Bioethics, Medical Ethics and Health Law

UNESCO Chair in Bioethics 10th World Conference on
Bioethics, Medical Ethics
and Health Law
Zefat Bioethics Forum
Program and Book of Abstracts
Crowne Plaza Hotel
Jerusalem, Israel
January 6-8, 2015
ISAS International Seminars • POB 574, Jerusalem, Israel • Tel: +972-2-6520574
[email protected] • www.bioethics-conferences.com
Program at a Glance
Tuesday, January 6, 2015 0900‐1030 HALL A Bioethics: General (1) 1030‐1100 1100‐1230 1230‐1330 1330‐1500 Coffee Break Opening Session Lunch Break Bioethics: General (2) 1500‐1630 Bioethics: General (3) 1630‐1700 1700‐1830 Coffee Break Bioethics: General (4)
1900 HALL B Medical Ethics HALL C Ethics: General (1) HALL D Psychiatry, Ethics and Law HALL E Medical Law (1) Military Medical Ethics
Ethics: General (2) Research (1) Medical Law (2) Military Law and Ethics Ethics: General (3) Research (2) Medical Law (3) Ethics: General (4) Research (3) Medical Law (4) HALL B Bioethics: Education (1)
HALL C Ethics: General (5) HALL D Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (1)
HALL E Psychology, Ethics and Law Bioethics: Education (2)
Ethics: General (6) Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (2) Emotional
Intelligence and Ethics for Effective Treatment
Bioethics: Education (3)
Ethics: General (7) Ethics and Regulation of Inter‐
Country Medically Assisted Reproduction (3) Ethics and Regulation of Inter‐
Country Medically Assisted Reproduction (4) Issues in Psychology, Law and Ethics in Israel
Ethical and Legal Issues in Medical Rehabilitation Welcome cocktail and Get‐together dinner Wednesday, January 7, 2015
0900‐1030 HALL A Bioethics: General (5) 1030‐1100 1100‐1230 Coffee Break Bioethics: General (6) 1230‐1330 1330‐1500 Lunch Break Bioethics: General (7) 1500‐1630 Bioethics: General (8) Bioethics: Education (4)
Hunger Strike of Prisoners 1630‐1700 1700‐1830 Coffee Break Bioethics: General (9) Bioethics: Education (5) End of Life (1) Assisted Reproduction (1) Medical Law (5) 1930
Gala farewell dinner and folkore evening
HALL C Bioethics: General (10) HALL D Assisted Reproduction (2) HALL E (1) ‫מושב בעברית‬
Technology Dependent Children: The Implication on Longevity and Quality of Life
Thursday, January 8, 2015 0900‐1030 HALL A Medical Law (6)
HALL B End of Life (2) 1030‐1100 1100‐1230 Coffee Break Medical Law (7)
1230‐1330 Lunch Break
1330‐1500 Ethics of Mental First Aid & First Aid Organizations End of Life (3) Gnawing Ethical Conundra
‫מושב דיאטניות‬
‫ועדות אתיקה‬
‫במערכת הבריאות‬
‫ אתגרים‬:‫בישראל‬
‫והצלחות – ניסיון‬
‫מהשטח‬
Ethics Dilemmas in Pain (2) ‫מושב בעברית‬
‫ מקומם של בני‬: ‫סדנה‬
‫המשפחה בתהליך הדיון‬
‫האתי‬
- ‫תקשורת אנושית‬
‫ רגש והתנהגות‬,‫מוח‬
‫)אינטליגנציה רגשית‬
(‫והיבטים אתיים‬
(3) ‫מושב בעברית‬
TABLE OF CONTENTS
UNESCO Chair in Bioethics, Unit Heads, Departments and Sponsors
4
Message from the Conference President
5
Call for Establishment of New Bioethics Units
6
General Information
7
UNESCO Chair in Bioethics – International Forum of Teachers
8
Scientific Program
10
Abstracts (alphabetical order by author)
Oral Presentations
17
Hebrew Presentations
81
Poster Presentations
87
Authors Index
93
UNESCO Chair in Bioethics
Prof. Carmi Amnon, President
Organizing Committee
Scientific Committee
Dr. Blachar Yoram, Chair
Dr. Atrakchi Dalit
Dr. Avnad Yitzchak
Mrs. Cohen Ilana
Prof. D’Sousa Russell
Dr. Eidelman Leonid
Prof. Kaplan Ruth
Dr. Kloiber Otmar
Prof. Knobler Haim
Mr. Kovachev Bogdan
Prof. Noguchi Thomas
Dr. Vasinova Miroslava
Prof. Linn Shai, Chair
Prof. Ashkenazi Shai
Prof. Bitterman Haim
Dr. Blackmar Jeff
Dr. Hildesheimer Galya
Dr. Hirschfeld Miriam
Prof. Kaplan Ruth
Prof. Kasher Asa
Dr. Kaufman Galit
Prof. Kitaee Eliezer
Prof. Knobler Haim
Dr. Mungherera Margaret
Prof. Porath Avi
Adv. Seebholm Annabel
Prof. Steinberg Avraham
Ms. Suipyte Jorune
Prof. Tabak Nili
Dr. Wagner Nurit
Adv. Wapner Leah
Dr. Weiss Dorit
Heads of Units
Albania: Dr. Altin Stafa
Argentina: Prof. Moty Benyakar
Armenia: Dr. Susanna Davtyan
Australia: Dr. Irina Pollard
Austria: Prof. Gabriele Werner Felmayer
Azerbaijan: Prof. Vugar Mammadov
Brazil: Prof. Jose Thome
Bulgaria: Prof. Sashka Popova
Canada: Prof. Joel Lamoure
China: Prof. Zhen Li
Colombia: Prof. Andrea Hellemeyer,
Prof. Gina Lorena Garcia Martinez
Croatia: Prof. Suncana Roksandic Vidlicka
Czech Republic: Prof. Tomas Dolezal
Fiji: Ms. Sharon Biribo
Finland: Dr. Helena Siipi
France: Prof. Frederique Claudot
Germany: Prof. Dr. Nils Hoppe
India: Prof. Dinesan N., Dr. Junaid Rahman,
Prof. Dr. P. Thangaraju, Dr. D. Balakrishnan
India, Calicut: Dr. C. Raveendran,
Dr. Jayakrishnan Thavody
India, Central New Delhi: Dr. Smita N. Deshpande
India, Gujarat: Dr. Barna Ganguly
India, Mangalore: Dr. Animesh Jain
India, Manipal: Dr. Mary Mathew
India North: Prof. Mushtaq Margoob,
Prof. Rafiq Ahmad Pampori
India South: Dr. Princy Louis Palaty
India, Tamilnadu: Dr. Kuryan George
India West: Prof. Anu Kant Mital
Indonesia: Prof. Siti Pariani
Israel: Prof. Shai Linn, Prof. Michael Tal
Italy: Dr. Miroslava Vasinova
Japan: Prof. Mitsuyashu Kurosu
Macedonia: Prof. Mentor Hamiti
Malaysia: Prof. Dato Mohd Zin bin Bidin
Nepal: Prof. Dr. Rupa Rajbhandari Singh
Nigeria: Dr. Victoria Nanben Omole
Pakistan: Prof. Rizwan Taj
Philippines: Dr. Rhodora C. Estacio,
Prof. Agnes D. Mejia
Poland: Prof. Joanna Rozynska,
Prof. Anna Alichniewicz, Prof. Monika Michalowska
Romania: Prof. Sandu Frunza
Russian Federation:
St. Petersburg: Dr. Galina Mirtikichan
Volgograd: Prof. Natalia Sedova
Serbia: Prof. Vojin Rakic
South Africa: Adj. Prof. Ames Dhai
Spain: Prof. Julian Valero-Torrijos,
Prof. Maria Magnolia Pardo-Lopez
Sri Lanka: Dr. Harischandra Gambheera
Taiwan: Prof. Daniel Fu-Chang Tsai
Ukraine: Dr. Radmila Hrevtsova
USA: Dr. Harold J. Bursztajn, Dr. Terry Bard
Vietnam: Prof. Nguyen Duc Hinh,
Dr. Tran Thi Thanh Huong
Asia Pacific Bioethics Network:
Prof. Russell D’Souza
4
MESSAGE FROM THE CONFERENCE PRESIDENT
For the first fifty years of bioethics we discussed the construction and development of its concept.
The original idea slowly gained its directions and followers, and constitutes a comprehensive
perception concerning many issues that are critical for our human society. We are now facing a
second stage, a new task, that seems to be even more important, complex and difficult, namely
the delivering of our message to society, by planting the ethical values into the soul of the people
and into their daily life and behavior.
Our task may be and should be realized in two ways, by two different tools: An educational tool
and a legal tool. The educational tool will consist of the use of novel methods that will enable us
access to the minds of potential “consumers” – the students, the caretakers, the patients and the
public at large. The theory and language of bioethics should be translated and adopted by the
legislator and the judiciary, and constitute the legal tool.
A concrete example can be found in the Universal Declaration of Bioethics and Human Rights of
UNESCO, and its application by the UNESCO Chair in Bioethics. The UNESCO Declaration includes 15
ethical principles that have been approved and accepted by all the states worldwide. Our UNESO
Chair in Bioethics was authorized to deliver the message of the Declaration to the students all over
the world. The first step has been made. We have published ten guidance books for teachers and
have established not less than 51 Units in 42 academic institutes on five continents. Each Unit is
committed to the advancement of ethics education in its university and around its country.
The experts that attend our conference in Jerusalem are expected to undertake this mission, to
start the second step and to establish additional units in their own institutes. You have the
knowledge and the close contact to the field of bioethics, you understand its relevance and
importance, you have the tools, the wisdom and the courage to motivate this process.
Let the Conference in Jerusalem function and serve as the bioethical lighthouse for the next
generation.
Prof. Amnon Carmi
Zefat Academic College
5
The UNESCO Chair in Bioethics promotes
A Call for the Establishment
of New Bioethics Units
You are invited to establish a new UNIT at your Institute!
The United Nations Educational Scientific and Cultural
Organization (UNESCO) established (2001) the
UNESCO Chair in Bioethics
The purpose of the CHAIR is to build, activate, co-ordinate and
stimulate an International Network of Units in Academic
institutes for ethics education.
The Chair has established until now 51 Units in 42 countries in
the five Continents.
If you wish to establish a new UNESCO Unit in your own institute
you may forward your application to:
[email protected]
For more details, guidelines and list of other Units, see:
www.unesco-chair-bioethics.org
6
GENERAL INFORMATION Conference Venue: Jerusalem Crowne Plaza Hotel Givat Ram, Jerusalem Telephone: +972‐2‐6588888 Information Desk: Jerusalem Crowne Plaza Hotel Lobby Early registration: January 5, 2015 – 17:00‐19:00 January 6‐8 – during conference hours Press Office: Dr. Giacomo Sado, +39 335 57 89671 or at the conference information desk Social Events: Welcome get‐together cocktail and dinner Tuesday, January 6, 2015 Jerusalem Crowne Plaza Hotel ‐ 19:30 Price: $65 Gala farewell dinner and folklore evening Wednesday, January 7, 2015 Jerusalem Crowne Plaza Hotel ‐ 19:30 Price: $70 Performing in the hotel ballroom after the gala dinner will be the Jerusalem Folklore Ensemble – founded in 1955 in Jerusalem by students of the Hebrew University, the Rubin Music Academy and Bezalel School of Arts. Today it is one of Israel’s leading Folklore groups. The ensemble is a voluntary nonprofit organization. The program is a selection of dances, songs and melodies of Israel and Jewish Folklore. The show features ethnic folklore of Jewish communities from Yemen, Persia, Turkey, North Africa, The Balkans, Romania, Poland and Russia. The group took part in many Folklore Festivals in Asia, Africa, Europe and the Americas. It has gained many international prizes and medals (such as “Le Collier D’or” Dijon, France). Accompanying Persons: Accompanying persons do not have entry to lecture halls. The registration fee includes the welcome get‐together cocktail and dinner and the gala farewell dinner and folklore evening. Tours and Hotel Accommodations: For tours, please contact Eran Brill at 03‐516‐6699. For hotels, please contact Atar Krauss at 052‐243‐0025; or contact the hospitality desk on January 6. Certificate of Participation: A certificate of participation will be supplied upon request. Access to lecture rooms: Your registration fee includes entry to sessions, conference program and book of abstracts, and coffee breaks. Seating is on a “first‐come, first‐served” basis. We recommend you go to the lecture room well before the session starts. Safety regulations require us to limit access to the session if the room is filled to capacity. A sweater or jacket is recommended, as the conference rooms may be cool. Name badges: Your personal name badge serves as your passport to the scientific sessions. Participants are expected to wear their badges visibly at all times. No badge = no entry. Badge replacement costs $25. Poster presentations should be put up in the lobby area from 08:00‐09:00 on the morning of presentation. A hostess will be available to help attach the posters each morning until 10:00. Posters must be removed at the end of the day. The Organizers will not be responsible for posters that have not been collected. Note: ISAS International Seminars and all sponsors shall not be responsible for and shall be exempt from any liability in respect of any loss, damage, injury, accident, delay or inconvenience to any person, or luggage or any other property for any reason whatsoever, for any tourist services provided. Personal travel and health insurance is recommended. Conference Secretariat: ISAS International Seminars • POB 574, Jerusalem 91004, Israel • Tel: +972‐2‐6520574 [email protected] • www.bioethics‐conferences.com 7
UNESCO Chair in Bioethics International Forum of Teachers Statutes The Steering Committee of the International Network of the UNESCO Chair in Bioethics discussed, decided and announced the establishment of the Chair's International Forum of Teachers in its Annual Meeting that was held on the 18 November, 2013, in Naples, Italy. Article 1: The Forum a. The International Forum of Teachers (referred to hereinafter as the "IFT") will be part of the Education Department of the International Network of the UNESCO Chair in Bioethics. b. IFT will consist of teachers that have been admitted pursuant to the requirements of these Statutes. c. English is the working language of IFT. d. The office of IFT shall be located in the country of residence of the Director. Article 2: Aims a. The aim of the IFT is to form and activate an organ that will function as a mechanism for the realization of the objectives and activities of the IFT. b. To collect, unite, involve and activate teachers of bioethics, ethics and medical law. c. To promote and advance the study, discussion and teaching of bioethics, ethics and medical law. d. To address any matters that involve issues of bioethics, ethics or medical law. Article 3: Activities The IFT will pursue its aims by, inter alia: a. Promoting and advancing synergies and co‐operation among its members; b. Facilitating exchange of experience and information of programs and projects; c. Developing and distributing educational programs and materials; d. Initiating and organizing meetings; e. Initiating and organizing courses and seminars; f. Initiating and encouraging compilation, publication and translation of professional materials; g. Establishing committees to deal with specific issues; h. Pursuing other means harmonious with the aims of IFT. Article 4: Membership a. Membership of IFT shall be open to all who have graduated from a university or equivalent academic institution, who are or were involved in teaching of bioethics, ethics or medical law, and who are interested in the fulfillment of the aims of IFT. b. An application for membership + a CV shall be addressed to the Director. The Director will verify that the application complies with Article 4(a) and will refer it to the President. c. The decision to admit a teacher to the IFT is made by the President and the Director. d. The refusal of membership shall be decided by the Council. e. The Steering Committee is entitled to bestow honorary membership. f. The Steering Committee is entitled to bestow Senior Membership titles. g. Membership shall terminate upon resignation, expulsion decided by the Council or death. h. A register of membership shall be kept under the authority of the Director. i. Members of the IFT shall be entitled, inter alia, to: 1. Attend and vote in person at the Assembly; 2. Stand for election to the Council; 3. Be appointed to IFT committees; 4. Enjoy specific benefits, rights and reduced fees available only to members of the IFT j. The Assembly is entitled to decide about the imposition of dues. 8
Article 5: Structure The organs of the IFT shall be the Assembly, the Council, the President, the Director, the Steering Committee and the committees. Article 6: The Assembly a. The Assembly shall be made up of currently members of the IFT. Each member shall have one vote. A member's vote shall be cast only in person. b. Extraordinary meetings of the Assembly may be convened by the Council or the Steering Committee. c. The Assembly shall meet ordinarily on the occasion of the world congress of the Chair. d. The agenda of the Assembly shall include the reports of the President, the Director, and the Chairperson of the Council, the election of the President, the Director, the members of the Council and the Steering Committee. The agenda will include the determination of membership dues and additional issues as proposed by a member of the Steering Committee. e. All decisions from the Assembly will be made with absolute majority of the valid votes. The President has a casting vote. Article 7: The Council a. The Council shall consist of not more than thirty members. b. The Assembly shall elect members of the Council for a two‐year period. Members of the Council shall be eligible for no more than two successive re‐elections. c. Candidatures for the Council shall be addressed to the Director at least three months before the commencement of the next world congress. d. The Council will prepare the Assembly. The Council will carry out the resolutions of the Assembly. The Council will develop activities with a view to realizing the IFT's aims. e. The Council may delegate any of its powers to the Steering Committee. Article 8: The Steering Committee a. The Steering Committee shall consist of the President, the Director and additional three members. b. The Steering Committee shall run the daily management of the IFT. The Steering Committee through the Director shall inform the members of the IFT activities, provide them with advice on request, and assist them when possible. Article 9: The President a. The President shall be eligible for re‐election as long as he or she is ready to do so. b. The President shall convene and chair the meetings of the Assembly, the Council and the Steering Committee. In the absence of the President the chair will be taken by the Director, and in the absence of the later by a member of the Steering Committee. Article 10: The Director a. The Director shall be eligible for re‐election as long as he or she is ready to do so. b. The Director shall take minutes of the proceedings of the various meetings, issue notices to the members, and conduct correspondence. The Director shall submit periodic report on activities to the Council. c. The Director shall exercise the day‐to‐day management of the IFT, as well as powers delegated by the Council and the Steering Committee. Article 11: Amendment of the Statutes All of the articles of these statutes may be amended by approval of the Assembly by a resolution adopted by a two‐
thirds majority of those present. Article 12: Dissolution The IFT will be dissolved through: a. A decision made by the Assembly. b. The complete absence of members. c. A decision made by the Head of the UNESCO Chair in Bioethics 9
Scientific Program ‐ Tuesday, January 6, 2015 08:00‐09:00: Registration 09:00‐10:30: Parallel Sessions HALL A HALL B Bioethics: General (1) Medical Ethics
Chair: D. Flescher Co‐Chair: S. Dejavsarov How not to run a vaccine program: Ethical issues and transparency Diana Flescher, Israel MOMA call center for monitoring and treatment Sara Dejavsarov, Israel Bioethical aspects of activities of the Heydar Aliyev Foundation Anar Alakbarov, Azerbaijan HALL C Ethics: General (1) Chair: Y. Blachar Co‐Chair: T. Karni The ethical roadblocks to medical tourism Elinor Goshen, Israel Chair: J. Lamoure Co‐Chair: V. Rakic Can moral bioenhancement be moral? Vojin Rakic, Serbia Freedom of expression versus respect for the Ethical considerations profession regarding evidence‐
Baruch Chen, Israel based medicine: Does one size fit all? Mass prisoner hunger Joel Lamoure, Canada strike in 2014: From theory to practice Do quality improvement Tami Karni, Israel (QI) activities need The role of the physician in approval by institutional review board (IRB) or "reality TV" are they an ethical Malke Borow, Israel obligation inherent to Vaccination of health any clinical activity? professionals Mayer Brezis, Israel Leah Wapner, Israel
HALL D Psychiatry, Ethics & Law
HALL E Medical Law (1) Chair: S. Wolfman Co‐Chair: R. Abramson Bioethical dilemmas in assessing causality in psychiatry Samuel Wolfman, Israel Chair: T. Doležal Co‐Chair: T.T. Noguchi Personal injury compensation in Czech Republic and the international classification of functioning, disability and health Tomáš Doležal, Czech Republic Ethical treatment in psychiatry Anthony Dinnen, Australia Some problems in medical ethics in modern psychiatric practice Ronald Abramson, USA “EU”, short form for “Ethical” Union? The role of ethics in European Union law Markus Frischhut, Austria A woman's right to The evolution of the abort a viable fetus To be or not to be a live objective cause concept Pnina Lifshitz‐Aviram, Israel kidney donor: A parent’s from the psychiatric and personal principle ‐ cause Overview of the US legal points of view for patient’s death quality assurance Marija Emilija Kukubajska, Roberto Mester, Israel program for health care Macedonia Thomas T. Noguchi, USA
10:30‐11:00: Coffee Break 11:00‐12:30: Opening Session Chair: Prof. Amnon Carmi, President of the Conference Welcome Greetings Dr. Xavier Deau, President, World Medical Association Prof. Thomas Noguchi, President, World Association of Medical Law Dr. Dafna Feinholz, Chief, Bioethics and Ethics of Science and Technology Section, UNESCO Mr. Nir Barkat, Mayor of Jerusalem Prof. Arnon Afek, Director General, Israel Ministry of Health Judge (ret.) Prof. Eliezer Rivlin, Chairman, Board of Governors, The International Center of Health, Law and Ethics Prof. Aharon Kellerman, President (ret.), Zefat Academic College Dr. Leonid Eidelman, Chairman, Israel Medical Association Opening Speeches The ethical side of Health Technology Assessment (HTA) Dr. Xavier Deau, President, World Medical Association Ethical dilemmas and moral duties of a hospital director Prof. Jonathan Halevy, Director General, Shaare Zedek Medical Center 12:30‐13:30: Lunch Break 13:30‐15:00: Parallel Sessions HALL A HALL B HALL C HALL D HALL E Bioethics: General (2) Military Medical Ethics: General (2) Research (1) Medical Law (2) Ethics
Chair: Z. Lederman Chair: M. Tal Chair: T. Chelouche Chair: P. Thangaraju Chair: F. Aliyeva Co‐Chair: S.M. Eagan Co‐Chair: Co‐Chair: R. Halpin Co‐Chair: M. Hamiti Co‐Chair: V. Mammadov Chamberlin M. Botbol Baum Force‐feeding hunger Conflict of interest between Malpractice, personal Bioethics and the Ethical issues in strikers: Humane or the institutional goals for damage & medical Holocaust: Teaching medical fields liability lessons from the past inhumane treatment? advancement of knowledge Rupa Rajbhandari and institutional ethics ‐ S. Davide Ferrara, Italy for future healthcare Mirko D. Garasic, Israel Singh, Nepal issues and solutions professionals Moral responsiblity Italian regulation of P. Thangaraju, India Tessa Chelouche, Israel during atrocities: The The use of fMRI for advance directives: Yuana Ken Case Study Compulsory vaccination and Legal comparison with research outside the The Jewish ethical the collective good: Going Zohar Lederman, other Western hospital setting response to beyond a civic duty? Singapore European countries Michael Tal, Israel bioethical dilemmas Nicola Glover‐Thomas, UK Denard Veshi, Albania Instrumentalization in the Holocaust Midwives’ experiences on the Capabilities as a of medicine: The The rights of disabled Alan B. Jotkowitz, Israel physician‐soldier & use of partogram in the challenge to justice as people in Azerbaijan management of women during equality, Helsinki's Republic Primum non nocere v. civilian medical care labour at Limpopo, S. Africa Sheena M. Eagan revisions and the Fatima Aliyeva, caveat emptor Chamberlin, Germany Thanyani G. Lumadi, South Africa violence of Azerbaijan Ross Halpin, Australia Ethical dilemma in the use of benevolence Political hunger Protection of public information technology The Biological Will™‐ strikes and force‐
Mylene Botbol Baum, health is in the focus of Mentor Hamiti, Macedonia
A paradigm in fertility feeding: An Belgium the state alternative view Irit Rosenblum, Israel Leading the change in medical Vugar Mammadov, Yechiel Barilan, Israel practice Azerbaijan Petar Chavdarovski, Bulgaria 10
Scientific Program ‐ Tuesday, January 6, 2015 15:00‐16:30: Parallel Sessions HALL A HALL B Bioethics: General (3) Military Law and Ethics Chair: D. Mishori Co‐Chair: M. Mullen The controversy over medical cannabis in Israel: Science, ethics and democracy Daniel Mishori & Zach Klein, Israel Under the regulation radar: Strategies and tactics of pharmaceutical companies to promote drugs and medical products in Israel Yaffa Shir‐Raz, Israel Negotiating away health? Legal and ethical implications of the Trans Pacific Partnership (TPP) and the Trans Atlantic Trade & Investment Partnership (TTIP) Elizabeth Wiley, USA Chair: L. Zhen Co‐Chair: W. Chen The study and analysis of confidentiality in the forensic identification Canping Wang, China The principles of fairness and justice in forensic investigation and identification work analysis Wenwubei Chen, China The study of the national customs in forensic identification Keran Li, China The application of public security, procuratorial policemen health survey in ethnic minority areas in Yunnan Province Xuecheng Liu, China
Ethical and socio‐historical challenges in providing health services to Inuit children and youth: Lessons for implementing health services in developing regions Michelle Mullen, Canada 16:30‐17:00: Coffee Break 17:00‐18:30: Parallel Sessions HALL A HALL B Bioethics: General (4)
Ethical and Legal Issues in Medical Rehabilitation Chair: E. Thorne Chair: A. Ohry Co‐Chair: A. Jain Co‐Chair: I. Treger Ebola virus and Ethical issues in infectious disease: The rehabilitation medicine duty of physician to cure Avi Ohry, Israel and the possible risks – the halachic dilemma Malpractice in Cesare Efrati, Italy rehabilitation medicine Iuly Treger, Israel Gender discourses and bioethics What should be the Angela Aparisi, Spain desired medical expertise when Evasion of one’s own evaluating plaintiff's rules: Implications for functional disability and ethical harmonization needs? Emanuel Thorne, USA Avi Rubinstein, Israel 19:30: Welcome cocktail and get‐together dinner HALL C Ethics: General (3) Chair: I. Zilberstein Co‐Chair: O. Lev Does directing patients to additional private physical therapy care provoke ethical dilemmas? Ilana Zilberstein, Israel Israeli code of ethics for practitioners of occupational health Raz Dekel, Israel Assisted reproductive technologies and parenting rights in a Jewish democratic state: The case of the Ova Donation Law Ori Lev, Israel Doctor competencies in medical ethic & effective communication skill among the alumni of faculty of medicine Universitas Airlangga Agung Pranoto, Indonesia HALL D Research (2) HALL E Medical Law (3) Chair: C.P.H. Myburgh Co‐Chair: V. Rahimzadeh Disclosing incidental findings in pediatrics: Health professional perceptions and insight Vasiliki Rahimzadeh, Canada Chair: M. Levy Co‐Chair: J. G. Makama Patients’ perception and actual practice of privacy & confidentiality in surgical outpatient departments of general hospitals, Kaduna, Nigeria Jerry G. Makama, Nigeria The impact of animal violence in the human violence Gina Lorena García M., Colombia The guilty innocence of consumers Pasqualino Santori, Italy The organ shortage and its consequences: Legal and ethical reflections on state incentives as possible remedies Melanie Levy, Israel HALL C Ethics: General (4) Chair: R. Gilbar Co‐Chair: M. I. Siebzehner Law, bioethics and medical decision‐
making: The impact of culture Roy Gilbar, Israel HALL D Research (3) HALL E Medical Law (4) Chair: D. Fu‐Chang Tsai Co‐Chair: J. Kuře Procedural ethics: Tensions between social sciences and biomedical sciences Séverine Colinet, France Chair: Z. Todorović Drugs funding and rationalization, in healthcare systems Carla Barbosa, Portugal Neuroethics in drug development Zoran Todorović, Serbia Ethical considerations in legal representation of people under guardianships in medical procedures Meytal Segal‐Reich, Israel How ethical are researchers during the practical implementation of research procedures? C.P.H. Myburgh, South Africa The rationale of the European Union human embryonic stem cell research funding Jana Zuscinova, Slovakia Governance and ethical regulation of human research in sub‐Saharan Africa: A systemic review of published studies from 1980 to 2014 Muhammed Suraj Yusuf, Nigeria Individual patient rights & new bio‐technologies in medicine Sanja Jovanovska, Macedonia The morality of deportation of sick illegal immigrants Miriam I. Siebzehner, Israel Doctors as bystanders during the Indigenous Australian genocide Peter Honeyman, Australia Capacity assessment in health care professionals – A major challenge in an aging society Yoram Maaravi, Israel 11
Developing joint ethics review mechanism for multi‐center clinical trial in Taiwan: Experience & reflection for two year result Daniel Tsai, Taiwan The ethical challenges of conducting a population‐
based screening for non‐
communicable diseases in a setting with limited universal health coverage Fatima L. Ciroma, Nigeria Research ethics committees: From theory to practice and back again Josef Kuře, Czech Republic Scientific Program ‐ Wednesday, January 7, 2015 08:00‐09:00: Registration
09:00‐10:30: Parallel Sessions HALL A HALL B Bioethics: General (5) Bioethics: Education (1)
Chair: M. Lupton Eliminating prenatal sex selection? The global agenda and national action plans Johanna Kostenzer, Austria “Dr.” Watson: AI, ethics, and the future of medicine Amy DeBaets, USA The ethical and legal consequences of converging biotechnologies Michael Lupton, Australia Chair: D. Balakrishnan Co‐Chair: S. Davtyan A vertically integrating model for teaching bioethics to under‐
graduate medical students D. Balakrishnan, India Chair: E. Richter Co‐Chair: A. Prokopiou Medical ethics and genocide: Troubling unmet challenges Elihu Richter, Israel Ethics of chronic pain control; a grey area of Problems and doctors’ power perspectives in bioethics Andreas Prokopiou, Cyprus education in the CIS countries Ubuntu: Alterity as a Susanna Davtyan, Armenia perspective for peace Problem formation of Flora Strozenberg, Brazil the ethical regulators of the physician Implications of professional activities ubiquitous use of smart Alena Donika, Russia spectacles or digital eyeglasses Knowledge and Sody Naimer, Israel attitudes of medical students concerning opiophobia – a cross sectional study Milica Prostran, Serbia
10:30‐11:00: Coffee Break 11:00‐12:30: Parallel Sessions HALL A HALL B Bioethics: General (6) Bioethics: Education (2)
Chair: E. Toader Co‐Chair: D. Sotirova Moral exclusion: Implications for bioethics Daniela Sotirova, Bulgaria Migration of doctors and multiculturality in the global context Elena Toader, Romania Human right, human responsibility and social responsibility in the communicable disease control Siti Pariani, Indonesia HALL C Ethics: General (5) Chair: S. Popova Co‐Chair: N. Sedova Bioethics in the training and management of sport Iva Miteva, Bulgaria Teachers of bioethics in search of new perspectives Sashka Popova, Bulgaria Ethnic bioethics in education Natalia Sedova, Russia Less talk – more action: Teaching ethics to Generation Y Zahava Davidow, Israel Teaching bioethics and human rights through cinema and popular TV series: A methodological approach Juan Jorge Michel Fariña, Argentina HALL C Ethics: General (6) Chair: S. Kottek Co‐Chair: C. Greenberger Jewish medical ethics: On physicians' prayers – devotion to the Lord, devotion to the patient Samuel Kottek, Israel The ethics of clinical judgment and medical intuition in the writings of Moses Maimonides Kenneth Collins, Israel Enteral nutrition in end of life: The Jewish halachic ethic Chaya Greenberger, Israel When religion and medicine intersect: The example of taharat hamishpacha Deena R. Zimmerman, Israel 12:30‐13:30: Lunch Break 12
HALL D 08:30‐10:30 Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (1)
Chair: C. Shalev Can we see the baby bump please? SAMA Resource Group for Women and Health, New Delhi, India FILM & discussion Capabilities approach for mutual fellowship in commercial surrogacy Sheela Saravanan, Germany Commodification of the female body: An anthropological view Adi Moreno, UK HALL E Psychology, Ethics and Law Chair: A. Quitz Co‐Chair: E. Katzenelson Interdisciplinarity: The role of the psychologist in the doctor‐patient relationship: Information and demand Patricia Oliveira, Argentina Cultural blindness: Potential pitfalls for psychologists, psychiatrists & pediatricians when diagnosing Ethiopian children Edna Katzenelson, Israel Psychological aspects of moral decision: Violations of professional discretion in Former East Germany (DDR) Andrea Quitz, Germany
Ethical implications of modification of traumatic memories Marcia Sokolowski, Canada HALL D Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (2) Chair: T. Eldar‐Geva Concepts of identity and related ethical issues in third‐party assisted reproduction Gabriele Werner‐Felmayer, Austria The rights of the child: A welfare principle applied to children born in transnational surrogacy arrangements Marsha J. Tyson Darling, USA Concerns about women in international child protection conventions Rhona Schuz, Israel From Baby M to Baby M(anji): Regulating international surrogacy agreements Yehezkel Margalit, Israel HALL E Issues in Psychology, Law and Ethics in Israel
Chair: M. Zaki Issues in psychology, law and ethics in Israel Moshe Zaki, Israel Principles of psychological assessment of parental competence in the Muslim ‐ Arab society in Israel Emad Gith, Israel Bio‐ethical issues concerning clinical neuro‐
psychology in general, and mainly in damages claims in cases of brain injury Chanan David, Israel In the worst interests of the child: Using non‐
validated psychological tools in child custody disputes Israel Oron, Israel Dilemmas concerning custody for high conflict divorce with a focus on early childhood Iris Berent, Israel Scientific Program ‐ Wednesday, January 7, 2015 13:30‐15:00: Parallel Sessions HALL A HALL B Bioethics: General (7) Bioethics: Education (3)
Chair: W. Canping Co‐Chair: Li Zhen The application of bioethics principle on forensic medicine Li Zhen, China The study and analysis on the principle of respect in the forensic investigation and identification Shuboqing Huang, China A paternity case with multistep microsatellite mutations in locus D5S818 Hong Liang, China The study and analysis on the principle of informed consent in the forensic identification Lv Duan, China Chair: V. Nanben Omole Co‐Chair: J. Hellmann Ethical issues arising from a comparative study of performances in two entrance examinations for medical undergraduate admission into a Nigerian University Victoria Nanben Omole, Nigeria Using innovative methods to inculcate ethical thinking and behaviour among health science students Animesh Jain, India Bioethics education of a diverse student group: Development of a curriculum Jonathan Hellmann, Canada Learning medical law and bioethics through an interprofessional experience – The Zefat legal clinics project Oren Asman, Israel 15:00‐16:30: Parallel Sessions HALL A HALL B Bioethics: General (8) Bioethics: Education (4)
Chair: V. Trigueiro Santos Adinolfi Co‐Chair: A. Alichniewicz Bioethical controversies – Personal dignity, homo economicus and commercialization of body Anastasia Zakariadze, Georgia Human enhancement and narrative self Anna Alichniewicz, Poland Human enhancement and morality: Some doubts Nenad Cekić, Serbia HALL C Ethics: General (7) Chair: A. Oyefabi Co‐Chair: L. Zur‐dovrat The autonomy question of the prostitution: An integrative model Renana Leviani, Israel Child marriage in Nigeria: A violation of human rights Awawu Grace Nmadu, Nigeria Willingness to treat infectious diseases: Comparing two distinctive medical schools Avram R. Shack, Israel Ethical issues in knowledge, perceptions and exposure to hospital hazards by patient relatives in a tertiary institution in North Western Nigeria Adegboyega Oyefabi, Nigeria HALL D Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (3) Chair: S. Kahn Surrogacy, the debate in Israel and France in cultural and historical perspectives Etienne Lepicard, Israel Moving towards an international convention on surrogacy and artificial reproduction: Is it time? Debra Wilson, New Zealand Mothering for money: Regulating international intimacy Pamela Laufer‐Ukeles, USA Epigenetics and the Assisted Reproductive Technologies Irina Pollard, Australia HALL E Emotional Intelligence and Ethics for Effective Treatment
Chair: D. Keidar Patient's rights law and culturally competent nursing care: An Israeli perspective Rabia Khalaila, Israel Emotional intelligence, ethics and ties between them Daniella Keidar, Israel
Ethics & professionalism: One and the same ethics workshop for physiotherapists and occupational therapists Lihi Zur‐dovrat, Israel HALL C Hunger Strike of Prisoners HALL D Ethics and Regulation of Inter‐Country Medically Assisted Reproduction (4) Chair: M. Benyakar Co‐Chair: M. Vasinova Chair: S. Glick Co‐Chair: R. Aroni Chair: G. Werner‐Felmayer Workshop for clinical ethics case conference – how should it be held? Mitsuyasu Kurosu, Japan Force feeding hunger strikers in the Jewish law Yisrael Katz, Israel Clinical courses in open distance learning. Is it ethically sound? Critical care nursing perspective Maria Moleki, South Africa Force‐feeding hunger‐
striking prisoners‐
another view Shimon Glick, Israel A parent or a gamete donor? Legal consequences of an unsettled debate Judit Sándor, Hungary Research data about teaching bioethics through cinema and TV series: House MD Moty Benyakar, Argentina Bioethics approach in engineering formation Youth bioethics project Valeria Trigueiro Santos Miroslava Vasinova, Italy Adinolfi, Brazil 16:30‐17:00: Coffee Break The right not to die: Who decides what constitutes autonomy, quality of life and futile treatment in a culture of ageism Rosalie Aroni, Australia 13
Fertility policy in Israel: From exemplary local practice to a global model Etti Samama, Israel Ethics and regulation of inter‐country medically assisted reproduction (ERIMAR) – A call for action Carmel Shalev, Israel The adoption of Buddhism’s Principles as means of improving physicians’ work with terminally ill patients Ruth Wolf, Israel The role of the Israeli courts in formulating the physician‐patient relationship Limor Malul, Israel Ethical dilemmas in physician‐patient relationship in multi‐cultural society Rotem Waitzman, Israel HALL E Technology Dependent Children: The Implication on Longevity and Quality of Life
Chair: Z. Hillel‐Diamant An overview of the needs of technology‐
dependent children in 2015 Eliezer Be'eri, Israel Ethical considerations in pediatric physical therapy Julie Smerling‐Kerem, Israel Beyond my body’s limits: Imagination in service of children with severe multiple disabilities Shifra Wohlgelernter, Israel Scientific Program ‐ Wednesday, January 7, 2015 17:00‐18:30: Parallel Sessions HALL A HALL B Bioethics: General (9) Bioethics: Education (5) Chair: B.P. White Co‐Chair: I.A. Joshua Treating dementia and multiculturalism: Exploring the perceptions of multicultural professional caretakers in Israel regarding autonomy and human dignity Miriam Bentwich, Israel Chair: O. Karnieli‐Miller When law, ethics, professionalism and psychology come alive: Teaching medical students an integrated course based on real‐life medical case Orit Karnieli‐Miller & Gad Cohen‐Rappaport, Israel Environmental refugees ‐ Electrohypersensitives (EHS) in the digital world – a disabled population, deprived of home, work and basic rights Yael Stein, Israel Case study and problem base methodology in bioethics education Irine Zarnadze, Georgia Promoting bioethics in the high school level by integrating the case‐
based approach to ethical decision‐making model Richard Deanne Sagun,
Philippines The expanded and evolving role of the ethics committee in a Planetree patient and family‐
centered environment Bernard Paul White, USA Children in armed conflicts and child Breaking bad news, soldiers in Africa: Human ethics & communication rights and ethical issues in the movies Istifanus Anekoson Ruth Kannai, Israel Joshua, Nigeria 19:30: Gala farewell dinner and folkore evening HALL C End of Life (1) HALL D Assisted Reproduction (1) HALL E Medical Law (5) Chair: C. Ding Co‐Chair: B. Broeckaert Withdrawal of life‐
sustaining treatment: A comparative analysis of mainland China, Taiwan and Hong Kong Ding Chunyan, Hong Kong Ripple effect of simulation training for end‐of‐life care Meir Frankel, Israel Belgian Muslims and end of life ethics Bert Broeckaert, Belgium Ethical dilemmas in the electronic medical era: An inter‐religious comparison Yitschak Copperman, Israel Chair: T. Le Xuan Co‐Chair: T. Katz Peled Reproductive ethics, rights and evolving Israeli legislation Yardena Cope‐Yossef, Israel Chair: D. Greenbaum Co‐Chair: N. Eyal Decreased mental capacity jeopardizes decision making process of patients in critical condition Ehud Shalmon, Israel Ethical, legal and social implications of new and emerging technologies: Exoskeletons Dov Greenbaum, Israel Development of patient rights and health care legislation policy in Georgia Shalva Zarnadze, Georgia Defending “Big Brother MD”: The ethics of electronic adherence monitoring in Uganda Nir Eyal, USA Pick‐Up babies ‐ surrogacy in the developing world: New technologies, old exploitation Tamar Katz Peled, Israel Reforming the law on surrogacy in Vietnam Tung Le Xuan, UK Reproductive rights, poverty & development Martha Miranda, Colombia Scientific Program ‐ Thursday, January 8, 2015 08:00‐09:00: Registration
09:00‐10:30: Parallel Sessions HALL A HALL B Medical Law (6)
End of Life (2) Chair: M. Ottonello Co‐Chair: F. Adiri Knowledge, attitude and practice of informed consent by medical doctors in a teaching hospital in Zaria, Northwest Nigeria Farouk Adiri, Nigeria Chair: D. Sperling Co‐Chair: I. Milinkovic Views on end of life situations as expressed by first‐degree relatives of patients in a vegetative state Ittai Dayan, Israel In defense of suicide tourism (ST) Daniel Sperling, Israel Disease awareness and quality of health information on clinical procedures: Observational study in patients with cancer and ALS Marcella Ottonello, Italy Patients’ perceived to their rights to information and its implementation in healthcare Ivan Rahmatullah, Indonesia Can prevention of eating disorders be regulated? Israel's "Modeling Act" as a case study Galya Hildesheimer & Hemda Gur‐Arie, Israel 10:30‐11:00: Coffee Break On ethical places: The practice of ‘terminal discharge’ in clinical settings and the good death in Taiwan Yicheng Chung, Japan Legal treatment of the right to a dignified death in Bosnia & Herzegovina: Legal and ethical issues Igor Milinkovic, Bosnia and Herzegovina HALL C Bioethics: General (10) HALL D Assisted Reproduction (2) Chair: D. Chemtob Co‐Chair: R. Veselska When only the wealthy recover: The medical ethics of addiction treatment and recovery Constance Scharff, USA National Ethics Committee on HIV/AIDS – the Israeli experience Daniel Chemtob, Israel Who owns our dead bodies? Renata Veselska, Czech Republic An Italian court ruling: “Autism is caused by MPR vaccine” Alessandra Pentone, Italy Chair: N. Salomé Lima Co‐Chair: R.Haimov‐Kochman Bioethics and its promethean challenge Natacha Salomé Lima, Argentina 14
Pre‐implantation genetic diagnosis for sex selection for non‐medical reasons: Position statement of the ethics committee of the Israel Fertility Society Ronit Haimov‐Kochman, Israel To what extent does a surrogate have real autonomy? Julia Feuer, Israel Communicating with sufferers: Lessons from the Book of Job Joseph Tham, Italy Cross‐border reproductive care: The case of pre‐implantation genetic diagnosis (PGD) Shachar Zuckerman, Israel HALL E (1) ‫מושב בעברית‬
‫ נילי טבק‬:‫יו"ר‬
‫רכיבים אפיסטמיים בביסוס‬
‫מוסרית‬-‫גישה טיפולית‬
‫בסיטואציות‬
‫קונפליקטואליות‬
‫אלה קורן‬
‫האחות בפסיכיאטריה‬
‫ סוהר או סוכן‬,‫משפטית‬
‫טיפול סיעודי? כפל‬
‫הנאמנות של אחות‬
‫בפסיכיאטריה‬
‫נוי‬-‫דור בר‬
:‫להתריע או לא להתריע‬
‫הגישה ההלכתית יהודית‬
‫חיה גרינברגר‬
‫טעויות בטיפול והסיעוד‬
‫חיה רז‬
‫עמדות של אחיות מוסמכות‬
‫אקדמיות כלפי אתיקה‬
‫בפרסום מדעי‬
‫נילי טבק‬
Scientific Program ‐ Thursday, January 8, 2015 11:00‐12:30: Parallel Sessions HALL A HALL B Medical Law (7)
End of Life (3) Chair: P. Apinis Co‐Chair: S. Zuckerman Some of medical ethical aspects of Eastern Europe after the collapse of the USSR Peteris Apinis, Latvia
Ethical considerations of using off label medical treatments and medications in disasters Shlomit Zuckerman, Israel Personal integrity, informed consent and human tissues/organ transplantation after Petrova versus Lithuania: Considerations from the Spanish legal system María Magnolia Pardo‐López, Spain Chair: P. Louis Palatty Co‐Chair: M. Gordon Determinants of ‘end of life’ decision making: A qualitative approach (patient/caregiver perspective) Princy Louis Palatty, India Rites and rituals of dying: A shift to medical technology Michael Gordon, Canada Ethical issues in the prolongation of life in the terminally ill Anu Kant Mital, India Last rights: End of life decisions in Canada Mark Handelman, Canada HALL C 11:00-13:30 HALL D 10:30‐12:30 ‫מושב דיאטניות‬
(2) ‫מושב בעברית‬
‫ אירית פורז‬:‫יו"ר‬
‫ועדות אתיקה במערכת‬
:‫הבריאות בישראל‬
– ‫אתגרים והצלחות‬
‫ניסיון מהשטח‬
‫ נעמה ויצ'נר‬:‫יו"ר‬
‫ קוד אתי‬:‫פתיחה‬
?‫ למה‬,‫לדיאטניות‬
‫אירית פורז‬
‫ועדת האתיקה במרכז‬
‫הרפואי לגליל המערבי‬
‫אירית ויסמן‬
‫דילמות אתיות בטיפול‬
‫התזונתי בקרב‬
‫מאושפזים‬
‫ ענבל‬,‫הילה זהרוני‬
‫ עפרה גולן‬,‫צוריאלי‬
‫הוועדה המוסדית לפי‬
‫חוק החולה הנוטה‬
‫למות במרכז הרפואי‬
‫רבין‬
‫שלומית פרי‬
‫משתנים המשפיעים על‬
‫התמודדות אנשי הצוות‬
‫הרפואי עם פטירת‬
‫תינוק במחלקה לטיפול‬
‫נמרץ בילוד‬
‫סופיה דומבה‬
‫תדמית הגוף ומקומה‬
‫במבנה האישיות‬
‫חנן דוד‬
‫פרטיות המידע הרפואי‬
‫בעידן רשתות חברתיות‬
‫שולמית אוחנה‬
‫ התנהגות‬,‫ רגש‬,‫מוח‬
‫ופסיכיאטריה‬
‫חיים קנובלר‬
‫השוואת הקוד האתי של‬
‫דיאטניות בישראל לקוד‬
‫האתי של דיאטניות‬
‫ תהליך בניה‬,‫בעולם‬
‫והטמעה‬
‫יוספה כחל‬
‫ועדת האתיקה של‬
‫מכבי‬
‫עפרה גולן‬
‫עמדות ותפיסות כלפי‬
‫אנשים עם עודף‬
‫השמנת יתר‬/‫משקל‬
‫בקרב פיזיותרפיסטים‬
‫מוסמכים‬
‫מיכל אלבוים גביזון‬
‫המרכז הבינלאומי‬
‫ משפט‬,‫לבריאות‬
‫ואתיקה‬
‫אמנון כרמי‬
Ethical dilemmas in the "Protective Edge" Operation Uria Moran, Israel 12:30‐13:30: Lunch Break 13:30‐15:00: Parallel Sessions HALL A HALL B Ethics of Mental First Aid Gnawing Ethical & First Aid Organizations Conundra
Chair: E. Jaffe Co‐Chair: E. Sharon Ethical dilemmas in the prevention of PTSD among volunteers responding to trauma Haim Y. Knobler, Israel Suicide prevention in emotional first aid services: Ethical dilemmas Itzhak Gilat, Israel A revised ethical code for an association of mental first aid Shiri Daniels, Israel ‫ועדת האתיקה הארצית‬
‫ ואיידס‬HIV‫ל‬
‫דניאל שם טוב‬
‫דיון וסיכום‬
HALL C Ethics Dilemmas in Pain You know it is torture when there is official terror Barry Roth, USA How tightly are pain medicine and moral standards related to each other? Elon Eisenberg, Israel Moral injury Mark F. Poster, USA Institutional approach of autistic children. A contribution from bioethics and psychoanalysis Carlos Tewel, Argentina ‫ עדי ליברטי‬:‫יו"ר‬
,‫ מוח‬- ‫תקשורת אנושית‬
‫רגש והתנהגות‬
‫)אינטליגנציה רגשית‬
(‫והיבטים אתיים‬
‫ דניאלה קידר‬:‫יו"ר‬
‫פתיחה וברכות‬
‫דניאלה קידר‬
‫דיון כללי‬
‫ידע ועמדות של אחיות‬
‫בתי חולים כלליים ביחס‬
‫לטיפול באסירים‬
‫כבולים‬
‫דורית רובינשטיין‬
Chair: M. Tal Decision making in settings of uncertainty Terry Bard, USA HALL F ‫דילמות אתיות‬
‫בבריאות וההקשר הרב‬
‫תרבותי‬
‫שרה ניסים‬
Chair: T. Bard HALL E Ethical dilemmas in the management of pain Alan Rubinow, Israel Towards a rational approach to the ethics of pain Z. Harry Rappaport, Israel Pain, consciousness and the cerebral cortex Marshall Devor, Israel * Subject to last minute amendments
15
HALL D 13:00-15:00 HALL E ‫ מקומם של בני‬: ‫סדנה‬
‫המשפחה בתהליך הדיון‬
‫האתי‬
‫ גילה יעקב‬:‫מנחה‬
(3) ‫מושב בעברית‬
‫ מקומם של בני‬: ‫סדנה‬
‫המשפחה בתהליך הדיון‬
‫האתי‬
‫תשאול צוות רפואי לגבי‬
‫ היבטים‬:‫אלימות במשפחה‬
‫אתיים וחוקיים‬
‫מירב בן נתן‬
‫ נילי טבק‬:‫יו"ר‬
‫קדושת החיים ובדיקות סקר‬
‫עפ"י פסקי הלכה של גדולי‬
‫הרבנים בישראל בדור‬
‫האחרון‬
‫מנחם חיים ברייר‬
‫הטמעת הקוד האתי בקרב‬
‫סטודנטים לסיעוד‬
‫עדי ליברטי‬
Poster Presentations
New models of public health research: Developing an ethical framework for research using surveillance data in resource limited countries Evelyn Anane‐Sarpong, Switzerland Psychological e‐volunteering among Russian speakers Olga Bermant‐Polyakova, Israel Heterologous in vitro fertilisation now admitted in Italy: Constitutional court’s judgment n. 162/2014 abolished the ban of involve gametocytes outside the couple Pietro Ferrara, Italy Ethical decision making and patient autonomy views among the nursing staff Shani Fisher, Israel The bioethics of compulsory treatment determined by a court order Gabriel José Gauer, Brazil Dermatological ethical problems of personalized medicine Irina Krainova, Russia The Italian information system for monitoring errors in healthcare Luigi Tonino Marsella, Italy Lawsuits related to the health in Brazil – a truly “factory” of indemnification for moral damages Paulo de Argollo Mendes, Brazil Behavioural subjects in the public health studies: Historic parallels and modern alternatives Vanina Michaylova, Bulgaria The waiting game: Is it time to change the rules? An ethical proposal to legalise a regulated system of kidney sales Erica Morris, UK Ethical issues in paediatric physiotherapy practice: A survey of physiotherapists in Ghana Bertha Oppong‐Yeboah, Ghana E‐Health: The necessary balance between effectiveness of the health system and protection of fundamental rights María Magnolia Pardo‐López, Spain Adolf Sannwald – enemy casualty How a notation can turn the worth of a German pastor into the wickedness of a Nazi evil Alessandra Pentone, Italy Mitochondrial replacement therapy and parenthood Daniel Sperling, Israel 16
Abstracts
Oral Presentations
Abstracts of Oral Presentations
PROTECTION OF PUBLIC HEALTH IS IN THE FOCUS OF THE STATE Adila Abbasova1, Mahammad Bazigov1, Vugar Mammadov2, Ilgar Mammadov3 1
Department of Social Policy Legislation of the Parliament of Azerbaijan Republic 2
Heydar Aliyev Center, Azerbaijan Bioethics and Medical Law Association, Azerbaijan Unit of International Network of UNESCO Chair in Bioethics 3
Ministry of Justice, Azerbaijan Republic [email protected] In recent years improvement of normative legal base on health and its raise to international level was constantly in the center of attention. For this purpose a number of laws were developed and adopted by the Parliament. Adoption of main Law on “Protection of health of population” of Azerbaijan Republic in 1997, which regulates created relations between state bodies, as well as governmental and non‐governmental subjects of health system, and citizens in the field of protection of health became a very important event in the history of Azerbaijan healthcare. One of the priority directions of protection of health of population is implementation of preventive measures. Laws “On Sanitary‐epidemiological well‐being”, “On Fight against tuberculosis in Azerbaijan Republic”, “On Prevention of AIDS”, “On Salt iodization”, “On Nutrition of infants and minors”, “On State care for persons suffering from inherited blood diseases ‐ hemophilia and thalassemia” and others serve namely in the preventive measures. At the same time legislative acts are adopted for the purpose of treatment of various diseases and medical‐social assistance to the patients under certain diseases (tuberculosis, diabetes, iodine deficiency, HIV virus, hereditary blood diseases, multiple sclerosis etc.). In order to ensure more efficient spending of funds allocated to health sector from state budget the preference is given to adoption of state programs like “On chronic kidney insufficiency”, “On hereditary blood diseases thalassemia and hemophilia”, “On Diabetes”, “On provision of cancer patients with basic antineoplastic drugs”, “On immunoprophlaxis of infectious diseases”, “On protection of health of mother and children”, “On development of blood, blood components donation and blood services”. SOME PROBLEMS IN MEDICAL ETHICS IN MODERN PSYCHIATRIC PRACTICE Ronald Abramson Tufts University School of Medicine, USA [email protected] In recent years the field of psychiatry has drifted toward an orientation in its teaching and treatment approaches that might best be termed “biological reductionism. This is the notion that all mental disorders or even mental experiences can be reduced to neuronal, genomic, or other biological activity. Mental disorders are considered to be brain diseases. The dominant supported psychotherapies are grounded in concrete cognitions and prescribed concrete exercises. This concrete rationalistic orientation lends itself to treatment approaches that emphasize mostly the prescription of medications done in the context of infrequent visits to psychiatrists and short term cognitive and behavioral psychotherapies oriented toward concrete goals. There is no room in this approach for appreciation of the life story of a patient as well as developing an understanding of how the patient experiences his/her own conceptual and perceptual 19
world. This way of thinking lends itself to mass production maintenance treatments which do not have much promise in helping patients who have these illnesses toward recovery. Yet there is a basis in science which supports the reality of subjective mental experiences. There are experiments in quantum physics that suggest that the consciousness of the experimenter can affect the outcome of the experiment. Some physicists have come to believe that consciousness is a fundamental property of the universe. Others have suggested that the universe is organized in levels of organization and causality and that consciousness occupies a different level from the underlying neurological level that supports it. In this presentation, these ideas will be spelled out and clinical examples will be given that document the ethical inadequacies of the currently dominant biological reductionistic approach in psychiatry. KNOWLEDGE, ATTITUDE AND PRACTICE OF INFORMED CONSENT BY MEDICAL DOCTORS IN A TEACHING HOSPITAL IN ZARIA, NORTHWEST NIGERIA Farouk Adiri1, Bilkisu Gulma2, Istifanus Joshua1, Grace Nmadu1 1 Kaduna State University, Nigeria 2
Ahmadu Bello University, Nigeria [email protected] The study was aimed at assessing the knowledge, Attitude and Practice of informed consent among medical doctors in Ahmadu Bello University Teaching Hospital, Zaria in Northwestern Nigeria. A descriptive cross‐sectional study design was used to select 185 medical doctors in March 2011 in a tertiary center of excellence and referral in Northwestern Nigeria. A multi‐stage sampling technique was used to select the respondent. Data was collected using self administered pre‐coded, pre‐tested questionnaire. The data was cleaned and analyzed using Statistical Package for Social Sciences version 17. The results were presented in tables and charts. The study showed 49.7% of the respondents were within the age group 30‐39 years, mean age of 33 years, 75.7% were males, in pediatrics department (31.4%) and house officers (33.5%) with 5 years of experience or less (44.9%). About 47% of respondents had good knowledge of informed consent. There was a statistically significant association between the respondents knowledge and the years of experience at p<0.05. Ninety‐seven (97.0%) percent of the respondents had good attitude towards informed consent but only 74% admitted to have given informed consent forms or secured informed consent during the previous one year of practice. The age and mental status of patients or their proxy was identified as criteria for competency to give informed consent (27.6%). There was a poor knowledge of informed consent among medical doctors. Therefore, there is need for healthcare administrators to increase awareness and sensitization of doctors while improving practice through training. BIOETHICAL ASPECTS OF ACTIVITIES OF THE HEYDAR ALIYEV FOUNDATION Anar Alakbarov Heydar Aliyev Center, Azerbaijan aal@heydar‐aliyef‐foundation.org The Heydar Aliyev Foundation’s numerous activities of recent years reflect the issues of tolerance, non‐discrimination, human rights, human dignity, equality, cultural diversity, pluralism, social responsibility, care of future generations, ecology, sustainable development, and other issues, which in the assemblage 20
UNESCO Chair in Bioethics 10th World Conference
constitute universal bioethical values. Their implementation promotes social‐economic development of the country. Numerous projects realized by the Heydar Aliyev Foundation, which was founded in 2004, cover, first of all, fields of science and education, public health, social sphere, culture and environment. These projects now are strongly supported by Heydar Aliyev Center, state organization created by Decree of the President of Azerbaijan Republic for support of such kind of social and humanitarian projects aimed for development of country for future generations. All this issues represent high significance from bioethical point of view. The Heydar Aliyev Foundation paying much attention to the general development of science and other fields is actively contributing to creation of favorable conditions for international dialogue, cooperation with international organizations. Thus, on initiative of Mrs. Mehriban Aliyeva, the President of the Heydar Aliyev Foundation, UNESCO and ISESCO Goodwill Ambassador, the First Lady of Azerbaijan Republic and with direct support of the Heydar Aliyev Foundation the 18th Session of the UNESCO International Bioethics Committee was held in Baku in May, 2011 and highly appreciated by UNESCO officials. Holding of this Conference promoted development of bioethics in Azerbaijan, raising public interest and creating grounds for scientific researches in the country. Implementation of the universal bioethical principles declared by the UNESCO Universal Declaration on Bioethics and Human Rights can be traced as the leitmotif of the Heydar Aliyev Foundation’s activities. Thus, activities in the field of public health such as building of medical institutions, implementation of charity actions aimed at ensuring of one of most significant human rights – right to health, protecting patients rights, reflect implementation of the universal bioethical principle of social responsibility and health. Various activities promoting cultural dialogue, including organizing of different exhibitions, cultural festivals reflect the bioethical principle of respect for cultural diversity and pluralism. Projects in the field of social sphere and activities in the field of education and science, including building of different‐type new schools, including boarding schools, kindergartens, secondary schools, reconstruction of the old buildings of schools, can be considered as the implementation of bioethical principles of human dignity and human rights, sharing of benefits, equality, justice and equity and others. In recent years Foundation’s and Heydar Aliyev Center’s activities aimed at environment protection are increasing responding to Article 16 “Protecting future generations” and the Article 17 “Protection of the environment, the biosphere and biodiversity” of the Universal Declaration on Bioethics and Human Rights. HUMAN ENHANCEMENT AND NARRATIVE SELF Anna Alichniewicz, Monika Michałowska Medical University of Łódź, Poland [email protected] In our presentation we address the alleged threat posed by human enhancement to personal identity. First, we analyze the main meanings of human enhancement developed by its advocates and critics. The first meaning of human enhancement we present has been developed by John Harris in “Enhancing evolution”, where he argues that human enhancement is “change for the better” implied by a moral obligation of self‐
improvement. An opposite view is claimed by Francis Fukuyama and Norman Daniels, who treat human enhancement as a threat to human nature that is our common heritage and therefore should be protected. Also, in Habermas’ opinion human enhancement threatens personal autonomy, since genetically enhanced people cannot consider themselves as “the sole authors of their own history”. Secondly, we present the narrative concept of personal identity developed by Charles Taylor and Alasdair MacIntyre. According to Taylor, we achieve the understanding of selfhood only and “inescapably in narrative”, the structure of narration is a meaningful wholeness assigning significances and values to the events of our lives. The individual narration unfolds itself in the social narration and draws meanings and values from the social frameworks. Social narration changes over time and the changing framework involves also the development of medicine and biotechnology. In our conclusions we argue that like some medical novelties have been incorporated into this ongoing process to become a common medical practice with time, also human enhancement could be embraced by social narration and become an element of the framework within which the individual self tells his/her meaningful life‐story. THE RIGHTS OF DISABLED PEOPLE IN AZERBAIJAN REPUBLIC F. Aliyeva, A. Aliyeva Baku State University, Azerbaijan [email protected] The democracy set up and expanded to the deepest stages of society by our National Leader Heydar Aliyev allows the protection of human rights in Azerbaijan. Firstly, the laid limitations were removed; wide group of society became the active players in the processes in society. Today disabled people who were considered as forgotten group at one time are integral part of our society. Disabled people have freedom and personal immunity rights in society as each person. It is allowed and made opportunities to protect the disabled people from discrimination, to expand the employment opportunities, to study with other people and to realize their intellectual, creative, physical potentials as full‐fledged and equal members of society, as well as most social welfares of disabled people. There is law on disabled people, as well as relevant official documents on social protection of disabled people. This law defines the state policy on disabled people in Azerbaijan. It ensures the participation of disabled people in economical, social and political fields of society life with other citizens. Disabled people in Azerbaijan have all social‐economical, political, personal rights and freedoms stipulated in declaration of rights of disabled people adopted by UNO General Assembly, in the Constitution of Azerbaijan Republic and other legislative acts. Discrimination of disabled people in Azerbaijan is forbidden and prosecuted by legislation. Note that, Azerbaijan joined the Convention on “The rights of disabled people” of UNO on October 02, 2008. It is defined the necessity of making opportunities to disabled people for having equal rights and executing these rights in most applicable legislative acts in Azerbaijan Republic. Analysis shows that many works in the direction of the solution of problems of disabled people were done, necessary legislative acts served for the integration of society and the protection of these people were improved, new laws, significant state programs were adopted over the past period. GENDER DISCOURSES AND BIOETHICS Angela Aparisi University of Navarra, Spain [email protected] The purpose of the paper is to present some of the contributions of the gender discourse to the bioethical debate, specifically in Abstracts of Oral Presentations
