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6 Ethical Issues in Healthcare in 2020

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“First, do no harm.” The seemingly simple maxim of healthcare proves far more complex when considered in the context of rapidly advancing medical technology, constant budget constraints, and new health threats. At a time when emerging technologies such as big data and artificial intelligence (AI) are challenging the fundamental notion of what a healthcare provider is, the battle to stop a worldwide pandemic reveals just how difficult ethical issues in healthcare can become when resources are strained.

How do you test the efficacy of a new medical technology without harming patients? Who gets care when the number of patients exceeds a hospital’s capacity? What organizations should have access to data that can predict a patient’s future health issues? Deliberating such complex practical and moral issues is a constant challenge in healthcare administration, and medical professionals can benefit greatly from training in ethical issues and public policy.

Here are just six of the major ethical issues facing the healthcare industry in 2020. Each issued-based section includes related questions that highlight specific challenges that leaders face when making day-to-day medical decisions and far-reaching policies that affect patient health.

Taking Advantage of Big Data Without Dehumanizing Patients

Medical professionals routinely make difficult decisions, including life-or-death calls, for patients and their families. They rely on extensive scientific training and increasingly sophisticated technology to do so, but their experience, instincts, and knowledge of individual patients also guide them. The increasing role of big data and predictive analytics in medical decision-making raises questions about the ethics of big data in healthcare — specifically whether data-driven decisions risk dehumanizing patients.

The term “big data” refers to the proliferation of digital information in the modern age. Advances in data storage and processing technology have dramatically changed the speed and volume of data analysis capabilities and given rise to predictive analytics. Such analysis promises more accurate diagnostic and therapeutic assessments, but assessments based purely on technology and data, no matter how accurate, lack an essential human touch. Imagine, for example, a decision to end treatment of a loved one’s terminal illness based solely on a predictive score produced by an algorithm.

As healthcare data collection technology advances, the industry faces questions about how to handle automatically collected data. Many modern medical devices are capable of reporting an incredible variety of health information, with or without a patient’s knowledge. For example, digital pills, also known as smart pills, are pharmaceuticals that contain an ingestible sensor that transmits data after the pill is consumed.

The first digital pill to be approved in the United States was a form of the antipsychotic medication aripiprazole (sold under the trade name Abilify) in 2017. A digital sensor in the pills is activated by the patient’s stomach acid and generates an electrical signal that’s picked up by a patch on the rib cage and then transmitted to a smartphone app. The technology offers a promising benefit for treating patients who struggle with medication adherence, but critics cite concerns about who should have access to such data and how it can be protected.

The advent of predictive and prescriptive algorithms that can analyze large amounts of data also increases the potential privacy risks associated with stored medical specimens. Medical researchers have long collected and stored blood and tissue samples for future research, but the value of biological samples has increased as advances have been made in genetics, genomics, and biotechnology.

Reusing stored biological samples and data collected from research participants in past studies, as well as samples collected from patients for clinical or diagnostic purposes, raises new issues about the responsibility of healthcare providers to obtain informed consent. A patient may give permission to a healthcare provider or clinical researcher to use a tissue sample for one test, for example, but have no control over its use in future projects.

Ethical Considerations

  • What is the best way to acquire a patient’s informed consent to the use of predictive analytics and other advanced analyses techniques that are based on the patient’s private data?
  • What are the ethical limitations on the use of data that is collected automatically by digital pills and other medical devices and technologies that report sensitive data, sometimes without the patient’s knowledge?
  • Do current policies and regulations related to biospecimens offer adequate privacy protection to patients?

Safeguarding Patient Privacy When Using Population Health Data

The digitization of patient information provides enormous benefits. Electronic health records (EHRs) create a centralized, shareable record of a patient’s entire medical history; allow for the automation of healthcare provider workflows; and enable advanced medical assessment tools. Because they hold large amounts of very personal data, they also carry the risk of privacy violation. Protecting patient data is a core responsibility of healthcare providers, and the federal law restricting release of medical information strictly regulates the handling of sensitive patient health information, but the field of population health complicates issues of patient privacy.

Population health is the analysis of health outcomes of large groups of people. The use and effectiveness of population health is increasing in the era of big data, which can be used to find links between diseases and specific environments or socioeconomic groups. Population health can discover widespread health problems or locate segments of the population that have a particularly high occurrence of a disease, for example.

Sharing patient data for secondary purposes, such as population health programs, requires either consent from the patient or anonymization of the data. However, even anonymized data can be misused. Through the practice of de-anonymization, or data re-identification, anonymous data can be compared with publicly available information and matched to an individual. The same information that public health officials use to diagnose, treat, and promote public policies could potentially be used by insurance companies, lenders, marketers, landlords, and employers.

Whether population health information is matched to an individual or applied in aggregate to a population, if it’s used for purposes other than promoting health, it has the potential to negatively impact those who supplied the data. An analysis that reveals a high rate of a disease in a given population could be used to focus education and treatment efforts; it could also be used to adjust insurance coverage.

  • What protections could be put in place to safeguard the de-anonymization of patient data?
  • How can patients be protected from the negative effects of inherent bias in the algorithms used to analyze public health data?
  • What level of control should individual patients have over the use of their private health information that becomes part of public health databases?

Ensuring Equal Access to Customized Medicine

Customized medicine refers to the creation of bioidentical limbs and organs to replace injured or missing ones. Biological 3D printers can create limbs and organs customized for a patient’s body, and scientists use DNA mapping to “grow” organs that are genetically identical to a patient’s own cells, according to Electronic Health Reporter.

The related field of precision medicine, or personalized medicine, also uses genomic data. Precision medicine doesn’t describe drugs or medical devices designed specifically for unique patients, but rather the tailoring of treatments to the individual characteristics of patients that have been classified using big data analytics and population health.

Enabled by advances in the understanding of how unique molecular and genetic profiles make an individual susceptible to a particular disease, personalized medicine has applications in risk assessment, prevention, detection, diagnosis, treatment, and management of diseases.

Customized medicine and other advanced treatments raise issues of income inequality and equal access to healthcare. Advances such as DNA mapping and bioidentical organs hold the potential to lengthen lives dramatically, but treatments that are prohibitively expensive for many or most patients violate the tenets of health equity.

  • How can healthcare providers ensure equitable access to expensive technologies that not only treat illnesses but also promise to promote longevity and enhance patients’ quality of life?
  • What are the ethics of cost/benefit analyses when human lives are at stake?
  • What policies could help avoid “genetic discrimination” when medical test results reveal conditions or genetic susceptibilities to specific diseases that weren’t the subject of the original tests?

Reconciling Patient Care Decisions with Financial Management

One of the constant ethical challenges facing healthcare administrators is how to make capital allocations that strike a balance between patients’ medical needs and fiscal responsibility. Health administrators responsible for healthcare finance management decisions may be put in a position to question, for example, whether a drug needs to be prescribed or an imaging test needs to be done. Even efforts to reduce waste and inappropriate use of resources, critical aspects of responsible fiscal stewardship, can unintentionally impinge on patients’ best interests.

The sometimes conflicting responsibilities of supporting optimal patient outcomes and fiscal responsibility can lead to a state of “moral injury.” Describing the injury of a person’s moral conscience and values resulting from the experience of committing a moral transgression, moral injury results in feelings of shame and guilt. The risk of moral injury can be particularly high in a profit-driven healthcare environment where multiple factors other than patient care influence treatment decisions.

  • What is the right balance between meeting the medical needs of patients and maintaining fiscal responsibility when making decisions about capital allocation?
  • How can healthcare administrators address waste and inappropriate use of resources without impinging on the medical decisions made by healthcare providers in the best interests of their patients?
  • What steps can be taken to address the moral injury that many healthcare providers feel when they’re forced by economic considerations to make decisions that go against their moral beliefs and their own expectations?
  • How can a sense of ethics be instilled in the day-to-day decision-making of healthcare workers in medical departments and in administrative roles?

Implementing Artificial Intelligence and Robotics Ethically

The growing use of AI and robotics also raises issues of healthcare technology ethics. AI refers to the ability of computers to mimic human intelligence and learning. Potential medical applications include analysis of radiologic images. AI used for health-related predictive analysis relies on large, diverse datasets, including EHRs.

