The Diagnosis-Related Group (DRG) system has had a significant impact on the healthcare community, particularly in areas of financial management and care quality monitoring. It is widely implemented as a hospital reimbursement model aimed at controlling costs while improving efficiency. However, the system has given rise to several ethical concerns, including the risks of under-treatment, upcoding, inequitable access to care and moral distress and burnout among physicians. This article explores these ethical dilemmas in depth and discusses various mitigation strategies, such as DRG modifications, ethical safeguards and hybrid reimbursement models. Special attention is given to the Malaysian healthcare context, with recommendations tailored to address the ethical challenges unique to its dual healthcare system. The goal is to ensure that cost-effectiveness is achieved without compromising the quality and equity of patient care.
COVID-19 intensified ethical tensions between clinicians' duty to care and self-protection amid PPE shortages. We explored frontline healthcare professionals' perspectives in Maputo, Mozambique. Semi-structured interviews with healthcare professionals at four hospitals (April-June 2022) were recorded in Portuguese, transcribed, and thematically analyzed. Fixed-response items were captured in REDCap and summarized descriptively. Fifty-three respondents described varied perspectives on duty. Nearly half affirmed unconditional obligations grounded in professional ethics. Many framed duty as contingent on available PPE and institutional support; 8% were unsure. Themes included irregular PPE distribution, unequal training, and reliance on informal information, shaping perceived risk, preparedness, and responsibility. Quantitative summaries echoed these patterns: only 58% reported receiving training, and as PPE re-supply declined many felt exposed. Sustaining duty to care in resource-constrained settings during an outbreak requires reliable PPE provision, equitable and timely training, and trustworthy communication systems to protect workers and strengthen health-system resilience. Sustaining duty to care in resource-constrained settings during an outbreak requires reliable PPE provision, equitable and timely training, and trustworthy communication systems to protect workers and strengthen health-system resilience.
The sharing of health data advances knowledge, fosters innovation, and promotes evidence-based decision-making. This practice involves using existing data for collaborative research or for purposes other than those for which it was originally collected. In South Africa, the secondary use of health data has significant potential to inform policy decisions, advance scientific research, and address societal challenges. However, the use of health data for secondary purposes in the public health sector is faced with several challenges and legal complexities. This article examines these challenges and legal dimensions, with particular attention to the regulatory framework governing health data in South Africa, including issues of consent, privacy, data ownership, and intellectual property rights. Understanding these legal considerations enables stakeholders to navigate the complexities of secondary data use in an ethically sound and legally compliant manner.
The body of a living organ donor is not merely a medicalized object but also a vessel for nurturing familial ethical bonds and reconstructing the self. The Confucian perspective on the body offers a unique lens for interpreting the donor's physical and existential situation. Confucianism interweaves the act of bodily donation with the harmony and continuity of the moral individual within the family, the production of ethical relationships, and the formation of self-awareness, thereby providing a multidimensional interpretation of the donor's bodily experience. Through their bodily sacrifice, living donors manifest three dimensions of bodily existence: the situated body, the ethical body, and the practical body. Their bodily practices uphold the family's ethical order and assert personal agency, highlighting the role of emotional practices and moral embodiment in Chinese families' medical decision-making.
Emergency healthcare workers in the West Bank deliver care under sustained structural constraint that limits access, resources, and clinical decision-making. This study examines how such conditions generate moral distress and shape ethical practice. A qualitative design was used. Nineteen semi-structured interviews were conducted with physicians and nurses in emergency departments across three cities. Data were analyzed using thematic analysis. Findings show a progression from acute, episode-based distress to chronic forms linked to persistent structural barriers, culminating in moral numbing. This trajectory reflects repeated exposure to situations where clinicians cannot act in line with professional obligations. Some participants reported that peer support and professional advocacy can partially interrupt this process, though these responses shift burden onto individuals. Moral distress in this context is structurally produced and sustained. Addressing it requires institutional and systemic responses rather than reliance on individual coping.
The post-1945 world order is standardly pictured as a Westphalian system, in which each state is equal under the law with sovereign authority over its territories. This paper argues that the Westphalian system is changing and examines the implications for bioethics. We show that cross-border health, economic, ecologic, and sociopolitical risks defy a Westphalian view and propose an alternative approach that draws insights from Chinese-Confucian tianxia (all-under-heaven) and African ubuntu (humanness). Sections I and II introduce the Westphalian system and highlight key challenges. Sections III through V introduce Chinese and African views and identify convergences between them. Section VI proposes the narrative of a 'global village' to capture these convergences and demonstrates its advantages over a Westphalian narrative using the example of climate change, while also acknowledging the importance of retaining certain elements of the Westphalian system. Section VII concludes that African and Chinese approaches furnish a promising path forward for bioethics.
