Indian Journal of Medical Ethics

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https://imsear.searo.who.int/handle/123456789/1371

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Using case-based role-play to learn professionalism in Pharmacology
(Forum for Medical Ethics Society, 2025-06) Mathew, Rohini; Kumar, Aniket; Wilfred, Premila; Shanthi, Margaret
Background: Professionalism has been identified as a key competency for physicians to conduct, effective and ethical practice. The current competency-based medical education curriculum lays great emphasis on the development of attitude, ethics, and communication (AETCOM) among medical students which is embedded in the core concepts of professionalism. Comprehending these concepts early in the course of medical training is especially important as such a change may lead to reducing future incidents of professional misconduct. However, teaching this complex topic to undergraduate students through routine didactic lectures alone is challenging. Methods: To address this, we divided the batch of second-year MBBS students into 5 random groups and assigned 1 case scenario for role play to each group with sub-questions for discussion and reflection. After a short introductory lecture on professionalism, each group presented their role-play and discussed the sub-questions. Assessment for the improvement in knowledge was done using pre and post-test multiple choice questions. Results: Our findings show a statistically significant improvement in the mean (± Standard Deviation) scores for post-test (16.76±3.00) vs the pre-test (11.56±2.81) (p< 0.0001). Participant feedback was overwhelmingly positive based on the 5-point Likert scale. Conclusion: This shows that an interactive and engaging model, such as relevant case scenarios and role-play with reflection, along with assessment and feedback, could be effective for medical students, in learning the complex topic of professionalism.
Children with cancer in India: An ethical framework for practice
(Forum for Medical Ethics Society, 2025-06) Bagai, Poonam; Kanwar, Vikramjit; Carnevale, Franco; Macdonald, Mary; Arora, Ramandeep
Background: Childhood cancer has been ranked the most common cause of death due to non-communicable disease among 5- to 14-year-old children in India. Ethical concerns have been identified in the care of children with cancer in India, yet there is a paucity of ethical standards for clinical practice to help address these concerns. For example, emerging research has demonstrated that many children are distressed when they are impeded from participating in discussions and decisions regarding their cancer care. Therefore, we sought to create an ethical framework to guide practice with this population. Methods: We developed this ethical framework by conducting (a) a normative analysis of relevant documents that articulate norms for healthcare providers working with children in India and (b) stakeholder consultations with childhood cancer survivors, parents, and clinicians. Results: The ethical framework is structured according to twelve key ethical principles and corresponding challenges or implications for clinical practice. We discuss how this ethical framework can help address three leading ethical concerns that we have identified within the care of children with cancer in India: (a) communication problems; (b) inadequate care of symptoms or promotion of comfort; and (c) injustices or inequities related to limited financial means or poverty. Conclusion: Ethical concerns that have been related to the care of children with cancer in India can be prevented or at least mitigated through the integration of this ethical framework in everyday clinical practice.
Knowledge attitude and practice among dentists in Dakshina Kannada, India regarding ethical concerns in extraction of wrong tooth
(Forum for Medical Ethics Society, 2025-03) Purushothaman, Athira; Naik, Poonam
Background: Truth-telling and autonomy go hand in hand. As a result, it is a breach of the patients' rights to autonomy when medical errors are not disclosed to them. The aim of this study is to describe knowledge, attitudes and practices regarding ethical considerations among dentists following extraction of the wrong tooth. Methods: A descriptive cross-sectional study was conducted among dentists in Dakshina Kannada, India, who have had a minimum experience of 50 extractions in their practice. A validated scenario-based questionnaire was used to collect data and circulated via Google forms forwarded through email or an instant messaging application. Results: A total of 116 dentists responded to the survey. The majority (83, 71.6%) agreed that extraction of the wrong tooth though unintentional is considered as maleficence or negligence in dental practice. More than 70% participants (85) believed that the patient had the right to be informed about the mishap and deserved compensation for the same, while 38.8% participants agreed that dentists are less likely to be complained against if they disclosed the mishap verbally. Six responses to open ended questions reported that extraction of the wrong tooth had occurred to their knowledge. Conclusion: The majority of responses in our study appear to indicate that participants embrace the ideals of justice, autonomy, and non-maleficence. This study may have influenced the participants' attitudes regarding ethical issues related to incorrect tooth extraction and other iatrogenic errors they may encounter in their own or in a colleague's practice.
