An Ethical and Legal Framework for Physicians as Surrogate Decision-Makers for Their Patients.

In Western industrialized countries, it is well established that legally competent individuals may choose a surrogate healthcare decision-maker to represent their interests should they lose the capacity to do so themselves. There are few limitations on who they may select to fulfill this function. However, many jurisdictions place restrictions on or prohibit the patient's attending physician or other provider involved with an individual's care to serve in this role. Several authors have previously suggested that respect for the autonomy of patients requires that there be few (if any) constraints on whomever they may appoint as a proxy. In this essay we revisit this topic by first providing a survey of current state laws governing this activity. We then analyze the clinical and ethical circumstances in which potential difficulties could arise. We take a more nuanced and circumspect view of prior suggestions that patients should have virtually unfettered liberty to choose their healthcare proxies. We suggest a strategy to balance the freedom of patients' right to choose their surrogates with fiduciary duty of the state as regulator of medical practice. We identify six domains of possible concern with such relationships and suggest straightforward methods of mitigating their potential negative effects that could be plausibly be incorporated into physician practice.

SELinux policy management framework for HIS

Health Information Systems (HIS) make extensive use of Information and Communication Technologies (ICT). The use of ICT aids in improving the quality and efficiency of healthcare services by making healthcare information available at the point of care (Goldstein, Groen, Ponkshe, and Wine, 2007). The increasing availability of healthcare data presents security and privacy issues which have not yet been fully addressed (Liu, Caelli, May, and Croll, 2008a). Healthcare organisations have to comply with the security and privacy requirements stated in laws, regulations and ethical standards, while managing healthcare information. Protecting the security and privacy of healthcare information is a very complex task (Liu, May, Caelli and Croll, 2008b). In order to simplify the complexity of providing security and privacy in HIS, appropriate information security services and mechanisms have to be implemented. Solutions at the application layer have already been implemented in HIS such as those existing in healthcare web services (Weaver et al., 2003). In addition, Discretionary Access Control (DAC) is the most commonly implemented access control model to restrict access to resources at the OS layer (Liu, Caelli, May, Croll and Henricksen, 2007a). Nevertheless, the combination of application security mechanisms and DAC at the OS layer has been stated to be insufficient in satisfying security requirements in computer systems (Loscocco et al., 1998). This thesis investigates the feasibility of implementing Security Enhanced Linux (SELinux) to enforce a Role-Based Access Control (RBAC) policy to help protect resources at the Operating System (OS) layer. SELinux provides Mandatory Access Control (MAC) mechanisms at the OS layer. These mechanisms can contain the damage from compromised applications and restrict access to resources according to the security policy implemented. The main contribution of this research is to provide a modern framework to implement and manage SELinux in HIS. The proposed framework introduces SELinux Profiles to restrict access permissions over the system resources to authorised users. The feasibility of using SELinux profiles in HIS was demonstrated through the creation of a prototype, which was submitted to various attack scenarios. The prototype was also subjected to testing during emergency scenarios, where changes to the security policies had to be made on the spot. Attack scenarios were based on vulnerabilities common at the application layer. SELinux demonstrated that it could effectively contain attacks at the application layer and provide adequate flexibility during emergency situations. However, even with the use of current tools, the development of SELinux policies can be very complex. Further research has to be made in order to simplify the management of SELinux policies and access permissions. In addition, SELinux related technologies, such as the Policy Management Server by Tresys Technologies, need to be researched in order to provide solutions at different layers of protection.

The importance of project governance framework in project procurement planning

Project Procurement is a ‘great’ environment for ethical issues with its low-price state of mind and competition. It has many opportunities that could contribute to illegal activities or unethical behavior especially in the construction industry. In 2006 alone, 17.3% of 417 Malaysian government contract projects were considered sick due to the poor performance by the contractors. Therefore it is important to govern the project procurement, especially the plan procurement stage to ensure the accountability and transparency of the decision made in awarding the right contract to the best contractor. This is where project governance framework (PGF) is really needed in project procurement planning. Project governance is a subset of corporate governance focusing on the areas of corporate governance related to project activities, including: portfolio direction, project sponsorship, project and program management and efficiency and disclosure and reporting. This paper highlights the importance of implementing project governance framework (PGF) to ensure that the decision makers are answerable and accountable to the stakeholders, and the decision making is transparent to avoid any ethical issues arises. A comprehensive preliminary literature is carried out to discover the importance of executing PGF in project procurement in Malaysian public sector. By understanding the important of PGF, it is hoped that this will bring a signal to other developing countries to implement the similar method in ensuring the transparency of the decision making in project procurement planning in their countries.

