Examining the determinants of family consent to organ donation is important to provide comprehensive information to policymakers and health planners, enabling them to enhance organ donation rates. Therefore, this study aimed to identify these determinants among families of brain-dead patients in Iran. This qualitative study was conducted using the conventional content analysis method among individuals who had experience with organ donation within their families, as well as key informants who were in contact with these families. Twenty-eight participants were identified through purposive and snowball sampling, and data were collected through semi-structured interviews until saturation was reached. For data analysis, the approach of Graneheim and Lundman was used, and Guba and Lincoln’s criteria were also adhered to for the rigor of the research. From the coding of the interviews, 4 categories, 13 subcategories, and 275 initial codes were obtained. These include cognitive and emotional maturity (awareness saturation, previous experiences of the suffering of patients in need of organ transplants, decision validation, altruistic sense, and respecting the patient’s wishes and desires), spiritual maturity (spiritual orientation and desacralization of the physical body), social maturity (social responsibility, social incentives, family consensus in decision-making, and social class), and effective communication between the patient’s family and the healthcare system (professional behavior of healthcare staff and trust in the organ donation process). The findings of this study showed that family consent to organ donation is influenced by various factors; therefore, increasing the rate of organ donation requires intervention at individual, spiritual, social, and healthcare levels.
In 2020, the German Federal Constitutional Court declared the criminal prohibition of assisted suicide as unconstitutional, thereby abolishing previous restrictions. Since then, requests and cases have increased steadily. To ensure transparency and traceability of national assisted suicide practices, systematic and reliable data are required. However, no comprehensive registry currently exists to document and analyze assisted suicide cases in Germany, resulting in a significant data gap for epidemiology, health reporting, and healthcare development. The development, implementation, and evaluation of such a registry is essential to better understand current practices, identify challenges, and improve prevention and support strategies. Iterative, mixed-methods, design-based implementation study with five work packages: 1. conceptual, ethical, and legal development of registry content through a scoping review and a group Delphi process; 2. establishment of the legal, ethical, and technical framework of the registry using an iterative, design-based approach; 3. evaluating and refining the registry through a formative mixed-methods design combining quantitative user surveys and web analytics with qualitative think-aloud and retrospective interviews; 4. exploring barriers to the adoption, continuation, and use of the registry through quantitative surveys and in-depth qualitative interviews with potential users; 5. strategic development, dissemination, and integration of the registry within existing healthcare and suicide prevention structures. The study involves expert consultations and stakeholder engagement and is conducted by a multidisciplinary consortium of palliative care and suicide prevention experts in Germany. The establishment of a permanent registry for assisted suicide could substantially improve transparency and empirical knowledge in a highly sensitive and ethically complex field. Systematic documentation may help identify needs, vulnerabilities, and structural challenges faced by individuals considering assisted suicide. In the long term, the findings derived from the registry are expected to contribute to the development of targeted support services in Germany. The study results may also provide valuable insights for other countries facing comparable ethical, legal, and regulatory challenges. Registered on 25 October 2025 in the BQS (Institute for Quality and Patient Safety) registry, No. 2020467 and on 29 April 2026 in the German Clinical Trials Register (DRKS), No. DRKS00040174.