However, the ability of AI-powered tools to analyze virtually any dataset, from income data to criminal records, raises concerns about its potential for abuse. The Genetic Information Nondiscrimination Act of 2008 prohibits employers and health insurers from considering genetic information when making decisions such as hiring and firing or health insurance eligibility. However, the law doesn’t apply to nongenetic predictive data.

Robotics are already heavily used in healthcare; robot-assisted surgeries are now commonplace, and robotic prosthetics are advancing rapidly. However, some see a future where robots care for the sick and elderly and robotic enhancements provide patients with superhuman capabilities — applications with more problematic implications.

Robotic health workers offer a potential answer to labor shortages, but their use could dehumanize those they’re meant to serve and those they replace. The evolution of robotics in healthcare beyond compensatory measures and into human enhancements raises issues of access and fairness for patients and challenges the definition of a healthcare provider.

  • What procedures are in place to ensure that AI, robotics, and other advanced technologies are adopted only after they’re proven to be effective in meeting the healthcare needs of patients?
  • How much say should patients have in the use of advanced technologies as part of their medical treatment?
  • Will predictions about a patient’s future health generated by AI systems be made available to insurance companies and other third parties?
  • What effect will AI-based medical care have on the relationship between patients and their doctors and other healthcare providers?

Devising Ethical Responses to Pandemics and Other Widespread Medical Emergencies

The outbreak of the COVID-19 virus provides a grim illustration of ethical issues in pandemic planning and response. When the World Health Organization (WHO) declared COVID-19 a pandemic in March 2020, tens of thousands of cases had been confirmed across more than 100 countries. The daily loss of life caused by the virus created an immediate healthcare crisis, prompting a rush to develop a vaccine and the enactment of social distancing measures in countries around the world.

A rapid response during pandemics is crucial, but rushing healthcare efforts can add risk to processes such as drug trials. Deciding how much risk is justified under the circumstances is an ongoing debate. Lacking a vaccine, public health officials have fought the outbreak with social distancing measures that slow the spread of the disease, helping to mitigate outbreak spikes that overwhelm medical facilities and ultimately result in more lives lost.

When determining how strict such measures should be, lawmakers and public health officials must balance the good of communities against individual liberties, a literal life-and-death decision with substantial financial, political, and social ramifications.

When pandemics and other widespread medical emergencies do overwhelm the capacity of medical facilities, even starker ethical questions arise. Healthcare professionals, who are themselves at risk of infection, may be forced to decide which patients should receive treatment or access to lifesaving equipment and treatment when need exceeds capacity.

  • How should healthcare providers decide who gets treated when the demand for their services outstrips their capacity to supply them to all patients who are in need?
  • How can healthcare professionals protect against age bias and other forms of discrimination when making these decisions?
  • In the race to develop vaccines and treatments for deadly diseases, such as COVID-19, how does the healthcare industry ensure that the potential risks to patients and caregivers of these new treatments are properly balanced with the potential rewards they promise?
  • What role do healthcare providers play in devising and enforcing policies, such as social distancing measures, that restrict the freedoms of their patients?

Combining the Science of Health with the World of Business

Addressing the difficult ethical issues influencing the science and business of healthcare requires leaders with exceptional knowledge and skills. Whether forming technology ethics committees, fostering greater collaboration between healthcare administrators and clinicians, or influencing regulations that protect the use of personal information and predictive data, such leaders support ethical healthcare while balancing medical and financial responsibilities.

With courses in innovation, strategy, and ethical issues and public policy, AdventHealth University Online’s  Master of Healthcare Administration in Strategy and Innovation and Master of Business Administration (MHA/MBA) Dual Degree  program develops strategic thinkers and leaders capable of making significant impacts and initiating positive change. Find out more about how this unique program offered through a partnership between AdventHealth University Online and Stetson University is creating leaders to shape the future of the healthcare industry.

Recommended Readings

AdventHealth University and Stetson University Announce Partnership and MHA/MBA Dual-Degree

Healthcare Administration: Salary, Careers, and Education

MHA vs. MBA: What Are the Differences?

American Medical Association, The Top 10 Ethical Issues Medical Students Should Be Taught

BMC Medical Ethics, “Addressing Harm in Moral Case Deliberation: The Views and Experiences of Facilitators”

BMC Medical Ethics, “Broad Consent for Biobanks Is Best — Provided It Is Also Deep”

BMC Medical Ethics, “Digital Pills: A Scoping Review of the Empirical Literature and Analysis of the Ethical Aspects”

BMC Medical Ethics, “Do Patients and Research Subjects Have a Right to Receive Their Genomic Raw Data? An Ethical and Legal Analysis”

Deloitte Insights, “Using Predictive Analytics in Health Care”

Electronic Health Reporter, “First Do No Harm: The Ethics of Healthcare in 2020”

GINAhelp.org, Genetic Information Nondiscrimination Act

Healthcare Financial Management Association, “Beyond Compliance: Healthcare CFOs Face Many Situations in Which Ethics Can Guide Decision-making”

HealthITAnalytics, “What Are Precision Medicine and Personalized Medicine?”

HealthTech,  “How Predictive Analytics in Healthcare Is Improving Patient Care”

Medical Xpress, “Artificial Intelligence in Medicine Raises Legal and Ethical Concerns”

National Center for Biotechnology Information, “Considerations for Ethics Review of Big Data Health Research: A Scoping Review”

RoboticsBiz, “8 Ethical Issues in the Use of Robotics in Healthcare”

STAT, “Research in the Time of Coronavirus: Keep It Ethical”

The Conversation, “The Coronavirus Pandemic Is Forcing Us to Ask Some Very Hard Questions. But Are We Ready for the Answers?”

The Hasting Center, “Why Health Care Organizations Need Technology Ethics Committees”

The Medical Futurist, “The Most Pressing Issues in Bioethics”

The New York Times , “First Digital Pill Approved to Worries About Biomedical ‘Big Brother’”

The Washington Post , “Too Many Tests, Too Little Time: Doctors Say They Face ‘Moral Injury’ Because of a Business Model That Interferes with Patient Care”

The Washington Post , “U.S. Hospitals May Have to Ration Care During the Pandemic. Here’s One Approach.”

U.S. News & World Report , “Why Will It Take So Long for a COVID-19 Vaccine?”

Recent Blogs


  • Open access
  • Published: 26 June 2005

Top 10 health care ethics challenges facing the public: views of Toronto bioethicists

  • Jonathan M Breslin 1 ,
  • Susan K MacRae 1 ,
  • Jennifer Bell 1 ,
  • Peter A Singer 1 , 2 &

the University of Toronto Joint Centre for Bioethics Clinical Ethics Group

BMC Medical Ethics volume  6 , Article number:  5 ( 2005 ) Cite this article

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There are numerous ethical challenges that can impact patients and families in the health care setting. This paper reports on the results of a study conducted with a panel of clinical bioethicists in Toronto, Ontario, Canada, the purpose of which was to identify the top ethical challenges facing patients and their families in health care. A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The panel was asked the question, what do you think are the top ten ethical challenges that Canadians may face in health care? The panel was asked to rank the top ten ethical challenges throughout the Delphi process and consensus was reached after three rounds.

The top challenge ranked by the group was disagreement between patients/families and health care professionals about treatment decisions. The second highest ranked challenge was waiting lists. The third ranked challenge was access to needed resources for the aged, chronically ill, and mentally ill.

Although many of the challenges listed by the panel have received significant public attention, there has been very little attention paid to the top ranked challenge. We propose several steps that can be taken to help address this key challenge.

Peer Review reports

It is not uncommon for health care professionals to clash with the family of the patients for whom they care over treatment decisions. Some patients will inevitably suffer the consequences of an error made during their care or hospitalization. Many people in need of diagnostic tests or surgical procedures are forced to wait months, and perhaps even years, to receive these services. These are just some examples of the kinds of ethical challenges that patients and their families may confront in the health care setting.

