EACME Newsletter European Association of Centres of Medical Ethics Executive Office: Angelique Heijnen Maastricht University, Dept. Health, Ethics and Society Faculty of Health Medicine and Life Sciences P.O. Box 616 6200 MD MAASTRICHT, THE NETHERLANDS Tel: +31 43 3882145
[email protected] www.eacmeweb.com Number 39 – April 2015
CONTENTS
EDITORIAL
Editorial R. Porz
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Public health and the Hepatitis C virus L. Harris and J. Hewitt
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A participatory approach to evaluating ethics support services S. Metselaar
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Conference Report A. McKeown
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La liberté ne vaut que par les limites qu’on accepte de lui mettre J. Martin
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Competence in obsessive-compulsive disorder. An empirical ethical study A. Ruissen
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Bien et maltraitance J. Martin
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How is research ethics understood and practiced in Muslim contexts? M. Suleman
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Visiting Scholarship Exchange C. Brall
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Special issue of the EACME Newsletter
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ECEN 2nd open Forum Day
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Livre Bioéthique Globale: Dans quel but?
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Editorial Board
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Dear readers, let me start with the most important: This newsletter lives thanks to your posts. Therefore, I would like to encourage you once more as an editor to send us short texts about new research projects, book projects, collaborations, announcements, etc. We are particularly pleased about contributions from young researchers (young in spirit!), for example abstracts of PhD projects or research visits. The EACME explicitly sees itself as a platform to promote young academics in the field of biomedical ethics. And mentioning the word "ethics", the EACME is also looking for genuinely ethical contributions, ie reflections about morality and normativity. I would also like to announce that the second newsletter this year will be a Special Issue on clinical ethics. Deadline is July 21, 2015 and you can find the call for abstracts on page 12. Suzanne Metselaar already gives you an appetizer on this topic in this newsletter with her skeptical approach to the evaluation of ethics. In particular, we would like to encourage contributions on topics like: Which current debates in clinical ethics do you observe in your country? Do you perceive any "blank areas" or neglected topics in clinical ethics that need to be stressed more thoroughly? What advantages and disadvantages does professionalization (and evaluation) of clinical ethics entail? Please do not hesitate to contact me or Ralf Jox (as guest editor). We are pleased to discuss your ideas also before submission. But let’s not rush to the next issue too quickly, and let’s first enjoy the present contributions, be it a look through the lens of public health approaches (as in the first post for example), or a careful look at research
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ethics in the Muslim context (as in the last post). Thank you to all contributing authors for this exciting edition of our newsletter. Have fun while reading. And last but not least: Do not forget to book your tickets to Sardinia. We'll hopefully see you all at this year's EACME conference in Cagliari, your Rouven Porz Ethics Unit Bern University Hospital ‘’Inselspital’’
circumstance as well as will. Lack of opportunities or severely limited opportunities are likely to affect selfefficacy in terms of health responsibility and determination. In this paper, we look at one aspect of public health policy in Wales, which has sought to reduce the incidence of Hepatitis C. We argue that socio-economic status has a significant effect on screening programmes and uptake of services for individuals at highest risk of Hepatitis C . We conclude that health promotion must therefore take account of circumstances before placing personal obligation at the forefront of health behaviours.
[email protected]
PUBLIC HEALTH AND THE HEPATITIS C VIRUS Despite the widespread discussion of bioethics in medicine over the past five decades, the ethical dimensions of public health and health promotion have been less fully addressed until recent years (Carter et al 2011). The range of ethical issues in the field of public health is wide and runs parallel to the field of bioethics in terms of respect for autonomy, beneficence, nonmaleficence and justice. The particular concerns of public health of interest to ethicists are health promotion and disease prevention, risk reduction, epidemiological and structural and socioeconomic disparities in health status (Callahan and Jennings, 2002). Public health and health promotion initiatives are explicitly directed towards education and risk management of target populations. However, health promotion messages are also value-laden; personal responsibility for health has become increasingly to the fore of health promotion initiatives in Britain, with poor life-style choices highlighted as being responsible for the rise in certain disease states. This view has had implications for those whose behaviour is deemed risky or irresponsible in terms of health choices. Smoking, obesity, alcoholism and illicit drug taking are seen as choices which affect not only the health of the individual but also society as whole in terms of the financial and resource burdens on healthcare. This has led to calls for healthcare to be prioritised in terms of personal responsibility for health behaviours. In an over-subscribed health service, emphasis on distributive justice has created ethical uncertainties in terms of respecting autonomous choices, where those choices are seen to limit the availability of health care for all. Lowering the risk of certain diseases has therefore become a moral as well as medical imperative, which has become relevant for the way in which health care policy is developed and enacted. However, life chances as well as life choices significantly impact on determinants of health (Marmot et al, 2008). Socio-economic circumstances may affect opportunities for health screening and uptake of services. Individual choice is dependent on
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The WHO (2014) define public health as an organised measure to prolong life through the prevention of disease and promotion of good health. Its ethos can be traced back to the 1200’s, where public health initiatives were concerned with the repairing of public sewers in order to prevent the spread of water borne diseases. Public health subsequently developed into a fluid and flexible approach that was responsible for, amongst other things, action against environmental issues stemming from industrialisation, poverty and the plague (Warren, 2000). To this day, public health still holds the same ethos which is now driving policy development and health surveillance at a governmental level. Health promotion is a more recent development within the realm of public health practice. Health promotion is defined by the Ottawa Charter for Health Promotion as the process of enabling people to increase control over their health. The charter was influential due to the emphasis placed upon health as a resource for everyday living and crucially it outlined how health promotion extends far beyond the healthcare sector. The reorientation of health services in the UK is evident through a shift in emphasis by the National Health Service from a service designed in 1948 to treat the acutely unwell, with little provision for prevention, to a service which now places a large responsibility on preventative measures. The NHS now focuses upon environmental and socioeconomic issues that contribute to poor health behaviour in order to eradicate preventative chronic illnesses. These priorities have been taken up by health professionals, to promote health, protect health and prevent ill health among at risk groups such as intravenous drug users in an attempt to reduce the rate of transmission and provide early interventions, treatment and psychological support. Hepatitis C is a global burden, affecting populations in industrialised and developing countries (Lavanchy, 2009). The Hepatitis C Virus (HCV) is defined by the National Institute of Health (NIH; 2002) as a chronic ribonucleic acid (RNA) virus that directly affects the liver. The World Health Organisation (2014) identify that