Clinical ethics support (CES) is increasingly recognised as essential in healthcare, yet its evaluation remains challenging due to the complexity of CES practices and the latent, psychosocial nature of relevant outcomes. The European Moral Case Deliberation Outcomes Instruments (Euro-MCD original and 2.0) represents important steps in operationalising CES outcomes. However, there remains a need for a further theoretically grounded and psychometrically robust instrument. This study aimed to revise the Euro-MCD 2.0 and to develop and psychometrically test a new measurement instrument for CES. A sequential mixed-methods instrument redevelopment and validation design was used, guided by an abductive, theory-driven approach. Content validity processes involved conceptual framing, item revision, item development, and cognitive evaluation. Construct validity processes involved psychometric testing using survey data, incorporating principal component analysis and complementary item-level assessments. The revision of Euro-MCD 2.0 resulted in the Clinical Ethics Support Measurement Instrument (CES-MI), assessing ethical competence and ethical climate. Ethical competence comprises holding moral judgement, being responsive, and acting with moral courage (9 items, using a 5-point scale assessing perceived difficulty). Ethical climate comprises permissive dialogue, supportive relationships, and managing ethical concerns together (7 items, using a 4-point scale assessing perceived extent). Measurement properties were generally strong: targeting was appropriate, response categories functioned as intended, and only minor issues, such as limited local dependencies were observed. Reliability indices were high, unidimensionality was supported across the constructs, and no differential item functioning was detected by sex or intervention groups. The CES-MI is a coherent, theoretically grounded, and psychometrically robust instrument for measurement, suitable for both clinical practice and research. The strong validity likely reflects the extensive qualitative and psychometric work underpinning the CES-MI, together with a user-friendly response format that supports reflective and authentic self-assessment. Next steps include examining the instrument’s sensitivity to change over time for example by exploring whether open-ended follow-up questions could deepen understanding of concrete changes, as well as, assessing applicability across diverse healthcare settings.
Increasing advances in medical technology and the complexity of healthcare environments have made ethical issues in clinical internship more diverse and challenging. Novice nursing student interns who have completed their training and are transitioning towards professional registration nurse need to gain experience and form heuristic patterns that inform clinical decision-making while facing ethical challenges and dilemmas. However, evidence regarding the factors influencing nursing student interns’ ethical decision-making competence in clinical internship remains limited. A descriptive qualitative study was conducted with 23 participants recruited from three general hospitals in eastern China. Interviews were conducted between March and May 2025. Data were analyzed using thematic analysis, and the identified themes were mapped onto the Ring Theory of Personhood for interpretation. Six themes were identified: Moral values, Personality traits, Emotional cognition, Decision-making dependence, Cognitive and cultural barriers, and Climate of organizational caring. Our findings suggest that the ethical decision-making competence of nursing student interns is influenced by the combined effects of multiple factors. The findings highlight the need for stronger collaboration between nursing schools and clinical internship institutions. Such collaboration may help develop realistic ethical scenarios and targeted interventions to support ethical reflection and effective decision-making in clinical internship.
The rapid integration of generative artificial intelligence into health sciences research has prompted major advisory bodies to establish ethical guidelines governing AI use in scholarly publishing. However, practical implementation at the journal level remains inconsistent, with considerable incongruence observed between individual journal policies and overarching publisher mandates. This study conducts a comprehensive analysis of AI guidance policies in international health-related journals to evaluate the current regulatory landscape and provide a robust framework for future guidance. A mixed-methods approach was employed, integrating qualitative subject analysis, inferential statistics, and Multiple Correspondence Analysis (MCA). Through qualitative subject analysis, an attribute-based regulatory schema spanning the research lifecycle was developed. Policy texts were independently evaluated using a dual-coder protocol and transformed into a standardized categorical dataset. Bivariate inferential statistics and MCA were subsequently applied to evaluate structural interrelationships between these regulatory stances and institutional characteristics. Descriptive analysis revealed profound regulatory disparities. While a robust consensus exists on prohibiting AI authorship (72.6
Assisted dying is frequently justified through appeals to individual autonomy and self-determination. However, contemporary end-of-life decision-making occurs within broader social, economic, and institutional conditions that may significantly shape experiences of suffering and the range of available choices. This paper presents an interdisciplinary normative analysis situated at the intersection of bioethics and public health ethics, examining how structural inequalities may influence assisted-dying decision-making. Drawing on scholarship in bioethics, relational autonomy, structural vulnerability, public health ethics, and global health equity, the paper develops the concept of structurally conditioned autonomy. The concept describes forms of autonomy shaped not only by individual preferences and interpersonal relationships but also by unequal access to healthcare, socioeconomic vulnerability, social isolation, disability-related inequities, and disparities in palliative care and long-term care systems. Unlike related frameworks, structurally conditioned autonomy focuses specifically on how structural conditions shape the substantive circumstances under which end-of-life choices are formed, interpreted, and ethically evaluated. The analysis examines ethical debates surrounding assisted dying in jurisdictions including Canada, the Netherlands, Belgium, and Switzerland, while also considering inequalities affecting vulnerable populations and under-resourced healthcare systems. Rather than arguing that assisted-dying requests are reducible to failures of care, the paper contends that structural inequities may influence, constrain, or intensify end-of-life preferences in ethically significant ways. It further proposes an illustrative framework for incorporating structural determinants into ethical evaluation of assisted-dying requests without undermining patient agency or introducing paternalistic restrictions. The paper concludes that ethically robust assisted-dying frameworks require not only procedural safeguards related to decisional capacity, voluntariness, and informed consent, but also greater attention to healthcare equity, structural vulnerability, and the social conditions under which autonomous choices are exercised. Structurally conditioned autonomy is presented as a complementary framework capable of integrating individual self-determination with broader commitments to healthcare justice and social responsibility.