Designing and validation of a professional autonomy questionnaire for clinical nurses
(Forum for Medical Ethics Society, 2025-03) Balasi, Leila; Ebadi, Abbas; Elahi, Nasrin; Hazrati, Maryam; Jahani, Simin.
Background: Autonomy is a major element of professional practice in nursing and an important factor in improving the quality of patient care. This study aimed to design and validate a questionnaire to assess the professional autonomy of clinical nurses. Methods: This study utilised an exploratory sequential design in three stages. In the first stage, the constructive themes of the concept of nurses' professional autonomy were determined using a meta-synthesis. In the second stage, semi-structured individual interviews were conducted with 19 nurses, and analysis was performed using the deductive content analysis method. Finally, a methodological study was conducted to design and validate the clinical nurses’ professional autonomy questionnaire by testing for face, content, and structural validity. Reliability of the questionnaire was calculated by examining internal consistency and stability. Results: Based on the first and second stages, the initial pool of the questionnaire of 99 items was designed. The content validity index for the entire questionnaire was 0.964. For exploratory factor analysis, 250 nurses were included using the convenience sampling method. Varimax rotation and maximum likelihood methods were used to extract the factors. Finally, the clinical nurses’ professional autonomy questionnaire with 31 items and seven dimensions including "professional care", "professional mutual respect", "professional decision making", "leadership role", "professional discipline", "clinical skills" and "critical thinking" was developed with a 5-point Likert scale. The reliability was confirmed by Cronbach's alpha coefficient of 0.885, and the stability was confirmed by the intra-cluster correlation coefficient of 0.840. Conclusions: According to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria, the present questionnaire has desirable psychometric properties and is the first questionnaire specifically designed in Iran to assess professional autonomy in clinical nurses with applicability in different clinical departments.
Insurance coverage for mental illness: A review through a lens of bioethics and the MHCA, 2017
(Forum for Medical Ethics Society, 2025-03) VARMA, Amiti; JAIN, Nikhil; MAHASHUR, Sayali; FERNANDES, Tanya Nicole; KAPOOR, Arjun; PATHARE, Soumitra
Introduction: Health insurance coverage can serve as protection against catastrophic health expenditures. Section 21 (4) of the Mental Healthcare Act, 2017 (MHCA) mandates insurance coverage for mental illness to be on par with that for physical illness. Despite this, anecdotal evidence shows persons with mental health conditions are routinely denied or face difficulties in obtaining medical insurance coverage due to their mental illness. Method: We undertook an analysis of all insurance policy documents published on the Insurance Regulatory and Development Authority of India (IRDAI) webpage for the year 2020-21 to examine their relevance to mental illness and to examine how the policy wording adheres to Section 21 (4) of the MHCA and the core principles of bioethics. Results: We sourced 459 health insurance policies for the year 2020-21 from the IRDAI webpage. Of these, 268 relevant insurance policies were analysed in depth for their adherence to the MHCA guidelines and principles of bioethics. Of the policies analysed (n=268), we found six policies (from two insurance providers) explicitly excluded mental illness across all domains, in direct contradiction of the MHCA and the subsequent guidance issued by the IRDAI. Most insurance policies excluded coverage for injuries due to attempted suicide or self-injury (n=224) or alcohol consumption/substance use (n=267). Out-patient services were included in 23 policies.>/p> Discussion: Health insurance policies continue to contain discriminatory terms for mental illness thus violating the principle of parity put forth by the MHCA and at odds with core principles of bioethics. Sustained advocacy efforts are required to ensure insurance providers abide by the principles of parity in letter and in spirit to remove differential or discriminatory terms for mental illness in their policies in compliance with Section 21 (4) the MHCA.
Ancient DNA research may be conducted in the absence of consent from descendant communities
(Forum for Medical Ethics Society, 2025-03) Moosa, Thaakira; Ewuoso, Cornelius
Background: Ancient deoxyribonucleic acid (aDNA) research studies the genomes of human ancestors. Since the archaeological remains that carry this aDNA are often those of the non-living ancestors of living humans, one less explored question is whether aDNA research ought to be permissible in the absence of informed consent of descendant communities. We interrogate this question. Method: To address this question, this paper is a primarily conceptual paper that draws on moral norms arising from pre-existing — albeit competing — formulations of harmony in African moral philosophy. This methodological approach is not uncommon and has been accepted as a valid research method. Result: The paper’s methodological approach yields the conclusion that it is ethically permissible to conduct aDNA research on human archaeological remains in the absence of informed consent from descendant communities or individuals. Although we justify the ethical permissibility of conducting research without consent, we also emphasise the importance of consultation with descendant communities — where they are known — and the researchers’ responsibility to share benefits with them before, during, and after aDNA research. Conclusion: The sort of aDNA research that this paper considers permissible is that which is likely to enhance harmonious relationships in relevant ways. aDNA research is advancing rapidly and in proportion to technological advances. To ensure that aDNA research in a more technologically advanced world is undertaken in ethically permissible ways, global research guidelines would be required. Future studies can focus on articulating such guidelines.