Although these challenges have been discussed widely in the literature as isolated ethical issues in health care, no attempt has ever been made to collate and prioritize them. Ranking the top ethical challenges facing the public can be an effective and valuable way of bringing them to the public's attention. Moreover, efforts to address ethical challenges in health care vary significantly from one to another, with some receiving a great deal of attention from the media and from government, while others go largely unnoticed; it would be valuable to discover whether the attention given to these challenges is allocated appropriately. Therefore, the purpose of this study was to identify the top ethical challenges facing patients and families in health care, from the perspective of a panel of clinical bioethicsts.

How the study was conducted

A modified Delphi study was conducted with twelve clinical bioethicist members of the Clinical Ethics Group of the University of Toronto Joint Centre for Bioethics. The justification for using a panel of bioethicists rather than a panel of community members is that clinical bioethicists will have a greater familiarity with the overall range of challenges than community members due to the fact that the ethical challenges are highly concentrated in their day-to-day work.

These clinical bioethicists work in a wide range of health care institutions, including quaternary-level institutions (for both adult and pediatric care), geriatrics/long-term care, rehabilitation, addiction and mental health, and community hospitals. In addition, the experience of the panel members covers both inpatient and outpatient health care. The Clinical Ethics Group at the Joint Centre for Bioethics is the largest institutionally-affiliated collection of clinical bioethicists in Canada, and perhaps in the world. Most of the panel members have several years of experience in clinical ethics, and the Clinical Ethics Group as a whole conduct more than 1200 consults per year. We believe that due to their extensive experience in ethics consultation and bioethics research, this group would be able to offer a uniquely informed perspective on the ethical challenges facing patients and their families. The twelve panel members chosen for the study represent a subset of the larger Clinical Ethics Group; although other members of the Clinical Ethics Group participated in various steps of the process, only the results of the twelve panel members who participated in all rounds were included in the results.

In the first round of the process the bioethicists were provided with a list of 38 themes that summarized the themes discussed during the previous two years of case conference discussions at the Joint Centre for Bioethics. The bioethicists were asked to provide a list of what they believed to be the top ten ethical challenges facing the public, which they could pull from the list of 38 themes or provide additional themes in their own words. In this context the phrase "ethical challenges facing the public" was meant to imply issues, situations, or problems, which have ethical implications, and would impact or affect the public either directly or indirectly. Although there were no formal criteria for determining the relative impact of the various challenges, the panel members considered such factors as the prevalence of the challenge (how often it occurs and is likely to occur in the future), how many patients and families are and will be affected by the challenge, and the seriousness of the impact on the public.

The panel members each responded by email with their list of ranked challenges, along with brief explanations as to why their chosen items were important and challenging. Two of the authors (SKM and JB) then clustered and reworded the themes as necessary to meet a desired level of specificity, and any themes from the original list not ranked by any panel member were dropped from the list. Following this, a list of 32 items was fed back to the panel in advance of a face-to-face meeting. The main purpose of this meeting was for the group to narrow the list further by grouping similar challenges together to make sure that all items were in fact distinct challenges. From this meeting a new list of 23 items was circulated for the second round of ranking, in which participants were again asked to rank their top ten items and give rationales for their rankings. This third round of ranking produced the final list of top ten challenges. The process was stopped after the third round because the list of challenges could not be specified or differentiated any further. The overall ranking was done as per the Delphi method, whereby the highest ranked scenario cited by a panel member was then assigned ten points, followed by the second highest ranked scenario receiving nine points, and so on until the tenth highest ranked scenario. Individual scores were summed up to create a total score for each scenario and a corresponding ranked list for the group. The maximum score that could be achieved by a single item was 120, which would result only if the same item was ranked as the top challenge by all twelve panel members.

Results of the study are listed in Table 1 . In addition to the rankings, the comments from the panel members made during both the face-to-face meeting and the third round of ranking were collected and serve as the basis for much of the content in the Discussion section. With a total of 113 out of a possible 120 points, the highest ranked ethical challenges facing the public in health care was disagreement between patients/families and health care providers over treatment decisions. According to the panel, these disagreements typically take one of two forms: health care professionals might push a treatment option (either for more or less treatment) that patients and families deep unacceptable, or conversely patients/families may push a treatment option (more or less treatment, or different treatment as in alternative or complementary treatments) that health care professionals deem unacceptable. We expand on this challenge in the "Discussion" section of the paper below.

The second highest ranked ethical challenge facing the public in health care, with 102 total points, was waiting lists. This has been a growing problem in Canadian health care as progressively increasing demand for health care services has put mounting pressure on the already strained Provincial health care systems in the country. According to the panel, waiting for needed care may in some cases compromise the health status and outcomes of patients, impede their ability to return to normal functioning at work and at home, and may also contribute to psychological distress. Waiting lists may also contribute to inappropriate use of scarce resources as is the case when acute care beds are used for long-term care patients, or ICU beds for chronic care patients. Waiting lists also raise the issue of geographical inequities among regions or various health centres.

The third highest ranked challenge was issues related to access to needed health care services for the aged, chronically ill and mentally ill. There are two components to this set of issues: one, according to the panel, is the marginalization of populations such as the elderly and mentally ill due to negative attitudes of many citizens toward those populations. The other component is the historical lack of priority of the needs of these populations in the funding allocation schemes of Canadian health care: the bulk of the funding has traditionally gone toward acute, life-saving care, while long-term care, rehabilitation care, and mental health have been grossly under-funded. According to the panel, socially or economically disadvantaged or mentally ill patients require appropriate advocacy to ensure their needs are met. Lack of patient compliance or self-care is sometimes used as reasons to withdraw resources. According to the panel members, we have an ethical obligation to acknowledge and challenge discriminatory beliefs around age, culture, and mental illness that are culturally and socially constructed in order to reduce the risk of emotional and physical harms of the vulnerable in our hospitals and nursing homes. Often these issues emerge when resources are limited.

The fourth ranked challenge was the shortage of family physicians or primary care teams in both rural and urban settings. According to a 2002 study published by the Canadian Institute for Health Information, the proportion of Canadian medical graduates starting practice as a general or family practitioner dropped sharply, from a high of 80% in 1992 to only 45% in 2000 [ 1 ]. This has become such a significant problem in Canadian health care that it was one of the major issues in the recent contract negotiations between the Ontario government and the Ontario Medical Association [ 2 , 3 ]. Many Canadians living in rural areas simply do not have family physicians; in urban settings many patients have to wait so long to see their family physicians that some choose to seek care in emergency rooms as an alternative. This just puts added pressure on already stressed emergency rooms in major Canadian cities. The shortage of family physicians is of considerable concern for a country whose health care system is centred on universal and reasonable access to medically necessary health care services.

The fifth ranked ethical challenge facing the public by the panel was the issue of medical error. Although errors have always been part of medicine, it wasn't until the 1999 report from the Institute of Medicine in the U.S., To Err is Human: Building a Safer Health System [ 4 ], that the public was made aware of how common medical errors actually are. Examples of such errors can include things that affect single patients, such as a patient receiving the wrong prescription or dosage of medication, or a patient having the wrong surgery performed, or things that impact a larger patient group, as when a hospital fails to properly sterilize surgical equipment. Although medical errors do not in themselves represent an ethical challenge per se, they do carry with them significant ethical implications. For instance, the prevalence of medical errors raises such ethical questions as if, under what circumstances, and how medical errors should be disclosed to patients and/or families.

Sixth on the list, but well behind the issue of medical error in overall scoring, was the challenge associated the appropriate use of pain medication in the terminally or chronically ill, and the use of palliative care at the end of life. For example, health care providers sometimes struggle with how to use pain medication appropriately for terminally ill patients because treating the patient's pain sufficiently can potentially hasten the death of the patient. The panel has suggested that this is one of the contributing factors behind the widespread under-treatment of pain in the terminally and chronically ill. Another challenge that falls into this category surrounds the timing of palliative care, i.e., decision making around when is the appropriate time to shift from a curative to a palliative approach to care.

Seventh on the list according to the panel was the challenge of obtaining informed consent in the health care setting. Research [ 5 ] and experience of the panel have shown that there is a huge gap between informed consent in theory and informed consent in practice: many patients do not or cannot read the consent forms they're asked to sign; consent discussions and capacity assessments are often superficial and rushed due to time constraints; and those same time constraints often contribute to staff not using interpreters with patients whose first language is other than English. The implication of this is that many patients may be subjected to medical interventions without providing properly informed consent. Since the ethical principle of respect for patient autonomy, on which the doctrine of informed consent is based, has become a central and foundational principle in modern Western health care, the implication of this challenge is troubling.