the field of nursing. At the same time, it will explain the contribution of the different feminist theories to the recognition and respect of human dignity. Basically, it will describe three fundamental models in the gender discourse: the egalitarian model, the difference model, and the model of equality in difference (also called reciprocity or responsibility). The starting point is that even though the first two models have made significant contributions in the field of bioethics, they have nonetheless brought with them some deficiencies and reductionisms inherent in their thinking. The model of reciprocity, on the contrary, when properly understood, allows for the combination of the principles of equality and difference between man and woman, which places it at a much more enriching standpoint within the bioethical debate. SOME OF MEDICAL ETHICAL ASPECTS OF EASTERN EUROPE AFTER THE COLLAPSE OF THE USSR Peteris Apinis World Medical Journal of the WMA, Latvia editorin‐[email protected] After the collapse of the USSR in 1991, a number of new sovereigns were either founded or consolidated in Eastern Europe, which until then were part of the USSR or the Warsaw pact. The former USSR countries were unified in their socialist economics and in the ideological USSR health care system headed by Semashko. As to the countries in Eastern Europe, though governed by state capitalism, socialist economics and communist ideology, they still enjoyed somewhat more freedom, and also health care development allowed certain modifications. Under socialist health care model, physicians’ training used to be quite good, though concise (six years of study + one year in internship according to specialisation field). To get qualifications of a physician was prestigious; therefore there was enormous competition to get enrolled in study programmes. Indirectly, Stalin's belief was: “People will feed a good doctor, and there is no use to pity a bad one”, therefore medical staff had very low wages, keeping in back of the mind that doctors would receive direct, unofficial, yet quite legal payments from the patients. Lengthy in‐patient treatment was characteristic to socialism, because hospitals also had a social function, especially in the cold season elderly and lone people stayed in hospital for months. Stalin's medicine was subject to war‐time doctrine, when there is high demand in mediocre‐trained medical staff, and this is why the number of physicians and medical staff relative to the number of population was much above the average figures in Western Europe. The principles of medical ethics were guided by the paternal relationship between the doctor and the patient, which voiced “the doctor knows everything, and the patient is supposed to take his pills”. Rather small notice was paid to prevention; use of alcohol and smoking was openly propagated. At the same time, the socialist order assured a perfect prevention of diseases, e.g., vaccination was done at nearly 100% rate, and any opposition to a child's vaccination could be a reason to invite a parent to security authorities in the capacity of a person endangering public order. This is the socialist past which lies in the foundation of ethical problems we are facing in the post‐socialist environment at the beginning of the 21st century. The collapse of the USSR was followed by an overall widespread economic crisis, leading to patients' treatment with medication and bandaging materials donated as human aid. Computer tomography, radiological diagnostic equipment was in every place: the equipment had served is life in the Western Europe or the USA, and was removed and transported to Eastern Europe. In this situation, 21
quite a few clinical trials of drugs were done, because pharmaceutical companies gave drugs, and there were no alternative drugs available, and also the purchasing capacity of patients was too low to afford medicines. Formerly in the USSR, nearly all analogues were manufactured in own factories, however, the factories were closed in mid‐90s, because they were not able to comply with GMP, were short of supplies, equipment, financing. 90s and also the first five years of the 21st century are also characterised by unobstructed collaboration of pharmaceutical companies with physicians, who were paid small amounts of money for each prescription and given presents for treating patients with specific drugs, and a blatant dictate of pharmaceutical sector in medicine. The Helsinki principles established more firmly only in 2006‐2009 after the countries of Eastern Europe and the Baltics had joined the European Union, when the European ethical standards emerged. Since 1990, the life expectancy of the population of the Baltic states has increased by 7.5‐9 years. The society is ageing, very many young people are working in the Western Europe, birth rate has declined. The care for chronic patients dominates in medicine, the causes of mortality are cardiovascular and oncological diseases and accidents. The attitude of the government to preventive measures has changed (success in tobacco product restriction, encouragements to eat healthy food). The awareness of patients has increased greatly. In the field of ethics, an informed patient has emerged who is further educated by the physician before starting a manipulation or a treatment. The main ethical problem in awareness is correct, accurate and unbiased information in electronic mass media, free of any influence from pharmaceutical companies and other groups with business interests. THE RIGHT NOT TO DIE: WHO DECIDES WHAT CONSTITUTES AUTONOMY, QUALITY OF LIFE AND FUTILE TREATMENT IN A CULTURE OF AGEISM Rosalie Aroni Monash University, Australia [email protected] Currently in Australia the discussions about potential legalization of doctor assisted suicide have taken place within a set of simplified narratives about “dying with dignity” with a focus on autonomy of the patient as the underlying ethical concern. These discussions have not only taken place in broad policy arenas, hospital boards and the media but also in faculties tasked with educating the next generation of clinicians. The introduction of futile treatment policies and the marketing of “advance care directives” in Australian acute care public hospitals (predicated on quality of life and health care rationing arguments) has framed both debate and research. What has not been adequately investigated is the way in which such policies have been implemented either formally or informally. Similarly, the views of patients with chronic illness and/or disabilities, their families and clinicians and the legal fraternity about such modes of implementation have not been critically examined. This presentation provides several case studies which highlight the ways in which competing interpretations of quality of life, resuscitation options and treatment utility are framed in bioethics and sociological discourses which have underpinned clinical and legal decisions. This includes the ways in which reason and ageism form part of these competing discourses and how the key stakeholders view what constitutes reasonable evidence upon which to make such decisions. The relationship 22
UNESCO Chair in Bioethics 10th World Conference
between health care access, casemix funding and these competing framings of evidence is also presented. LEARNING MEDICAL LAW AND BIOETHICS THROUGH AN INTERPROFESSIONAL EXPERIENCE – THE ZEFAT LEGAL CLINICS PROJECT Oren Asman Zefat Academic College, Israel [email protected] The "Zefat Patients rights legal clinic", is an Educational Program initiated at the Zefat Academic College Law school in collaboration with the Ziv Medical Center and the Technion Medical School ethics forum, now already in the middle of its fourth year of operation. This program is based on an interprofessional collaboration of experts from the health field and from the ethical and legal fields. This is done under the assumption that in the sphere of Medical Law and Bioethics, collaborative work between Philosophers, ethicists, lawyers and health care professionals such as physicians, nurses, social workers, hospital managers and risk managers is an important factor in improving ethics based clinical decision making and legal reasoning. The program now operates using its unique instructive methods of “A shared learning community” and “field based inquiry” which prove to be of important educational value. The presentation refers to: 1. Outlines of the program, general topics and teaching methods, target audience 2. Short term and long‐term goals of this program and others similar to it. 3. Evaluation of the program and its effectiveness over the past years. Based on this description, we conclude that such programs are of importance, not only for the students attending but also to the professionals collaborating as teachers and guides, and to the promotion of an inter‐organizational collaboration between their respective organizations. A VERTICALLY INTEGRATING MODEL FOR TEACHING BIOETHICS TO UNDERGRADUATE MEDICAL STUDENTS D. Balakrishnan1, P. Thangaraju1, Russell D’Souza2 1
UNESCO International Chair on Bioethics, SRM University, India 2
Asia Pacific Chair, UNESCO Bioethics Network [email protected], [email protected] The patient‐doctor relationship, traditionally, used to be one of mutual trust. Over the years, the focus has shifted to greater accountability. The medical student must learn to identify the ethical issues, and apply the fundamental principles. The current medical curriculum is already packed fully. There is little time available to teach bioethics. This model is a humble effort towards elimination of the some hurdles of implementation. The Syllabus of our model follows the Bioethics Core Curriculum UNESCO 2008 ver 1. The entire curriculum is divided into five units viz. 1.Introduction to Bioethics, 2. Core Bioethics, 3. Current perspectives, 4. Bioethics in Specific Clinical situations and 5. Applications and practicum. The curriculum is designed to integrate with the existing curriculum, vertically into each year of medical study. The lessons start from the first day of entry into the medical school. As the regular medical curriculum progresses through the individual subjects in each year, the bioethics portions of each subject will be taught by the regular teachers of the same subject. In the middle years, the core bioethics will be taught. Integrated teaching‐learning methods shall be employed. The advantages are minimal additions to the total teaching time, minimal manpower needs and maximal efficacy. The resources: The manuals and booklets, prepared by the UNESCO International Chair on Bioethics will be the mainstay. Further teacher manuals shall be prepared. Evaluation will be a continuous process. In each of the university papers of the various subjects, a few questions relevant to bioethics, (within the subject matter of that field) shall be asked. The relative quantum of the bioethics content within each subject paper shall be minimal e.g. decorum within the anatomy hall, surgical ethics in the surgery paper, etc. However, there must be one individual university examination in bioethics, after the core bioethics had been taught, in the third year. The marking schema shall focus on the concepts and not on the factual knowledge. Internal evaluation (I.A.) shall be done, by alternative methods of evaluation viz. assignments, seminars and case studies. The attendance also shall be an essential part of the I.A. This model had been seen by both the Asia Pacific Chair and by the International chair, and is currently being circulated to all the chairs. Their critiques will be incorporated. DRUGS FUNDING AND RATIONALIZATION, IN HEALTHCARE SYSTEMS Carla Barbosa University of Coimbra, Portugal [email protected] In 2012, the Portuguese Ethics National Board for the Life Sciences made public an opinion about the Drugs Funding and its Rationalization in the Healthcare System. Nowadays, in order to have legitimacy in a Healthcare Policy, it is necessary to make priorities explicit at the planning and implementation of those policies (Williams, 2012). The Price evolution of drugs, medical interventions, and additional diagnostic methods has set challenges on the potential earnings on Health and on the constant costs growth. Therefore it is crucial to implicate all the health professionals and researchers, around guidelines to set priorities (Gibson et al., 2004). This is a very serious issue in Portugal and in some European countries, aggravated by the existing crisis. The debate about drugs costs and drugs prescription restrictions, it´s a growing problem that has been intensified among the Health professionals, and among the public debate. It is urgent, the creation of a decision model based on the principle of justice, which protects the dignity of both the healer and the healed. DECISION MAKING IN SETTINGS OF UNCERTAINTY Terry R. Bard Harvard University Medical School, USA [email protected] Increasingly decision making in both industrial and clinical settings is becoming linked with reductionist models influenced by statistical analyses often based upon primary and commonly accepted ethical values. As utilitarian as such models might be, they do not capture the dynamics of decision‐making that can confound even the most well‐intended reductionist models. This presentation will identify many of the complexities inherent in decision‐making processes urging greater attention to the individual psychological and philosophical aspects that attend almost every decision. Abstracts of Oral Presentations
POLITICAL HUNGER STRIKES AND FORCE‐FEEDING: AN ALTERNATIVE VIEW Yechiel Michael Barilan Tel Aviv University, Israel [email protected] Hunger Strikes (HS) have always been considered as a non‐
violent political toll to achieve some results from a condition of weakness. In cases of imprisonment this is even more evident, as those individuals involved in the practice have an extremely limited room for expressing their dissent. Examples like that of Gandhi have provided the collective imaginary that HS are the ultimate method of engaging into a political battle without putting at risk anybody else but the hunger strikers. As a result, any attempt to force‐feed those political activist has been labelled as against the right of the prisoners to affirm their autonomy. In this presentation, I will challenge such a position by providing arguments that will support the force‐feeding of hunger strikers in prisons as a morally sound alternative. AN OVERVIEW OF THE NEEDS OF TECHNOLOGY‐DEPENDENT CHILDREN IN 2015 Eliezer Be'eri Alyn Hospital, Israel [email protected] The population of children who are dependent on technology to maintain health and facilitate participation in society today has grown far beyond the four medical conditions and technologies (mechanical ventilation, parenteral nutrition, renal dialysis and plasmapheresis) that originally defined "technology dependence" when the term was first introduced in 1987. Today the term includes, in addition, a wide spectrum of neuromuscular disorders, as well as disorders of vision and communication, with their attendant technologies. This review will describe the spectrum of conditions and technologies encountered by healthcare providers who treat technology‐dependent children today, with a focus on the technical, emotional and psycho‐
developmental needs of these children and their families. Examples of contemporary technologies used for facilitating mobility, communication, mechanical ventilation and activities of daily living will be shown, and a conceptual model for holistically identifying the needs of technology dependent children will be presented. TREATING DEMENTIA AND MULTICULTURALISM: EXPLORING THE PERCEPTIONS OF MULTICULTURAL PROFESSIONAL CARETAKERS IN ISRAEL REGARDING AUTONOMY AND HUMAN DIGNITY Miriam Bentwich1, Amitai Oberman1,2, Nomy Dickman1 1
Bar‐Ilan University, Israel 2
Poriah Medical Center, Israel [email protected] Treating patients suffering from Dementia brings up the tension among the principles of autonomy, human dignity, beneficence and non‐maleficence. Most of the literature in this area is based on a Western‐liberal perspective, so that it does not include representation of non‐Western viewpoints and their application held by multicultural professional caretakers of demented patients in Israel. We present here the results of a qualitative study, utilizing content analysis of interviews done with 20 nurses, social workers and other professional caretakers 23
regarding their perceptions of autonomy and human dignity in the context of treating patients with dementia. Our results show substantial differences regarding the concept of human dignity and the extent to which it is developed when comparing nurses and other professional caretakers that migrated from Russia with Arab nurses and other professional caretakers. Thus, whereas this concept seems to be very developed and referred to among Arab nurses and professional caretakers, it is nearly absent among the nurses and caretakers that migrated from Russia. Additionally, the study shows certain differences between both of these groups and secular Jewish professional caretakers born In Israel. Finally, the study shows fewer differences between these 3 groups regarding the concept of autonomy and its utilization. By exposing the varied viewpoints regarding human dignity among the three aforementioned groups, this study may enrich the liberal‐mainstream conception of human dignity, while stressing the need to augment possible deficiencies in the comprehension and utilization of this concept among professional caretakers from other groups (e.g. professional caretakers migrated from Russia). RESEARCH DATA ABOUT TEACHING BIOETHICS THROUGH CINEMA AND TELEVISION SERIES: HOUSE MD Moty Benyakar1, Irene Cambra Badii2, Juan Jorge Michel Fariña2 1
Universidad del Salvador (USAL), Argentina 2 University of Buenos Aires, Argentina [email protected] This paper presents the results of the first PhD Thesis result of rigorous research on the subject. This is an analysis of the main articles of the Universal Declaration on Bioethics and Human Rights through its manifestation in the most popular medical series in the world. 166 selected episodes of the medical drama House MD were distributed among 245 students. They worked on these selected episodes, establishing a theoretical synthesis and articulation work. Then, the same students defining situations (in the manner of vignettes) where they could locate a possible bioethical problem. 1340 vignettes were defined in total. The analysis of this vast material allowed to demonstrate the double articulation of ethics. On the one hand the deontological dimension and on the other hand the singularity as its appear in each case. DILEMMAS CONCERNING CUSTODY FOR HIGH CONFLICT DIVORCE WITH A FOCUS ON EARLY CHILDHOOD Iris Berent Israel [email protected] The effects of divorce on the social and emotional development of children are in high priority and as the amount of children who are affected since their early childhood by parents who were separated is increase and the portion of affected children is bigger if we are taking into consideration children's parents separated without getting divorced. Joint custody reflects the changes in society. Like many other countries, Israel also went through changes in the division of labor within the family: mothers work more outside of home and fathers make more efforts in child care. These changes had been dealt at the legislative level in the so called "Divorce Laws Revolution" which started in 2005 with the establishment of the Committee for Examining the Legal Aspects of Parental Responsibility in Divorce ("The Shnit Committee"). Recommendations regarding the best custody arrangements for very young children are complex and 24
UNESCO Chair in Bioethics 10th World Conference
depend on the studies and theories of child development. The situation is further complicated when parents cannot communicate without making the children the victims of their quarrels. What is the best interest of the child when parents are in conflict and unable to communicate? Why parents who are concerned about their child's best interest find it difficult to focus on it clearly? What are the conditions required in order for a couple to put their conflict aside and the best interests of the child at the center? I shall offer two main directions of coping with these questions: 1. Psychological education that teaches parents to separate between parenthood responsibility and parental conflict 2.Systemic understanding as a means to identify the hidden strategies which increase the conflict and constitute a basis for effective interventions and recommendations regarding custody and treatment. THE ROLE OF THE PHYSICIAN IN "REALITY TV" Malke Borow, Leah Wapner Israeli Medical Association, Israel [email protected]; [email protected] The phenomenon of "Reality TV" has become prominent in recent years. Although the ethical issues with such programs are plentiful, there are also issues specifically related to medical ethics, such as: is it ethical to perform plastic surgery on television? When and how should a physician treat participants of such programs? Although the American Medical Association has had ethical rules regarding reality TV since 2005, the issue arose in 2012 in Israel when charges were raised that a psychiatrist employed by the broadcaster prescribed psychiatric drugs to participants of one such show. In response, the Israeli Medical Association ethics committee met and formulated a series of guidelines on this very current and controversial topic. The committee found that contestants on reality TV are under pressure and deprived of important information in order to heighten the element of surprise, and therefore can't give proper informed consent. The committee formulated a set of rules designed to protect the contestants' health and well‐being, including ensuring that they are physically and psychologically fit; monitoring their condition throughout and for a short time afterward, and requiring that physicians affiliated with the show should be independent. This will ensure that the physician's first priority is the contestants' health and not ratings. S/he will be the sole arbiter of whether the contestant is physically or mentally fit to continue on the show. The guidelines issued by the committee reflect ethics of a changing culture and will undoubtedly be tested further in the coming years. CAPABILITIES AS A CHALLENGE TO JUSTICE AS EQUALITY, HELSINKI'S REVISIONS AND THE VIOLENCE OF BENEVOLENCE Mylene Botbol Baum UCL, Belgium [email protected] The theoretical debate over capabilities and capacity building, in a world that often confuses the private and the public, makes of bioethics the acclimatization garden of new forms of discourses, which are often globalized without empirical perspective on how to realize social justice in modern medicine. In a global world where experimentation is often exported the dilemma for assuring decent minimum of health care to participants of research can be acute. By lack of any real analysis of the socio‐economical impact of the introduction of a research agenda or technologies in contexts of scarcity, emerging countries, which have no capacities to host them in a situation of minimal symmetry, are bound to exchange economical alienation for a form of development that brings knowledge alienation and dependency. This recurrent debate is very problematic. It has been discussed mostly in terms of Anglo‐Saxon liberal political models, often confusing the notions of capacity building and capabilities, as perceived by the agents themselves. I will analyze from these perspective how to avoid what I call "the violence of benevolence". In order to analyze some empirical situations in bioethical discourse, and the evolution of mentalities in “traveling experiments” I will propose resistance as a new form of narrative. I will argue why this resistance it requires an innovative model of judgment. DO QUALITY IMPROVEMENT (QI) ACTIVITIES NEED APPROVAL BY INSTITUTIONAL REVIEW BOARD (IRB) OR ARE THEY AN ETHICAL OBLIGATION INHERENT TO ANY CLINICAL ACTIVITY? Mayer Brezis Hadassah Hebrew University Medical Center, Israel [email protected] Activities of quality and safety in healthcare aim at monitoring performance of services, comparing and improving them, as well reducing errors. Scientific rigor (for validity and reliability) and publication (for benchmarking, public transparency and sharing ideas for improvement) make these activities similar to other types of research – and thereby currently requiring IRB approval. QI starts by acknowledging imperfections in the current situation: “any defect is a treasure” (slogan of the Japanese industry). Conflicts may therefore arise when senior executives in the organization prefer to hide the problems to preserve façade in media coverage. We observed misuse of IRB to limit quality and safety activities perceived as potentially damaging to institutional image – culminating in an attempt to close down our unit of Clinical Quality and Safety. Moreover, as journals require IRB approval for publication, we also witnessed rejection of a paper on safety because of missing consent by physicians to observations, as if, for instance, monitoring of team adherence to hand hygiene should require their prior approval. Most editors do not understand those issues and have not yet developed appropriate policies for the ethics of QI. A leading group of ethicists, clinicians and scholars convened by the Hastings Center concluded: QI activities should not undergo review by IRB but rather be part of professional supervision of clinical practice (Ann Intern Med. 2007;146:666). We propose that QI activities are an ethical obligation for any healthcare service. A regulatory reform of ethical requirements in healthcare is in order in primary legislation. BELGIAN MUSLIMS AND END OF LIFE ETHICS Bert Broeckaert, Chaïma Ahaddour, Goedele Baeke, Stef Van den Branden KU Leuven, Belgium [email protected] Background: In just a few decades Islam has become the second largest religion in most European countries. This evolution constitutes an important challenge to European health care Abstracts of Oral Presentations
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(including palliative care), as this is still deeply influenced by secular‐Western and/or Christian approaches. Aims: Part of the exploratory research programme (2002‐2014, 3 PhDs) presented here aimed to analyse real world end of life views and attitudes of elderly Muslims in Flanders, Belgium. Methods: Semi‐structured interviews with elderly Moroccan men (20 interviews), elderly Turkish and Moroccan women (60) and specialists (20). All interviews were transcribed, coded and categorized using Grounded Theory methodology. Results: Euthanasia and assisted suicide are strongly rejected; non‐treatment decisions and the refusal of treatment are only allowed in exceptional circumstances; pain control does not pose an ethical problem. God controls illness and health, life and death; it is unacceptable to interfere in this divine plan. Patience is the central virtue. We found hardly any differences between the guidelines in the international normative Muslim sources and the actual attitudes of our respondents. Discussion: The attitudes of the generation of Belgian Muslims studied here are deeply influenced by a shared religious framework. Nevertheless, even in these very homogeneous groups a few dissident voices were found. In palliative care it remains essential to start from the ethical and religious views of the unique individual in front of you; not from the views that are typically associated with the community he/she belongs to. human moral capacities, we must have some “objective” picture of ideal (virtuous) human being. That ideal must have some objective features that are subject of human knowledge. That picture of the ideal man is nothing else than the goal or purpose of moral enhancement. Like in metaethics, prior theoretical discussion (here in the triad utilitarianism‐deontology‐virtue ethics) is still in progress without any obvious resolution on the horizon. Nobody has presented why virtue ethics is the best model for bioethical researches, yet. However, that normative dispute in has to be concluded before applying of its results further. Finally, metaphysical presupposition of moral enhancement seems to be that only humans could be moral agents and, consequently, subject of moral enhancement. Furthermore, it seems that very idea of moral enhancement brings us to the idea of morally perfect man. That man cannot make moral mistakes. If this idea is an implicit in enhancement thesis, please let us remember supercomputer HAL 9000 from Stanley Kubrick’s classic 2001: A Space Odyssey. First of all, HAL is not a human. Second, HAL has not become a moral being because it (he? she?) is “enhanced”. By definition, HAL is perfect and cannot be “enhanced”. That finally means that HAL becomes moral exactly at the moment when he becomes capable of evil. HUMAN ENHANCEMENT AND MORALITY: SOME DOUBTS BIOETHICS AND THE HOLOCAUST: TEACHING LESSONS FROM THE PAST FOR FUTURE HEALTHCARE PROFESSIONALS Nenad Cekić Belgrade Faculty of Philosophy, Serbia [email protected]; [email protected]; [email protected] The apparent tension between the idea of bio‐technological or medical moral enhancement and the concept of freedom is a result of three overlapping implicit premises hidden in the very notion of moral enhancement. First is metaethical, second normative and third metaphysical. Metaethical presupposition behind idea of human moral enhancement is pretty straightforward. If we believe in the possibility of artificial improvement of human moral behavior, we must belong to some group of metaethical descriptivists or cognitivists. The central thesis of traditional cognitivism is that ethical judgments can be either true or false in the fashion on scientific or empirical statements are. Why are proponents of bioethical enhancement almost necessarily metaethical cognitivists? They are cognitivists because improvement of any human capacity presupposes objective knowledge about that capacity. Hence, enhancement of human moral capacity presuppose objective knowledge of what “to be moral” descriptively mean. In short: ethics must be either science or some branch of a priori knowledge, similar to mathematics or logic. The real problem is that cognitivism/non‐cognitivism dispute in metaethics is far from being settled, and there is a strong possibility that it ever won’t be resolved. However, philosophy is full of unsettled problems, and that is nothing new. On the other hand, cognitivistic idea of objective moral knowledge similar to scientific inquiry is in direct opposition with ideas of freedom and choice. For example, if we always (could scientifically?) know what course of action is right – where is the room for choice and freedom? This thesis is not a plea for moral relativism but rather attempt to point out that foundation of morality could or even should not be found in literally perceived “science”. Normative problem of moral enhancement is quite similar to metaethical one. Idea of moral enhancement forces us to take one very distinct normative side. A proponent of moral enhancement must show that virtue ethics is a correct (true? scientific?) normative ethical theory. Like in metaethics the reason for this is almost obvious. If we would like to enhance Tessa Chelouche Clalit Health Services, Israel [email protected] When reflecting upon medicine and the Third Reich and the Holocaust, we encounter some of the most difficult and profound choices of our humanity. Medical practice during this era provided the basis for the present bioethical doctrine. Consequently, it is safe to state that this subject does not belong to history but rather, as I believe, to the future. Discourse on the lessons that can be learned from the practice of medicine during the Third Reich and the Holocaust should be an essential component of all healthcare professional education. With this in mind, under the auspices of the International Center for Health, Law and Ethics at Haifa University and the Israel National Commission for UNESCO and the Israeli Head of the Chair of Bioethics, Professor Amnon Carmi, I together with Geoffrey Brahmer and Susan Benedict, have published a casebook using personal cases from the Holocaust on various bioethical issues that are relevant and pertinent to today's bioethical discussion. The various aspects of medicine during the Third Reich are demonstrated, reflecting both the perpetrators and the victims, and include cases of both Nazi physicians and prisoner physicians. Each case is accompanied by an historical background in order to provide the correct social context and a wider perspective on the issue. This is followed by an ethical discussion whose aim is to provide a tool for reflection and dialogue on bioethical issues both in the Holocaust, and in our own times. Greater knowledge and ethical discussion on these profound issues can not only help combat ignorance and prejudice, but can also inspire healthcare professionals to practice with greater compassion, knowledge, tolerance, respect and justice on behalf of their patients. Moreover, we believe that by promoting education on the medical discourse of the Holocaust we can inform the students on human and scientific values that will be of great value to their future lives and careers. 26
UNESCO Chair in Bioethics 10th World Conference
In this presentation I shall demonstrate how these cases can serve as a platform for present and future bioethical education. NATIONAL ETHICS COMMITTEE ON HIV/AIDS – THE ISRAELI EXPERIENCE Daniel Chemtob1, Avigdor Salton2, Efrat Haddad1, 3
2
4
Estelle Rubinstein , Yifat Aharon , Israel Yust 1
Ministry of Health, Israel 2
National Ethics Committee on HIV/AIDS, Israel 3
Hadassah University Medical Center, Israel 4
Tel Aviv Sourasky Medical Center, Israel [email protected] Background: Prevention, diagnosis, notification and treatment of people living with HIV (PLWHIV) often raise important ethical dilemmas for health care workers (HCWs) that apparently conflict with human rights or public health. Therefore, a "National Ethics Committee on HIV/AIDS" was established in 2005 (under Section 20 of the Israeli Patient's Rights Act, 1996). Accordingly, any HCW as defined by the act or any interested party can apply to the Committee. Objective: To analyze the types of requests brought before the Committee, and their outcome. Methods: All requests received in 2005‐2012 by the Department of Tuberculosis and AIDS were analyzed according to demographics, HIV transmission groups and nature of requests. Results: Thirty‐three cases (M/F=1.75) were presented. Mean age for males: 37.7 years; SD: 8.4; range: 19‐50; for females: mean: 31.1; SD: 6.6; range: 19‐47. Numbers of cases per HIV transmission groups were: 22 (66.7%) Israelis of Ethiopian origin; 4 (12.1%) other Heterosexuals; 5 (15.1%) Men who have Sex with Men; and 2 (6.1%) Injecting Drug Users. The reasons HCWs requested a meeting were: disclosure of HIV to sexual partner (75.8%); "protecting Public Health" (12.1%); HIV testing/ treatment for fetuses/newborns of HIV+ mothers (9.1%); non‐
adherent patient (3%). Eight (24.2%) requests were beyond the committee's statutory jurisdiction. Among the 25 remaining cases, 19 (76%) were summoned to the committee and resolved without further procedure (five of an unknown outcome), and 6 (24%) cases were resolved before the committee convened. Conclusions: Despite complex socio‐cultural issues, the Committee assisted in successfully mediating between PLWHIV and HCWs facing ethical dilemmas. FREEDOM OF EXPRESSION VERSUS RESPECT FOR THE PROFESSION Baruch Chen, Elinor Goshen, Tami Karni Israeli Medical Association, Israel [email protected]; [email protected] During the tumultuous period following the deaths of three Jewish teenagers and one Arab teenager in Israel, and continuing with the conflict in Gaza, the IMA Ethics Committee addressed several complaints regarding political or social policy statements made by doctors who expressed their views publicly, either in print and electronic media or the internet in general. Complaints received by the Ethics Committee concerned the ability of these physicians to give the best professional care to everyone, in light of the statements they had made. The Ethics Committee addressed whether they could make a recommendation in favour of restricting freedom of expression based on these concerns—after all, isn’t free expression part of civil conduct in a democracy? What happens when a form of free expression may adversely affect patients’ trust in doctors and respect for the profession? Ethics Committee members were asked to find the middle ground between the realization of the right to freedom of expression and a doctor’s duty to protect the dignity of the profession. The committee agreed to the following principles: 1. Doctors have the same right to freedom of expression as any other citizen of the state. 2. It is recommended that a doctor consider his comments when expressing himself in the media and in general. 3. The doctor will be responsible, considerate, respectful and tolerant in general and when speaking to the media in particular. 4. The doctor will speak with restraint in every framework related to his profession or workplace. 5. The doctor will not abuse his position when he voices his opinions, as if the opinions are based on his medical knowledge. THE PRINCIPLES OF FAIRNESS AND JUSTICE IN FORENSIC INVESTIGATION AND IDENTIFICATION WORK ANALYSIS Wen Wu‐Bei Chen, Sheng Gao, Kai Liu, Shu Bo‐Qing Huang, Tao Wei, Zhen Li Kunming Medical University, China [email protected] Objective Understanding and view of forensic ethics principles of fairness and justice in the on‐the‐job police in Yunnan province. Put forward some preliminary discussion. Method Using cluster sampling method to carry on the questionnaire survey to the police in some areas of Yunnan Province behavior in his work, the investigation time for one year. Statistical methods are descriptive statistics, logistic regression analysis. Results (1) for the simple folk area handling cases, accounting for 89.1% of the work need to be more careful (2) in the investigation of the police group, do not agree to give the appraisal conclusion of vulnerable groups is slightly biased accounted for 91.3%. Conclusions In the process of judicial appraisal of forensic medicine involves ethical issues related to the principles of fairness and justice, need to pay attention to, research on forensic medicine and investigate the cause of all. At the same time in the reality of daily work, identification of disputes related to forensic workers should pay attention to ethics problems caused by the need to continue to strengthen the consciousness of justice, fairness. ON ETHICAL PLACES: THE PRACTICE OF ‘TERMINAL DISCHARGE’ IN CLINICAL SETTINGS AND THE GOOD DEATH IN TAIWAN Yicheng Chung Ritsumeikan University, Japan [email protected] In discussions of end‐of‐life care, the place where one wishes to die is thought to be as one of the deciding factors in considerations of quality of life. In Taiwan, the place of dying is related to not only the quality of life, but also the quality of death. There is a strong belief about home death and its relation to the good death, and a customary practice in end‐of‐life care is derived from such belief. The so‐called ‘terminal discharge’ is a practice which discharges dying patients on patients’ or family members’ wishes, and arranges private ambulances to take patients home and die there. This indicates how medical Abstracts of Oral Presentations
practices accommodate themselves to the cultural beliefs about life and death in Taiwan, and the transference from hospitals to home suggests ethical considerations in the place of dying in Taiwanese society. Based on the practice of terminal discharge, this presentation will address a relationship between place and ethics in end‐of‐life care in Taiwan from three parts: 1) the guidelines and legal regulations concerning the practice; 2) the traditional beliefs about good death and places of dying in Taiwanese society; 3) the concept of ‘ethical place.’ The aim of this presentation is to elaborate the concept of ‘ethical place,’ which suggests different ethical rules may apply in different places, and by using ethnographic data, to give a full picture of the development of end‐of‐life care in Taiwan. THE ETHICAL CHALLENGES OF CONDUCTING A POPULATION‐BASED SCREENING FOR NON‐COMMUNICABLE DISEASES IN A SETTING WITH LIMITED UNIVERSAL HEALTH COVERAGE Fatima L. Ciroma, MA Kana, F Adiri, MS Yusuf, OM Avidime, A Abdulrazak, MN Sada Kaduna State University, Nigeria [email protected] Background: Many developing countries with high disease burden have inadequate universal health coverage. In this setting, epidemiological screening is constrained by ethical dilemma for investigators. On one hand, the screening confers awareness for participants. But factors like limited availability and costly healthcare services reinforce the unwillingness of the screened participants to seek and utilize the available healthcare service on a sustainable basis. This paper aims to describe the experience of a population‐based hypertension and obesity screening survey in northwestern Nigeria. Method: A cross‐sectional descriptive study was conducted on 1,900 University staff and students that are not covered by the National Formal Sector Social Health Insurance Program. The WHO Stepwise protocol for the screening of non‐communicable disease was employed. It begins with obtaining informed consent from all participants, and then questionnaires administered, anthropometric and blood pressure measurement done. Participants with abnormal findings were counseled and referred to the hospital for clinical management. Subsequently, we conducted an awareness seminar for all participants. Results: The age of participants ranged from 16‐67 years constituted by 36.6% and 63.4% respectively of females and males. The prevalence of systemic hypertension was 7.4% with 9 participants severely hypertensive, while 21.9% were either overweight or obese and 13 of them extremely obese. Conclusion: Our findings highlight the ethical challenge of the role of researchers as observers during observational studies on participants with limited healthcare access. It is recommended that epidemiological screening surveys in similar settings should have adequate arrangement for referral of participants with pathological diagnosis. PROCEDURAL ETHICS: TENSIONS BETWEEN SOCIAL SCIENCES AND BIOMEDICAL SCIENCES Séverine Colinet University of Cergy‐Pontoise, France severine.colinet@u‐cergy.fr The presentation will aim to explain the stakes at the beginning of a research that involves a social sciences team and five 27
medical teams in France. After having defined the “research with”, the presentation will propose reflection about the confrontation between a qualitative research protocol and an objectivist and utilitarian conception of the “procedure ethics”, ethics that would be at the service of instrumental rationality (de Gauléjac, 2009) and would limit the creativity of the protocol the “research with”. This presentation will bring to light disciplinary and epistemological tensions between social sciences research and biomedical research. We will talk about the difficulties that researchers are faced with as well as the strategies and workaround solutions. In the context of procedural ethics, we will show how the “research with” logic, that consists of adapting the protocol to the realities on the ground, gives way to the one of normal standard with conditioned effect on the production of knowledge. THE ETHICS OF CLINICAL JUDGEMENT AND MEDICAL INTUITION IN THE WRITINGS OF MOSES MAIMONIDES Kenneth Collins Hebrew University of Jerusalem, Israel [email protected] The contemporary practice of medicine is increasingly governed by clinical guidelines based on evidence derived from scientifically valid criteria. While scientific knowledge remains crucial in achieving clinical improvement, doctors still need good communication skills, ethical sensitivity and a humane attitude. Without the appropriate interpretive skills and the insights of good clinical judgement a comprehensive approach to patient care may not be possible. Clinical judgement thus has scientific and ethical components, reflecting both the modern medical technological base and the historic medical art. The recent emergence of a movement promoting the ‘medical narrative’ in the patient’s illness gives space for the insight that is required in understanding the patients’ health issues, eliciting the patient’s often hidden emotions and understanding their cultural, religious and personal sensitivities. It reclaims the centrality of the doctor‐
patient relationship in the clinical encounter. Clinical judgement involves the traditional processes of observation, investigation, diagnosis and treatment. Intuition, once seen as critical in a physician, has given way to scientific advance but can still have a role in providing the context for the clinical knowledge and ethical values of the physician. Such values have a long history and can be identified in the writings of great physicians of the past. This paper will follow the guidance of Moses Maimonides (1138‐1204) who saw his medicine as part of the knowledge base of the philosopher, giving the practical application of the physician’s craft the necessary intellectual underpinning. Thus, judgement and intuition become key components in the ethical care of the patient by the compassionate and competent physician. REPRODUCTIVE ETHICS, RIGHTS AND EVOLVING ISRAELI LEGISLATION Yardena Cope‐Yossef ITIM – Jewish Life Advocacy Center, Israel [email protected] "The Right To Bear Children Through ART" is a right whose definition and boundaries are debated throughout the world. The results of those debates ultimately inform the legislation in countries around the world. New definitions of what constitutes a family and the value a particular society attaches to natalism also have a decisive impact on that society's norms and laws. In 28
UNESCO Chair in Bioethics 10th World Conference
Israel the director general of the Ministry of Health appointed the Mor‐Yossef committee to conduct in an‐depth investigation of societal norms, values, ethics and rights vis‐à‐vis reproductive technologies and surrogacy, and in 2012 the committee published a report addressing the comprehensive picture of optimal Israeli legislation. This presentation will present a few landmark cases decided before or parallel to the committee's hearings, key findings and recommendations of the committee's report and the emerging case law and legislation based on the report. Key questions that will be addressed: what is the extent of the "right" to parent through ART recognized by the committee and what ethical principles and considerations informed the recommendations of the committee? Lastly – to what extent are those being implemented and to what extent are they being overridden by competing values and ethical considerations? ETHICAL DILEMMAS IN THE ELECTRONIC MEDICAL ERA: AN INTER‐RELIGIOUS COMPARISON Yitschak Copperman Israel [email protected] The ability to prolong life by electronic medical equipment has presented to us new ethical dilemmas that were not seen in previous generations. A middle aged man had a pacemaker inserted. Over a period of time, his mental condition degenerated to the extent that he was unable to recognize his own wife and children. Physically, he was strong and healthy and had a life expectancy of many years. Without his pacemaker, he will die. When the battery starts to weaken, should it be replaced, or rather let nature take its course? An elderly man had a defibrillator inserted to prevent sudden cardiac arrest from dangerous heart arrhythmias. As his general condition deteriorated, he was concerned that when he "died", the device would continue to resuscitate him, and not allow him to die in peace. He asked his cardiologist to externally electronically deactivate the device. This would prevent the device giving him an electric shock if he had an arrhythmic cardiac arrest, and not prolong his suffering artificially. These real life cases were presented to authoritative representatives of the Jewish, Muslim, Christian Catholic and Protestant faiths. Their attitudes, points of agreement and differences of opinion will be the subject of this paper. A REVISED ETHICAL CODE FOR AN ASSOCIATION OF MENTAL FIRST AID Shiri Daniels, Tal Peri, Lidia Sela, David Koren The Israeli Association for Emotional First Aid (ERAN), Israel [email protected] ERAN, the Israeli Association for Emotional First Aid by the telephone and the internet, is revising its ethical code. The need for the revision came from several changes that occurred since the past code was formed, including technical advances, practice modifications, and social changes. A committee for the code's revision was formed, and the revision relates to several aspects of the telephone and internet "hot lines" services, including: conduct and misconducts – borders and limits of the calls; anonymity – of the clients as well as of the responders; quality control, and risk management. The revised code will be discussed, and comments from the audience will be appreciated. THE RIGHTS OF THE CHILD: A WELFARE PRINCIPLE APPLIED TO CHILDREN BORN IN TRANSNATIONAL SURROGACY ARRANGEMENTS Marsha J. Tyson Darling Adelphi University, USA [email protected] Children are the reason there is a growing transnational fertility industry. My presentation applies a welfare principle, integral to Hague legal standards regarding the paramountcy of the best interests of the child, to the complex set of issues related to the global commercial fertility industry’s main enterprise—baby making. My comments will explore how a welfare principle applies to infants born into and adopted through the agency of cross‐border surrogacy arrangements. In this vein, while many infants born via transnational gestational surrogacy arrangements—especially where the intended parents have contracted with a poor woman in a low resource country (i.e., India, Thailand, or the Ukraine)—accompany the commissioning adults who have paid for them safely back to the nations they will call home, an increasing number of newborns are caught in a legal quagmire and are denied admission to the home country of the intended parents. My comments will provide examples of how immigration officials, the courts, and policymakers are negotiating the political, legal, and ethical terrain between claims for expansions of the reproductive freedom of adult citizens on the one hand—and securing the well‐being of infants born through transnational gestational surrogacy. A second focus of my comments explores the “right” of a child to know of its birth ancestry in the context of the expansion in the use of assisted reproductive technologies. BIO‐ETHICAL ISSUES CONCERNING CLINICAL NEUROPSYCHOLOGY IN GENERAL, AND MAINLY IN DAMAGES CLAIMS IN CASES OF BRAIN INJURY Chanan David Israel [email protected] The Clinical Neuropsychology actually deals with one of the most complicated issues in the domain of bio‐ethics – since in both its conceptual and 'practical' aspects it is posed in the shadow, or rather in the light, of the enigmatic psycho‐physical problem – that is the unsolved issue concerning the relationship between the brain, and the mind of the "owner of that brain". One arena, in which both neuroscience and psychology – and specifically neuropsychology – meet is the court; for example, in cases of damage claims of brain injuries. The neuropsychological opinion which might be essential, in such cases, is based on qualitative analysis of the results of appropriate psychological tests taken by patients, and on a proper differential diagnosis. These two procedures as well as dealing with the causal effect concerning the disorders that were found, might pose an ethical problem of their own. LESS TALK – MORE ACTION: TEACHING ETHICS TO GENERATION Y Zahava Davidow University of Haifa, Israel [email protected] Teaching ethics to today's health science students must be done differently than in the past. Out with frontal lectures and long Abstracts of Oral Presentations
reading assignments, and In with movies, interesting cases, peer interactions, and fun tactics. Today's students are people of "Generation Y". They learn best by multimedia formats, case presentations, audience participation, and group discussions. This lecture presents didactical methods in teaching ethics to health science students. Methods that are interesting and exciting. Methods that engage the students in the material, and invite them to fall in love with the world of ethics. The lecture will explore the following topics: • Why we need to teach differently today • How ethics can be taught so the students want to learn • How ethics are being taught today to Physical Therapy students in the University of Haifa What do the Students learn using this teaching method? • How to document a clinical situation in a clear, concise and ethical manner • How to identify an ethical problem, and determine if it is an ethical dilemma or an ethical issue and how it differs from a legal problem. • How to analyze an ethical dilemma through “Ethical Reasoning”. • Ethical terms, principles, and values and how to implement them when discussing ethical issues • The Professional Code of Ethics and how it can assist in understanding clinical ethical situations and in solving ethical dilemmas • How to recognize and evaluate their own moral values and examine how they differ from their peers PROBLEMS AND PERSPECTIVES IN BIOETHICS EDUCATION IN THE CIS COUNTRIES (SOCIO‐PHILOSOPHICAL ANALYSIS) S. Davtyan, K. Ghazaryan Armenia [email protected] The higher medical education in all the CIS countries aims at achieving three inter‐related and inter‐determined goals: 1. To provide graduates with updated knowledge and skills on fundamental branches of medicine; 2. To develop the ability for self‐education, their pursuit of new knowledge and their self‐actualization in the chosen profession; 3. To create conditions for the development of a motivated, dedicated and moral personality of a physician. Nowadays humanization of medicine and the search of new models of medical education corresponding to modern requirements relating to the progress in scientific and social life is very urgent. Inter‐relations of medicine and education acquire a new meaning due to the emergence of integrative concept of bioethics having a compound social and philosophical status. Until now, there is no distinct opinion about who should teach bioethics to medical students: philosophers, physicians, jurists or other specialists. A special character for medical students implies an interdisciplinary aspect. There should be a proper balance between applied profession biomedical ethics and fundamental moral and philosophical approach to bioethical problems. In their professional activity, physicians will constantly face bioethical problems and have to make decisions requiring not only a profound medical knowledge, but also knowledge on ethics, law and philosophy. There is a need to harmonize education programs on bioethics used in the CIS countries being, at the same time, UNESCO member‐states. Currently, none of the CIS countries has a system for training specialists of higher qualification (Candidates and Doctors of 29
Science) in bioethics. The “List of Scientific Specialties” does not include bioethics. VIEWS ON END OF LIFE SITUATIONS AS EXPRESSED BY FIRST‐DEGREE RELATIVES OF PATIENTS IN A VEGETATIVE STATE Ittai Dayan1, Esther‐Lee Marcus2, Uriel Heresco‐Levy2 1
Hadassah – Hebrew University, Israel 2
Herzog Hospital, Israel [email protected] The increasing population of patients in a vegetative state poses ethical, social, and cultural questions regarding indefinite maintenance of life in end‐stage disorders of consciousness. In our research, we aimed to identify and achieve a better understanding of views on end‐of‐life situations as expressed by first degree relatives of vegetative state patients in Herzog Hospital, a long‐term‐care facility in Jerusalem. We interviewed 30 family members of 19 patients, hospitalized for a mean duration of 30 months, regarding their views on intensive care, as well as palliative care that they personally would want to receive in the case of terminal disease or permanent loss of consciousness. None of the patients and only two relatives held advanced directives for end‐of life decision making. We quantitatively collected the data and then correlated their opinions with different socio‐economic, religious, psychological, and pathological data, focusing on Complicated Grief Disorder among the relatives. Our findings show that views embracing the prolongation of life under any circumstance are virtually identical in terminal disease and permanent loss of consciousness. Family views embracing prolongation of life are strongly and positively correlated with higher levels of religiosity, and to a lesser degree with abrupt clinical deterioration of the patient and male gender of the relative. Complicated Grief Disorder, while not influencing end‐
of‐life decisions, is highly prevalent and associated with greater burden on the relatives. We believe that under such circumstances family views and emotional reactions towards their loved ones situation should be taken into account. THE ETHICAL SIDE OF HEALTH TECHNOLOGY ASSESSMENT (HTA) Xavier Deau World Medical Association [email protected] The technological progress is getting faster and faster with even more efficiency. But at the same time, this could entail potential drifts and diversions. Technological progress cannot be directly applied to human beings. Contrary to technology which is related to industrial processes, medicine is deeply rooted in individuals with a profound and central human dimension. While talking about HTA, there is a subtle balance that must be found between the necessary development of new technologies which can bring positive outcomes for patients’ health and safety and the need to stop developing old technologies that are money consuming and harmful to health. Having said that, the importance of better considering ethical considerations while assessing health technologies must be clearly underlined. The respect of the ethical standards should not halt the technological progress (like e‐health, m‐health, health databases/bio‐banks…). On the contrary, according to the World Medical Association (WMA), ethics includes progress in a 30
UNESCO Chair in Bioethics 10th World Conference
sustainable and human perspective as masterly demonstrated in the WMA Declarations of Helsinki and Lisbon. Ethical standards refer among other things to information/consent of the patients, independence of the physician, medical secrecy/ confidentiality but also equal access to healthcare. The technological standards should be adapted to the human beings. It is thanks to ethics than the technological progress can be applied to the medical level by ensuring the transition from technics to the human and individual dimension. “DR.” WATSON: AI, ETHICS, AND THE FUTURE OF MEDICINE Amy DeBaets Kansas City University of Medicine and Biosciences, USA [email protected] The development of the field of bioethics is intricately bound up with the advent of new medical technologies that hold both promise and peril for patients and healthcare workers. Emerging technologies continue to shape the landscape of healthcare, and this presentation will analyze some current trends in the development of artificial intelligence and robotics technologies that affect healthcare providers, patients, delivery systems, and capabilities. As advanced bioinformatics allow for less reliance on provider knowledge in healthcare decisions and assistive robots reduce the strain of healthcare jobs and provide companionship to patients, the roles and responsibilities of healthcare providers can be expected to change substantively. Likewise, realtime monitoring of health status using wearable computers may provide options in preventative care that are not currently realized. Whether these new technologies serves to augment, replace, or supersede human healthcare workers remains to be seen, and will likely be dependent upon a variety of policy choices and other developments in workforce education and healthcare financing. Such technologies may be used to either advance or inhibit the humanization of healthcare and the work of caring for patients as whole people. In one scenario, AI and robotics technologies may be used to simply replace human caregivers and could leave patients increasingly isolated. On the other hand, the same technologies could also be used to free human caregivers from the physically challenging aspects of caregiving in order to focus on the humane side of healthcare. MOMA CALL CENTER FOR MONITORING AND TREATMENT Sara Dejavsarov, Angela Irony Maccabi Healthcare Services, Israel [email protected] Population aging and the increased demands to care for complex chronic conditions press an economic stress on the healthcare system. Thus, novel service solutions are needed assuring quality care besides cost effectiveness. Maccabi Healthcare Services, in conjunction with the Gertner Institute, has established an innovative call center for monitoring and treatment a range of chronic conditions. Moma's population involves around 7000 concurrent patients suffering from a range of chronic conditions (CHF, COPD, DM‐II). Since it's opening in July 2012 Moma has served around 10,000 patients. The novel technology call center presents a new approach to management of large population with complex chronic conditions and co‐morbidity. It offers better accessibility to medical advice for broad range of population. It empowers the patient in decision making for improved health outcomes. The Center is manned by members of a multi‐disciplinary staff, including nurses, physicians, social worker, nutritionist, and clinical pharmacist, who use diverse technologies, including telephone calls and video calls, to monitor clients. Simple, easy‐
to‐use, high‐quality video communications help solve many client concerns involving accessibility and availability. Moma works in collaboration with various factors in the community services including primary and secondary physicians, multi‐disciplinary team, at home care units, Maccabi nonstop call center, emergency medicine services and primary clinics. In diabetes team Moma center proved to be efficient in improving A1C levels, HVA measurement and compliance in 1300 patients, whiten half a year. Moreover, it is interesting to find that the improvement in glycemic control concept constant over time ‐ that is, the group also released for other reasons do not return to the values of HbA1c before the intervention. Together with these impressive results, there is a need to examine the significance of this innovative style and its ethical meanings on patient care. This work will present the processes that were mad in Maccabi HealthCare Services in order to prevent possible issues, and the way high ethical and professional tele‐treatment is saved. ISRAELI CODE OF ETHICS FOR PRACTITIONERS OF OCCUPATIONAL HEALTH Raz Dekel PPO Meuhedet, Israel [email protected] The practitioners of occupational health face many ethical challenges in performing their duties. Double loyalties, pressures by involved parties and attempts to influence their decisions are commonplace. The Israeli national council of worker's health appointed a committee representing many occupational health professions for drafting a code of ethics for practitioners of occupational health. The code, integrating principles from parallel national ethical codes and a few "local" principles was ratified by the council and will be presented alongside the ethical challenges it is meant to aid in solving. PAIN, CONSCIOUSNESS AND THE CEREBRAL CORTEX Marshall Devor Hebrew University of Jerusalem, Israel [email protected] The ability to suffer pain is a sentinel of conscious perception. Many ethical dilemmas vanish, or are at least diminished, if the individual or non‐human organism involved feels no pain. It is generally presumed that consciousness, and by extension pain perception, is a function of an intact cerebral cortex. For this reason, in situations in which the cortex is absent or severely compromised it is generally presumed that pain perception, and the ability to suffer, are absent. This widely accepted presumption has practical implications for ethical decisions concerning lower animals in which there is no cortex, embryos and fetuses in which the cortex is not yet mature, and adults who have suffered severe cortical damage. In this presentation I will consider the evidence that pain perception is indeed seated in the cortex and necessarily absent when cortical function is lacking. Based on available evidence from direct brain stimulation, lesions, electrophysiological recording and non‐
Abstracts of Oral Presentations