COMMENTARY: Navigating the conundrum of mandatory reporting under the POCSO Act: Implications for medical professionals
(Forum for Medical Ethics Society, 2024-03) Batra, N.
To address the under reporting of sexual offences against children, the Protection of Children from Sexual Offences (POCSO) Act, 2012, makes reporting of such offences mandatory. The duty to report such offences has been extended to healthcare professionals. The inclusion of healthcare professionals within mandatory reporting, however, strikes at the very foundation of the doctor patient relationship based on trust and confidentiality and conflicts with the patient confidentiality safeguards of the Mental Healthcare Act, 2017. It also has unintended public health consequences, such as denial of medical termination of pregnancy due to fear of prosecution under POCSO. An urgent reassessment of these mandatory reporting norms for healthcare professionals, and a solutionbased approach that harmonises societal interest in the reporting of sexual crimes with the child’s right to health is essential.
“Our curriculum ourselves”: A participative approach to curriculum development on ethics and professionalism for community health workers
(Forum for Medical Ethics Society, 2024-12) Gopichandran, V; Subramaniam, S; Palaniswamy, B; Chidambaram, P.
Based on a felt need for training of community health workers on ethics and professionalism, we embarked on an attempt to develop a curriculum for the short course. We conducted interviews among community health workers and community members in Tamil Nadu and compiled a set of case vignettes to use in this course. Then we gathered an expert panel to come together for a two day consultative workshop to develop and refine this curriculum. This expert panel had community health workers, civil society representatives, representatives from non governmental organisations working in the health sector and academics and researchers from public health. We deliberated on various aspects of the course. In this report, we describe the participative process of curriculum development for training of community health workers on ethics and professionalism.
Antimicrobial stewardship in low- and middle-income countries: Developing a broader perspective through an ethical analysis
(Forum for Medical Ethics Society, 2024-03) Sinha, I; Dayama, S
The increase in the number of cases of antimicrobial resistance has gained attention worldwide. The main drivers of this situation are the misuse and overuse of antimicrobials for human and animal health. The imbalance between ensuring appropriate use of antimicrobials and providing equal access in the community makes this an ethical issue. The antimicrobial stewardship programme was initiated in response to this global crisis. Its framework includes interventions targeting the optimisation of antimicrobials in hospitals. Various countries have adopted stewardship interventions, and many success stories have been published. However, the steering of this programme faces hurdles due to the complexity that surrounds decision making in antimicrobial prescription, and the challenges of health systems in lower and middle income countries like India. Addressing these issues will extend the reach of these programmes, increase their sustainability and promote healthrelated justice to the community.
RESEARCH ARTICLE: Adolescent abortions in the Covid-19 landscape: Exposing the legal Achilles’ heel
(Forum for Medical Ethics Society, 2024-03) Jain, D; Rastogi, A.
The law ought to ensure that reproductive health services are accessible to all persons — married or unmarried — without subjecting them to heightened scrutiny or procedural requirements. However, the intersection of various laws and their impact on the willingness of medical professionals to offer abortion and reproductive health services to adolescents makes timely, safe, and affordable abortions difficult for adolescents to obtain. This challenge is exacerbated by a lack of public healthcare facilities, particularly in rural areas, and the overall restricted access to healthcare services during the Covid 19 pandemic. We delve into how legal uncertainties and gaps in multiple legislations pose obstacles for adolescents seeking abortion services, particularly in consensual sexual relationships. We specifically examine the unintended barriers stemming from the Protection of Children from Sexual Offences Act, 2012 (POCSO), which categorises consensual sexual relationships among adolescents as sexual offences without recognising their evolving sexual autonomy. Notably, POCSO includes a mandatory reporting provision, compelling the reporting of all sexual offences involving a “child” to law enforcement. This complexity is further compounded by the requirement for third party authorisation for abortion by medical boards. The Indian courts, in rendering inconsistent, moralistic, and biased judgments on adolescent access to abortion services during the Covid 19 pandemic, contributed to the complexities.