Protecting life and restoring health have been at the core of the conception of medical care since antiquity, for health professionals and the public alike. Assisted dying represents a practice that appears to challenge this traditional conception. In jurisdictions where assisted dying is condoned, the question remains as to whether the practice should be medicalized or deferred to non-medical actors. Irrespective of the divisive controversy surrounding assisted dying and its medicalization per se, the practice gives rise to high-stakes ethical, legal and organizational challenges when intersecting with organ transplantation, tissue banking, and Structural Brain Preservation or cryonics. In this narrative account, we describe the contextual framework and outline our experience and operational scope for addressing them at a university hospital in Germany. Based on this description we propose a structured pathway for increasing donation and preservation options for terminal patients while retaining ethical integrity and professional accountability.
The Netherlands has an established euthanasia practice. The increase in euthanasia cases for psychiatric suffering over the past 10 years is subject to ongoing public and political debate. During the fieldwork of the research project “ritualisation of euthanasia”, remarkable differences between euthanasia cases for somatic suffering and psychiatric suffering were observed, which sparked a closer investigation. This article analyses how euthanasia is ritualised differently in cases of those two groups and tentatively explained using theories from ritual studies, sociology and anthropology. Between November 2023 and November 2025, 52 euthanasia cases were explored using a multi-sited focused ethnography approach. Through observations and prospective and retrospective interviews, data was collected and analysed using constant comparative methods. This paper reveals that psychiatric cases, often younger people and more socially stigmatised, engage in more expressive, symbolic, and creative rituals, such as curated funerals, memory boxes, and tattoos. In contrast, somatic cases tend to focus on relational closure through familiar and everyday rituals. The paper highlights how ritual behaviour reflects age, stigma, and social positioning, with rituals in psychiatric cases serving the creation of a post-self, recognition, agency, and active narrative shaping at the end of life. The findings suggest that ritualisation is not only personal but also deeply socio-cultural and moral, offering insight into how different forms of suffering shape the meaning of a “good death”.
Opioid diversion—the unauthorized redirection of prescription opioids—is a growing global concern with significant public health implications. While diversion can occur at many points in the supply chain, instances involving healthcare professionals (HCPs) are particularly complex, as they often occur within clinical settings and most often involve self-medication, substance use disorders among healthcare professionals, or peer dynamics. These cases raise not only legal and professional concerns but also profound ethical dilemmas. To date, the ethical perspectives of HCPs in relation to opioid diversion have been underexplored. This multinational qualitative study aims to investigate how HCPs experience and navigate ethical conflicts related to opioid diversion in clinical contexts. The study focuses on the lived experiences and moral reasoning of HCPs who encounter diversion, either among colleagues or in relation to their own practice. It seeks to explore and identify barriers to seeking help and accessing harm reduction, and to understand how these challenges vary across different healthcare systems. Semi-structured interviews will be conducted with HCPs working in clinical settings where opioids are used. A fictional scenario involving suspected diversion among peers will be used to encourage reflective discussion. This approach is intended to minimize social desirability bias and potential legal concerns in comparison to assessing experienced diversion. The interview guide is structured around the five steps of ethical analysis as outlined by Marckmann, supporting a theory-informed exploration of individual and systemic dilemmas. Data will be analyzed using reflexive thematic analysis (RTA), allowing for nuanced insights into both explicit reasoning and latent moral constructs. Recruitment of HCPs takes place in hospital departments characterized by frequent opioid use. The study protocol is intended for international implementation to support cross-national comparative analysis. This study will generate a deeper understanding of the ethical tensions HCPs face in the context of opioid diversion. By identifying structural and cultural drivers behind moral distress, the findings may help address stigma and inform the development of ethically guided harm reduction strategies as well as supportive structures for HCPs. The cross-national comparative perspective aims to contribute to an international framework for reducing opioid-related harm in healthcare.
