Donal O'Mathuna

Global health engagement increasingly occurs in the context of war and violent conflict. Many health‐related decisions are made which should be guided by evidence. Health research is needed to provide evidence, yet conducting research in conflict settings raises multiple ethical issues. However, the ethical issues involved in conducting research during war and violent conflict have received insufficient attention. The literature suggests that these ethical issues, while similar to those of research conducted in humanitarian crises, are also distinct. This article provides a review of the ethical issues faced by researchers in conflict zones with a goal to inform future research into such issues. The review was organized around an established 8‐principle ethics framework for research in low‐income settings. We conclude with a number of recommendations and call for additional attention by bioethicists to this important area to protect participants and support researchers in conflict settings, whether coming from military or nonmilitary organizations.

Background Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses’ experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. Research aim To analyze frontline U.S. nurses’ experiences of ethics during the COVID-19 pandemic. Research design Qualitative analysis using a directed content methodology. Participants and research context The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. Ethical considerations Participant privacy and data confidentiality were addressed. Findings Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. Discussion This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. Conclusions Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.

Respect for patient autonomy continues to gain momentum in nursing and healthcare practice. The general public is more aware of the right to self-determination and choice regarding the care, support, and treatment they can receive. This right is supported by healthcare policy, enshrined in professional codes, mandated by legislation, and underpinned by a human rights-based care agenda. While respect for patient autonomy, as well as associated patient choice, is accepted in professional practice, supporting autonomy can create tensions for nurses and healthcare professionals. Such tensions arise when patient choice conflicts with professional care obligations and available clinical evidence, raising concerns about professional accountability for patient welfare. This chapter explores the complexities of respecting patient autonomy in ‘real-world’ nursing and healthcare contexts. We argue that equating autonomy with independence is unrealistic in the lives we live. A case study highlights practical concerns. We propose ways of reconciling professional accountability with respect for patient autonomy. We draw on recent research, a more relational understanding of autonomy and contemporary health and social care guidance. We conclude that Autonomy by Negotiation represents a more accurate account of our autonomy as social beings.

The COVID-19 pandemic brought many challenges for nursing practice, including many ethical challenges. These have deeply impacted nurses and continue to have deep emotional and psychological consequences. Nurses and other healthcare workers need support and resources as they continue to grapple with various consequence of dealing with the moral challenges during the pandemic. We also need to learn from these experiences and use this learning to prepare better for the next pandemic or other crisis.Pandemic ethics for nursing practice can learn from past pandemics and the relatively new field of humanitarian ethics. Many of the same types of ethical issues are faced regularly in humanitarian and disaster settings. For example, humanitarian workers regularly deal with scarce resources and frequently work in the midst of unjust or insecure environments. Humanitarian ethics includes other principles such as solidarity and impartiality which can contribute to broader ethical deliberations about pandemics.Humanitarian ethics points to some limitations in standard approaches to ethics education which can help improve education for the types of ethical issues faced in pandemics. This includes acknowledging that sometimes in ethics no option is completely ethically satisfactory and requires identifying the best of a number of bad options. Such situations often have emotional consequences and point to the importance of addressing emotions in ethics. Both reason and emotions should be engaged in ethical decision-making. Situations and cases which reflect the complex, emotional, relational and cultural dimensions of ethics should be used or developed for pandemic ethics education.

Health care workers (HCWs) often suffer the brunt of injuries during chemical, biological radiological, nuclear and explosive (CBRNE) events. Throughout history, those caring for the injured, dying and dead put themselves at risk of harm, infection or contamination. Recent events include the 2014–2016 infectious outbreak of Ebola virus disease in West Africa and the targeting of health facilities in the conflict in Syria. Decisions by HCWs to care for others in the face of such risks have been lauded as heroic whether undertaken for personal moral reasons or in response to an ethical duty to care. However, some have questioned whether such a duty to care is ethically obligatory in the face of some CBRNE events. Ethical analysis of the SARS outbreak found that additional ethical reflection was needed on HCWs’ obligations during CBRNE events. The ethical arguments used to justify the duty to care are reviewed in this chapter. However, other duties exist for HCWs which may conflict with the duty to care. The World Health Organization’s guidance on ethics in pandemics notes that the duty to provide care in pandemics is not unlimited, and that employers and governments have reciprocal obligations to provide training and protective equipment to HCWs during CBRNE. Empirical research raises questions about whether health care organisations are adequately prepared for CBRNE, particularly for the ethical decision-making that will be required. Rather than taking a regulatory or legal approach to this issue, this chapter will argue that the ethical virtues of courage and volunteerism should be fostered in HCW training. In keeping with a virtue ethics approach, leadership takes on an important role in ethical decision-making, as well as praising those who respond to CBRNE by caring for others in spite of the personal risks and their conflicting obligations.

