OBJECTIVES:Newly qualified doctors look to senior doctors for support in dealing with the unique ethical challenges of end-of-life care. The aim of this study was to explore senior doctors' experience of supporting first-year and second-year resident doctors including the strategies used. METHODS:A qualitative descriptive design involved focus group interviews followed by inductive content analysis. RESULTS:70 senior doctors from medicine, surgery, orthopaedics, geriatrics, palliative medicine, cardiothoracic surgery, neurosurgery and vascular surgery participated in 15 focus groups. Two themes explained the clinical reality of senior doctors who supervise junior doctors and how they support them. The first theme, Context: 'the job is brutal', details the pressure on and vulnerability of both senior and junior doctors. The second theme, Support: 'it is the human part we want to live, we also have the expertise', encompasses what senior doctors do and would like to do more of to support junior doctors. Meeting junior doctors on a human level and role modelling self-awareness and reflection are the most effective ways of support. The lack of value placed on these ways of support is a source of frustration. CONCLUSIONS:In the intense setting of the acute hospital, when dealing with ethical questions in caring for patients who are dying, junior doctors are challenged by their inexperience of mortality, personally and professionally. Senior doctors have much to impart from their years of experience and reflection. Recognising the value of senior doctor support is essential for the personal and professional well-being and growth of the next generation of doctors.

Objective Literature identifies that doctors struggle in navigating ethical issues at the end of life. Residents look to senior doctors for support. Senior doctors are aware of the latter’s needs. However, systemic factors and clinical demands preclude attention being given to the impact on both groups. The question arose as to what both groups working together would identify as the best support. Method Study design was qualitative, informed by the principles of co-design. 12 resident and 15 senior doctors participated in 6 workshops. Senior and resident doctors worked collaboratively to identify the best support. Inductive content analysis of the recorded group discussion followed. Results Practising medicine was practising ethics—both of which involved human relationships. Senior doctors acknowledged that constraints in the practice context and lack of clinical experience contributed to residents’ concerns about patient harm. Lack of support for resident doctors coping with ethical issues when patients were dying was itself an ethical issue. Coping, as a resident in a system under pressure, was challenging. Senior and resident doctors unanimously believed that taking time for support was paramount. Acknowledging human vulnerability was the second most valued strategy. Informal debriefing, either at the time or later, was identified as the third. Conclusion In determining how to support doctors and specifically residents we need to understand the context in which doctors work. Including both groups in identifying the solution, we found that central to any intervention is taking time to acknowledge the human impact and fostering relational support.

PURPOSE:This qualitative study investigates how Canadian physician-providers of medical assistance in dying (MAiD) perceived their role in making judgements when assessing patients for MAiD. METHODOLOGY:21 Canadian physician MAiD providers were interviewed about their experience as early-adopting providers. The data were analysed using a phenomenological approach to identify themes and thematic groupings regarding providers' perceptions of roles and reasoning while undertaking MAiD assessments. FINDINGS:Participants universally endorsed a focus on providing patient-centred care. They varied in how they approached decision-making for patients applying for MAiD and how they viewed their role within the doctor-patient relationship. Group 1 participants placed moral decision-making with the patient, indicating a limited role for the provider. They focused on guiding the competent patient through the statutory MAiD requirements to actualise patient autonomy. Some described their role as 'conduits'. Group 2 had intermediate views. Group 3 participants described their professional judgement as important to the moral calculus of approval for MAiD. Their role was like that of a train conductor in that they positioned themselves as responsible for wider patient interests as part of maintaining their own professional and moral integrity during MAiD. CONCLUSIONS/SIGNIFICANCE:Participants' narratives indicate that decisions about MAiD assessments are strongly influenced by provider reasoning regarding the physician's role in MAiD assessment and provision. This divergence reflects unclear role expectations in the context of rapidly changing cultural expectations regarding MAiD.

Background In China's clinical settings, it is common for families to have the final say in informed consent when the patient has a terminal or critical illness, even when the patients are fully competent. This practice is different from the individual-based pattern in the majority of Western countries, which is grounded in respect for individual autonomy. One common justification of family-oriented informed consent (FOIC) is that Chinese patients prefer to have their families make decisions on their behalf, and this aligns with China's familial culture, which emphasises relational autonomy. However, recent empirical findings show that FOIC is not as widely supported by Chinese patients as is often assumed. Methods In this study, semi-structured interviews were conducted with 13 Chinese patients, 14 family caregivers, and 9 health professionals in two megacities in northern China to explore their perceptions and attitudes of FOIC Their experiences of and attitudes towards FOIC were explored Results Many family and patient participants believed FOIC is a good way to preserve hope for patients and therefore supported the approach. However, when imagining themselves as patients, many of them preferred individual-based informed consent, citing a patient's right and autonomy as the reasons. Healthcare professionals were conflicted on FOIC They acknowledge the impact of familial culture but also mentioned practical factors that may equally contribute to FOIC. Conclusion The interviews of this study and the literature indicate there are similarities between China and the West when it comes to family involvement in decision making which may have been overlooked or downplayed. The qualitative findings with participants reveal that there are other equally significant social-economic factors such as medical violence contributing to the prevalence of FOIC Although FOIC is widespread in China, familial culture neither fully explains the practice nor provides an adequate justification for it.