invasive imaging I will argue that there is in fact considerable uncertainty about the reigning dogma that pain, and by extension consciousness, require a functioning cerebral cortex. WITHDRAWAL OF LIFE‐SUSTAINING TREATMENT: A COMPARATIVE ANALYSIS OF MAINLAND CHINA, TAIWAN AND HONG KONG Chunyan Ding City University of Hong Kong, Hong Kong [email protected] Withdrawal of a life‐sustaining treatment from an incompetent patient at the end of his life is a complex issue involving social, ethical and legal concerns. Little has been known about how Chinese societies deal with the issue, let alone the comparison of ethical and legal norms on the issue adopted by different Chinese societies. To conduct a comparative analysis, this article selects Mainland China, Taiwan and Hong Kong because they root in the Chinese culture and share the traditional Chinese views on life and death, but have not adopted the similar rules on withdrawal of life‐sustaining treatment. This article aims to identify the similarities and differences of the law and practice regarding withdrawal of life‐sustaining treatment among these three jurisdictions, and further explore the underlying reasons from social, ethical and legal aspects. ETHICAL TREATMENT IN PSYCHIATRY Anthony Dinnen Anthony Dinnen P/L, Australia [email protected] From Soranus of Ephesus 2000 years ago through Pinel 300 years ago to the emptying out of the asylums in our times Psychiatry has had to grapple with the ethics of treatment. The history of Psychiatry, perhaps more than any other field of Medicine, reflects the moral dilemmas we face. Are increasing numbers of homeless with mental illness in our cities a reflection of “moral treatment” or an abandonment of the physician’s duty to heal. We have to reconcile the madhouse of Bedlam and the myth of mental illness of Thomas Szasz with our duty of care as physicians to our troubled patients. Do we act, as a leading psychiatrist in Australia advised, according to what a roomful of our peers would approve? To address these ethical challenges, current treatment practices in Psychiatry, particularly with regard to the treatment of Posttraumatic stress disorder, are discussed. 31
particulars of the individual case). Nonetheless this new approach, personal injury lawyers, insurers and judges lack something like guidelines, that will assist courts and insurers in the assessment and quantification of noneconomic damages. This guidelines (especially by assessment of the loss of amenities) are based on the International Classification of Functioning, Disability and Health (WHO). The novelty of this idea can be seen in a specific use of this classification (ICF). Usually is ICF used in clinical settings for functional status assessment, goal setting & treatment planning and monitoring, as well as outcome measurement. Due to this primary goals of ICF looks Czech usage of this classification very uncommon and rather unsuitable. On the other hand ‐ this might be the first attempt how to unify the system of the assessment and quantification of noneconomic damages in Europe on the basis of internationally accepted classification. PROBLEM FORMATION OF THE ETHICAL REGULATORS OF THE PHYSICIAN PROFESSIONAL ACTIVITIES Alena Donika Volgograd State Medical University, Russia [email protected] Implementation of bioethical principles in medicine is impossible without recognition of their absolute and meaningful use of a professional group of doctors. In this context, we conducted a study on the value orientations of doctors on the undergraduate stage to assess the formation of ethical regulators of the professional activities of doctors. Conducted a comparative analysis of value motivations of doctors and medical students revealed underdevelopment moral qualities of empathy considered undergraduate professional group on stage. According to our data, only 46.3% of the surveyed medical students have expressed an altruistic orientation and 37.3% of the study ‐ the selfish orientation (p> 0.05). At the same time, similar studies on model groups of doctors have shown that the majority of physicians (69.2% of physicians and 83.3% of surgeons) has altruistic orientation (p <0.05). Orientation selfishness marked by no more than 15.7% of physicians. The obtained results reflect the overall negative trend in the orientation of the youth society and can be predictive of future decline in the importance of ethical principles of medical practice. CHALLENGES FOR WESTERN ETHICS IMPLEMENTED IN HEALTH CARE OF MULTI‐CULTURAL COMMUNITY – AN AUSTRALIAN ETHICAL DILEMMA PERSONAL INJURY COMPENSATION IN CZECH REPUBLIC AND THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH Russell D’Souza Australia [email protected] Tomáš Doležal Institute of State and Law of Academy of Sciences, Czech Republic [email protected] Australia is a multicultural society yet its dominant ethical paradigm is firmly placed in the western philosophical tradition. The fundamental concept that western ethics is based on, is that of autonomy which implies that the individual is a free agent able to make their own decisions. These are based on the individual’s right to be informed about all treatment options. This presentation will examine the ethical concepts of autonomy and truth telling. We argues that the western bioethical concepts of autonomy and truth telling in the practice domain may not be appropriate for different cultural groups. This can become a source of ethical dilemmas and a challenge for western ethics. The presentation will conclude with an option for those working in multicultural societies suggesting the need to accommodate In January 2014 came in Czech Republic into force new civil code. Traditionally was compensation for non‐economic damage claims determined with the aid of tables. This tables prescribed overall assessment of the claim on the basis of a basic point value and the exact allocation of the points were the tasks of forensic medical experts. New civil code abolished this tables and currently there is no statutory basis for assessing bodily injury claims with the aid of tables. The courts have to judge the cases based on equity (that means based on precedents and the 32
UNESCO Chair in Bioethics 10th World Conference
differing cultural perspectives, while not comprising the ethical principles. THE STUDY AND ANALYSIS ON THE PRINCIPLE OF INFORMED CONSENT IN THE FORENSIC IDENTIFICATION Lv Duan, Shu Bo‐Qing Huang, Zhi‐Min Su, Kai Liu, Tao Wei, Zhen Li Kunming Medical University, China [email protected] Objective: We try to understand the relevant realization, knowledge structure, attitude and behaviour, from those policeman and police woman who work in various public security bureaus (PSB) distributed in certain parts of Yunnan province in people republic of China about medical ethics in forensic fields. We also try to find out the way to prove the knowledge, concepts and behaviors about the forensic ethics. Method: Making the enquiring forms by our investigator. Carry out the investigation work in Puer, Xishuangbanna and Yuxi states, which distribute the southern part of Yunnan province. The way of investigation is Self‐Administered Questionnaire Survey Method. The content of the survey includes the principles of informed consent, principles of confidentiality, the principles of respect and the principles of justice and equality. Result: (1)Among the informants, about 87% of them believed that before performing the autopsy, there should be an informal consent taken about autopsy permit must be granted by the relatives of the deceased ,and about 13% of them believe that they do not have to get any informal consent, according to the relevant provision(Criminal Procedure Law) (2)During the investigation ,we found out that those who believe that before taking the human tissues for histological/toxicological examination the forensic police must get the permission, accounts for 91.3% of the crowd. Conclusion: Although the forensic police have a higher knowledge concepts and behaviors about the forensic ethics, but sometimes it still needs to be proved and dealt with a certain level of precaution to avoid any kind of postmortem conflicts between the two parties. THE INSTRUMENTALIZATION OF MEDICINE: THE PHYSICIAN‐SOLDIER & CIVILIAN MEDICAL CARE Sheena M. Eagan Chamberlin University of Maryland University College, Germany [email protected] Military medicine involves more than the care of soldiers and their families. Another side of military medicine involves the care of civilians and the instrumentalization of medicine by the Armed Forces. In the U.S. military, civilian medical care has been used as a strategic tool since the Vietnam War. This use includes programs such as Medical Civic Action Programs (MEDCAPs) and Medical Readiness Training Exercises (MEDRETEs), which have expanded in scale and scope since their initial inception. Recently other national militaries have begun to employ these models of civilian medical care (provided by the military). Unfortunately, these programs represent a uniquely complicated moral experience for the military physician. As a result physicians have faced ethical dilemmas, moral distress and sometimes even refused to participate. This presentation will explore and analyze these programs, focusing on the physician experience, and the realities of participation. Examples will be drawn from the US military experience in the past, as well as contemporary international cases. Emphasis will be placed on differentiating these programs or missions from other forms of civilian or humanitarian aid. While humanitarian or altruistic goals are often associated with the work of civilian or NGO organization, and thus in line with the ethics of the medical profession, the strategic intent behind medical civilian assistance programs in the military presents unique challenges representative of the problem of dual loyalty. EBOLA VIRUS AND INFECTIOUS DISEASE: THE DUTY OF PHYSICIAN TO CURE AND THE POSSIBLE RISKS – THE HALACHIC DILEMMA Cesare Efrati 1, Nicole Piazza o Sed2, Claudio Cannaviello1 1
Jewish Hospital of Rome, Italy 2
Policlinic of Milan, Italy [email protected] Is it possible for a doctor to endanger himself for treating a patient? The Rama writes that we do not find anywhere that we can differentiate between infectious and non infectious disease with regard to visit the sick, except for a particular illness of which the Gemara warns that one must not sit "in the shadow of the patient". However, Rav Chaim Palaggi writes that there is no obligation for one to put oneself in danger to fulfil the mitzvah of “bikkur cholim”. The Sefer Chassidim writes that a person with an infectious skinhead disease should not bathe together with another unless he has told him of his disease, for the Torah says "you shall not stand idly by while your fellow's blood is shed". Rav E.Y Waldenberg writes that a physician and anyone else whose duty it is to care for the sick, is permitted to endanger himself to do so and moreover, it is considered a great mitzvah on his part. He is not halachically bound to do so, but, on the other hand he must be certain that there is only a possible risk to himself should he treat the patient. Rav A.S Abraham asks why a doctor should not be obligated to treat such a patient who was in a life‐threatening situation. Since the doctor, nurse, or any other caregiver entered their profession on their own free will, knowing that there would be risk attached to their job, surely they should be obligated to treat such a seriously or possibly seriously ill patients also if there is a slight risk involved. VACCINATION OF HEALTH PROFESSIONALS Leonid Eidelman, Leah Wapner, Malke Borow Israeli Medical Association, Israel [email protected]; [email protected] Although vaccination has been proved to be a safe and cost‐
effective intervention, immunisation rates remain suboptimal in many countries, resulting in poor control of numerous vaccine‐
preventable diseases. Influenza alone accounts for between 250,000‐500,000 annual deaths globally and 3.5 million cases of severe illness. Between 11‐59% of healthcare workers get the virus while caring for infected patients. In spite of this, health professionals also have low vaccine coverage. Influenza vaccination of health care workers is recommended by various health authorities worldwide in order to prevent influenza, reduce staff absenteeism and protect vulnerable patient populations from the increased morbidity and mortality that influenza carries. Mandatory vaccination of health care workers has been implemented in some settings. For example, a number of Abstracts of Oral Presentations
healthcare facilities require immunity to infections such as measles, rubella, mumps and tuberculosis, as a condition of employment. Nevertheless such policies have raised considerable controversy and ethical questions among them issues of personal autonomy versus professional responsibility and whether there exists sufficient scientific basis to justify mandatory vaccination of health care workers. The presentation will provide a background to different campaigns targeting medical professionals and discuss the ethical implications of mandatory vaccination of healthcare professionals. HOW TIGHTLY ARE PAIN MEDICINE AND MORAL STANDARDS RELATED TO EACH OTHER? Elon Eisenberg Rambam Health Care Campus and Technion – Israel Institute of Technology, Israel [email protected] Although the obligation to alleviate pain and suffering has been the core of medicine since ancient times, pain medicine, as an independent profession, is only at its infancy. Nonetheless, pain medicine is already challenged by significant ethical dilemmas, some of which to an extent which may question the future of pain medicine as an independent medical profession. First, due to historical and conservative notions, major deficiencies in pain education occur in medical schools worldwide. Consequently, care givers who lack proper skills to diagnose and treat pain, often ignore their basic moral obligation by opting not to treat pain. The rising number of reports and warnings regarding adverse effects of commonly used pain treatments, such as opioids and anti‐inflammatory drugs, some of which life threatening, fuel this tendency. Notably, law suits have already been filed against caregivers in the United States who failed to adequately treat cancer pain. Second, private‐ and more recently public‐medicine has been pushed to adopt economical or 'business oriented' models of health care. As such, revenue generation treatments, invasive procedures in the case of pain medicine, have increased dramatically whereas other less lucrative treatments (i.e. multi‐
disciplinary pain management programs) fail to thrive even if shown to be more effective than other treatments for chronic pain. Judgment of treatments according to income rather than outcome creates a second, critical ethical dilemma in pain medicine. Lastly, the amazing increase in use of medical marihuana for pain in Israel creates another moral dilemma. Encouraged by medical authorities, prosecuted by the media when fail to comply, and demanded by patients, caregivers often feel forced to prescribe medical marihuana, even when evidence of efficacy and safety (for both individual patients and for the society) are minimal at best. These dilemmas will be presented and discussed during the presentation. DEFENDING “BIG BROTHER MD”: THE ETHICS OF ELECTRONIC ADHERENCE MONITORING IN UGANDA Nir Eyal1, Jeff Campbell1, Jessica Haberer2, Angella Musiimenta3, Dan Wikler4 1
Harvard Medical School, USA 2
Massachusetts General Hospital, USA 3
Mbarara University of Science & Technology, Uganda 4
Harvard School of Public Health, USA [email protected] Within a week of Edward Snowden’s revelations that America’s NSA monitors citizens’ Facebook accounts, Google searches, and 33
emails, sales of George Orwell’s 1984 were up by 7,000%. For years, journalists and academic experts have been raising concerns about what they call “Big Brother” in medical surveillance and monitoring. As early as 2000, referring to then‐
new techniques to monitor patients’ medical adherence, Cynthia Rand and Mary Ann Sevick have warned, “We are on the threshold of having an armamentarium of ‘big brother’ strategies to determine who is noncompliant.” Other writers use “Big Brother” for a cluster of more recent and technologically‐
advanced interventions for closer surveillance of patient behaviour and patient outcomes. Let us set aside worries about Big Brother fears and their cogency outside medicine. How cogent are those fears within medicine? We argue, not very much. We focus on the case of Electronic Adherence Monitors (EAMs), especially in the Ugandan setting in which we use them. EAMs record and report an array of health behaviors, ranging from taking daily medication to wearing medical devices. These devices are used in studies around the world, and are being considered for use by clinicians. They have become a key tool for studying health behaviors. However, use of EAMs is increasingly alleged in the media to represent a move towards “Big Brother” in medicine. We highlight the unique benefits as well as the potential ethical challenges that electronic monitoring generates. Potential philosophical and practical solutions to many of these challenges are presented. MALPRACTICE, PERSONAL DAMAGE AND MEDICAL LIABILITY S. Davide Ferrara University of Padova; International Academy of Legal Medicine, Italy [email protected] The Hippocratic Oath of the Third Millennium founded the ethical role of the physician in relation to his professionalism and the capacity to reduce the uncertainty in science, improving the quality of the health system. With the adoption of the “Oviedo Convention” in 1997, the principle that a “patient has a fundamental right to obtain compensation for unjustified damage (harm) suffered as a result of a medical intervention” was established, furthermore calling for an “intervention in the healthcare sector”. Despite these auspices, there has not been any normative action intended to harmonize the regulations regarding medical professional liability and personal damage estimation in Europe; while the multi‐fragmentation of each discipline is exhausted in the endless comparison between “reason and fact”, which belong to the current global society of risk. This is not only a matter of health laws, but an issue involving medical ethics balancing opposite requirements: the health costs due to “defensive” medicine, lack of physicians for more exposed specialties and high transaction costs on one hand; the need to promote civil justice, deter substandard care, identify incompetent practitioners, and encourage systemic quality improvement on the other. The International Medicolegal Academic Community has commenced the virtuous course of action and the difficult task of contending with Medical Malpractice and Personal damage estimation, a real pandemic. Two International Interdisciplinary Guidelines where produced on these issues, and here presented to answer the unsettled demand for the harmonization of ascertainment methodology and evaluation criteriology on such topics, with so many direct and/or indirect ethical implications. 34
UNESCO Chair in Bioethics 10th World Conference
TO WHAT EXTENT DOES A SURROGATE HAVE REAL AUTONOMY? school vaccination programs in the US and Israel against the human papilloma virus (HPV) will be used as a case study. Julia Feuer Bar Ilan University, Interdisciplinary Center (IDC) in Herzliya, Israel [email protected] In contemporary society, the concept of autonomy is discussed as a norm. This may be true in a western democratic society but may not occur on a global basis. This paper will explore whether surrogates in cross border surrogacy arrangements really have autonomy. Surrogacy can only be undertaken by women; therefore this subject should be explored from a feminist perspective taking into account the theories of ethics of care and relational autonomy. Cross border surrogacy is a growing industry, but the area is often unregulated or without sufficient safeguards to protect the needs of the surrogate during the whole process. There are many legal, cultural and circumstantial differences between surrogates in this global phenomenon. Not all women are able to exercise their rights and many are led to surrogacy from a situation of poverty. To some surrogacy may lead to empowerment and to others abuse. It can be concluded that the concept of relative autonomy is different according to the circumstances of the surrogate and her location. In many ways she is exercising her autonomy, taking into account the needs of her family, but if circumstances were different contractual surrogacy may not be her choice. Protective legislative measures and full informed consent should become standard procedures, so that she can be safeguarded and be able to influence the medical procedures and the conditions to which she is subject in order to achieve real autonomy. HOW NOT TO RUN A VACCINE PROGRAM: ETHICAL ISSUES AND TRANSPARENCY Diana Flescher Israel [email protected] National vaccination programs purport to serve the public good by preventing disease morbidity and mortality, absenteeism from work and school and chronic disability. However, in the developed world the public has been increasingly expressing "vaccine hesitancy" i.e. questioning the benefits of vaccination and alarmed by possible risks. Public mistrust of reassurances by government bodies has led many parents and individuals to refuse or delay vaccination. The benefit of a particular vaccine must outweigh the risks of vaccination, especially since vaccination targets healthy individuals, who may never come in contact with the offending virus. A national vaccination program must therefore adhere to at least three tenets: 1) the disease must be clearly linked to the targeted virus, in the absence of confounding cofactors 2) the lethality of the virus must be clearly documented and accepted in the public perception and 3) the incidence of serious adverse events caused by the vaccine must be acceptably low, i.e. lower than the morbidity in an unvaccinated population. This last is the most challenging in a widely vaccinated and healthy population with no communal memory of diseases prevalent in the prevaccination era. This presentation will review the issues and actions leading to public mistrust and will delineate the standards necessary for ethical vaccination programs, involving greater transparency in preclinical trials and post‐marketing studies and improvement in reporting systems. In this way, governments can allay public fears and prevent the reemergence of devastating diseases. The recent RIPPLE EFFECT OF SIMULATION TRAINING FOR END‐OF‐LIFE CARE Meir Frankel1,2, Yael Lahat2, Adir Shaulov3, Matan J. Cohen3, 3
3
4
Ran Eliaz , Charles L. Sprung , Alan Rubinow , 2
2
5,6
3
Henia Perry‐Mezare , Rina Yahalom , Amitai Ziv , Mayer Brezis 1
Meir Medical Center, Israel 2
Clalit Health Services, Israel 3
Hadassah – Hebrew University Medical Center, Israel 4
Ministry of Health, Israel 5
MSR – Israel Center for Medical Simulation, Israel 6
Sheba Medical Center & Tel Aviv University, Israel [email protected] Improving quality of end‐of‐life (EOL) care demands a paradigm shift in attitudes of healthcare providers and patients to discuss and respect care preferences at EOL. Coping with uncertainty requires capacity for paradoxical thinking and for bioethical discourse. Institutions need to develop preparedness to EOL with palliative care, appropriate resources and executive policy. In 2011, we initiated a 1‐day simulation‐based training workshop to improve EOL skills with professional actors, personal feedback and video‐based debriefing discussions. In 3 years, over 350 residents, senior physicians and nurses from 21 hospitals and 3 nursing homes attended the workshop, which was conducted at MSR – Israel Center for Medical Simulation. Surveys and focus groups up to one year later indicated high satisfaction with workshops, improved knowledge, attitudes, skills and practice. Group discussions at workshops portrayed a rich picture of field challenges and triggered a series of “bottom‐up” initiatives. Collaboration with Clalit Health Services, Ministry of Health (MOH), and Israeli medical associations of Internal Medicine, Geriatrics and Intensive care, secured systematic training of workforce in medicine and geriatrics, later extended and adapted to intensive care units and other specialties. Workshop participants were involved in the delivery of lectures on EOL to healthcare executives and the general public as well as in local initiatives such as seminars, research projects (e.g. – survey of nursing homes), publications and the establishment of a palliative care unit. All the above was presented to the MOH, which initiated a national evaluation of preparedness to EOL and nominated a committee for reforming regulation. In conclusion, simulation training appears to trigger multi‐level effects to improve EOL care in Israel. “EU”, SHORT FORM FOR “ETHICAL” UNION? THE ROLE OF ETHICS IN EUROPEAN UNION LAW Markus Frischhut MCI Management Center Innsbruck, Austria [email protected] Background: In various legal (binding and non‐binding) documents, the European Union (EU) refers to the concept of “ethics” (and/or “morality”), without providing a definition or at least indicating a certain understanding. However, if a certain activity is qualified as “unethical”, there can be important consequences, such as exclusion from funding under the “Horizon 2020” program, or no right to cross‐border healthcare under the “EU Patient Mobility Directive”, just to name a few examples. Method: In this research, the author reviewed both EU Primary (TEU, TFEU), and especially EU Secondary law. In the latter Abstracts of Oral Presentations
category, approx. 60 relevant documents have been identified, where the term “ethics” (etc.) has been used. A special emphasis has been put on bioethics, although also other sectors have been involved in this study, in order to draw a more holistic picture. Results: I will argue that in a lot of cases (especially EU Primary law), ethics is (only) used in order to avoid interference of the EU in Member States competences, especially in sensitive fields, like abortion. However, in EU Secondary law there are also positive approaches of increasing clarity. This is done by Ethics Committees and/or Code of conducts, in both cases either at EU or at national level. In some examples, there are even some hints or references to other sources, or to the national level, in order to determine the relevant content. Still, there are also documents without any determination as regard the content. I will further argue that those gaps mainly have to be filled at EU level with reference to the EU fundamental rights, especially the “key stone” of human dignity, the right to life and the right to integrity (Articles 1‐3 of the EU Charter). EAST AND WEST BIOETHICS – MORE SIMILARITIES AND GOOD FOR GREATER HUMANITY Harischandra Gambheera Sri Lanka [email protected] We consider two major cultures in the world, east and west. The ethical values derived from Hippocratic Oath and developed in the west was considered western tradition. Similarly in the eastern culture, ethical guidelines for doctors (healers) have been laid down in the oath of Initiation for physician by Acharya Charak in his renowned work “Charak Samhita” which is considered as encyclopaedia of Ayurveda. Even though we observe minor variance those could be justified considering cultural differences in these two major cultures, there are large similarities accounted for greater humanity. In fact there are more similarities than difference in these two traditions of ethics in medical practice. This presentation will elucidate the ethical traditions in East and West, then attempt to consider the similarities and differences including the cultural differences EMPHASIS ON SOCIO CULTURAL DIVERSITY IN TEACHING BIOETHICS IN MEDICAL Barna Ganguly India [email protected] Medical profession is confronted by an explosion of technology, globalisation. The medical professional everywhere is embedded in diverse cultures natural traditions. There are wide variations in medical delivery and practice. As a result the physicians find it difficult to meet the responsibilities to patients and society. There is now increased concern about the knowledge of socio‐
cultural diversity for the medical professionals both in practice and research. Responding to this challenges, one of the ways to avoid the difficulties is to recognize and emphasize on sociocultural diversity while teaching Bioethics in undergraduate medical curriculum. 35
THE STUDY OF THE NATIONAL CUSTOMS IN FORENSIC IDENTIFICATION Sheng Gao1, Ke‐Ran Li 1, Wen Wu‐Bei Chen1, Hong Liang2, Zhen Li1, Tao Wei1 1
Kunming Medical University, China 2
People's Procuratorate of Kunming, China [email protected] Objective: Involved in the forensic identification of the police in Yunnan Province, ethnic customs issues are conducted investigates, providing guidance for forensic medicine appraisal work. Method: Using cluster sampling method to carry on the questionnaire survey to the police in some areas of Yunnan Province behavior in his work, the investigation time for one year. Results: We will divide the respect for the national customs into three levels, including great importance, importance and unimportance, people thinking of great importance to the respect for the national customs account for 71.09%, people thinking of importance to the respect for the national customs account for 28.99%, people thinking of importance to the respect for the national customs account for 0%. In the investigate of disagreement to do a postmortem because of the special of National customs, people agreeing to give up do a postmortem account for 11.59%, agreeing to force to do a postmortem account for 4.35%, agreeing to do a postmortem after working on them account for 84.06%, people thinking that Case need to be more cautious in minority nationality areas account for 76.09%. Conclusions: Involved in the process of forensic identification of ethnic customs problem is of great significance to Forensic medicine appraisal work, and all of the forensic workers should strengthen forensic ethics study. Meanwhile, in the actual daily work, forensic workers should adequately combine national customs problem, the rights and obligations of forensic expert witnesses and identified person and Code of ethics in the forensic medicine appraisal. FORCE‐FEEDING HUNGER STRIKERS: HUMANE OR INHUMANE TREATMENT? Mirko D. Garasic Tel Aviv University, Israel [email protected] In the USA, Israel and other countries there has been a wave of Hunger Strikes (HS) in recent years. In line with the nature of this panel, in this paper I will take into account two recent articles that discussed the moral implications for doctors involved in situations of HS –particularly in relation to Guantanamo’s prisoners. The authors of these articles, Annas et al. and Gross, call on physicians to refrain from force‐feeding (FF) inmates for two reasons: 1) FF is a direct violation of one’s autonomy, and complicity of physicians in the act implies violation of medical ethics, and 2) if physicians indeed stop FF, the conditions of at least some prisoners will improve. I will provide a few additional considerations concerning the issues at stake that are worth of attention. In what follows, I will first briefly review these papers and the ethical dilemmas raised by them. Second, I will enlarge the analysis of HS at a global level, showing that its detachment from politics is impossible. 36
UNESCO Chair in Bioethics 10th World Conference
GLOBAL BIOETHICS AND THE CHALLENGE OF CONVERGENCE IN CULTURAL AND RELIGIOUS DIVERSITY LAW, BIOETHICS AND MEDICAL DECISION‐MAKING: THE IMPACT OF CULTURE Alberto Garcia UNESCO Chair in Bioethics and Human Rights, Italy [email protected] In contemporary bioethics some secular scholars and politicians claim that global bioethics should ignore religious convictions since religion, through history, has been cause of conflicts, wars and misunderstanding. Religions are so different that dialogue and common ground in bioethics is useless and fruitless since believers are biased by their religious convictions. We claim that in a multicultural and multireligious world, to foster convergence and cooperation in global ethics is not only possible but it is a moral and political demand entailing to assure effective and democratic participation of the different cultures in bioethical debates. Academic institutions might develop and important role in this endeavor. A global bioethics ignoring religious beliefs would cause that “universal” principles and guidelines established by international organizations be challenged as illegitimate or unjust, being rejected or disobeyed, invoking freedom of conscience. Its Conventions or Declarations, even though formally supported by State representatives, would be essentially antidemocratic. Those claiming that bioethics should be rooted in a particular religion and that “only their God” or “tradition” is the only source of moral behavior would deny freedom of conscience and religion of others believers as well of non believers. They should learn from moderate positions within their own religious traditions and respect reasonable secular approach. An spirit of dialogue and mutual understanding should help to foster the art of convergence and cooperation in bioethics. Theological reflection might help to understand, through faith, ultimate sense and foundation of life and moral behavior according to different religious beliefs, but only science and reason should illuminate bioethical debate in a globalized world. Human dignity and human rights/duty language might be helpful to facilitate this understanding in global ethics. SUICIDE PREVENTION IN EMOTIONAL FIRST‐AID SERVICES: ETHICAL DILEMMAS Itzhak Gilat The Israeli Association for Emotional First Aid (ERAN), Israel [email protected] Services of emotional first aid provided by trained volunteers are viewed as valuable source of crisis intervention and suicide prevention for more than five decades. From their very beginning, these services faced ethical dilemmas regarding interactions with callers who expressed explicit wish to die or threatened to commit suicide. The dilemmas emerged from two conflicting ethical guidelines: Respecting the anonymity of callers to these services (which is a major principle in the ethical code) on the one hand and saving lives of individuals at risk, which sometimes requires to violate the anonymity, on the other. We shall present in detail and exemplify the nature of this dilemma within the context of the Israeli Association for Emotional First Aid (ERAN), that offers assistance via telephone and internet. Roy Gilbar1, Jose Miola2 1
Netanya Academic College, Israel 2
University of Leicester, UK [email protected] Western medical law and bioethics have developed in a way that has promoted a liberal‐individualistic approach to patient autonomy. These two areas have also perceived the patient alone as the unit of care and focused on the personal rights of the patient. In light of this approach, it has been less clear how Western medical law and bioethics address the cultural values of patients from non‐Western backgrounds who believe that “you are your family and your family is you”, and prefer, inter alia, hope to full disclosure and family‐determination to self‐
determination. This paper will examine whether and how medical law and bioethics deal with the desire of patients from non‐Western backgrounds to follow their cultural values, to remain passive in decision‐making and to provide their family the decision‐making authority. This paper will argue that this desire is not catered for effectively either in English and Israeli medical law or by the professional ethical guidelines published by the British General Medical Council and by the Israeli Medical Association. The paper will examine an alternative approach based on relational autonomy that might serve both to allow such patients to follow their personal preferences while still allowing them to include family members in the decision‐making process. The paper will offer some legal solutions in this context. PRINCIPLES OF PSYCHOLOGICAL ASSESSMENT OF PARENTAL COMPETENCE IN THE MUSLIM‐ARAB SOCIETY IN ISRAEL Emad Gith International Center for Health, Law and Ethics, University of Haifa, Israel [email protected] According to Sharia law, a son remains under his mother's care until he reaches age 7 and a daughter remains in her mother's care until age 9. Once they reach these ages, the father is granted custody of the children. If there is no father, custody is granted to their grandfather. Muslim‐Arab citizens in Israel consider the Sharia court the legal authority certified to deliberate and rule on laws pertaining to divorce, custody, adoption and guardianship. In case of disagreements between parents regarding custody of their children, the Sharia court or the family court determines who shall be granted custody. In order to do so, it requests psychological assessment of parental competence. It should be noted that professionals often encounter various professional and ethical issues in the Muslim‐Arab society as the assessment is highly culture‐dependent. Muslim society is a collective one, in which the extended family plays a very dominant role and men are considered to have higher standing than women. When psychological assessment is required, it is conducted according to diagnostic data and accepted diagnostic tools. Today, there are no psychological assessment tests that have been adjusted for the Arab population. A test must be reliable and reflect the circumstances being evaluated and the lack of standardization for many of the existing tests makes the assessment process irrelevant. In certain cases, initial counter‐
examination puts the professional in an uncomfortable situation. This is true for the Arab world as well. It is clear to almost all Abstracts of Oral Presentations
psychologists that they must use their own professional training and experience after conducting the assessment in order to make a diagnosis that accurately reflects the patient's inner‐emotional or cognitive reality. As a result, the existing general model for assessment of parental competence in Israeli society cannot be applied as it is culture‐
dependent, and does not reflect the culture of the Muslim‐Arab minority in Israel. Therefore, I believe that there is a need to develop a model that is suited to the emotional‐culture world in question. The new model should take into account the Sharia legal system and the impact of the extended family on the individual, and emphasize the differences between men and women in Arab society. Most importantly, the model should reflect sensitivity to the patient's cultural world. A model of this kind will, of course, serve as a complimentary tool to existing diagnostic tools that are commonly used today for this purpose. FORCE‐FEEDING HUNGER‐STRIKING PRISONERS – ANOTHER VIEW Shimon M. Glick Ben Gurion University of the Negev, Israel [email protected] During the past few decades many Western medical organizations including the Israel Medical Association have forbidden physicians to feed hunger‐striking prisoners without their consent as a violation of human rights and as torture. I contend that in line with decisions by Israeli courts and in line with Jewish culture the right to life should take precedence over that of human dignity in these cases. In the face of such hunger‐strikers there are three alternatives‐
Permit them to fast until permanent disability or death – this causes more suffering than passing a nasogastric tube; acquiescing to the prisoners' demands, which makes hunger striking the ultimate weapon of prisoners, leading to anarchy; or imposing feeding of the prisoners against their will, which I contend is far more humane and reasonable. Hundreds of hunger strikers have been permitted to die in Great Britain, South Africa and Turkey, which in my opinion does reflects shame on those societies. Many hunger‐strikers after being force‐fed express gratitude that their lives have been spared, since almost all of them did not wish to die. Almost all prisons go to great lengths to prevent suicide by prisoners; it should similarly make it clear to hunger‐
striking prisoners that while they will be permitted to fast, if and when a serious danger develops to their health and life an end will be put to the fast. This approach is in keeping with the Jewish tradition of incommensurability of human life and with a communitarian rather than an individualistic ethic. 37
also increasingly concerned that the H2N2 strain of influenza could threaten another pandemic. However, the question of compulsory vaccination raises a number of important questions which go to the heart of medical law and ethics: how far should government act in order to promote or protect the public good? Is it legitimate to constrain individual interests/rights in autonomy, liberty, privacy or property in trying to protect collective interests in health? Compulsory vaccination is often regarded as an unwarranted government interference with autonomy and liberty, but to what extent does this present an irreconcilable tension? Does the potential benefit of herd immunity trump all other individual interests? Should a compulsory vaccination programme be undertaken as part of an overarching civic duty to the collective? The responsibilities for our own health and that of others are interactional in nature. Arguably, this is brought starkly into focus in the vaccination context when it is considered that in tax based, national health care systems, such as the NHS, increasingly it is recognised that not all responsibilities for good health can fall upon the system and none on the users of the system. RITES AND RITUALS OF DYING: A SHIFT TO MEDICAL TECHNOLOGY Michael Gordon Baycrest Geriatric Centre and University of Toronto, Canada [email protected] The shifting world of medical technology has had a profound impact on the way individuals view the dying process. The process of dying was accompanied by rites and rituals of dying, drawn from religious, cultural, ethnic and community/family traditions. Prayers, chants, songs and human communication and physical and emotional touch, prepared the loved one to leave the world and those left behind to be part of the transition from life to death. The rapid growth of medical technologies has shifted the focus from traditional rites and rituals to a replacement with medical technologies the most dramatic of which include “salvage” therapies such as CPR, potent antibiotics for what are often terminal or pre‐terminal infections, chemotherapies for advanced malignancies and a range of medical and surgical interventions that meet the needs of the families as much as or more than the clinical benefit of the patients. During the grieving period one often hears families laud the attempts to postpone death through medical technologies. Commonly heard phrases include: “the most powerful antibiotics were used in an attempt to save him”; “they did not give up the resuscitation until he was too far gone to continue” or most important, “we did our best to save him”. The recognition of the quasi‐ritualistic role of end‐ of‐ life medical technologies must be included in how we communicate with family members who focus on such treatments rather than comfort and quality at the end of life. COMPULSORY VACCINATION AND THE COLLECTIVE GOOD: GOING BEYOND A CIVIC DUTY? Nicola Glover‐Thomas University of Manchester, UK nicola.glover‐[email protected] Distrust of vaccines, from the pertussis vaccine controversy in Great Britain in the 1970s and 1980s through to the MMR study in 1998, has threatened efforts to protect patients from preventable diseases. Latterly, this distrust has evinced further difficulties in responding to more recent threats presented by the H1N1 and seasonal influenza viruses; public health officials are THE ETHICAL ROADBLOCKS TO MEDICAL TOURISM Elinor Goshen, Baruch Chen, Tami Karni Israeli Medical Association, Israel [email protected]; [email protected] Medical tourism has noticeably increased over the years due to the ease and diminishing costs of travel, increasing healthcare costs, and globalization. In tandem with this, increasingly aggressive marketing campaigns, in some countries hospitals and insurance companies have begun to leverage their connections 38
UNESCO Chair in Bioethics 10th World Conference
to grow the medical tourism business into a major economic force. This raises several ethical questions. The rise of medical tourism emphasises the privatisation of health care, uneven access to health resources and the ever‐
increasing globalisation of both health care and tourism. However, empirical evidence regarding the health and safety risks facing medical tourists is limited. While individual patient risks may be offset by credentialing and sophistication in (some) destination countries, lack of benefits to poorer citizens in developing countries offering medical tourism remains a generic equity issue. The effect of medical tourism on the host country's population, particularly the poor, to be pushed farther down the queue to receive care is also a cause for concern. In many countries, resources are used to build up their foreign trade instead of developing the local healthcare system. Another potential problem is the obligation of the home‐country physician to provide follow‐up care. There are a myriad of problems and ethical questions associated with this area, including quality of care, adequate documentation, doctor‐patient relationship, and complete patient information. There is also the issue of promotion of medical tourism. This presentation will explore the current situation of medical tourism in Israel and address these issues. ETHICAL, LEGAL AND SOCIAL IMPLICATIONS OF NEW AND EMERGING TECHNOLOGIES: EXOSKELETONS Dov Greenbaum Radzyner Law School, Israel; Interdisciplinary Center (IDC), Israel; Yale University School of Medicine, USA [email protected], [email protected] Science fiction has become reality: FDA approved exoskeletons are now available to help disabled patients gain back lost mobility. Succinctly, exoskeletons are mechanical appendages that allow paraplegics the ability to stand and walk. While this incredible technology has the potential to help tens of thousands, it raises new and interesting ethical, legal and social issues that ought to be dealt with before the technology becomes entrenched. These concerns include the development of the technology for military use, particularly, when that use dehumanizes soldiers and makes them more likely to kill or be killed. Dual uses also exist for high‐strain, repetitive work environments where exoskeletons developed for the disabled could be co‐opted (some might argued abused) for the able bodied worker. Similarly, the ability of this technology to allow formerly wheelchair bound individuals to walk skews the line between abled and disabled. The high cost of this technology raises social justice concerns relating to fair access, and the use of these potentially always‐on mechanical attachments raises issues related to human enhancement. These concerns will become more apparent when direct neurological links to an exoskeleton further confuses the boundaries between human and cyborg. Legally, there are issues associated with the regulation of these devices, how different are they from motorized wheelchairs? Further regulatory controls may be necessary to prevent hacking the systems to further enhance and possibly unintentionally harm a patient. Additionally, there are legal concerns related to liability, particularly as eventual iterations of these exoskeletons become semi‐autonomous or even fully autonomous. ENTERAL NUTRITION IN END OF LIFE: THE JEWISH HALACHIC ETHIC Chaya Greenberger Israel [email protected] Providing versus foregoing enteral nutrition is a central issue in end of life care, affecting patients, families, and health professionals. This presentation examines the Jewish approach to nourishing the dying in the context of other ethical perspectives and analyzes their implications for practice. Jewish ethics is based on religious law, called Halacha. Many halachic scholars perceive withholding nourishment even enterally, as hastening death in principle. This reflects the divide they perceive between allowing a fatal disease to naturally run its course until an individual's vitality (life force or viability) is lost, versus withholding nourishment for the vitality that still remains. The latter they maintain, introduces a new cause of death. Nevertheless, coercing an individual to accept enteral nourishment is generally considered undignified and counterproductive. A minority of halachic scholars classify withholding enteral nutrition as refraining from prolonging life, permitted in principle under certain circumstances, especially in situations where nutritional problems flow directly from a fatal pathology. In the event of enteral nourishment becoming a source of overwhelming discomfort, two halachic ethical mandates would come into conflict: sustaining life by providing nourishment and alleviating suffering. As in all moral conflicts, these would have to be resolved in practice. In the very final stages of dying there is a general consensus that enteral nourishment may be withheld, providing that this reflects the dying individuals' wishes. In a world that remains broadly religious, it is necessary for health professionals to broaden their understanding of religious perspectives on ethical issues and how they compare to those of a secular nature. PRE‐IMPLANTATION GENETIC DIAGNOSIS FOR SEX SELECTION FOR NON‐MEDICAL REASONS: POSITION STATEMENT OF THE ETHICS COMMITTEE OF THE ISRAEL FERTILITY SOCIETY Ronit Haimov‐Kochman1, Shlomo Mashiah2, David Heyd3, 4
1
5
Aviad Hcohen , Einat Eisenman , Shlomo Vilk, Zvia Mimoni , 6
1
Etti Peretz, Hedva Eyal , Neri Laufer 1
Hadassah Hebrew University Medical Center, Israel 2
Tel Aviv University, Israel 3
Hebrew University, Israel 4
Shaarei Mishpat School of Law, Israel 5
Shaarei Zedek Hebrew University Medical Center, Israel 6
Haifa University, Israel [email protected] Sex selection with in‐vitro fertilization (IVF) and pre‐implantation genetic diagnosis (PGD) is permitted in Israel only after the birth of four children of one gender and following approval by the national committee that was appointed to deliberate such cases. The committee was formed to prohibit sex determination except in exceptional cases. The Ethics Committee of the Israel Fertility Society considered diverse aspects of this issue but failed to reach a consensus whether sex selection for non‐medical reasons should be permitted at all. The majority opinion asserts that sex selection is not necessarily motivated by sexism, nor does it bear grave societal Abstracts of Oral Presentations
consequences. The advances in IVF and PGD change the prohibition of sex selection from a theoretical debate to a regulation limiting free choice and individual autonomy. Denial of the option to determine sex before implantation may even lead to the deplorable decision to terminate a pregnancy to prevent the birth of a child of the unwanted gender. These assertions support the change of across‐the‐board prohibition of pre‐
implantation sex selection to a policy of allowing it under specific limitations. The minority opinion contends that the reasons for sex selection often reflect prejudicial attitudes and stereotypical opinions; therefore, permitting pre‐implantation sex selection would be counter to principles of human rights, which are based on the presupposition of gender equality. Based on the profile of applications to the committee in Israel, a clear preference for males exists, creating a real risk to the welfare of the family and society. Prohibition of pre‐implantation sex selection sends a clear message to society that preference of one sex over the other is morally unacceptable. The committee supported the provision of IVF‐PGD for sex selection under these limitations: 1. In a patient undergoing IVF (with or without PGD) for medical reasons. 2. Only in families with three or more children of the same gender. 3. In any case the cost will not be covered by the national health insurance. ETHICAL DILEMMAS AND MORAL DUTIES OF A HOSPITAL DIRECTOR Jonathan Halevy Shaare Zedek Medical Center, Israel [email protected] It is customary to ascribe to the head of an organization "ministerial responsibility" for all that occurs within his establishment, a term which in itself carries ethical implications. Nevertheless, to date, little attention has been given to defining the moral responsibilities of the hospital director, who, for the public, remains a shadowy authority unrelated to more direct encounters with hospital physicians and staff. In fact, the director is accountable to four distinct entities – his patients, his staff, the community served by the hospital and the national health authorities. As such he is the final address for the numerous ethical and moral questions that arise daily in the many‐faceted functioning of the hospital. Assessing the circumstances surrounding exceptional medical outcomes such as maternal death, .prioritizing admissions to departments of limited size, allocating scarce financial resources, introducing new technologies and medications, weighing professional skills against unsatisfactory bedside manner, maintaining good inter‐
ethnical relationships, ensuring transparency in reports to the ministry of health and sick funds – are discussed in this paper as examples of moral dilemmas for which the hospital director must provide definitive responses. Solutions considered appropriate are reviewed in the perspective of the Israeli Patient's Rights Act, 1996 and with the proviso that personal judgments, rather than text book answers, are frequently the ultimate guide in the ethical decisions and moral responsibility demanded by the position of hospital director. 39
PRIMUM NON NOCERE V. CAVEAT EMPTOR Ross Halpin Sydney University, Australia [email protected] The barbaric actions of Nazi doctors in medical research during the Holocaust were the genesis of the Nuremberg Medical Code of Ethics. It was expected this code and similar codes established internally by the research institutes, would be recognized, applied and respected by all medical scientists and all institutes involved in medical research. Similarly the Hippocratic Oath has been a powerful guiding light for doctors and physicians. However based on evidence from what has and is occurring in medical research, marketing of pharmaceutical products and the relationship between the medical fraternity and pharmaceutical companies the question must be asked if medical ethics is being undermined or in some cases abandoned. In this presentation I will discuss two issues: First: the results of a survey of a number of doctors, medical researchers, scientists and philosophers who were presented with human experiments carried out by SS doctors. The respondents were then asked questions related to the use of the data. Second: during the latter part of the 20th century and into the 21st century a number of the largest pharmaceutical companies in the world have been made to pay multi billion dollar fines for selling off label drugs. This practice has resulted in the death of a number of people. Ironically on the one hand there is a link between the two issues that questions the place of ethics in medical research and medical practice. The link is the question of life and death. On the other hand ethics is being eroded because of the influence of shareholders, profit and greed. What needs to take place to maintain high ethical standards and yet meet the changing world of corporate dominance? ETHICAL DILEMMA IN THE USE OF INFORMATION TECHNOLOGY Mentor Hamiti Macedonian Unit, UNESCO Chair in Bioethics [email protected] In recent years, we have witnessed that ethics is being treated very seriously in any modern society. It directly affects the lives of communities, family life, human relations, democracy and all social areas, including education and research institutions. It is worth mentioning the current trend of enriching study programs with courses dedicated to ethics. Moreover, research centers and professional units are continuously emerging as well as many international conferences are organized, where ethical issues are examined and explored from different angles. In this context, the ethics of the use of Information Technology, considering the large number of users and the differences between them, is an important research topic and it deserves proper treatment. Therefore, in the framework of this paper is examined the current trend of internet usage in relation to ethical values. A random survey was conducted at the South East European University in Macedonia, where are handled few cases dealing with freedom of expression while online, privacy and anonymity issues and up to cases that are categorized as computer crime. Also we requested an answer to the question of what to expect in the future and how to support users in maintaining ethical values when using Information Technology! 40
UNESCO Chair in Bioethics 10th World Conference
LAST RIGHTS: END OF LIFE DECISIONS IN CANADA Mark Handelman University of Toronto, Canada [email protected] In 2013, The Supreme Court of Canada heard the appeal of two intensive care physicians who argued that withdrawing life‐
sustaining treatment they said offered no medical benefit to the patient did not require the consent of the patient’s surrogates because something offering no medical benefit is not a “treatment.” The physicians were unsuccessful in both lower courts and in the Supreme Court. This presentation examines the Supreme Court rationale and the consequences, in Canada, of that Judgment. BIOETHICS EDUCATION OF A DIVERSE STUDENT GROUP: DEVELOPMENT OF A CURRICULUM Jonathan Hellmann1,2, Rebecca Greenberg2, Dennis Scolnik2, Helen Stolte2, Celine Kim2, Randi Zlotnik Shaul2 1
University of Toronto, Canada 2
The Hospital for Sick Children, Canada [email protected] Aim. The aim of this study was to review the history and evidence‐based literature regarding SPT, describe and provide a model for ethical SPT practice, and present two case examples illustrating ethical concerns. Methods. Literature review and report of clinical experience were the methods used. Main Outcome Measure. Results of literature review and clinical experience were assessed for this study. Results. Sex therapy pioneers Masters and Johnson introduced surrogacy in sex therapy; however, there is a lack of published evidence supporting treatment efficacy and ethico‐legal questions have limited the practice from becoming a common intervention. SPT can be an effective intervention that may enhance sexual medicine practice. However, SPT must be offered according to legal, professional, and ethical standards. Conclusions. Sexual medicine practitioners should consider SPT based on the ethical paradigms offered, and sex therapy practices utilizing SPT should collect and publish outcome data. CAN PREVENTION OF EATING DISORDERS BE REGULATED? ISRAEL'S "MODELING ACT" AS A CASE STUDY Galya Hildesheimer, Hemda Gur‐Arie Peres Academic Center, Israel [email protected] The WHO calls for stronger cross‐cultural emphasis in medical training. Bioethics education can build such competencies as it involves the conscious exploration of values and principles. Since 2004, The Hospital for Sick Children, Toronto has conducted a ‘health through peace’ 4 week elective in Paediatric Emergency Medicine for Canadian, Israeli, Jordanian and Palestinian (3 each) students encompassing 4 elements: clinical shifts, leadership, global health and peace building. The elective fosters dialogue and cooperation via lectures and seminars in addition to students living and working together. In the past two years a formal bioethics component has been incorporated into the program based on a perceived need by emergency department faculty. We sought to determine what such a bioethics curriculum should contain and how to evaluate it. Semi‐structured interviews were conducted with the students of 2013 to determine ethical issues arising in their country of training and in the elective, and with the 2014 students to evaluate the bioethics teaching in the elective. A secondary objective was to determine how cultural differences affected their experience. Focus groups were also conducted with elective supervisors. We obtained insights into students’ conceptualization of bioethics, their perceived bioethical needs, preferred formats and evaluation of the teaching. Faculty responses largely resonated with students’ identified needs and formats. Despite the complexities and contextual realities of students’ home environments there was broad agreement on key topics, preferred learning formats and assessment. Also apparent was student engagement and appreciation of opportunities for bioethical discourse during the elective alongside their clinical teaching. The Limitation of Weight in the Modeling Industry Act, 2012 is an innovative legislation initiative, aiming at combating eating disorders. The Act places two major limitations upon the modeling industry: first, the Act restricts employment of models of a BMI below 18.5, and second, the Act requires placing upon ads a noticeable disclaimer specifying that digital editing (such as "photoshop") has been used to reduce body sizes of models. The motivation behind this law is to limit the presentation of unnatural body images and to restrict the exploitation of ultra‐
thin models. The legislators assume a direct link between public exposure to slim models and the rapidly increasing rates of eating disorders in western societies especially among women and female adolescents. In a desperate aspiration to adopt unnatural and unhealthy looks of digitally altered images of models or of underweight models, some women presumably engage in health detrimental dieting, which may further develop into eating disorders. Although Israel is the first country to adopt such legislation, not much can be inferred from the Israeli experience. In this paper, we wish to elaborate upon major limitations of the "Modeling Act". Inter alia, we claim the law to be of a narrow scope, under‐
enforced and only partly effective. We additionally wish to discuss whether legal intervention is an appropriate mechanism to combat the social causes of eating disorders, or more broadly, whether freely adhered to social practices can and should be regulated? SURROGATE PARTNER THERAPY: ETHICAL CONSIDERATIONS IN SEXUAL REHABILITATION MEDICINE 2,3
2
1
Rafi Heruti , Ronit Aloni , Talli Rosenbaum 1
Inner Stability, Ltd., Israel 2
Tel Aviv University, Israel 3
Reuth Medical Center, Israel [email protected] Introduction. Surrogate partner therapy (SPT) is a controversial and often misunderstood practice in Sexual Rehabilitation Medicine, especially from the ethical point of view. DOCTORS AS BYSTANDERS DURING THE INDIGENOUS AUSTRALIAN GENOCIDE Peter Honeyman Sydney University, Australia [email protected] The British colonization of the Australian continent, starting in in 1788, is now judged to have been an invasion accompanied by genocide. The violence, disease, displacement, and removal of children from families, led to the collapse of the indigenous populations and their cultures. Abstracts of Oral Presentations
Doctors arrived with the first and subsequent fleets, cared for and recorded the health and mortality of the populations. This presentation questions the ethical performance of the doctors and their organizations in relation to these events. This is done through timelines of the genocide, the growth of the profession, and the enlarging ethical expectations, up to current times. The doctors acted as bystanders to the genocide, recording the disease related causes of the indigenous decline. A few doctors joined the fashion of comparative anatomizing of indigenous remains, but this activity, including the large volume export of skulls, was generally undertaken by non‐medical scientists. Hospital care was segregated till the 1960’s. Changes have occurred from the 1970’s onwards that have shifted the profession to better identifying the continuing health disasters of the indigenous population and to actively campaigning to improve. The current medical profession could learn to be more vigilant in preventing any population being defined as inferior in the need for medical care. The topical Australian example is the campaign to ensure refugees, deemed illegal, do not receive reduced standards of medical care. THE STUDY AND ANALYSIS ON THE PRINCIPLE OF RESPECT IN THE FORENSIC INVESTIGATION AND IDENTIFICATION Shu Bo‐Qing Huang, Lv Duan, Sheng Gao, Tao Wei, Zhen Li Kunming Medical University, China [email protected] Objective: We try to understanding and respect for the views of the principles of forensic ethics in Yunnan Province, the policeman on duty. Put forward some preliminary discussion. Method: Using cluster sampling method to carry on the questionnaire survey to the police in some areas of Yunnan Province behavior in his work, the investigation time for one year. Results: (1) in the police forensic science inspection and identification of the suspect, think the need to respect the dignity of human personality accounted for the total number of the 93.5% investigations. (2) in the investigation of the police group, does not recognise the autopsy process action rough accounted for 87%. Conclusions: Although the forensic police have a higher knowledge concepts and behaviors about the forensic ethics, but sometimes it still needs to be respect is the identification of people to avoid any kind of postmortem conflicts between the two parties. USING INNOVATIVE METHODS TO INCULCATE ETHICAL THINKING AND BEHAVIOUR AMONG HEALTH SCIENCE STUDENTS Animesh Jain1, Princy Louis Palatty2, K. R. Nagesh2, Rashmi Jain3, Mary Mathew1, Ramya Shenoy4 1