The eighth top challenge was a family of issues associated with participant involvement in research. There are a wide range of ethical issues related to research in the health care setting, including obtaining informed consent, the balance between providing participants with fair compensation and the risk that the compensation will be a coercive influence, the challenge of balancing benefits and risks of the research, issues around patient privacy and confidentiality, and the ethical appropriateness of involving in research participants who are not capable of giving an informed consent.

The ninth ranked challenge, finishing closely behind the challenges associated with research, was the challenge of substitute decision making. When a patient is incapable of making a particular health care decision, the health care team will turn to the substitute decision maker to make the decision. Depending on the particular jurisdiction there may be a legal hierarchy of decision makers, which typically places the patient's most intimate relationship at the top (spouse or partner) and other relatives toward the bottom of the hierarchy (many Canadian provinces and US states have such a hierarchy written into health care consent legislation). In the experience of the panel members, substitute decision makers often find this task to be a heavy burden, and struggle with the responsibility attached to making a potentially life-altering (and often life-ending) decision on behalf of their loved ones. This burden is experienced to the greatest degree when no guidance has been provided by the patient as to what his or her wishes would be in the current circumstances. When there is no guidance from the patient, conflict often ensues between the health care providers and the family/substitute decision makers as to what would be in the patient's best interests.

Finally, the tenth ranked challenge was that of surgical innovation. This is a challenge that patients and families will only face indirectly, as the general public is likely unaware of what the issues are related to surgical innovation. Surgical innovation raises such questions as, should innovative surgical techniques be considered research and be required to go through research ethics approval? Since variation is often part of the routine process of perfecting surgical techniques, it becomes difficult to ascertain when a surgical innovation becomes an experiment that requires research ethics approval. Also, what protections should be in place to ensure that innovative techniques or procedures can be developed while the risks to patients are minimized?

There are a number of benefits that can be realized with an exercise focused on ranking the top ten ethical issues the public may face. These include providing new contributions to knowledge, raising public awareness, and re-focusing attention on the top challenge. These benefits will be discussed in the discussion section below.

Providing new contributions to knowledge

The issues described as top ethical challenges by the panel have all been discussed individually in the literature, some extensively. And there have been a few attempts in the past to elicit the views of particular groups on major ethical issues in specific areas. For example, Ersek at al. surveyed a group of oncology nurses to elicit the ethical issues determined to be most important to that group [ 6 ]. Along slightly different lines, Walker et al. interviewed a group of physicians and nurses to elicit their perception of "ethics problems" in the care of their patients [ 7 ]. However, these previous studies have typically focused on the views of a specific group of health care professionals on ethical issues in particular health care contexts. No attempt has ever been made to seek the opinion of clinical bioethicsts who are in a unique position to offer comment on the overall ethical issues in the health care system. Furthermore, despite extensive coverage of ethical issues in the healthcare literature, no systematic effort has been made to collate and rank these kinds of issues from the perspective of the impact on the public.

Raising public awareness

A second benefit of such an exercise is that it can be part of an effective strategy to bring these challenges to the public's attention. Another component of the public awareness strategy might include a press release or other form of media attention coordinated with the publication of the research paper. Even the paper itself can spark discussion and bring the issues to the public's attention. Not only would this help to inform the public about ethical challenges they may confront in the health care system to they can be better prepared for those challenges, but it can help garner the public's support in advocating for steps to be taken to address the top challenges.

The challenges described by the panel will impact patients and their families in different ways and to varying degrees. For example, waiting lists (ranked 2 nd ) and the shortage of family physicians (ranked 4 th ) are challenges that will likely have an impact that is felt directly by a large percentage of the public. The same can be said of the third ranked challenge, access to needed health care resources for the aged, chronically ill, and mentally ill, and that challenge will impact an increasing number of patients and families in the future as our populations age and the number of elderly and chronically ill patients rise. This direct impact on the public, combined with the attention that issues like waiting lists do receive in the media, means that some of the challenges described by the panel are already at the forefront of the public's attention. On the other hand, the public is likely to be largely unaware of some of the other challenges mentioned by the panel. These are the challenges that tend to impact a smaller number of patients and families, such as issues related to participation in research (ranked 8 th ), or may impact patients and families more indirectly, such as the issues related to surgical innovation (ranked 10 th ).

Re-focusing attention on the top challenge

The most interesting result of this study is that the ethical challenge ranked highest by the panel is a challenge that actually receives very little attention in the popular media and at the level of government, and a challenge of which most members of the public are likely completely unaware. It is not surprising, however, that a panel of clinical bioethicists ranked disagreements between patients/families and health care professionals over treatment decisions as the top ethical challenge facing the public in health care. It is not surprising because it is probably the most common reason for requests for ethics consultations, and an area in which many bioethicists focus their research activities. A 2001 study by DuVal et al. found that the most common trigger for ethics consultations among U.S. internists was a desire for help to resolve a conflict [ 8 ]. Although the most common arena in which these disagreements occur is the intensive care unit, they can and do occur between patients/families and health care professionals in virtually every health care context: palliative care, rehabilitation, mental health, surgery, general internal medicine, family medicine, and so on. These conflicts can be as serious as an emotionally charged fight over a decision to withdraw aggressive treatment from a terminally ill patient in the intensive care unit, or as mundane as a family physician refusing to acquiesce to a patient's request for antibiotics for a viral infection.

According to the panel, it's the end-of-life critical care cases that tend to be the most emotionally charged, and the most intractable, because these are the cases in which the most is at stake – they typically amount, literally, to conflicts over life and death. A paradigm example of what has become the most common scenario would involve a patient in the late stages of a terminal illness, such as cancer with multiple metastases, or an elderly patient with multiple co-morbidities, who is ventilated in the intensive care unit. The family would be demanding that "everything" be done to maintain the patient's life, while the team feel strongly that subjecting the patient to aggressive interventions would amount to torture. Emotions run high, conflict ensues, and communication inevitably breaks down.

The above is a paradigm example of what is often referred to in the literature and by health care professionals in the clinical setting as a "futility" case. Although there are volumes of literature on the problems associated with the definition and use of the concept of futility, health care professionals know exactly what is meant when a colleague uses the concept: the likely harms of the aggressive intervention(s) outweigh the potential benefits to such a degree that subjecting the patient to the intervention(s) violates their professional (and sometimes personal) values. From the perspective of the health care professionals, the "right" decision is obvious and they cannot understand why the family doesn't see it the way they do. This often leads to these families being labelled as "irrational" or "unreasonable" by members of the health care team.

The family, on the other hand, views the situation very differently. They will tend to focus on the positive, holding out hope that their loved one will beat the odds. If the physician tells them their loved one has a 90% chance of mortality, what they hear is that their loved one has a 10% chance of survival. They aren't guided by success rates or statistics or prognostics; they are guided by devotion and/or a sense of duty to their loved one, a protective instinct, and hope. They may also be guided by deeply held religious beliefs, which they claim are also held by the patient. From the family's perspective, the health care professionals are being insensitive and disrespectful, unwilling to listen to or accept what is important to them. Sometimes families will go so far as to accuse the health care team of wanting to withdraw treatment to save money or to give the resources to another patient. Many of the panel members reported having been involved in ethics consultations where family members have expressed these sentiments.

What lies at the root of these conflicts is a clash of value systems. It is our value systems that influence the decisions we make, especially when we are faced with significant life-altering decisions in the health care setting. But it is not just patients and their families that are guided in their decisions by their values; health care professionals also come to their encounters with patients and families with their own value systems, both personal and professional. The fact that Canada is one of the most culturally diverse nations in the world means that clashes between the value systems of patients/families and health care professionals may be more common in Canadian health care institutions than in other countries.

Addressing the top challenge

Compared to the attention given to many of the challenges listed in the top ten, it is remarkable how little attention has been given to the top challenge. It is especially remarkable given that these conflicts occur in health care institutions across the country on a daily basis. Below, we propose several steps to help address this top challenge.