This chapter introduces the aims and objectives of this book. Books on chemical, biological, radiological, nuclear and explosive (CBRNE) crises are usually technical and scientific. This introduction highlights some of the reasons why a volume on the ethical and legal dimensions of CBRNE crises is needed. The chapter then provides a brief summary of each of the chapters and how these develop the topic more generally. It concludes by acknowledging the EU funding which made it possible to produce this volume.

This chapter examines ways that disasters have led to reflection within Christian theology. Mention will be made of other religious traditions, but because of the volume of material available, the focus will be on biblical accounts of disasters, God’s role in them, and discussions about how believers can and should respond to them. First, the chapter will examine accounts where God is stated to have sent disasters as a judgement for human sin. This will require a broad overview of some central theological positions. Then, the chapter will examine historical and contemporary claims that disasters can be blamed on human sin. This will lead to a review of theodicy, theological arguments developed to justify why God could allow evil and suffering, which could include disasters. Then some popular reactions to disasters that blame particular sins will be critiqued. In contrast, the Bible calls for responses that include practical help for those impacted by disasters. A full response must go further, including empathy for those hurt and working to overcome injustice when that has been a contributing factor. The final theological perspective is the belief that God works with believers to bring good out of bad situations, in spite of how bad the disaster can be. The chapter concludes with a discussion of how theological reflection can bring hope in the midst of disasters.

This introduction explains the rationale behind the volume at hand against the backdrop of the existing state of the art in research related to disasters and disaster bioethics. The volume offers an overview of how disasters are conceptualized in different academic disciplines relevant to disaster bioethics (Part I), and addresses normative issues that arise in responding to disasters from the perspective of a number of fundamental normative approaches in moral and political philosophy (Part II). Part I aims at identifying and exploring the dominant approaches to basic concepts and categorization criteria of disasters in different academic disciplines, including Philosophy, Theology, Law, Economics, Public Health, Literature Studies, Political Science, and Gender Studies. The eight chapters in Part I provide an introduction to conceptual research in disasters and aim to stimulate further work. It thereby contributes to enhanced awareness and recognition of the real-world importance of basic concepts and disaster criteria. Part II provides a broad range of normative perspectives (Consequentialism, Virtue Ethics, Kantian virtue ethics, Capabilities approach, Deontology, Human Rights and Communitarianism). These chapters are offered as a starting point, not a final conclusion on the topic of disaster ethics. Ethical justification for actions taken in the face of disasters needs recourse to normative traditions and this book aims at setting the stage for more focused normative debates.

Ambient assisted living technologies can provide assistance and support to persons with dementia. They might allow them the possibility of living at home for longer whilst maintaining their comfort and security as well as offering a way towards reducing the huge economic and personal costs forecast as the incidence of dementia increases worldwide over coming decades. However, the development, introduction and use of AAL technologies also trigger serious ethical issues. This paper is a systematic literature review of the on-going scholarly debate about these issues. More specifically, we look at the ethical issues involved in research and development, clinical experimentation, and clinical application of AAL technologies for people with dementia and related stakeholders. In the discussion we focus on: the value of the goals of AAL technologies, the special vulnerability of persons with dementia in their private homes, the complex question of informed consent for the usage of AAL technologies

This symposium includes twelve narratives from individuals or groups who have worked to help the sick and injured receive healthcare during armed conflict. Four commentaries on these narratives are also included, authored by experts and scholars in the fields of bioethics, human rights, sexual violence in armed conflict, the forced displacement of civilians, and policy development for resource constrained healthcare. The goal of this symposium is to call attention to the the difficulties and ethical dilemmas of providing healthcare during violent armed conflict.