Kasturba Medical College, Manipal University, India 2
Father Muller Medical College, India 3
Yenepoya University, India 4
Manipal College of Dental Sciences, India [email protected] Health sciences students need to develop a rational approach to solve medical dilemmas that they will face in the future. Just as they learn various subjects to tackle medical problems, they also need ethics to solve the moral dilemmas that they are likely to face in their future practice. The current curriculum does not have medical ethics as a separate subject in any of its courses. 41
Assessment drives learning is a known fact. Since there is no assessment the will to learn or even to attend bioethics class/sessions will be seen as an added burden unless it is mandated by the regulatory bodies and an examination is conducted in this subject. However, that may not yield the desired learning and the effect or sensitization needed. To do so, we need to inculcate ethical thinking by creating interest for the subject and learning. We need to sensitize medical and health sciences students regarding the bioethical principles and their importance. Hence with a view to kindle interest and also to make students learn in a fun way, some unconventional and innovative methods were tried and explored as a voluntary optional add on. These included movies, newspaper clippings and discussions based on current issues, debates and even a skit competition. The initial feedback seems to be very encouraging and the response is good. This paper would narrate the evolution, experience, methodology and challenges in implementing innovative teaching learning methods for bioethics. CHILDREN IN ARMED CONFLICTS AND CHILD SOLDIERS IN AFRICA: HUMAN RIGHTS AND ETHICAL ISSUES Istifanus Anekoson Joshua1, Jerry Gabriel Makama1, Audu Onyemocho2, Awawu Grace Nmadu1, Zainab Muhammad‐Idris1, Farouk Adiri1 1
Kaduna State University, Nigeria 2
Benue State University, Nigeria [email protected] Children are not simply a biological group but constitute a social group whose history differs depending on whether they are in developed or developing countries such as Africa. Children’s involvement in armed conflicts and Child soldiers are not recent phenomena and the African continent is often presented as the hardest hit. In the 1990s, Sub‐Saharan Africa (SSA) was marked by a long series of civil conflicts (in Liberia, Sierra Leone, Somalia, Burundi, Rwanda, Congo‐ Brazzaville, Democratic Republic of the Congo, Sudan, Ivory Coast) and recently insurgency has become an issue of concern in Nigeria. Children are more likely to become child soldiers if they are separated from their families, displaced from their homes, living in combat zones, or have limited access to education. A child soldier has been defined as a person under the age of 18 years who directly or indirectly participates in armed conflict as part of an armed force or group. Seven out of nine reports by Human Rights Watch on the use of child soldiers in the last ten years concern SSA countries; and it is estimated that some 300,000 children are today involved in more than 30 conflicts worldwide. They suffer from disruption of their education and basic health care, injuries from land mines, substance abuse, sexual violence in form of rape and post traumatic disorders among others. This paper examines the magnitude of child soldiers and children in armed conflicts in Africa, the correlates of child soldiers, Human Rights, Ethical and public health issues. THE JEWISH ETHICAL RESPONSE TO BIOETHICAL DILEMMAS IN THE HOLOCAUST Alan Jotkowitz Ben‐Gurion University, Israel [email protected] Fifty‐nine years ago, Dr Leo Alexander published his now famous report on medicine under the Nazis. In his report he describes the two major crimes of German physicians. The participation of 42
UNESCO Chair in Bioethics 10th World Conference
physicians in euthanasia and genocide and the horrible experiments performed on concentration camp prisoners in the name of science. In response to this gross violation of human rights by physicians, the Nuremberg military tribunal, which investigated and prosecuted the perpetrators of the Nazi war crimes, established ten principles of ethical conduct in medical research in 1949. Notwithstanding all these important efforts and impressive achievements in understanding the ethical failings of Nazi physicians, the bioethical community has almost completely ignored the moral challenges facing the victims of the atrocities. These dilemmas and their responses have continued relevance for modern medicine. The responsa of the Holocaust survivor Rabbi Ephraim Oshry and other rabbinical figures are a valuable source to help understand the Jewish ethical response to unimaginable horror and tragedy. Topics to be discussed include: May one put yourself at risk to save a friend? Can one save one's own child at the expense of another? When if ever is abortion and contraception sanctioned in the ghetto? Is euthanasia ever permitted? And issues related to the survivors. In analyzing these responsa we can see the high moral standards that the victims held themselves too in the most trying of circumstances. INDIVIDUAL PATIENT RIGHTS AND NEW BIO‐TECHNOLOGIES IN MEDICINE Sanja Jovanovska UN Political Affairs Officer, Republic of Macedonia [email protected]; [email protected] This presentation is part of the researcher PHD work, ongoing under the title “Individual patient rights and new biotechnologies in medicine”. This paper reflects the relation between individual patient rights, ethical concepts – as the human dignity, and biotechnologies used in the area of reproduction. The research focus in the paper is on particular legal and ethical issues related to sex selective feticide, abortion and surrogate motherhood. Statistical indicators alarms that in some societies there is a latent, but strong preference of a male child mirrored in abuse of biotechnologies. This phenomena has been pinpointed by obvious differences in the proportion between male and female newborns in favour of the male ones, which has been artificially created through abuse of reproductive biotechnologies in medicine. The deficit of women in some countries has progressively increased as evident from the sex ratio of the population. In some cultures, sons are preferred over daughters for a number of reasons such as economic, social and religious including old age security, property inheritance, prestige and power, birth and death rituals and beliefs about religious duties and salvation. The findings indicate possibility of relation between early sex detection and illegal abortions. Deeply, the issues seem to be rooted in women discrimination requiring adequate national measures in its addressing. The paper will present the main legal and ethical positions and controversies on the issues, using national, regional and international legal and ethical framework. BREAKING BAD NEWS, ETHICS AND COMMUNICATION IN THE MOVIES Ruth Kannai Hadassah Hebrew University School of Medicine, Israel [email protected] In Hadassah Hebrew University Medical School, in the second semester of the third year, a course on "Breaking Bad News" is taught in 3 concentrated study days. Bad News is defined as information which is undesirable to the patient and causes a significant change in his/her life. Bad news is part of various conditions such as a handicap or developmental disability in children, chronic illness or disability, terminal illness or death. The course relates to breaking bad news from the view point of the receiver as well as from that of the deliverer. Students learn the SPIKES protocol, meet with physicians who deliver bad news as part of their work, as well as with patients who had received bad news and tell the students about their experience. In addition to lectures, a significant part of the course is held in small groups. Each group is led by two facilitators, one of whom is a physician and the other is a social worker, who collaborate on a regular basis as part of their clinical role. The teams that teach this course come from various specialties, including intensive care of adults and of children, emergency medicine, gynecology, oncology, hematology and premature births. The last meeting of the course is devoted to end of life care. Students learn about spiritual support through an experiential workshop. The course ends with a lecture demonstrating breaking bad news in movies, where the film scenes are analyzed according to the SPIKES model. In the workshop I will show the audience a series of movie scenes that may be of precious value in teaching how breaking bad news is described in popular films. We will follow the SPIKES protocol step by step and discuss how these scenes can help the student to understand and practice the model in clinical situations. MASS PRISONER HUNGER STRIKE IN 2014: FROM THEORY TO PRACTICE Tami Karni, Baruch Chen, Elinor Goshen Israeli Medical Association, Israel [email protected]; [email protected] This summer, hundreds of prisoners participated in a hunger strike. Until the strike was ended voluntarily in July, dozens of prisoners and detainees were admitted to various public hospitals throughout the country. The management of hunger strikes raises difficult ethical dilemmas. How can a doctor reconcile his obligation to preserve life with the obligation to maintain human dignity and respect autonomy? The Israeli government proposed new legislation that would enable authorities to force feed hunger strikers. Against the backdrop of this complex situation, and to bring professional dialogue and agreement between the various parties responsible for the medical treatment of the prisoners, the Israeli Medical Association held a consensus conference. International ethical consensus holds that a prisoner who willingly embarks on a hunger strike is not to be force fed or treated against his will. On the other hand, medical professionals are challenged by being forced to stand idly by as a patient's condition deteriorates, even to the point of death. Other ethical dilemmas include the fact that keeping hunger strikers together can foment discontent and peer pressure, but separating them (especially to solitary confinement) may be undue punishment. The Israeli Medical Association position recognizes the clash of interests but states that a physician shall not participate in the force feeding of any hunger striker or try to dissuade him from the action he has freely chosen. Following the suspension of the summer’s hunger strikes Tel Aviv's Ichilov Hospital received a surprising thank you letter from Palestinian prisoners who were treated there. "We are administrative detainees… and are proud to thank the medical staff at the hospital and employees who support them," "During our hospitalization of over a month we felt there was a great deal of interest and concern for our situation and our health". "The staff were professional, independent and clearly Abstracts of Oral Presentations
shared the values of international human rights", signed "Administrative detainees who were on a hunger strike for 63 days." WHEN LAW, ETHICS, PROFESSIONALISM AND PSYCHOLOGY COME ALIVE: TEACHING MEDICAL STUDENTS AN INTEGRATED COURSE BASED ON REAL‐LIFE MEDICAL CASE Orit Karnieli‐Miller 1, Adi Niv‐Yagoda 1, Edna Katzanelson 1, 1,2
1,3
4
Tami Karni , Dida Fleisig , Judith Fadlon, Alon Ben Nun , 1,5
Gad Cohen‐Rappaport 1
Sackler School of Medicine, Tel Aviv University, Israel 2
Assaf Harofeh Medical Center, Israel 3
College of Management Academic Studies, Israel 4
Sheba Medical Center, Israel 5
Shalvata Mental Health Care Center, Israel [email protected] Teaching medical students that relevance of law, ethics, professionalism, communication, and psychology is a challenge. It creates the need to learn new concepts, theories, ways of dealing with a situation and understanding complexity. Usually each of these topics is taught separately, in a short, introductory, theoretical course. Within these the relationship between the different disciplines, the similarities, contradictions and their ability to help understand complexity in medical interactions is rarely discussed. This presentation will focus on an integrated course that includes the use of a "real‐life" medical case analysis from the perspectives of medical law, ethics, psychology, sociology, communication and professionalism. Seven scholars from five disciplines present their perspectives on key features of a medical case of an 82 year‐old woman (and her adult children) faced with a decision about her treatment, after being admitted to the surgical ward for an esophageal tumor. Each discipline provides a unique perspective that emphasizes specific concepts and practical suggestions when understanding and dealing with this case. Utilizing the case scenario from different disciplines and integrating the different perspectives exposes the complexity and dilemmas within medical encounters, encourages a broader view of the social and cultural influences that play a role in medical care and facilitates discussion of applicable tools. The multidisciplinary analysis demonstrates the value of crosstalk between disciplines as‐well‐
as the contribution of each discipline. FORCE FEEDING HUNGER STRIKERS IN THE JEWISH LAW Yisrael Katz Clalit Health Services; Hebrew University, Israel [email protected] A hunger strike is defined as a deliberate refusal to eat, undertaken in protest against imprisonment, objectionable conditions or other reasons. To deal with the hunger strikes some countries have adopted methods of force feeding. Several international conventions relate to these methods as torture. In Israel, a new law proposal suggests allowing force feeding in special circumstances. In this paper I present the Jewish law principles concerning force feeding. The main ethical dilemma in this issue is between autonomy and the value of life. Jewish law gives supremacy to the value of life. Only in extreme cases may other values be considered, such as in the case of a terminal patient with severe pain. 43
Patient autonomy on the other hand is a new concept, and Jewish law is still trying to define its status. Rabbis who address this concept relate to the value of human dignity, a value that has sources in the Mishnah and Talmud. After we conclude that the value of life usually has ethical precedence over autonomy, we have to discuss imposing medical treatment in Jewish law. Imposing medical treatment may be considered a legitimate option within two different frameworks. If we define receiving medical care as a religious obligation, we may require imposing treatment as we require the performance of other religious obligations. Many Poskim (Jewish halachic authorities) follow this approach, but it has many difficulties, both technical and inherent. Another approach to this problem is through the obligation to save the other, but here we also face difficulties when the "other" resists. th
Rabbi Moshe Feinstein, an important 20 century Posek objects to force feeding and interprets "imposing" as trying to persuade the patient. On the other hand, Rabbi Yitzchok Zilberstein, a contemporary Israeli Posek, claims that if we can save the patient's life we can take any measure required, including imposing treatment. PICK‐UP BABIES – SURROGACY IN THE DEVELOPING WORLD: NEW TECHNOLOGIES, OLD EXPLOITATION Tamar Katz Peled University of Haifa, Israel [email protected] Surrogacy in countries as India, Ukraine, Georgia and Armenia form part of international new‐born trade: Pre‐embryos created of reproductive cells extracted from people around the world are implanted in poor surrogate mothers in the developing world and delivered to clients. The moral attitude to this practice is community‐specific and is the outcome of legal, social and cultural narratives which explain the phenomenon. In order to exploit the surrogate mothers, powerful interested parties such as mediators, physicians and aspiring parents use the media to disseminate narratives which void the humanity and maternity of the foreign surrogate mother. According to their tales: Since the implanted embryo does not belong to her genetically she is just a biological incubator; The surrogacy is an act of free will and compensation is fair (about 7,000 USD in India as opposed to 35,000 USD in Israel and the USA). In practice, as my PHD dissertation shows, surrogate mothers in developing countries are birthing slaves: Without international regulations they are subjected to dangerous medicines and procedures with severe implications. In India they are kept away from their families. Their chances to conceive are minor but the meagre compensation is paid only after delivering a live infant (often by primitive Caesarean section). They choose surrogacy because of poverty, and their understanding of its implications is questionable. The newborn may be abandoned without identity or caregivers. Local surrogacy laws (like Israeli) can’t properly supervise international arrangements. I suggest an international treaty of co‐operation in respect of inter country surrogacy. 44
UNESCO Chair in Bioethics 10th World Conference
CULTURAL BLINDNESS – POTENTIAL PITFALLS FOR PSYCHOLOGISTS, PSYCHIATRISTS AND PEDIATRICIANS WHEN DIAGNOSING ETHIOPIAN CHILDREN Edna Katzenelson Tel‐ Aviv University, Israel [email protected] Diagnosing children from other cultures poses a serious challenge to mental health and medical experts from professional and ethic point of view. Pre‐existing stigmas regarding people different from ourselves can be found both in the conscious and the subconscious. Some stigmas are expressed through miming, body language and verbal and nonverbal signals. They are created by viewing the other as “unlike ourselves,” through social exclusion (marginalization) and the assumption that anything different is necessarily worse or negative. Mental health professionals must be aware of their own stigmas and stereotypes concerning patients from other origins. As an example of this phenomenon, we will present certain mistakes made by psychologists in Israel in their diagnosis of children who themselves, or whose parents, moved to Israel from Ethiopia within the past 30 years or so. The diagnostic mistakes made in relation to Ethiopian children are rooted in unfamiliarity with the children’s native culture and a lack of culturally appropriate diagnostic tools, both of which result in erroneous interpretation of the available diagnostic tools applied to the child. I shall bring a number of examples of erroneous diagnostic conclusions concerning Ethiopian children and discuss the emotional and educational damage they cause the children and their families. EMOTIONAL INTELLIGENCE, ETHICS AND TIES BETWEEN THEM Daniella Keidar International Center for Health, Law and Ethics, University of Haifa, Israel [email protected] In recent years, the study of emotions has broadened its scope and established its standing as a new scientific discipline. Humanity has become increasing conscious of the seminal role played by the emotional components in both intrapersonal and interpersonal behavior. A deeply rooted and inherent correlation exists between emotional intelligence (E.I. – Emotional Intelligence) and positive social results: social adaptation, quality social relationships, the capacity for healthy social behaviors, caring, altruism, empathy, enlightened communication and the efficacy and personal coherence essential to moral and ethical behavior including its manifestation in the sphere of bio‐ethics. The importance of the personal relationship between the doctor and the patient is especially fundamental in the current era of immense and accelerated scientific‐technological development forcing doctors to cope with an increasingly complicated technical environment. Precisely because of this reality, it is essential that a doctor's actions and interpersonal relationship with the patient will proceed from an ethical base grounded in both professional and emotional responsibility. Emotional responsibility is one of the central elements underlying bio‐
ethical conduct; it is the element that provides the guideposts for the treatment of others. The symbiotic connection between emotional intelligence and the sphere of ethics and morals is what delineates human beings. Human beings by definition and in essence bear responsibility for their actions. The beginning of ethics is in the human being's consciousness of choice in relation to self and to others. An individual's choices integrate emotion and cognition. That ability to integrate alongside the capacity for choice enables the human race to act in accordance with ethical and moral codes. At work, on a daily basis, a doctor is positioned opposite the physical, emotional, cognitive and ethical entirety of the patient. Beyond the doctor's technical ability to heal, there also exists the capacity to create within the patient the desire to heal themselves and to nurture within the patient the emotional and mental coping skills that constitute part of the process of physical healing. The doctor acts as a catalyst for healing not only through technical knowledge but also through the ability to reach the patient on an emotional level. The practical implementation of the quadrangular cluster – emotional intelligence, morals, ethics and bio‐ethics – is dependent upon the instilling of these principles beginning from pre‐school age and conducted with even greater intensity during medical training and throughout a doctor’s career. The practical steps to effective implementation demand experiential and applicable teaching of these subjects to students in the medical faculties (and to practicing physicians through specially focused training) so that these principles will be assimilated and became an integral part of a doctor's daily professional conduct thereby contributing to the quality of medicine and medical care. PATIENT'S RIGHTS LAW AND CULTURALLY COMPETENT NURSING CARE: AN ISRAELI PERSPECTIVE Rabia Khalaila Zefat Academic College, Israel [email protected] Aims: The purpose of the current article is to discuss the culturally competent nursing practice according to patient's rights law. It aimed also to suggest strategies and models to facilitate culturally competent nursing care. Background: According to the patient's rights law, health care providers have to inform the patient about his/her health condition by understandable language and appropriate to their culture. However, communication with culturally and linguistically diverse patients has been shown to be difficult. Cultural and linguistic differences may impede access to health care, accurate diagnosis, and effective treatment. The culturally competent nursing approach was suggested as the most appropriate way to minimize these difficulties. Conclusion: This paper contributes to nursing care quality by suggesting best available standards and models of care to improve culturally appropriate care. Nurses should placed cultural competence as a priority of care, and protect the culturally and ethnically diverse patients' rights. ETHICAL DILEMMAS IN THE PREVENTION OF PTSD AMONG VOLUNTEERS RESPONDING TO TRAUMA Haim Y. Knobler1,2,3,4,5, Eli Jaffe4,6, Yoram Blachar2,3 1
Hebrew University Hadassah Medical School, Israel 2
Peres Academic Center, Israel 3
UNESCO Chair of Bio‐Medical Ethics, Israel 4
Magen David Adom, Israel 5
The Israeli Association for Emotional First Aid (ERAN) , Israel 6
Ben‐Gurion University of the Negev, Israel [email protected] A major ethical concern is the finding that first responders to traumatic events are at a special risk of developing mental symptoms, mostly post‐traumatic. Abstracts of Oral Presentations
The aims of this study were to describe the solutions of the Magen‐David‐Adom Prevention Program among volunteers who are first responders to some of these ethical dilemmas. Ethical aspects of the program were evaluated, in regard to its 3 stages: 1. The primary prevention stage (before the traumatic event); 2. The secondary prevention stage (immediately after the event); 3. The tertiary prevention stage (prompt and effective treatment to symptomatic subjects). The preventive interventions are comprehensive, aimed to reduce the underlying stress, prevent development of acute and chronic stress reactions, and screen for those that need treatment. Therefore, the prevention program addresses the concern that exposure of first responders to trauma and its' victims may result in mental traumatization. It also addresses some of the other ethical dilemmas. The MDA Prevention Program addresses basic ethical dilemmas raised regarding PTSD treatment and research. Future systematic research has to target issues such as: Is there a place for a preliminary treatment by psychotropic medications? How "voluntary" is the subjects' willingness to be included in a PTSD prevention/treatment study? Are all PTSD trauma victims able to give a genuine informed consent? How many times may trauma survivors be included in studies? Studies in the field may benefit from adopting the PTSD Prevention Program, which attenuates these ethical dilemmas. ELIMINATING PRENATAL SEX SELECTION? THE GLOBAL AGENDA AND NATIONAL ACTION PLANS Johanna Kostenzer Management Center Innsbruck & University of Innsbruck, Austria [email protected] Prenatal sex selection favoring boys over girls has led to a distortion of sex ratios in several countries across the globe. The natural sex ratio at birth ranges from 100 to 106 male per 100 female newborns. However, this ratio has reached levels of up to 120 for firstborns to 160 or even higher rates for second and third born children in certain regions. Particularly in China, India or Vietnam, but also in some Southeastern European and South Caucasian countries as Armenia, Albania and Azerbaijan, the demographic imbalance due to sex selective abortion can be observed. Due to its rootedness in gender inequality and the impact on women and the society as a whole, the issue of prenatal sex selection is also of concern to the international community. Demography, reproductive health, public security and human rights constitute the main focus areas in this context. International organizations but also the relevant countries might share the need for action but they address the issue from different perspectives. The presentation will shed light on the extent to which international organizations as well as the affected nations’ governments have taken up the matter. Based on a method mix consisting of a discourse analysis and observation at international conferences, the research concludes with an analysis of the international organizations’ and the respective governments’ policy response (eg. facilitative vs. restrictive). 45
JEWISH MEDICAL ETHICS: ON PHYSICIANS' PRAYERS – DEVOTION TO THE LORD, DEVOTION TO THE PATIENT Samuel Kottek Hebrew University Medical School Jerusalem, Israel [email protected] In their daily prayers, observant Jews pray to the Lord, three times daily, to allow them to be healed whenever necessary. Jewish tradition accords physician the rights and responsibilities to healing the sick. This role has often led physicians to be stigmatized for being conceited. In order to counter this risk of conceit, several Hebrew medical Oaths and Prayers have been th th
recorded, from the early Oath of Assaf Judaeus (7 ‐8 cent.) to the Oath for accomplished medical students of Hebrew University, some 70 years ago. A Hebrew paraphrase of the Hippocratic Oath has been discovered in a 15th century manuscript and published in 1976. We shall however focus our essay on two Prayers composed by Jewish physicians for their colleagues, with the aim of curbing them toward meekness and obedience to the Lord. They should be sensitive to the fact that they are forwarding their service to their patients as a religious duty, while entreating the Lord to assist them in their endeavors. We shall consider and compare two remarkably impressive examples. One dates back to 1665, when it was published by the Roman Jewish physician Jacob Zahalon (1630‐1693), who was also a Rabbi in the Roman ghetto. th
The other has been attributed to Maimonides (12 cent.), but is now considered as a composition of the German physician Markus Herz and was published in 1783. Quite different in size, the two prayers are similar in spirit and interpretation; both are highlights of Jewish medical ethics. They are indeed both enlightening, in the Biblical words of Zahalon: "In Your light will I behold light" [Psalm 18: 29]. TO BE OR NOT TO BE A LIVE KIDNEY DONOR: A PARENT’S PERSONAL PRINCIPLE – CAUSE FOR PATIENT’S DEATH Marija Emilija Kukubajska University Goce Delcev, Republic of Macedonia [email protected] In the cultural and bioethical process of attitude change towards live donor kidney transplant, how could personal character‐
principles be a destructive change agent with detrimental impact upon a daughter’s life, after his refusal to be the only compatible live donor? The refusal to save the 27 year old life resulted in her death. Research examines real data: parental impact upon the family‐belief‐system of his child, and later upon her death. Case study: Lupus Nephritis final stage renal failure patient (from age 15), on dialysis for 11 years. Controversial findings point to personal ethical and cultural convictions that prioritized concerns about marital stability and family reaction, to life of his daughter from first marriage. General data is given on Macedonian recent increase in kidney transplants from live donors, as a positive context juxtaposed with loss of life resulting from self‐centered value systems and rejection of daughter’s plea for his kidney. Sequence of events leading to patient’s death at age 27 are documented in hospital and health care environment settings. 46
UNESCO Chair in Bioethics 10th World Conference
RESEARCH ETHICS COMMITTEES: FROM THEORY TO PRACTICE AND BACK AGAIN ETHICAL CONSIDERATIONS REGARDING EVIDENCE‐BASED MEDICINE: DOES ONE SIZE FIT ALL? Josef Kuře Masaryk University, Czech Republic [email protected] Joel Lamoure Canadian Section Head, UNESCO Chair in Bioethics director@eim‐care.org Historically research ethics committees have been established as bodies protecting research subjects. Later also an extended task, namely protection of research institution and protection of researchers has been added to their goals. Generally research ethics committees became ethical and legal standard for human subject research almost worldwide. The establishment of research ethics committees is governed by hard law in many countries, by soft law in other countries. Despite the fact that research ethics committees became standard instrument for human subject research, there are no universal standards regarding their establishing and functioning. The paper deals with competence and responsibility of research institutions with regard to research ethics committees, analyzing the establishment and functioning of research ethics committees. Finally the paper provides some suggestions for improvement of the system of research ethics committees. The study was supported by the project CEB: OPVK CZ.1.07/2.3.00/20.0183. Evidence based medicine (EBM) has been a template of care and decision making since the 1980’s. However, emerging knowledge in patient centric care and pharmacogenomics has rendered challenges with the EBM concept. Defined CANMEDS role for the clinician as a scientist and communicator, plus health advocate have advanced clinical practice from Dr. Engel’s bio‐psycho‐social model in the 1970’s to a new paradigm in decision making for the clinician. Ensuring that the right medication is given to the right patient helps prevents treatment resistance and enhances patient functionality, while preventing hospitalization and medical‐legal and ethical challenges. Are we providing the right medication at the right time for the right patient? Does one size fit all? Empowering the clinician to effectively critique literature and use patient centric keys in the patient and family history will lead to a more advanced clinical decision making, characterized in evidence informed medicine. Effective and goal‐driven care using the evidence available and integrating with the patient, family, inter‐disciplinary team on top of standard EBM templates defines true evidence informed medicine. In this lecture, clinicians will be provided a review of bias and the basics of critical review. In the second part of the course pharmacogenomics, personalized medicine and drug interactions will be explored and addressed. The third piece of the course will be a practical, hands‐on group dynamic addressing patient cases and approaches to therapy from an evidence informed concept to derive an ethical provision of health. WORKSHOP FOR CLINICAL ETHICS CASE CONFERENCE – HOW SHOULD IT BE HELD? Mitsuyasu Kurosu Tokyo Medical University, Japan krs‐uou@tokyo‐med.ac.jp In Japan a clinical ethics case conference has been held in some hospitals. We held workshop for clinical ethics case conference two times in our university hospital in 2014 to familiarize clinical ethics case conference in medical facilities. I studied how it should be held to hold the conference continuously. Two clinical ethics case conferences, which were held in 2014, were analyzed and their improvements were distilled. The first conference: 34 participants, 11 stuffs, 6 or 7 persons per group, 5 groups. Members of each group were 2 or 3 doctors, 2 or 3 nurses, and others including ethicists, medical anthropologist, education stuffs of pharmaceutical companies, care manager and so on. The schedule was as following; introduction of Japan Unit of the International network of UNESCO Chair in Bioethics, self‐introduction, explanation of 4 boxes method (by Jonsen et al), group and plenary discussion of two common clinical cases and 5 cases which were offered by the participants. Many participants attended at the get‐together meeting after the conference. The second conference: 17 participants, 9 stuffs, 4 or 5 persons per group, 6 groups The differences from the first conference were as following; participation of many doctors and a few nurses, group and plenary discussion of one common clinical cases and 4 cases which were offered by the participants. Conclusion: A group should be composed of over 4 kind occupations. For half day a conference should be composed of 4 groups, one common clinical case, 4 participant‐clinical cases. 4 boxes method is useful. A get‐together meeting after the conference is beneficial for information exchange. MOTHERING FOR MONEY: REGULATING INTERNATIONAL INTIMACY Pamela Laufer‐Ukeles University of Dayton School of Law, USA and Bar‐Ilan University, Israel [email protected] In this presentation I will consider both the ethical dilemmas that make surrogacy such a controversial process and also consider the great benefits of the process as well as the low levels of litigation that have resulted. I will argue that what makes surrogate motherhood such a complex process is that it embodies commercial intimacy. It is both a job for hire and yet, pregnancy, is an intimate process that is closely connected with personhood. I will argue for a “mixed commodification” perspective on surrogacy that both recognizes the vulnerability that needs to be protected due to the intimacy involved and the fundamental and ultimately useful commercial nature of the process. Therefore, I argue for a regulated system of surrogacy that protects the human dignity of the surrogate and the over commodification of the body. With this conceptual background, I will focus on international surrogacy particularly as practiced in India, but in other countries as well. I will argue that international surrogacy is much more likely to exploit and over commodify the human body and thus is in need of strict regulation as well as national openness to allowing domestic surrogate systems instead of allowing citizens to look to employ women abroad. Abstracts of Oral Presentations
REFORMING THE LAW ON SURROGACY IN VIETNAM Tung Le Xuan University of Southampton, UK [email protected]; [email protected] Surrogacy is prohibited in Vietnam for the time being. This prohibition has caused many worrying problems for the Vietnamese society. For instance, the emergence of the black market, where surrogacy arrangements have been made between infertile people and brokers or surrogate mothers, has put the welfare of concerned parties (infertile couples, surrogate mothers and children born of surrogacy) at risk. There were cases where Vietnamese women, who were lured into surrogacy arrangements and acted as surrogate mothers, became victims of physical violence or subject to human trafficking across borders. The increasing incidence of surrogacy as reported by the Ministry of Health of Vietnam shows that the current ban on surrogacy seems to be uneffective and the need to reform the law on surrogacy is urgent. There are many reasons which may be accounts for the use of surrogacy by Vietnamese infertile people in spite of the prohibition of surrogacy. From cultural and social perspectives, to have genetically related children is regarded as a social duty in Vietnam. Even infertile people strive to have their own biological children in order to continue their family line, to show respect for their parents and ancestors, and more and less importantly, to maintain their marriage. The childlessness of a married couple might result in a divorce. Allowing surrogacy, therefore, would facilitate Vietnamese infertile people to exercise their right to procreate (with the help of assisted reproductive technologies) in the pathway to biological parenthood. A few months ago, the National Assembly (Parliament of Vietnam) amended the Law on Marriage and Family 2000, permitting surrogacy in Vietnam (which will come into force from 1st January 2015). However, surrogacy arrangements are only legally permitted between sister first cousins. The problem is that some infertile women do not have sisters, and in some circumstances, sisters do not want to be surrogate mothers. That means that the situation still remains and the legal permission of surrogacy as such hardly enables infertile people in Vietnam to fulfil their dreams of having their own biological children through surrogacy. Consequently, the law on surrogacy in Vietnam still needs a further reform. MORAL RESPONSIBILITY DURING ATROCITIES: THE YUANA KEN CASE STUDY Zohar Lederman National University of Singapore, Singapore [email protected] In the 1930’s and 1940’s, the Japanese Unit 731 conducted the most elaborate and rigorous medical experimentations in biological and chemical warfare in history. In their resulting peer‐
reviewed publications, the Unit’s researchers listed their subjects as monkeys, but now, (as well as back then) it is well known that these subjects were human beings, mostly Manchurian Chinese. More than half a million innocent civilians were “sacrificed” by scientists and medical clinicians. In this paper, I will discuss the moral responsibility of medical professionals involved in genocides and atrocities. I will use as an example the experiments conducted by Unit 731, first providing a brief historical overview. I will focus on a particular individual, army surgeon Yuana Ken, who actively participated in these experiments and later repented. His situation as a soldier on the one hand and a researcher‐healer on the other illustrates the 47
complex ethical issues arising in similar cases. I will make three normative claims. First, that in contrast to Daniel Nadav, we can and should judge those who faced this kind of dilemmas in the past, in the hope of learning from their past misguided moral decisions and better guide future ones. Second, that hurting persons for the sake of saving one’s life or the lives of those who are close to one is immoral. Third, that hurting persons with the intention of eventually benefiting them or other potential victims is morally acceptable. SURROGACY, THE DEBATE IN ISRAEL AND FRANCE IN CULTURAL AND HISTORICAL PERSPECTIVES Etienne Lepicard School of Health Professions, Ashkelon College, Israel [email protected] While surrogacy had been legalized in Israel since 1996, it is to this day one of the heated debates on reproductive technologies in France. After recalling the historical setting that brought Israel to be one of the first countries that legalized surrogacy, I will look after possible cultural and historical reasons that may explain the differences in public reaction between France and Israel. For this purpose, I will look on one hand, at the difference of status bioethical debates enjoyed in France and Israel, especially looking at the role played by bioethics councils in arousing a public debate in both countries. And on the other hand, I will look on how deeper cultural and religious roots had been mobilized in the two contexts. Finally, as one of the main characteristics of surrogacy is the distance maintained between the emotional and the physiological contexts of human reproduction, I will check the tentative performed by the Nazis in their project of arising “perfect children” within the Lebensborn institutions and its links – or absence of links – to the current topic and debate. TRUST AND ETHICS IN THE PHARMACEUTICAL INDUSTRY: WILL A RATING SYSTEM HELP? Marie Catherine Letendre1, Jennifer Miller2 1
Bioethics International, USA 2
Duke University, USA [email protected] Numerous studies have shown that transparency in drug research is low, including and perhaps particularly in the dissemination of clinical trial results for newly approved medicines and vaccines. Gaps in trust and ethics continue to challenge the bio‐
pharmaceutical industry, providing fodder for the media and provoking chagrin from consumers — including concerns about the quality and accessibility of medicine, essential life‐saving therapies and human research subject protections. Curiously, despite the number of publicized breaches of trust and ethics, we’re in an age that demands excellence in health care ethics in developed countries. We’re also concerned that the poor in developing countries aren’t used solely as means to an end. Yet the practicality of articulating, ensuring, monitoring and evaluating excellence in ethical standards remains both a challenge and an opportunity. Bioethics International proposes a rating system. This initiative is both timely and representative of the cultural changes in the health care sector. A culture of trustworthy innovation mirrors the words of Aristotle that “we are what we repeatedly do. Excellence, then, is not an act but a habit.” BEI’s initiative is committed to providing a practical tool to attain excellence because in matters of health and life, just enough isn’t good enough. 48
UNESCO Chair in Bioethics 10th World Conference
ASSISTED REPRODUCTIVE TECHNOLOGIES AND PARENTING RIGHTS IN A JEWISH DEMOCRATIC STATE: THE CASE OF THE OVA DONATION LAW Ori Lev1, Arnon Keren2 1
Sapir Academic College, Israel 2
Haifa University, Israel [email protected] prostitute. In light of these claims, I argue for a new model for institutionalization of prostitution, which includes inspecting the process leading one's decision to prostitute and an active protection of the prostitute during the sexual servicing. THE ORGAN SHORTAGE AND ITS CONSEQUENCES: LEGAL AND ETHICAL REFLECTIONS ON STATE INCENTIVES AS POSSIBLE REMEDIES In light of the significance of reproduction to many people's lives, the right to reproduce has been widely recognized. However, many couples are unable to reproduce naturally. Artificial reproductive technologies (ARTs), such as ova donation, can help such couples. Interestingly, unlike natural reproduction, which is usually not subject to legal regulation and prohibitions, as long as it is performed by consenting adults, many governments tightly regulate the use of ARTs, and place limitations on their use. Can the greater extent of governmental regulation of the use of ARTs be justified? And if so, what kind of considerations can justify such regulation? By examining the Israeli Ova Donation Law (2010) as a case study this paper attempts to shed some light on the kind of considerations that might justify limiting the use of ARTs. We argue that while greater regulation of the use of ARTs, as compared with natural reproduction, is justified, there are also significant limitations to a government's ability to legitimately interfere with consenting adult's reproductive choices. The paper proposes that the law’s prohibitions on ova donation from married women and on inter‐religious donations—prohibitions that were intended to prevent harm from children born through the use of ova donation—are unjustifiable. On the other hand, the legislature was right to remove from the law the previously existing prohibition on ova donation from volunteers who are not undergoing fertility treatment—a prohibition that was intended to prevent harm from such volunteers. Organ transplantation is a very successful medical procedure, which saves the lives of thousands of patients worldwide every year. However, this success is limited by a major problem: a chronic shortage of transplantable organs. Here we consider the medical, social and economic issues raised by transplantation medicine and define organ shortage as a public health problem. The organ shortage and its serious consequences on patients and society open up the question of the role of the state in the context of transplantation medicine. This leads us to analyze the possibility for the state to promote organ donation with incentives, i.e., regulatory instruments to reward organ donation, in the context of a public policy. We show how these incentives can be designed to increase organ donation rates and present several innovative incentives such as tax breaks for willing donors; priority status on the waiting list for a registered donor should he or she ever need an organ transplant; discounts on health insurance premiums; or a rebate on a donor’s funeral costs. Considering the legal and ethical framework in which these incentives have to operate, we conclude that legal and ethical constraints can be addressed by carefully choosing the modalities of these incentives. THE AUTONOMY QUESTION OF THE PROSTITUTION: AN INTEGRATIVE MODEL THE APPLICATION OF BIOETHICS PRINCIPLE ON FORENSIC MEDICINE Renana Leviani Bar Ilan Univeristy, Kibbutzim College of Education Technology and the Arts, Israel [email protected] Zhen Li, Canping Wang, Ruihong Zhang Kunming Medical University, China [email protected] The phenomenon of prostitution has been debated intensely in moral philosophy. In my perspective, the core of the significant aspects of that debate is the autonomy question of the prostitute and the different approaches of interpreting it. Based on that, throughout the lecture I examine the phenomenon in the light of the autonomy question and divide the central critique towards the phenomenon into two distinguished categories. The first category is the substantive critique. According to that critique, the idea of selling sexual services stands in an essential contradiction with the autonomy term. I include two components in this critique, the sexual enslavement and the attitude towards the prostitute. The second category is the practical critique of the prostitution. This critique undermines the autonomy of the prostitute due to diverse variations that frequently accompany with the phenomenon. This critique has two components. The first focuses on the procedural aspects of making the decision to work as a prostitute. The second contains the physical and emotional harms might be caused by prostitution. Grounded on that, I argue that although in some cases this phenomenon accompany, in the current situation of the prostitution, with harsh circumstances and harms, the idea of selling sex itself does not contradict with the autonomy of the Melanie Levy Tel Aviv University, Israel [email protected] UNESCO bioethics institute committee go to the southern and western district (city) and county in Yunnan province, to take a investigation about forensic ethics and health condition priority to with forensic policemen of public security, procuratorial system on‐the‐job police. Group using self‐designed questionnaire overall sampling survey method in 2013 to 2014 in China many times, on‐the‐job police in Yunnan province in respect of forensic ethics principle, the principle of informed consent, confidentiality, fair and just principles, such as knowledge structure, the state of consciousness, attitude and behavior, to prove the current forensic knowledge of ethics, ethical consciousness and behavior, and the results were analyzed, and find problems existing in current forensic work ethics, improving Suggestions about the present situation of current forensic ethics in Yunnan. In addition, here is so many minority population and ethnic minority areas throughout the province, the various ethnic minority areas have different customs, local forensic workers should take forensic judicial authentication work on the basis of respecting local customs, which is of great significance to safeguard national unity, we also carries on the analysis and research to this, in order to understand the status quo, and the guidance of judicial authentication work of ethnic minority region. Abstracts of Oral Presentations
A PATERNITY CASE WITH MULTISTEP MICROSATELLITE MUTATIONS IN LOCUS D5S818 Hong Liang, Hong Du Ma, Jie Yang Kunming Municipal People’s Procuratorate, China [email protected] Mutations of STR loci have been observed and reported during the paternity testing. However, single‐step mutations account for about 90% of STR mutation events. It was very rare that multistep mutations occurred at a STR loci. Here we show a non‐
exclusion paternity case with multistep mutations in the locus D5S818. The composition of the alleles of this locus in the suspected father, mother, the questioned child was 13, 11/13 and 7/13, respectively. The sequence analysis of the regions flanking the locus D5S818 of the suspected father, mother and the questioned child excluded the possibility of null allele as a cause of the allelic mismatch in the child. A total of 39 autosomal STR loci were typed using three Commercial kits and the 9
paternity index is up to 2.461×10 . Furthermore, genotyping of sixteen Y chromosome STR loci in the questioned child matched completely with the suspected father. These results proved conclusively multistep microsatellite mutation in the maternally or paternally transmitted locus D5S818 of this case. A WOMAN'S RIGHT TO ABORT A VIABLE FETUS Pnina Lifshitz‐Aviram Israel [email protected] What underlie the terms "healthy" or "perfect", is one of the questions I wish to examine, when discussing the dichotomy between a woman's right on her own body, and the fetus right for life at the viable stage of pregnancy. I ask if protecting the future rights of a fetus is a value worthy of society's and judicial system's protections, or whether it is the woman's dignity, freedom and autonomy in selecting her siblings that outweigh those of the fetus. I seek to discuss judicial terms and rights (woman versus fetus), but not only. I wish to discuss ethics, moral, philosophy and values. The fetus should have the right to be born and lead a healthy life, and this right may outweigh the right of the woman to terminate the pregnancy. A fetus unable to express its desires does not equal a "right‐less" entity. Some may claim a comatose person is also "right‐less" and many will use the term "vegetable" – but will they even think of bringing this life to an end because of it? Some will also claim that a patient with Alzheimer's disease is "right‐
less" – should we end this life as well? Can society decide when a being unable to claim its rights has no longer right for living? In my view, we as a society, should respect the potential of life of a viable fetus and protect it even from its parents. BIOETHICS AND ITS PROMETHEAN CHALLENGE Natacha Salomé Lima1, Predrag Cicovacki2 1 University of Buenos Aires, Argentina 2 College of the Holy Cross, USA [email protected], [email protected] Contemporary bioethics presents to us huge challenges in several fields of knowledge. The ever‐increasing technological power to interfere with the nature of things (including human nature) demands our increased ethical awareness and considerations. How are we going to respond to this demand? Our proposal is to address this complex issue through the revisiting of one of the 49
founding myths of Western culture, that of Prometheus. We will first address three famous variations of the ancient myth: 1) Goethe’s poem (1772), 2) Mary Shelley’s novel Frankenstein: The Modern Prometheus (1818), and 3) Franz Kafka’s short piece entitled “Prometheus” (1918). Our understanding of this myth would help us to narrow the pathos involved in every bioethical dilemma and give us the chance to reflect on the scope of our human actions in the fields of recent scientific‐breakthroughs. As a relevant bioethical example which can be better understood through the myth of Prometheus, we will in the second part of the paper consider the power of creation involved in the process of assisted reproductive technologies. Reprogenetics, we can say, is the post‐modern Prometheus: the development of assisted reproductive technologies has changed the world as we knew it and we should be aware of this power. Located In‐between chance and necessity, the concerns of reprogenetics present to us with significant questions dealing with the evolution of our human condition and an erosion of the foundations of the “traditional family model.” The human being is an extraordinary creature, essentially unique and singular; something of its intrinsic value might be found there. Finally, through the analysis of certain scenarios, in which science, law, and ethics are intertwined, we will revisit the title of an etching of the Spanish painter Francisco Goya: “The Sleep of Reason produces Monsters “(1799). This title contains multiple meanings, but the one in terms of which we understand the heart of the problem with the contemporary bioethics is (as Michael Foucault expressed it) that of “the circulation of power over bodies.” THE APPLICATION OF PUBLIC SECURITY, PROCURATORIAL POLICEMEN HEALTH SURVEY IN ETHNIC MINORITY AREAS IN YUNNAN PROVINCE Xuecheng Liu, Zhen Li Kunming Medical University, China [email protected] We investigate the healthy condition of the forensic police in Yunnan Province. The investigation included the subjective understanding of their health, objective indicators (blood pressure, blood sugar, blood fat), living habits (smoking, drinking, eating, sleep), the psychological state of self‐awareness and evaluation of the work environment, etc. Team overall sampling survey by self‐made questionnaire on the results of the survey, to understand the current forensic police health status and the existing problems and risks, further on the forensic police work environment, work mode, life style, etc. improvement opinions and suggestions are put forward. THE EFFECT OF VALUES AND CULTURE ON LIFE SUPPORT DECISIONS Theong Ho Low Australia [email protected] When patients and health professionals are from different ethnic backgrounds, value systems that form the basis of such decisions may conflict. Many cultural groups do not place the same emphasis on patient autonomy and self‐determination that western society does and finds the idea of terminating life support offensive. This presentation will examine views on life support from varied cultural views. The presentation will then reveal that by becoming aware of the diversity of beliefs, health professionals can avoid the damage to the health care professional ‐ patient relationship caused by conflicting value systems. 50
UNESCO Chair in Bioethics 10th World Conference
MIDWIVES’ EXPERIENCES ON THE USE OF PARTOGRAM IN THE MANAGEMENT OF WOMEN DURING LABOUR AT LIMPOPO, SOUTH AFRICA T.G. Lumadi University of South Africa, South Africa [email protected] Partogram has been adopted globally in many countries as a tool to record maternal and foetal observations in a simple and pictorial form in order to detect problems, manage and refer for appropriate treatment early. Partograms are mostly used by midwives; hence a qualitative, explorative, descriptive and contextual study on midwives’ experiences was conducted at the three hospitals in the district located at Limpopo Province of South Africa. Face to face semi structured interviews were conducted with 17 midwives who were purposely selected and working in the maternity wards. The findings were analysed using Tesch’s eight steps of data analysis and four themes emerged which are: benefits of using the partogram, challenges experienced, attitudes of midwives and evaluation on how the partogram was plotted. Several recommendations were made including emphasis on communication among staff members, education and training and provision of necessary equipment. THE ETHICAL AND LEGAL CONSEQUENCES OF CONVERGING BIOTECHNOLOGIES Michael Lupton Bond University, Australia [email protected] Definition: The previously distinct and parallel lines of progression in biotechnological disciplines such as stem cells, cloning, genetic engineering and nanomedicine are now rapidly trending towards interconnection and achieving a holistic goal. Convergence on a narrow scale: The convergence of distinct disciplines such as genomics, cloning, stem cell research and artificial reproduction can be classified as convergence on a narrow scale. The combined power of these biosciences has the potential to dramatically increase our understanding of human life and provide scientists with the ability to radically manipulate and transform human nature itself. Convergence on a broader scale: Convergence on a broader scale would include nanotechnology, biotechnology, information science and cognitive science (the so called NBIC). The consequences arising from this group of converging sciences st
is that it will provide our 21 century society with unique opportunities to enhance human performance on a scale that will transform society. The scientific tools created by this convergence is growing exponentially more powerful. This in turn will result in an increased capacity for speedy innovation and invention way beyond what currently exists. Therapeutic benefits: Society can anticipate that the following ethically neutral benefits will flow from convergence viz enhanced pain management, slowing of the aging process, replacing of diseased and worn out organs. Challenges arising out of convergence will include the option for parents to create ‘designer babies’, synthetic genes, genetic interventions, augmented cognitive power. Market for Performance Enhancement: The increased capacity arising out of the convergence of the technologies will extend to everything from restoring sight and hearing to manipulating genetic material resulting in enhancements which will be desirable to millions around the world. These enhanced capacities will also have the effect of challenging existing ethical boundaries. Control Measures: The current legal regulations and ethical guidelines lag far behind the new capacities which converged technologies will deliver and will require a major overhaul in order to safely integrate the new medical technologies into mainstream medical treatment. This paper will explore some of the new technologies and their ethical demands. CAPACITY ASSESSMENT IN HEALTH CARE PROFESSIONALS: A MAJOR CHALLENGE IN AN AGING SOCIETY Yoram Maaravi1, Lotan Brit2, Eyad Abu Saraa3, Efrat Adler3 1
Hadassah ‐ Hebrew University Medical Center, Israel 2
Hadassah ‐ Hebrew University Medical School, Israel 3
Hadassah ‐ Hebrew University School of Nursing, Israel [email protected] Human autonomy is universally sacred in western societies. It is well accepted that every human is competent for any decisions unless proven otherwise. Yet our societies are aging rapidly and cognitive abnormalities related to conditions such as dementia, delirium, depression and other neuropsychiatric ailments are prevalent. Preserving autonomy in the elderly is becoming challenging and is based on knowledge, competency and attitudes of the health care professionals. Moreover, this autonomy is at the core of every patient‐provider interaction and the informed consent. The objective of our study was to assess the knowledge and competency of physicians and nurses to acquire informed consent and their ability at capacity assessment. The study surveyed 207 physicians and nurses in acute care hospitals in Jerusalem. The research tool was a questionnaire consisting of a skill assessment part with five clinical vignettes examining ability to correctly identify competent and incompetent patients, and a theoretical part assessing knowledge through four multiple choice questions. The average total score was 52.2/100 (±14.5/100) and the skill assessment part score was 32.6/100 (±20.4/100). Performance was better in the vignettes in which patients were described as competent. The average score in the theoretical part was 61.5/100 (±17.8/100). Less than five percent of participants correctly identified the four commonly accepted criteria for assessing capacity. This study demonstrates lack of knowledge and skills for capacity assessment amongst physicians and nurses. Improving knowledge and competency of health‐care professionals in capacity assessment is of high priority in an aging society. PATIENTS’ PERCEPTION AND ACTUAL PRACTICE OF PRIVACY & CONFIDENTIALITY IN SURGICAL OUTPATIENT DEPARTMENTS OF GENERAL HOSPITALS, KADUNA, NIGERIA JG Makama1, IA Joshua1, ES Garba2 1
Kaduna State University, Nigeria 2
University of Abuja, Nigeria [email protected] Background: The principles of informed consent, confidentiality and privacy are often neglected during patient care in developing countries. We assessed the degree to which Doctors in Kaduna adhere to these principles during surgical outpatient consultations. Abstracts of Oral Presentations
Material & Method: The descriptive cross sectional study was conducted at surgical out‐patient departments (SOPDs) of General hospitals [GHs] in Kaduna. Twelve (12) [GHs] were selected using multi‐stage sampling. Thirty three (33) patients were selected from each hospital. Doctors' adherence to the principles of informed consent, privacy and confidentiality was observed through client flow analysis performed by trained personnel. Overall patient perception was also assessed regarding these practices and was compared with the assessment made from the practice. Results: Informed consent was obtained from only 19.7% patients in the hospitals under study. Sixty three percent of patients in the hospital were accorded some degree of privacy. Of this number, 75% were female patients. Complete informational confidentiality was maintained only in 10.8% cases in the hospitals. Informed consent and confidentiality were less practiced in the hospital than was expected by patients (two‐