The full-scale invasion of Ukraine in February 2022 launched years of large-scale combat operations, requiring rapid and recurrent generation of combat medical capabilities in order to maintain the fighting force. The operational requirements drove changes in the training and development of combat medics serving on the front lines. Duration of training was significantly shortened, resulting in challenging decision making on which skills to prioritize within the time available. Ethical principles of beneficence and nonmaleficence must be considered when operational requirements drive modifications of combat medic training.
Global health engagement (GHE) has emerged as a central instrument of foreign and defense policy across multiple nations, reflecting the growing convergence of health and national security. This manuscript examines the ethical and strategic roles of military health diplomacy and health security in GHE activities primarily oriented toward advancing national security objectives. It argues that military GHE is ethically justified only when it promotes health security alongside, rather than subordinate to, national security interests. Drawing on contemporary examples, including U.S. military medical efforts, medical coordination in Ukraine, and Indo-Pacific health engagement activities, the paper highlights how military GHE strengthens partner capacity, enhances interoperability, and supports operational readiness. However, ethical challenges exist and must be addressed, including dual loyalty among military physicians, risks to medical neutrality, and perceptions of coercion or instrumentalization. The manuscript concludes that transparency, local partnership, and adherence to core ethical principles are essential to ensuring that military GHE remains both strategically effective and ethically legitimate.
Military leaders must support health care and research to protect the health and readiness of their forces. Part of this effort entails conducting human subjects research to address current and emerging international health threats. The military is also attentive to the national security interests associated with global health, such as protection from widespread disruption due to disasters and epidemics. While military leaders' global health research objectives relate to the military's strategic goals, including force health protection and national security, it is only through longstanding partnerships with partner nations in several world regions that much of the relevant research is possible. Yet military priorities may differ starkly from those of the collaborating partner nations, raising concerns about the potential for exploitation in global health partnerships. However, in spite of differences in overall strategic priorities, a convergence of stakeholder interests allows for appropriate alignment in the choice of clinical research activities at global health sites supported by the military. These complex collaborative research arrangements depend on negotiating and navigating the selection of research goals and activities to ensure fairness and balancing of priorities among partners, thereby maintaining research infrastructure and capacity. Leaders of military institutions and partner nations must attend to the need for this sustained effort to balance priorities to ensure equity and successful maintenance of these essential relationships.
Global health engagement increasingly occurs in the context of war and violent conflict. Many health-related decisions are made which should be guided by evidence. Health research is needed to provide evidence, yet conducting research in conflict settings raises multiple ethical issues. However, the ethical issues involved in conducting research during war and violent conflict have received insufficient attention. The literature suggests that these ethical issues, while similar to those of research conducted in humanitarian crises, are also distinct. This article provides a review of the ethical issues faced by researchers in conflict zones with a goal to inform future research into such issues. The review was organized around an established 8-principle ethics framework for research in low-income settings. We conclude with a number of recommendations and call for additional attention by bioethicists to this important area to protect participants and support researchers in conflict settings, whether coming from military or nonmilitary organizations.
Current US military international research protocols involving human subjects are reviewed, approved, and overseen by both US and regulatory bodies. In some cases host nation research partners are disadvantaged due to slower processing times and redundant protocol reviews when competing for opportunities to conduct clinical trials. This article considers international legal and regulatory tensions between protecting host nations' patient-subjects and supporting host nation researchers' ability to conduct phase 2 and phase 3 clinical trials in support of important military and global health objectives.
The Department of Defense has a long history of Global Health Engagement, beginning with identifying and developing vaccines for yellow fever, influenzae, and malaria. Contemporary examples of global health engagement include the worldwide deployment of military assets to aid in natural disasters, and deployment of ship and land based medical teams for short-term medical and surgical engagements. In 2017, the Department of Defense Instruction on Global Health Engagement was published to help guide these efforts. Surgery is an indispensable part of global health and presents unique ethical challenges.
Military global health engagements (GHEs) present complex ethical questions to clinicians with dual professional roles as physicians and officers. These questions' importance is heightened in regions with histories of colonialism and exploitation, where well-intentioned actions can still perpetuate harms. This article identifies "traditional" ethics frameworks' limitations for addressing these harms and tension around them and proposes a context-sensitive and relationally grounded alternative to making clinical and ethical guidelines for clinicians, planners, military leaders, and policymakers engaged in military global health. This article describes the importance of an alternative ethical framework that draws on values such as humility, responsiveness, and sustained local partnership.