Medical assistance in dying (MAiD) is permitted for minors under specific conditions in the Netherlands, Belgium, and Colombia. In Canada, MAiD became available to eligible adults (18 years and older) under specific conditions as of 2016. Since then, the Canadian Parliament has examined and ultimately recommended extending MAiD eligibility to mature minors whose natural death is reasonably foreseeable; however, this has not been enacted into legislation, and no implementation timeline has been established. Pediatric palliative care (PPC) teams are expected to play a key role in such complex cases, yet their perspectives remain underexplored. This study explored the perspectives of a specialized PPC team and its collaborators on MAiD for minors, with particular attention to their anticipated ethical challenges. We conducted a qualitative study based on semi-structured interviews with members and collaborators of the PPC team at a tertiary pediatric hospital in Montreal, Quebec, Canada. Participants included professionals who have worked within the team since its creation in 1999, as well as institutional and external collaborators. Data were collected between April 2022 and June 2023 and analyzed through descriptive-interpretative thematic analysis. Twenty-four participants were included, over half (n = 15;62,5
Compensation for research participants in clinical trials is a critical yet ethically complex issue, especially in low- and middle-income countries (LMICs) like Ghana. This study explores diverse stakeholder perspectives on appropriate compensation levels and types in clinical trials conducted within Ghana. Using an exploratory phenomenological qualitative design, we gathered views and perspectives through 6 focus group discussions with clinical trial participants and 18 in-depth interviews with clinical trial experts, including principal investigators, ethics experts, clinical trial managers, and community opinion leaders. Data collection was carried out using a focus group discussion (FGD) guide and an in-depth interview (IDI) guide. Data was thematically analysed. This study revealed a strong preference for compensation that acknowledges the time, inconvenience, and physical discomfort associated with study participation, with recommendations for both monetary and non-monetary forms. Participants emphasised the importance of compensation frameworks that consider study demands and participant vulnerabilities, while avoiding undue inducement. There was also significant support for developing national guidelines on research compensation to ensure consistency, fairness, and respect for participants’ contributions. This study adds to the existing literature on research participant compensation in low- and middle-income countries and gives in-depth viewpoints to help policymakers and ethics review boards in Ghana and elsewhere create ethical and equitable compensation frameworks.
In-vitro fertilization (IVF) presents complex ethical challenges, particularly in settings like Ghana, where cultural diversity and limited regulation exist. This study explored the lived experiences of healthcare professionals regarding the strategies they use to address the social, ethical and legal issues that arise in the provision of IVF services at the University of Ghana Medical Centre (UGMC). A qualitative phenomenological study was conducted. Ten (10) healthcare providers were purposively selected from UGMC’s Assisted Reproductive Technology (ART) unit using a maximum variation sampling strategy. In-depth interviews were conducted using an open-ended interview guide. Interviews lasted between 30 and 60 min. All interviews were audio-recorded, transcribed verbatim, and analysed thematically. The study revealed that healthcare providers primarily addressed ethical challenges in IVF service delivery through comprehensive counselling before, during, and after treatment. They also relied on collaborative decision-making, often involving multidisciplinary teams, to navigate complex dilemmas. Further, they adapted international guidelines to develop internal policies to guide their practice. Additionally, continuous professional development including ethics training, mentorship, and reflective practices was reported as essential for enhancing ethical competence and informed decision-making among IVF service providers. IVF service providers at UGMC employ multi-layered strategies to address the social, legal and ethical challenges that arise in the provision of IVF services. However, these efforts remain largely context-specific and might not be enforceable across facilities. To strengthen ethical practice in the delivery of IVF services beyond this study context, mandatory ethics education and collaborative policy and guidelines development are essential.