sample t‐test > 2, p value < 0.05). There was marked disparity between the patients' perspective of these ethical practices and the assessment of the practice obtained in General Hospitals. Conclusion: Simple ethical considerations at SOPDs of General Hospitals, Kaduna, were inadequate. Doctors should be imparted formal training on medical ethics. Patients should be made aware of their rights to basic medical ethics too. THE ROLE OF THE ISRAELI COURTS IN FORMULATING THE PHYSICIAN–PATIENT RELATIONSHIP Limor Malul Haifa University; Zefat Academic College; Zefat Forum for Bioethics, Israel [email protected] The nature of physician‐patient relationships has been documented in the ancient Greek and Roman literature, as well as in that of the Middle Ages and modern times. As far back as in Hippocrates' writings, ethical dilemmas including those concerning patient‐physician relationships, patient consent to treatment and end of life issues have been raised and discussed. Over time, changes have occurred in the dynamic between the diverse values that are taken into consideration when defining the therapeutic milieu. The nature of this dyad has moved from a paternalistic framework that empowers the physician and emphasizes the patient's wellbeing to an interpersonal framework that empowers the patient and is focused on his desires and rights. The pendulum of the physician‐patient relationship is, in each era, continually adjusted in accordance with contemporary social values and by norms that have been shaped by judicial tribunals and legislation. Viewing the issue of physician‐patient relationship as an ethical dilemma deeply rooted within social‐cultural contexts, demands the formulation of a theoretical framework that incorporates the relevant ethical principles and a system of implementation that constitutes a declaration of intention concerning the values we thereby wish to protect. The current state of affairs’ legal and legislative arrangements prefer patient autonomy above other significant social values that could provide the foundation for a more stable, appropriate and fruitful physician‐patient relationship . This article wishes to critically examine the questions of whether, and in what ways, the law influences the character of the physician‐patient relationship and what are the implications of such an influence on the medical policy and practice. In light of the inconsistency of rulings in this domain, the necessity to adopt ethical guidelines through legislation and the need for a legal system to constructively and systematically balance the diverse ethical approaches regarding the physician‐
patient relationship become clear. As will be argued below, the 51
law is inconsistent in its declarations and in its definition of the principles underlying its approach to the issue of the physician‐
patient relationship. I will argue that law's difficulty in coping with the regulation of the physician‐patient relationship is a conceptual‐theoretical impediment created by the relatively new legal vantage point that is grounded in the ethical field. With the intention of providing an alternative proposal to supplement the existing and currently dominant approaches, I will suggest a theoretical framework that incorporates and takes into consideration a number of additional elements that characterize the physician‐patient relationship. FROM BABY M TO BABY M(ANJI): REGULATING INTERNATIONAL SURROGACY AGREEMENTS Yehezkel Margalit Tel Aviv University, Israel [email protected]. The American public’s attention was first drawn to the practice of surrogacy in 1988 with the drama and verdict of the Baby M case. Similarly, three years earlier in the U.K, the drama of Baby Cotton was exposed to the public when, for the first time, Kim Cotton became Britain's first commercial surrogate mother. These two leading domestic surrogacy dramas involved the most basic arguments regarding how we should treat surrogacy: as a unique and meaningful act of giving life to a barren couple or as an act of dehumanizing and exploiting not only of the specific surrogate mother, but of women as a whole. Nowadays, troubling dilemmas have evolved around international surrogacy agreements. The discussion in this paper centers on whether regulation should be domestic or international and what is the best approach to achieving it. In my presentation I will explore the modern dilemma of international surrogacy agreements and embedded ethical and legal pitfalls. I will describe a variety of solutions suggested in the research and I will enumerate their advantages and disadvantages. Afterwards, I will suggest articulating a Hague international convention to regulate international surrogacy agreements similarly to the existing Hague Convention on Protection of Children and Co‐operation in Respect of Intercountry Adoption. In my opinion, this is the best legal method to regulate and address ethical and legal dilemmas of international surrogacy agreements. Finally, I will demonstrate how the recent Israeli expert committee, the Shlomo Mor‐Yosef committee published in May 2012, and the proposed 2014 Regulation suggested a similar suggestion in the context of domestic regulation, without any need for international convention or regulation. THE EVOLUTION OF THE OBJECTIVE CAUSE CONCEPT FROM THE PSYCHIATRIC AND LEGAL POINTS OF VIEW Roberto Mester1, Jacob Margolin2 1
Tel Aviv University Sackler School of Medicine, Israel 2
Israel [email protected] The characteristics of the of the objective cause concept is undergoing evolutions in the psychiatric and in the legal fields as can be observed in court rulings and in psychiatric diagnostic criteria. In this presentation those evolutions will be analyzed and discussed using two types of materials: a) a recent Israel Supreme Court ruling related to an appeal of an army officer who claimed to have developed a psychiatric disorder due to his army 52
UNESCO Chair in Bioethics 10th World Conference
service. b) the changes of the (A) diagnostic criteria from the DSM‐III, through the DSM‐IV till the recently published DSM‐V. Awareness and understanding of those evolutions are helpful for psychiatrist who are in the process or preparing medicolegal reports and/or acting as expert witnesses in court. TEACHING BIOETHICS AND HUMAN RIGHTS THROUGH CINEMA AND POPULAR TV SERIES: A METHODOLOGICAL APPROACH Juan Jorge Michel Fariña1, Moty Benyakar2 1
University of Buenos Aires, Argentina 2
Universidad del Salvador (USAL), Argentina [email protected] Since its origins, cinema has promoted awareness of ethical problems. With the expansion of the film industry, these subjects have reached wider audiences, promoting interesting discussions inside and outside the academic world. Meanwhile, studies of explicit ethical subjects related to Science and Technology have increased, as has the attention paid to Human Rights problems. Unfair Discrimination, Multiple Relationships, Conflict of Interests, Exploitative Relationships, Informed Consent, Privacy and Confidentiality, Deception in Research, and Forensic Issues are some of an array of topics that have become central to the conflict presented in numerous films. Furthermore, over the last few years, this phenomenon has exceeded the limits of the movie industry and ethical conflicts have begun to appear regularly in popular television series, in which the ethical dilemmas that arise between a therapist and their patient are dealt with deliberately and explicitly. Scintillating episodes from series such as CSI, The Sopranos, In Treatment, House MD and Grey’s Anatomy have brought these matters into the homes of a far‐reaching and diverse audience. A selection of these materials is currently being used to teaching and to train members of interdisciplinary committees dedicated to the question of ethics within the health field of practice. Regardless of whether the ethical dilemmas are presented in an explicit matter through films or televisions series, or the whether the audiences themselves infer moral or ethical issues that the director may not have intended to present, utilizing these resources as a means for exploring these issues lends itself to an extraordinary opportunity for academic thought and reflection. THE CURRENT STATE OF BIOETHICS EDUCATION IN THE SYSTEM OF MEDICAL EDUCATION IN THE CIS MEMBER‐COUNTRIES G.L. Mikirtichian1, A.E. Nikitina1, L.A. Pinchenkova3, O.I. Kubar2 1
Saint‐Petersburg State Paediatric Medical Academy, Russia 2
Saint‐Petersburg Pasteur Institute, Russia 3
Inter‐Parliamentary Assembly of the CIS, Russia The higher medical education in all the CIS countries aims at achieving three inter‐related and inter‐determined goals: firstly, to provide graduates with updated knowledge and skills on fundamental branches of medicine; secondly, to develop the ability for self‐education, their pursuit of new knowledge and their self‐actualisation in the chosen profession, and thirdly, to create conditions for the development of a motivated, dedicated and moral personality of a physician. Particularly important aspects of medical education are including principles of respect for human rights and basic freedoms as a principal moral component of medical profession. Inter‐relations of medicine and education acquire a new meaning due to the emergence of integrative concept of bioethics having a compound social and philosophical status. Comprehension of the moral perspective of medical profession is the main orienting point of modern human relations in the sphere of medicine and biology. The ideology of the UNESCO Core Curriculum on Bioethics rests on this postulate, which determines the motivation for developing a normative and methodical platform for harmonizing education in bioethics to achieve subsequent harmonization in understanding and implementing universal bioethical principles in healthcare everywhere and with due account for the beauty and great variety of cultural and historical tendencies. LEGAL TREATMENT OF THE RIGHT TO A DIGNIFIED DEATH IN BOSNIA AND HERZEGOVINA: LEGAL AND ETHICAL ISSUES Igor Milinkovic University of Banja Luka, Bosnia and Herzegovina [email protected], [email protected] Euthanasia is one of the most controversial subjects in medical law and bioethics. Proponents of euthanasia legalization usually invoke the right to a dignified death. In the first part of the paper, the concept of euthanasia will be explained and the basic classifications of this notion will be clarified. Ethical complexity of the problem will be explored. Special emphasis will be placed on the different meanings ascribed to the term dignity by the opposing sides in the euthanasia debate (on one side are those who claim that dignity requires a patient’s freedom of choice, including the right to choose the time and manner of his/her death; on the other side are those who use the concept of dignity to defend the inviolability of human life). In the second part, the legal treatment of the various forms of euthanasia in Bosnia and Herzegovina (its entities: Republic Srpska and the Federation Bosnia and Herzegovina) will be explained. Current legal regulations will be compared with solutions accepted in comparative law (the practice of the European Court of Human Rights will be considered as well). Although the legalization of active euthanasia does not seem realistic at the moment, certain legislative changes are necessary in order to facilitate dealing with practical problems in the terminal patients' treatment. The deficiencies of the current criminal legislation will be pointed out, as well as possible changes in other fields of law relevant for the right to a dignified death regulation. REPRODUCTIVE RIGHTS, POVERTY AND DEVELOPMENT Martha Miranda University of La Sabana, Colombia [email protected] Reproductive rights have been considered as the cornerstone of development, promoting gender equality, improving reproductive health, making motherhood safer, preventing HIV/AIDS, but also for fighting poverty especially in the less developed countries, in particular those of the Sub‐Saharan Africa and Latin America. It has also been considered that reducing poverty lies in supporting reproductive health, because the problems in this area undermine the productivity of individuals, especially women, and push families into poverty. However, is the lack of reproductive health the real cause of poverty and less‐development? Controlling the number of people through reproductive rights; is it a real solution to poverty? What are the outcomes of these policies so far? Are there significant results in this area? Abstracts of Oral Presentations
It seems that there is a doublespeak on reproductive rights. On one hand, they are shown as a benefit for less‐developed societies to overcome poverty, and on the other hand, they are considered as a very important outcome of the expression of liberty and women’s rights, especially in our contemporary days. But at this point, it is necessary to consider the ways in which population‐control programmes could violate basic human rights and can be a form of violence against women. From the foregoing, the objective of this paper is to analyze whether the implementation of Reproductive rights is a convenient way of fighting against poverty, taking into account that there are other important aspects related to development like; the need for children as a source of labour and security, high infant mortality, limited economic opportunity for the poor. In addition, the role of equality and human rights in this aspect are being considered. THE CONTROVERSY OVER MEDICAL CANNABIS IN ISRAEL: SCIENCE, ETHICS AND DEMOCRACY Daniel Mishori, Zach Klein Tel Aviv University, Israel [email protected] Cannabis is regarded in Israel, as in many other countries, as a dangerous illegal drug. However, a long struggle in recent years made cannabis a de‐facto medical drug (for pain relief, spasticity, PTSD, or as an appetite stimulant for people undergoing chemotherapy) available only under severe restrictions, and only after traditional treatments were practiced. Presently there are about 17,000 patients using cannabis as medicine. A bill to legally define cannabis as a medicine, submitted by MK Tamar Zandberg in 2014, was rejected by the government. Thus, the state simultaneously prohibits any use or possession of cannabis and allowing the use of cannabis in (limited) medical contexts. This controversy is between supporters of expanding the use of medical cannabis and facilitating the process (no‐restrictions on physicians to prescribe cannabis), and those who believe that this is a dangerous drug whose advocates seek to legalize through the medical system. Other parties involved in the debate include the Ministry of Health, Ministry of Public Security, the Israel Anti‐
Drug Authority (IADA), physicians, patients, scientists, growers of cannabis for medical use, and pharmaceutical corporations. The background of this controversy is the debate whether the state should make cannabis illegal in the first place, and whether the state should criminalize individual users. The current legal situation has enormous implications on research and on the promotion of cannabis‐bases medical treatments and restricts data collection. In this paper we will survey the parties involved in this controversy and examine the different arguments and values involved, with special focus on the Israeli arena, on the background of massive changes that are now occurring in the field of medical cannabis and legalization of cannabis in different countries overseas. 53
caregivers. On the one hand we have the laudable extension of the life expectancy, while on the other we have the increase in the therapeutic efficacy of treating Diseases. Similarly there is the issue of extending life in cases where the disease is no longer curable nor containable, but progressive to an inevitable end. Therein lies the issue, Axiologically speaking, of comparing the Value – both intrinsic and extrinsic, of the extension of such life and the quality of it. The ethical issues of Autonomy – of the patient and the caregivers, may be in conflict with the ethics of the Medical personnel involved and assigned the task of providing such care. In addition for the physicians there are more complex bio medical ethics issues of Beneficence as well as Non Maleficence which again need to be evaluated in terms of their value for both sets of stakeholders. This has led to the unique issue of “Therapeutic Obstinacy” a complex phrase whose meaning can only be debated and discussed on an individual case basis by the stakeholders but needs to have some structured format and guidelines, as at times it may result in achieving quite the opposite of what the basic tenets of the Biomedical Ethics intends to achieve. The other major paradox is that of euthanasia as it is viewed in the fraternity, whether it is a case of an act of Commission as in Assisted Suicide or it is an act of omission of withholding Artificial Nutrition and Hydration (ANH) or providing Ventilator Support for one who is in a Permanent Vegetative State (PVS). How does one take cognizance of Advanced Directives, Living Wills and Do Not Resuscitate in light of the moral theology and dictates of our own religious beliefs and traditions, are questions that need answers and that too quite clear and concise ones, so that the basic rights of one created by God are not denied or violated by us mortals. CULTURALLY COMPETENT ETHICAL CARE AT THE END OF LIFE: A HINDU PERSPECTIVE Anu Kant Mital Unit Head, UNESCO Chair (Haifa) International Network for Biomedical Ethics, Western India [email protected] Knowledge of particular cultural requirements is especially important in times of transition such as at the end of life, where issues of death and dying require great sensitivity to cultural and religious differences. Healthcare professionals need to understand different cultures and deliver ethical care accordingly. This presentation explores the cultural aspects of end‐of‐life care among Hindus. The purpose of this paper is to investigate the experience of families of terminally ill Hindu patients. The presentation will then explore aspects of the Hindu faith and their implications for doctors and nurses, specifically in the context of end‐of‐life care. It will outline the rituals and ceremonies that help a Hindu have a good death and which have meaning for families and friends. Understanding of the Hindu philosophy will encourage health care professionals to facilitate a more ethically sympathetic environment for a dying person and their family at the end of life. ETHICAL ISSUES IN THE PROLONGATION OF LIFE IN THE TERMINALLY ILL Anu Kant Mital Unit Head, UNESCO Chair (Haifa) International Network for Biomedical Ethics, Western India [email protected] The rapid progress in the fields of Medical Diagnostics and Therapeutics has created conundrums of their own, for both, the Medical fraternity as well as the Users i.e. the Patients and their BIOETHICS IN THE TRAINING AND MANAGEMENT OF SPORT Iva Miteva Medical University of Sofia, Bulgaria [email protected] Introduction. The policy of strengthening of quality physical education and sport needs an appraisal of approaches to manage 54
UNESCO Chair in Bioethics 10th World Conference
the challenges in sports medicine. Therefore, the aim of our study is examining the opportunities and problems presented by the increasing availability of technologies capable of enhancing sporting performance and identifying the risks in sports for creating educational and sports management practices to lead with justice, honesty, and beneficence. Methods. A questionnaire is developed to consider the social determinants and risks of health aspects of sports and was self‐
completed by 300 professionals and 100 amateurs. Descriptive and correlation analysis were used for data analysis. Results. The study identifies health risks connected with the intensive loading of locomotors system as well as poor working conditions which cause working trauma and diseases. It was found that health culture among professionals and amateurs is on a low level regarding the effects of performance‐enhancing drugs including anabolic steroids, stimulants, human growth hormone and supplements. Because of an insufficient appreciation of the specific risks among the active engaged professionals we intend to contribute in taking on this challenge to initiate a teaching module in the undergraduate program for students in different medical specialties. Conclusion. There are arguments that sports medicine bridges the gap between science and practice in the development of principle‐centered leadership practices, and can serve as a good introduction to the many ethical dilemmas frequently arising within the context of sport management. Strengthening the quality of sport education will be achieved by addressing the study of sports ethics coupled with a study of management and law. CLINICAL COURSES IN OPEN DISTANCE LEARNING: IS IT ETHICALLY SOUND? CRITICAL CARE NURSING PERSPECTIVE Maria Mabibiti Moleki University of South Africa, South Africa [email protected] Background: The practice of critical care nursing in open distance learning (ODL) represents a complex domain of applied knowledge that requires expert skills of decision making, clinical problem solving, critical thinking and effective clinical reasoning. The foundation for acquiring these discipline related expertise is achieved through instruction, modelling and mutual problem solving skills. Offering clinical courses through distance learning education becomes a challenge for both the lecturer and the student. Aim: This article presents the experiences of critical care nursing students doing clinical courses in open distance learning. Method: A qualitative phenomenological hermeneutic and contextual design. Purposive sampling was carried out with eight critical care nurses registered for this clinical course. Data was collected through individual face to face in‐depth interviews. The interviews were recorded and analysed using basic elements of Heidegger’s hermeneutic interpretive approach. Results The interpretation culminated in four relational themes pertaining to the lecture, preceptor, the clinical settings and the preceptors. In this last theme two subcategories emerged (a) absent and inconsistent relationship; and (b) relationship of compromise and favours. Conclusion: The study has a direct implication for the quality of teaching and learning which translate to quality patient care. The challenges faced by the students registered in ODL were highlighted. Recommendations for improvement and effective supportive measures are also discussed. ETHICAL DILEMMAS IN THE "PROTECTIVE EDGE" OPERATION Uria Moran1, Yaron Tilinger2,3 1
Israel Defense Forces, Israel 2
Maccabi Healthcare Services, Israel 3 Israeli Physiotherapy Ethics Committee, Israel [email protected]; [email protected] The missile attack from the Gaza strip on the south and center of Israel in July 2014 resulted in an intensive IDF ground assault on several areas in Gaza strip to neutralize major firing zones and offensive underground tunnels. Thousands of regular and reserve forces took part in the operation, their activity consisting of 2‐4 days on intensive missions in alien area followed by several days of recovery in Israel. Prior to their entry, the forces were given a crash training course to prepare them best for the type of warfare there were likely to encounter. The forces were located in gathering grounds both prior to entry and following their exit. The intensiveness of the training and battle, together with effects of exposure to the sun and humidity caused an accumulation of musculoskeletal and dermatological complaints among the soldiers. The IDF Center for Medical Services responded by relocation senior clinicians from central rehabilitation centers and clinics to the gathering grounds where the troops were located. These included teams consisting of an orthopaedic surgeon, a dermatologist two physiotherapists and support personnel, who set up field clinics providing advanced musculoskeletal and dermatological services. Due to the solidarity and patriotism, many civilians travelled to the gathering grounds to offer variety of services to the soldiers off duty. Some civilian physiotherapist requested to volunteer to assist the IDF Center for Medical Services teams, but legal issue prevented drafting them. Some of these civilian physical therapists decided to join other civilians offering services to the off duty soldiers in the gathering grounds giving treatment in parallel to the IDF teams. We present some of the ethical issues this situation creates, including documentation, follow‐up, the fact that soldiers are prohibited by order from receiving medical treatment not through the Medical Corps, and not less important the question of how does the physical therapy profession want to label itself: as a professional clinical organization or as a nice to have service. COMMODIFICATION OF THE FEMALE BODY: AN ANTHROPOLOGICAL VIEW Adi Moreno University of Manchester, UK [email protected] Contemporary neoliberal capitalism is characterized by the sharpening of economic inequalities within states and between states, and in the expansion of market transactions into realms that were previously deemed private or intimate. In this economic‐cultural climate, intimate exchanges (involving care, relationships, sexuality, and reproductive capacities) have increasingly come to resemble other forms of utilitarian transactions. It is precisely the extension of market logics to the realm of the personal and intimate that brings about an increased imaginability to the use of the body, sexuality and intimacy as a resource for economic advancement. Neoliberal practices of self‐commodification, instead of negating the existence of a subject (as was the case in the slave trade) are now based on the very existence of selves who actively 'choose' Abstracts of Oral Presentations
to sell body parts, access to their bodies and different kinds of emotional and intimate labour in the capitalist market. Thus subjugating themselves into regimes of control and harm. In this context, discourses of self‐authorship and freedom of choice enable the masking of harsh realities of impoverishment, in which bodies and bodily capabilities from the Global South serve the needs and desires of the more affluent populations in the Global North. This paper is based on ethnographic accounts of women who take part in certain bodily trades (namely sex‐workers and surrogates), and on public discourses that assess the legitimacy of these trades. By utilising these examples I explore the importance of providing ethical frames that are context‐bound, and look beyond the individual 'informed consent' paradigm. ETHICAL AND SOCIO‐HISTORICAL CHALLENGES IN PROVIDING HEALTH SERVICES TO INUIT CHILDREN AND YOUTH: LESSONS FOR IMPLEMENTING HEALTH SERVICES IN DEVELOPING REGIONS Michelle Mullen University of Ottawa, Children’s Hospital of Eastern Ontario, Canada [email protected] Canadians wishing to travel to the developing world do not need a passport. Despite its status as a G‐8 economy, there are aboriginal communities whose living conditions fall far below the national average. Fundamental services are critical challenges. In the extreme north, Nunavut was formed in 1999 and is one of the most remote and sparsely populated regions on earth. The Children’s Hospital of Eastern Ontario (CHEO) undertook to deliver tertiary health services to the children and youth of the region known as Baffin, or, Qikiqitani. The task proved far more problematic than anticipated. Geographic, cultural and linguistic distances generated poor understanding on both sides. Providing excellent tertiary health care into communities with only the most basic health services proved complex and frustrating. Some very medically fragile children required ongoing care of such complexity that they were unable to return to their communities of origin. Mindful of the historical context of disenfranchisement of aboriginal persons and communities, a process has been undertaken toward improvement. Working with regional partners, the program is being revitalized taking key values as pillars. First, that the program needs to be Northern led and supported by the South. Further, success relies on attention to aboriginal voices, and the traditional knowledge, needs and values of the communities served. Provision of excellent services along with the goals of reunification of children with family and repatriation to community are key. This paper examines the experiences and process of developing ethical health care services in the context of postcolonial aboriginal experiences. HOW ETHICAL ARE RESEARCHERS DURING THE PRACTICAL IMPLEMENTATION OF RESEARCH PROCEDURES? CPH Myburgh, M Poggenpoel University of Johannesburg, South Africa [email protected] & [email protected] Background: Empirical research always starts with an “idea”. Usually this idea grows in the mind(s) of the researchers. Enthusiasm takes over and the researchers often become emotionally involved with the research idea. To guard against ethical acting out, researchers should adhere to the cornerstones 55
of respect for autonomy, non‐maleficence, beneficence and justice. Objectives: • To explore and describe practical research situations in which subtle and even explicit transgressions of ethical principles present them self. • To formulate guidelines to prevent and address such transgressions Method: Both presenters are part of ethics committees and act as assessors to proposals of research projects for which ethical clearance is applied. The implications of some of the proposals being presented for ethical clearance will be discussed. Results: Ethical implications of examples of research conducted will be discussed and include: • Orphan‐headed households • Healthy participant’s skin treated with laser to cause sores and then treated to heal. • Chairperson of professional board conducting research in her profession and does not allow for anonymity Conclusion: Researchers should guard against getting so involved with practical research issues and the results their desire to obtain that the participants and their needs are forgotten. Researchers should always adhere to the principle that benefits should be greater than harm and that as little harm as possible should be caused by them. IMPLICATIONS OF UBIQUITOUS USE OF SMART SPECTACLES OR DIGITAL EYEGLASSES SA Naimer Ben Gurion University, Israel [email protected] Every truly disruptive technological advance leads to its own set of ethics standards. Consider the prospects of the recently introduced digital eyeglasses into a socially accepted attire. Those caught "out" without metamorphosis into dressing with the smart spectacles may be viewed as backward and primitive as one that chooses not to carry a cellphone. Such devices may hold honest and true benefits to both physician and patient. For instance, face recognition revealing identity, items to be discussed at the visit, lists of medications, previous documents, tests required by consultants, previous visits, medical literature, real time roll down of differential diagnoses, medical agents and their doses, even documentation of parts or the complete interaction, medical educational tool etc.. Conversely, we are confronted with potential recording and documentation at all times which can lead to communication obstacles and denial to bring up sensitive issues, fear of litigation, deceipt, distraction, privacy imposition etc... If socially acceptable by all, who may raise the legitimacy of demanding either side of the doctor‐ patient interaction to refrain from donning a perfectly normative part of modern dress? The purpose of this presentation is to raise the disputable issues of permanently carrying an audio‐video recorder with a screen in front of our faces with unlimited streaming information at all times. With a specially orientated look at its influence on the doctor – patient visit. A number of suggestions will be presented in order to accept the advantages of such utensils without creating superfluous imposition by its harmful repercussions. 56
UNESCO Chair in Bioethics 10th World Conference
CHILD MARRIAGE IN NIGERIA: A VIOLATION OF HUMAN RIGHTS Awawu Grace Nmadu1, IA Joshua1, A Onyemocho2, Z Muhammad‐Idris1, F Adiri1 1
Kaduna State University, Nigeria 2
Benue State University, Nigeria [email protected] Child marriage is a global scourge that is practiced in many parts of the world but remains prevalent in Africa, Latin America, the Caribbean and Southern Asia and predominantly affects girls. By international conventions, 18 years has been established as the legal age of consent to marriage. In Nigeria, the practice of child marriage is deeply entrenched in tradition, culture and religion and is not uncommon to find girls below the age of 12 years being betrothed to marriage, especially in the northern part of the country where many girls are given away to marriage without their consent and this denies the basic human rights of these children, putting them in a disadvantaged position. Despite the prohibition of child marriage in many international and national laws, the current legal framework in Nigeria does not support the implementation and enforcement of laws prohibiting child marriage. There is no definite age specified in the relevant enactments as the marriageable age for girls in Nigeria. Several strategies are being adopted globally to address the psychological, social, health and developmental problems posed by child marriage. However, regional and local variations in its occurrence necessitate adoption of global strategies in combination with development of local initiatives to address it. This paper reviews the prevalence, causes and consequences of child marriage in Nigeria, the status of implementation of existing legislation and laws on early marriage in Nigeria and its implications on the rights of the girl child and proffers recommendations on the way forward to promote and safeguard the rights of the girl child. OVERVIEW OF THE US QUALITY ASSURANCE PROGRAM FOR HEALTH CARE Thomas Noguchi University of Southern California Keck School of Medicine, USA [email protected] Recent Development in Quality Assurance: The most recent development in the quality assurance and patient safety program in a health care setting, 1) development of national reporting system based on the standardized sentinel event reporting. In past, we have to try to improve the patient safety within the department or individual hospital, 2) Peer Review Organization is now well situated as a standard system for search of root cause, 3) Standardized the competency of all healthcare workers: doctors, for all personnel working the patient care to be update in knowledge and holds requires certificate or licenses. It is a life long learning is stressed. The agency in charge of the graduate education, called the Accredited Council for Graduate Medical Education (ACGME) formalizes the graduate medical training program. There has been stressed that need for a life learning. Each physician must maintain a minimal education credit by the CME, but more recently the SAM (Self Assessment Module) with short quiz is for the specialty education. This specialty certificate must be renewed every 10 years. A role of licensing agency in quality assurance: Most healthcare workers have license issued by the licensing board. The license is renewed every two years. For renewing process, requirement of minimal academic course in the field be taken. Medical licensing agency is a part of quality assurance program. It makes sure that licensed doctors are competent physicians. If any complaint against licensed physician registered by public or reports from an insurance company or hospital, the investigation is conducted. An appropriate action is taken for licensees. Hospital based quality assurance program has been regularly conducted by the Join Commission for the Health Organization (JCHO). It is now known as the JC. The JC developed the national reporting system that is identified as sentinel events. Last 10 years, the inspection and accreditation program of the hospital is more focused to concentrate the hospital where they need more assessment of system evaluation. Which hospital will be inspected depends on the type of sentinel event occurred and need for root cause analysis. The most recent health care legislation, Affordable Care Act emphasizes in quality assurance and performance for payment. Hospital Credentialing Program: In order to be admitted as attending staff of the hospital, physician must go through the credential process, and such privilege is renewable every two years. Prior to any patient care, physician must be fully credentialed. Forensic Pathologist in QA Management: There is a need for the pathologist, especially for forensic pathologists working as a team with a quality assurance of health care system. Any death as results of old or recent injury must be processed with the Medical Examiner’s or Coroner’s Office. Forensic pathologist would be a desirable liaison person for the Trauma Center QA. TEACHING BIOETHIC AT SAINT‐PETERSBURG STATE MEDICAL PEDIATRIC UNIVERSITY O.K. Ochkur, M.M. Muratova, O.A. Jarman Saint‐Petersburg State Paediatric Medical University, Russia [email protected] Bioethics at SPbSPMU is taught since 1997. In the beginning this course was meant for sixth‐year students. Currently, the program nd
is extended to include students in the 2 year. The interdisciplinary course aims at facilitating comprehensive understanding of moral challenges in modern medicine in the context of human rights and values, developing communication skills consistent with fundamental principles of patient‐physician relationship and acquainting students with national and international documents on ethics and law regulating various aspects of medical practice. The profile and history of our University both imply a special attention to ethical issues in pediatrics: informed consent and decision making; a right to life of embryo, fetus impaired newborns; rights of children born due to assisted reproductive technologies; ethical problems of prenatal diagnostics and genetic counseling; experiments involving children; child euthanasia, et al. Students’ response reveals their involvement in the subject and motivation to learn more about practical aspects of applying principles and rules of bioethics in caring for patients as unique individuals and addressing their biological, psychological, social and spiritual needs and values. Much interest is shown to the development of therapeutic relationship with patients and their families through efficient communication skills and emphatic approach. Abstracts of Oral Presentations
ETHICAL ISSUES IN REHABILITATION MEDICINE Avi Ohry Tel‐Aviv University & Reuth Medical Center, Israel [email protected] When dealing with ethical issues in today’s rehabilitation medicine (RM), one must keep in mind the significant particularities of this branch of medicine: the multidisciplinary team work, the long and costly treatment as well as the absence of any immediate or dramatic cure. Our clients (patients) now have longer life expectancy, and questions about the value of the quality of their lives as well as about equal opportunities have become prominent, while moral dilemmas have changed. At the same time, contemporary medicine in general has acquired new characteristics. The relevant concepts now are cost constraint, more science, evidence based on prospective double‐blind controlled studies, and diagnosis‐related groups instead of fee‐for‐ service. Hospitals have to function under the watchful eyes of society, the legal system, and the media. All efforts of the rehabilitation team are concentrated toward fighting physical pathology, preventing disability, relieving pain and distress, and promoting a better life. However, since this is usually unrealistic, RM tries to maintain residual functions and develop compensatory ones to prevent secondary and tertiary complications of the existing disability and to restore the patient’s emotional well‐being. These aims are evidently subject to varying interpretations when translated into everyday action on the search for an optimal therapy. It is my belief that the patient should become an integral part of the rehabilitation team. During the period of “parenting,” patient autonomy is gradually restored. An atmosphere of mutual trust should be created, so that when the patients become a partner to their care providers, the ideal of common decision making can be pursued. INTERDISCIPLINARITY: THE ROLE OF THE PSYCHOLOGIST IN THE DOCTOR‐PATIENT RELATIONSHIP – INFORMATION AND DEMAND Patricia Oliveira AASM, Argentina [email protected] To report is to communicate, meet, learn, warn; but at the same time, information is the patient’s right to full exercise freedom of choice, becoming a prerequisite for the exercise of other rights, as the disposition of the body itself, the treatment, etc. In the context of the doctor – patient relationship, the proper handling of the information acquires a capital importance which will result in the success or failure of that relationship, stimulation or hindering the establishment of a therapeutic alliance between the doctor and his patient will ultimately condition the development of the treatment. Ethics in medicine, as in "do things right", forces to consider that such straight, moral, legal conduct translates into "respect, righteousness, responsibility and reciprocity". Bioethics is understood in this context as a multidisciplinary converge in which medical science and the Humanities such as philosophy, anthropology, sociology, and law; understood as those disciplines that study man and his existence outside the biological field. In Bioethics the center of action is the downsizing of the axis of the medical activity: the relationship doctor ‐ patient. The psychologist place in this process is the work with whatever information has been generated into the patient. The psychologist will work with “what” and “how” the patients realize, with their fantasies, myths and theories underlying. Our intervention will help the patient to process the perceived information. 57
ETHICAL ISSUES ARISING FROM A COMPARATIVE STUDY OF PERFORMANCES IN TWO ENTRANCE EXAMINATIONS FOR MEDICAL UNDERGRADUATE ADMISSION INTO A NIGERIAN UNIVERSITY Victoria Nanben Omole, MA Kana, IA Joshua, AG Nmadu, Z Muhammed‐Idris Kaduna State University, Nigeria [email protected] Background: The Unified Tertiary Matriculation Examination (UTME) is a mandatory entrance examination for candidates seeking admission into tertiary institutions in Nigeria (medical students inclusive) since 1978. An additional examination, the post‐UTME was introduced in 2005 because UTMEs were considered to be generally untidy, uncoordinated and sometimes compromised. This study evaluated the performances of medical undergraduates of Kaduna State University (KASU) in the 2 (mandatory) entry examinations written in the same season and the ethical issues arising. Methodology: A comparative, cross‐sectional descriptive was carried out on candidates of Medicine in KASU for the year 2012. A total population study was conducted, with 653 candidates who had successfully scaled through the UTME (the first examination) in the year 2012; 530 (ie, 81.16%) of whom sat for the post‐UTME (the second examination) internally‐conducted by the university. Results: The success rate among the candidates in post‐UTME was only 12.83%; while the difference between the candidates’ performance in both examinations was found to be statistically‐
significant (p<0.05). Conclusion: This calls for a closer review, scrutiny and screening of the apparently “good grades” candidates applying for admission into institutions of higher learning parade or present. Quality control and ethical issues should be at the fore in considering the selection procedures & admission of students/candidates into medical schools and the medical profession in the long run. IN THE WORST INTERESTS OF THE CHILD – USING NON‐VALIDATED PSYCHOLOGICAL TOOLS IN CHILD CUSTODY DISPUTES Israel Oron (Ostre) International Center for Health, Law and Ethics, University of Haifa, Israel [email protected] In most legal systems there is a longstanding tradition that in custody disputes during divorce proceedings, the court will order a psychological evaluation based on "the best interests of the child". During a child custody evaluation psychologists use tests and other assessment tools (i.e., observation of family interactions, interviews with parents and children). In this talk it will be argued that these standard methods of evaluation are devoid of methodological validity because they fail to measure what they purport to measure, which is parental fitness after a divorce. It will be shown that the tests and other assessment tools lack criterion‐related validity. Namely, no predictive criterion has ever been defined or employed to measure the effectiveness of the recommended custody arrangement (and the court's decision) in either the short or long term. Moreover, psychologists involved in custody disputes tend to disregard considerations that could broaden the scope of validity beyond its traditional technical questions, such as the possible negative side effects or unintended deleterious consequences for 58
UNESCO Chair in Bioethics 10th World Conference
each family member of using tests and other assessment tools. However, neglecting these considerations by psychologists and courts is far removed from the best interests of the child, and in fact constitutes a detriment to his/her psychological development. DISEASE AWARENESS AND QUALITY OF HEALTH INFORMATION ON CLINICAL PROCEDURES: OBSERVATIONAL STUDY IN PATIENTS WITH CANCER AND ALS Marcella Ottonello1, Ines Giorgi2, Debora Pain3, Anna Giardini4, Carlo Pasetti2 1
Salvatore Maugeri Foundation (IRCCS) – Scientific Institute of Nervi, Italy 2
Salvatore Maugeri Foundation (IRCCS) – Scientific Institute of Pavia, Italy 3
Salvatore Maugeri Foundation (IRCCS) – Scientific Institute of Milano, Italy 4
Salvatore Maugeri Foundation (IRCCS) – Scientific Institute of Montescano (PV), Italy [email protected] Introduction: Often a quality of health information incomplete and unclear causes the risk that Informed Consent can lose its fundamental role to promote an active participation of patients in decision‐making process. The aim of study was to observe possible differences between patients with cancer (in palliative care) and Amyotrophic Lateral Sclerosis (ALS) on the disease awareness and on the knowledge of clinical procedures and new tools, such as Advance Directives. Material and Methods: 53 subjects (30 with cancer and 23 with ALS) compiled the “Information about disease and therapeutic decisions” Questionnaire. The 12‐items questionnaire aimed at getting patients’ opinion about their right to be informed and their consent to treatments. The answers to the questionnaire were analyzed items by item and observed differences between groups (Fisher’s exact test). Results: All patients have claimed the right to know their diagnosis (83%) and prognosis (60%). Both groups declared to be aware of their disease (73%) and its evolution (66%). Differences have been found on opinions about the time dedicated from health care professions to the diagnosis and diseases information (p=0.05). In addition, both groups showed not to know the meaning of the terms “Invasive Therapy” (70%) and “Overtreatment” (85%). A significant difference (p=0.001) was the preference of patients respect the type of Advance Directive. Conclusions: The study shows that Health information appeared incomplete and unclear, with differences in function of diagnosis. This causes a risk to lose the principle of autonomy and the centrality of patients in decision making processes. ETHICAL ISSUES IN KNOWLEDGE, PERCEPTIONS AND EXPOSURE TO HOSPITAL HAZARDS BY PATIENT RELATIVES IN A TERTIARY INSTITUTION IN NORTH WESTERN NIGERIA Adegboyega Oyefabi1, Yahuza Basahua Sani2 1
Kaduna State University, Nigeria 2
Ahmadu Bello University, Nigeria [email protected] Introduction: Patient relatives are significant part of the health care team in any hospital setting. This study determines their knowledge, perceptions and factors responsible for their exposure to health hazards at the Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State. Method: This is a cross sectional descriptive study involving One hundred participants selected by systematic random sampling technique from the ten admission wards of the ABUTH. The data were analysed using the Statistical Package for Social Sciences IBM 20 and STATA SE12. Results: The mean age of the respondents was 35 years. They were mainly Hausa (58%) female (79%) Muslims (76%). Sexual harassment (13.3%), abusive insults from Health Care Workers, (13.3%) and aggression from other patients were reported. Being the sole care giver, type of illness, handling of patients blood and faeces and length of hospital stay were significantly associated with exposure to hospital hazards. (p<0.05, X 2 >1, OR>1) Conclusion: Abusive insults from Health workers, sexual harassment and undue handling of patients’ specimen constitute major ethical challenges in this setting. Recommendations: The hospital should have a manual specifying the roles and responsibilities of patients and their relatives. The Health Care workers need continued medical ethics education. Safe accommodation is needed for patient relatives. SOCIAL ASPECTS OF END OF LIVE DECISIONS MADE IN INDIA Princy Louis Palatty India [email protected] Society plays a watchful and subtle effect on decisions at end of life. Common traditional practices are discarded for novel practices, which soon becomes way of life. It is advocated to promote ethical practices by involving community at large. Community end of life discussion. Many ethicists and scientists approve promotion of community end of life discussions. The societal traditions, religious beliefs will lead to variations in the interpretation of the end of life principle. This presentation will elucidate the factors relied on in making end of life decisions. It will conclude that the aim of humane supportive care at end of life is achieved through ethical decision making. Often, it is the joint decision of patient, physician and family. Establishing plans of care with patient and his kin, is a necessity. The decision maker may be family, friend, physician and or the religious person. It is not enough to prolong life, the quality should be reckoned. DETERMINANTS OF ‘END OF LIFE’ DECISION MAKING – A QUALITATIVE APPROACH (PATIENT/CAREGIVER PERSPECTIVE) Princy Louis Palatty, Ashish Kumar, Prajwith, MS Baliga, Alvin Joggy India [email protected] Introduction: Despite scientific and technological advancements, morbidity and quality of life remains unfavourable to medically futile patients. The aging slice of population is ever increasing, even in developing countries like India, with the antecedent burden on health. India is a country of rich cultural heritage and every Indian has deeply ingrained beliefs on aspects of life, death and daily conduct. The ever‐changing cultural flux is evident among differences in generations. Erosion of orthodox customs has given way to a more accommodative, comfort zone. Looking through the Indian perspective would go a long way in understanding the dynamics in decisions at ‘end of life’ situations. Ethical dilemmas may be unravelled in conformity Abstracts of Oral Presentations
with patients’ autonomy that often mirrors the prevailing value system in the region. Ethics have to be viewed mandatorily in the Indian perspective. This study ventures into investigate on the various cultural, religious and other predominances on ‘end of life’ issues. Ethical appropriation from presently available literature survey on this topic was undertaken by, this team of researchers. Also the present needs and opinions on ‘end of life’ issues by patients’ bystanders and HCP have been taken from a random crossection of those attending a tertiary care centre. A qualitative approach was utilized to gain insight into the various reasons that actively determine their decision, by conducting in depth interviews. Methodology: Design qualitative – subject selection: Exploratory Method chosen: In depth interview Participants were randomly chosen from the pool of patients, patients’ relatives. The lists of probable participants were reviewed and at personal ease and convenience, interviews were conducted Conclusion: The Indian patient is different, due to their inherent heritage and socio cultural dimensions. The decision making process, unraveled by this study, showed the parameters influencing decision making to be – disease prognosis, functionality, comfort, social relationship, independence, type of treatment care and availability / ability of caregivers. The health care policy and legalization change the course of decisions, the patient characteristics and physician influence also guide patient/ caregiver decision making at EOL. PERSONAL INTEGRITY, INFORMED CONSENT AND HUMAN TISSUES/ORGAN TRASPLANTATION AFTER PETROVA VERSUS LITHUANIA: CONSIDERATIONS FROM THE SPANISH LEGAL SYSTEM María Magnolia Pardo‐López University of Murcia, Spain [email protected] Under the guiding line of an overall review of the legal regulation on transplantation of human organs and tissues currently effective in Spain and the European Community, a detailed study of the different forms of informed consent that converge in cases of human organs or tissues removal and transplantation is performed, both in cases of deceased donors as well as living ones. Taking as a starting point the complementarity between basic legal rules on informed consent and specific ones, both in conjunction with advanced directives or living wills, we have to distinguish between absolutely different situations (deceased/living donor; minor/adult donor). Regarding the figure of the deceased donor, it is of fundamental importance to pay attention to the considerations made in JECHR of June 24, 2014 (case Petrova v Lithuania) close to the Spanish Act on Organ Transplantation (1979). On the contrary, the figure of the living donor and his informed consent places us in the context of autonomy of the patient. In addition, the very special situation of the minors is analyzed. 59
that agent or its products from an infected person, animal or inanimate reservoir to a susceptible host; either directly or indirectly through an intermediate plant or animal host, vector or the inanimate environment. Than individual in the community can be infectious people or infected people. Strategies to do communicable disease control include: preventing infection through teaching and prophylaxis (including immunization), limiting the spread of infections by timely investigation and follow‐up of modifiable communicable disease incidents and putting protective measures in place, providing epidemiologic data for reporting and public health response measures, continuous monitoring and surveillance of communicable diseases in the community so they may be found and responded to before people get sick or there is a disease outbreak. Human rights are rights inherent to all human beings, whatever our nationality, place of residence, sex, national or ethnic origin, color, religion, language, or any other status. We are all equally entitled to our human rights without discrimination. These rights are all interrelated, interdependent and indivisible. Human responsibilities are the universal responsibilities of human beings regardless of jurisdiction or other factors, such as ethnicity, nationality, religion, or sex. Social responsibility is an ethical theory that an entity, be it an organization or individual, has an obligation to act to benefit society at large. Social responsibility is a duty every individual has to perform so as to maintain a balance between the economy and the ecosystems. This paper would like to describe the role of human right, human responsibility and social responsibility in the communicable diseases control. Every individual has human right, however every individual also has human responsibility and social responsibility to control communicable diseases in the society. AN ITALIAN COURT RULING: “AUTISM IS CAUSED BY MPR VACCINE” Alessandra Pentone, Liliana Innamorato, Francesco Introna “Aldo Moro” University of Bari, Italy [email protected] And the king said, “Divide the living child in two, and give half to the one and half to the other.” (1 Kings 3:16‐28) There was a time when a king was the supreme judge who made life and death decisions. He had the destiny of people in his hands, and was considered to be the source of absolute truth and justice. Nowadays, after the evolution of democracy over the millennia, judges are often the ones in society who are charged with making some of the most important decisions. In 1975, the Daubert Standard established the universal guidelines for admitting scientific expert testimony in court. In spite of this, in 2012, a judge in Italy accepted a medical expert’s opinion, which was based on false and invalidated studies, declaring that “A child now suffers from autistic disorder with associated medium cognitive delay due to, on well‐founded scientific probability, the administration of the MPR vaccine”. Since its discovery, almost 70 years ago, the exact causes of autism are still unknown in the scientific community. And so, on what foundation was “well‐
founded scientific probability” based in the blaming of autism on the administration of the MPR vaccine? And what might be the consequences of this particular sentence on public opinion and on public health safety? For example, one of the consequences of this sentence, and others like it, is that parents of children with a wide range of pathologies try to connect these diseases to vaccines in order to obtain outstanding compensation for the supposed harm done. Communicable disease is an illness due to a specific infectious agent or its toxic products that arises through transmission of HUMAN RIGHT, HUMAN RESPONSIBILITY AND SOCIAL RESPONSIBILITY IN THE COMMUNICABLE DISEASE CONTROL Siti Pariani Airlangga University, Indonesia [email protected]; [email protected] 60
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EPIGENETICS AND THE ASSISTED REPRODUCTIVE TECHNOLOGIES Irina Pollard Macquarie University, Australia; UNESCO School of Ethics; Chair, Australian Unit of the International Network of the UNESCO Chair in Bioethics (Haifa) [email protected] Parental health has direct impacts on the development of the offspring; but the means by which particular stresses impact on crucial health parameters across the generations are less well understood. The hypothesis known as ‘developmental origins of health and disease’ postulates that certain epigenetic influences (that is, all the external environmental variables which regulate gene activity) modulate normal developmental processes. Developmental pathways in humans and other organisms are generally buffered against epigenetic change; however, should this protective buffer break down then development of certain tissues or organs may follow abnormal trajectories. That's why attention is being directed toward children whose conception was medically assisted in the expectation of establishing whether certain developmental anomalies may be explained by epigenetic mechanisms. Normal development may be disrupted by harmful epigenetic variables that a) disrupt DNA, forming deleterious mutations, b) change gene imprinting processes and their consequent expressions, and c) activate ‘fetal programming’ strategies that are triggered by unfavorable intrauterine conditions. Accordingly; stresses experienced at critical periods of developmental plasticity may initiate increased risk of non‐
communicable diseases in the future conceptus, neonate, infant and adult. Importantly, the health and living conditions of both parents from the time of gamete formation to the conception of the offspring are just as crucial as the mother’s situation during pregnancy and lactation. Nevertheless, to beat infertility increasing numbers of couples are seeking medical treatment and, as familiarity with the available technology broadens, so does its acceptance leading to further demands for new technological interventions. With increasing use of assisted reproductive technology (ART), concern about likely long‐term health implications of ART is growing. Medically assisted reproduction involves several steps that subject gametes and early developing embryos to environmental manipulations. Consequently there is growing interest in investigating links between these techniques and imprinting alterations associated with ART manipulations. This presentation develops from a bioscience ethical standpoint focusing firstly on metabolic parameters that influence epigenetic characteristics and, secondly, on the possibility of developing an effective international code of ethics that addresses the existing unregulated global market of human embryo and stem cell transfers, egg cell and sperm donation, and surrogate arrangements. TEACHERS OF BIOETHICS IN SEARCH OF NEW PERSPECTIVES Sashka Popova, Krasimira Markova, Kristina Popova Medical University of Sofia, Bulgaria [email protected] As the Bulgarian health care system undergoes fundamental reforms during the last twenty five years, bioethics curricula in medical training is becoming very beneficial to prepare students from different medical specialties for practicing in the new environment. Recent evidence from research suggests substantial deficiencies in the quality of public health care delivery system. These deficiencies show that in order to improve the quality we need to ensure that care is safe, effective, responsive to patients and equitable. A strong focus on quality improvement in health care by health professionals would further spur attentive observation, reflection, innovative thinking, and action in this area. Our analysis estimated that bioethics is dedicated to improve education by building greater awareness and understanding of the critical bioethical and social dimensions of medical practice. We aim to teach students about the pragmatic, medical and social complexity of providing health care – not only how to treat and care for the patients, but how to educate them and address the systematic challenges of doing so in the context of a country’s economic and health situation. Teachers of bioethics have to articulate their unique role and objectives so that they can establish adequate educational and training standards and programs. There is a need also to define core competencies in bioethics decision making in conformity with the professional code of ethics. We are actively looking for ways to build programs that are respectful and offer basic values, standards of practice, and a mechanism for accountability. Quality improvement is a worthy goal and one that teachers of bioethics can contribute to, significantly and measurably. Teachers need to carry out that responsibility. MORAL INJURY Mark F. Poster Brockton VAMC, USA [email protected] In his groundbreaking study Achilles in Vietnam, Jonathan Shay identified betrayal of themis, or “what’s right”, as the source of lifelong moral injury. He was writing about combat trauma and comparing that described in Homer’s Iliad twenty‐seven centuries ago with that experienced by US soldiers 45 years ago. The concept of moral injury applies to non‐combat traumas as well. It has broader clinical utility than a symptom complex such as post‐traumatic stress disorder. While moral injury is manifest in PTSD symptoms (e.g. intrusive thoughts, avoidance, numbing), it also is manifest in shame, guilt, demoralization, depression and suicidal behavior. Because moral injury has such broader manifestations and also connects to intrapsychic and interpersonal and societal sources, it has greater potential for research and treatment in each of those domains. This paper will explore the concept of moral injury in recent scientific literature and in case examples of US combat veterans. ETHICS OF CHRONIC PAIN CONTROL; A GREY AREA OF DOCTORS’ POWER Andreas Prokopiou St Georges Medical School at University of Nicosia, Cyprus [email protected] Medical knowledge and power have long been regarded as a defining feature of health care systems. It is acknowledged that the increase in medical knowledge could result in an increase in power. It is also recognised that doctors’ have a prima facie duty to relieve pain, which is more evident in those patients who are suffering from chronic pain. From an ethical point of view, effective pain management is a moral and professional imperative, as well as a personal responsibility. Why it is believed that there are “grey” areas in Abstracts of Oral Presentations