1. Educating health care professionals : Although most health care professionals are now taught communication skills, they are not taught the negotiation and mediation skills needed to address serious disagreements. The key is to make an attempt to understand the patient's perspective. We recommend that all health professional programs – undergraduate, postgraduate and continuing – takes steps to address this deficiency;

2. Creating policies for health care institutions : Some institutions have developed policies on cases of disagreement, especially at the end of life, but there is no consistency in this area across institutions. Some national accreditation organizations, such as the Canadian Council on Health Services Accreditation http://www.cchsa.ca and the Joint Commission on Accreditation of Healthcare Organizations in the U.S. http://www.jcaho.org , require health care institutions to have systems in place to address ethical issues facing patients, family members, and staff. We recommend this requirement be sharpened to include mechanisms to resolve disagreements between the health care team and patents or their substitute decision makers. In addition, it may be worthwhile to explore the plausibility of approaching policy development in this area through a process of public consultation. Having stakeholders with diverse value systems come together to discuss the challenge may prove to be a more fruitful approach than applying the standard top-down approach;

3. Examining the patient's perspective : Disagreements between patients or their substitute decision makers and health care teams present a difficult problem with no perfect solution. What is needed is a better understanding of the patient's perspective on this challenge. Some excellent work has been done in the attempt to shift the focus of end-of-life issues from the perspective of health care professionals and bioethicists to patients themselves [ 9 , 10 ]. However, what is still needed is quality research that focuses specifically on the perspectives of patients toward disagreements over treatment decisions;

4. Reporting to the public : Research studies like ours are only one part of a strategy to address the top challenge. A key part of the strategy would be a systematic effort to keep the public informed of such research and the attempts being made to address the challenge. National health councils or other similar bodies would be an excellent mechanism to pull together the diverse initiatives described above and to keep the public informed. Not only should the public be kept informed of steps to address the challenge but they should ideally be involved in the process itself. As mentioned above, one example of involving the public in the process would be to engage the public in the development of policies or guidelines to help address the top challenge.

Limitations of the study

The main limitations of this study relate to the generalizability of the results. First, the ranking of challenges may not be generalizable to contexts outside of Canada. Some of the challenges listed may be challenges that are particular to the Canadian context because of our Medicare system, such as the challenge of waiting lists or the shortage of family physicians. If this same study were conducted in other countries, it is possible that these challenges would be ranked much lower than in our study, or may not be ranked as a major challenge at all. However, we believe that on the whole our results are likely generalizable at least to other industrialized nations. The challenge of medical error, for example, is a universal challenge because medicine is, by its nature, a human endeavour. As long as humans remain imperfect, medical errors will occur. Moreover, we would predict that the top ranked challenge, disagreements between patients/families and health care providers over treatment decisions, would probably appear at or near the top of similar lists in other industrialized nations. Thus, although the panel was asked to report on the top ethical challenges facing Canadians in health care, we believe the results of this study would be of interest to other countries.

Second, because the panel was made up of clinical bioethicists in Toronto, the ranking of challenges may not be representative of the challenges facing the entire Canadian public. Some of the challenges might be considered more or less significant or prevalent in other parts of Canada, especially since there are some very apparent differences between the health care systems of the different provinces. Nevertheless, for the same reasons as mentioned above in the context of generalizability to other nations, we believe the results are in general representative of the challenges facing the Canadian public.

Third, since our panel was made up entirely of clinical bioethicists, we recognize that the results may not be generalizable to other groups. For example, if the panel was comprised of, or included, members of the public, hospital administrators, or clinicians, the results might have looked very different. Moreover, although the panel members do represent a wide range of health care instutitions, there were health care settings not represented amongst the group (e.g., home care or community family medicine). However, we believe that this is not a significant limitation of the study because the purpose was not to make a factual claim about what, objectively speaking, are the top ten ethical challenges facing the public. Rather, the purpose was to identify what those top ten challenges are from the perspective of a group of highly qualified and experienced clinical bioethicists who work in a variety of health care institutions.

Finally, we recognize that the modified Delphi process that we have presented in this paper is not typical because of the face-to-face meeting of panel members that took place prior to the final round of ranking. One of the potential limitations of including a face-to-face meeting during a consensus process is that a member or members of the group could exert influence over others, thus skewing the process away from genuine consensus. Nevertheless, we believe this potential problem was mitigated by the fact that the face-to-face meeting was not actually part of the ranking process but was an intermediate step between ranking rounds for the purpose of clarifying and differentiating the items. Thus, the consensus process itself was not directly affected by the face-to-face meeting.

Patients and their families face a number of ethical challenges in health care. Many of these challenges are no different from the kinds of challenges faced by patients and families in other industrialized nations. Other challenges on the list are more particular to our social context, with their roots in the very nature of the Canadian Medicare system. Waiting lists, access to needed care for the aged, chronically ill, and mentally ill, and the shortage of family physicians, are challenges that may impact Canadians to a greater or lesser degree than citizens of other nations. Interestingly, these three context-specific challenges were all ranked in the top four of the top ten ethical challenges facing Canadians. Moreover, some of the challenges have received far more public attention than others. Since so little attention has been given to the top ranked challenge, disagreements between patients/families and health care professionals over treatment decisions, we have suggested several steps to help address this top challenge.

Chan BTB: What Happened to Canada's Physician Workforce in the 1990's?. 2002, Canadian Institute for Health Information:

Google Scholar  

Bonnell G: Family Docs Won't Back Temporary Deal. National Post. March 17 2005

Ferguson R: Town's Last Six Doctors Quitting. Toronto Star. Feb 18 2005

Kohn LT, Corrigan JM, Donaldson MS, Editors: To Err is Human: Building a Better Health System. 1999, Institute of Medicine, Committee on Quality of Health Care in America:

Flory J, Emanuel E: Interventions to Improve Research Participants' Understanding in Informed Consent for Research: A Systematic Review. JAMA. 2004, 292: 1593-1601. 10.1001/jama.292.13.1593.

Article   Google Scholar  

Ersek M, Scanlon C, Glass E, Ferrell BR, Steeves R: Priority Ethical Issues in Oncology Nursing: Current Approaches and Future Directions. Oncology Nursing Forum. 1995, 22: 803-7.

Walker RM, Miles SH, Stocking CB, Siegler M: Physicians' and Nurses' Perceptions of Ethics Problems on General Medical Services. Journal of General Internal Medicine. 1991, 6: 424-9.

DuVal G, Clarridge B, Gensler G, Danis M: A National Survey of U.S. Internists' Experience with Ethical Dilemmas and Ethics Consultation. Journal of Medical Ethics. 2001, 27: i24-i29. 10.1136/jme.27.suppl_1.i24.

Powis J, Etchells E, Martin DK, MacRae SK, Singer PA: Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients. BMC Palliative Care. 2004, 3: 2-10.1186/1472-684X-3-2.

Singer PA, Martin DK, Kelner M: Quality end-of-life care: patients' perspectives. JAMA. 1999, 281: 163-8. 10.1001/jama.281.2.163.

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Grant support: Dr. Singer is supported in part by a Distinguished Investigator award from the Canadian Institutes of Health Research.

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Breslin, J.M., MacRae, S.K., Bell, J. et al. Top 10 health care ethics challenges facing the public: views of Toronto bioethicists. BMC Med Ethics 6 , 5 (2005). https://doi.org/10.1186/1472-6939-6-5

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Ethics: Contemporary challenges in health and social care

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Ethics: Contemporary challenges in health and social care

Two Ethics and contemporary challenges in health and social care

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This chapter explains ethical theories, principles, and issues of relevance in health and social care, including some recent trends in contemporary policy and practice with ethical implications. The first section separates ethics from morality. It examines the distinctions between normative and non-normative ethics, virtue ethics, ethics, and law. Examples of ethical challenges are identified, highlighting issues common to health and social care. Finally, the changing nature of professional roles and relationships, the role of protocols in relation to professional autonomy, lack of trust, changing social trends, potentially infinite demand for finite resources, increasing ethnic diversity, policy drivers towards quality and targets, and risk assessment and risk management are explored.

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Defining ethical challenge(s) in healthcare research: a rapid review

Guy schofield.