Mapping the ethical journey of experienced nurses now practising in rural and remote hospitals in central and south-west Queensland and in domiciliary services in Brisbane : a grounded theory approach

The aim of this thesis has been to map the ethical journey of experienced nurses now practising in rural and remote hospitals in central and south-west Queensland and in domiciliary services in Brisbane. One group of the experienced nurses in the study were Directors of Nursing in rural and remote hospitals. These nurses were “hands on”, “multi-skilled “ nurses who also had the task of managing the hospital. Also there were two Directors of Nursing from domiciliary services in Brisbane. A grounded theory method was used. The nurses were interviewed and the data retrieved from the interviews was coded, categorised and from these categories a conceptual framework was generated. The literature which dealt with the subject of ethical decision making and nurses also became part of the data. The study revealed that all these nurses experienced moral distress as they made ethical decisions. The decision making categories revealed in the data were: the area of financial management; issues as end of life approaches; allowing to die with dignity; emergency decisions; experience of unexpected death; the dilemma of providing care in very difficult circumstances. These categories were divided into two chapters: the category related to administrative and financial constraints and categories dealing with ethical issues in clinical settings. A further chapter discussed the overarching category of coping with moral distress. These experienced nurses suffered moral distress as they made ethical decisions, confirming many instances of moral distress in ethical decision making documented in the literature to date. Significantly, the nurses in their interviews never mentioned the ethical principles used in bioethics as an influence in their decision making. Only one referred to lectures on ethics as being an influence in her thinking. As they described their ethical problems and how they worked through them, they drew on their own previous experience rather than any knowledge of ethics gained from nursing education. They were concerned for their patients, they spoke from a caring responsibility towards their patients, but they were also concerned for justice for their patients. This study demonstrates that these nurses operated from the ethic of care, tempered with the ethic of responsibility as well as a concern for justice for their patients. Reflection on professional experience, rather than formal ethics education and training, was the primary influence on their ethical decision making.

Project governance : ethical decision making in project procurement in the Malaysian public sectors

Managing public sector projects in Malaysia is a unique challenge. This is because of the ethical issues involved during the project procurement process. These ethical issues need attention because they will have an impact on the quality, cost and time of the project itself. The ethical issues here include conflict of interest, bid shopping, collusive tendering, bid cutting, corruption and the payment game. In 2006, 17.3% of 417 Malaysian government contract projects were considered sick due to contractors' performances that failed to conduct the project according to the project plan. Some of the sick projects from these statistics are due to the ethical issues involved. These construction projects have low quality due to the selection of the contractors, done unethically due to personal relationships instead of professional qualifications. That is why it is important to govern the project procurement processes to ensure the accountability and transparency of the decision making process to ensure that these ethical issues can be avoided. Extensive research has been conducted on the ethical issues in the tendering process or the award phase of project management. There is a lack of studies looking at the role of clients, including the government client, in relation to unethical practice in project procurement in the public sector. It is important to understand that ethical issues not only involve the contractors and suppliers but also the clients. Even though there are codes of ethics in the public sectors, ethical issues still arise. Therefore, this research develops a project governance framework (PGEDM) for ethical decision making in the Malaysian public sectors. This framework combines the ethical decision making process together with the project governance principals in guiding the public sectors with ethical decision making in project procurement. A triangulation of questionnaire survey and Delphi study was employed in this research to collect required qualitative and quantitative data. A questionnaire survey was conducted among the public officials (the practitioners) who are currently working in the procurement area in the Malaysian public sectors, in identifying the ethical behaviours and factors influencing further ethical behaviour to occur. A Delphi study was also conducted with the assistance of a panel of experts consisting of practitioners that have expertise in the area of project governance and project procurement as well as academician, which further considered the relationship and the influence of the criteria and indicators of ethical decision making (EDM) and project governance (project criteria, organisational culture, contract award criteria, individual criteria, client's requirements, government procedures and professional ethics). Through the identification and integration of the factors and EDM criteria as well as the project governance criteria and EDM steps for ethical issues, a PGEDM framework was developed to promote, and drive consistent decision outcome in project procurement in the public sector. The framework contributes significantly to ethical decision making in the project procurement process. These findings not only give benefit to the people involved in project procurement but also to the public officials in guiding them to be more accountable in handling ethical issues in the future and to have a more transparent decision making process.