In clinical practice in China, a family-oriented approach to informed consent is widely used. Under this approach, families may control whether patients are provided with information and make medical decisions for the patient without asking what they would want. One of the main justifications is its purported benefits for patients. Recent studies have begun to expose ways in which this approach may be more harmful than beneficial to patients. Integrating empirical investigation with normative analysis, this study examines the experienced and perceived benefits and harms of family-oriented informed consent by Chinese patients, family caregivers, and healthcare professionals from two megacities. Semi-structured and in-depth interviews were undertaken with 13 patients, 14 family caregivers, and 9 medical professionals in Tianjin and Beijing, two megacities in northern China. The findings of these interviews were thematically analysed. When taking the perspective of a caregiver, most of the participants across the three groups described the family-oriented approach as more beneficial to patients. However, when thinking of themselves as the patient, most participants believed that it would be better for them if they were provided with information and given an opportunity to decide. The interviews revealed some significant harms of family-orientated informed consent, such as delay in treatment, psychological abandonment, and suppression of self-management. This study challenges the widespread assumptions about the benefits of family-oriented informed consent. Some of the harms of this approach are unveiled and discussed. Two opposing attitudes toward this approach to informed consent, derived from the contrasting views of family members and patients, uncover the potential flaws in the beneficence-based justification for this practice.

PurposeMedical assistance in dying (MAiD) in Canada places the medical provider at the centre of the process. The MAiD provider holds primary responsibility for determining eligibility and becomes acquainted with patients’ inner desires and expressions of suffering. This is followed by the MAiD procedure of administering the lethal agent and being present at the death of eligible patients. We report participants’ perceptions of the emotional and moral impacts of this role.MethodologyTwo years after MAiD was legalised in Canada, 22 early-adopting physician providers were interviewed. Data were examined using both phenomenological analysis and a novel ChatGPT-enhanced analysis of an anonymised subset of interview excerpts.FindingsParticipants described MAiD as emotionally provocative with both challenges and rewards. Providers expressed a positive moral impact when helping to optimise a patient’s autonomy and moral comfort with their role in relieving suffering. Providers experienced tensions around professional duty and balancing self with service to others. Personal choice and patient gratitude enhanced the provider experience, while uncertainty and conflict added difficulty.ConclusionsParticipants described MAiD provision as strongly aligned with a patient-centred ethos of practice. This study suggests that, despite challenges, providing MAiD can be a meaningful and satisfying practice for physicians. Understanding the emotional and moral impact and factors that enhance or detract from the providers’ experience allows future stakeholders to design and regulate assisted dying in ways congruent with the interests of patients, providers, families and society.

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

Mental health legislation that requires patients to accept 'care' has come under increasing scrutiny, prompted primarily by a human rights ethic. Epistemic issues in mental health have received some attention, however, less attention has been paid to the possible epistemic problems of mental health legislation existing. In this manuscript, we examine the epistemic problems that arise from the presence of such legislation, both for patients without a prior experience of being detained under such legislation and for those with this experience. We also examine how the doctor is legally obligated to compound the epistemic problems by the knowledge they prioritise and the failure to generate new knowledge. Specifically, we describe the problems of testimonial epistemic injustice, epistemic silencing, and epistemic smothering, and address the possible justification provided by epistemic paternalism. We suggest that there is no reasonable epistemic justification for mental health legislation that creates an environment that fundamentally unbalances the doctor-patient relationship. Significant positive reasons to counterbalance this are needed to justify the continuation of such legislation.

If a person is competent to consent to a treatment, is that person necessarily competent to refuse the very same treatment? Risk relativists answer no to this question. If the refusal of a treatment is risky, we may demand a higher level of decision-making capacity to choose this option. The position is known as asymmetry. Risk relativity rests on the possibility of setting variable levels of competence by reference to variable levels of risk. In an excellent 2016 article in Journal of Medical Ethics (JME), Rob Lawlor defends asymmetry of this kind by defending risk relativity, using and developing arguments and approaches found in earlier work such as that of Wilks. He offers what we call the two-scale approach: a scale of risk is to be used to set a standard of competence on a scale of decision-making difficulty. However, can this be done in any rational way? We argue it cannot, and in this sense, and to this extent, risk relativity is a nonsense.