doctors’ power? In which ways can the medical power be misused? Are the patients and relatives aware of that power, and if so, in which levels they believe it can affect them? In this presentation, an attempt is made to identify possible ways of misused medical power in doctors’ everyday practice. Additionally, a proposal is presented with certain pre‐emptive actions, which may be applied to prevent abused authority from doctors over their patients. It is argued that regardless the size and specific area of the problem, it is essential for the healthcare professionals to examine their own use of power and to also continue their lifelong learning in medical ethics. Moreover, they have to remember that the care to the sufferers should be an act, where professionals demonstrate factually their expression of love. In conclusion, according to Plato, “science without virtue (areti) and love can be unregulated, alienated and avail us nothing from pursuing the good”. KNOWLEDGE AND ATTITUDES OF MEDICAL STUDENTS CONCERNING OPIOPHOBIA – A CROSS SECTIONAL STUDY Milica Prostran, Branislava Medic, Bojan Stopic, Katarina Savic Vujovic, Danilo Obradovic, Sonja Vuckovic, Dragana Srebro, Radan Stojanovic University of Belgrade, Serbia [email protected], [email protected] Opiophobia is an irrational fear of using or prescribing opioids. Key barriers to prescribing opioids in physicians included addiction potential, abuse or misuse, side effects and fear of review by professional bodies. The consequence is an inadequate pain management. We aimed to assess knowledge and attitudes of 3rd and 6th year medical students towards the issue of opiophobia in our community. A self‐completed questionnaire was delivered to 361 out of 548 students of the 3rd year (65,87 %) and 307 out of 504 students of the 6th year (60,91 %). Sixth year students estimated that they were more informed on the issue of opioid analgetics (3rd year median value ‐ 2, interquartile range 2‐3; 6th year median value ‐ 3, interquartile range 3‐4, scale 1‐5; P < 0,05). Most of students stated that they do not know or not sure what a term “opiophobia” represents (3rd year 67.86%, 6th year 55.92%). Although most of our respondents believe that these drugs can relieve the strongest pain, they point out that the risk of abuse of opioids is conspicuous (3rd year median value ‐ 3, interquartile range 3‐4; 6th year 4, interquartile range 3‐4, P <0, 05). The final year students provided significantly more accurate answers concerning the effects of opioids (P <0.001). Also, students estimate that patients are greatly feared of certain side effects of opioids sucs as tolerance and respiratory depression (P> 0.05). The role of undergraduate medical education is essential in providing good foundation for future doctors involved in this issue, especially in order to be able to activate the ethical principle of informed consent regarding these drugs. Therefore, it is necessary to improve knowledge and attitudes of our medical students towards the issue of opiophobia. 61
PSYCHOLOGICAL ASPECTS OF MORAL DECISION: VIOLATIONS OF PROFESSIONAL DISCRETION IN FORMER EAST GERMANY (DDR) Andrea Quitz Universitätsklinikum Erlangen and Friedrich‐Alexander‐University Erlangen‐Nuremberg, Germany [email protected]; andrea.quitz@uk‐erlangen.de The Hippocratic Oath is used by physicians under both democratic and dictatorial circumstances and conditions. Even in former East Germany, physicians were bound to professional discretion. However, about 3 to 5 percent of the physicians were working for the secret service and violated their patients’ right of discretion. The current study uses material from the former German Democratic Republic (DDR) found in the documents from the secret‐service archive (BStU) and publications on bioethics. Using content analysis in ethical discourse or reports from the BStU, it was possible to find declarations in motives and justifications which refer to the stages of Kohlberg’s theory. East German socialist ideology refused universal ethical principles and named them as bourgeois and unprogressive. They held a view of a “class‐bound” moral. The secret service (Stasi) preferred to not employ principle‐oriented people and in most cases these people consciously decided to work for the “Stasi,” even in case of physicians or medical ethicists. East German ethicists did not argue with universal ethical principles and their own motives for collaboration were mostly norm‐oriented. Through their ethical discourses we can observe a strong relation between discourse level and moral behavior. But what was the official opinion about the professional discretion and how did it occur in practice? Which theoretical approach offers the most understanding to moral psychology by explaining physicians’ or others’ behavior in the case of moral dilemmas? DISCLOSING INCIDENTAL FINDINGS IN PEDIATRICS: HEALTH PROFESSIONAL PERCEPTIONS AND INSIGHT Vasiliki Rahimzadeh1, Denise Avard1, Karine Sénécal1, Bartha Maria Knoppers1, Daniel Sinnett2 1
McGill University, Canada 2
University of Montreal, Canada [email protected] Background: Progress in understanding childhood disease using next‐generation sequencing (NGS) portends vast improvements in the nature and quality of patient care. However, ethical questions surrounding the disclosure of incidental findings (IFs) persist, as NGS and other novel genomic technologies become the preferred tool for clinical genetic testing. Thus, the need for comprehensive management plans and multidisciplinary discussion on the return of IFs in pediatric research has never been more immediate. Objective: The aim of this study is to explore the views of investigators concerning the return of IFs in the pediatric oncology research context. Methods: We conducted a qualitative study with a purposeful sample of 16 investigators in pediatric oncology from across Canada. The study protocol and consent procedures were reviewed and approved by the research ethics boards at McGill University and the Sainte‐Justine Hospital University Health Center (SJUHC). Results: Our findings reveal at least four contextual themes underlying the ethics of when, and how, IFs could be disclosed to participants and their families: clinical significance of the result, respect for individual, scope of professional responsibilities, and 62
UNESCO Chair in Bioethics 10th World Conference
implications for the healthcare/research system. Moreover, the study proposes two action items toward anticipatory governance of IF in genetic research with children. Conclusion: The need to recognize the multiplicity of contextual factors in determining IF disclosure practices, particularly as NGS increasingly becomes a centerpiece in genetic research broadly, is heightened when children are involved. Sober thought should be given to the possibility of discovering IF during the course of pediatric genetic research, and to proactive discussions about disclosure considering the realities of young participants, their families, and the investigators who recruit them. PATIENTS’ PERCEIVED TO THEIR RIGHTS TO INFORMATION AND ITS IMPLEMENTATION IN HEALTHCARE Ivan Rahmatullah, Sukmawati Basuki, Nancy Margarita Rehatta Universitas Airlangga, Indonesia ivan‐[email protected] Patients’ rights to information is one of the rights guaranteed under the health act, medical practice act, hospital act, and consumer protection act in Indonesia. We intended to explore patients’ perceived to the right and its implementation in healthcare, which focus on disease and prescribed medication knowledge. We are also interested in assessing the implementation of the right by asking whether the patients were able to mention their disease and the prescription, and the reasons if they were unable to mention them. Our study design is a descriptive cross sectional study. We interviewed 309 respondents recruited from outpatient clinic at four community health centers across Surabaya, Indonesia. Our respondents consist of 100 male (32.4%), and 209 female (67.9%). Our results showed that 96.5%, and 97.4% of them perceive that the knowledge of the disease, and the prescription is importance. Meanwhile, there are 65% and 47.9% of them able to mention the name of their disease and the prescription. The reasons of their inability to mention the disease and the prescription are mostly because of difficulties in pronouncing the disease and the prescription (41.2% and 35.85%), and the doctors did not tell them the disease and the prescription (31.78% and 34.59%). In conclusion, the awareness of patients’ right to information among the respondents, specifically to the disease and prescribed medication knowledge, is high. However, we should emphasize to the doctors and medical students to ensure their patient understanding on provided medical information, which plays important role in improving patients’ health outcomes. CAN MORAL BIOENHANCEMENT BE MORAL? Vojin Rakic University of Belgrade, CAEE Network of the UNESCO Chair in Bioethics, Serbian Unit of the UNESCO Chair in Bioethics, Serbia [email protected] I will concur with various arguments against moral bioenhancement, especially to its necessary implication of the state in a controversial moral perfectionism, arguing however that they apply only to compulsory moral bioenhancement. I will show why these arguments do not prove that we should abandon moral bioenhancement altogether, as we have the possibility of voluntary moral bio‐enhancement. Voluntary moral bio‐enhancement can be shown to be preferable to the option of no moral bioenhancement at all and to the option of compulsory moral bioenhancement. If we embark on a moral bioenhancement enterprise on a voluntary basis, it can be demonstrated that moral bioenhancement is moral. TOWARDS A RATIONAL APPROACH TO THE ETHICS OF PAIN Z. Harry Rappaport Rabin Medical Center, Tel‐Aviv University School of Medicine, Israel [email protected] Pain has variously been used as tool for punishment, testing commitment, education, or social control, as a commodity for sacrifice, or for sport and entertainment. Attitudes concerning these uses have undergone major changes in the modern era. Our shared convictions on what is right and what is wrong are generally attributed to religious tradition or to secular‐humanist reasoning. Here we elaborate the perspective that ethical choices concerning pain have much earlier roots and are based on instincts and brain‐seated empathetic responses. They are fundamentally a function of brain circuitry shaped by processes of Darwinian evolution. Social convention, with its variability, is an overlay. The neurobiology of pain processing, including the question of where in the brain the experience of pain is generated, needs to have an effect on decision making, particularly in end‐of‐life situations. By separating innate biological reactions to pain and empathy to suffering in others from culturally imposed attitudes (memes) we may arrive at a more reasoned approach to a morality of pain prevention. ETHICS AND PROFESSIONALISM: ONE AND THE SAME Rebecca Reicher‐Atir1,2,3, Lihi Zur‐dovrat1,2, Nira Cohen‐Zubary1,2, Sara Turkenich1,2, Boaz Tadmor1,2 1
Rabin Medical Center, Beilinson Hospital, Israel 2
Tel Aviv University, Israel 3
Academic Academy College of Tel Aviv Yaffo, Israel [email protected]; [email protected] Moral distress and ethical erosion are major sources of work dissatisfaction, burnout, and attrition in health professionals. We describe a one‐year workshop established at a tertiary medical center to help minimize the risk of those among physiotherapists and occupational therapists. In the introductory session, participants were shown how the medical environment is a potential “hornet’s nest” of moral conflicts and ethical dilemmas. Emphasis was placed on keeping ethical issues at the forefront of health care and the need to resolve them on both the systemic and the individual level. During the course of the workshop, participants were asked to describe events (prepared in advance) from their professional experience that had posed an ethical conflict for them. This was followed by an open discussion on ways to cope with the problem, with adherence to professional ethical codes. Issues of managing professional disagreements and tensions in multidisciplinary medical staff; witnessing colleagues' ethical misconducts; professional interventions under "Zuk Eitan" atmosphere and dealing with political, gender, religious, and sectorial differences in patient‐therapist relationships were raised. Methods of evaluating the effectiveness of the workshop and its conclusion will present. Abstracts of Oral Presentations
MEDICAL ETHICS AND GENOCIDE: TROUBLING UNMET CHALLENGES Elihu Richter1, Tamar PiIleggi2, Yoram Finkelstein3, Peter Honeyman4 1
Hebrew University, Israel 2
Jerusalem Center for Genocide Prevention, Israel 3
Shaare Zedek Medical Center, Israel 4
Sydney University, Australia [email protected] Since the beginning of the 20thcentury, the toll from genocidal mass murder is estimated to be 180 to 250 million victims. In the Armenian Genocide and Holocaust, health professionals were complicit directly as architects, planners, perpetrators, and executioners, —or as bystanders. Doctors used Social Darwinism and Eugenics to propagate “scientific” rationales for mass murder, sterilizing, expulsions and other atrocities. We ask: Do current ethical codes in public health and medicine ensure that doctors and other medical professionals will not again be complicit in mass killings, –either as actors or bystanders The Nuremberg Trials of Nazi War Criminals led to the Code of Helsinki, which requires informed consent for experiments in humans. But current ethical codes were not adequate for deterring a psychiatrist from serving as a major architect in the Bosnian genocide or deterring a doctor from ordering the use of nerve gas agents in Syria. Nor did ethical codes deter public health doctors from withholding treatment for HIV in infected populations (South Africa). Nor do doctors challenge the hijacking of epidemiologic terms for dehumanizing a population —a recognized early warning sign of genocidal intentions. We propose that doctors be equipped with an ethical code that calls attention to their roles and responsibilities investigating, reporting and interventions to protect populations subject to genocidal threats. This role includes a responsibility to identify the misuse of medical terminology as hate speech. THE BIOLOGICAL WILL™ – A PARADIGM IN FERTILITY Irit Rosenblum New Family Organization, Israel [email protected]; [email protected] Death is not necessarily the end of life. Children can be conceived after the death of one or both parents. Posthumous paternity is possible when sperm from a deceased man is used to inseminate a woman. Posthumous maternity is possible when a woman’s ova are frozen and used to inseminate a surrogate. If embryos created by a couple during their lifetime are gestated by a surrogate, a child can be born years after their parents’ death, necessitating the legal system to determine the legal parents and stakeholders rights. No nation has comprehensively regulated posthumous reproduction, leaving posthumously‐conceived children without clear legal parentage or rights. The Biological Will™ is a legal testament that documents the intended use or disposal of any individual’s sperm, ova or embryos in case of death, incapacitation or infertility. It offers an alternative to anonymous sperm or ova donations by receiving gametes from a known donor. Everyone benefits: the donor leaves descendants, the designated parent and donor’s family continue bloodlines, and the child gets a genetic record. In an age where a child can have multiple biological, legal and social parents, the Biological Will™ resolves questions of gamete ownership, donor consent, legal parentage, and children’s rights. From my proposal to establish an IDF sperm bank in 2001 through birth of the world’s only child born of posthumous maternity in 2011, The Biological Will™ broke nature’s 63
boundaries to actualize this new paradigm in fertility. Four children were born by Biological Will™, and six will be born in 2015. YOU KNOW IT IS TORTURE WHEN THERE IS OFFICIAL TERROR Barry Roth Harvard Medical School, USA [email protected] The technical parameter to ask, “How did you survive?” during forensic psychiatric assessment of torture survivors with Posttraumatic Stress Disorder led to a powerful heuristic. Torture is a crime of specific intent; namely, an attempt to break non‐
material human connections that sustained survivors. A priori, these shared bonds of social contract are force we have to do right. Ethics reveal our attitudes to the metaphysics of ontology (practice) and epistemology (validation of knowledge); ethics eclipse the 4 dimensions of space and time. We always have choice. The calls of the Prophets’ for social justice marked all th
time; and revealed the 5 dimension of right and wrong. Understanding that the criminal intent of torture aims to destroy civilized ties improves current torture definitions and protocols.Forensic examination of PTSD in survivors’ shows that official state torture and terrorism are synonymous in bio‐
psychosocial and ethical dimensions. Torture states and terrorists both use systematic means to instill terror‐‐‐overpowering fear to coerce and intimidate. Under the color of authority, states use terror to torture; doing so, states perform terrorist acts. Criminal acts of state performed under the color of authority derive from and display mental illness. Torture is not an aberration: we confront official terror in “counterterrorism”, “war on terror”, surveillance, drones and kill lists. Our shared project of culture and civilization also confronts official propaganda, deception, misinformation and lies. Sane ties of civil society oppose, resist, transform and supersede violent intimidation and coercion of torture and terrorism. ETHICAL DILEMMAS IN THE MANAGEMENT OF PAIN Alan Rubinow Hadassah ‐ Hebrew University School of Medicine, Israel [email protected] Pain and suffering are two distinct phenomena and the main reasons for which people turn to the medical establishment for assistance. It is universally accepted that it is the moral mandate of the physician and all those caring for the sick to alleviate pain and suffering. Informed consent is the anchor, and ethical principle around which physicians and paramedical health providers apply their professional knowledge and skills in the management of the sick. In the context of pain management does the patient need to explicitly consent to have his/her pain relieved or is it presumed that such consent is given in the very act of seeking care? The balance of power in the management pain is clearly in the hands of the caregiver and the patient, the sufferer, is often the passive bystander and not proactive in demanding relief of his/her pain. Pain management on medical wards often lack the required sensitivity needed to understand that relief of pain goes beyond the treatment of any specific medical condition and is the constant compelling duty of the caregiver. Indeed it has been suggested that not providing optimal pain is the equivalent of moral malpractice. 64
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WHAT SHOULD BE THE DESIRED MEDICAL EXPERTISE WHEN EVALUATING PLAINTIFF'S FUNCTIONAL DISABILITY AND NEEDS? Avi Rubinstein DR.A.Rubinstein – S.Yakirevitch Law Office, Israel [email protected] The legal meaning of the existence of opinions by doctors with different specialties is that when the court is faced with two opinions, it may give more weight to an opinion of a doctor who is an expert in a certain area. This does not deal with the admissibility of the expert's testimony, but with its weight in the courts eyes. When damages of the crippled plaintiff are considered in the framework of the trial, the court will be guided by a basic principle in the law of torts, which is the desire for restitution that is bringing the victim (financially) to its situation before the trauma. In this framework, when the court wants to determine the plaintiff's disability and his (or her) needs, and their actual translation into financial compensations, it would base itself on an opinion and a testimony of an expert doctor. In practice, opinion on functional disability and the evaluation of needs are given by experts in various medical fields, not necessarily by rehabilitation expert. We already said – that the opinion – even though written by neurosurgeon or an orthopedic surgeon – will be admissible. But what should be the desired expertise of that doctor? Is it more desirable, for the purpose of determining functional abilities, ability to work or nursing needs ‐ that the doctor should be an orthopedic surgeon or a neurosurgeon, which have treated the plaintiff at the acute stage of his trauma or disease, or a rehabilitation doctor? It is my view that it is more desirable that an expert on rehabilitation – which has the professional ability to sum up the entirety of medical disabilities will be the expert. He (or she) will assist the court to evaluate the significance of the disabilities of the patient's daily functioning, as well as the needs deriving from the medical and functional disability, and will be the expert helping the court to do justice and grant the disabled what they deserve. We suggest then, that the court will do the right thing if it gives the rehabilitation expert's opinion a greater weight – since we believe that the opinion of experts who are not from the rehabilitation area can harm the crippled plaintiff mainly because of lack of professionalism combined with the lack of ability to foresee the future. At the same time, the rehabilitation expert has the ability to provide the court with tools to evaluate the scope of additional treatment or additional needs in years to come. PROMOTING BIOETHICS IN THE HIGH SCHOOL LEVEL BY INTEGRATING THE CASE‐BASED APPROACH TO ETHICAL DECISION‐MAKING MODEL Richard Deanne Sagun Ateneo de Manila University High School, Philippines [email protected], [email protected] Bioethics education is commonly observed in the medical and health field. Most case studies are geared towards analyzing medical‐related situations that allow one to arrive at a decision that is ethically sound. However, the integration of bioethics education in the high school level is not commonly adopted and observed. Article 23 of the Universal Declaration on Bioethics and Human Rights (2005) emphasizes the need to foster bioethics education and to disseminate information and knowledge about bioethics at all levels, particularly to the young people. The paper describes a study conducted in a private high school institution in the Philippines having an existing bioethics education program integrated in the Biology subject. The goal was the evaluate and elicit feedbacks from the students as they analyze a case study applying the Case‐Based Approach to Ethical Decision‐Making Model by Jonsen, Siegler, and Winslade (2006). The participants were grade 10 high school students enrolled in a semi‐honors biology program. The participants were divided into groups. A case study lifted from UNSECO Casebook on Benefit and Harm (2011) was given to each group for them to analyze applying the case‐based approach model. Findings indicated that the integration of the case‐based approach model enhanced students’ understanding and awareness of bioethical issues and concerns. Furthermore, the participants were able to adopt a scheme that will allow them to analyze and evaluate bioethics cases leading to ethical decision‐making. FERTILITY POLICY IN ISRAEL: FROM EXEMPLARY LOCAL PRACTICE TO A GLOBAL MODEL Etti Samama Israel [email protected] Israel is a leader in fertility treatments, offering greater public funding of treatments than any other country, and enacting the first surrogacy law. Nearly twenty years of experience in implementation of the law enable us to discern the meaning of allowing surrogacy within a state and between states. Alongside the original intention of surrogacy as a solution for end cases of infertility, a thriving industry of interested parties grew, mostly economic, which markets surrogacy and as a result enhances the phenomenon. The increase and commercialization are inversely proportional to the research findings collected, which point out the harmful components of surrogacy, particularly the low success rates, process results, and the impact on the partners, especially the surrogate mother and her children. The collected data shows the most difficult stages, which require professional support, are fertility treatments, pregnancy and post‐separation, and not necessarily signing the agreement and handing the baby over which are viewed by the policymakers as the most difficult. The study shows that creating a respectful relationship between the parties, including with the baby, lessen the feelings of hurt, objectification and exploitation. Surrogacy which crosses continents, cultures and languages enhances the harmful components and removes the chance for an interpersonal relationship and minimization of damage. Abandoning the media arena into the hands of the mediation agencies leads to publication of biased information, hiding the difficulties and harm which leads to a dramatic increase in market volume. This study finds some positive clinical outcomes, yet we cannot help but be concerned by the implications that were brought into light by this study. Lessons can be learned from the Israeli surrogacy process and problematic points can be pointed out, even across continents, in order to minimize the damage to surrogates, especially of low socio‐economic class, while maintaining surrogacy as heroic and unique. Abstracts of Oral Presentations
A PARENT OR A GAMETE DONOR? LEGAL CONSEQUENCES OF AN UNSETTLED DEBATE Judit Sándor Central European University, Hungary [email protected] Human rights often require reinterpretation on the cellular level. Social movements for gender equality seem to have little impact on the new biotechnological inventions. This explains why the legislation of the various countries consider egg donation as being different from sperm donation, that surrogacy is forbidden in many places where egg donation is legal and that single women have to fight in a number of countries if they wish to use reproductive services or if they want to have their egg frozen for future reproduction. My objective is to investigate an issue that the majority of legislators have so far neglected: what are the consequences of the techno‐scientific approach for the perceptions of fundamental rights? In June 2014, the European Court of Human Rights examined in two cases (Mennesson v. France and Labassee v. France) the recognition of the family status of children born as a result of surrogacy agreements. In the first case, the French couple from Toulouse had concluded a surrogacy agreement in Minnesota, where the daughter named Juliette was born in 2001 after the egg of an anonymous donor was fertilized with the father’s sperm and the embryo was implanted in the surrogate mother’s uterus. The other French couple followed the same path in California, where their twins were born. Upon their return to France, the Labassees encountered difficulties when trying to obtain a birth certificate and citizenship for the child. The applicants argued before the European Court of Human Rights that failure to recognize their children’s status was in violation of the Convention on the Rights of the Child and Article 8 of the European Convention for the Protection of Human Rights and Fundamental Freedoms and that it had already been raised in the Genovese v. Malta case that citizenship was an integral part of personal identity. The court ruled that Article 8 was, indeed, violated in both cases and concluded that the child’s origin is an important element of privacy rights, which were damaged by the French authorities’ failure to recognize the child’s relationship with the parents. From recent legal cases in the field of assisted reproduction I will try to reconstruct the current problems of double terminology and its legal consequences in the field of human rights. THE GUILTY INNOCENCE OF CONSUMERS Pasqualino Santori Bioethical Committee for Veterinary Science, Italy [email protected] The Bioethical Committee for Veterinary Science (CBV) considers dutiful to morally connect food to the destiny of millions of farmers, of animals and of the environment. Compared to other consumptions, food consumption has different characteristics since it is inevitable for survival and because it is largely permeated with injustices among the complicated passages from production to use. An urgent reason to acquire an active and critical attitude, in regard to food, lies first in ethical responsibility and then on health reasons or on quality of food itself. The consumer citizen has not only the right to be informed but also the moral duty to search for information and the moral responsibility of the relapse of his/her choices on the life of the weak and unknown part of the production chain. 65
Talking about moral responsibility, the CBV hopes in a change of pattern or mental approach and in the start of a cultural debate on the origin of food. A careful attention in food purchasing and a consumer much more conscious of his/her own choices, could lead to the practical effect of engendering a virtuous circuit on the remote actors eager not to disappoint who judges them. This results particularly important in regard to the future risk of food shortage and the necessity of having to recourse to new technologies of production. It will be necessary to review concepts such as: price‐quality relationship, animal welfare, food and pathologies relationship, environment pollution. CAPABILITIES APPROACH FOR MUTUAL FELLOWSHIP IN COMMERCIAL SURROGACY Sheela Saravanan Lichtenberg Kolleg; University Medical Center Goettingen, Germany [email protected], [email protected]‐goettingen.de India is growing to be a popular global destination for people seeking surrogacy services. This phenomenon has been mushrooming in the backdrop of prevailing socio‐economic issues such as; widening inequalities, slow increase in employment rate, stagnating poverty and increasing gender inequalities. Ineffective governance, unclear surrogacy regulations that is inclined towards the medical private sector’s interests, unethical medical practices and increasing inflow of couples from abroad seeking commercial surrogacy makes India an ideal environment for global injustice. Using ethnomethodology, this paper draws on Nussbaum’s ‘capabilities approach’, to examine possibilities of global equality and mutual fellowship in the practice of commercial surrogacy. The study reveals that surrogate mothers in India attempt at converting their limited entitlements into capabilities by involving in exploitative surrogacy agreements. They need more protection both for short term and long term issues related with surrogacy, life and medical insurance and psychological and legal support. The State holds the primary responsibility to promote capabilities to enable people to enhance their entitlements and live a life worthy of human dignity. Individuals need to assist the State in doing their duties by adhering to the justice and taxation system, property rights with an aim to maximize collective welfare. The medical practitioners and intended parents need to reflect on the exploitative dynamic of their involvement in this practice rather than merely an economic/contractual perspective. At the global level, the practice of transnational commercial surrogacy in developing countries calls for an international declaration of women’s and child rights in third party reproduction. WHEN ONLY THE WEALTHY RECOVER: THE MEDICAL ETHICS OF ADDICTION TREATMENT AND RECOVERY Constance Scharff Cliffside Malibu, USA [email protected] Addiction has historically been a disorder for which treatment was largely ineffective and the prognosis for recovery was poor, no matter a person’s economic resources or social status. Twelve‐step programs, the time‐honored gold standard for addiction treatment, are estimated to have a recovery rate of 5‐
10%. Long the best hope for addicts, the twelve‐steps are a treatment modality that relies heavily on prayer and “miracles,” 66
UNESCO Chair in Bioethics 10th World Conference
not the stock‐in‐trade of medical professionals or typical treatment for a medical disorder. Today there is hope for addicts. New, evidence‐based therapies have been developed that have much higher efficacy rates than in the past, some as high as 70%. Yet despite low efficacy rates, those without resources continue to be sent to twelve‐step recovery groups and many treatment centers use twelve‐step treatment to remain cost‐effective and maximize profits. Evidence‐based treatment programs are available almost exclusively to those with significant financial means. These treatment programs are quietly being used by the wealthy to secure their recovery from addiction. In the USA, even with the mental health parity act, most with fewer resources may not know better quality care exists and have no access to it. This presentation will examine the changes in addiction treatment; the gulf in access to quality addiction treatment between those with and without significant financial resources; and efforts to bring the most effective recovery resources to those who need them, regardless of financial resources or global location. CONCERNS ABOUT WOMEN IN INTERNATIONAL CHILD PROTECTION CONVENTIONS homosexuality, etc. are signs of such self‐preservation behavior. Therefore, assessment and standards in modern bioethics cannot be exactly the same for all countries and peoples; they must correspond to ethnic age of this particular ethnic group. Therefore, scientific invariant of biomedical ethics always functionally acts as a cultural reflection of the national model of medicine. On the other hand, normative bioethical regulation allows adapting national standards for medicine as a cultural complex to international requirements. Therefore, the curriculum on bioethics should include three parts: Universal context Theoretical bioethics Knowledge and values Confessional context Religious traditions Ethnic context Cultural traditions of the ethnic group Rhona Schuz Sha'arei Mishpat Law School, Israel [email protected] The two major child protection conventions of the Hague Conference on Private International Law, the 1980 Convention on the Civil Aspects of International Child Abduction and the 1993 Convention on Protection of Children and Co‐operation in Respect of Inter‐country Adoption, are widely considered to have enjoyed a good deal of success in promoting the welfare of children abducted or adopted from one country to another. Yet, there is some evidence that these Conventions have not done sufficient to protect the interests of women and in some respects have actually caused harm to women. This paper will examine the impact of the Hague Abduction and Inter‐Country Adoption Conventions on women. It will then go on to consider similarities and differences between the abduction and adoption contexts and that of inter‐country medically assisted reproduction, in order to see in what ways the lessons that might be learned from the experience of the two Hague child protection conventions are of relevance to a proposed international convention to regulate inter‐country medically assisted reproduction. ETHNIC BIOETHICS IN EDUCATION Natalia Sedova Volgograd Medical Scientific Centre, Russia [email protected] Ethnic evolution is based on differentiation; social evolution is based on integration. These two trends come into conflict now. The ethnic groups that are losing their distinctive features resist the tendency integration by all means. But technological and economic needs, speaking in political form, suppress ethnic uniqueness. The disappearance of ethnic division leads to a loss of genetic diversity. One of the tasks of bioethics is to save them. Self‐protective behavior ethnos is a natural process. Ethnic extinction feels some discomfort in different areas, taken private measures to eliminate it. And there are already modifications ethical standards and legislative change. Liberal‐moral issues of cloning, euthanasia, surrogate motherhood/ fatherhood, Practical bioethics Norms and patterns of international bioethical regulation Religious restrictions normative regulation in medicine Normative structure of national health systems Applied bioethics
Personal maxims of conduct, approved by the society Correction of personal Maxim of conduct religious beliefs Implementation in the behavior of ethnic identity ETHICAL CONSIDERATIONS IN LEGAL REPRESENTATION OF PEOPLE UNDER GUARDIANSHIPS IN MEDICAL PROCEDURES Meytal Segal‐Reich Bar‐Ilan University and Ministry of Justice, Israel [email protected] Legal representation of people under guardianship has different ethical aspects. The basic assumption is that the person is well qualified to express will and has the legal capacity to do so. Therefore, the representation is expected to be as with any other client. Still, the lawyer has to be aware of different situations, such as a cognitive impairment, that impose special responsibilities. Medical procedures involving people under guardianship regard delicate ethical considerations and involve special legal representation. Once the procedure requires a court order, the patient is entitled to be represented. The lawyer's role in such representation involves special skills and knowledge, cooperation with professionals from different disciplines, such as medical experts, social workers and others. The lawyer also has to maneuver between his responsibilities to his client and the guardian who has a special legal status and is entitled to decide for the client. High ethical standards will assure true representation of clients in these situations. WILLINGNESS TO TREAT INFECTIOUS DISEASES: COMPARING TWO DISTINCTIVE MEDICAL SCHOOLS Avram Raphael Shack, Dan Zecharia Milikovsky, Renana Ben‐Yona, Dikla Akselrod, Alan Jotkowitz, Shimon Glick Ben Gurion University of the Negev, Israel [email protected] Introduction: Outbreaks of serious communicable infectious diseases remain a major global medical problem and force healthcare workers to make hard choices with limited information, resources and time. While information regarding Abstracts of Oral Presentations
physicians’ opinions about such dilemmas is available, research discussing students’ opinions is more limited. Methods: Medical students from two programs at BGU were surveyed — an Israeli 6‐year MD, and a global health‐focused 4‐
year MD for international students (MSIH) — and their responses were compared. Results: Compared to their counterparts, MSIH students are more likely to strongly agree to perform several procedures as a doctor (medical history [94.3% vs. 82.9%, p=0.02], draw blood [83.7% vs. 76.5%, p=0.02], participate in surgery [77.6% vs. 67.5%, p=0.093]). In preclinical years, they are less likely to agree to participate in surgery as a student [40.4% vs. 63.6%, p=0.011] or treat a patient with swine flu as a student [68.1% vs. 90.3%, p=0.001]. In clinical years, they are more likely to agree as a student to participate in surgery [61.0% vs. 24.5%, p=0.020], draw blood [83.3% vs. 69.8%, p=0.097]), and to treat a patient with tuberculosis [83.3 vs. 66.0%, p=0.043] or SARS [76.2% vs. 50.9%, p=0.034]. Overall they are less likely to agree that by deciding to enter medical school they are morally obligated to treat any patient [65% vs. 74%, p=0.032]. Discussion: MSIH students are more likely to agree to participate in the care of patients with serious communicable diseases despite being less likely to agree that they are morally obligated to do so. ETHICS AND REGULATION OF INTER‐COUNTRY MEDICALLY ASSISTED REPRODUCTION (ERIMAR) – A CALL FOR ACTION Carmel Shalev Haifa University, Israel [email protected] In recent years there has been a rapid growth of medically assisted reproduction (MAR), as well as an unregulated global market of medical tourism for repro‐genetic purposes, due to variations in national regulation and global economic gaps. The emergence of a profitable market in practices of inter‐country MAR (IMAR) involves transnational reproductive collaborations that have increased the risks of and actually incurred grave violations of the human dignity and rights of women and children. A lack of professional self‐governance and the absence of internationally accepted clinical‐ethical guidelines for MAR in inter‐country settings create conditions for potential reproductive abuse. In light of all this, there is an urgent need for debate and action at international, national and professional levels so as to take all possible measures to respect, protect and fulfil the human rights of women and children involved in IMAR. This paper describes an initiative of engaged academics in Israel – the ERIMAR Project – to initiate a worldwide process of deliberation on the complexities of IMAR, that will lead eventually to the adoption of an international code of ethics and an international human rights convention on IMAR practices. DECREASED MENTAL CAPACITY JEOPARDIZES DECISION MAKING PROCESS OF PATIENTS IN CRITICAL CONDITION Ehud Shalmon Ono Academic College, Assaf Harofe Medical Center, Israel [email protected], [email protected] The Lisbon Declaration on Patients' Rights protects the autonomy of any person to consent or to reject the recommend treatment. Occasionally patients in life‐threatening condition deliberately make unreasonable decisions, which jeopardize their lives. These 67
irrational decisions should query the mental competence patients in critical medical condition possess. Three cases illustrate a spectrum of patients in life‐threatening condition who conscientiously reject lifesaving treatment knowing the fatal consequences: 1) Young adult who refused a simple lifesaving surgery to repair stabbed cardiac injury. 2) Elderly person who consciously declined a lifesaving urgent operation for abdominal aneurysm. 3) Middle aged person who suffered a brain stroke but refuse lifesaving treatment. Any patient's request should be legally respected unless his mental capacity to analyze the consequences of his grave decision is inadequate. Although the legal competence to make a decision is dichotomized (yes or no), the level of mental capacity to make the same decision is commensurate with the severity of the situation, thus grave medical decision requires the greatest level. While physicians are constrained to the principle of beneficence (prevent harm, protect patient's autonomy, promote good), the patient is supposed to act along with his best interest. When the patient's decision evidently opposes his wellbeing it is imperative to assess the essence of his decision, to consider hidden external influence and to evaluate his mental capacity that may lead to an unreasonable behaviour in an urgent situation. It is the society duty to protect its member from being the victim of his fatal decision. UNDER THE REGULATION RADAR: STRATEGIES AND TACTICS OF PHARMACEUTICAL COMPANIES TO PROMOTE DRUGS AND MEDICAL PRODUCTS IN ISRAEL Yaffa Shir‐Raz University of Haifa, Israel [email protected] The pharmaceutical industry is a major player with powerful political and economic interests, who attempts to influence the media, the public, and policy health agendas. This study assesses the pharmaceutical industry's influence attempts process in Israel, and examines the strategies and tactics used by companies to promote their products among the public. Data generated by qualitative and quantitative content analysis of 1,465 press releases forwarded by PR consultants representing pharmaceutical companies. In addition, 49 semi‐
structured interviews took place, with PR consultants and executives of pharmaceutical companies; health journalists; hospitals and HMOs' speakers; and senior physicians. A case study was also explored – the HPV Gardasil Vaccine, marketed in Israel by MSD Pharmaceutical. The study reveals how complex and sophisticated the corporate influence attempts process is, and indicates that many of the strategies and tactics used extensively by pharmaceutical companies and their PR consultants are those defined by scholars as "disease mongering", and some are very similar to those used by the tobacco industry. In many cases, these strategies are not only unethical, but also opposed to laws, rules and regulations in Israel. As for the regulatory authorities in Israel, the findings indicate that they do not constitute a damping force: a lack of supervision and enforcement, and vague and unclear regulations allow aggressive companies to use strategies and tactics that evade the regulation radar, and which would never receive approval, even in countries where DTCA is allowed. 68
UNESCO Chair in Bioethics 10th World Conference
THE MORALITY OF DEPORTATION OF SICK ILLEGAL IMMIGRANTS Miriam I. Siebzehner1,2, Dorit Rubinstein1 1
Ministry of Health, Israel 2
Gertner Institute for Epidemiology and Health Policy Research, Israel [email protected] In recent decades efforts have been made by migrant workers from third world countries, to immigrate to developed countries in order to improve their wages and quality of life. This is often done in contravention of immigration laws of the destination country, especially when seeking a better life, such as infiltration made to the United States from Mexico. This phenomenon also exists in Israel. The possibility of sick illegal immigrant’s access to health care institutions in most European countries is limited to emergency situations. In the United States hospitals deal with the constant need to health expenditures, some are choosing "unlawful" deportations of illegal patients in order to save money. Utilitarianism states that ‘the ends justify the means’ i.e. the value of an action is determined by its contribution to overall utility and happiness while minimizing the suffering. This doctrine argues that actions are morally correct, as they tend to increase happiness. This philosophy depends on consequentiality and is considered as a selfish approach as it doesn’t take into account any kind of suffering which the society may face due to a particular action plan. In contrast, deontology is based on fairness and social justice. The moral value of the action lies in the act itself. There are things that are worth doing and there are things that we will do and no matter what will be the outcome. The presentation includes the arguments of the questions arise, the ethical approaches involved and conclusions regarding health coverage for illegal immigrants. ETHICAL ISSUES IN MEDICAL FIELDS Rupa Rajbhandari Singh Head, Nepal Unit of UNESCO Chair in Bioethics, B.P. Koirala Institute of Health Sciences, Nepal [email protected] Ethics are norms of conduct that distinguish between acceptable & unacceptable behavior. Bioethics is a way of understanding and examining what is “right” and what is “wrong” in biomedical research and practice. It is the philosophical study of the ethical controversies brought about by advances in biology and medicine. Importance of ethics & bioethics was realized with the study of McGill University & Tuskegee Study. The need for regulation and codes of behavior emerged from revelations of the research atrocities committed by the Nazis. Helsinki Declaration (1964) provides guidance in such areas as the use of animals for research purposes. The Objective of this paper is to find out the ethical issues faced in medical fields including research & how to avoid these unforeseen problems. Research ethics should aim at good ethics in everything we do. Research often involves human beings, to whom duties are owed, hence, it is necessary to formally scrutinise any study projects & role of bioethics is important here. Ethical research deliberately minimises the risk of harm, by thinking about possible outcomes during research design. Principles of Research Ethics see to the Respect & Autonomy of participants involved & Protection of vulnerable persons. The research should generate more good than harm & it should be justifiable & fair. Risk of research should be reasonable in the light of expected benefits to the individual and to the society. Ethical issues discussed are: human cloning, In‐Vitro Fertilization, Euthanasia, surrogacy, sex‐selective abortion, is it legalized? Does a fetus have rights? What about embryos? Etc. Should a mother be legally liable for drinking or taking drugs while pregnant? This of course would cause harm to their unborn child? Should you be allowed to genetically modify your children before they are born to prevent disease? What about to change eye color make them taller, stronger, smarter, and better behaved? Should college students be forced to get the meningitis vaccine? Other Ethical Issues of concern are organ donation, face transplants, biopiracy, etc. Should people be allowed to sell their extra kidney or a portion of their liver to a person in need of a transplant? This is currently illegal. Conclusion: Research Ethics should aim at good ethics in all research projects. The task of true bioethics is to deepen and propose the truth about humans, and to offer facts and guidelines for action directed also to the ones who are responsible for culture and common wellbeing of one & all. ETHICAL CONSIDERATIONS IN PEDIATRIC PHYSICAL THERAPY Julie Smerling‐Kerem Alyn Hospital, Israel [email protected] While lifesaving medical procedures are now quite common place in neonatal and pediatric medicine, the effect of these procedures on the overall outcome of the child and his/her family are less discussed in realm of medicine. The impact of these interventions on the lives of these children and their families are discussed in the realm of pediatric/developmental rehabilitation. The physical therapist, who is one of the first allied health professionals who meets these children and their families, and often follows them for years at a time, is often caught between conflicting issues while attempting to advocate for the child and his family while understanding the medical background and the natural history of what is expected. This presentation will show the complicated relationships that the physical therapist attempts to balance in the effort to represent the child his family and the medical system. ETHICAL IMPLICATIONS OF MODIFICATION OF TRAUMATIC MEMORIES Marcia Sokolowski Baycrest Health Sciences and University of Toronto, Canada [email protected]; [email protected] This case‐based presentation will begin more broadly with an introduction to the definition of Neuroethics and its role in the identification of ethical implications related to neuroscientific advancements. The field of Neuroethics can be divided into two realms: the practical and the philosophical. The former has to do with the application of neursoscience and its likely consequences for persons and society; the latter is concerned with the ways in which we think about ourselves as persons and moral beings. The importance of these two realms will be highlighted throughout the presentation as I pose the question of how scientific advances affect our understanding of moral responsibilities. While neuroscientific innovation is largely involved with development of techniques related to cognitive enhancement, with a focus on memory enhancement, I will narrow my Abstracts of Oral Presentations
presentation focus to the controversial topic of whether or not it is ethical to tamper with traumatic memories. This question will be posed in the context of case review that centers on persons diagnosed with Post Traumatic Stress Syndrome, such as soldiers or Holocaust survivors, and where use of a beta blocker could be potential useful in order to reduce the negative valence of their memories. Ethical issues both pro and contra memory distortion will be identified. While research on the use of beta blockers in this context is currently ongoing, and holds promise that modification of traumatized memories might be possible from a neuroscientific point of view, it begs the question of whether or not we should do it, from an ethical perspective. MORAL EXCLUSION: IMPLICATIONS FOR BIOETHICS Daniela Sotirova Medical University of Sofia and Technical University of Sofia, Bulgaria [email protected] Bioethics benefits from the concepts used in other appliеd ethics such as organizational and business ethics. Among them is moral exclusion – the process of setting psychological barriers of moral space by the community. Usually these limits are connected with ethical principles as fairnesse or universalism. It is argued that it would be beneficial for the quality of decision making in bioethical groups of stakeholders to view actors’ positions through the lens of moral exclusion. The former is connected with some soft ways of separation of individuals and groups inside and outside, own and others. What constitutes such a process from an ethical perspective, what are the behavioral symptoms, are the questions to discuss. The concept of moral exclusion in applied ethics was set for the first time in environmental debates. It was also used in interpreting the differences between patent and innovation in legal regulation of biotechnology. At the level of behavior in a community the moral exclusion is an aspect of the conflicts and their constructive solution. Then moral stereotypes, labeling, prolonging, postponing, and aggressive style of conflict resolution are emphasized. The pluralistic perspective (i.e. the recognition of legitimate participation of various actors) counteracts the exclusion. Moral ехсlusion is a consequence of moral rationalization. Based on the study of literature and a comparison between decision making in business organizations and ethics committees, the following signs of moral exclusion are defined: appling double standards; dehumanizing – denying of one's rights; minimizing the potential benefits of any interested party; normalizing imposed decisions and aggressive style; de‐individualizing – neglecting individual participation and its importance; blurring of responsibility – denying personal responsibility under the pretext that it is organizational. These procedures are often presented as quick, expert and managerial actions. Behind decisions that we usually consider opaque, bureaucratic, hasty or biased lies the process of moral exclusion. IN DEFENSE OF SUICIDE TOURISM (ST) Daniel Sperling The Hebrew University of Jerusalem, Israel [email protected] Recent reports from across the world involve stories of citizens embarking on trips mainly to Switzerland and Mexico to be assisted in their suicide by some other person/s. In Switzerland, for example, once contacted, a Swiss organisation named 69
Dignitas provides background information and examines whether there are other ways of tackling or minimizing the suicidal person’s suffering, including through access to palliative care. However, when a person's wish to die is strong and firm, Dignitas may locate a Swiss doctor who will issue the lethal barbiturate prescription following a screening process and some legal examination. From legal and ethical perspectives there are few alternatives for jurisdictions whose citizens are embarking on assisted suicide tourism. These include restricting particular benefits and services (Euthanasia) to residents and/or preventing residents from leaving to take up options available elsewhere; providing a unified and harmonized moral stance with regard to ST; or permitting ST under the assumption that ST can be justified by an appeal to the principle of interstate moral pluralism. Yet, the choice between such alternatives derives from the moral justifications of the practice of suicide tourism that in themselves are linked to the symbolic and emotional meanings that death carries in each or every society. The article will analyze and discuss these latter justifications and provide a prima facie argument in support of the practice of ST. ENVIRONMENTAL REFUGEES – ELECTROHYPERSENSITIVES (EHS) IN THE DIGITAL WORLD – A DISABLED POPULATION, DEPRIVED OF HOME, WORK & BASIC RIGHTS Yael Stein1, Mbong Eta Ngole2, Gaurav Aggarwal3, 4
Joel M. Moskowitz 1
Hebrew University – Hadassah Medical Center, Israel 2
University of Yaounde, Cameroon 3
UNICEF, India 4
University of California Berkeley, USA [email protected] Hypersensitive reaction to electromagnetic fields (EMF) was known as Microwave Disease, in radar and electrical workers in the 1940s. Today, ordinary people encounter electrohypersensitivity (EHS) to various forms of EMF, ranging from low EMF to microwave radiation, also known as radiofrequency waves. As cities apply city‐
wide Wi‐Fi and Wi‐Max, and schools expand Wi‐Fi to younger ages – those with EHS are deprived of the basic human rights to housing, work and public safety. When exposed to cellphones, routers, Wi‐Fi, cell towers, smart meters, baby monitors or other cordless electronic devices, those with EHS experience diverse symptoms: physical pain including headaches, paraesthesia, cardiac irregularities, chest pressure, impaired thinking, fidgetiness, skin rashes and sleep disturbance. Many are unable to work and must quit their jobs in order to save their health. EHS is not psychosomatic. According to the World Health Organization: “EHS is characterized by a variety of non‐specific symptoms that differ from individual to individual. The symptoms are certainly real and can vary widely in their severity. Whatever its cause, EHS can be a disabling problem for the affected individual.” Electrohypersensitivity is estimated to be prevalent in at least 3% of exposed population. Once developed, electrohypersensitivity symptoms can occur at much lower levels of exposure. In most cities today, the electrohypersensitive cannot enter an airport, a hospital, a courthouse, banks, most workplaces, shopping malls, supermarkets. Electrohypersensitive children are forced to stop attending schools in which Wi‐Fi and wireless devices are employed or face disabling exposures that limit their education due to induced serious health impairment. This paper presents several sentinel clinical case reports of individuals with EHS, in order to stimulate public policy 70
UNESCO Chair in Bioethics 10th World Conference
discussion of the ethical rights of those with EHS, and to promote additional clinical research into this growing problem. Including: (1) Sweden (where electrohypersensitivity is an officially recognized functional impairment / disability) ‐ a former Chief Technology Officer of Nokia recently indicated that he developed EHS and the demyelinating disease Multiple Sclerosis after years of EMF and RF exposures; (2) Canada ‐ a senior commercial jet pilot forced to retire after developing EHS; (3) Scotland – an experienced electrical engineer who became increasingly sensitive and unable to work with RF devices that he helped to design. These testimonies bring out symptoms and signs, early indicators of EHS, that health care providers and employers should watch out for in patients and employees. UBUNTU: ALTERITY AS A PERSPECTIVE FOR PEACE Flora Strozenberg, Edna Raquel Santos Hogemann, Willis Santiago Guerra Filho, Luiz Otávio Ferreira Barreto Leite, Milanna Nagib, Hellen Cristina Silva de Oliveira, Ana Carolina Antão, Matheus Novais da Silva Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Brazil [email protected] It looks for deepening the connections between peace, intercultural dialogue and communalism in the light of Ubuntu, an ethical concept that emphasizes the alliances constructed between people and the relations established by them, and is seen as fundamental to the African thought of the groups that adopt Bantu languages. It develops an original exercise in diatopical hermeneutics – a methodology proposed by Raimon Panikkar –, taking as the main goal to approach the Western ethical and political thinking to the epistemic and ontological category of Ubuntu, recognized in the Zulu maxim umuntu ngmuntu ngabantu (a person is a person through other persons). It chooses as the basis of such study some contemporary thinkers as Lévinas, Bauman, Kunene and Nussbaum, who show a common concern with reverting a context of war and disregard of the integrity of human beings, connected to an ethics of alterity, zealous of the values of conviviality and respect for the cultural differences. It reveals the political dimension of Ubuntu and the impacts of this conception on the process of facing the problems of human rights in post Apartheid South Africa. Grounded on such transdisciplinary reflexion, it tries to point through a path to the implementation of policies for peace based on interculturality and communalism within different cultures. THE USE OF FMRI FOR RESEARCH OUTSIDE THE HOSPITAL SETTING Michael Tal The Hebrew University of Jerusalem, Israel [email protected] Magnetic resonance imaging (MRI) has become a common tool recently, including research on subjects not related to clinical situations. In Israel there are two separate channels for reviewing research protocols involving human subjects. There are: 1) A clinical related channel with review and approve by a hospital IRB committee (named Helsinki), and 2) A non‐clinical channel with approve by an academic ethics committee of university. Since the MRI is a medical device and routinely employed in clinical practice, the issue of approving protocols involving its use outside of a hospital, on a university campus in a non‐medical setting needs in depth consideration. On one hand, the proper use of a medical device in general is in a hospital; on the other hand, the use of MRI for non‐hospital base research purposes has already become prevalent on university campuses in the USA. Several issues should be considered before decisions on this matter are made. Does MRI protocol fall into the category of a “under minimal risk” procedure? Because the magnet of the MRI scanner attracts certain metals to the instrument’s base, were the subject lies, it could move loose metallic objects at high velocity in the MRI room. This might harm the subject. Individuals with pacemakers, heart rhythm disturbances, permanent cosmetics (tattoo), or certain metallic implants could also be affected, as could those who suffer claustrophobia. Do we need a physician in charge during the procedure? How we should handle “Incidental” medical findings? Who is eligible to execute the research protocol and what form of qualification is needed? These issues will be discussed. INSTITUTIONAL APPROACH OF AUTISTIC CHILDREN: A CONTRIBUTION FROM BIOETHICS & PSYCHOANALYSIS Carlos Tewel Red Iberoamericana de Ecobioética de la UNESCO, Argentina [email protected] In the present paper we will broach different theoretical and practical matters raised by the daily work in a Therapeutic Educational Centre (as of now, TEC), located in the city of Buenos Aires, where we work with seriously disturbed children and young people, between the ages of 4 and 25 years old. The disturbances in the subjective constitution of these young people are displayed in breaks in the contact with the outside world: some don’t fix their gaze, others utter amorphous sounds, others rock rhythmically, or walk continuously. The manifestations are various, and so are the diagnoses: autism, psychosis, PDD, etc. The work in the institution has a double objective: educational‐
pedagogical and clinical‐therapeutic. Both are carried out from a psychoanalytic approach which bears in mind the guidelines in Bioethics. The relationship between psychoanalysis and institution, the process of subjectivation in children, the modification aroused from the work in the TEC, and the functioning of the institution will be our axes of analysis. We consider that the institutional work, together with each child’s family (through workshops for parents, individual interviews, movie workshops, etc.), is vital, given that the achievements of each of these children as regards their Self‐