A digital watermarking framework with application to medical image security

Dealing with digital medical images is raising many new security problems with legal and ethical complexities for local archiving and distant medical services. These include image retention and fraud, distrust and invasion of privacy. This project was a significant step forward in developing a complete framework for systematically designing, analyzing, and applying digital watermarking, with a particular focus on medical image security. A formal generic watermarking model, three new attack models, and an efficient watermarking technique for medical images were developed. These outcomes contribute to standardizing future research in formal modeling and complete security and computational analysis of watermarking schemes.

Mapping the integrity of differential obligations within the United Nations framework convention on climate change

This chapter unpacks public institutional integrity concepts through an examination of differential obligations within the global climate regime.

A Framework for Stakeholder Management and Corporate Culture

Purpose: This paper investigates the link between two knowledge areas that have not been previously linked conceptually; stakeholder management and corporate culture. Focussing on the UK Construction Industry, the research study demonstrates mutual dependency of each of these areas on the other and establishes a theoretical framework with real potential to impact positively upon industry.

Design/methodology/approach: The study utilises both qualitative and quantitative data collection and then analysis to produce results contributing to the final framework. Semi-structured interviews were used and analysed through a cognitive mapping procedure. The result of this stage, set in the context of previous research, facilitated a questionnaire to be developed which helped gather quantitative values from a larger sample to enhance the final framework.

Findings: The data suggests that stakeholder management and corporate culture are key areas of an organisation’s success, and that this importance will only grow in future. A clearly identifiable relationship was established between the two theoretical areas and a framework developed and quantified.

Originality/value: It is evident that change is needed within the UK Construction Industry. Companies must employ ethical and social stakeholder management and manage their corporate culture like any other aspect of their business. Successfully doing this will lead to more successful projects, better reputation and survival. The findings of this project begin to show how change may occur and how companies might intentionally deploy advantageous configurations of corporate culture and stakeholder management.

Gaining ethical approvals to undertake sexual health research with young people in the UK: Applying a 'Children's Rights Based Approach'

This paper (co-written with Dr Maria Lohan, Dr Carmel Kelly & Professor Laura Lundy) will describe the ethical review process to undertake health research in the UK, and explain an approach that can help researchers deal with ethical and methodological dilemmas in their research. Ethical review is necessary to ensure researchers and participants are protected, yet the requirement to ‘pass’ numerous committees may be challenging particularly for health researchers who work with vulnerable groups and sensitive topics. The inclusion of these groups/topics is crucial if health researchers are to understand health disparities and implement appropriate interventions with health benefits for vulnerable populations. It is proposed that to overcome ethical and methodological challenges and pitfalls, researchers must implement strategies that advocate for, and increase the participation of, vulnerable populations in health research. A ‘children’s rights based approach’ using participatory methodology will be described that draws on the jurisprudence of international law, (United Nations Convention on the Rights of the Child, 1989) and provides a framework that may empower ethics committees to carry out their function confidently. The role of the researcher, framed within the context of doctoral level study, will be reviewed in terms of the investment required and benefits of utilising this approach. It will be argued that adopting this approach with vulnerable groups, not only guarantees their meaningful participation in the research process and permits their voices to be heard, but also offers ethics committees an internationally agreed upon legal framework, ratified by their governing States, from which to fulfil their obligations and resolve their ethical dilemmas. Increasing the representation and participation of vulnerable groups in health research can inform the development of health policy and practice based on ‘insider knowledge’ that better engages with and more adequately reflects their specific needs. This is likely to yield numerous health, social and economic benefits for all of society through the delivery of more equitable, effective and sustainable services.