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60% of those infected will develop some degree of liver damage, whilst 30% will develop chronic liver disease in the form of liver cirrhosis. HCV is predominantly associated with Intravenous Drug Use (IDU); transmission statistics report that 60 – 90% of individuals with the virus have a history of IDU (Schaefer and Mauss, 2008). The Welsh Assembly Government (2010) identify HCV as a cause for public concern based on two issues: high risk of transmission to others through contact with infected blood or bodily fluids and due to its contribution to the ever growing disease burden throughout Wales. Chronic liver disease resulting from HCV places a heavy burden on the NHS and national economy. Epidemiological data suggests that over 12000 people (0.4% of the population) are infected with HCV (Public Health Wales, 2013). A commonality across the majority of cases is a history of illicit Intravenous Drug Use (IDU), with the principle means of transmission through sharing injecting paraphernalia (NHS Scotland, 2000). Prevalence rates reveal 60 – 90% of IDUs in England and Wales test positive for HCV (Schaefer & Mauss, 2008). The Hepatitis C Trust (2013) suggest there to be a silent epidemic, as data indicates deaths from the virus have increased by 400% since 1996. There is a distinct lack of public and professional awareness surrounding the severity of the virus with only 3% of those diagnosed receiving the appropriate treatment (Harris, Thomas, Griffiths et al, 2014). However, more worrying statistics reveal over 50% of individuals living with the virus are undiagnosed and therefore risk unknowingly transmitting it to others (Chen & Morgan, 2013). Individuals must overcome any number of socioeconomic, environmental, and lifestyle/behavioural barriers before they attempt to access healthcare services for HCV. However even once overcome, they are often met with provider reluctance to treat (Harris & Rhodes, 2013). This largely stems from issues surrounding perceived adherence to treatment regimens (Grebely et al, 2011), whereby healthcare workers are sceptical as to whether patients will adhere to the full course of treatment. Intravenous drug users report stigma and discrimination as barriers to HCV screening and treatment with healthcare settings the most common environment for this discrimination to occur (Harris, Rhodes and Martin, 2013). Attending hospital appointments is largely met with fear of a breach in confidentiality (McGowan & Fried, 2012). Life chances as well as life choices significantly impact upon the health status of an individual. Low Socio Economic Status (SES) is associated with an increased
risk of HCV infection (Armstrong et al, 2006). Literature suggests that individuals with low SES are more susceptible to engage in risky behaviour surrounding the use of illicit intravenous drugs, including sharing injecting equipment and self-medicating with heroin to alleviate/manage pain (Fisher et al, 2004). Individuals from low SES are more likely to engage in risky behaviours owing to a lack of understanding of the risks attached to IDU (Winkleby et al, 1992). As a consequence, poor understanding leads to a lack of perceived susceptibility and as a result has a negative impact upon attendance to screening programmes. 50% of HCV hospital related admissions are from the most deprived areas of society (THCT, 2013). Whilst individuals from socially deprived areas are at more risk, they are also faced with a number of environmental and socioeconomic factors that impact upon the care and treatment available to them. Statistics reveal that only 3% of those diagnosed with HCV are receiving the appropriate treatment (Harris et al, 2014), with a number of barriers to prevention, diagnosis, referral and treatment linked to socio-economic status. At an environmental level, individuals from socially deprived areas have limited access to screening services. Geographical access can have a negative influence upon attendance for screening; the cost of transport for example has been shown to impact upon the uptake of screening programs (John-Baptiste et al, 2009). Owing to the nature of the virus and the social circumstances that accompany it a wider and more inclusive approach that encompasses a number of services and authorities is therefore necessary to address all factors which contribute to its transmission, treatment and management of HCV. Previous attempts to manage the virus from a public health perspective have been narrow in their approach, interventions being largely based within the hospital setting with little/no provision for community based interventions (THCT, 2013). However in moving forward to manage the virus a broad approach must be utilised that is not only based within hospitals and primary care settings, but within the community, as individuals most at risk of HCV occupy a subgroup of society that may have little/no contact with health services. Low socio-economic status significantly impacts personal heath and may equally impact upon life-style choices. Over-emphasis on personal responsibility for health may ignore a crucial determinant of a person’s capacity for choice – life chances – and unjustly stigmatise individuals for contributing to economic health care burden through risky choices. We conclude that that health promotion as a key strand of public health policy should therefore be equally determined with the community aspects as it is with individual responsibility for health. Over-emphasis on the latter
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may lead to injustice and stigmatisation of individuals who are most at risk of bearing the burden of disease. Luke Harris and Jeanette Hewitt Swansea University
[email protected] References Armstrong, G I., Wasley, A., Simard, E P., McQuillan, G M., Kuhnert, W L., Alter, M J. (2006). The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Annals of Internal Medicine, 144, p 705 – 714. Carter, S. M., Rychetnik, L., Lloyd, B., Kerridge, I. H., Baur, L., Bauman, A., ... & Zask, A. (2011). Evidence, ethics, and values: a framework for health promotion. American journal of public health, 101(3), 465-472. Chen, S., Morgan, T R. The Natural History of Hepatitis C Virus (HCV) Infection. International Journal of Medical Sciences, 3 (2), p 47 – 52 Fisher B, Haydon, E., Rehm, J., Reimer, J. (2004). Injection drug use and the hepatitis C virus: Considerations for a targeted treatment approach – The case study of Canada. Journal of Urban Health, 81, p 428 – 447. Grebely, J., Bryant, J., Hopwood, M., Lavis, Y., Dore, G J., Treloar, C. (2011). Factors associated with specialist assessment and treatment for hepatitis C virus infection in New South Wales, Australia. Journal of Viral Hepatitis, 18 (4), p 104 – 116. Harris, M., Rhodes, T. (2013). Hepatitis C treatment access and uptake mapping for people who inject drugs: a review mapping the role of social factors. Harm Reduction Journal, 10 (7), p 1 – 11. Harris, M., Rhodes, T., Martin A. (2013). Taming systems to create enabling environments for HCV treatment: negotiating trust in the drug and alcohol setting. Journal of Social Science and Medicine, 83, p 19 – 26. Harris, R J., Thomas, B., Griffiths, J., Costella, A, Chapman, R., Ramsey, M… (2014). Increased uptake and new therapies are needed to avert rising hepatitis C-related end stage liver disease in England: Modelling the predicted impact of treatment under different scenarios. Journal of Hepatology, 61 (3), p 530 – 537. John-Baptiste, A., Verenbut, M., Lingley, M., Nedd-Roderique, T., Teplin, D., Tomlinson, G… (2009). Treatment of hepatitis C infection for current or former substance abusers in a community setting. Journal of Viral Hepatitis, 16 (8), p 557 – 567. Lavanchy, D. (2009). The global burden of hepatitis C. Liver International, 29(s1), 74-81. (NHS Institute, 2013). Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372(9650), 1661-1669. McGowan, C E., Fried, M W. (2012). Barriers to hepatitis C treatment. Journal of Liver International, 32, p 151 – 156. National Health Service Scotland. (2000). Scottish Needs Assessment Programme: Hepatitis C. Glasgow: Office for Public Health Public Health Wales. (2013). Hepatitis C. Retrieved September 28, 2014 from – http://www.wales.nhs.uk/sitesplus/888/page/43746 Schaefer, M., Mauss, S. (2008). Hepatitis C treatment in patients with drug addiction: clinical management of interferon-alphaassociated side effects. Journal of Current Drug Abuse Reviews, 1 (2), p 177 – 187. The Hepatitis C Trust. (2013). The Uncomfortable Truth, Hepatitis C in England: The State of the Nation. Retrieved from http://www.hepctrust.org.uk/Resources/HepC%20New/The%2 0Trust/The%20Uncomfortable%20Truth.pdf