The humanitarian sector continually faces organizational and operational challenges to respond to the needs of populations affected by war, disaster, displacement, and health emergencies. With the goal of improving the effectiveness and efficiency of response efforts, humanitarian innovation initiatives seek to develop, test, and scale a variety of novel and adapted practices, products, and systems. The innovation process raises important ethical considerations, such as appropriately engaging crisis-affected populations in defining problems and identifying potential solutions, mitigating risks, ensuring accountability, sharing benefits fairly, and managing expectations. This paper aims to contribute to knowledge and practice regarding humanitarian innovation ethics and presents two components related to a value-sensitive approach to humanitarian innovation. First is a mapping of how ethical concepts are mobilized in values statements that have been produced by a diverse set of organizations involved in humanitarian innovation. Analyzing these documents, we identified six primary values (do-no-harm, autonomy, justice, accountability, sustainability, and inclusivity) around which we grouped 12 secondary values and 10 associated concepts. Second are two proposed activities that teams engaged in humanitarian innovation can employ to foreground values as they develop and refine their project’s design, and to anticipate and plan for challenges in enacting these values across the phases of their project. A deliberate and tangible approach to engaging with values within humanitarian innovation design can help to ground humanitarian innovation in ethical commitments by increasing shared understanding amongst team members, promoting attentiveness to values across the stages of innovation, and fostering capacities to anticipate and respond to ethically challenging situations.

This Open Access Book is the first to examine disasters from a multidisciplinary perspective. Justification of actions in the face of disasters requires recourse both to conceptual analysis and ethical traditions. Part 1 of the book contains chapters on how disasters are conceptualized in different academic disciplines relevant to disasters. Part 2 has chapters on how ethical issues that arise in relation to disasters can be addressed from a number of fundamental normative approaches in moral and political philosophy. This book sets the stage for more focused normative debates given that no one book can be completely comprehensive. Providing analysis of core concepts, and with real-world relevance, this book should be of interest to disaster scholars and researchers, those working in ethics and political philosophy, as well as policy makers, humanitarian actors and intergovernmental organizations..

Disasters and public health emergencies raise a variety of ethical dilemmas, often including those that require balancing the best interests of individuals against those of groups or communities. The on-going COVID-19 pandemic provides examples of these ethical conflicts, as do other recent outbreaks. Decisions and actions in this context must address different ethical issues, ranging from those directly related to autonomy, consent, privacy and confidentiality to those related to interventions and technologies, such as efficacy, effectiveness, safety and fair access. This paper aims to identify ethical conflicts with complex resolutions involving aspects related to values, rights and needs of individuals and the collective, and to suggest how such challenges could lead to more positive experiences and outcomes when confronted in future emergencies.

Moral theory has generally focused on resolving ethical dilemmas by identifying ethically sound options. Whether the focus is on consequences, duties, principles or virtues, ethical cases are often approached in ways that assume morally sound solutions can be found and followed. Such ‘ideal morality’ assumes that moral goodness is always possible, leaving people confident they have done the right thing. Such an approach becomes inadequate in disaster settings where any good solution is often difficult to see. This paper examines recent work on nonideal moral theory as a useful model for disaster bioethics. This approach views moral dilemmas as situations where no choice is ideal and every option involves some element of unavoidable wrongdoing. Rather than straining for ideal answers, this approach acknowledges that sometimes the lesser of two evils is the best that can be done. Such situations inevitably lead to feelings of regret or guilt, commonly encountered in discussions of disaster bioethics. This paper explores the practical implications of nonideal approaches for disaster responders working in tragic situations.

This book provides a current analysis of the legal and ethical challenges in preparing for and responding to chemical, biological, radiological, nuclear and explosive crises. From past events like the Chernobyl nuclear incident in Russia or the Bhopal chemical calamity in India, to the more recent tsunami and nuclear accident in Japan or the Ebola crisis in Africa, and with the on-going threat of bioterrorism, the need to be ready to respond to CBRNE crises is uncontroversial. What is controversial is whether we are on a path that adequately prepares us for the next event. The ethical and legal scholars in this volume hold that much work remains to be done and offer this book to stimulate further reflection and dialogue around CBRNE crises. This is an indispensable book for both students and scholars of bioethics, international law, public health, as well as for regulators and administrators developing policy and legislation related to public health planning and emergency responses.