How can sensitive health information be governed when consent cannot provide the basis for its legitimate use? This question is acute for healthcare records created in contexts of historical injustice — such as forced sterilization and the segregation of stigmatized groups. Such records are indispensable for accountability and redress yet capable of inflicting renewed harm, while the people whose lives they document may be deceased, unreachable, or never have had a meaningful opportunity to consent. In Japan, the Supreme Court’s July 2024 ruling that the former Eugenic Protection Law was unconstitutional has sharpened these questions; however, public views on the conditions of legitimate preservation and use remain largely undocumented. We conducted a cross-sectional online panel survey in Japan in November 2024 (n = 1,143), using quotas for sex, age group, and prefecture among adults aged 20–69. Respondents reported their attitudes toward preservation and preferred custodians; the acceptability of six purposes of research use under three personal-proximity conditions (no personal information; self or living family members; ancestors); and their perceptions of benefits and risks. Variation by proximity and purpose constituted the primary comparison; demographic comparisons were exploratory and were summarized using Cramér’s V. Most respondents (86.8
Loneliness has emerged as a clinically significant health concern, prompting growing interest in systematic screening in care settings. However, the ethical justification for such screening remains uncertain when intervention capacity is limited or inequitably distributed. Drawing on Wilson and Jungner’s classical screening criteria and contemporary social risk screening literature, we argue that screening without response capacity violates core ethical principles including autonomy, beneficence, nonmaleficence, and justice. Potential ethical tensions are not hypothetical but are documented across implementation studies and qualitative research on social needs screening. Ethically defensible loneliness screening requires alignment between identification and response capacity, including adequate referral pathways, clinician training, community partnerships, and transparent communication about the limits of available assistance.
Healthcare ethics education is essential for supporting trainees and health professionals to build ethical reasoning skills necessary to resolve complex ethical issues, support equitable health outcomes, and promote just healthcare systems. Traditional ethical decision-making frameworks, grounded in principles-based approaches, may be insufficient in supporting a process of resolving clinical and public health ethical dilemmas that is attentive to both sociopolitical context and inclusion of parties most impacted by ethical issues. While many approaches to ethics education show promise, healthcare system resource constraints result in challenges in delivering ethics education. The aim of this project was to develop an equity-focused process for resolving ethical dilemmas in healthcare and to produce evidence-informed public health ethics education resources in British Columbia, Canada. A consultation process was undertaken to develop and refine an ethical resolution process to support healthcare ethics practice. An empirical qualitative study was conducted with members of equity-denied communities to inform educational resource development. An online course was collaboratively developed, based on the ethical resolution process and empirical data, that used universal design principles, scaffolded learning activities, and original artwork. The ethical resolution process supports iterative and flexible analysis of clinical and public health ethics issues, consisting of five components: ethical dilemma, impacted parties, information, options, resolution. Public health ethics values and principles prioritized by participants included accessibility, transparency, and wholistic wellbeing. Other points of emphasis were acknowledgement of upstream causes, focus on current ethical issues, application of intersectionality, and incorporation of Indigenous Ways of Knowing. Participants made several recommendations to support development of education resources. The end products included a public health ethics guide and an accompanying openly accessible asynchronous online course in which fictional scenarios based on findings from the qualitative study were analyzed through the ethical resolution process. This project incorporated theoretical understandings of ethics and instructional design with qualitative data and the realities of providing ethics education in resource-constrained environments. A collaborative, interdisciplinary approach brought together those most impacted by public health ethics dilemmas, public health professionals, ethicists, and instructional designers to develop evidence-informed, context-specific, openly accessible online resources to support healthcare ethics education.