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Treloar, C., Newland, J., Rance, J., Hopwood, M. (2010). Uptake and delivery of hepatitis C treatment in opiate substitution treatment: perceptions of clients and health professionals. Journal of Viral Hepatitis, 17, p 839 – 844. Warren, M D. (2000). A Chronology of State Medicine, Public Health, Welfare and Related Services in Britain 1066 – 1999. London: Faculty of Public Health Medicine. Welsh Assembly Government. (2010). Blood Borne Viral Hepatitis Action Plan for Wales 2010 – 2015. Cardiff: Welsh Assembly Government. Winkleby, M A., Jatulis, D E., Frank, E., Fortmann, S P. (1992). Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. American Journal of Public Health, 82 (6), p 816 – 820. World Health Organisation. (2014). Media Centre: Hepatitis C. Retrieved September 24, 2014, from http://www.who.int/mediacentre/factsheets/fs164/en/
A PARTICIPATORY APPROACH TO EVALUATING CLINICAL ETHICS SUPPORT SERVICES The formalization of evaluation We live in an ‘evaluation society’. Measuring ‘good care’ in an authoritative, objective and quantitative way has become imperative. This implies a process of formalization and delegation: intuitive judgments concerning the quality of health care services are replaced by evaluation through standardized and validated techniques, such as auditing and using a standard evaluation protocol. These tasks are usually delegated to external agencies. This also goes for the evaluation of clinical ethics support services (CESS), which has gained substantial importance and has thoroughly formalized the last decade. A consequence of this formalization is that a shift of ownership has occured from the people actually involved in CESS to external committees that have increasingly come to determine what ‘good CESS’ should look like by articulating its criteria and terms for measurement. However, it can be strongly doubted whether this relocation of ownership does justice to the insights and needs of those who are actually involved in concrete CESS practices (receivers, providers, or both). This doubt particularly relates to the fact that this formalized approach to evaluation presupposes that the criteria for good ethics support can be decided upon detached from concrete contexts and practices. A participatory approach As an alternative to the formal approach, we developed a participatory approach to CESS evaluation. It is based on and in line with the principles of Moral Case Deliberation (MCD). MCD proceeds from the idea that in CESS, professionals and ethicist should engage in a joint process of moral deliberation and moral learning, in which their expertise and input is complementary in determining what constitutes ‘good care’. This internal principle of MCD can be extrapolated to the evaluation of CESS.
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A participatory approach to CESS evaluation based on the principles of MCD focuses on the concrete contexts in which CESS activities are embedded, assuming that CESS evaluation cannot be based on values, norms, and principles that are defined beforehand and detached from practice: what is ‘the right thing to do’ is always context-bound and based on the reflection on lived experiences. In this way, we seek to prioritize the ‘life-world’ of CESS, i.e. an insiders’s perspective, rather than an approach imposed on a specific context from the ‘system,’ i.e. a formalized, outsiders perspective Another important characteristic is that a participatory evaluation process should be democratic, inclusive, and dialogical. CESS should therefore be evaluated by its various actual stakeholders. With ‘stakeholders’, we mean not only the receivers of CESS, but also those who facilitate MCD sessions, coordinate, initiate, and fund it. Also patients and their relatives could be regarded as stakeholders. A third aspect of this approach is its focus on mutual learning. It goes beyond either measuring with external criteria (objectivism) or accepting whatever is considered to be good by the participants (subjectivism), but is based upon a joint critical inquiry with all stakeholders involved, in which these stakeholders can learn from each other. In this way, the different positions, perspectives, expertise and experiences of stakeholders are complementary in a more encompassing assessment of ‘good CESS’ in an institution. Putting the participatory approach in practice We are currently putting this participatory approach to CESS evaluation in practice at the Inselspital Bern. The Inselspital is the largest academic hospital in Switzerland. It employs around 7700 professionals and it has recently been merged with seven other, smaller hospitals in the Bern area, expanding its staff to 10.000 members. In 2012-2013, a group of 16 health care professionals was trained to become MCD facilitators Among them were pastoral care takers, medical doctors, nurses and social workers. The objective of this project was to strengthen a clinical ethics support network. At present, a large group of the trainees are actually implementing and facilitating MCD-based CESS. In a qualitative study, we asked sixteen health care professionals trained in facilitating MCD to evaluate their own MCD-based CESS activities. Rather than providing pre-set criteria for the measurement of the quality of CESS, we asked them what constitutes good CESS for them and whether they were able to live up to these criteria, what they would need to improve their practices and what is holding them back. Their perspectives and experiences were gathered through a questionnaire and in individual interviews. The results were discussed in a focus group, which had the form of
a dialogue group in which the participants shared perspectives in a joint learning process about good CESS in their specific situation. If you want to learn more about our evaluation project in Bern, its outcomes, or our ideas on CESS evaluation in general, please contact me:
[email protected]. Suzanne Metselaar VU University Medical Center, Dept. of Medical Humanities/EMGO+
[email protected] CONFERENCE REPORT Ethics and Professionalism in Health Care. Backgrounds, Frameworks, Challenges International conference for young scholars 9th – 13th February 2015 Institute for Medical Ethics and History of Medicine Ruhr University Bochum, Germany The international conference ‘Ethics and Professionalism in Health Care - Backgrounds, Frameworks, Challenges’, organized by Jan Schildmann, Sabine Salloch, Verena Sandow, and Jochen Vollmann, took place at the Institute for Medical Ethics and History of Medicine, Ruhr th th University Bochum from February 9 to 13 , 2015. The conference was sponsored by the German Federal Ministry for Education and Research. The primary aim of the conference was to provide an opportunity for junior scholars - PhD students and postdoctoral researchers - from across Europe to discuss normative and empirical aspects of human medical research from the perspective of different disciplines. To this end, twelve junior academics from six European countries spent the week at the historic “Malakowturm” - a former mining shaft tower – working on the concept of professionalism in the context of healthcare. Representing a range of disciplinary perspectives across philosophy, history, literary studies, sociology, nursing, and clinical medicine, the participants presented a diverse selection of papers focusing on different ethical questions pertaining to this central conceptual issue. In addition, the conference featured several workshops and lectures from renowned speakers with longstanding expertise in the area of ethics and medical professionalism. The presentations were organised each day according to themes of relevance to the overarching concept of professionalism in healthcare. These were, in order from Monday to Friday: Historical and societal aspects of healthcare professions; Learning and teaching