Military clinicians in disaster relief must treat health diplomacy not just as an operational tool but as a potential ethical obligation that actively prevents the political misuse of healthcare in situations of acute ethical tension. In settings where host nation military actors may threaten vulnerable populations, clinicians assume dual roles as caregivers but also as ethical diplomats often acting as an advocacy for at risk groups. This paper argues that military clinicians must treat health diplomacy as an active ethical responsibility rather than solely a neutral operational function. It suggests it is essential to prevent the political exploitation of healthcare and protect vulnerable groups in unstable and challenging environments. The paper uses an adapted four-pillars framework to analyse challenges of impartiality, host-nation influence and ethnic bias. It examines how clinicians negotiate complex health-diplomacy environments, especially where vulnerable groups may face racially motivated harm.
This case commentary explores whether and when it is justifiable NOT to direct injured or ill host nation patients to international coalition military hospitals that are better equipped than host nation hospitals to meet patients' health needs in order to ensure sufficient patients for success in clinical partnering. The case discusses Medical Rules of Eligibility as a policy to determine the destination of patients who present for medical care to international military medical services. It also discusses the ethical challenges for international military healthcare workers when working as clinical partners to support capability-building in host national medical facilities. This can be particularly difficult if it involves shared care of patients rather than didactic training. Finally, the case discusses the ethical dimensions of news reporting within medical facilities, especially if this is part of the military effort to share information about the military campaign. The case highlights ethical aspects of higher-level military policy that impact clinical care and the importance of considering if external review of such policies is needed to ensure alignment with legal and professional ethical obligations.
The commercialisation of Malaysia's private healthcare sector has intensified conflicts between doctor's professional autonomy and financial pressures, raising ethical and legal concerns. Private practitioners increasingly face incentives to prioritise revenue-generating treatments, leading to defensive medicine, excessive testing and escalating healthcare costs. These financial and legal pressures undermine clinical independence, shifting the doctor-patient relationship toward a transactional model. This study employs a qualitative analytical approach to examine how financial imperatives shape medical decision-making and defensive practices in Malaysia's private healthcare sector. By assessing revenue-driven policies, litigation risks and their impact on professional autonomy, the analysis highlights the need for standardised guidelines, interdisciplinary collaboration and transparency in decision-making. Strengthening regulatory safeguards is crucial to preserving medical ethics while ensuring financial sustainability in private healthcare.
The use of human genetic variation to comprehend complex diseases has also introduced several ethical, legal, and societal issues (ELSI). Despite the important contribution of Human Genome Research (HGR), full comprehension of these issues by all its stakeholders remains challenging. This research focused on exploring the understanding of research participants on the informed consent process of HGR. Nineteen Ethiopian TB patients, who participated in genomics research, were purposely selected for in-depth interviews. Their recorded responses were transcribed into text-based versions and analyzed thematically using MAXQDA Analysis Software.The patterns in the informed consent process showed the following themes: Therapeutic misconception, Limited clarity on perceived benefit, Partial understanding of third-party use, Addressed suspicion or concerns, Mixed feelings about sample and data extraction, Concerns about sample governance, Variations in information and understanding, Barriers and facilitators to comprehension, and Volunteerism and influencing factors. The findings incorporated both the strengths and challenges of the consenting process of a genomic study, while informing the need for ethical improvements.
Islamic bioethics is a recent, albeit growing, academic discipline. Despite commendable contributions, the field remains critically limited. Most notably, its methodology of strict application of Islamic law to ethical analyses and recommendations often lacks sufficient moral analysis, intellectual engagement, or social context. The practice's emphasis on religio-legal rulings- without an investigation of their underpinning moral values- has resulted in a field of inquiry devoid of robust normative foundations and dependent upon ineffective and unsubstantiated claims. This paper calls for a revival of Islamic philosophical discourse to enrich Islamic bioethical practice. Although once popularized by Medieval Muslim philosophers like Ibn Sina (Avicenna) and Ibn Rushd (Averroes), philosophical discourse has fallen out of favor in the Muslim world, largely due to a perceived tension with religion. This work highlights the rich tradition of philosophical discourse in the Medieval Muslim world, disproving claims of an inherent conflict between philosophy and Islam. Following an Islamic philosophical framework, three goals for Islamic bioethics are established. First, theoretical rigor aimed at continually re-assessing and re-understanding concepts integral to the practice of bioethics such as personhood, dignity, futility, autonomy, and justice. Second, a shift from essentialist understandings of the Quran- and other sources of Islamic law- to more contextual examinations in the formulation of ethical opinions. Third, an active and interdisciplinary collaboration between Muslim scholars in the determination of Islamic rulings on medical matters. Only when these goals are met is the practice of Islamic bioethics capable of meeting the needs of Muslim patients and clinicians.