Patient registry data are increasingly used to generate real-world evidence (RWE) for medicines decision-making. This study aimed to identify stakeholders’ views on registries’ ethics practices and to explore potential differences across stakeholder groups. European regulators, Health Technology Assessors (HTA), payers, patients, academia, industry, and healthcare professionals (HCPs) were invited to complete an online survey (Dec 2024 – Jan 2025). It included questions regarding the importance of information on six ethics aspects of registries (5-point Likert scales), acceptability of industry funding for registries (visual analogue scale: 0-100
Obtaining high-quality informed consent for research is an ethical imperative and crucial for protecting participants’ rights. For vulnerable populations, including pregnant women, this concern becomes even more paramount. We evaluated the quality of informed consent for research participation obtained at different times during pregnancy in Uganda. This study was a nested prospective observational birth cohort study within the Placentas, Antibodies, and Child Outcomes (PACO) birth cohort. A total of 216 pregnant women were enrolled either during the second trimester (gestational weeks 16–24) or during labor at Mbarara Regional Referral Hospital and Kabwohe Clinical Research Centre in Uganda. The primary outcomes were objective (Quality of Informed Consent [QuIC]-A) and subjective (QuIC-B) informed consent scores. At the time of consent, we also assessed anxiety (Spielberger State-Trait Anxiety Inventory), pain (Wong-Baker Faces scale), and trust in medical researchers (Medical Researcher Trust scale, see Appendices for tools). We performed multivariable linear regression analyses to examine the association between consent timing and objective and subjective quality of informed consent for research participation. Of 216 participants, 134 (62
The integration of data-driven continuous monitoring into chronic disease management is often presented as a solution for clinical efficiency. However, this technological shift may substantially reshape care relations, power, and intimacy. Prevailing research, focused on technical validation, fails to capture how such systems operate as social forces. A critical, theory-informed examination of these lived transformations is needed. This study goes beyond documenting ethical dilemmas by critically investigating how data-driven surveillance restructures nurse-patient dynamics. We aim to uncover the mechanisms through which data-driven surveillance disciplines both caregivers and recipients, and to identify where and how the irreducible elements of humanistic care persist and resist. A critical qualitative design was employed, guided by Foucault’s concept of governmentality as a sensitising lens. Semi-structured interviews were conducted with 12 registered nurses and 15 patients with hypertension or type 2 diabetes in one Chinese tertiary hospital that had, for six months, implemented real-time automated physiological monitoring. Data were analysed using reflexive thematic analysis with a hybrid (deductive-inductive) approach. Our analysis reveals three core mechanisms: (1) systematic arbitration (nurses as constant negotiators between automated alerts and situated clinical judgment); (2) datafied self-surveillance, patients internalise the data-driven gaze, policing their own behaviour; (3) a shared convergence around the human boundary, both nurses and patients actively defend empathy, contextual interpretation, and emotional recognition as domains irreducible to data. This boundary is not a passive remnant but an active, shared accomplishment. Digital surveillance in chronic care does not act as a neutral adjunct. Instead, it operates as a disciplinary technology that asymmetrically disciplines nurses and patients. However, the identified human boundary represents a critical site of resistance and re-humanisation. The future of humane digital health depends on deliberately designing socio-technical systems that strengthen, rather than erode, the relational and interpretive core of clinical practice. What is already known: Research on digital monitoring in chronic care largely focuses on technical validation or abstract ethical principles, with limited critical examination of how data-driven systems reshape care relationships. The importance of human oversight is acknowledged, but few studies empirically investigate how power and intimacy are reconfigured through institutional surveillance. Existing qualitative work often examines nurses or patients separately, lacking a comparative, relational analysis. What this paper adds: A novel empirical application of Foucault’s governmentality lens to rule‑based digital surveillance, reconceptualising it as a disciplinary force that co‑produces asymmetric power dynamics. Identification of three concrete mechanisms, systematic arbitration, datafied self‑surveillance, and a shared convergence around the human boundary — that reshape clinical practice. Demonstration that both nurses and patients actively defend empathy, context, and emotional meaning as irreducible domains, offering a grounded model for “re‑humanisation by design.” A prescriptive shift from ethics checklists to design politics, arguing that future digital health must amplify rather than erode the humanistic core of care.