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medical professionalism; Transformation of healthcare professions; Ethical challenges to healthcare professions; and Professional leadership and team decision-making. The conference began with introductory remarks from Prof. Vollmann, Dr. Schildmann, Dr. Salloch, and Ms. Sandow, who introduced themselves, the activities for the week, and some background about the Institute and its work. Following this, the first day of presentations commenced with Dr. Clemens Tangerding and his historical analysis of the move from religious to secular nursing care in hospitals and its effect on communication. This was followed by Katharina Fürholzer from University of Muenster, who presented her work in the medical humanities, examining physicians’ letters to patients, and the ethical implications for professional practice following different ways of communicating sensitive information. Continuing the theme of historical and societal aspects of the healthcare professions, these were followed by a workshop from Prof. Vollmann and Dr. Schildmann on the subject of physician assisted suicide. The participants were invited to reflect on the legal status of physician assisted suicide in their own countries and discuss the ethical merits of different practices and cultural attitudes towards it. Tuesday featured two presentations from the perspective of nursing, from Sarah Berger and Kristin Fragemann of the Universities of Heidelberg and Regensburg respectively. The former reported on a qualitative study about interprofessional decisionmaking amongst healthcare students; the latter on attitudes towards pain management and learning within an interprofessional pain curriculum. Again, the presentation sessions were followed by an expert seminar from Prof. Annie Cushing from Barts and the London School of Medicine and Dentistry, who gave an insightful and interactive overview of effective teaching and facilitate of learning about medical professionalism within the context of UK healthcare training. The transformation of healthcare professions was the theme for the third day of the conference, and featured three presentations. Dr. Tetiana Stepurko of the National University of Kiev presented her work on the professionalism of the healthcare workforce in Ukraine. Dr. Andrei Famenka from the Belarus State Service of Legal Medicine in Minsk gave a socio-historical analysis of the implications for changing clinical ethics procedures in post-Communist eastern European nations since the end of the Soviet Union. Finally, Dr. Alex McKeown of the University of Bristol presented a paper examining the philosophical relationship between medical professionalism and human enhancement, analysing the ethical and social
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impact that the former may have on the latter if enhancement technologies were to proliferate within the context of public health and preventive, rather than curative, medicine. Although there was no afternoon workshop on Wednesday, the evening featured a lecture from Dr. Ellen Kuhlmann of the University of Dortmund, who gave a fascinating talk about differing international perspectives on the appropriate institutional role and extent of management in medical practice. The two talks on the penultimate day of the conference, united under the theme of ethical challenges to healthcare professionalism, were given by Dr. Christopher Yu, a junior physician from Leeds; and Dr. Dorina Stanescu from the University of ClujNapoca. Dr. Yu’s talk presented his team’s qualitative research into the presence and prevalence of ‘Akrasia’ – the state of mind in which someone acts against their better judgement – amongst junior doctors when following the orders of more senior physicians, and the implications for professionalism that this can create. Dr. Stanescu’s presentation also drew on empirical research, framing an analysis of the ‘brain drain’ of healthcare professionals moving abroad for economic reasons in terms of the ethical tensions between Nozickian libertarianism, and Rawlsian social contract theory within political philosophy. The final expert workshop of the week, which followed these two presentations, was given by Prof. Elmar Doppelfeld, Honorary Chairman of the German Working Group of Research Ethics Committees. Prof. Doppelfeld drew on his wealth of expertise in a comprehensive overview of the threat to professional integrity posed by conflicts of interest in medical research. The conference was closed on the fifth day by three talks drawing on original empirical research within the theme of professional leadership and team decisionmaking. Dr. Gemma Clarke of Cambridge University spoke about multidisciplinary team decision-making for individuals with compromised decision-making capacity. Dr. Martina Šendula-Pavelić of the University of Rijeka presented work on group-level outcomes of ethical leadership in healthcare teams. Finally, Stephanie Rüsch from the Technical University of Dortmund, whose talk focused on the entrepreneurialism in senior medical managers, and the implications of this for strategic decision-making in non-profit hospitals. The final day was rounded off by group reflections on what had been learnt during the conference and subsequently a discussion about the edited collection of papers which has been proposed as an appropriate output for recording and disseminating the important findings of the presentations made throughout the week. Finally, it must be mentioned that not only was the conference a valuable, informative, and interesting
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opportunity for learning, but it was also a friendly and convivial week both in and out of the official sessions. Each day there was ample time set aside for networking, where the participants were able to get to know each other and learn about each other’s work. A generous social programme was also provided by the conference organisers, as the participants were able to enjoy group dinners in Bochum each evening, at which new friendships and alliances for future research were made. Between the social events and the working sessions, the five days provided an ideal platform for learning about ethics and professionalism in healthcare across Europe from a diversity of disciplinary perspectives. The whole week was a fantastic experience for all the participants, and last but not least praise and thanks are therefore due to the organising committee, the University, and the sponsors for organising this excellent event. Alex McKeown University of Bristol Centre for Ethics in Medicine
[email protected] LA LIBERTÉ NE VAUT QUE PAR LES LIMITES QU’ON ACCEPTE DE LUI METTERE Je viens de faire un séjour aux Etat-Unis dans la famille d’un de nos enfants. Il y a quelques mois, le pays a été vivement interpelé par le meurtre à Ferguson, Missouri, d’un jeune Noir par un policier. Début mars, un rapport officiel a conclu à des pratiques manifestes de discrimination raciale par la police locale, dont le chef a dû démissionner le 11 mars. Au même moment, l’Université d’Oklahoma excluait deux étudiants qu’une vidéo montrait chantant des thèmes racistes rappelant l’époque de la ségrégation et des lynchages. Ainsi, s’il existe encore beaucoup de racisme ordinaire aux Etat-Unis, illustré notamment par des chiffres montrant comment les tribunaux punissent très différemment les actes délictueux ou criminels selon qu’ils sont le fait d’un Blanc ou d’un Noir, certaines réactions correctrices appropriées interviennent ; il y a lieu bien sûr de s’en féliciter. A relever qu’une certaine ambiance nostalgique avec des facettes racistes est confortée par la résistance du parti républicain (caricaturé comme celui des « vieux mâles blancs ») à tout changement susceptible de promouvoir un pays plus équitable, divers et multiculturel, qui corresponde à sa réalité actuelle. A vrai dire, les attaques extrêmes dont est victime le Président Obama – et son épouse, souvent teintées de racisme, font douter de la raison (sanity) de plusieurs politiciens et journalistes.
