OBJECTIVE: As part of the FERN feasibility study, this qualitative research aimed to explore parents\' and clinicians\' views on the acceptability, feasibility and design of a randomised controlled trial (RCT) of active intervention versus expectant management in monochorionic (MC) diamniotic twin pregnancies with early-onset (prior to 24 weeks) selective fetal growth restriction (sFGR). Interventions could include laser treatment or selective termination which could lead to the death or serious disability of one or both twins.
METHODS: Qualitative semi-structured interviews with parents and clinicians. Data were analysed using reflexive thematic analysis and considered against the Principles of Biomedical Ethics.
METHODS: We interviewed 19 UK parents experiencing (six mothers, two partners) or had recently experienced (eight mothers, three partners) early-onset sFGR in MC twin pregnancy and 14 specialist clinicians from the UK and Europe.
RESULTS: Participants viewed the proposed RCT as \'ethically murky\' because they believed that the management of sFGR in MC twin pregnancy should be individualised according to the type and severity of sFGR. Clinicians prioritised the gestational age, size, decrease in growth velocity, access to the placental vessels and acceptability of intervention for parents. Discussions and decision-making about selective termination appeared to cause long-term harm (maleficence). The most important outcome for parents and clinicians was \'live birth\'. For clinicians, this was the live birth of at least one twin. For parents, this meant the live birth of both twins, even if this meant that their babies had neurodevelopmental impairment or disabilities.
CONCLUSIONS: All three pregnancy management approaches for sFGR in MC twin pregnancy carry risks and benefits, and the ultimate goal for parents is to receive individualised care to achieve the best possible outcome for both twins. An RCT was not acceptable to parents or clinicians or seen as ethically appropriate. Alternative study designs should be considered to answer this important research question.

BACKGROUND: The Joint Commission emphasizes the importance of cultural competence and effective communication in quality medical care, particularly during end-of-life (EOL), when decisions are influenced by diverse cultural and religious backgrounds. For Orthodox Jewish patients, the philosophical framework used for EOL decision-making may conflict with that used in traditional Western medical ethics. In this paper, we explore the complexities of EOL decision-making for devout Jewish patients and highlight how approaches may differ from a Western ethical framework.
OBJECTIVE: This paper aims to familiarize clinicians with EOL preferences of Orthodox Jewish patients, organized into an ethical framework called \'casuistic deontology\'. Leading with an open-minded approach emphasizing cultural humility, we explore ways in which integrating this perspective can allow for culturally appropriate and compassionate EOL care.
METHODS: Using a case study methodology, we focus on a 79-year-old Orthodox Jewish male hospitalized with severe injuries. The patient\'s medical course is analyzed, highlighting how the decisions made by his family in consultation with their Rabbi may differ from the decisions made with a philosophy of a Western ethical framework.
CONCLUSIONS: This case illustrates the ethical tensions that may arise when Western medical practices intersect with Orthodox Jewish beliefs, particularly regarding brain death, resuscitation, and artificial nutrition. We underscore the need for cultural sensitivity when approaching EOL decision-making, allowing for compassionate and comprehensive care that respects religious perspectives. This paper helps provide a structure for clinicians to navigate the complex EOL care needs for the devout Jewish patient in a manner consistent with their cultural and religious identity.

OBJECTIVE: To evaluate the extent and trends of personal payments from pharmaceutical companies to cardiologists board-certified by the Japanese Circulation Society.
METHODS: A retrospective analysis study using data from a publicly available database.
METHODS: The study focused on payments to cardiologists in Japan.
METHODS: All 15 048 cardiologists who were board-certified by the Japanese Circulation Society as of 2021.
METHODS: The primary outcome was the extent of personal payments to cardiologists in 2016-19. Secondary outcomes included the analysis of trends in these payments over the same period.
RESULTS: Of all 15 048 board-certified cardiologists, 9858 (65.5%) received personal payments totaling $112 934 503 entailing 165 013 transactions in 2016-19. The median payment per cardiologist was $2947 (IQR, $1022-$8787), with a mean of $11 456 (SD, $35 876). The Gini Index was 0.840, indicating a high concentration of payments to a small number of cardiologists. The top 1%, 5% and 10% of cardiologists received 31.6%, 59.4% and 73.5% of all payments, respectively. There were no significant trends in the number of cardiologists receiving payments or number of payments per cardiologist during the study period.
CONCLUSIONS: More than 65% of Japanese cardiologists received personal payments from pharmaceutical companies over the 4-year study period. Although the payment amount was relatively small for the majority of cardiologists, a small number of cardiologists received the vast majority of the payments.