Donation-based prosocial interventions for health, such as monetary donations for diagnostic tests, aim to encourage voluntary actions that benefit others while fostering public participation to promote health. These interventions are increasingly used in public health, but the associated ethical issues have not been comprehensively described. We conducted a scoping review using the Arksey and O’Malley framework to synthesize bioethics and public health literature on the ethical issues encountered with donation-based prosocial interventions for health. We searched PubMed, PsycINFO, SCOPUS, NIH Reporter, and ClinicalTrials.gov for empirical qualitative, quantitative, and mixed-methods studies. Two independent reviewers extracted data and coded data from each study according to a codebook. Categories of similar codes were analyzed to name cross-cutting issues across the included studies. The search identified 2,585 citations; 34 publications were included in our review. The publications described studies involving donations of blood, organs, biospecimens, data, and money. Most studies (32/34) were conducted in high-income countries and used observational designs (31/34). We identified three broad categories of benefits associated with donation-based interventions: health (physical and psychological), social (generosity, kindness, and community cohesion), and economic (improving welfare). We also identified several problematic ethical concerns at different levels (donor, recipient, provider, and system), such as undue pressure, privacy concerns, and inaccurate information. To mitigate these concerns, the literature discussed strengthening informed consent, ensuring confidentiality, building public trust, and ensuring appropriate stewardship of donations. We found that most studies did not empirically measure adverse consequences associated with donation-based prosocial interventions. Donation-based prosocial interventions offer several health, social, and economic benefits. However, it is essential to consider the potential ethical concerns that may arise in their design and dissemination. Further research is needed to evaluate the success of mitigation strategies for addressing these concerns and thereby enhance the overall benefits of prosocial interventions.
China’s recent anti-corruption efforts in the healthcare sector have focused on senior hospital administrators and on procurement processes for pharmaceuticals and medical supplies, with comparatively little attention paid to frontline clinical physicians. Yet the everyday practices of frontline physicians—including excessive testing, overtreatment, and overprescription—constitute a major source of cost inflation and have contributed to a substantial erosion of patient trust. Drawing on principal–agent theory and on responsive regulation theory, this study examines whether introducing a statutory fiduciary duty between physicians and patients, enforced through emerging medical audit mechanisms, is associated with reductions in physicians’ self-reported willingness to engage in inappropriate practices. We conducted a sequential exploratory mixed-methods study comprising (i) a qualitative phase of eight semi-structured interviews with practicing clinical physicians in Beijing and Shenyang (March–July 2023), analyzed using reflexive thematic analysis, and (ii) a between-subjects scenario-based questionnaire experiment with 120 practicing physicians recruited from hospitals in Jinan, Qingdao, Shenyang, and Beijing. Participants in the quantitative phase were systematically allocated to an experimental condition (a proposed statutory fiduciary duty enforced through medical audits and graduated sanctions) or a control condition (the existing ethics-based framework). The primary outcome was self-reported willingness to reduce inappropriate medical practices, measured on a five-point Likert scale. Statistical analyses comprised an independent-samples t test, a Mann–Whitney U test, multiple linear regression with HC3 heteroscedasticity-robust standard errors, and a three-step hierarchical moderation analysis with mean-centered predictors and simple-slope decomposition. Participants in the experimental condition reported a significantly higher willingness to reduce inappropriate medical practices than those in the control condition (M = 4.07, SD = 0.73 vs. M = 1.93, SD = 0.69; t(118) = 16.46, p < 0.001; mean difference = 2.13, 95