In this short response to Gray's article Capacity and Decision Making we double down on our argument that risk-relativity is a nonsense. Risk relativity is the claim that we should set a higher standard of competence for a person to make a risky choice than to make a safe choice. Gray's response largely involves calling attention to the complexities, ramifications and multiple value implications of decision-making, but we do not deny any of this. Using the notion of quality of care mentioned by Gray, we construct an argument that might be used to support risk relativity. But it is no more persuasive than the arguments put forward by risk-relativists.

The COVID-19 global pandemic has highlighted the potential roles and responsibilities of medical students in healthcare systems. Senior clinical students may be able to contribute practically, but all medical students, regardless of their level of training have the opportunity to assist public health measures, eg supporting vaccination uptake. Medical students may tread a difficult line in such situations. On one hand, students are advised not to act beyond their level of expertise, yet they can feel an expectation to be authoritative by the community. Navigating these spaces can be challenging for medical students and an important part of their professional development.

Click to increase image sizeClick to decrease image sizeThis article is referred to by:Capacities to Refuse Treatment: A ReplyThis article refers to:Three Kinds of Decision-Making Capacity for Refusing Medical Interventions Additional informationFundingThe author(s) reported there is no funding associated with the work featured in this article.

Background Previous studies report a majority of the general public support euthanasia/assisted dying (EAD), while a majority of doctors are opposed. In considering policy decisions about EAD, some may discount the views of doctors because they take them to be based on personal values or tradition, rather than reasons that the general public might share. One way to explore this notion is to examine whether medical students’ views change during their medical education. The objective of this study was to learn how New Zealand medical students view EAD and whether students at different year levels have different views. Methods An on-line survey of undergraduate medical students was conducted asking whether they supported a law change to allow EAD. Quantitative data was analysed using unadjusted and multiple logistic regression. Thematic analysis was conducted with the qualitative data. Results A total of 326 students replied to the survey. The overall response rate was 28%. 65% of 2nd year students were supportive of EAD, compared to 39% in 5th year. The odds of 5th year students supporting a law change compared to 2nd year was 0.30 (95% CI: 0.15–0.60). The predominant themes found in the qualitative results indicate that medical students support or oppose EAD for reasons similar to those found in the wider debate, and that their views are influenced by a range of factors. However, several at all year levels cited an aspect of medical school as having influenced their views. This was mentioned by participants who were supportive of, opposed to, or unsure about EAD, but it was the type of influence most often mentioned by those who were opposed. Conclusions The quantitative findings show students at the end of 5th year were less likely to support EAD than students at the end of 2nd year. We suggest that this difference is most likely due to their time in medical education. This suggests that the lower support found among doctors is in part related to medical education and medical work rather than age, personality, or social context. The qualitative findings indicate that this is not related to a particular educational experience at Otago Medical School but a range.

Background The history of infant mortality inequities among Māori in New Zealand provides a remarkable case study for understanding the shortcomings of policy which fails to consider the differential risks associated with disadvantaged groups. Specifically, the failure of the initial 1991 reform in addressing Māori infant health, followed by the relative success of post-1994 policy, demonstrate that disadvantaged populations carry differential social risks which require adjusting policy accordingly. Literature on these policies show that differential risks may include disparities in representation, access to resources, socioeconomic status, and racism. The consideration of differential risks is important in analyzing the underlying causes of inequities and social policy deficiencies. Aim To describe and illustrate the need for policy addressing inequities to consider the differential risks associated with disadvantaged groups through an analysis of New Zealand’s Māori infant mortality policy progression. Methods The article is a commentary on a series of policies aimed at reducing infant mortality in New Zealand. It analyses three policies and how their differences are linked to the corresponding trends in equity between Māori and non-Māori populations. Findings The progression of Māori infant mortality policy clearly demonstrates that equitable social policy must be culturally sensitive and inclusive towards disadvantaged groups, as well as willing to adapt to changing circumstances and shortcomings of current policy. Prior to 1994, health policy which did not account for the differential risks of Māori populations caused inequities in infant mortality to increase, despite infant mortality decreasing on a national level. After policy was adjusted to account for Māori-specific risks in 1994, infant mortality inequities significantly declined. A comprehensive analysis of these policies shows that the consideration of differential risks is highly related to a decrease in corresponding inequities. Conclusions As New Zealand, and other countries facing inequities such as the United States and Australia, move forward in constructing policy, they would do well to consider the lessons of how New Zealand policy changed the frequency of infant mortality in Māori populations. The study shows that the consideration of differential risks associated with disadvantaged groups is necessary for policy to successfully address inequities.