Some personal reflections on prison medical care
(Forum for Medical Ethics Society, 2024-12) Gonsalves, V.
This is a personal account of medical practices and healthcare behind bars, which draws on direct experiences and narrations from fellow prisoners, accumulated during eleven years in custody. It touches on issues of the relationship of medical professionals with the torture of detenus, the anarchy of everyday prison medication, frailty and death among older inmates and the proposals and prospects for prison healthcare reform. It sees a need for systemic change, but the prognosis is not optimistic.
Prison systems must embrace disability rights as a human rights imperative
(Forum for Medical Ethics Society, 2024-12) Tripathi, S; Tripathi, S; Singh, S.
For decades, India has been a staunch supporter of the human rights regime. However, lately, its positive role has been jeopardised by glaring instances of human rights violations against prisoners, especially those with disabilities. Since the edifice of the Convention on the Rights of Persons with Disabilities and the subsequent Rights of Persons with Disabilities Act emphasises non discrimination and reasonable accommodation, our policies, laws, and procedures need to be aligned with the human rights model of disability. We offer insights into the current challenges and propose disability inclusive prison reforms, advocating for data disaggregation, legislative amendments, accessibility measures, and decision making autonomy support. Upholding ethical healthcare standards is vital. Adhering to human rights principles and legal mandates in policymaking is crucial to combat systemic injustices and ensure equitable access to justice for all.
Alzheimer Disease research and A?*56: The star that never was
(Forum for Medical Ethics Society, 2024-03) Desai, BT.
Alzheimer's Disease is the most common form of dementia which affects 55 million people worldwide. Not surprisingly, it is a key focus of research involving huge funding. Scientific fraud has inevitably surfaced in this research area. This essay discusses a report of alleged fraud and its implications for the credibility of scientific research.
Reasons for retraction of clinical research articles in PubMed indexed medical journals from 2012 to 2022
(Forum for Medical Ethics Society, 2024-12) Maurya, M; Munshi, R.
Background: Misconduct in the publication of research articles is a serious concern for the scientific community. This study was conducted with the objective to assess various reasons for retraction of clinical research articles published in PubMed indexed journals from all over the world since 2012 to 2022. Methods: A search was performed on the PubMed database for retracted research articles using filters for “retracted publication”. A total of 314 eligible research articles were assessed for studying basic details. The study outcome measures were to evaluate the reasons for the retraction and authors’ and journal editors’ responses to retractions. Results: Of the original research articles retracted, 150/242 (61.98%) were clinical trial publications. Of the total 314 retracted research articles, the most retractions were in 2014 (47, 14.96%) and 2013 (40, 12.73%) while the fewest retractions were in 2012 (3, 0.95%) and 2022 (9, 2.86%). The most common reasons for retraction were data errors or data analysis errors (120/314, 38.21%) followed by plagiarism (37/314, 11.8%), duplicate publication (35/314, 11.1%), ethical concerns (23/314, 7.3%) and methodological flaws (22/314, 7%). These concerns were raised mainly by the editor or editor in chief (228/314, 72.61%), followed by authors (29/314, 9.23%). Out of 228 editorial concerns on publications, authors of only 91/228 (39.91%) agreed and 17/228 (7.45%) completely disagreed with the editorial decision. Conclusion: Authors need to be more careful about dataanalysis errors, fabricated or falsified data, and plagiarism while submitting their research papers. On the part of editors, detecting misconduct at the submission and peer review stages will help lower the retraction rate and avoid citation of such articles by other authors.
National Medical Commission’s new rule on capping the number of undergraduate medical seats in high performing States: pragmatic or quixotic?
(Forum for Medical Ethics Society, 2024-12) Venkatachari, M; Thirunavukkarasu, AB.
The article analyses the recent amendment by the National Medical Commission (NMC) in India, capping the number of undergraduate medical seats in high performing states, which has sparked a debate. With a healthcare system catering to the diverse needs of 1.4 billion people, regional disparities in healthcare personnel distribution have emerged, especially among doctors. The advantages of the amendment include a focused approach on lagging states and the potential distribution of doctors to improve overall health indices. However, concerns arise over infringement of the autonomy of state governments, potential hindrance to high performing states, and the impact on doctors' postgraduate choices. This commentary explores the complex factors influencing doctor distribution, including state policies, infrastructure and migration patterns. While emphasising the need for equitable healthcare access, and it also stresses the need for a balanced approach to address the challenges in doctor distribution to ensure both state and national healthcare needs are met effectively.