A noter que les étudiants exclus de l’Université d’Oklahoma ont leurs soutiens, qui allèguent la garantie constitutionnelle de la liberté d’expression dans la foulée de dérives de type libertarien encouragées par des milieux qui ne comptent pas l’argent qu’ils y consacrent. En Suisse aussi, la norme pénale antiraciste (art. 261 bis de notre Code pénal), pourtant adoptée en vote populaire, est attaquée avec une motivation semblable. Or, l’invocation idéologique d’un « droit à faire tout et n’importe quoi » est un danger sérieux pour notre vivre ensemble. Je crois à la formule « La liberté ne vaut que par les limites qu’on accepte de lui mettre » (qui fait écho à « la liberté de l’un s’arrête là où commence celle de l’autre »). Peuton contester que le respect de l’autre doit être, pour la vie en société, un impératif aussi fort qu’une conception maximaliste de la liberté ? Ici on est amené à évoquer les assassinats odieux, à Paris le 7 janvier, de journalistes de « Charlie Hebdo ». Il faut haïr de tels actes, je les hais. Mais je ne peux pas être d’accord avec les revendications dogmatiques d’un droit absolu à l’insulte ou au blasphème. D’abord, il y a de longue date des dispositions réprimant la calomnie ou la diffamation. Ensuite, une société qui voudrait ignorer, ou pire éradiquer, le fait religieux est condamnée à s’enfermer, comme la France actuellement, dans une laïcité ombrageuse, coercitive, réagissant de manière stridente dès que la dimension religion de la vie apparaît en public. Intransigeance qui à vrai dire a des aspects bornés. Comment ne voit-on pas que les anathèmes laïcs lancés à des paroles ou actes qui ne sont que l’expression, non belliqueuse et non prosélyte, de ses convictions nie précisément cette liberté qu’on entend mettre sur un piédestal ? Le principe prévalant en Suisse de la neutralité des pouvoirs publics en matière religieuse est certainement plus adéquat. Il importe donc de promouvoir une convivialité marquée par le respect et par l’ouverture à comprendre l’autre et ses raisons. Etant entendu que, s’il y a lieu de chercher à comprendre, il ne peut être question de tout excuser et que certaines choses doivent être punissables – et punies ! La question est de savoir ce que nous voulons privilégier : une forme exacerbée de liberté individuelle ou un vivre ensemble respectueux. A mon sens, la première option est une voie discutable, qui se révèlera une impasse source d’incessants conflits. Une civilité fondamentale et le civisme que nous vouons faire nôtre demandent qu’on souligne que sa propre liberté n’inclut certainement pas de pouvoir insulter ad libitum autrui, ses croyances, ses caractères raciaux ou d’origine. PS : Autre sujet : ce sont aussi des « libertaires » qui s’opposent à la dispensation raisonnable, comme cela se fait avec succès, en Suisse par exemple, depuis plusieurs décennies, d’éducation sexuelle à l’école, sous une forme adaptée à l’âge. Une telle démarche a
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aussi des aspects discriminatoires : une partie des enfants ne reçoivent pas du tout à la maison les messages équilibrés, sains, nécessaires dans ce domaine et ils seraient alors désavantagés, et plus à risque d’erreurs ou malheurs ultérieurs, s’ils n’en entendent plus parler à l’école. Jean Martin Ancien membre de la Commission nationale suisse d’éthique et du Comité international de bioéthique de l’UNESCO
[email protected] COMPETENCE IN OBSESSIVE-COMPULSIVE DISORDER. AN EMPIRICAL ETHICAL STUDY When a physician wants to treat a patient, the patient’s informed consent is needed. Not everyone is able to consent. Patients that are delirious or suffer from dementia are incompetent to give informed consent. To assess competence international criteria have been formulated. These criteria focus on the capacity to understand information, to apply it to one’s situation, and to reason about consequences of various options. Andrea Ruissen studied competence in people with obsessive-compulsive disorder. Based on interviews with patients and mental health care professionals, she concluded that criteria for competence in obsessivecompulsive disorder differ from those used in the international literature. Next to cognitive functions, emotions and values are relevant. She found that one not only should be able to reason about what is the best thing to do, but also should have the ability to integrate a certain decision in one’s life. This is in line with Aristotle’s concept of practical wisdom, which does not refer to the capability to infer conclusions from general rules, but to have insight in what is valuable in the concrete situation. In short, results can be organised in three sections: results on the concept of competence and the assessment of competence; results on insight as a classification-specifier related to competence; and results on the importance of dialogue en deliberation in competence assessment and empowerment of incompetent patients. Competence conceptualization and assessment There is no consensus about an exact definition of competence, but there is international consensus about conditions for assessment: competence is assumed until proven otherwise; it is task-specific; concerns the decision-making ability and not the decision itself; and may vary over time and may depend on the situation. A categorical approach, e.g.
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all patients with a certain disorder are incompetent, is obsolete. The debate on competence conceptualization and assessment continues, but authors and stakeholders agree that if there are doubts on a patient competence and important treatment decisions are at stake, including the refusal of potential beneficial interventions, a competence assessment is relevant. A non-psychotic diagnosis, including the diagnosis obsessive compulsive disorder, is not enough to state that the patient is probably competent. The most used tool for assessment is the MacCAT (Grisso et al., 1997), which focuses on the ability to make a choice, to understand information, to appreciate the situation, and to reason. The MacCAT is critiqued for its cognitive bias. Other factors, such as emotions and values are relevant for assessment as well. In our study other factors, such as insight, identity, and the ability to integrate various values in life proved to be of importance too, in patients with OCD. Therefore we plead for a competence assessment that is embedded in a broader process of deliberation and care to do right to the complexity of competence conceptualization and assessment. Insight and competence do not overlap in OCD Insight is an important aspect of competence. In the standard approach, competence entails being able to appreciate the situation, that is, being able to see that the information about the disease and the possibilities for treatment are applicable to oneself. Yet, insight is not enough. In non-psychotic disorders, patients with adequate insight can be incompetent. This is especially relevant in OCD, as it is one of the few disorders in DSM with a specifier for insight. The patients in our study mostly met criteria for sufficient insight. All but one patient fully agreed on the diagnosis of OCD, the one that did not fully agree was ready to at least consider the diagnosis. All patients recognized descriptions of symptoms and also were able to see that those symptoms had disadvantages in one way or another. Given the importance of disorder awareness and attribution in the conceptualization of insight, most of them might have been assessed as having adequate insight. The health care professionals in our study, however, had serious doubts on their patient's competence. This is similar to findings in anorexia nervosa (Tan et al., 2006), in which insight was adequate but MacCAT outcomes were falsepositive. The importance of dialogue and deliberation Patients with OCD describe difficulties in combining values related to the disease and other values in life. Patients perceive being able to reflect on ambivalences and to find a balance between various values in life as important. The process of learning to integrate OCD in life can be characterized as a quest.