1 Centre for Ethics in Medicine, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK

3 Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, BS8 2PS UK

Mariana Dittborn

2 Paediatric Bioethics Centre, Great Ormond Street Hospital, London, WC1N 3JH UK

Lucy Ellen Selman

Richard huxtable, associated data.

All data is presented in this manuscript.

Despite its ubiquity in academic research, the phrase ‘ethical challenge(s)’ appears to lack an agreed definition. A lack of a definition risks introducing confusion or avoidable bias. Conceptual clarity is a key component of research, both theoretical and empirical. Using a rapid review methodology, we sought to review definitions of ‘ethical challenge(s)’ and closely related terms as used in current healthcare research literature.

Rapid review to identify peer-reviewed reports examining ‘ethical challenge(s)’ in any context, extracting data on definitions of ‘ethical challenge(s)’ in use, and synonymous use of closely related terms in the general manuscript text. Data were analysed using content analysis. Four databases (MEDLINE, Philosopher’s Index, EMBASE, CINAHL) were searched from April 2016 to April 2021.

393 records were screened, with 72 studies eligible and included: 53 empirical studies, 17 structured reviews and 2 review protocols. 12/72 (17%) contained an explicit definition of ‘ethical challenge(s), two of which were shared, resulting in 11 unique definitions. Within these 11 definitions, four approaches were identified: definition through concepts; reference to moral conflict, moral uncertainty or difficult choices; definition by participants; and challenges linked to emotional or moral distress. Each definition contained one or more of these approaches, but none contained all four. 68/72 (94%) included studies used terms closely related to synonymously refer to ‘ethical challenge(s)’ within their manuscript text, with 32 different terms identified and between one and eight different terms mentioned per study.


Only 12/72 studies contained an explicit definition of ‘ethical challenge(s)’, with significant variety in scope and complexity. This variation risks confusion and biasing data analysis and results, reducing confidence in research findings. Further work on establishing acceptable definitional content is needed to inform future bioethics research.

Methodological rigour within research is a cornerstone in the production of high-quality findings and recommendations. Across the range of empirical methodologies, a broad collection of protocol development tools, methodology guidelines, and reporting guidelines have been developed and evidence of their use is increasingly required by journals [ 1 – 6 ]. Within both empirical bioethics and descriptive ethics, there has been an accompanying increase in the acknowledgment of the importance of methodological rigour in the empirical elements, including within the recent consensus statement on quality standards in empirical bioethics research by Ives et al. [ 7 – 9 ]. Aligned with this aim for rigour, definitional clarity of key terms used within a research project is a component of research quality [ 10 , 11 ]. Improving the quality of empirical bioethics is also itself an ethical imperative [ 9 ].

We recently conducted a systematic review examining ‘ethical challenges’ as reported by specialist palliative care practitioners [ 12 ]. Our review, alongside our initial scoping search findings and reading of the literature, suggested that, although many authors use the term ‘ethical challenge(s)’ in empirical ethics research, there appeared to be no commonly described or accepted definition. Furthermore, papers retrieved rarely defined ‘ethical challenge(s)’ explicitly , which has also been noted by other researchers examining other topic areas [ 13 – 15 ]. Our review further suggested that authors frequently use terms closely related to ‘ethical challenge(s)’—such as ‘moral dilemmas’ or ‘ethical issues’—interchangeably with ‘ethical challenge(s)’ throughout manuscripts, rather than staying with the original term. Research shows that non-philosophers may understand these related terms in heterogeneous ways which may additionally affect understanding of texts across different readerships [ 16 , 17 ].

Without a clear definition of an ethical challenge, each researcher must use individual judgement to ascertain whether they have identified an instance of one within their dataset. This potentially generates an unnecessary source of bias, particularly if multiple researchers are involved in data collection, extraction, or analysis. This risks generating misleading ethical analyses, evaluations, or recommendations. Additionally, and more broadly, if primary studies do not define the term, then work based on these—such as systematic reviews of individual studies or those undertaking secondary data analysis—may unknowingly compare different phenomena without a mechanism for mitigating the effects this introduces.

In the hope of prompting a debate on this topic, we therefore undertook a rapid review, which aimed to explore existing definitions of “ethical challenge(s)” and the use of other closely related terms within recent empirical healthcare ethics literature.

We conducted a rapid review examining the usage of the term ‘ethical challenge(s)’ over the last 5 years in published research articles, in order to identify and summarise if, and how, the term was defined. As a secondary aim, we examined authors’ uses of closely related alternative terms within the included article texts separate to their use within any explicit definitions that may be present.

Rapid reviews use abridged systematic review methodology to understand the evidence base on a particular topic in a time and resource efficient manner [ 18 – 22 ]. Comparative reviews of topics in which both a rapid review and a systematic review had been undertaken demonstrated that the overall conclusions were similar, although rapid reviews were less likely to contain social and economic data, and systematic reviews contained more detailed recommendations [ 18 – 20 , 23 , 24 ]. The Cochrane Rapid Review Methods Group has recently released interim methodological guidelines for undertaking rapid reviews [ 6 ], advising authors to describe where their protocol deviates from a systematic review and detail any biases that these deviations may introduce [ 18 , 19 , 21 ]. We have followed the Cochrane recommended methodology [ 6 ]. A rapid review reporting guideline is currently under development [ 25 ] and this review is therefore reported based on the PRISMA 2020 statement for systematic reviews, with justifications provided where our approach deviated [ 26 ].

Prospective review protocol registration on the PROSPERO database is the current gold standard, but, at the time of writing, PROSPERO does not accept records for rapid reviews [ 27 ]. The protocol was therefore not published in advance.

Eligibility criteria

The inclusion and exclusion criteria are summarised in Table ​ Table1. 1 . We used Strech et al.’s Methodology, Issues, Participants (MIP) structure for our eligibility criteria, which is recommended for systematic reviews in ‘empirical bioethics’ [ 28 ]. The criteria reflect three assumptions. First, that the inclusion of ‘ethical challenge(s)’ in the title would increase the likelihood that this was the authors’ preferred term for the concept under investigation, and therefore increase the probability of a definition being provided. Second, that studies aiming to describe empirical data and identify ethical challenges in real-world contexts are most likely to contain a definition to guide researchers in identifying these challenges as they collect and analyse data. Third, that structured reviews of studies of ethical challenges are likely to include a definition to allow researchers to reliably recognise an ethical challenge in retrieved records. We used a 5-year timeframe as a date restriction. This reflected a balance between adequately covering recent use of the term and time and resource restrictions of the rapid review.

Inclusion and exclusion criteria

Inclusion criteriaExclusion criteria
Types of participantsAny participantsNo study will be excluded based on participant characteristics
IssuesStudies examining ‘ethical challenge(s)’ in any healthcare contextStudies not reporting research in a healthcare context
MethodologiesQualitative studies, mixed methods and quantitative studies, systematic reviews, structured but non-systemic reviews (narrative syntheses, rapid reviews, scoping reviews and other records with a described protocol that could be independently followed.) or their published protocolsThese may include expert opinion, bioethical argument pieces or case studies and analysis.Expert reviews on topics with no formal structure or published protocol details
TimeframeFive years. Publications indexed between 01/04/2016 and 31/03/2021Indexed outside of this timeframe
Type of publications

Reports that contain the phrase ‘ethical challenge(s)’ in the title

Peer-reviewed journal publications of empirical research or structured reviews published in English

Where no full text is available through the university subscription, study authors will be contacted for full text. If there is no response within two weeks, the study will be excluded

The following will also be excluded:

Conference abstracts

Editorials, letters, or comment/opinion pieces

Book sections

Information sources

The search strategy was as follows:

‘ethical challenge’.ti OR ‘ethical challenges’.ti.

We searched Medline (Ovid interface), Philosopher’s Index (OVID interface), EMBASE (OVID interface), and CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCO interface) for studies indexed over a five-year period between April 2016 and April 2021. These resources cover the breadth of healthcare research. Including Philosopher’s Index increased coverage of the bioethics literature. We did not search the grey literature [ 6 ]. The search strategy was tested by successfully retrieving three sentinel studies known to the research team.