Does the existing Corporate Governance structure and strict Legal Framework, affect the strategic decisionmaking of CEOs?

This thesis is a case study on Corporate Governance and Business Ethics, using the Portuguese Corporate Law as a general setting. The thesis was conducted in Portugal with illustrations on past cases under the Business Judgment Rule of the State of Delaware, U.SA along with illustrations on current cases in Portugal under the Portuguese Judicial setting, along with a comparative analysis between both. A debate is being considered among scholars and executives; a debate on best practices within corporate governance and corporate law, associated with recent discoveries of unlawful investments that lead to the bankruptcy of leading institutions and an aggravation of the crisis in Portugal. The study aimed at learning possible reasons and causes for the current situation of the country’s corporations along with attempts to discover the best way to move forward. From the interviews and analysis conducted, this paper concluded that the corporate governance structure and legal frameworks in Portugal were not the sole influencers behind the actions and decisions of Corporate Executives, nor were they the main triggers for the recent corporate mishaps. But it is rather a combination of different factors that played a significant role, such as cultural and ethical aspects, individual personalities, and others all of which created gray areas beyond the legal structure, which in turn accelerated and aggravated the corporate governance crisis in the country.

Analysis of the Ethical, Social and Legal Issues Related to the Delivery of the Prenatal Genetic Testing in Argentina

L'introduction de nouvelles biotechnologies dans tout système de soins de santé est un processus complexe qui est étroitement lié aux facteurs économiques, politiques et culturels, et, par conséquent, demande de remettre en cause plusieurs questions sociales et éthiques. Dans la situation particulière de l’Argentine - c’est-à-dire: de grandes inégalités sociales entre les citoyens, la rareté des ressources sanitaires, l’accès limité aux services de base, l’absence de politiques spécifiques - l'introduction de technologies génétiques pose de sérieux défis qui doivent impérativement être abordés par les décideurs politiques. Ce projet examine le cas des tests génétiques prénataux dans le contexte du système de santé argentin pour illustrer comment leur introduction peut être complexe dans une nation où l’accès égale aux services de santé doit encore être amélioré. Il faut également examiner les restrictions légales et les préceptes religieux qui influencent l'utilisation des technologies génétiques, ce qui souligne la nécessite de développer un cadre de référence intégral pour le processus d'évaluation des technologies afin d’appuyer l’élaboration de recommandations pour des politiques cohérentes et novatrices applicables au contexte particulier de l’Argentine.

Ricoeur's "Petite éthique": an ethical epistemological perspective for clinician-bioethicists

This is a preprint of an article published in HEC Forum, 2010 22(4): 311-26. URL: http://www.springerlink.com/content/jj08821k513u5747/

What is the new medicines use review ‘patient survey’ attempting to capture in the context of existing patient satisfaction with pharmacy questionnaires and a new conceptual framework?