BACKGROUND: As Artificial Intelligence (AI) becomes pervasive in healthcare, including applications like robotic surgery and image analysis, the World Medical Association emphasises integrating AI education into medical curricula. This study evaluates medical students\' perceptions of \'AI in medicine\', their preferences for AI training in education, and their grasp of AI\'s ethical implications in healthcare.
METHODS: A cross-sectional study was conducted among 325 medical students in Kerala using a pre-validated, semi structured questionnaire. The survey collected demographic data, any past educational experience about AI, participants\' self-evaluation of their knowledge and evaluated self-perceived understanding of applications of AI in medicine. Participants responded to twelve Likert-scale questions targeting perceptions and ethical aspects and their opinions on suggested topics on AI to be included in their curriculum.
CONCLUSIONS: AI was viewed as an assistive technology for reducing medical errors by 57.2% students and 54.2% believed AI could enhance medical decision accuracy. About 49% agreed that AI could potentially improve accessibility to healthcare. Concerns about AI replacing physicians were reported by 37.6% and 69.2% feared a reduction in the humanistic aspect of medicine. Students were worried about challenges to trust (52.9%), patient-physician relationships (54.5%) and breach of professional confidentiality (53.5%). Only 3.7% felttotally competent in informing patients about features and risks associated with AI applications. Strong demand for structured AI training was expressed, particularly on reducing medical errors (76.9%) and ethical issues (79.4%).
CONCLUSIONS: This study highlights medical students\' demand for structured AI training in undergraduate curricula, emphasising its importance in addressing evolving healthcare needs and ethical considerations. Despite widespread ethical concerns, the majority perceive AI as an assistive technology in healthcare. These findings provide valuable insights for curriculum development and defining learning outcomes in AI education for medical students.

Ethical disclosure of adverse events (AE) presents opportunities and challenges for physicians and has unique ramifications for anesthesiologists. AE disclosure is supported by patients, regulatory organizations, and physicians. Disclosure is part of a physician\'s ethical duty toward patients, supports fully informed patient decision making, and is a critical component of root cause analysis. Barriers to AE disclosure include disruption of the doctor-patient relationship, fear of litigation, and inadequate training. Apology laws intended to support disclosure and mitigate concern for adverse legal consequences have not fulfilled that initial promise. Training and institutional communication programs support physicians in providing competent, ethical AE disclosure.

The development of critical care stimulated brain death criteria formulation in response to concerns on treatment resources and unregulated organ procurement. The diagnosis centered on irreversible loss of brain function and subsequent systemic physiologic collapse and was subsequently codified into law. With improved critical care, physiologic collapse (while predominant) is not inevitable-provoking criticisms of the ethical and legal foundation for brain death. Other criteria have been unsuccessfully proposed, but irreversibility remains the conceptual foundation. Conflicts can arise when families reject the diagnosis-resulting in ethical, cultural, and communication challenges and implications for diversity, equity, and inclusion.

In 1992, the American Society of Anesthesiologists Committee on Ethics was formed primarily to address the rights of patients with existing Do-Not-Resuscitate orders presenting for anesthesia. Guidelines written for the ethical management of these patients stated that such orders should be reconsidered-not rescinded-thus respecting patient self-determination. The Committee also rewrote the reigning Guidelines for the Ethical Practice of Anesthesiology by expanding its ethical foundations to reflect the evolving climate of ethical opinions. These Guidelines described ethically appropriate conduct and behavior, including anesthesiologists\' ethical responsibilities to patients, themselves, colleagues, health-care institutions, and community and society.

It is since the beginning of the so-called \'digital revolution\' in the 1950s that technological tools have been developed to simplify and optimise traditional, time-consuming, and laborious anamnestic collection for many physicians. In recent years, more and more sophisticated \'automated\' anamnestic collection systems have been developed, to the extent that they can actually enter daily clinical practice. This article not only provides a historical overview of the evolution of such tools, but also explores the ethical and medico-legal implications of the transition from traditional to digital anamnesis, including the protection of data confidentiality, the preservation of the communicative effectiveness of the doctor-patient dialogue and the safety of care in patients with poor digital and health literacy.

The principle of non-directiveness remains an important tenet in genetics. However, the concept has encountered growing criticism over the last two decades. There is an ongoing discussion about its appropriateness for specific situations in genetics, especially in light of recent significant advancements in genetic medicine. Despite the debate surrounding non-directiveness, there is a notable lack of up-to-date international research empirically investigating the issue from the perspective of those who actually do genetic counselling. Addressing this gap, our article delves into the viewpoints and experiences of medical geneticists in Germany and Switzerland. Twenty qualitative interviews were analysed employing reflexive thematic analysis. Participants\' responses revealed substantial uncertainties and divergences in their understanding and application of the concept. It seems to cause distress since many geneticists stated that the principle was difficult to put into clinical practice and was no longer ethically justified given the increasing likelihood of therapeutic implications resulting from genomic testing outcomes. The insights provided by our qualitative empirical study accord with the ongoing theoretical debate regarding the definition, legitimacy, and feasibility of the principle. An adequately nuanced understanding and application of non-directiveness seems crucial to circumvent the risks inherent in the principle, while promoting patient autonomy and beneficence.

Future warfare will likely involve near-peer or peer-peer conflict in which there is a great risk of mass casualty scenarios. Because of anti-access and area denial, air superiority will not be guaranteed, which will hamper rapid evacuation of casualties as well as resupply. Under such circumstances, military medical personnel may be forced, due to the constraints of the battlefield and tactical necessity to return servicemembers to duty, to implement reverse triage in which servicemembers with less severe injuries are treated first. However, reverse triage is potentially incongruent with international humanitarian law. Furthermore, should reverse triage need to be implemented, from the extant military doctrine it is not certain when this would be appropriate or the steps that might be followed, which highlight the gaps that exist before reverse triage should be considered as military doctrine on the battlefield. Lastly, we question the psychological impact that reverse triage could portend on military medical personnel, unit morale and unit cohesion. While there have been recent recommendations that reverse triage might need to be implemented in a near-term future conflict, these issues linger. It is time for Western militaries to assess the merits of reverse triage and the potential drawbacks.