Study selection

Retrieved studies were imported into Endnote X9.2 [ 29 ]. Records unavailable through institutional subscriptions were requested from corresponding authors. If unavailable 14 days after the request, the record was excluded. A random sample of 20% of records were dual screened at the title/abstract level by GS/MD. After discussion, the remainder were screened by GS. At full-text screening, a further 20% were dual screened by GS/MD and, again after discussion, the remaining studies were screened by GS.

Data extraction and analysis

Data extraction was undertaken using a pre-piloted form, with the first 5 records dually extracted by GS and MD. Data from the remaining included studies was then extracted by GS, with correctness and completeness checked by MD. We collected data on date of publication, authors, journal, country (for primary studies), methodology, definition of ‘ethical challenge(s)’ (present (yes/no)) and (where offered) the definition provided, and any closely related terms used, with counts of all terms used in each article. For closely related terms, data was extracted from the authors’ text, but not from direct quotations from qualitative research. Where definitions of ‘ethical challenge(s)’ were offered and/or related terms were identified, these were categorised and counted following the principles of summative content analysis [ 30 ]. Summative content analysis combines both the quantitative counting of specific content or words/terms with latent content analysis to identify and categorise their meanings. We identified keywords (‘ethical challenge(s)’ and closely related terms) deployed by the authors of the included papers, both prior to and during data analysis, and analysed the retrieved definitions. This approach allowed for exploration of both the content of definitions and development of insights into the use of related terms.

Risk of bias assessment

The focus of the rapid review was the definition of the term ‘ethical challenge(s)’ within retrieved records. We therefore did not undertake quality assessment for the included studies and reviews.

831 records were retrieved, reduced to 393 after de-duplication. 238 records were excluded after reviewing the title and/or abstract. 157 records were identified for full text screening, with 3 unavailable [ 31 – 33 ]. 82 records were excluded at full text stage and 72 records were included for analysis. See Fig.  1 for the PRISMA flowchart.

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PRISMA flow diagram of record identification

Record characteristics

Of the 72 included records, 53 were empirical studies [ 34 – 86 ], 10 non-systematic reviews [ 87 – 96 ], 7 systematic reviews [ 12 – 14 , 97 – 100 ], 1 systematic review protocol [ 101 ], and 1 non-systematic review protocol [ 102 ]. Of the 53 empirical studies, 42 (79%) were qualitative studies [ 34 – 36 , 38 – 44 , 47 , 48 , 50 – 52 , 54 – 58 , 60 , 62 – 67 , 69 , 71 – 77 , 79 – 81 , 83 – 86 ], 6 (12%) used a mixed methods approach [ 45 , 46 , 53 , 59 , 61 , 68 ], and 5 (10%) were quantitative [ 37 , 49 , 70 , 78 , 82 ]. 7/56 empirical studies, all qualitative interview studies, recruited participants internationally with no specific location stated [ 40 , 54 , 55 , 58 , 60 , 63 , 73 ]. Of the remaining studies, all but one were single-country studies: Botswana [ 75 ], Canada [ 41 , 65 ], China [ 57 ], Denmark [ 39 , 43 ], Dominican Republic [ 44 ], Germany [ 51 , 84 ], India [ 61 ], Iran [ 38 , 46 , 49 , 68 , 70 – 72 , 78 , 82 , 98 ], Italy [ 45 ], Mexico [ 87 ], the Netherlands [ 76 ], New Zealand [ 47 ], Norway [ 42 , 52 , 56 , 64 , 80 , 81 , 83 ], Saudi Arabia [ 34 – 37 ], Tanzania [ 69 , 74 ], Uganda [ 67 ], UK [ 86 ], and USA [ 50 , 53 , 59 , 62 , 66 , 77 , 79 , 85 , 85 ]. The remaining study was undertaken in both Sierra Leone and the UK [ 48 ]. See Table ​ Table2 2 for a summary.