Scientific evaluation of Ayurvedic drugs — the use of N-of-1 clinical trials
(Forum for Medical Ethics Society, 2024-03) Chatterjee, A; Subramaniam, S; Sankaranarayanan, A.
Despite its ancient roots and prominence in India as an accepted alternative to modern medicine, Ayurveda’s growth has been hampered by an inability to carry out clinical studies of its effectiveness and safety using modern scientific methods — while preserving the core of Ayurveda, which is personalised medicine. In this comment, we propose that the N of 1 trial be used as a practical method to evaluate Ayurvedic treatments, which is simultaneously consistent with the canons of modern medicine and of Ayurveda. We emphasise the importance of doing this as a practical alternative that will benefit patients. We need not wait to resolve the epistemic inconsistency between Ayurveda and modern medicine to take steps in this direction.
Advance care planning and the ethical obligation of death literacy as a public health initiative in India
(Forum for Medical Ethics Society, 2024-12) Butola, S; Gursahani, R
This article highlights the importance of advance care planning (ACP) in good end of life care (EOLC). The judgement by the Supreme Court of India legalised Advance Medical Directives in 2018 and in January 2023, amended the procedure to make it easier. The article describes the advantages of ACP, the numerous ethical dilemmas at the end of life that it seeks to address and avoid, the latest legal procedure, the barriers, the need for awareness among healthcare providers, legal professionals as well as the public, and the need for legislation to translate the law into action. Educating citizens about their right to choose the kind of care they want at the end of life, including the right to refuse treatment, is the moral and ethical duty of all health professionals. Making death literacy and ACP a part of a public health initiative would be a major step towards meeting the obligations reflected in the World Health Organization guidelines and National Health Policy 2017, which envisage palliative care and EOLC as an integral part of Universal Health Coverage, requiring support from the government as well as the participation of civil society.
The healing power of the doctor-patient relationship
(Forum for Medical Ethics Society, 2024-12) Karkal, R.
Humane and empathic care are quintessential to the medical profession. In this narrative, a psychiatrist reflects on a difficult patient encounter which highlights the influence of trauma on a patient with psychosis and how the doctor patient relationship is paramount in the treatment of any illness.
A quasi-experimental study of trigger films for teaching the doctor-patient relationship
(Forum for Medical Ethics Society, 2024-12) Khaliq, F; Gangwani, N; Singh, S
Background: It is challenging to teach the complexity of the doctor patient relationship through attitude, ethics, and communication (AETCOM) modules, particularly without being formally trained and especially to first year medical students who do not interact directly with patients. The present study was undertaken to assess the effectiveness of trigger films (TFs) or short movie clips as a teaching learning tool to train undergraduate medical students on various aspects of doctor patient relationships. Methods: Two modules on various aspects of the doctor patient relationship were developed using TFs and written case studies and implemented on Phase I medical students. Quantitative and qualitative feedback were collected from learners. Perception, understanding, and knowledge were assessed using pre and post questionnaires. The results of the feedback and questionnaires collected after using TFs were compared with those collected after using written case studies. Results: There was a gain in knowledge and understanding after TF sessions, and TF sessions were rated much higher by the students than traditional methods. Most students found TFs to be an innovative and interesting tool. The satisfaction index calculated for TFs from the feedback of both students and teachers was above 96%. Conclusion: TFs engaged the students’ affective domain, promoted reflective attitudes, and linked their learning toexperiences. It was reported not only to be interesting and engaging but also effective as a teaching tool.
Ethical obstacles in health systems research in India: Need for focused guidelines
(Forum for Medical Ethics Society, 2024-03) SINGH, SHIPRA
This paper focuses on the ethical tensions seen in health systems research by researchers owing to their scientific obligations to their research, ethical obligations to study participants, and social obligations to the community. Health systems research differs from other public health research fields in terms of the participants selected, power relations within health systems and the socio political environment. The study seeks to answer the following questions through experiences in health system research. 1. What are the ethical tensions experienced by researchers in field work? 2. How are the existing guidelines used in resolving tensions arising in field work in India? To understand these ethical tensions, the World Health Organization’s Ethical Considerations for Health Policy and Systems Research were applied to research conducted in the health system settings. These tensions faced by researchers are explained through four emerging themes: the researcher’s position in the health system; voluntariness of participation: participation; and social justice.

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