reliance must be sustained by their cohabitation group. This way we can boost what each of them can attain as achievements, not from an unshakeable and a priori objective, but from the institutional focus, which poses a unique outlook, as well as a special approach to listening. COMMUNICATING WITH SUFFERERS: LESSONS FROM THE BOOK OF JOB Joseph Tham School of Bioethics, Italy and UNESCO Chair in Bioethics and Human Rights, Italy [email protected] This presentation will look at the question of sin and disease in bioethics with a spiritual‐theological analysis from the book of Job. The biblical figure Job is an innocent and just man who suffered horrendously. His dialogues with others—his wife, his friends, and God—can give many valuable insights for patients who suffer and for those who interact with them. Family, friends, Abstracts of Oral Presentations
physicians, nurses, chaplains, and pastoral workers can learn from Job how to communicate properly with sufferers. The main question for Job was how to maintain the tension between God’s justice and God’s mercy and not yield to the temptation of cursing God but to speak well of Him in moments of difficulties. CONFLICT OF INTEREST BETWEEN THE INSTITUTIONAL GOALS FOR THE ADVANCEMENT OF KNOWLEDGE AND INSTITUTIONAL ETHICS – ISSUES AND SOLUTIONS P. Thangaraju, D. Balakrishnan UNESCO International Chair on Bioethics, SRM University, India [email protected], [email protected] Quest for knowledge requires experimentation. Clearly, the Traditional ethical mechanisms do not measure up to emerging issues. Some researchers in their enthusiasm to gather knowledge overlook ethics. Certain others fall a prey to indoctrination. A few knowingly trample on ethics. There is a fine distinction between Research misconduct and Unethical research. Research misconduct pertains to fraudulent practices like intentional fabrication and commercial considerations. On the contrary, the term ‘Unethical Research’ indicates unethical practices e.g. disregard of non maleficence, autonomy, consent, etc. It is this category, that requires our attention. Solutions for this sorry state of affairs must fulfill two criteria (i) They must be consistent and (ii) they must be realistic and be applicable. We must mount a three pronged effort. I. General measures like Public funding of Biomedical research, avoidance of commercial interests, Establishment of Trial Registries, strict adherence to publishing ethics etc. II. Incorporating Bioethics in the Medical curriculum, right from the first day of medical education and, III. Enforcement of the ethical canons, among the practising physicians and researchers. These efforts can be eminently implemented at the field level by the Project Evaluation Committee and the Institutional Review boards. These committees must include lay men, jurists and philosophers. Standard Operating Procedures must be scrupulously followed. Further, it is imperative to endow these committees with adequate disciplinary powers. One aphorism of Hippocrates summarises all the above. Art is long, vitality is brief, occasion precipitous, experiment perilous, judgment difficult [Latin: Vita brevis, ars longa, occasion praeceps, experimentum periculosum, judicium difficile]. EVASION OF ONE’S OWN RULES: IMPLICATIONS FOR ETHICAL HARMONIZATION Emanuel Thorne Brooklyn College of the City University of New York, USA [email protected] People and countries resist ethical regulation. A common alternative to rejecting ethical regulation, or changing or complying with it, is to evade it by obeying its letter while eviscerating its spirit. It is this last response to ethical rules that this paper investigates. Consider: A Jewish couple in Bat Yam wished to neuter their cat. Their rabbi told them that causing pain to an animal for their convenience was impermissible. What did they do? They sold the cat to a Muslim neighbor, who had it neutered and then sold it back to them. This story crystallizes three insights: 1) people often choose to deal with their own rules by evading them; 2) such evasion often requires an “other” who can supply the proscribed service; and 3) trade facilitates the evasion. 71
With the trade and tourism opportunities afforded by globalization, people can take advantage of differences in regulation and values, and seek abroad goods and services, such as transplant organs and surrogate mothers, that are outlawed at home. Countries, too, use trade to violate their own rules. England banned slavery but imported slave‐made goods from its colonies. Countries that ban torture sometimes engage in “rendition,” relying on an “other” to commit the torture to extract the needed information. Effective regulation of most ethically fraught activities will require universal adherence. However, because of people’s and communities’ willingness to evade their own rules and the availability of “others” to facilitate evasion, harmonization of rules may be elusive. When is harmonization desirable, and when is it not? Under what conditions does harmonization occur naturally? How might desirable harmonization be fostered? This paper suggests some answers to these questions. MIGRATION OF DOCTORS AND MULTICULTURALITY IN THE GLOBAL CONTEXT Elena Toader Gr. T. Popa University of Medicine and Pharmacy, Romania [email protected] In the cultural intersection of globalization, the adjustment to the new social and cultural context and the embracing of pluralism are actions which converge towards the essence of the ethical principles of autonomy and equity, and the considerations of justice on human rights. Central ethical issue: the manner in which the migrating doctor could maintain his or her own values but also develop authentic respect for a multitude of values, traditions and experiences produced by various professional and social circumstances. Approach / methods / arguments: Primarily, we will extract the main ethical issues that the interconnection between globalization, migration of doctors and the multicultural context involves in the medical field. We will show how these matters are reflected or not in the specific national context. In order to achieve a realist image of the local situation, we will analyze the information obtained through participatory observations and comprehensive interviews applied at two job fairs for doctors for the representatives of the recruitment firms, doctors who attended the fair and doctors who exerted or are exerting their profession abroad. All the aspects regarding the empirical investigation will be correlated with the debates in the literature and the legal framework. Conclusions: We will highlight the situations deemed as representative for the manner in which the migrating doctors adjusts and integrates professionally in the cultural diversity. We will identify, present and motivate the aspects that determine the manner in which the migrating doctor relates to fundamental values in the context of the meetings with the ethnocultural patient. NEUROETHICS IN DRUG DEVELOPMENT Zoran Todorović1,2, Dragana Protić1 1 University of Belgrade, Serbia 2 Serbian Unit of the International Network of the UNESCO Chair in Bioethics [email protected], [email protected] Neuroethics studies ethical, legal and social implications of scientific and technological advances in neurosciences on human 72
UNESCO Chair in Bioethics 10th World Conference
brain, cognition and behavior. In particular, it deals with human health problems in neurology, psychiatry and other specialties; function of ethics committees, government agencies and other bodies which consider the ethics of research in the field of neuroscience; work in pharmaceutical companies; care and treatment of vulnerable groups; work in non‐governmental organizations (eg. patients' organizations) and others. Neuroethics arises from bioethics as a new field that provides more deep insight into the brain structure and function, which affect the fundamental issues such as free will and moral responsibility (eg. euthanasia, consent for organ donation, etc.). As regards drug development, neuroethics is involved in all phases, from drug discovery and preclinical testing to clinical trials. In particular, neuroethics may be focused on animal experimentation, translational pharmacology research, as well as clinical topics such as informed consent, research in vulnerable population, legal aspects in drug development etc. Ethical aspects of the use of epigenetic drugs which affect brain structure and function may be of a particular importance. MALPRACTICE IN REHABILITATION MEDICINE Iuly Treger Ben‐Gurion University of the Negev and Soroka Medical Center, Israel [email protected] Malpractice issues are a concern for medical rehabilitation specialists, but little information specific to the field is readily available. It was previously shown that the number of claims brought was one‐third of that predicted relative to the size of the specialty. Dollar losses were found to be significantly lower than expected compared with other specialties classified by insurance carriers to be of similar risk such as neurology, pediatrics and general/family practice and one specialty considered to be very low, dermatology. Injuries may occur in rehabilitation medicine field during doctors or nurse's treatment and multidisciplinary team member's therapy sessions for a variety of reasons, including: the improper diagnosis or medical treatment technique, therapist's unfamiliarity with the patient, inadequate supervision, or broken equipment. Rehabilitation treatment plan is based on maximizing function through the collective and coordinated implementation of physical modalities, physical training with therapeutic exercise, medication, movement and activities modification, adaptive equipment and assistive devices, orthotics, prosthetics, and experiential training approaches. Improper rehabilitation program or patient's placement in wrong professional facility can also be a reason of patient's physical, mental or psychological harm. To avoid a malpractice report few guidelines must be followed: 1. the patient, family members and support network must know all about the patient’s rehabilitation plan and expected optimal timelines; 2. rehabilitation physician must document the patient’s achievement of optimal recovery, requirements for ongoing therapy, treatment plan and the patient’s response to rehabilitation and recovery; 3. written protocols and guidelines must cover most of standard rehabilitation interventions; and 4. for treatment involving durable medical equipment the medical record documentation must include the precise descriptions and technical protocols of equipment management. BIOETHICS APPROACH IN ENGINEERING FORMATION Valeria Trigueiro Santos Adinolfi São Paulo University and Paraiba Valley University, Brazil [email protected], valeria‐trigueiro‐[email protected] Engineering (in general, not just biomedical) affects life, health, environment and society as much as biomedical fields, producing benefits and harms. It can increases mechanized food production but also the rural exodus, fossil fuel dissemination impacts on morbidity and mortality because of pollution, f. ex. Engineering, as biomedical fields, uses technical knowledge to solve problems, often heuristically, and make decisions in a scenario of uncertainty about all the benefits and harms of a project. Engineers share responsibility about risks acceptance, and must include moral values. Therefore, not all the risks on life, environment and health value in an Engineering project can´t be described as mere calculus. This have been a frequent demand from some professors of Engineering in Brazil to us. However, it´s no usual Engineering regular curricula have Bioethics in Brazil, or even Engineering Ethics. Therefore, it´s necessary includes bioethical approach since graduation training. It brings also the need of textbooks and materials, given Bioethics provides a viewpoint from the life and its values, health and environment maintenance. In this paper, we investigates in literature (in Portuguese and English languages) Bioethics approach in engineering textbooks. There is nothing in Portuguese language literature, therefore in English often authors uses Beauchamp & Childress principialism, Pellegrino Virtue´s Ethics and Potter. However, more discussions on Bioethics approach to Engineering and risk assessment are needed, as much as specific materials to enrich Engineering formation and even Bioethics debate. DEVELOPING JOINT ETHICS REVIEW MECHANISM FOR MULTI‐CENTER CLINICAL TRIAL IN TAIWAN: EXPERIENCE AND REFLECTION FOR TWO YEAR RESULT Daniel Fu‐Chang Tsai National Taiwan University, Taiwan [email protected] After horrifying abuses of research subjects during and after the World War II being revealed, ethics review by Institutional Review Board (IRB) or Research Ethics Committee (REC) before human trials has been developed for protecting research subjects for four decades. To ensure the IRB/RECs are doing their job properly, IRB/REC recognition or accreditation were also established for quality assurance for ethics review. However, careful and lengthy review processes due conceptual consideration, administrative or bureaucratic reasons were alleged to be procrastinating important and live‐saving clinical researches. This is especially serious in multi‐nations and multi‐
centers clinical trials since the same protocol may need to be reviewed by dozens or even hundreds of different Hospital IRB/RCs. How to form IRB/REC alliance or consortium to reduce repetitive processes and dis‐harmonization in review results and improve efficiency have become ethical issues as well as industry or academia survival issues. The speaker will in this talk share the process of developing the joint Review Mechanism under National Research Program in Bio‐Pharmaceutical, the NRPB‐IRB, and a government coordinated Central‐IRB which were developed in the past 3 years. The result shows the NRPB‐IRB and Central‐IRB have effectively reduced the ethics review and approval time down to less than 30 days, and prevented many repetitive administrative and application processes. Ethics review can hence play its Abstracts of Oral Presentations
proper role of human subject protection without delaying research process. YOUTH BIOETHICS PROJECT Miroslava Vasinova, Alessandra Pentone European Centre for Bioethics and Quality of Life – UNESCO Chair in Bioethics Italian Unit [email protected] Childhood is the ground on which we will walk for our whole life (Lya Luft) We are pleased to present our ongoing pioneering project regarding bioethics for children and teen‐agers. This initiative came into being in Aosta Valley, Italy, in 2004 where the European Centre for Bioethics and Quality of Life – UNESCO Chair in Bioethics Italian Unit began using some of the fundamental principles of bioethics (e.g. autonomy, mutual respect, do no harm, decision making, etc.), and applied them in an educational setting. Taking for granted that there is a seed of respect for human rights in every human being, our goal is to nourish it by allowing the basic principles of bioethics to grow and flourish in all children. According to Patrick Estrade we believe that "the age and nature of a person's earliest memory reveal the extent to which he has been able to grasp and master the whole of his life." Keeping this in mind, our aim is to develop strong “bioethical” roots in these “adults of the future” by thinking of them as “not a vase to be filled, but a fire to be lit” (Francois Rabelais). WHO OWNS OUR DEAD BODIES? Renata Veselska Masaryk University, Czech Republic [email protected] This presentation brings an overview of the current practice, ethical aspects and legal framework of the use of human tissues taken from cadavers in the Czech Republic. Although the first specialized Transplantation Act based on the principle of presumed consent entered into force in the country in 2002 and this law is in accordance with the Oviedo Convention, the real situation is more complicated. In fact, additional new legislation concerning the use of human tissues and cells for applications in human medicine allowed private companies to get control of all commercial utilization of human tissues removed from cadavers. Furthermore, the public awareness of this situation is minimal. All these aspects raise serious questions about correctness and justice of the principle of presumed consent if it is applied to the use of human tissues for commerce purposes. This study is supported by project CEB OPVK CZ.1.07/2.3.00/20.0183. ITALIAN REGULATION OF ADVANCE DIRECTIVES: LEGAL COMPARISON WITH OTHER WESTERN EUROPEAN COUNTRIES Denard Veshi1, Gerald Neitzke2 1
University of Bologna, Albania 2
Hannover Medical School, Germany [email protected] In this presentation, Advance directives shall be analyzed through ethical and legal comparative approaches. A thorough examination of the latest version of the Italian Bill No. 2350, 73
emended from the Chamber of Deputies on July 2011, is included. The importance of the extended view of autonomy and of the narrative approach of identity, which give the ethical validity of living wills and of advance directives of durable power of attorney for health care affairs, will be highlighted. The Italian Bill grants advance directives an advisory force, limits their application over time and does not consider the validity of oral declarations. The legal effects of this Bill will be studied in a comparative approach, especially by taking into account the French, German and English models. The French law also grants an advisory legal force to advance directives, which are included in the Code de la Santé Publique (public law). Instead, in Germany, where advance directives have legally‐binding force, norms of advance directives are included in the Bürgerliches Gesetzbuch (civil law). In England and Wales, the Mental Capacity Act introduces for the first time the lasting power of attorney, substituting the endurable power of attorney dedicated only to the management of propriety and finance. To conclude, some ethical principles that the Italian Legislator must take into consideration, are pointed out at. Further, some possible modifications of this Bill are suggested based on the experience of other European Legislations. LEADING THE CHANGE IN MEDICAL PRACTICE Alexandrina Vodenicharova, Antonya Ianakieva, Vlayko Vodenicharov, Petar Chavdarovski Medical University of Sofia, Bulgaria [email protected] Context. Advances in medical technologies and knowledge have made a positive impact on the quality and efficiency of medical practice but also created a complicated healthcare system and unanticipated ethical dilemmas. This complexity brings its own set of risks no matter how dedicated and professional staffs are. In this complex environment the leadership and management both are essential to the success of any enterprise. The aim of our study is to describe the involvement of medical professionals in leading the ongoing changes in medical practice as well as their knowledge and skills for these roles. Methods. A mixed methods approach was adopted combining a questionnaire survey of medical professionals and a review of the national and international literature on this matter. Respondents identified a number of evolving challenges and contexts facing them, including recent changes in the health care market, payment arrangements, factors affecting quality of care. Results. Our study revealed that the majority of medical professionals are not prepared to become involved in leadership roles ‐ roles that can lead and influence the future of our profession, and the future of health care in the country. They find it difficult to take appropriate action to raise and act on concerns about patient care, dignity and safety. They lack an ability to think creatively and adapt evidence‐based practices, and an ability to contribute and work in a team. Conclusion. We conclude that a greater degree of professionalism needs to be brought to bear in the development of medical professionals that will, whatever their role, take appropriate action to lead effectively the changes in medical practice. Quality improvement of care requires dealing with the new challenges understanding fundamental approaches to leading, motivating, and aligning medical professionals behind a common vision or direction during the day‐to‐day practice of medicine, and to assist physicians in taking responsibility for health to individuals, the family, communities, and other entities. 74
UNESCO Chair in Bioethics 10th World Conference
ETHICAL DILEMMAS IN PHYSICIAN‐PATIENT RELATIONSHIP IN MULTI‐CULTURAL SOCIETY CONCEPTS OF IDENTITY AND RELATED ETHICAL ISSUES IN THIRD‐PARTY ASSISTED REPRODUCTION Rotem Waitzman Union Graduate College and Icahn School of Medicine at Mount Sinai Hospital, USA [email protected] Gabriele Werner‐Felmayer Medical University Innsbruck, Austria gabriele.werner‐felmayer@i‐med.ac.at Israel in a state with many cultures and all the time we have more and more cultures that come to Israel. This situation can cause conflicts between physician and patient. In the article I looked on couple of cases in them, the culture can cause a conflict and I have suggested a way of communication that can help to prevent conflicts between physician and patient that arise because of the culture different. THE STUDY AND ANALYSIS OF CONFIDENTIALITY IN THE FORENSIC IDENTIFICATION Canping Wang, Zhen Li, Ruihong Zhang Kunming Medical University, China [email protected] Objective: We try to understand the relevant realization, knowledge structure, attitude and behaviour, from those policeman and policewoman who work in various public security bureaus(PSB) distributed in certain parts of Yunnan province in people republic of China about medical ethics in forensic fields. We also try to find out the way to prove the knowledge, concepts and behaviors about the forensic ethics. Method: Making the enquiring forms by our investigator; Carry out the investigation work in Puer, Xishuangbanna and Yuxi states, which distribute the southern part of Yunnan province; The way of investigation is Self‐Administered Questionnaire Survey Method: The content of the survey includes the principles of informed consent, principles of confidentiality, the principles of respect and the principles of justice and equality. Results: Principles of confidentiality: for this principle the voice of the people concludes that 73.9% of the people think that the above principle is very important to be taken care of, whereas 26.1% of the people had a very indifferent response to the above ideology, and none of the people had a negative view to the above stated idea. Whether the police share the case information of the investigation with the family, relatives and friends of the deceased? For the above question the response of the people suggested that 52.2% do not get any information of the investigation, whereas 47.8% of the result suggested that people are provided with the appropriate information of the investigation. A survey was carried out which was to determine that what percentage of the policemen use security protection in there computer to make sure that their investigations are not hacked. It was found out that 65.2% of the employees use security protection whereas 34.8% of the employees were not taking the basic precautions. Conclusion: After carrying out the above survey we can conclude that following the principles of confidentiality is one of the main criteria for the investigators. Whereas sharing the key information found out during the investigation with the family and friends must be prohibited. And keeping security protection in their computers is also very important to avoid any sort of leakage of the investigation is also a key aspect of the whole procedure. The use of assisted reproductive technology (ART) is rapidly progressing. In high‐income countries, the rate of children born due to ART is up to 3%. During recent years, third‐party reproduction using donated egg or sperm cells without or with surrogacy, often in a trans‐national setting, has become increasingly practiced. There is a general consensus that individuals involved as gamete donors or surrogates should remain anonymous (although this practice has been changed in some countries) and by donating their “genetic material” or by “renting” their body they resign from any role as parent of the future child. The concept behind having one’s “own” child is the biological, i.e. genetic, link between parents and child. This is the main reason to use ART in case of infertility. However, once a third party is involved the concept of one’s “own” child is obviously no longer entirely a genetic one. There also can be different degrees of “own” depending on whether both gametes are donated and if surrogacy is used. Another case is “mitochondrial donation” where only the enucleated donated egg cell and its healthy mitochondria are used but not the nuclear genome which stems from the future mother. Here, I will analyze concepts of identity underlying these practices from scientific (biological) as well as from ethical perspectives. I argue that there is no consistency in how identity is defined in these various settings and that this is a major ethical issue in third‐
party reproduction as currently the relationship of the involved three parties is inherently asymmetric. THE EXPANDED AND EVOLVING ROLE OF THE ETHICS COMMITTEE IN A PLANETREE PATIENT AND FAMILY‐CENTERED ENVIRONMENT Bernard Paul White, Maria Hale, Members of the Northern Westchester Hospital Ethics Committee Northern Westchester Hospital, USA [email protected] Planetree is a small but growing community of over 200 healthcare institutions in the United States and almost 70 institutions throughout the world that is dedicated to patient centered care. As one of the first 5 Planetree Designated Hospitals in the world, Northern Westchester Hospital has extensive experience in applying this patient and family centered philosophy to all facets of the hospital experience. The role of our medical ethics committee has expanded far beyond clinical consultations and the typical end‐of‐life issues addressed by most ethics committees. We participate in hospital financial decisions, care management decisions, community outreach, emotional and clinical support of the health care team, patient care initiatives and practically every aspect of the hospital environment. Our extremely broad‐based committee, which consists of members of every level of the health care team as well as hospital administration and multiple community members gives us a wide ranging and, we feel, unique perspective on all of these issues. We invite and welcome participation in all clinical and ethical discussions by the involved patient and family members. We will discuss specific examples of these activities and how they can be used to impact the entire hospital environment including how to select and orient community members to be active participants in ethical discussions, how to create an environment that inspires candor Abstracts of Oral Presentations
in expressing opinions regardless of clinical or ethical training and the significant role our ethics committee plays in supporting the clinical providers of care, especially in times of crisis. MOVING TOWARDS AN INTERNATIONAL CONVENTION ON SURROGACY AND ARTIFICIAL REPRODUCTION: IS IT TIME? NEGOTIATING AWAY HEALTH? LEGAL AND ETHICAL IMPLICATIONS OF THE TRANS PACIFIC PARTNERSHIP (TPP) AND THE TRANS ATLANTIC TRADE & INVESTMENT PARTNERSHIP (TTIP) Elizabeth Wiley1, Thorsten Hornung2, Deborah Vozzella Hall3, Xaviour Walker4, Anya Gopfert5, Claudel Pétrin‐Desrosiers6, Caline Mattar7, Will Perry8, Freya Langham9, Kostas Roditis10, Gabriela Noles Cotito11, Maria Ignacia Alvarez Argaluza12, 13
14
15
16
Ivana Di Salvo , Wunna Tun , Ian Pereira , Diogo Martins 1
University of Maryland, USA 2
University of Bonn, Germany 3
University of Connecticut School of Medicine, USA 4
Johns Hopkins Bloomberg School of Public Health, USA 5
Newcastle University, UK 6
University of Montreal, Canada 7
Washington University in St. Louis, USA 8
Nyes Institute, New Zealand 9
Monash University, Australia 10
National Kapodistrian University of Athens, Greece 11
Cayetano Heredia University, Peru 12
Universidad Católica del Norte, Chile 13
University of Pavia, Italy 14
University of Medicine – Yangon, Myanmar 15
Queens University, Canada 16
University of Beira Interior, Portugal [email protected] Over the last five years, a new generation of “mega” multilateral trade agreement negotiations has emerged. With a focus on regulatory harmonization and reductions in non‐tariff trade barriers, the Trans Pacific Partnership (TPP) and the Transatlantic Trade & Investment Partnership (TTIP) aim to further trade liberalization and boost economic growth. These agreements seek to establish a new global framework for trade governance and may have far‐reaching implications for the health and health care landscape around the world. TPP and TTIP negotiations are unprecedented in their size, scope and lack of transparency. With forty countries representing 65 percent of the global GDP participating, the potential economic power of these agreements is significant. On a truly global scale, the TPP and TTIP could profoundly reshape health care and social services, access to medicines and intellectual property, communicable diseases, drug safety and research, prevention of noncommunicable diseases including tobacco and alcohol control, environmental protection, food safety and supply, environmental/occupational health, medical education and the supply of health professionals. In this context, this paper will first review states’ legal and ethical obligations and authority to protect health and promote universal health coverage. We will then identify and analyze potential legal and ethical implications of the TPP and TTIP on health and health care. Potential strategies and recommendations for ensuring that this next generation of trade agreements promote rather than undermine health will be considered. 75
Debra Wilson University of Canterbury, New Zealand [email protected] While accurate statistics relating to the prevalence of international surrogacy are difficult to obtain, some indication may be found in the Australian government’s recent statement that it is aware of 400‐500 such arrangements currently operating between Australian citizens and Thai surrogates. In addition, further evidence can be found in the European Parliament’s labelling of surrogacy as a “global phenomenon”, and by the Hague Conference’s description of it as a “well entrenched practice”. The legal issues surrounding surrogacy are numerous and complex, while the laws utilized to address these issues are often general, vague, or out of date. In addition, laws relating to the fundamental issue of the child’s parentage and citizenship can be inconsistent, resulting in the child being considered legally stateless. While some legal issues are surrogacy‐specific, others (for example the definition of a parent) are clearly of broader application to new and developing artificial reproductive technologies. Addressing these issues now could minimize further issues later. This paper will discuss some of the recent surrogacy stories to illustrate these emerging issues and the gaps in the law that have often, by necessity, resulted in non‐legal and inconsistent solutions. Using New Zealand cases as examples, it will suggest that given a clear indication that current domestic laws and guidelines are unable to appropriately address these issues, the logical next step is not piecemeal and reactionary law reform, but a reconsideration of surrogacy laws in general. This can then provide the basis for the consideration of an international convention. BEYOND MY BODY’S LIMITS: IMAGINATION IN SERVICE OF CHILDREN WITH SEVERE MULTIPLE DISABILITIES Shifra Wohlgelernter, Orit Ben‐Yosef, Esther Jacobowsky, Roni Eilati, Liraz Menasheoff, Molly Katzav, Maya Barghil Alyn Hospital, Israel [email protected] Background: Guided imagery is a widely applied method for stress reduction and pain control. Two groups of children (ages 4‐
7 and ages 7‐16) with severe multiple disabilities were introduced to imaginative ideas. The younger group experienced guided imagery aimed at creating emotional regulation and positive sensations. The older group was involved in a multidisciplinary AAC (Augmentative and Alternative Communication) ‐ based program aimed at enhancing self‐
identity by using guided imagery. Objective: We describe guided imagery used in two programs within one special‐needs school, and ethical questions that arise: 1. in the context of AAC, is the child truly expressing his/her preferences, or is it merely a shadow of the adult's ideas? 2. Is this intervention enlarging a gap between the child's preferred reality (imagination) and actual reality? May this buffer the child's motivation to achieve realistic, rehabilitative goals? Methods and results: Psychologist led a weekly group session in collaboration with speech therapists and teachers. In the older group, children created an imaginary personal “safe place” via questions and answers on their AAC computers. In the younger 76
UNESCO Chair in Bioethics 10th World Conference
group, the children were invited to “go places” and “do things” as they wished, in their imagination. Conclusion: This is a presentation of a novel combination of interventions with a unique population: Imagination in the service of promoting psychological and social development in children with severe multiple disabilities. Ongoing doubts and correspondence with bioethical experts regarding these questions will be presented. THE ADOPTION OF BUDDHISM’S PRINCIPLES AS MEANS OF IMPROVING PHYSICIANS’ WORK WITH TERMINALLY ILL PATIENTS Ruth Wolf Israel [email protected] The medical approach as summarized by Leibowitz ‐ “We must treat the person, not just the disease” ‐ highlights the importance of treating the sick person and not only the illness’ pathology. This approach calls for healing not only the physical side, but also ‐ and mainly ‐ the mental aspect of the patient. One of the goals of this article is to turn physicians' attention towards the compassion necessary in treating a person with a severe or chronic illness, or a person who is dying – precisely because sometimes there is no medical cure for the physical state of such a patient. Therefore, physicians’ attention does need to be directed to providing emotional assistance to such a patient. Sometimes, the emotional strength the patient draws from the medical team that is treating him can change his view of, and approach to, the illness, and can enable his body to muster the emotional strength necessary to deal with his situation. Buddhism’s approach enables the sick patient to experience his illness in a different way, by making peace with one’s situation and, sometimes, even viewing the situation differently ‐ viewing the illness as a type of renewal. Buddhism, therefore, enables a sick person to choose a different point of view when his energy is exhausted and he loses hope, providing quality of life to patients. In such a situation, a sick person finds emotional strength in the knowledge that the end of his life is actually a renewal somewhere else. The limited life expectancy of the terminally ill patient demands that he be able to spend his time with minimal concerns and worries, and does not leave much time for treating the emotional side – the patient’s fear. In light of this fact, the patient’s ability to look ahead and grasp at hope is the most important issue. As much as possible, this is accomplished in an atmosphere of acceptance and with the absence, or reduction, of fear. The freedom to decide for oneself how to behave, according to one’s own approach, is what makes it possible for the sick individual to feel empowered, and is liable to encourage the patient to adopt a different point of view. The Buddhist approach recommends replacing the helplessness that usually accompanies the predicament of terminally ill patients with acceptance of responsibility for their behavior in any given situation; this is Buddhism’s main contribution to both physicians and patients alike. BIOETHICAL DILEMMAS IN ASSESSING CAUSALITY IN PSYCHIATRY Samuel Wolfman Haifa University, Israel s.wolfman@wolfman‐law.com Causality is an indispensable term in many areas of the law, in particular in tort law as well as in labor law. When a plaintiff submits a negligence suit against a person who allegedly neglected his duty against the damaged plaintiff, one of the major issues to be proved to the court is the causality between the wrong doing and the damage. When the damage is bodily or mentally, the court has to rely on medical experts opinions. It is more obvious when the damage is a physical one. Here the expert can base his opinion on laboratory or imaging findings and the questions can focus on the interpretations of such findings. When it is a mental damage, however, the medical expert, the psychiatrist cannot base his opinion on any objective data but his own impression from the verbal behavior of the patient. Same is true when the court has to assess causality in labor law, regarding the question whether a mental disease has been caused by work stressors. Another area related to labor law is the Israeli Statue for the compensation of people hurt or becoming ill during service in the armed forces. In both areas the compensation of the disabled person is directly linked to the question of causality. Here too, the court has to rely on medical experts and in the case of a mental disease, on psychiatrists. The problematic issue is that such an expert may have a predetermined agenda regarding etiology and causality of mental diseases. The presentation shall discuss the bioethical dilemmas of assessing causality in psychiatry and will argue that it is very easy to abuse the psychiatric "superiority" of the expert over the Judge who may accept medical statements as absolute truth. GOVERNANCE AND ETHICAL REGULATION OF HUMAN RESEARCH IN SUB‐SAHARAN AFRICA: A SYSTEMIC REVIEW OF PUBLISHED STUDIES FROM 1980 TO 2014 Muhammed Suraj Yusuf, Abubakar Kana Musa, Victoria Nanben Omole Kaduna State University, Nigeria [email protected] Background: The establishment of good research governance ensures integrity in research through accountability, transparency and responsibility. This systematic review aims at describing the evolution of the institutions of human research governance and ethical regulation in sub‐Saharan Africa. Method: PubMed was search from January 1980 up to November 2014 to identify studies on human research governance and ethical regulation in sub‐Saharan Africa. Result: We applied pre‐defined exclusion criteria to select 113 eligible studies from 146 studies. A progression in the number of studies was observed over the past thirty‐four years: 1980‐1990 [2], 1991‐2000 [10], 2001‐2010 [62] and 2011‐Nov 2014 [39]. In terms of geographical coverage the main countries represented were South Africa [30], Nigeria [10], Kenya [6], Uganda [5], Cameroon, Ghana, Malawi, Tanzania and Zimbabwe with 3 studies each. The studies were heterogeneous in terms of topic, method and outcome: research ethics policies and oversight of human research by governments [17], establishment, certification, capacity building and functioning of governance and ethics institutions of human research (including ethics committee Abstracts of Oral Presentations
and clinical trial centers) [27], management of conflict of interest in human research and ethical protection of participants and biological samples (e.g. biobanks) [40], and registration, ethical approval process, conduct, reporting of research studies and trials [29]. Conclusion: Over the past three decades sub‐Saharan African countries have made uneven progress in setting up institutions, policies, processes and oversight of human research governance and ethical regulation. We hope this systematic review will provide better understanding and specification of areas requiring improvement for various countries. BIOETHICAL CONTROVERSIES – PERSONAL DIGNITY, HOMO ECONOMICUS AND COMMERCIALIZATION OF BODY Anastasia Zakariadze Ivane Javakhishvili Tbilisi State University, Georgia [email protected], [email protected] Bioethical controversies and dilemmas are reflections of antagonistic correlations of postmodern society‐man as Homo Economicus and environmental world. Application of new biotechnologies has an essential influence on formation of moral consciousness, new values and evaluative criteria. As a result the self‐identification of human being as spice is vanished; the anthropological essence of man comes up the question. The issues of dignity of man and dignity of human life are very crucial at that moment. These issues differ. The right of somebody else’s’ intervention in human’s life‐esp.‐the ending of life, harvesting of organs from people who are in state of irreversible coma, persons with disabilities, those‐who could not take responsibility for their life, etc. This would mean that different organs or tissues could be taken from the patient to benefit someone in need. Presumably, this would be done with the permission of the so called donor’s relatives and possibly for a fee. Would such a revision of the law be ethical? Analyzing bioethical controversies is difficult even if cases are relatively simply. Genesis of problematic situations is characterized with several phases. Phase of contradiction is followed by phases of conflict and critical phase. We have a set of criteria to use, but for success we have to make following steps: investigating the details of case, identifying the relevant criteria, determine possible courses of action and at last to decide which action is most ethical. Presentation analyses Georgian National Bioethical Committee’s work, their general strategies to meet every day bioethical challenges. ISSUES IN PSYCHOLOGY, LAW AND ETHICS IN ISRAEL Moshe Zaki University of Haifa, Israel [email protected] The field of forensic psychology in Israel has matured considerably in the past 11 years after the creation of the Department of Psychology, Law and Ethics at the International Center for Health, Law and Ethics at Haifa University (Israel), in the beginning of the 2004. The progress has been achieved in the academic level (instruction and research), as well as in applied Forensic Psychology (assessment and treatment). Today, forensic psychology is still coping with professional and ethical issues in forensic assessment and treatment as services delivery to the court, in civil as well as in criminal proceedings. 77
CASE STUDY AND PROBLEM BASE METHODOLOGY IN BIOETHICS EDUCATION Irine Zarnadze, Shalva Zarnadze, Levan Baramidze Tbilisi State Medical University, Georgia [email protected] Introduction: Case Study and EBM (Evidence‐Based Methodology) is a relatively new concept in education, but one that is rapidly gaining acceptance as an important approach in assisting students, residents, and practicing physicians with their clinical decision‐making. Case Study and Problem base learning in Bioethical education has become a widespread and effective method of using the literature. Goals: Analysis of effectiveness of teaching methodology Methods: Observational Study Results and Discussion: The skills to be mastered to use the EBM approach include that of question formulation, literature searching, critical appraisal of articles, and application of evidence. The CS and PB component in TSMU has the aim of assisting students to learning objectives. Problems form the organising focus and stimulus for learning, Problems are a vehicle for the development of problem‐solving skills, New information is acquired through self‐ directed learning, Learning is student centred, Learning occurs in small student groups, Teachers are facilitators or guides Problems form the organising focus and stimulus for learning. Role of the tutor: facilitator, help clarify discussion, suggest avenues of investigation, put problem in context of other learning, suggest prioritising of learning issues, intervene in negative group dynamics, guide discussions about group process. Conclusion: Outcomes of CS and PBL are the Problem‐solving skills, Self‐directed learning skill, Ability to find and use appropriate resources, Critical thinking, Measurable knowledge base, Performance ability, Social and ethical skills, Self‐sufficient and self‐motivated, Leadership skills, Ability to work on a team, Communication skills, Proactive thinking, Congruence with workplace skills. DEVELOPMENT OF PATIENT RIGHTS AND HEALTH CARE LEGISLATION POLICY IN GEORGIA Shalva Zarnadze, Irine Zarnadze Tbilisi State Medical University, Georgia [email protected] Introduction: Development of Patient Rights and Legislation policy in Health Care is the base of Good service delivery and a vital element of any health system. Service delivery is a fundamental input to population health status, patient rights among with other factors, including social determinants of health. Implementation European standards and processes of harmonization of Legislations now is the fundamental aim of our Governance. Aim: Analyses of Development Legislation processes in Health Care, Patient Rights, Health Services Problem development for all social groups. Methods and Materials: Statistical review, Governance reports, Expert analyses‐more 60 experts‐respondents. Expert analyzes of development documents of Legislation of Health Care, medical services and Healthy Problems in Georgia. Results: Survey was conducted to study Starting from 90‘th, the Government of Georgia made several attempts to transform Georgian health care system into one with improved efficiency, accessibility, and quality services. The main principles of health 78
UNESCO Chair in Bioethics 10th World Conference
care reform since 2006 were to make the transition towards complete mercerization of the health sector: private provision, private purchasing, liberal regulation and minimum supervision. After 2013 in Georgia new regulations of Governance system of Insurance. Conclusion: Governmental efforts in Development of legislation, promotion and disease prevention can have significant impact on health status by preventing chronic diseases and detecting health problems at a treatable stage. DOES DIRECTING PATIENTS TO ADDITIONAL PRIVATE PHYSICAL THERAPY CARE PROVOKE ETHICAL DILEMMAS? Ilana Zilberstein Ministry of Health; International Center for Health, Law and Ethics, Israel [email protected] "Mr. Cohen is a post CVA patient in a rehabilitation center. He receives daily Physical Therapy (PT) treatment by Eli, who also offered him additional private treatment on weekends.” "Mrs. Green is being treated for a post whiplash injury in a public clinic. She asked a private PT for parallel treatment in order to speed up her rehabilitation. The private PT agreed.” “Mr. Dwyer is a nursing home resident. Following a thorough physical assessment his care plan calls for three treatments a week. Being unhappy about too few treatments, his daughter purchased additional treatments from an external PT.” These are a few of many examples that raise ethical dilemmas, many of which are integrated with clinical considerations. For example, when a PT offers or is asked to provide additional treatments, in parallel or in addition to ongoing care, in a public or a private facility of Physical Therapy service – does the patient really needs additional treatment?" This presentation’s objective is to elaborate on such dilemmas relating to therapist‐patient relationships, professionalism and collegiality. These ethical dilemmas and the clinical considerations involved means answers are not straight forward. It will be proposed that these dilemmas require specific regulations and guide lines within different PT frameworks and patient populations. This presentation will also offer methods to hone clinical and ethical reasoning skills for each situation. These ethical dilemmas are unique to the essence of our profession within the health system in Israel. WHEN RELIGION AND MEDICINE INTERSECT: THE EXAMPLE OF TAHARAT HAMISHPACHA Deena R. Zimmerman Jerusalem District Health Department; Nishmat – The Jeanie Schottenstein Center for Advance Torah; TEREM – Emergency Medical Services; Maccabi and Meuchedet Health Services, Israel [email protected] Patient centered care is currently considered an optimal paradigm of clinical practice. For adherents of a religiously observant lifestyle, the dictates of one’s faith can have an important impact on one’s medical needs. The goal of this oral presentation is to use the example of couples adhering to Orthodox Jewish practices as an illustration of this tenet. Specifically, it will describe the intersection taharat hamishpacha (also known as hilchot niddah – Jewish religious rules relating to the physical relation of husband and wife) with medical topics such as childbirth, menstrual disorders, sexuality and infertility. The issues chosen for presentation are based on an analysis of approximately 5,000 out of over 14,000 questions presented to a website supervised by the presenter dedicated to providing on‐
line advice on all topics related to taharat hamishpacha. This database has undergone both quantitative and qualitative study and the results of these analyzes will be presented. The ethical issues in the use of hormonal manipulation for religious needs will be discussed as well. This presentation will allow practitioners to better understand the needs of couples who keep the laws of taharat hamishpacha and address the overall topic of respecting the beliefs of those receiving medical care. CROSS‐BORDER REPRODUCTIVE CARE: THE CASE OF PRE‐IMPLANTATION GENETIC DIAGNOSIS (PGD) Shachar Zuckerman, Gheona Altarescu Shaare Zedek Medical Center and Hebrew University – Hadassah Medical School, Israel [email protected] Cross‐border reproductive care (CBRC) is a growing phenomenon, mostly for surrogacy and gametes donations. Less discussed issue is pre‐implantation genetic diagnosis (PGD) performed in foreign country, because of regulatory differences between restrictive homes countries in which legislation strictly bans this procedure versus other permissive countries where it is common practice. One cause for CBRC when couples interested in PGD is the search for laboratories performing this technique for medical conditions considered mild/non‐morally permitted in some countries, while the same condition is considered severe enough to justify PGD in other countries. An example of this ethical controversy is represent in a case of a British couple in which the female was affected with Gaucher disease and her spouse was a carrier for the same disease. The couple had a 50% chance of an affected child and wished to perform PGD in order to prevent the disease in next generation. The couple applied in their country for PGD but was rejected since this condition was not considered severe enough to justify the procedure. Seeking other avenues to perform PGD anyway, the couple reached Israel, in which performing PGD for Gaucher disease is both allowed and a relatively common procedure. Ethic committees worldwide are involved in understanding which medical usage for PGD is justified and ethical. Gaps between different countries' regulation, growing demand and relative ease of traveling abroad inevitably raises the question of how we define severe condition and moreover who is best placed to make decisions about these controversial questions and their implications. ETHICAL CONSIDERATIONS OF USING OFF LABEL MEDICAL TREATMENTS AND MEDICATIONS IN DISASTERS Shlomit Zuckerman Tel Aviv Yaffo Academic College School of Nursing, Israel [email protected] Off‐label use of medications in the western world is widespread. For example, recent data shows that children receive 25‐31% off‐
label products. Moreover, 70% of children and 90% of neonates receive off‐label products. A report from 2003 found that highest rates of off‐label use were anticonvulsants (74%), antipsychotics (60%) and antibiotics (41%). Off‐label use is also common for many biologics (Avastin). In addition, medications are frequently used off‐label in the psychiatric and pain management settings. I will start this presentation with the various definitions of off‐
label use of medications and the scope of using it in various Abstracts of Oral Presentations
clinical settings and in different countries. Then I will describe the inherent tension and key players in this practice. Next I will discuss the advantages and negative consequences of its use, as well as the research ethics and patient rights' perspectives of this practice. I will then focus on off‐label use in disaster settings. In particular, I will discuss medications which had actually been used off‐label in disasters and the ethical issues that evolved from its use. In the last section I will discuss whether or not regulation of off‐label use in disasters is warranted. Finally, I will try to determine why or why not models of off‐label use which exist in other relevant fields (e.g. epidemiology, emergency medicine) should be applied to the disaster setting and propose guiding principles for use of off‐label medications in disaster settings. THE RATIONALE OF THE EUROPEAN UNION HUMAN EMBRYONIC STEM CELL RESEARCH FUNDING Jana Zuscinova European Parliament, Brussels [email protected] European Union funds research projects involving human embryonic stem cells since 1998 within its multi‐annual Framework Programme for Research and Innovation. Compromise achieved among EU Member States was decided to be maintained also in current research programme Horizon 2020 for the period of 2014‐2020. Several aspects of human embryonic stem cells research are critically discussed with regard to constantly present argument of potential treatments for currently untreatable diseases. Call for clarity of scientific and ethical language in debate on the EU level is accentuated. Recent legal developments represented by decision of the Court of Justice of the European Union in case Brüstle vs. Greenpeace on non‐patentability of biotechnological inventions derived from human embryonic stem cells and also European Citizens’ Initiative One of Us bring forward necessity of re‐evaluation of the EU approach. After almost three decades of the EU discussion on human embryo research, it remains to be controversial. 79
ADDENDUM DOCTOR COMPETENCIES IN MEDICAL ETHIC AND EFFECTIVE COMMUNICATION SKILL AMONG THE ALUMNI OF FACULTY OF MEDICINE UNIVERSITAS AIRLANGGA Lilik Djuari, Agung Pranoto, Siti Pariani, Subur Prajitno, Ivan Rahmatullah Universitas Airlangga, Indonesia [email protected] Indonesian Doctor Competency Standard (SKDI) 2012 mandated that every physician should acquire competencies in acting according to medical ethic principal, and information exchange verbally and nonverbally with patient, and the family member. These competencies have significant contribution to better health outcomes among the patients. Faculty of Medicine Universitas Airlangga (FMUA) conducted a tracer study in 2013 that assessed their alumni competence in those area. The study questioned 75 users of the alumni who graduated from the faculty in 2010, 2011, and 2012 about the aspects of medical ethics and effective communication competencies, including medical ethic implementation at clinical work, communication skill with patient, the family member, and colleagues. The percentage of the users who perceive that the alumni practice good medical ethic is 78.3%. Meanwhile, the percentages of those who perceive that the alumni practice good communication with patient, and the family member are 71%, and 71% respectively. In general, this study exhibited decent results. However, this results still do not reflect whether the alumni incorporate four medical ethics, respect for autonomy, beneficence, nonmaleficence, and justice into their daily communication practice at clinical work. The medical education program at the faculty teach the medical ethic and effective communication skills courses during preclinical phase with the total of five credits. Therefore, the next tracer study will be required to evaluate more specific aspects of the medical ethic and communication skills implemented by the alumni in order to improve the teaching curriculum. Abstracts
Hebrew Presentations
‫‪83‬‬
‫‪Abstracts of Hebrew Presentations‬‬
‫הגופנית‪ .‬סיבות אלה יכולות לעודד עמדות שליליות מצד‬
‫פיזיותרפיסטים כלפי אנשים עם משקל יתר‪.‬‬
‫מטרת הרצאה זו היא הצגה של תפיסות ועמדות אודות אנשים עם‬
‫עודף משקל‪/‬השמנת יתר בקרב פיזיותרפיסטים מוסמכים‪ .‬‬
‫פרטיות המידע הרפואי בעידן רשתות חברתיות‬
‫שולמית אוחנה‬
‫מרכז רפואי קפלן‬
‫‪[email protected]‬‬
‫‪ ‬‬
‫‪ ‬‬
‫חובת הסודיות הרפואית נכללה עוד בשבועת היפוקרטס‪ ,‬המורה בין‬
‫היתר על שמירתה‪ .‬זכות הפרט לסודיות רפואית הינה זכות יסוד‬
‫הנכללת במסגרת זכותו של אדם לפרטיות‪.‬‬
‫מעמדה של זכות זו קיבל אופי חוקתי עם עיגונה בחוק יסוד‪ :‬כבוד‬
‫האדם וחירותו ועם חקיקת חוק זכויות החולה קיבלה החובה‬
‫לשמור על סודיותו הרפואית של מטופל משנה תוקף‪ .‬‬
‫בעידן המודרני‪ ,‬אחד המאפיינים הבולטים של התפתחות‬
‫הטכנולוגיה‪ ,‬הינו התפשטות הרשתות החברתיות‪,‬‬
‫והפיכתן לפלטפורמת תקשורת נפוצה עבור מיליוני משתמשים‬
‫וביניהם גם הצוות הרפואי והמטופלים‪.‬‬
‫בד בבד מתרחשת מהפיכה תרבותית וטכנולוגית במערכת הבריאות‪,‬‬
‫אשר מתמודדת עם אתגרים של הרחבת הקשר הבלתי אמצעי של‬
‫הצוות הרפואי עם המטופלים‪ .‬התקשורת האינטרנטית עוברת‬
‫לעידן של העצמת מטופלים וגישה מתרחבת למתן מידע רפואי‪,‬‬
‫חינוך לבריאות ומידע למטופלים עם עניין משותף‪.‬‬
‫מדובר במגמה שהולכת וגוברת של שימוש באמצעים טכנולוגיים‬
‫חדישים לשם מעקב רפואי‪ ,‬הזנת מידע ואף לשם הענקת טיפול‪.‬‬
‫ברחבי העולם יש כיום יותר מ‪ 10,000-‬אפליקציות בתחומי רפואה‬
‫ואיכות חיים‪ ,‬הזמינות לכולם‪ .‬סקרים שונים שנעשו בארצות‬
‫הברית הצביעו על שביעות רצון של המשתמשים באפליקציות‪ ,‬על‬
‫שיפור בנגישותו של הסיוע הרפואי‪.‬‬
‫לצד היתרונות‪ ,‬רשתות חברתיות פותחות את הדלת לגישה בלתי‬
‫הולמת‪ ,‬שימוש לרעה‪ ,‬גילוי של נתונים רפואיים אישיים וחשיפת‬
‫מידע רפואי לגורמים לא מורשים‪ ,‬לרבות‪ ,‬ניצול המידע לשימוש‬
‫מסחרי‪ .‬הסכנות שמציבה בפתחה המדיה החברתית עשויות להיות‬
‫דרמתיות למטופלים‪ ,‬בשל אופי השימוש בנתונים שפורסמו ובשל‬
‫ההשלכות הנובעות מהפרת הפרטיות‪.‬‬
‫בשנת ‪ 2013‬פורסם בארצות הברית דו"ח הקובע כי כמעט ‪ 30‬מיליון‬
‫אמריקאים גילו כי המידע הרפואי האישי שלהם נפרץ מאז שנת‬
‫‪ .2009‬ההיבט המדאיג יותר הוא שכמעט ‪ 50‬אחוז מהארגונים אינם‬
‫מודעים לסיכונים אלו‪ .‬‬
‫‪ ‬‬
‫עמדות ותפיסות כלפי אנשים עם עודף משקל‪/‬השמנת יתר‬
‫בקרב פיזיותרפיסטים מוסמכים‬
‫מיכל אלבוים גביזון‬
‫אוניברסיטת חיפה‬
‫‪[email protected]‬‬
‫‪ ‬‬
‫‪) Obesophobia‬שמנופוביה( הוא מושג המתייחס לפחד וחרדה‬
‫מאנשים בעלי עודף משקל‪ ,‬היוצרים מסכת של עמדות ותפיסות‬
‫כלפי האדם השמן ומייחסים לו תכונות נלוות שליליות כמו עצלנות‬
‫והיעדר משמעת עצמית‪.‬‬
‫תופעת עודף המשקל מוכרת בעשורים האחרונים כמגיפה כלל‬
‫עולמית‪ ,‬במדינת ישראל נמצא ש‪ 49% -‬מהאוכלוסייה סובלת מעודף‬
‫משקל או השמנת יתר‪.‬‬
‫מספר רב של מחקרים הדגימו את תופעת השמנופוביה בקרב‬
‫רופאים ושאר אנשי מערכת הבריאות המלווים בהשלכות שליליות‬
‫על הטיפול הרפואי הניתן לאוכלוסייה זו‪ .‬תופעת ההשמנה דווחה‬
‫כסיטואציה שלילית ע"י רופאים‪ ,‬כאשר קדמו לה שלושה‬
‫סיטואציות שליליות נוספות והם התמכרות לסמים‪ ,‬אלכוהוליזם‬
‫ומחלות נפש‪ .‬נמצא שחלק לא מבוטל מהדיאטניות מביעות רגשות‬
‫שלילים יותר כלפי המטופלים השמנים‪ .‬רגשות אלו הובילו‬
‫להתנהגות שלילית מצדם ולאפליה שבאה לידי ביטוי בהימנעות‬
‫ממגע בין בין‪-‬אישי וזמן טיפול קצר יותר מזה שניתן לאחרים‪.‬‬
‫האם בעולם המקצועי של הפיזיותרפיה קיימת תופעת השמנופוביה?‬
‫תופעה‪ ,‬שהינה הפרה מתמשכת של אחד מהסעיפים הבסיסים של‬
‫הקוד האתי המקצועי והוא "הפיזיותרפיסט ימנע מאפליה‪ ,‬קבלת‬
‫החלטות מקצועיות או משוא פנים‪ ,‬בגין מחלה‪ ,‬נכות‪ ,‬מגדר‪ ,‬דת‪,‬‬
‫לאום וגיל‪".‬‬
‫השאלה המתעוררת היא‪ :‬האם הסטנדרטים המקצועיים של‬
‫הפיזיותרפיסטים מושפעים מעמדות שלילות על אוכלוסיית‬
‫המטופלים בעלי משקל עודף? ישנם‪ ,‬היבטים ייחודים בנוגע לתופעת‬
‫ה‪"-‬שמנופוביה" בקרב הפיזיותרפיסטים נוכח העובדה שעבודתם‬
‫כרוכה לעיתים קרובות במגע פיזי ישיר עם המטופל‪ .‬כמו כן‪ ,‬הטיפול‬
‫הפיזיותרפי באדם הסובל מהשמנה יכול אף להיות תובעני ברמה‬
‫תשאול צוות רפואי לגבי אלימות במשפחה‪:‬‬
‫היבטים אתיים וחוקיים‬
‫מירב בן נתן‬
‫ביה"ס האקדמי לסיעוד בהלל יפה‬
‫‪[email protected]‬‬
‫תופעת האלימות כלפי נשים בישראל הינה שכיחה ובעייתית‪.‬‬
‫ההערכה לשיעור התופעה בישראל עומדת על כ‪145,000-200,000 -‬‬
‫נשים מוכות‪ .‬לפי הנתונים‪ ,‬כל אישה שביעית הוכתה בידי בן זוגה‬
‫לפחות פעם אחת בחייה‪ ,‬ובממוצע פעם בחודש נרצחת אישה בידי‬
‫בן‪-‬זוגה‪ .‬למרות הנתונים היקף תופעת האלימות אינו ידוע במדויק‬
‫לא כל המקרים מדווחים‪ ,‬המקרים המדווחים הם קצה הקרחון‪.‬‬
‫עפ"י נתוני סקר ארצי שנערך בשנת ‪ ,2000‬ניתן לשער כי כ‪40,215 -‬‬
‫נשים נזקקות לטיפול רפואי מדי שנה בגלל תוקפנות בן הזוג‬
‫כלפיהן‪.‬‬
‫אי לכך על מנת להגן ולסייע לנשים אלה יצא חוזר מנכ"ל בתאריך‬
‫‪ – 23.2003‬איתור וטיפול בנשים נפגעות אלימות במשפחה ע"י‬
‫מטפלים במסגרות הבריאות – באשפוז ובקהילה‪ .‬חוזר זה דורש‬
‫לבצע תשאול לכל אישה הנזקקת לטיפול רפואי על היותה אישה‬
‫נפגעת אלימות במשפחה‪ .‬לדרישה זו יתרונות רבים עבור הנשים‬
‫אולם מנגד מעמידה הדרישה את הצוות הרפואי בלבטים אתיים‪.‬‬
‫הרצאה זו תציג את הלבטים האתיים והחוקיים בסוגית התשאול‬
‫האוניברסלי של מטופלות לגבי אלימות במשפחה‪.‬‬
‫‪ ‬‬
‫האחות בפסיכיאטריה משפטית‪ ,‬סוהר או סוכן טיפול‬
‫סיעודי? כפל הנאמנות של אחות בפסיכיאטריה‬
‫דור בר נוי‪ ‬‬
‫מרכז לבר"ן שער מנשה‬
‫‪[email protected]; [email protected]‬‬
‫רקע‪ :‬מחלקות‪ ‬לפסיכיאטריה‪ ‬משפטית‪ ‬מאופיינות‪ ‬בתשתיות‪ ‬פיזיות‪ ‬‬
‫המדמות ‪ ‬מתקן ‪ ‬כליאה‪ ,‬ומתמקדות ‪ ‬באבחון‪ ,‬מתן ‪ ‬חוות ‪ ‬דעת ‪ ‬‬
‫פסיכיאטריות ‪ ‬וטיפול ‪ ‬במטופלים ‪ ‬אלימים‪ ,‬שביצעו ‪ ‬מעשה ‪ ‬פלילי‪,‬‬
‫והמאושפזים ‪ ‬בכפייה‪ .‬במחלקות המשפטיות הניגוד ‪ ‬שבין ‪ ‬העיסוק ‪ ‬‬
‫בסיעוד ‪ ‬פסיכיאטרי‪ ,‬לבין ‪ ‬העיסוק ‪ ‬בשמירה ‪ ‬על ‪ ‬בטחון ‪ ‬מעלה את‬
‫שאלת תפקידו של הסיעוד בפסיכיאטריה משפטית – סוהר או סוכן‬
‫טיפול סיעודי?‪.‬‬
‫תחומי המחקר‪ (1 :‬הכרת סביבת העבודה והיחס בין שמירה על‬
‫בטיחות לעומת מקצועיות ‪ (2‬תפיסת תפקיד מקצועית בדגש על‬
‫הקשר בין סביבת העבודה למרכיבים אישיים והשפעתם על כוונות‬
‫התנהגות מקצועיות‪.‬‬
‫מטרות המחקר‪ (1 :‬בחינת השפעת סביבת העבודה על תפיסת‬
‫התפקיד ושביעות רצון מהעבודה במחלקות פסיכיאטריות‪(2 .‬‬
‫בדיקת הקשר בין אקלים הבטיחות לתפיסת תפקיד הצוות הסיעודי‬
‫במחלקות פסיכיאטריות משפטיות בהשוואה למחלקות‬
‫פסיכיאטריות אחרות‪ .‬‬
‫השערות מחקר‪ .1 :‬ימצא הבדל בתפיסת האחות את תפקידה‬
‫במחלקות משפטיות לעומת אחיות במחלקות אחרות‪.2 .‬קיים קשר‬
‫בין אקלים הבטיחות לתפיסת האחות את תפקידה‪.3 .‬קיים קשר בין‬
‫תפיסת האחות את תפקידה לבין כוונות התנהגות )טיפול לעומת‬
‫שליטה(‪.‬‬
‫שיטה – ‪ ‬ישתתפו ‪ 191‬אחים‪/‬אחיות ממחלקות משפטיות‪ .‬ו‪91-‬‬
‫אחים‪/‬אחיות מחמישה מחלקות פסיכיאטריות בבתי חולים‬
‫כלליים‪ .‬כלי המחקר הנו שאלון מובנה להשבה עצמית הכולל‪:‬‬
‫שאלות לגבי תפיסת תפקיד האחות בפסיכיאטריה‪ ,‬אקלים בטיחות‬
‫בעבודה‪ ,‬כוונות התנהגות ושביעות רצון מהעבודה‪.‬‬
‫תרומות המחקר – בתחום הקליני – הכרות עם הכוחות בשדה‬
‫הקליני תאפשר לממונים לבחון באם העשייה הסיעודית בפועל‬
‫תואמת את העקרונות שמנסה הארגון להנחיל‪ .‬בתחום המנהלי –‬
‫התוצאות עשויות לסייע בהבנייה מחודשת של הגדרת תפקיד הצוות‬
‫הסיעודי בפסיכיאטרייה בכלל ובפסיכיאטרייה משפטית בפרט‪.‬‬
‫בתחום החינוכי – בניית תוכנית לימוד והתנסות מותאמות לשדה‬
‫הקליני‪ .‬בתחום המחקרי – חקר השפעת אקלים הבטיחות בעבודה‬
‫והשפעתו על תפיסת התפקיד עשוי לפתוח נתיב מחקרי חדש‪.‬‬
‫‪UNESCO Chair in Bioethics 10th World Conference‬‬
‫קדושת החיים ובדיקות סקר עפ"י פסקי הלכה של גדולי‬
‫הרבנים בישראל בדור האחרון‬
‫‪84‬‬
‫ושל רב המרכז הרפואי כמו שקורה ב"מעיני הישועה"‪ ,‬ע"י כך ניצלו‬
‫וניצלים חיי עוברים לא מעטים! ‪ ‬‬
‫‪ ‬‬
‫מנחם חיים ברייר‬
‫מרכז רפואי מעיני הישועה‬
‫‪[email protected]‬‬
‫‪ (1‬חולה סופני הנוטה למות‪ :‬בדעת תורה שנפסקה לפני ‪ 20‬שנה‬
‫)שנחתמה ע"י הרבנים הרב ‪ ‬‬
‫אלישיב זצ"ל והרב שלמה זלמן אויעארבך זצ"ל ויבדלו לחיים‬
‫ארוכים הרב שמואל הלוי ואזנר שליט"א‬
‫ורבי ניסים קרליץ שליט"א בי"ט כסלו תשנ"ה( נאמר‪:‬‬
‫יש לטפל בחולה סופני הנוטה למות בכל התרופות והטיפולים‬
‫הרפואיים השגרתיים כמו בחולה אחר‬
‫ואין לקרב קיצו בכל דרך כדי להקל על סבלו‪.‬‬
‫הטיפול התרופתי המצוין הינו הזנה ע"י זונדה או עם גסטרוסטום‬
‫או עם פג‪ ,‬עירוי נוזלים ‪ ,IV‬אינסולין‪,‬‬
‫מורפיום במינון מבוקר‪ ,‬אנטיביוטיקה‪ ,‬מנות דם לפי הצורך‬
‫הרפואי‪ .‬במהלך השנים התווסף שאם‬
‫נכנסה בעיה רפואית צדדית במהלך המחלה הממאירה אזי לפי‬
‫הצורך מנשימים את החולה כמו בפניאומוניה דלקת ריאות שבעטיה‬
‫החולה נכנס למצוקה נשימתית המאיימת על חייו‪ TPN ,‬הזנת על‬
‫תוך ורידית ודיאליזה‪.‬‬
‫הדברים משתנים כשנכנס החולה למצב של גסיסה שאלו הם ה‪72 -‬‬
‫שעות האחרונות לחייו )עד כמה שאפשר לחזות( שאז צריך לשקול‬
‫את הטיפול הרפואי המתאים ולהזהר שלא לשנע אותו שלא לצורכו‪.‬‬
‫‪ (2‬סרטן השד‪ :‬לפני ‪ 13‬שנה בנושא של סרטן השד קבעו ‪ 4‬רבנים‬
‫המובילים בעולם )הרב שלום אלישיב זצ"ל‪ ,‬הרב אהרון לייב‬
‫שטיינמן‪ ,‬הרב שמואל הלוי ואזנר והרב ניסים קרליץ( שיש לבצע‬
‫בדיקות סקר בנשים‪.‬‬
‫הוראתם היא‪ :‬שכיום ישנה אפשרות לכל אחת באופן קל לבחון‬
‫בעצמה ענינים יסודיים של בריאות גופה ולעמוד על המשמר ולקדם‬
‫פני רעה במחלה הידועה‪ .‬דבר גדול ונשגב עושים בזה כי זה נוגע‬
‫לפיקוח נפש וודאי ראוי שכל אחת תקבל הדרכה בענינים אלו לקיים‬
‫"רק השמר לך ושמור נפשך" וכו'‪.‬‬