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In this process, the patient also develops commitment with treatment. Mental health care professionals, when explaining competence, refer to issues which go beyond cognitive rationality, such as the possibility to have a conversation with the patient. When discussing incompetence, they refer to patients’ emotions, values, and identity. Professionals can engage in the patient’s quest, which empowers competence and might improve treatment outcome. A professional can facilitate and support the quest for meaning and significance in having OCD and finding en explicating values in life. They may use strategies such as a motivational approach, convincing and focusing on patients’ values and identity. Both patients’ and professionals’ conceptualizations of competence refer to the importance of conversation and dialogue. Support in the patient’s quest requires attention for the patient’s values and helping the patient to reflect on these values. This goes beyond a paternalistic approach, since not the physician’s values, but the patient’s values are important. It also goes beyond the informative model, since patient’s values are not taken for granted, but regarded as open to reflection and deliberation. Thus, the deliberative model of the physician-patient relationship seems most appropriate in the communications with OCD patients who have difficulties in deciding about treatment and engaging with treatment (Emanuel and Emanuel, 1992). Interventions which are in line with experiences of patients and professionals also require dialogue. Paying attention to tensions between values, and discussing them with patients, not only sheds more light on the competence of patients with obsessive compulsive disorder, but also provides a basis for interventions, such as shared decision making, personal medicine and interventions focused on persuasion rather than coercion. Andrea Ruissen VU University Medical Center
[email protected] BIEN- ET MALTRAITANCE Fin janvier 2015, rencontre à Fribourg (Suisse) des Conseils d’éthique des associations cantonales d’établissements pour personnes âgées dépendantes, sur le thème de la maltraitance et de son contraire la bientraitance, terme d’usage croissant. Substantiels échanges avec des responsables engagés. D’abord, la juriste Céline a présenté la situation légale en Suisse. Ce qui existe au niveau fédéral est en rapport avec des éléments généraux d’atteinte à la personnalité ou à l’intégrité corporelle, sexuelle, voire
au patrimoine, mais il n’y pas de dispositions spécifiques. Il peut y en avoir au niveau cantonal (la loi vaudoise par ex. fait obligation au professionnel qui observe chez un collègue des actes de « maltraitance ou soins dangereux » de le signaler- renversement complet du principe antérieur qui voulait qu’on ne dise jamais de mal d’un collègue). Au reste, il ne faut pas attendre de la loi qu’elle soit le bon instrument pour régler des paroles ou gestes inadaptés ou critiquables qui sont plus du registre des « bonnes pratiques » que de celui du délit (on voit mal que le fait de frapper avant d’entrer dans une chambre, l’attitude à prendre vis-vis d’un résidant réticent à prendre sa douche, ou un éventuel tutoiement, trouve place dans le Code pénal). A cet égard, m’est revenu vivement cet enseignement de ma carrière de médecin officiel qu’il y a passablement de choses que la loi, avec ses « gros sabots », ne sait pas faire. Delphine Roulet-Schwab, professeure à la Haute Ecole La Source, à Lausanne, a exposé le point de vue soignant. Citant une définition de l’Agence française de l’évaluation et de la qualité : « La bientraitance est une culture inspirant les actions individuelles et les relations collectives au sein d’un établissement. Elle vise à promouvoir le bien-être de l’usager en gardant à l’esprit le risque de maltraitance. Elle se caractérise par une recherche permanente d’individuation et de personnalisation de la prestation ». La bienveillance est la disposition d’une volonté visant le bien de l’autre, la bienfaisance l’inclination à faire du bien. Ce qui est « bien » ne dépendant pas seulement du soin mais de la façon dont on communique. Ici ont été soulignés les défis que lance la multiculturalité qui marque nos pays – parmi les résidants, au sein des personnels et entre les uns et les autres. NB : on peut être bienveillant mais simultanément maltraitant si comportements ou soins sont inadaptés. Se méfier parfois de notre envie de faire bien ou mieux, de l’activisme qui crée une situation de « mouche du coche ». Est déterminant le consentement du patient, obtenu en prenant le temps de donner des explications et de solliciter son avis ; particulièrement s’agissant de personnes âgées, pour qui les habitudes sont valorisées et qui ne devraient pas être bousculées sans bonne raison. «Tender loving care », oui mais sans imposer ses bonnes intentions. Eviter la surprotection, a-t-il été dit, considérer que des risques font partie de la vie, à quelque âge que ce soit. Une sensibilisation à cet égard va dans le sens de « Less is more » ; réflexion très actuelle où le principe millénaire « D’abord ne pas nuire » retrouve toute sa signification (une nouvelle jeunesse ?). On a parlé de prévention, suggérant qu’il faut se garder de mettre l’accent sur la poursuite à tout prix de sanctions, au reste souvent bien ingrate (au vu de la difficulté d’apporter des preuves objectives ainsi que
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EACME Newsletter
d’une juridisation galopante) - et qui brouille des messages qu’on veut pédagogiques. Il a été dit que, cas échéant, le geste maltraitant ne doit pas être vu d’abord comme relatif à la personne, mais bien à un acte dans une situation donnée - et l’amélioration doit être cherchée en analysant d’abord l’acte et ses circonstances. En général, développer et implanter une culture de l’erreur, ainsi que cela est promu en milieu hospitalier aigu. Jean Martin
[email protected] HOW IS RESEARCH ETHICS UNDERSTOOD AND PRACTICED IN MUSLIM CONTEXTS? In recent years, biomedical research in developing countries has been expanding, with important implications for the development of novel, lifesaving 1 therapies for pandemics such as HIV. It has also been suggested that health research conducted in developing countries may represent a valuable source of healthcare, be a means of addressing conditions specifically affecting these areas, or as a vehicle for implementing such solutions whilst capacity building in the form of infrastructure development and the training of local staff. Biomedical advancement, however, has to be carefully monitored with sufficient governance processes to 2 ensure there is no compromise on ethical standards. Recent work on global biomedical ethics has transformed dramatically, considering not only 3 challenges in consent procedures but also more subtle questions relating to exploitation, the need for research to be responsive to local population needs and the sustainability of research. This shift has occurred, as there is growing realization that some of the most contentious contemporary ethical controversies are not related to informed consent but rather to the ethics of appropriate risk-benefit ratios, exploitation and the value of research to the local 4 community, where the endemic socioeconomic injustices also cannot be overlooked. Nuffield Council on Bioethics (2002). The ethics of research related to healthcare in developing countries. London: Nuffield Council on Bioethics. http://www.nuffieldbioethics.org/research-developing-countries/researchdeveloping-countries-chapter-downloads (Last accessed 20th June 2013) 2 Lurie P, Wolfe SM. Unethical trials of interventions to reduce perinatal transmission of the human immunodeficiency virus in developing countries. N Engl J Med 1997; 337:853–5. 3 Freedman B. Scientific value and validity as ethical requirements for research. IRB 1987; 9:7–10. 4 Emanuel E, Wendler D and Grady C. What makes clinical research ethical? JAMA. 2000; 283(20), 2701-2711. 1