Research ethics is an integral part of research, especially that involving human subjects. However, concerns have been expressed that research ethics has come to be seen as a procedural concern focused on a few well-established ethical issues that researchers need to address to obtain ethical approval to begin their research. While such prospective review of research is important, we argue that it is not sufficient to address all aspects of research ethics. We propose retrospective review as an important complement to prospective review. We offer two arguments to support our claim that prospective review is insufficient. First, as currently practiced, research ethics has become for some a ‘tick box’ exercise to get over the ‘hurdle’ of ethics approval. This fails to capture much of what is important in ethics and does not promote careful reflection on the ethical issues involved. Second, the current approach tends to be rules-based and we argue that research ethics should go beyond this to develop people’s capacity to be sensitive to the relevant moral features of their research, their ethical decision-making skills and their integrity. Retrospective review of a project’s ethical issues, and how they were addressed, could help to achieve those aims better. We believe that a broad range of stakeholders should be involved in such retrospective review, including representatives of ethics committees, participating communities and those involved in the research. All stakeholders could then learn from others’ perspectives and experiences. An open and transparent assessment of research could help to promote trust and understanding between stakeholders, as well as identifying areas of agreement and disagreement and how these can be built upon or addressed. Retrospective review also has the potential to promote critical reflection on ethics and help to develop ethical sensitivity and integrity within the research team. Demonstrating this would take empirical evidence and we suggest that any such initiatives should be accompanied by research into their effectiveness. Our article concludes with a discussion of some possible objections to our proposal, and an invitation to further debate and discussion.

Conducting research during or in the aftermath of disasters poses many specific practical and ethical challenges. This is particularly the case with research involving human subjects. The extraordinary circumstances of research conducted in disaster settings require appropriate regulations to ensure the protection of human participants. The goal of this study is to systematically and qualitatively review the existing ethical guidelines for disaster research by using the constant comparative method. We performed a systematic qualitative review of disaster research ethics guidelines to collect and compare existing regulations. Guidelines were identified by a three-tiered search strategy: 1) searching databases, 2) an Internet search, and 3) a search of the references in the included documents from the first two searches. We used the constant comparative method for analysis of included guidelines. Fourteen full text guidelines were included for analysis. The included guidelines covered the period 2000-2014. Qualitative analysis of the included guidelines revealed two core themes: vulnerability and research ethics committee review. Within each of the two core themes, various categories and subcategories were identified. Some concepts and terms identified in analyzed guidelines are used in an inconsistent manner and applied in different contexts. Conceptual clarity is needed in this area as well as empirical evidence to support the statements and requirements included in analyzed guidelines.

This essay responds to Tristram Engelhardt’s critique of Christian bioethics. There is much to be commended in his essay, particularly his concern that Christian bioethics has failed to be authentically and distinctively Christian. To address such concerns, my essay argues that greater prominence needs to be given to the Bible in Christian bioethics. This would involve several challenges and difficulties, some of which are reviewed. Given the centrality of Scripture to Christian life and practice, including ethics, its use should be encouraged within Christian bioethics. Such an undertaking requires an approach to using Scripture, which the grammatico-historical method provides. This approach is described briefly, with resources for further study referenced. The approach is then applied to a small number of examples to demonstrate the rich source of distinctive insight that the Bible brings to Christian bioethics.

A connection has long been made between music and moral education. Recent discussions have focused on concerns that certain lyrics can lead to acceptance of violence, suicide, inappropriate views of women, and other unethical behaviour. Debate over whether such connections exist at least illustrates that popular songs engage listeners with ethical issues; this arises from the unique blend of emotional and cognitive reactions to music. And while the emotional side of ethics has received less attention than other aspects of ethics, it is important and music can be a powerful and unique tool to introduce the emotional aspects of ethics. Music appeals to almost everyone. Throughout history songs have rallied people to action and drawn people into deeper reflection. Music engages our emotions, our imagination and our intellect. Students already spend many hours listening to songs, some of which address ethical issues; it is thus an ideal pedagogic aid in teaching subjects like ethics. This article will discuss how carefully selected songs can encourage thoughtful reflection and critical thinking about ethical issues: a number of specific examples will be described, along with a discussion of the general practicalities of using popular songs in teaching ethics and a demonstration of how students learn to listen critically and actively reflect on the ethical messages they receive. The enjoyment of music helps to engage students with ethics and its relevance for their lives and careers. This article aims to share some of the excitement and enthusiasm that popular songs have brought to my teaching of ethics.