The community pharmacy service medicines use review (MUR) was introduced in 2005 ‘to improve patient knowledge, concordance and use of medicines’ through a private patient–pharmacist consultation. The MUR presents a fundamental change in community pharmacy service provision. While traditionally pharmacists are dispensers of medicines and providers of medicines advice, and patients as recipients, the MUR considers pharmacists providing consultation-type activities and patients as active participants. The MUR facilitates a two-way discussion about medicines use. Traditional patient–pharmacist behaviours transform into a new set of behaviours involving the booking of appointments, consultation processes and form completion, and the physical environment of the patient–pharmacist interaction moves from the traditional setting of the dispensary and medicines counter to a private consultation room. Thus, the new service challenges traditional identities and behaviours of the patient and the pharmacist as well as the environment in which the interaction takes place. In 2008, the UK government concluded there is at present too much emphasis on the quantity of MURs rather than on their quality.[1] A number of plans to remedy the perceived imbalance included a suggestion to reward ‘health outcomes’ achieved, with calls for a more focussed and scientific approach to the evaluation of pharmacy services using outcomes research. Specifically, the UK government set out the main principal research areas for the evaluation of pharmacy services to include ‘patient and public perceptions and satisfaction’as well as ‘impact on care and outcomes’. A limited number of ‘patient satisfaction with pharmacy services’ type questionnaires are available, of varying quality, measuring dimensions relating to pharmacists’ technical competence, behavioural impressions and general satisfaction. For example, an often cited paper by Larson[2] uses two factors to measure satisfaction, namely ‘friendly explanation’ and ‘managing therapy’; the factors are highly interrelated and the questions somewhat awkwardly phrased, but more importantly, we believe the questionnaire excludes some specific domains unique to the MUR. By conducting patient interviews with recent MUR recipients, we have been working to identify relevant concepts and develop a conceptual framework to inform item development for a Patient Reported Outcome Measure questionnaire bespoke to the MUR. We note with interest the recent launch of a multidisciplinary audit template by the Royal Pharmaceutical Society of Great Britain (RPSGB) in an attempt to review the effectiveness of MURs and improve their quality.[3] This template includes an MUR ‘patient survey’. We will discuss this ‘patient survey’ in light of our work and existing patient satisfaction with pharmacy questionnaires, outlining a new conceptual framework as a basis for measuring patient satisfaction with the MUR. Ethical approval for the study was obtained from the NHS Surrey Research Ethics Committee on 2 June 2008. References 1. Department of Health (2008). Pharmacy in England: Building on Strengths – Delivering the Future. London: HMSO. www. official-documents.gov.uk/document/cm73/7341/7341.pdf (accessed 29 September 2009). 2. Larson LN et al. Patient satisfaction with pharmaceutical care: update of a validated instrument. JAmPharmAssoc 2002; 42: 44–50. 3. Royal Pharmaceutical Society of Great Britain (2009). Pharmacy Medicines Use Review – Patient Audit. London: RPSGB. http:// qi4pd.org.uk/index.php/Medicines-Use-Review-Patient-Audit. html (accessed 29 September 2009).

Ensuring operational compliance and ethical responsibility in the regulation of ART: the HFEA, past, present, and future

Under the Public Bodies Bill 2010, the HFEA, cornerstone in the regulation of assisted reproduction technologies (ART) for the last twenty years, is due to be abolished. This implies that there is no longer a need for a dedicated regulator for ART and that the existing roles of the Authority as both operational compliance monitor, and instance of ethical evaluation, may be absorbed by existing healthcare regulators. This article presents a timely analysis of these disparate functions of the HFEA, charting reforms adopted in 2008 and assessing the impact of the current proposals. Taking assisted conception treatment as the focus activity, it will be shown that the last few years have seen a concentration on the HFEA as a technical regulator based upon the principles of Better Regulation, with little analysis of how the ethical responsibility of the Authority fits into this framework. The current proposal to abolish the HFEA continues to fail to address this crucial question. Notwithstanding the fact that the scope of the Authority's ethical role may be questioned, its abolition requires that the Government consider what alternatives exists - or need to be put in place - to provide both responsive operational regulation and a forum for ethical reflection and decision-making in an area which continues to pose regulatory challenges

Online data processing consent under EU law: a theoretical framework and empirical evidence from the UK

This article analyses the results of an empirical study on the 200 most popular UK-based websites in various sectors of e-commerce services. The study provides empirical evidence on unlawful processing of personal data. It comprises a survey on the methods used to seek and obtain consent to process personal data for direct marketing and advertisement, and a test on the frequency of unsolicited commercial emails (UCE) received by customers as a consequence of their registration and submission of personal information to a website. Part One of the article presents a conceptual and normative account of data protection, with a discussion of the ethical values on which EU data protection law is grounded and an outline of the elements that must be in place to seek and obtain valid consent to process personal data. Part Two discusses the outcomes of the empirical study, which unveils a significant departure between EU legal theory and practice in data protection. Although a wide majority of the websites in the sample (69%) has in place a system to ask separate consent for engaging in marketing activities, it is only 16.2% of them that obtain a consent which is valid under the standards set by EU law. The test with UCE shows that only one out of three websites (30.5%) respects the will of the data subject not to receive commercial communications. It also shows that, when submitting personal data in online transactions, there is a high probability (50%) of incurring in a website that will ignore the refusal of consent and will send UCE. The article concludes that there is severe lack of compliance of UK online service providers with essential requirements of data protection law. In this respect, it suggests that there is inappropriate standard of implementation, information and supervision by the UK authorities, especially in light of the clarifications provided at EU level.