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However, the field of global health research ethics faces the continuing challenge of its application within ethnographically diverse settings. Although bioethics has increasingly developed a global consciousness, the universal principles to successfully guide ethical decision-making irrespective of cultural or religious contexts are not available and may never be 5, 6 established. Despite the variety of work that has been accomplished thus far (in deriving ethical principles, applying them and reviewing them), some authors suggest that many researchers fail to take into consideration the pertinence of religious pluralism, cultural differences and moral diversity which pervades 7 in different societies. They consider that it is therefore necessary to assess existing research protocols to establish whether they allow for the necessary cultural diversity and therefore enhance applicability. It is also important to consider the role religious views and values play in defining what counts as an ethical problem and what it means to be an ethical researcher. The latter is critical in order to gain a deeper understanding of the moral universe of researchers who consider themselves affiliated with a religious school of thought or the challenges researchers may face when working with a religious community. As very little study has been done within this area, my thesis aims to elucidate some of the questions and challenges that occur within the field of bioethics, with the aim to make recommendations for future practice. Islam forms the second largest religious affiliation across the world and very little study has been done to explore its role in the context of research ethics. Currently there are 1.57 billion Muslims across the globe accounting for just under a quarter of the world’s population. The majority of Muslims live in the developing world and therefore can form a significant cohort for research as well as those who carry out the research. Islam has generally encouraged the use of science, medicine and biotechnology as solutions to human suffering and as such it would be useful to assess its influence on local (regional and national) ethical decision-making. Another important consideration that needs to be made here is that, within the Muslim tradition, although the formulation of religio-ethical opinions has usually been perceived as the exclusive charge of religious scholars, more recently physicians and scientists themselves have taken on this task. Studies have shown that Muslim medical and scientific experts are Ryan MA (2004) Beyond a Western Bioethics? Theol Stu 65(1):158-77 Chattopadhyay S and De Veries R (2012) Respect for Cultural Diversity in Bioethics is an Ethical Imperative Med Health Care and Philos (online DOI 10.1007/s211019-012-9433-5) 7 Durante C (2009) Bioethics in a pluralistic society: bioethical methodology in lieu of moral diversity Med Health Care and Phil 12:35-47 5 6
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keen to adopt the language of Islamic theology, and to draft Islamic legal rulings in an attempt to answer emerging religio-ethical challenges. In my thesis I will assess the nature of this emerging multifaceted role of the Muslim physician/scientist/researcher and the impact it may have on the global health research ethics discourse. Such developments present an exciting opportunity to explore how ethical decision making occurs in Muslim contexts and what the evolving role is of the Muslim researcher/scientist in assisting the research prioritisation process at the state level. The religious and political authorities traditionally made such prioritisation decisions, but contextual experts are being called to take part in such national and 9 international deliberations. What will such shifts mean in the traditional understanding of authority amongst Muslims and within Islam? And what will this mean for the existing international standards? Will they become more or less relevant as researchers themselves have a greater role in determining what research is done and how it is conducted, in these contexts? And finally is it justified for religious leaders to influence ethical standards? I aim to address these and other related questions within my thesis. Mehrunisha Suleman DPhil Candidate The Ethox Centre University of Oxford
[email protected] VISITING SCHOLARSHIP EXCHANGE My research stay at the Ethox Centre University of Oxford Just coming back from my research stay at the Ethox Centre at the University of Oxford, which was supported by the EACME visiting scholarship, I would like to share my experiences at this unique and knowledge throbbing place. My motivation for conducting this research stay rose when I met Angeliki Kerasidou, who is working on austerity measures and its ethical implications in the health care setting – the same topic I am working on within my PhD project. Thus, the idea of spending some weeks in Oxford was born: I applied for the Ghaly, Mohammed. "Collective religio‐ scientific discussions on Islam and hiv/aids: I. Biomedical scientists." Zygon® 48.3 (2013): 671-708. 9 Ramadan, Tariq Radical Reform: Islamic Ethics and Liberation, OUP, Oxford, 2009 8
EACME visiting scholarship and soon made travel arrangements. Angeliki, Susan Barrington and Ruth Horn helped me to organize my stay (thank you for that!) and provided me with all necessary information about the Ethox Centre and Oxford`s nice places, making my stay most pleasant. Also the other members of the institute immediately made me feel ‘at home’, when welcoming me with a coffee and chat break as soon as I came from the airport. I was offered a working desk at the institute, where I spent 4-5 days weekly, working on improving the theoretical underpinning of my research and advancing the empirical part. During the latter, I am conducting qualitative interviews with Members of the European Parliament (MEPs) with the aim to investigate which values and norms guide EU politicians in decisionmaking and how their ethical considerations – if any – form their judgments about the current health crisis and austerity. Since I have a background in public health, I am interested in bringing ethics to the macrolevel-oriented public policy sphere. The rationale for interviewing MEPs is that there has been a fundamental shift in power towards the European level brought about by the financial crisis with MEPs representing a mix of ideologies, nationaleconomic backgrounds and last but not least the citizens of the European Union. The goal of the study is thus to frame and evaluate health policy responses to the economic crisis from a policy-maker’s perspective and to gather policy-makers’ opinions about which ethical values (or criteria) are desirable