Objective To understand the unique ethical and professional challenges confronting first and second year doctors in caring for people who are dying, and to learn what factors help or hinder them in managing these. Method 6 first year and 7 second year doctors were interviewed one-to-one by a senior palliative medicine physician (SD), quarterly over 12 months, using a semistructured approach. Thematic analysis was conducted with the findings, following the general inductive approach. Results 21 hours of recorded interviews were analysed by SD, and ethical and professional issues were identified. These were discussed with SW, and sorted into seven broad categories. The participants' accounts of the issues convey a strong ethical sensitivity, developed through their undergraduate training. A recurring challenge for them through their first 12-24 months of work as doctors is being responsible for the decisions, knowing that what they do can have life and death consequences. The participants frequently describe senior doctors as an important source of support, and the lack of such support as leading to moral distress and demoralisation. Another important factor is having opportunity to discuss and reflect on the decisions after they are made. Where such reflection had been facilitated properly, participants displayed considerable growth in their ability to manage ethical challenges. Conclusion Senior support and opportunities for reflection need to be recognised as key factors in enabling first and second year to respond appropriately to ethical challenges in end-of-life care, and in sustaining their well-being through this critical stage of their professional life.

Ethical reasoning is a basic feature of human life, inherent to the ways we think and act. Ethics teaching should improve students' and clinicians' ethical understanding by providing them with the conceptual resources to identify what is at stake in a given situation and to discern a solution that upholds as well as possible the values that are relevant. In this chapter, the authors provide a theoretical basis for these claims that may be used to support ethics teaching programs. Walker and McMillan use Korsgaard's account of normativity to show how the sense of obligation arises with rational self-reflection and how the normative force of concepts are linked to the value structure through which the person reflecting values their life. They extend this account through Kant's analysis of concepts, showing how ethical understanding can be regarded as a form of conceptual understanding. The authors then link Kant's analysis to a Wittgensteinian understanding of rule-following. This pragmatic perspective complements the individual grounding for normativity established by Korsgaard's theory. From this standpoint the authors revisit the connections Kant draws between abstract understanding and practical experience, and briefly outline what this means for ethics teaching.

Background Previous studies report a majority of the general public support euthanasia/assisted dying (EAD), while a majority of doctors are opposed. In considering policy decisions about EAD, some may discount the views of doctors because they take them to be based on personal values or tradition, rather than reasons that the general public might share. One way to explore this notion is to examine whether medical students’ views change during medical education. The objective of this study was to learn how New Zealand medical students view EAD and whether their views change during medical education. Methods An on-line survey of undergraduate medical students was conducted. Quantitative data was analysed using unadjusted and multiple logistic regression. Thematic analysis was conducted with the qualitative data. Results A total of 326 students replied to the survey. The overall response rate was 28%. 65% of 2 nd year students were supportive of EAD, compared to 39% in 5 th year. The odds of 5 th year students supporting a law change compared to 2 nd year was 0.30 (95%CI 0.15-0.60). The predominant themes found in the qualitative results indicate that medical students support or oppose EAD for reasons similar to those found in the wider debate, and that their views are influenced by a range of factors. However, several at all year levels cited an aspect of medical school as having influenced their views. This was mentioned by participants who were supportive of, opposed to, or unsure about EAD, but it was the type of influence most often mentioned by those who were opposed. Conclusions The quantitative findings suggest that aspects of medical education made students less likely to support EAD. The qualitative findings indicate that this is not related to a single educational experience at Otago Medical School but a range. Together, these findings suggest that the lower support found among doctors is in part related to medical education and medical work rather than age, personality, or social context. They indicate a practical basis to ethical and professional formation that should be considered in curriculum design, policy decisions and when interpreting public opinion surveys on this issue.

Introduction Donation of human tissue is essential for biomedical research to improve our understanding of the causes and treatment of diseases. To facilitate this, researchers need to understand what approaches and processes make donation and storage more acceptable for various communities. This study explores the perspectives of Pacific peoples living in Dunedin, New Zealand on the use of human tissues for biomedical research. Methods In April 2018, four focus groups (total of 18 participants) were held with members of the Pacific community in Dunedin. Each group was demographically different, with groups consisting of; elders of mixed ethnicity, university students, medical doctors and one Tongan group of mixed ages. An open-ended questioning style was used, with specific prompts about participant’s perceptions of the purpose and processes for donating tissues for research and things that might make them more or less likely to donate. Findings There were a diverse range of views expressed, reflecting the diversity of participants across different ethnicities and ages. While participant responses varied widely in terms of enthusiasm or caution towards different types of donation, similar themes emerged regarding the importance of detailed informed consent, and respect and trust towards both the donors and/or their tissues. The importance of culture and religion on the attitudes or perspectives towards donation was also highlighted. Finally, it was perceived that donation is likely to be more acceptable if researchers are able to explain why their work is meaningful in a Pacific context and adapt to Pacific situations and/or concerns within the research protocols. Conclusions For Pacific peoples to derive the most benefit from research initiatives it is important that processes to collect human tissue are respectful of cultural protocols and expectations to support participation. This study provides useful information to support the evolution of guidelines within the NZ research context.