‫ולפי הרמב"ם זו מצות עשה לשמירת הגוף‪.‬‬
‫מאז עלו מס' הבדיקות בציבור החרדי ובציבור שומרי התורה‬
‫והמצוות דהיינו בדיקות ממוגרפיה‪ ,‬אולטרה סאונד וביאופסיות‪.‬‬
‫ב"מעיני הישועה" מרכז רפואי המתנהל עפ"י תורת ישראל נעשים‬
‫כ‪ 420 -‬בדיקות ממוגרפיה לחודש‪ ,‬כ‪ 5000 -‬לשנה!‬
‫‪ (3‬בדיקות קולונוסקופיה הומלץ מאוד ע"י הרבנים לבצע זאת‬
‫כבדיקות סקר באוכלוסיה לגילוי מוקדם של ממאירות המעי הגס‬
‫מעל גיל ‪ 50‬ארעות המחלה מעל גיל ‪ 50‬הינה ‪ 6%‬דהיינו ‪ 1‬ל‪ 17 -‬איש‬
‫מדובר בשכיחות גבוהה‪ .‬‬
‫‪ (4‬חולה דמנטי חסר דעה‪ :‬לפני כחודשיים נפסק ע"י ‪ 9‬רבנים‬
‫מגדולי הדור בהקשר לחולה דמנטי‪ -‬חסר דעה שיש חובה לטפל בו‬
‫כדרך שחובה לטפל בחולה הצלול בדעתו‪ .‬כמו כן אין לחלק בין‬
‫חולה צעיר לזקן‪ .‬‬
‫חיוב ההצלה הוא גם לחיי שעה דהיינו לזמן קצר ועבור זה מחללים‬
‫שבת לקיים "ולא תעמוד על דם רעך" ומצווה לפרסם ברבים דין‬
‫פשוט זה‪ .‬הפסק הנ"ל מתאים ל"חוק זכויות החולה" עפ"י‬
‫המחלקה המשפטית של משה"ב‪.‬‬
‫חתומים הרבנים‪ :‬הרב שמואל הלוי ואזנר‪ ,‬הרב אהרון לייב‬
‫שטיינמן‪ ,‬הרב ניסים קרליץ‪ ,‬הרב חיים קניבסקי‪ ,‬הרב יצחק‬
‫זילברשטיין‪ ,‬הרב שלום כהן ‪ ,‬הרב שמעון בעדני‪ ,‬הרב משה שאול‬
‫קליין‪ ,‬הרב שריאל רוזנברג‪.‬‬
‫בישראל יש כ‪ 120.000 -‬דמנטים ואולי יותר ויש כ‪ 320.000 -‬איש‬
‫זקנים מעל גיל ‪ 75‬ובעולם מליונים רבים‪ .‬קביעות אתיות מוסריות‬
‫אלו יש להם גם השלכות משמעותיות בשטח‪.‬‬
‫בשנים האחרונות אנחנו מוצאים יותר ויותר חולים מונשמים בתוך‬
‫מחלקות יעודיות למונשמים ברחבי ישראל‪.‬‬
‫‪ (5‬בדיקות סקר גנטיות "דור ישרים" למספר מחלות גנטיות‬
‫רצסיביות חמורות‪ .‬הבדיקות נעשות בציבור החרדי והדתי לרווקים‬
‫ולרווקות לפני פגישות הכרות ע"מ למנוע נישואין של בני זוג נשאים‬
‫של מחלה גנטית סמויה כדי למנוע מחלות גנטיות שכיחות בילדים‬
‫הנולדים‪ .‬מדובר במחלות א( ציסטיק פיברוזיס ב( טאי זקס ‪ ‬‬
‫ג( דיסאוטונומיה משפחתית‪ ,‬ד( ‪ CANAVAN DIS‬ה( ‪FANCONI ‬‬
‫‪ ANEMIA‬מסוג ‪ C‬ו( תסמונת בלום ז( נימן פיק ח( מחלת אגירה‬
‫גליקוגן מסוג ‪ 1‬ט( ‪MUCOLIPIDOSIS ‬טיפ ‪ . 4‬עד היום נבדקו כ‪-‬‬
‫‪ 350.000‬צעירים וצעירות בישראל! ‪ ‬‬
‫‪ (6‬הפסקת הריון ‪ -‬עקב העדר דופק של העובר תעשה הפסקת‬
‫הריון רק לאחר אבחון ודאי של ‪ 2‬רופאים מיומנים באולטרה סאונד‬
‫להתריע או לא להתריע‪ :‬הגישה ההלכתית יהודית‬
‫חיה גרינברגר‬
‫בית הספר למקצועות הבריאות‪ ,‬המרכז האקדמי לב‬
‫‪ [email protected]‬‬
‫הגישה ההלכתית היהודית להתרעה של האחות על טעות או רשלנות‬
‫מקצועית משקפת את המתח בין שתי חובות שיכולות לעמוד‬
‫בסתירה אחת עם רעותה‪ .‬מצד אחד‪ ,‬אנו מצווים להציל אדם מעולה‬
‫נוכחית או פוטנציאלית העלולה להתרחש‪ ,‬אך מצד שני‪ ,‬אנו מצווים‬
‫נגד הלשנה‪ .‬הדילמה סביב ההרתעה נעשית מורכבת יותר בהתחשב‬
‫עם החובה להוכיח את עמיתנו‪ ,‬כלומר להעמיד אותם על חומרת‬
‫מעשיהם‪.‬‬
‫יובאו לדיון משקלם של המרכיבים הבאים בהליך קבלת ההחלטות‬
‫בעניין ההרתעה מההיבט ההלכתי‪:‬‬
‫• חומרת המעשה‪ ,‬לכאורה‬
‫• אמינות העובדות הידועות‬
‫• מערכת היחסים בין המרתיע והמבצע‪ ,‬לכוראה‬
‫• מאפייני המערך הארגוני בתוכו מתרחש האירוע‪ ,‬לכוראה‬
‫• הסיכוי שדברי המרתיע יתקבלו וייעשה בהם שימוש נכון‬
‫• הסכנה הצפויה למרתיע‬
‫‪ ‬‬
‫משתנים המשפיעים על התמודדות אנשי הצוות הרפואי עם‬
‫פטירת תינוק במחלקה לטיפול נמרץ בילוד‬
‫‪2‬‬
‫סופיה דומבה‪ ,1‬נילי טבק‪ ,2‬שולמית קרייטלר‬
‫‪ 1‬מרכז רפואי אסף הרופא‬
‫‪ 2‬אוניברסיטת תל אביב‬
‫‪[email protected]‬‬
‫אחד האירועים הקשים ביותר שחווים אנשי צוות רפואי העובדים‬
‫במחלקות טיפול נמרץ בילוד במהלך עבודתם הוא פטירת תינוק‬
‫במחלקה‪ .‬מתוך הספרות העולמית בנושא העוסקת בקשיים‬
‫שבהתמודדות רופאים ואחיות עם פטירת מטופל עולה כי הם חווים‬
‫תהליך אבל הדומה לזה של המשפחות‪ .‬המחקר יתמקד בתהליך זה‬
‫ובמשתנים המשפיעים על עוצמת תגובותיהם ודרכי התמודדותם של‬
‫אנשי הצוות‪ .‬השערות המחקר מתייחסות לקשרים שבין אירוע‬
‫פטירת התינוק לבין תגובת איש הצוות )תהליך אבל( והמשתנים‬
‫המתווכים ביניהם – פחד ממוות ומשאבים‪ .‬ובנוסף‪ ,‬לקשרים שבין‬
‫תהליך האבל אותו חווה איש הצוות לבין תגובות של תסמינים‬
‫פוסט טראומתיים‪ ,‬לשחיקה ולצמיחה‪ .‬מדגם המחקר יכלול ‪200‬‬
‫רופאים ואחיות העובדים במחלקות טיפול נמרץ בילוד במספר בתי‬
‫חולים בישראל‪ .‬נתוני המחקר יאספו באמצעות שאלון שנבנה על ידי‬
‫החוקרת ומורכב משאלונים קיימים ומשאלות שנוספו על ידי‬
‫החוקרת‪ .‬בפיילוט שנערך נמצאה עקביות פנימית גבוהה בין משתני‬
‫המחקר ואחד הממצאים הבולטים הוא שעד רמת שחיקה בינונית‪,‬‬
‫הצמיחה גבוהה יותר‪ .‬ואילו כשרמת השחיקה היא גבוהה מבינונית‪,‬‬
‫יש ירידה ברמת הצמיחה‪ .‬מכאן שלשחיקה יש כנראה השלכה על‬
‫היכולת והמוטיבציה לצמיחה‪ .‬עולות מנושא המחקר סוגיות‬
‫אתיות‪ :‬מהי החובה האתית של מערכת הבריאות כלפי המטפלים‬
‫ומאידך‪ ,‬חובת המטפלים כלפי מטופליהם? ממצאי המחקר עשויים‬
‫יהיו לתרום להבנת סוגיות אלו ובמציאת פתרונות עתידיים‬
‫במערכת מטפל ‪ -‬מטופל ובאיכות הטיפול במחלקות טיפול נמרץ‬
‫בילוד‪ .‬בנוסף‪ ,‬הממצאים יוכלו להגביר את המודעות לצורך בטיפול‬
‫במטפל‪ ,‬שפעמים רבות מדי אינו מקבל את המקום הראוי לכך‬
‫במציאות של ימינו‪ .‬‬
‫‪ ‬‬
‫עמדות של אחיות מוסמכות אקדמיות כלפי אתיקה בפרסום‬
‫מדעי‬
‫נילי טבק‪ ,‬סמיון מלניקוב‪ ,‬צביה בר‪-‬נוי‬
‫‪[email protected]; [email protected]‬‬
‫רקע‪ :‬מאמר מדעי הוא תוצאה של ייצור ידע על בסיס מחקרי‪ .‬על‬
‫מנת שהמאמר יעמוד בקריטריונים מקובלים הוא חייב להיות בהיר‬
‫בכתיבה‪ ,‬מדויק בעובדות‪ ,‬מיוחד בנושא ואובייקטיבי בנתונים‪ .‬יחד‬
‫עם זאת‪ ,‬לא פעם נתקלים באי שמירה על היושר ונורמות אתיות‬
‫במחקר ופרסום‪ .‬בין הבעיות הנפוצות בפרסום מאמר מדעי –‬
‫‪85‬‬
‫‪Abstracts of Hebrew Presentations‬‬
‫פרסום כפול‪ ,‬גניבה ספרותית והוספת אנשים בתור מחברים למרות‬
‫שלא תרמו תרומה מספקת לכתיבת מאמר‪.‬‬
‫מטרת המחקר‪ :‬לבחון עמדות של אחיות מוסמכות אקדמיות כלפי‬
‫אתיקה בפרסום מדעי‪.‬‬
‫שיטות‪ :‬אוכלוסיית המחקר‪ :‬אחיות אקדמאיות הלומדות במדרשה‬
‫לתארים מתקדמים בחוג לסיעוד באוניברסיטת תל אביב ואחיות‬
‫אקדמאיות העובדות במרכזים רפואיים גדולים במרכז הארץ‪.‬‬
‫הליך‪ :‬מחקר סקר‪ .‬הנתונים ייאספו באמצעות שאלון מובנה למילוי‬
‫עצמי בקרב כ‪ 100-‬אחיות אקדמאיות‪.‬‬
‫כלים‪ :‬שאלון מובנה למילוי עצמי שיבחן עמדות לגבי אתיקה‬
‫בפרסום‪ ,‬סוגיות אתיות במחקר והתנהגות לא אתית של חוקר‪.‬‬
‫תרומת המחקר‪ :‬ממצאי המחקר יסייעו לשפוך אור על הגורמים‬
‫שעשויים להשפיע על העמדות אל אחיות אקדמאיות לגבי האתיקה‬
‫בפרסום המדעי‪ .‬מתוך כך יהיה ניתן להתוות מדיניות לעמידת‬
‫אחיות חוקרות במידות אתיקה מקובלות‪.‬‬
‫‪ ‬‬
‫הטמעת הקוד האתי בקרב סטודנטים לסיעוד‬
‫עדי ליברטי‬
‫במסגרת השנה השלישית בלימודי סיעוד כוללת תכנית הלימודים‬
‫קורס אתיקה שחלק ניכר ממנו מוקדש לקוד האתי של האחים‬
‫והאחיות בישראל‪ ,‬ובהתאם גם בבחינת הסיכום של הקורס מוקדש‬
‫חלק ניכר לקוד אתי זה‪.‬‬
‫מטרת מחקר זה לבדוק את מידת התמיכה בשימוש בקוד האתי‬
‫בקרב אנשי סיעוד‪.‬‬
‫במסגרת מחקר זה נבדקו עמדות של סטודנטים בשנה הרביעית‬
‫ללימודי הסיעוד )שלמדו בשנה הקודמת קורס אתיקה( וכן של‬
‫אחים ואחיות מוסמכים ביחס לקוד האתי של האחים והאחיות‬
‫בישראל‪.‬‬
‫המדגם כלל כ‪ 150-‬סטודנטים לסיעוד מחמישה בתי ספר שונים‬
‫לסיעוד וכ‪ 30-‬אחים ואחיות ממגוון תחומים קליניים‪.‬‬
‫המחקר בדק את השימוש שהם עושים בקוד האתי בהטמעת הקוד‬
‫כמצפן מקצועי‪ ,‬חשיבות הלימוד שלו בעיניהם ואיזה ערך מהערכים‬
‫המנויים בקוד האתי זוכרים הנבדקים והוא נחשב בעיניהם לחשוב‬
‫ביותר‪.‬‬
‫תוצאות המחקר הצביעו על ידע דלקרטיבי רב יותר מצידם של‬
‫הסטודנטים לעומת אחים ואחיות מוסמכים; יחד עם זאת‪ ,‬ניכר‬
‫באופן בולט הו בקרב הסטודנטים והן בקרב האחים והאחיות‬
‫המוסמכים כי נעשה שימוש מועט בקוד האתי כמקור המשמש‬
‫לתמיכה בקבלת החלטות מקצעיות‪.‬‬
‫‪ ‬‬
‫אוכלוסיית מחקר‪ :‬קבוצות של אחיות ורופאים בישראל ובמדינות‬
‫חבר העמים‪.‬‬
‫מטרת המחקר‪ :‬בחינה ותיאור תהליכי קבלת החלטות מוסריות‬
‫בסיטואציות טיפוליות לא שגרתיות‪ ,‬וזיהוי הרכיבים האפיסטמיים‬
‫והמוסריים המשפיעים על תהליך זה‪.‬‬
‫שיטות מחקר‪ :‬סימולאציה של סיטואציה טיפולית על פי שני‬
‫תרחישים‪ ,‬ראיון מובנה בקבוצות מיקוד‪ ,‬ראיון מאזכר בתום ראיון‬
‫מובנה‪ .‬דיווח פרטני על החוויה של האינטראקציה הטיפולית‬
‫הסימולאטיבית ודיווח קבוצתי‪.‬‬
‫שלבי המחקר‪:‬‬
‫• סימולאציה של אינטראקציה טיפולית‪ :‬הצגת סיטואציה‬
‫טיפולית‪ ,‬שאיננה מייצגת את הפרקטיקה ואת הנורמות‬
‫השכיחות; הגדרת עמדה אישית ביחס לפנייתו של המטופל‬
‫ונימוק עמדה זו;‪ ‬קבלת החלטה טיפולית ‪ ‬‬
‫• קבוצת מיקוד ודיון על עמדות אישיות‪ ,‬נימוקים של העמדות‬
‫וביסוס ההחלטות ‪ ‬‬
‫• ראיון מאזכר להבהרת התהליכים והגורמים בהן גובשו העמדות‬
‫האישיות ‪ ‬‬
‫תוצאות המחקר‪:‬‬
‫• המשתתפים מכירים את עקרונות המוסר ושואפים לממש אותם‬
‫בפרקטיקה המקצועית‬
‫• האינטואיציה המוסרית של המטפלים בסיטואציות טיפוליות‬
‫לא שגרתיות מוטה בעקבות תגובותיהם הרגשיות ‪ ‬‬
‫• המשתתפים משתמשים בידע מקצועי לרציונליזציה של‬
‫ההחלטות אישיות ‪ ‬‬
‫• המשתתפים נוטים לפטרנליזם והיעדר אמפתיה בסיטואציות‬
‫קונפליקטואליות‬
‫התמות המרכזיות בתום שלבי המחקר‪:‬‬
‫• קונפליקט ערכי ‪ ‬‬
‫• רכיבים רגשיים בתגובות ‪ ‬‬
‫• נטייה לשיפוטיות ‪ ‬‬
‫• אתנוצנטריזם ‪ ‬‬
‫• פטרנליזם‬
‫מסקנות‪ :‬תהליך הכשרה של המטפלים כיום מבוסס בעיקרו על‬
‫גישה אפיסטמית אינטרנליסטית‪ ,‬המנחה לקבלת החלטות על בסיס‬
‫ראיות מחקריות וגוף ידע מקצועי‪-‬טענתי‪ .‬אינטראקציות טיפוליות‬
‫המעוררות קונפליקט מניעות לתהליך קבלת החלטות אינטואיטיבי‬
‫בהתאם לגישה אפיסטמית אקסטרנליסטית‪ .‬המלצת המחקר –‬
‫פיתוח מנגנונים אפיסטמיים אקסטרנליסטים מהימנים כחלק‬
‫מהכשרה מקצועית של המטפלים‪.‬‬
‫‪ ‬‬
‫דילמות אתיות בבריאות וההקשר הרב תרבותי‬
‫ידע ועמדות של אחיות בתי חולים כלליים ביחס לטיפול‬
‫באסירים כבולים‬
‫ביה"ס האקדמי לסיעוד ע"ש אדית וולפסון‬
‫דורית רובינשטיין‪,‬מיכל פייזר‪ ,‬נורית וגנר‬
‫שרה ניסים‬
‫‪saran@son‐wolfson.co.il‬‬
‫‪[email protected]‬‬
‫משחר ההיסטוריה ועל פני כל הגלובוס‪ ,‬מתחבטים בני אדם‬
‫בשאלות קיומיות ומהותיות הקשורות לחיים ומוות‪ ,‬של מה הוא‬
‫"טוב"‪" ,‬נכון"‪" ,‬ראוי"‪" ,‬בסדר"‪" ,‬מתאים" וכד'‪.‬‬
‫מתוך הכרה זו‪ ,‬עולות תהיות רבות ומשמעותיות‪:‬‬
‫האם ה"ערכים המכוונים" על פיהן מבססת תרבות את תשובותיה‬
‫לשאלות אלו‪ ,‬הינם אוניברסליים? האם קיים בכלל מושג כזה? כיצד‬
‫ערכים אלו יבואו לידיי ביטוי בהחלטות האתיות‪ ,‬תרבויות שונות ?‬
‫האם יש מקום ליחסיות תרבותית בעת קבלת החלטות אתיות? ‪ ‬‬
‫בהרצאה זו אנו ננהל דיון בשאלות אלו ונבחן היבטים תרבותיים‬
‫הקשורים לקבלת החלטות אתיות במסגרות העוסקות בבריאות‪,‬‬
‫בחיים ובמוות‪.‬‬
‫הטיפול הסיעודי במסגרות טיפוליות שונות‪ ,‬חושף לעיתים את‬
‫הצוות הסיעודי לצורך במתן טיפול לאדם כבול )אזוק(‪ .‬מצב זה יוצר‬
‫דילמות‪ .‬מחד‪ ,‬הצורך לטפל בפרט תוך שמירה על זכויותיו‬
‫הבסיסיות ועל שלומו מצד שני‪ ,‬הצורך להגן על הצוות המטפל ועל‬
‫מטופלים אחרים בשל החשש לפגיעתם מהאסיר‪.‬‬
‫הקונפליקט בין הגוף האחראי על שמירת האסיר לבין הגוף המטפל‬
‫לא מצא את פתרונו‪ .‬כן הנהלים הקיימים לא אפשרו טיפול נאות‬
‫באסירים ויצרו קונפליקטים‪ .‬משרד המשפטים בהשתתפות כל‬
‫הגורמים העוצרים והמטפלים באסירים‪ :‬משרד הבריאות‪ ,‬ארגוני‬
‫זכויות אדם ולשכות האתיקה של הסתדרות הרופאים ושל‬
‫הסתדרות האחים‪/‬ות ניסחו נהלים חדשים‪.‬‬
‫לשכת האתיקה של הסתדרות האחיות בחרה לבדוק בסקר הנוכחי‬
‫את הקף הבעיה‪ ,‬את הידע העמדות והנכונות של אחיות לפעול‬
‫בתחום‪.‬‬
‫מטרות המחקר לבחון את‪:‬‬
‫‪ .1‬שכיחות ההיתקלויות של אחיות בטיפול באסירים כבולים‬
‫במחלקות בתי החולים‬
‫‪ .2‬הידע לגבי נהלים הקשורים בטיפול באסיר אזוק‪.‬‬
‫‪ .3‬העמדות של האחיות ביחס לטיפול באדם ‪ /‬אסיר כבול )אזוק(‬
‫בבתי חולים‪.‬‬
‫‪ .4‬הנכונות של האחות לפעול בהקשר לטיפול באסיר כבול‪.‬‬
‫‪ ‬‬
‫רכיבים אפיסטמיים בביסוס גישה טיפולית‪-‬מוסרית‬
‫בסיטואציות קונפליקטואליות‬
‫אלה קורן‬
‫בית הספר האקדמי לסיעוד ע"ש זיוה טל‪ ,‬שיבא ‪ ‬‬
‫‪[email protected]‬‬
‫גישת המידות דוגלת בפיתוח המידות האישיות האתיות‬
‫והאפיסטמולוגיות‪ .‬המחקר המוצג מתאר תהליך של התבוננות‬
‫פנימית ותובנות לגבי התפקוד המוסרי והאפיסטמי של המטפלים‪.‬‬
‫‪UNESCO Chair in Bioethics 10th World Conference‬‬
‫אוכלוסיית המחקר – ‪ 359‬אחיות )‪ 79%‬נשים( העובדות במסגרות‬
‫אשפוז שונות בבתי חולים כלליים בארץ‪ ,‬הלומדות באחד‬
‫מהקורסים העל בסיסיים‪.‬‬
‫הכלי – שאלון אנונימי למילוי עצמי‪ .‬המחקר קיבל אישור וועדה‬
‫אתית מוסדית ומנהלות בתי ספר לסיעוד בהם התקיימו הקורסים‬
‫העל בסיסיים‬
‫ממצאים – אחיות שטיפלו באסיר אזוק במהלך השנה האחרונה‬
‫)‪ ,(n=162‬באופן מובהק היו בעלות ידע רב יותר ‪ (P <.001) T= 3.28‬‬
‫והאמינו שלכבילה ישנה השפעה על איכות הטיפול ‪(P <.05) T =‐2.91‬‬
‫יותר מאשר אחיות )‪ (n = 183‬ללא ניסיון קודם בטיפול באסיר אזוק‬
‫במהלך השנה האחרונה‪ .‬לא נמצא הבדל מובהק בנכונות לפעול בין‬
‫שתי הקבוצות‪.‬‬
‫מסקנות והמלצות – שיפור הנהלים הקיימים בנושא טיפול באסיר‬
‫הכבול‪ .‬קביעה ברורה ויידוע הצוותים הרפואיים‪ ,‬באילו תנאים‬
‫אסירים ועצורים‪ ,‬הנתונים למשמורת שב״ס והמאושפזים בבית‬
‫חולים‪ ,‬יהיו כבולים באזיקים‪ .‬הפצת המידע על פקודת נציבות‬
‫שירות בתי הסוהר מס׳‪ 04.15.01‬משנת ‪ 2008‬בעניין ״כבילת אסיר‬
‫במקום ציבורי״‪.‬‬
‫‪ ‬‬
‫‪86‬‬
‫טעויות בטיפול והסיעוד‬
‫חיה רז‬
‫המרכז האקדמי לב‪ ,‬בית הספר למקצועות הבריאות‬
‫‪[email protected]; [email protected]‬‬
‫בטיחות הטיפול הוא נושא שמעסיק את עולם הרפואה מאז עבודתם‬
‫של ‪ Leape‬וחב' ב‪ ,1991-‬שהרשימו את הציבור בהציגם את חומרת‬
‫הבעיה‪ .‬כחלק מהצוות הרפואי‪-‬המטפל‪ ,‬חובה גם על האחיות‬
‫להתמודד עם טעויות בטיפול‪ .‬אחת הדרכים בקידום בטיחות‬
‫הטיפול היא הלקחים המופקים מדיווח על טעויות ועל כמעט טעות‪.‬‬
‫תובא סקירה היסטורית קצרה כיצד האחריות בטיפול הואצלה גם‬
‫לאחות‪ .‬מתפקיד של "לויאליות בלעדית לרופא" בימי נייטינגיל דרך‬
‫"היותה סנגור של המטופל" ועד היותה מייצגת את טובת המוסד בו‬
‫היא עובדת‪.‬‬
‫יובא תקציר המדגיש את הדילמות של האחיות כפי שמיוצגות‬
‫בספרות המקצועית‪ ,‬בהתמודדות עם החובה לדווח בעולם‬
‫ובישראל‪ .‬למי נתונה הלויאליות של האחות‪ :‬למקצוע‪ ,‬לרופא‪,‬‬
‫לצוות האחיות‪ ,‬לצוות הרב מקצועי‪ ,‬למטופל‪ ,‬למשפחתו‪ ,‬לקהילה‬
‫או למוסד שבו היא עובדת‪.‬‬
‫‪ ‬‬
Abstracts
Poster Presentations
Abstracts of Poster Presentations
NEW MODELS OF PUBLIC HEALTH RESEARCH: DEVELOPING AN ETHICAL FRAMEWORK FOR RESEARCH USING SURVEILLANCE DATA IN RESOURCE LIMITED COUNTRIES Evelyn Anane‐Sarpong1, Bernice Simone Elger1, Marcel Tanner1, 1
2
3
Tenzin Wangmo , Osman Sankoh , Angus Dawson 1
University of Basel, Switzerland 2
International Network for the Demographic Evaluation of Populations and their Health, Ghana 3
University of Birmingham, UK evelyn.anane‐[email protected] Surveillance and research are key evidence generating tools in public health (PH). It is normal practice for PH models like health and demographic surveillance systems to build upon prior research, but whenever research seeks to involve pre‐collected surveillance data, higher and obligatory rules of human participant protections are thought necessary to ensure adherence to research ethics regulations. To our knowledge, re‐
use of surveillance data for research/publications (RUSD) is gaining grounds, but has not been empirically investigated for ethical issues. There is no clear direction on applying ethics principles to RUSD, standards for ethics review, nor the authority to institute ethical guidelines. We therefore hypothesize that professionals and ethics committees muddle through existing frameworks using discretionary “good effort” extrapolations and deductive analysis to define what is ethical in RUSD. Imprecise guideline interpretation and misapplication of principles to critical issues may arise. Waiting for the right RUSD ethical guidance to naturally evolve could be slow, and given population numbers, costly. This study uses a mixed methods approach involving theoretical and normative ethics literature review and an empirical phase of field work in Ghana, Tanzania and Uganda. The presentation will discuss literature that tends to distinguish research from surveillance to conceptualize RUSD; examine ethics guidelines, regulations and laws to understand the current knowledge‐practice base on which RUSD operates, and adequacy of existing frameworks. The ultimate outcome is an ethical framework that addresses unique characteristics of RUSD, offers straightforward guidance to researchers and ethics committees, and supports health research involving use of existing data. 89
All texts are available online; the access is free of charge. During the last twelve years the amount of participants has grown significally, and now there are 30,000 Live Journal users, 120,000 participants from other social networks, and about 400 requests and 2,8 million watches of request's discussions per month on the site http://ru_psiholog.livejournal.com. We report about setting, psychotherapeutic effects, management issues, ethical dilemmas, e‐volunteering trends and opportunities in our work, based on seven years practice of co‐
directoring the community. HETEROLOGOUS IN VITRO FERTILISATION NOW ADMITTED IN ITALY: CONSTITUTIONAL COURT’S JUDGMENT N. 162/2014 ABOLISHED THE BAN OF INVOLVE GAMETOCYTES OUTSIDE THE COUPLE Pietro Ferrara Second University of Naples, Italy [email protected] In Italy, the assisted reproductive processes are regulated by Law no. 40 of 19 February 2004. It forbade the recourse to heterologous assisted reproductive technics; on April 9th, 2014 a Constitutional judges’ decision has removed this prohibition. The Law no. 40 of 2004 imposed a biological bond as prerequisite to access to IVF programs. This clause forced lot of Italian couple moving in other Country to go along with their parental wishes: foreign medical travels make, in Constitutional judges’ opinion, inequality (social injustice) among citizens as well as they amount to great costs to both National Health Service and patients. Moreover, Constitutional Court analysed various other assumptions: so, its judgment no. 162/2014 stated as unconstitutional some sections of Law no. 40, because these posed threats to parental wish and personal liberty, will and right in building a family. Consulta’s decision gave rise to heterogeneous voices coming from scientific community and from public opinion. Even though opposite feelings are licit – and perhaps helpful – about a such thorny issue as assisted fertilisation process is, at the moment upright bioethical considerations are necessary for regulating the legislative void and creating guidelines as instructed by Constitutional Court itself, coherently to European recommendations. PSYCHOLOGICAL E‐VOLUNTEERING AMONG RUSSIAN SPEAKERS Olga Bermant‐Polyakova Israel [email protected] An ethical message is delivered to society, into the mind and into daily life and behaviour, by traditional educational and legal ways. This task may be realized by a novel way of e‐volunteering. An online volunteer is a volunteer who completes tasks, in whole or in part, via Internet. Currently there is no organization tracking the best practices in e‐volunteering, amount of people are engaged in online volunteering, or how many organizations involve online volunteers. When an ethical thought, moral values and principles determine a construction and technique of interaction, a new format of relationship, similar to psychotherapeutic setting, comes into being in virtual space. This template exists in unique online volunteering community "Be Your Own Shrink" on Live Journal. Thousands of Russian speakers from 65 countries engage in collaborative work online that provides psychological support and psycho‐educational help nonstop. An archive of transcripts counts 19,200 group discussions, subdivided into 70 categories. ETHICAL DECISION MAKING AND PATIENT AUTONOMY VIEWS AMONG THE NURSING STAFF Shani Fisher1, Aya Solomon1, Michael Peker1, Akiva Nachshon2, Naama Schwartz1,3 1
Emek Medical Center, Israel 2
Beth Israel Deaconess Medical Center, USA 3
University of Haifa, Israel [email protected], [email protected] Background: Several studies explored the attitude of doctors towards patients' autonomy, while others examined the family's role in patients' decision making in autonomy related manners. Yet, only few studies investigated the nursing staffs' views on the subject of patient's autonomy. Objectives: We aim to explore the views of nurses, concerning the patient's autonomy and to compare the views in relation to their ethnicity, seniority and religion. Methods: A survey amongst nurses was preformed between May and July 2014. We examined the approaches to patient autonomy through the attitude towards medical dilemmas represented in the form of six clinical cases and six additional 90
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general statements (Ruhnke et al. (2000) Questionnaire). The clinical cases are designed to explore the attitude issues relating to patient autonomy, family involvement and the doctors' authority in these cases. Results: The survey included 185 nurses. Approximately 43% of the nurses had a strong tendency towards patients' autonomy with low regard towards the family and/or the doctors' authority. A significant association was found between the nurses seniority and the tendency towards patients' autonomy (P=0.0046). Regard for patient autonomy was higher among secular nurses compared to religion ones (P=0.0368). Family authority in these matters was considered significantly higher among Arab nurses compared to Jewish nurses (P=0.0389). Doctor authority was deemed significantly higher by senior nurses (P=0.0161). Conclusion: Novice nurses tend to consider the patient as the sole authority regarding his medical decisions. Family authority was perceived as a crucial factor by Arab and religious nurses (of all ethnical spectrums). procedure of ethical review cases when it is necessary to violate the privacy of a patient without his consent to the notification of his family members are potentially exposed to the risk of disease. So the technology implementation of personalized medicine will exacerbate many ethical issues in the clinic. Therefore it is necessary to develop effective ethical and legal ways of their resolution until promising scientific developments are transformed into everyday clinical practice. We believe that it is necessary to supplement the Basic educational program in the specialty "medical business" and programs of post‐graduate training dermatologists themes for personalized medicine, genetic testing and pharmacokinetics, to Supplement regional programs of development of health issues, raise awareness of the population about personalized medicine. THE BIOETHICS OF COMPULSORY TREATMENT DETERMINED BY A COURT ORDER Gabriel José Chittó Gauer, Anamaria Feijó, Lívia Pithan, Paulo Vinicius Souza Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Brazil [email protected] Are there ever circumstances under which people should be deprived of their liberty and subjected, without their consent, to psychiatry treatment? The Brazilian law allows people who are supposedly making use of psychoactive substances in a harmful way to be hospitalized by a court order. An important aspect to be considered is that in this country any person may request the hospitalization as well as it can be determined in some circumstances only by a judge decision. The judge may take the decision even without an evaluation of a mental health team. From the standpoint of bioethics here, we have a dilemma that mainly involves the principles of beneficence and autonomy. Principles which should always be considered in situations where there is a disagreement between what a health professionals or others disagree with the patient decision. We also should consider that such kind of treatment although very beneficial for some, will not be of any help for a few, only partially effective for many, and may even harm some of them. In this paper, we will address the issue focus based on a principialist point of view and analyzing situations where there were a court order for hospitalization without the patient consent. DERMATOLOGICAL ETHICAL PROBLEMS OF PERSONALIZED MEDICINE Irina Krainova Volgograd State Medical University, Russia [email protected] As personalized medicine is based on a genetic typing of patients, its development actualizes the bioethical problems of genetic technologies, caused by the special nature of genetic information. Population survey and interviews with the patients dermatological practice evidences of high significance for them confidentiality of genetic information, only a tenth of the population is indifferent to the principle of confidentiality. The special nature of genetic information produces another ethical dilemma: the conflict between principle of respect for autonomy and principle of «do no harm». It’s important to develop the THE ITALIAN INFORMATION SYSTEM FOR MONITORING ERRORS IN HEALTHCARE Luigi Tonino Marsella1, Alessandro Feola2, Valeria Marino1, Elisabetta Bernardel3, Antonella Masullo2, Sergio De Dominicis4 1
University of Rome “Tor Vergata, Italy 2
Second University of Naples, Italy 3
Law Firm “Cannata & Associati”, Italy 4
Law Firm “De Dominicis”, Italy [email protected] The Italian Government, through the Decree of the Ministry of Labor, Health and Social Policies of the 11.12.2009, instituted an information system for errors in Healthcare. It is agreed upon that in the healthcare environment this system of recognizing and signaling errors is the base for prevention and improvement of the system. In fact, in the past few years, units for clinical risk management have been created in our general hospitals. Nevertheless, signaling errors has always been seen as a taboo; a good example would be Ernest A Codman, one of the founders of the American College of Surgeons, who was ostracized by his colleagues for the preciseness with which he recorded damages caused to the patients by surgery. Security for patients and clinical risk management are critical points for all clinical systems, in fact, the complexity of the clinical organizations, the high level of technology and the increased amount of services provided are intrinsic factors of the system and can increase the possibility of errors occurring with adverse consequences for the patients. It is evident that error and the possibility of an incident can’t be fully eliminated, but all possible measures must be taken so that they can be controlled, and most of all, reduced to a minimum. Since in Italy there is a regionalization (devolution) of the National Healthcare System that becomes the Regional Healthcare System, which as a consequence each Region must set forth the laws issued by the National Legislator, the Authors will discuss the implementation of the Information System for monitoring errors in Healthcare in the Lazio Region. LAWSUITS RELATED TO THE HEALTH IN BRAZIL – A TRULY “FACTORY” OF INDEMNIFICATION FOR MORAL DAMAGES Paulo de Argollo Mendes, Maria Rita de Assis Brasil, Vitor Dossa, Diego Baisch SIMERS – Medical Trade Union of Rio Grande do Sul, Brazil [email protected] In the past 10 years the lawsuits related to the health area have increased more than 200%, reaching the record level of 241 thousand claims in Brazil. The State of Rio Grande do Sul alone accounts for almost half of the Brazilian legal cases, being the state with the far most lawsuits involving health in the country. Abstracts of Poster Presentations
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Data show that about 10% of these lawsuits are related to the alleged medical error, or malpractice, which would be somewhere around 24,100 cases in Brazil, and 12,050 in the State of Rio Grande do Sul alone. It is known that the growing number of lawsuits, in the health area, in Brazil is due to the fact of the existence of free justice that allows access to the judiciary to all citizens who have low/ non financial capability, by not making any form of collection, creating, therefore, a truly “factory” of indemnification for moral damages. As a consequence, the natural flow of the indemnification cases are not followed, since only 7% of the Physicians sued for malpractice, will be also facing ethical charges in the regulatory professional committee. Compensation industry weakens the country's health system, particularly in the State of Rio Grande do Sul, and threats the Physicians, preventing them, in many cases, from using more appropriate, or more invasive, treatments, since they are afraid of facing legal cases. demands that the case of organ sales be reconsidered, this article considered a variety of proposed options with specific focus on the legalisation of compensated live kidney transplantation. Whilst this debate has been discussed for many years amongst ethical scholars the article sought to review the arguments presented in the current literature and challenge them against the context of today’s social and ethical beliefs and within an evolving healthcare system that increasingly recognises the importance of patient autonomy. Topics discussed include; 1) fair re‐imbursement 2) patient and donor autonomy 3) the current sale of bodily materials 4) exploitation 5) regulation and 6) the threat to personhood in the presence of bodily commodification. The author established that the arguments against organ sales do not stand up strongly to scrutiny suggesting that the sale of kidneys is an ethically acceptable practice. In the presence of numerous logistical hurdles such practice needs comprehensive and sensitive consideration by legal, clinical and ethical healthcare teams. BEHAVIOURAL SUBJECTS IN THE PUBLIC HEALTH STUDIES: HISTORIC PARALLELS AND MODERN ALTERNATIVES ETHICAL ISSUES IN PAEDIATRIC PHYSIOTHERAPY PRACTICE: A SURVEY OF PHYSIOTHERAPISTS IN GHANA Vanina Michaylova1,2, Mariana Lyochkova1,2, Maria Semerdzhieva1,2, Adolf Alakidi1 1
Medical University – Sofia, Bulgaria 2
Medical University – Plovdiv, Bulgaria [email protected] Our attention is focused on two essential subjects from the area of behavioural science that are taught in higher medical schools, namely medical ethics and health promotion. We make a brief historic overview of the introduction and evolution of these subjects that we refer to as ‘the Plovdiv model’ and as the experience of the Medical University, in particular of the Faculty of Public Health. While preserving the particularities of their respective content, as concepts they include number of common aspects that contribute to the behavioural and management turn of mind of health care officers. Among other factors, the exceptional interest shown by students caused an essential transformation consisting at present of: upgrade and penetration of medical ethics in the wider theoretical and research field of global philosophic and ethical issues of bioethics; achieving an unusual symbiosis between the fundamentally applied level of bioethics and the specific area of business relationships in the business environment; introduction of the salutogenic approach as counterpoint to the modern epidemiology and the pathogenic approach as a launch point for a paradigm change in preventive medicine and health promotion. THE WAITING GAME: IS IT TIME TO CHANGE THE RULES? AN ETHICAL PROPOSAL TO LEGALISE A REGULATED SYSTEM OF KIDNEY SALES Erica Morris Leeds Teaching Hospitals, UK [email protected] The current system of kidney procurement and rationing is inadequate, both in the UK and on a global scale. For the past four decades attempts to bridge the ever‐increasing gap between the supply and demand of kidneys have failed hence the lives of those on waiting lists continue to be put at risk. There is now a medical and social responsibility to consider new options to address the growing problem of organ shortages. Whilst the report from the International Forum for Transplant Ethics Bertha Oppong‐Yeboah, Caleb Andoh, Gifty Nyante University of Ghana, Ghana [email protected] Background: Paediatric physiotherapists work with one of the most vulnerable populations. Majority of their clients are children with neurological and cognitive deficits which may likely present complex ethical dilemmas. Worldwide there are a few studies that focus on ethical issues in paediatric physiotherapy. In Ghana however such research is nonexistent. Objective: This study is the first of several that seeks to explore the peculiar ethical issues in physiotherapy practice in Ghana. This first study focuses on therapists who are involved in the rehabilitation of children. Methods: All physiotherapists who have worked for at least a year in the paediatric unit of five hospitals in Ghana will be recruited to participate in the survey. A questionnaire of thirty items that describe situations suggestive of ethical problems developed by Andrew Guccione will be modified for use in this survey. The tool requires respondents to score items according to the frequency with which they had encountered a situation of the type described in their own professional practice and the difficulty they experienced in reaching a decision in those instances. Additional data on respondent’s demographics and client factors that influence these ethical situations will be collected. Expected outcome: Data would aid a first descriptive mapping of the ethical issues paediatric physiotherapist face and how they deal with them. It would also highlight demographic factors of the therapists and patients that influence the frequency of occurrence of such ethical situations and how they are handled. E‐HEALTH: THE NECESSARY BALANCE BETWEEN EFFECTIVENESS OF THE HEALTH SYSTEM AND PROTECTION OF FUNDAMENTAL RIGHTS María Magnolia Pardo‐López University of Murcia, Spain [email protected] In general terms, e‐Administration is (or might be) the future of Public Administration and this happens to be true (or should be) also when it comes to talk about the Health System run by public 92
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powers. This poses many challenges for jurists used to traditional methods well known to them and not always aware of the ever increasing possibilities (and dangers, why not say so) offered by new technologies. Technology embodies an “opportunity to improve health” in two different ways. First of all, it offers a direct chance to enhance Medicine by bettering medical diagnosis, interventions and treatments. It also provides the adequate means to administer in a much more effective and efficient way the scare human and economic resources in order to satisfy the right to health recognized in Constitutions and Statutes. Information is the key to the modern Health Systems, mainly information about patients. Nevertheless, in managing and processing such pieces of information called data many risks arise. Data protection and privacy of the patients ought to be carefully protected without hindering public health, medical research or any other general interest that deserves to be secured. In our paper we intend to analyze this second aspect since it is closely related to the proper protection of fundamental rights public powers are committed to. Special attention to the Spanish Public Health System will be paid. Nowadays that the European Union is going through the complete review of its legal norms regulating personal data protection as well as the implementation of Directive on Public Sector Information Reuse is being carried out by Member States, it may be a good moment to comment the scare specific mentions to health data in general terms and make proposals in the sense of balancing the protection of these fundamental rights (data protection and privacy, mainly) and the general interests involved. ADOLF SANNWALD – ENEMY CASUALTY HOW A NOTATION CAN TURN THE WORTH OF A GERMAN PASTOR INTO THE WICKEDNESS OF A NAZI EVIL Alessandra Pentone European Centre for Bioethics and Quality of Life – UNESCO Chair in Bioethics Italian Unit, Italy [email protected] January 8, 1901. Son of a mechanic, Sannwald won a scholarship to prepare for a career in theology when he was fourteen years old and in 1923 was ordained a Lutheran minister. In 1924 ‐1925, he was a visiting fellow at the Divinity School at Harvard. After this experience he came back to Germany, teaching at Tubingen University where he met Anna von Sehrwald, the woman he married. In 1930, he became the pastor of St Mark's church in Stuttgart. In 1931, preaching one of his sermons, he angered local National Socialists. Adolf Sannwald belonged to the Confessing Church formed in opposition to Hitler's German Christian Church. In 1934, he wrote a pamphlet "Why not German Christians?"(available on http://sannwald.org/page4.html) where he wrote: " God does not choose his children on the basis of race". After the "Jew‐lover" graffiti on his house, he was threatened with being banned from speaking publicly by the authorities. In 1936, after several warnings by the Gestapo to take him to jail, he moved with his wife and daughters to Dornhan in the German Black Forest. Here his rectory became a haven for fugitive Jews on their way to France. No one of the family knew their names in order to prevent the children from accidently commenting on their “visit”. Sannwald, moreover, pressed the local Nazi leader about the disappearance of detainees in Poland. He always refused to follow the Nazi party. As a result, in January 1942, Sannwald was drafted into the Wehrmacht as a common soldier, not a chaplain, and was sent to the Russian border where he served at first on the front as soldier, and then as a cook's helper, a janitor and a clerk, after his fifth child was born. After 18 months he was killed in an air raid, on June 3, 1943. “Sannwald died a soldier in the army of a regime he despised; he was indeed an enemy casualty.” Don’t let prejudice influence us, don’t judge by appearances: let the search for truth always be our goal. MITOCHONDRIAL REPLACEMENT THERAPY AND PARENTHOOD Daniel Sperling The Hebrew University of Jerusalem, Israel [email protected] The World War II memorial in the chapel at Harvard University pays tribute to the Harvard students that were killed during the war. Included in this tribute is Adolf Sannwald with the notation "Enemy Casualty" following his name. This notation has created considerable interest over the years as well a much speculation. Wonder and/or anger could be the feeling of the typical visitor presuming that the name of a soldier in Hitler’s army was included on a Memorial. Such feelings are only the after‐math of the controversy that took place in 1951 when the Harvard student newspaper opined “whatever Sannwald’s motives for fighting in the Nazi cause, it is obvious he was not defending in any way the principles that had nourished Harvard.” The outrage of some alumni and veterans induced the University’s governing board to promise that Adolph Sannwald’s name would be expunged—but it never has been. For whatever reason the German name was not removed. The debate died. But the doubts about Adolf Sannwald’s life and morality once raised still remain and have not been extinguished. Adolf Karl Sannwald was a German Lutheran pastor born on 2014 will be a decisive year for the future of Mitochondrial Replacement Therapy (MRT) –at least in the Western world. Currently, the UK and the US governments are undergoing a process of ethical and scientific evaluation of the technique to decide whether to allow its implementation or not. MRT requires the fusion of the DNA of three parents (although of a minimal percentage in the case of one of the two female genitors) into an embryo –and this creates a number of worries for what this scientific innovation will lead to. These worries might be well placed and worth of consideration, but not on the grounds that some opponents bring forward. In this paper, we will analysis a recent EU petition that urges the UK government (but could be applied to the US well) to refrain from legalizing MRT, to stress that other techniques such as Preimplantation Genetic Diagnosis (PGD) already accept a more direct eugenic potential than MRT. Our conclusion is that what seems to be really at stake instead, is whether or not we are willing to reconceptualise the notion of parenthood as something not necessarily binominal and genetically‐related. Authors Index
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Abbasova, A ......................................... 19 Abdulrazak, A ....................................... 27 Abramson, R ........................................ 19 Abu Saraa, E ......................................... 50 Adiri, F .................................. 19,27,41,56 Adler, E ................................................ 50 Aggarwal, G ......................................... 69 Ahaddour, C ......................................... 24 Aharon, Y ............................................. 26 Akselrod, D .......................................... 66 Alakbarov, A ........................................ 19 Alakidi, A .............................................. 91 Alichniewicz, A ..................................... 20 Aliyeva, A ............................................. 20 Aliyeva, F ............................................. 20 Aloni, R ................................................ 40 Altarescu, G ......................................... 78 Alvarez Argaluza, MI ............................ 75 Anane‐Sarpong, E ................................ 89 Andoh, C .............................................. 91 Antão, AC ............................................. 70 Aparisi, A.............................................. 20 Apinis, P ............................................... 21 Aroni, R ................................................ 21 Asman, O ............................................. 22 Avard, D ............................................... 61 Avidime, OM ........................................ 27 Baeke, G............................................... 24 Baisch, D .............................................. 90 Balakrishnan, D ............................... 22,71 Baliga, MS ............................................ 58 Baramidze, L ........................................ 77 Barbosa, C ............................................ 22 Bard, TR ............................................... 22 Barghil, M ............................................ 75 Barilan, YM .......................................... 23 Barreto Leite, LOF ................................ 70 Basuki, S ............................................... 62 Bazigov, M ........................................... 19 Be'eri, E ................................................ 23 Ben Nun, A ........................................... 43 Bentwich, M ........................................ 23 Benyakar, M ................................... 23,52 Ben‐Yona, R ......................................... 66 Ben‐Yosef, O ........................................ 75 Berent, I ............................................... 23 Bermant‐Polyakova, O ......................... 89 Bernardel, E ......................................... 90 Blachar, Y ............................................. 44 Borow, M ........................................ 24,32 Botbol Baum, M ................................... 24 Brezis, M ......................................... 24,34 Brit, L ................................................... 50 Broeckaert, B ....................................... 24 Cambra Badii, I .................................... 23 Campbell, J .......................................... 33 Cannaviello, C ...................................... 32 Cekić, N ................................................ 25 Chavdarovski, P ................................... 73 Chelouche, T ........................................ 25 Chemtob, D .......................................... 26 Chen, B ...................................... 26,37,42 Chen, WWB .................................... 26,35 Chung, Y ............................................... 26 Cicovacki, P .......................................... 49 Ciroma, FL ........................................... 27 Cohen, MJ ........................................... 34 Cohen‐Rappaport, G ........................... 43 Cohen‐Zubary, N ................................. 62 Colinet, S ............................................. 27 Collins, K.............................................. 27 Cope‐Yossef, Y .................................... 27 Copperman, Y ..................................... 28 D’Souza, R ...................................... 22,31 Daniels, S ............................................. 28 Darling, MJT ........................................ 28 David, C ............................................... 28 Davidow, Z .......................................... 28 Davtyan, S ........................................... 29 Dawson, A ........................................... 89 Dayan, I ............................................... 29 de Assis Brasil, MR .............................. 90 De Dominicis, S ................................... 90 Deau, X ................................................ 29 DeBaets, A ........................................... 30 Dejavsarov, S ....................................... 30 Dekel, R ............................................... 30 Devor, M ............................................. 30 Di Salvo, I ............................................ 75 Dickman, N .......................................... 23 Ding, C ................................................. 31 Dinnen, A ............................................ 31 Djuari, L ............................................... 79 Doležal, T ............................................ 31 Donika, A ............................................. 31 Dossa, V .............................................. 90 Duan, L ........................................... 32,41 Eagan Chamberlin, SM ........................ 32 Efrati, C ............................................... 32 Eidelman, L .......................................... 32 Eilati, R ................................................ 75 Eisenberg, E ........................................ 33 Eisenman, E ......................................... 38 Elger, BS .............................................. 89 Eliaz, R ................................................. 34 Eyal, H ................................................. 38 Eyal, N ................................................. 33 Fadlon, J .............................................. 43 Feijó, A ................................................ 90 Feola, A ............................................... 90 Ferrara, P ............................................ 89 Ferrara, SD .......................................... 33 Feuer, J ................................................ 34 Finkelstein, Y ....................................... 63 Fisher, S ............................................... 89 Fleisig, D .............................................. 43 Flescher, D .......................................... 34 Frankel, M ........................................... 34 Frischhut, M ........................................ 34 Gambheera, H ..................................... 35 Ganguly, B ........................................... 35 Gao, S ............................................ 26,35, Garasic, MD......................................... 35 Garba, ES ............................................. 50 Garcia, A .............................................. 36 Gauer, GJC .......................................... 90 Ghazaryan, K ....................................... 29 Giardini, A ........................................... 58 Gilat, I .................................................. 36 Gilbar, R ............................................... 36 Giorgi, I ................................................ 58 Gith, E .................................................. 36 Glick, SM ........................................ 37,66 Glover‐Thomas, N ............................... 37 Gopfert, A ............................................ 75 Gordon, M ........................................... 37 Goshen, E .................................. 26,37,42 Greenbaum, D ..................................... 38 Greenberg, R ....................................... 40 Greenberger, C .................................... 38 Guerra Filho, WS ................................. 70 Gulma, B .............................................. 19 Gur‐Arie, H .......................................... 40 Haberer, J ............................................ 33 Haddad, E ............................................ 26 Haimov‐Kochman, R ............................ 38 Hale, M ................................................ 74 Halevy, J .............................................. 39 Halpin, R .............................................. 39 Hamiti, M ............................................ 39 Handelman, M..................................... 40 Hcohen, A ............................................ 38 Hellmann, J .......................................... 40 Heresco‐Levy, U .................................. 29 Heruti, R .............................................. 40 Heyd, D ................................................ 38 Hildesheimer, G ................................... 40 Hogemann, ERS ................................... 70 Honeyman, P .................................. 40,63 Hornung, T .......................................... 75 Huang, SBQ ............................... 26,32,41 Ianakieva, A ......................................... 73 Innamorato, L ...................................... 59 Introna, F ............................................. 59 Irony, A ................................................ 30 Jacobowsky, E ..................................... 75 Jaffe, E ................................................. 44 Jain, A .................................................. 41 Jain, R .................................................. 41 Jarman, OA .......................................... 56 Joggy, A ............................................... 58 Joshua, IA ........................ 19,41,50,56,57 Jotkowitz, A .................................... 41,66 Jovanovska, S ...................................... 42 Kana, MA ........................................ 27,57 Kannai, R ............................................. 42 Karni, T ................................. 26,37,42,43 Karnieli‐Miller, O ................................. 43 Katz Peled, T ........................................ 43 Katz, Y .................................................. 43 Katzav, M............................................. 75 Katzenelson, E ................................ 43,44 Keidar, D .............................................. 44 Keren, A ............................................... 48 Khalaila, R ............................................ 44 41 Kim, C .................................................. 40 Klein, Z ................................................. 53 Knobler, HY ......................................... 44 Knoppers, BM ...................................... 61 Koren, D .............................................. 28 Kostenzer, J ......................................... 45 Index
Kottek, S .............................................. 45 Krainova, I ........................................... 90 Kubar, OI ............................................. 52 Kukubajska, ME ................................... 45 Kumar, A ............................................. 58 Kuře, J ................................................. 46 Kurosu, M............................................ 46 Lahat, Y ............................................... 34 Lamoure, J ........................................... 46 Langham, F .......................................... 75 Laufer, N ............................................. 38 Laufer‐Ukeles, P .................................. 46 Le Xuan, T ............................................ 47 Lederman, Z ........................................ 47 Lepicard, E ........................................... 47 Letendre, MC ...................................... 47 Lev, O .................................................. 48 Leviani, R ............................................. 48 Levy, M................................................ 48 Li, KR ................................................... 35 Li, Z ........................ 26,32,35,41,48,49,74 Liang, H .......................................... 35,49 Lifshitz‐Aviram, P ................................ 49 Lima, NS .............................................. 49 Liu, K .............................................. 26,32 Liu, X ................................................... 49 Low, TH ............................................... 49 Lumadi, TG .......................................... 50 Lupton, M ........................................... 50 Lyochkova, M ...................................... 91 Ma, HD ................................................ 49 Maaravi, Y ........................................... 50 Makama, JG ................................... 41,50 Malul, L ............................................... 51 Mammadov, I ...................................... 19 Mammadov, V .................................... 19 Marcus, EL ........................................... 29 Margalit, Y ........................................... 51 Margolin, J .......................................... 51 Marino, V ............................................ 90 Markova, K .......................................... 60 Marsella, LT ......................................... 90 Martins, D ........................................... 75 Mashiah, S........................................... 38 Masullo, A ........................................... 90 Mathew, M ......................................... 41 Mattar, C ............................................. 75 Medic, B .............................................. 61 Menasheoff, L ..................................... 75 Mendes, PDA ...................................... 90 Mester, R ............................................ 51 Michałowska, M .................................. 20 Michaylova, V ..................................... 91 Michel Fariña, JJ ............................. 23,52 Mikirtichian, GL ................................... 52 Milikovsky, DZ ..................................... 66 Milinkovic, I ......................................... 52 Miller, J ............................................... 47 Mimoni, Z ............................................ 38 Miola, J ................................................ 36 Miranda, M ......................................... 52 Mishori, D ........................................... 53 Mital, AK ............................................. 53 Miteva, I .............................................. 53 Moleki, MM ........................................ 54 Moran, U ............................................. 54 Moreno, A ........................................... 54 Morris, E .............................................. 91 Moskowitz, JM .................................... 69 Muhammad‐Idris, Z ................... 41,56,57 Mullen, M ............................................ 55 Muratova, MM .................................... 56 Musa, AK ............................................. 76 Musiimenta, A ..................................... 33 Myburgh, CPH ..................................... 55 Nachshon, A ........................................ 89 Nagesh, KR .......................................... 41 Nagib, M .............................................. 70 Naimer, SA .......................................... 55 Neitzke, G ............................................ 73 Ngole, ME ............................................ 69 Nikitina, AE .......................................... 52 Niv‐Yagoda, A ...................................... 43 Nmadu, AG ........................... 19,41,56,57 Noguchi, T ........................................... 56 Noles Cotito, G .................................... 75 Novais da Silva, M ............................... 70 Nyante, G ............................................ 91 Oberman, A ......................................... 23 Obradovic, D........................................ 61 Ochkur, OK .......................................... 56 Ohry, A ................................................ 57 Oliveira, P ............................................ 57 Omole, VN ...................................... 57,76 Onyemocho, A ................................ 41,56 Oppong‐Yeboah, B .............................. 91 Oron, I ................................................. 57 Ottonello, M ........................................ 58 Oyefabi, A ............................................ 58 Pain, D ................................................. 58 Palatty, PL ....................................... 41,58 Pardo‐López, MM ........................... 59,91 Pariani, S......................................... 59,79 Pasetti, C ............................................. 58 Peker, M .............................................. 89 Pentone, A ................................. 59,73,92 Pereira, I .............................................. 75 Peretz, E .............................................. 38 Peri, T .................................................. 28 Perry, W .............................................. 75 Perry‐Mezare, H .................................. 34 Pétrin‐Desrosiers, C ............................. 75 Piazza o Sed, N .................................... 32 PiIleggi, T ............................................. 63 Pinchenkova, LA .................................. 52 Pithan, L .............................................. 90 Poggenpoel, M .................................... 55 Pollard, I .............................................. 60 Popova, K ............................................ 60 Popova, S ............................................. 60 Poster, MF ........................................... 60 Prajitno, S ............................................ 79 Prajwith ............................................... 58 Pranoto, A ........................................... 79 Prokopiou, A ........................................ 60 Prostran, M ......................................... 61 Protić, D ............................................... 71 Quitz, A ................................................ 61 95
Rahimzadeh, V ..................................... 61 Rahmatullah, I ................................ 62,79 Rakic, V ................................................ 62 Rappaport, ZH ..................................... 62 Rehatta, NM ........................................ 62 Reicher‐Atir, R ..................................... 62 Richter, E ............................................. 63 Roditis, K .............................................. 75 Rosenbaum, T ...................................... 40 Rosenblum, I ........................................ 63 Roth, B ................................................. 63 Rubinow, A ..................................... 34,63 Rubinstein, A ....................................... 64 Rubinstein, D ....................................... 68 Rubinstein, E ........................................ 26 Sada, MN ............................................. 27 Sagun, RD ............................................ 64 Salton, A .............................................. 26 Samama, E ........................................... 64 Sándor, J .............................................. 65 Sani, YB ................................................ 58 Sankoh, O ............................................ 89 Santori, P ............................................. 65 Saravanan, S ........................................ 65 Savic Vujovic, K .................................... 61 Scharff, C ............................................. 65 Schuz, R ............................................... 66 Schwartz, N .......................................... 89 Scolnik, D ............................................. 40 Sedova, N ............................................. 66 Segal‐Reich, M ..................................... 66 Sela, L .................................................. 28 Semerdzhieva, M ................................. 91 Sénécal, K ............................................ 61 Shack, AR ............................................. 66 Shalev, C .............................................. 67 Shalmon, E ........................................... 67 Shaulov, A ............................................ 34 Shenoy, R ............................................. 41 Shir‐Raz, Y ............................................ 67 Siebzehner, MI ..................................... 68 Silva de Oliveira, HC ............................. 70 Singh, RR .............................................. 68 Sinnett, D ............................................. 61 Smerling‐Kerem, J ................................ 68 Sokolowski, M ..................................... 68 Solomon, A .......................................... 89 Sotirova, D ........................................... 69 Souza, PV ............................................. 90 Sperling, D ...................................... 69,92 Sprung, CL ............................................ 34 Srebro, D .............................................. 61 Stein, Y ................................................. 69 Stojanovic, R ........................................ 61 Stolte, H ............................................... 40 Stopic, B ............................................... 61 Strozenberg, F ..................................... 70 Su, ZM .................................................. 32 Tadmor, B ............................................ 62 Tal, M ................................................... 70 Tanner, M ............................................ 89 Tewel, C ............................................... 70 Tham, J ................................................ 70 Thangaraju, P .................................. 22,71 Thorne, E ............................................. 71 96
UNESCO Chair in Bioethics 10th World Conference
Tilinger, Y ............................................. 54 Toader, E .............................................. 71 Todorović, Z ......................................... 71 Treger, I ............................................... 72 Trigueiro Santos Adinolfi, V ................. 72 Tsai, DFC .............................................. 72 Tun, W ................................................. 75 Turkenich, S ......................................... 62 Van den Branden, S ............................. 24 Vasinova, M ......................................... 73 Veselska, R ........................................... 73 Veshi, D ................................................ 73 Vilk, S ................................................... 38 Vodenicharov, V .................................. 73 Vodenicharova, A ................................ 73 Vozzella Hall, D .................................... 75 Vuckovic, S ........................................... 61 Waitzman, R ........................................ 74 Walker, X ............................................. 75 Wang, C .......................................... 48,74 Wangmo, T .......................................... 89 Wapner, L ....................................... 24,32 Wei, T ................................... 26,32,35,41 Werner‐Felmayer, G ............................ 74 White, BP ............................................ 74 Wikler, D ............................................. 33 Wiley, E ............................................... 75 Wilson, D ............................................. 75 Wohlgelernter, S ................................. 75 Wolf, R ................................................ 76 Wolfman, S ......................................... 76 Yahalom, R .......................................... 34 Yang, J ................................................. 49 Yust, I .................................................. 26 Yusuf, MS ....................................... 27,76 Zakariadze, A ....................................... 77 Zaki, M ................................................ 77 Zarnadze, I .......................................... 77 Zarnadze, S .......................................... 77 Zhang, R ......................................... 48,74 Zilberstein, I ........................................ 78 Zimmerman, DR .................................. 78 Ziv, A ................................................... 34 Zlotnik Shaul, R ................................... 40 Zuckerman, S ...................................... 78 Zur‐dovrat, L ....................................... 62 Zuscinova, J ......................................... 79 83 .............................................. ‫ש‬ ,‫אוחנה‬
83 .................................... ‫מ‬ ,‫גביזון‬ ‫אלבוים‬
83 ............................................... ‫מ‬ ,‫נתן‬ ‫בן‬
83 ................................................ ‫ד‬ ,‫נוי‬ ‫בר‬
84 ............................................. ‫מח‬ ,‫ברייר‬
84 ................................................ ‫צ‬ ,‫בר‐נוי‬
84 .......................................... ‫ח‬ ,‫גרינברגר‬
84 .............................................. ‫ס‬ ,‫דומבה‬
85 ................................................... ‫נ‬ ,‫וגנר‬
84 .................................................. ‫נ‬ ,‫טבק‬
85 .............................................. ‫ע‬ ,‫ליברטי‬
84 ............................................ ‫ס‬ ,‫מלניקוב‬
85 ............................................... ‫ש‬ ,‫ניסים‬
85 ................................................ ‫מ‬ ,‫פייזר‬
85 .................................................. ‫א‬ ,‫קורן‬
84 ........................................... ‫ש‬ ,‫קרייטלר‬
85 ......................................... ‫ד‬ ,‫רובינשטיין‬
86 .................................................... ‫ח‬ ,‫רז‬