for practical policy-making with regard to health. In general, the study aims to contribute to strengthen the importance of integrating ethics into decision-making processes and policy-making. Several discussions with the members of the institute, bilaterally as well as during a presentation I gave, helped me to organize my thoughts and frame the interview study more profoundly, e.g. as to apply my theoretical perspective of the Capability Approach more to the interviews. Angeliki and Patricia, a sociologist, who are both involved in a research project on austerity measures and health care provision in Greece, also brainstormed with me about possible sampling strategies for realising further interviews. I especially enjoyed the calm and effective atmosphere in the institute, which was interrupted by vivid lunch breaks with the colleagues, having excitatory talks about interests besides ethics / the philosophical ivory tower such as gardening, sports or cooking. I also had the opportunity to shadow teaching for medical students: it was great to see such highly motivated and ethics-interested students! During the weekends, I explored Oxford with its amazing architecture and unique learning atmosphere. Spending the mornings in the Bodleian library – where you feel as in a previous century with its ancient books and historic walls –, the afternoons left plenty
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EACME Newsletter
opportunity to explore the distinct college grounds, each having its own unique peculiarities, such as a lake or a deer park. Strolling around the beautifully (English-)gardened, spring-awakening parks and cloisters was just enchanting and I caught me thinking how great it would have been to spend my whole studies in such a picturesque surrounding. I ended my stay in Oxford with a pub visit with some of the colleagues, cheering to such an enjoyable and inspiring time with great people. I would like to thank the colleagues at the Ethox Centre for their hospitality and support and the EACME for the financial support. Caroline Brall Department of International University, The Netherlands
Health,
Maastricht
[email protected] UPCOMING SUMMER 2015: SPECIAL ISSUE OF THE EACME NEWSLETTER ON THE TOPIC CLINICAL ETHICS – DEBATES, TRENDS AND CHALLENGES CALL FOR SHORT PAPERS st
Deadline: 21 of July 2015 The second EACME newsletter in 2015 aims to give special attention to the issue of "Clinical Ethics". This is, on the one hand, due to this year's EACME conference in Sardinia which is dedicated to exactly this topic (Sept 18-20, see: http://www.eacme2015.org). On the other hand, the discipline and practice of clinical ethics has become more and more professionalized and with this development questions about implementation, quality assurance, and evaluation ensue. Are you interested in contributing a short text (1500-2000 words) to this special issue? In particular, we would like to encourage contributions/comments on the following topics: - Which current debates and trends in clinical ethics do you observe in your country? - Do you perceive any “blank areas” or neglected topics in clinical ethics that need to be stressed or discussed? - What advantages and disadvantages does professionalization (and evaluation) of clinical ethics entail and what suggestions do you have to advance the clinical field?
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Please do not hesitate to contact us. We are pleased to discuss your ideas also before submission. Best regards, Ralf J. Jox;
[email protected] Guest Editor of the Special Issue) and Rouven Porz;
[email protected] Chief Editor EACME Newsletter EUROPEAN CLINICAL ETHICS NETWORK (ECEN) nd
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OPEN FORUM DAY
Information and preliminary program Wednesday 16th of September 2015 Cagliari, Sardinia, Italy
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We hereby invite you to attend and contribute to the second ECEN Open Forum Day! The European Clinical Ethics Network (ECEN) was founded in 2005 by Veronique Fournier (Paris) and Bert Molewijk (VUmc Amsterdam) in order to share both clinical and research experiences regarding clinical ethics support in general (such as: clinical ethics consultation and moral case deliberation). The increasing prominence of these activities within the domain of clinical ethics necessitates transparency and improvements with respect to theory, methodology, quality and results of research of clinical ethics support services. The ECEN is a small working group consisting of approximately 27 members from 12 European countries. The ECEN meets twice a year. The Open Forum Day is organized prior to the EACME conference (see http://www.eacme2015.org/en-us/). This Open Forum Day is organized by and for people with experience in the practice, research and training of clinical ethics support. Please share your clinical experiences, research designs & plans, results and questions with your professional peers within the field of Clinical Ethics Support Services (CESS) and submit an abstract for a presentation, case-report, research proposal etc. With the ECEN Open Forum Day the ECEN hopes: To exchange and share ideas and experiences with colleagues who have experience in CESS or who are just about to implement or have already implemented CESS structures; To inform colleagues about the ECEN and its work regarding clinical ethics support and services (CESS); To make CESS practices better known outside the ECEN network. We hope to see you in Sardinia !
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Bert Molewijk, Pierre Boitte, Cristina Gavrilovici, Jan Schildmann & Anne Slowther The ECEN Steering Group
[email protected] LIVRE BIOETHIQUE GLOBALE: DANS QUEL BUT?
Jean-Philippe Cobbaut Centre d'Éthique Médicale 56, rue du Port F-59046 LILLE Cedex FRANCE
[email protected] Angelique Heijnen
C’est avec grand plaisir que nous vous informons que le livre « Bioéthique globale : Dans quel but ? 20e anniversaire du Programme de bioéthique de l’UNESCO » vient d’être publié. Il est à la vente dans la librairie de l’UNESCO pour 22 euros. Nous vous enverrons deux exemplaires par la poste à votre adresse personnelle. Le livre existe aussi en ligne et en libre accès à l’adresse suivante : http://unesdoc.unesco.org/images/0023/002313/23139 7F.pdf Prière de noter que le livre existe en français, en anglais et en espagnol.
Maastricht University Health, Ethics and Society P.O. Box 616 6200 MD MAASTRICHT THE NETHERLANDS
[email protected] Jeanette Hewitt
EDITORIAL BOARD
Department of Philosophy, History & Law School of Health Science SWANSEA South Wales SA2 8PP UNITED KINGDOM
Rouven Porz, Editor
[email protected]
Ethics Unit Bern University Hospital ‘’Inselspital’’ CH – 3010 BERN SWITZERLAND
Ralf Jox
[email protected]
Institute of Ethics, History and Theory of Medicine Lessingstr. 2 D-80336 Munich GERMANY
Alessandra Bernardi
[email protected]
Fondazione Lanza Via Dante, 55 35139 PADOVA ITALY
Elleke Landeweer
[email protected]
Medical Humanities, VUmc P.O. Box 7057 1007 MB AMSTERDAM THE NETHERLANDS
Caroline Brall
[email protected]
Department of International Health School for Public Health and Primary Care (CAPHRI) Maastricht University P.O. Box 616 6200 MD Maastricht THE NETHERLANDS
Jean Martin La Ruelle 6 CH-1026 ECHANDENS SWITZERLAND
[email protected]
[email protected]
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