integrity, Department of Health and Human Services
• Responsible Conduct of Research (RCR) , Research Ethics and Compliance Training, CITI Program
• Responsible Conduct of Research Training , Office of Intramural Research, National Institutes of Health
• HIPAA Training and Resources , Department of Health and Human Services
• Online Ethics Center for Engineering and Science ,University of Virginia
• World Association of Medical Editors (WAME)
• Council of Science Editors (CSE)
• European Association of Science Editors (EASE)

ACP supports National Academies’ call for withdrawal of Notice of Proposed Rulemaking (NPRM) for ‘Common Rule’ and for appointing a new commission (Dec. 31, 2015) ACP issued a statement in support of the National Academies' call for withdrawal of the Common Rule NPRM and for appointing a new research ethics commission.

ACP Comments on Notice of Proposed Rule Making (NPRM) (Dec. 31, 2015) ACP submitted comments to the Office for Human Research Protections of the U.S. Department of Health and Human Services on the Notice of Proposed Rule Making, "Federal Policy for the Protection of Human Subjects," also known as the Common Rule. ACP also submitted an earlier round of comments on the proposed rule making on Oct. 25, 2011.

NEW Scientific Integrity and Disinformation -->

Ethics and Academic Discourse, Scientific Integrity, Uncertainty, and Disinformation in Medicine: An American College of Physicians Position Paper (Ann Intern Med.doi:10.7326/M24-0648)

Stewardship of Health Care Resources

"Physicians have a responsibility to practice effective and efficient health care and to use health care resources responsibly in practicing high-value care. Parsimonious care that utilizes the most efficient means to effectively diagnose a condition and treat a patient puts the patient first but also respects the need to use resources wisely and to help ensure that resources are equitably available" (Ethics Manual, seventh edition).

Conflicting duties? The physician's primary duty, first and foremost, is to the individual patient. She or he must advocate for the patient—in a health care system that grows more and more complex by the year—based on the best interests of the patient. But the physician also should use health care resources responsibly and efficiently. Are these duties in conflict? The Ethics Manual and ethics case studies explore these issues and provide help in sorting them out.

Is it rationing? Parsimonious care is not rationing. The goal of medical parsimony is to provide the care necessary for the patient's good on the basis primarily of evidence-based medicine. Although this may have the welcome side effect of preserving resources, reducing resource use is not the intent. It is this difference in intent and action that helps provide a foundation for the ethical distinction between parsimonious medicine and rationing.

• Resource Allocation

ACP’s High Value Care Project aims to improve health, avoid harms, and eliminate wasteful practices. The project website offers learning resources for clinicians and medical educators, clinical guidelines, best practice advice, case studies and patient resources on a wide variety of related topics.

Patient Requests for Specific Care: 'Surely You Can Explain to My Insurer That I Need Boniva?' CME (ACP Ethics Case Studies Series. CME by Medscape. 2018)

Who Should Get What? Mammography and the Stewardship of Health Care Resources CME (ACP Ethics Case Studies Series. CME by Medscape. 2012)

The following ethics case studies were developed through an award from the ABIM Foundation's Putting the Charter into Practice project. Watch a video report of the ACP's work on this project presented by Dr. David Fleming, former President of the College.

Stewardship of Health Care Resources: Allocating Mechanical Ventilators During Pandemic Influenza CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Stewardship of Health Care Resources: Responding to a Patient's Request for Antibiotics (ACP Ethics Case Studies Series. CME by Medscape. 2014)

Teaching, Training and the Hidden Curriculum

• Attending Physicians and Physicians-in-Training

Resident Duty Hours: To Hand Over or Gloss Over? CME (ACP Ethics Case Studies Series. CME by Medscape. 2017)

Hidden Curricula, Ethics, and Professionalism: Optimizing Clinical Learning Environments in Becoming and Being a Physician (Ann Intern Med. 2018;168:506-8)

CME/MOC activities based on this ACP position paper are available:

Annals offers two CME/MOC activities:

Ethics, Professionalism, and the Hidden Curriculum (Click on “CME/MOC” on the left sidebar.)

Annals On Call – Hidden Curriculum

In this Curbsiders Podcast , Sanjay Desai, MD, coauthor of ACP’s position paper and Internal Medicine program director at Johns Hopkins, reviews several cases that illustrate how institutional norms can shape the practice of medicine. Detailed summaries of the cases discussed are available here .

Archived Ethics Position Papers

Health Information Technology & Privacy (July 2011)

Cognitively Impaired Subjects (November 1989)

• Ethics Position Papers by Publication Date