Diagnostic self-testing devices are being developed for many illnesses, chronic diseases and infections. These will be used in hospitals, at point-of-care facilities and at home. Designed to allow earlier detection of diseases, self-testing diagnostic devices may improve disease prevention, slow the progression of disease and facilitate better treatment outcomes. These devices have the potential to benefit both the individual and society by enabling individuals to take a more proactive role in the maintenance of their health and by helping society improve health and reduce health costs. However, the full implications of future home-based diagnostic technology for individuals and society remain unclear due to their novelty. We argue that the development of diagnostic tools, especially for home use, will heighten a number of ethical challenges. This paper will explore some of the ethical implications of home-based self-testing diagnostic devices for the autonomous and relational dimensions of the person. This will be facilitated by examining the impact of diagnostic devices for individual autonomy, for the delivery of accurate diagnosis and for the personal significance of the information for the user. The latter will be examined using Charles Taylor's view of personhood and his emphasis on human agency and interpretation. While the ethical issues are not necessarily new, the development of home-based self-testing diagnostic devices will make issues regarding autonomy, accuracy of information and personal significance more and more demanding. This will be the case particularly when an individual's autonomous choices come into conflict with the person's relational responsibilities.

Background The justification for Nazi programs involving involuntary euthanasia, forced sterilisation, eugenics and human experimentation were strongly influenced by views about human dignity. The historical development of these views should be examined today because discussions of human worth and value are integral to medical ethics and bioethics. We should learn lessons from how human dignity came to be so distorted to avoid repetition of similar distortions. Discussion Social Darwinism was foremost amongst the philosophies impacting views of human dignity in the decades leading up to Nazi power in Germany. Charles Darwin's evolutionary theory was quickly applied to human beings and social structure. The term 'survival of the fittest' was coined and seen to be applicable to humans. Belief in the inherent dignity of all humans was rejected by social Darwinists. Influential authors of the day proclaimed that an individual's worth and value were to be determined functionally and materialistically. The popularity of such views ideologically prepared German doctors and nurses to accept Nazi social policies promoting survival of only the fittest humans. A historical survey reveals five general presuppositions that strongly impacted medical ethics in the Nazi era. These same five beliefs are being promoted in different ways in contemporary bioethical discourse. Ethical controversies surrounding human embryos revolve around determinations of their moral status. Economic pressures force individuals and societies to examine whether some people's lives are no longer worth living. Human dignity is again being seen as a relative trait found in certain humans, not something inherent. These views strongly impact what is taken to be acceptable within medical ethics. Summary Five beliefs central to social Darwinism will be examined in light of their influence on current discussions in medical ethics and bioethics. Acceptance of these during the Nazi era proved destructive to many humans. Their widespread acceptance today would similarly lead to much human death and suffering. A different ethic in needed which views human dignity as inherent to all human individuals.

In this paper, the theory and practice of therapeutic touch (TT) is scrutinized from a number of perspectives. Firstly, the alleged close relationship between TT and Martha Rogers’ Science of Unitary Human Beings is evaluated. Secondly, the employment of the language of modern physics in Rogers’ theory and TT is critically examined. The authors then review the research literature on TT's efficacy, completing their critique by discussing the ethical issues involved in the practice of TT. As each of the perspectives considered reveals some concerns, the paper concludes that TT is a questionable intervention, underpinned by a very weak theoretical, clinical and research base.

This paper aims to critique the phenomenon of advanced patient autonomy and choice in healthcare within the specific context of self-testing devices. A growing number of self-testing medical devices are currently available for home use. The premise underpinning many of these devices is that they assist individuals to be more autonomous in the assessment and management of their health. Increased patient autonomy is assumed to be a good thing. We take issue with this assumption and argue that self-testing provides a specific example how increased patient autonomy and choice within healthcare might not best serve the patient population. We propose that current interpretations of autonomy in healthcare are based on negative accounts of liberty to the detriment of a more relational understanding. We also propose that Kantian philosophy is often applied to the healthcare arena in an inappropriate manner. We draw on the philosophical literature and examples from the self-testing process to support these claims. We conclude by offering an alternative account of autonomy based on the interrelated concepts of relationality, care and responsibility