Included study details

ReferencesTitlePublishedCountryResearch MethodologyDefinition
Draper and Jenkins [ ]Ethical challenges experienced by UK military medical personnel deployed to Sierra Leone (operation GRITROCK) during the 2014–2015 Ebola outbreak: a qualitative study2017UK/Sierra LeoneQualitativeY
Forbes and Phillips [ ]Ethical Challenges Encountered by Clinical Trials Nurses: A Grounded Theory Study2020USAQualitativeY
Hem et al. [ ]Ethical challenges when using coercion in mental healthcare: A systematic literature review2018n/a reviewSystematic ReviewY
Heggestad et al. [ ]Ethical challenges in home-based care: A systematic literature review2020n/a reviewSystematic ReviewY
Jakobsen and Sørlie [ ]Ethical challenges: Trust and leadership in dementia care2016NorwayQualitativeY
Jia et al. [ ]Nurses' ethical challenges caring for people with COVID-19: A qualitative study2021ChinaQualitativeY
Larkin et al. [ ]Ethical challenges experienced by clinical research nurses: A qualitative study2019USAQualitativeY
Mlughu et al. [ ]Voluntary HIV Counseling and Testing Among Commercial Motorcyclist Youths: An Exploration of Ethical Challenges and Coping Mechanisms in Dar es Salaam2020TanzaniaQualitativeY
Saghafi et al. [ ]Examining the ethical challenges in managing elder abuse: a systematic review2019n/a reviewSystematic ReviewY
Schofield et al. [ ]Real-world ethics in palliative care: protocol for a systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice2019n/a reviewSystematic Review protocolY
Schofield et al. [ ]Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice2021n/a reviewSystematic ReviewY
Storaker et al. [ ]From painful busyness to emotional immunization: Nurses' experiences of ethical challenges2017NorwayQualitativeY
Alahmad et al. [ ]Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia2020Saudi ArabiaQualitativeN
Alahmad et al. [ ]Ethical Challenges of Pediatric Cancer Care: Interviews With Nurses in Saudi Arabia2020Saudi ArabiaQualitativeN
Alahmad et al. [ ]Ethical challenges in consent procedures involving pediatric cancer patients in Saudi Arabia: An exploratory survey2021Saudi ArabiaQualitativeN
Alahmad et al. [ ]Ethical Challenges Related to the Novel Coronavirus (COVID-19) Outbreak: Interviews With Professionals From Saudi Arabia2021Saudi ArabiaQualitativeN
Ayala-Yáñez et al. [ ]Violence against trainees: urgent ethical challenges for medical educators and academic leaders in perinatal medicine2020n/a ReviewNon-systematic ReviewN
Bijani and Mohammadi [ ]Ethical challenges of caring for burn patients: a qualitative study2021IranQualitativeN
Binns et al. [ ]Ethical Challenges in Infant Feeding Research2017n/a ReviewNon-systematic ReviewN
Bladt et al. [ ]Empirical Investigation of Ethical Challenges Related to the Use of Biological Therapies2020DenmarkQualitativeN
Boulanger et al. [ ]Developing and Implementing new TB Technologies: Key Informants' Perspectives on the Ethical Challenges2020InternationalQualitativeN
Bourbonnais et al. [ ]Conditions and ethical challenges that could influence the implementation of technologies in nursing homes: A qualitative study2019CanadaQualitativeN
Brodtkorb et al. [ ]Preserving dignity in end-of-life nursing home care: Some ethical challenges2017NorwayQualitativeN
Bruun et al. [ ]Ethical challenges assessed in the clinical ethics Committee of Psychiatry in the region of Southern Denmark in 2010–2015: a qualitative content analyses2018DenmarkQualitativeN
Canario Guzmán et al. [ ]Ethical challenges for international collaborative research partnerships in the context of the Zika outbreak in the Dominican Republic: a qualitative case study2017Dominican RepublicQualitativeN
Carnevale et al. [ ]Correctional nursing in Liguria, Italy: examining the ethical challenges2018ItalyMixed-methodsN
Cartolovni and Habek [ ]Guidelines for the management of the social and ethical challenges in brain death during pregnancy2019n/a reviewNon-systematic ReviewN
Delpasand et al. [ ]Ethical challenges in the relationship between the pharmacist and patient in Iran. International Journal of Human Rights in Healthcare2020IranMixed MethodsN
Donnelly and Walker [ ]Enabling first and second year doctors to negotiate ethical challenges in end-of-life care: a qualitative study2021New ZealandQualitativeN
Ebrahimi and Ebrahimi [ ]Pediatric residents' and attending physicians' perspectives on the ethical challenges of end of life care in children2018IranQuantitativeN
Ewuoso et al. [ ]How do healthcare professionals respond to ethical challenges regarding information management? A review of empirical studies2021n/a reviewSystematic ReviewN
Forbes and Phillips [ ]Ethical Challenges Encountered by Clinical Trials Nurses: A Grounded Theory Study2020USAQualitativeN
Gagyor et al. [ ]Ethical challenges in primary care: a focus group study with general practitioners, nurses and informal caregivers2019GermanyQualitativeN
Haugom et al. [ ]Ethical challenges of seclusion in psychiatric inpatient wards: a qualitative study of the experiences of Norwegian mental health professionals2019NorwayQualitativeN
Hawking et al. [ ]"Can virtue be taught?": a content analysis of medical students' opinions of the professional and ethical challenges to their professional identity formation2020USAMixed-methodsN
Hofmann [ ]Informing about mammographic screening: Ethical challenges and suggested solutions2020n/a reviewNon-systematic ReviewN
Hunt et al. [ ]Ethical Challenges in the Provision of Mental Health Services for Children and Families During Disasters2018n/a reviewNon-systematic ReviewN
Hyder and Krubiner [ ]Ethical Challenges in Designing and Implementing Health Systems Research: Experiences from the Field2016InternationalQualitativeN
Jackson et al. [ ]Trust and the ethical challenges in the use of whole genome sequencing for tuberculosis surveillance: a qualitative study of stakeholder perspectives2019InternationalQualitativeN
Johnson and Parker [ ]Ethical challenges in pathogen sequencing: a systematic scoping review2020n/a reviewNon-systematic ReviewN
Kalkman et al. [ ]Stakeholders' views on the ethical challenges of pragmatic trials investigating pharmaceutical drugs2016InternationalQualitativeN
Kasper et al. [ ]Perspectives and Solutions from Clinical Trainees and Mentors Regarding Ethical Challenges During Global Health Experiences2020USAMixed-methodsN
Kelley et al. [ ]Ethical challenges in research with orphans and vulnerable children: A qualitative study of researcher experiences2016InternationalQualitativeN
Kemparaj et al. [ ]The Top 10 Ethical Challenges in Dental Practice in Indian Scenario2015IndiaMixed-methodsN
Klitzman [ ]Unconventional combinations of prospective parents: ethical challenges faced by IVF providers2017USAQualitativeN
Komparic et al. [ ]A failure in solidarity: Ethical challenges in the development and implementation of new tuberculosis technologies2019InternationalQualitativeN
Laholt et al. [ ]Ethical challenges experienced by public health nurses related to adolescents' use of visual technologies2019NorwayQualitativeN
Laliberte et al. [ ]Ethical Challenges for Patient Access to Physical Therapy: Views of Staff Members from Three Publicly-Funded Outpatient Physical Therapy Departments2017CanadaQualitativeN
Larkin et al.[ ]Ethical challenges experienced by clinical research nurses:: A qualitative study2019USAQualitativeN
MacDonald and Shemie [ ]Ethical Challenges and the Donation Physician Specialist: A Scoping Review2017n/a reviewScoping ReviewN
Martins Pereira and Hernandez-Marrero [ ]Ethical challenges of outcome measurement in palliative care clinical practice: a systematic review of systematic reviews2018n/a reviewSystematic ReviewN
Mbalinda et al. [ ]Ethical challenges of the healthcare transition to adult antiretroviral therapy (ART) clinics for adolescents and young people with HIV in Uganda2021UgandaQualitativeN
Mehdipour Rabori et al. [ ]Nursing students' ethical challenges in the clinical settings: A mixed-methods study2019IranMixed-methodsN
Moeini et al. [ ]Ethical challenges of obtaining informed consent from surgical patients2020IranQuantitativeN
Morley et al. [ ]Moral Distress and Austerity: An Avoidable Ethical Challenge in Healthcare2019UKQualitativeN
Naseri-Salahshour and Sajadi [ ]Ethical challenges of novice nurses in clinical practice: Iranian perspective2020IranQ ualitativeN
Naseri-Salahshour and Sajadi [ ]From Suffering to Indifference: Reaction of Novice Nurses to Ethical Challenges in First Year of Clinical Practice2019IranQualitativeN
Nicholls et al. [ ]The ethical challenges raised in the design and conduct of pragmatic trials: An interview study with key stakeholders2019InternationalQualitativeN
Pancras et al. [ ]Non-medical facilitators and barriers towards accessing haemodialysis services: an exploration of ethical challenges2018TanzaniaQualitativeN
Sabone et al. [ ]Everyday ethical challenges of nurse-physician collaboration2020BotswanaQualitativeN
Saigle and Racine [ ]Ethical challenges faced by healthcare professionals who care for suicidal patients: a scoping review2018n/a reviewNon-systematic ReviewN
Saigle et al. [ ]Identifying Gaps in Suicide Research: A Scoping Review of Ethical Challenges and Proposed Recommendations2017n/a reviewNon-systematic reviewN
Seekles et al. [ ]Inspectors' Ethical Challenges in Health Care Regulation: A Pilot Study2017NetherlandsQualitativeN
Segal et al. [ ]County Jail or Psychiatric Hospital? Ethical Challenges in Correctional Mental Health Care2018USAQualitativeN
Shayestefar et al. [ ]Ethical challenges in pediatrics from the viewpoints of Iranian pediatric residents2018IranQuantitativeN
Sinow et al. [ ]How Anesthesiologists Experience and Negotiate Ethical Challenges from Drug Shortages2020USAQualitativeN
Slettebo et al. [ ]Conflicting rationales: leader's experienced ethical challenges in community health care for older people2018NorwayQualitativeN
Solvoll et al. [ ]Ethical challenges in everyday work with adults with learning disabilities2015NorwayQualitativeN
Sun et al. [ ]Ethical challenges related to assistive product access for older adults and adults living with a disability: a scoping review protocol2017n/a reviewScoping Review ProtocolN
Taebi et al. [ ]Ethical Challenges of Embryo Donation in Embryo Donors and Recipients2018IranQuantitativeN
Tonnessen et al. [ ]Ethical challenges related to next of kin—nursing staffs' perspective2016NorwayQualitativeN
Ullrich et al. [ ]Ethical challenges in family caregivers of patients with advanced cancer—a qualitative study2020GermanyQualitativeN
Verma et al. [ ]Ethical Challenges in Caring for Unrepresented Adults: A Qualitative Study of Key Stakeholders2019USAQualitativeN
West et al. [ ]Operationalising ethical challenges in dementia research-a systematic review of current evidence2017n/a reviewSystematic reviewN
Wilson et al. [ ]Ethical Challenges in Community-Based Participatory Research: A Scoping Review2017n/a reviewNon-systematic ReviewN

12/72 (17%) of retrieved studies offered an explicit definition for ‘ethical challenge(s)’ [ 12 – 14 , 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 , 101 ]. Definitions were more likely to be found in more recent publications, with 4/12 included studies published in 2016–2018 [ 14 , 48 , 56 , 81 ], and 8/12 published in 2019–2021 [ 12 , 13 , 50 , 57 , 66 , 69 , 98 , 101 ]. The included study locations were evenly distributed, matching the overall pattern of retrieved studies, with studies from high- [ 48 , 50 , 56 , 66 , 81 ], middle- [ 57 , 98 ], and low-income settings [ 48 , 69 ]. The identified studies included eight qualitative studies [ 48 , 50 , 56 , 57 , 66 , 69 , 81 , 98 ], 3 systematic reviews [ 12 – 14 ], and 1 systematic review protocol [ 101 ]. Two of these records were the systematic review protocol and the report from our group, which accordingly contained the same definition [ 12 , 101 ], leaving 11 unique definitions. Definitions of ‘ethical challenge(s)’ identified in included studies are provided in Table ​ Table3. 3 . Additionally, 68/72 (94%) reports used closely related terms synonymously in place of ‘ethical challenge(s)’ throughout their manuscript text, with between 1 and 8 different terms used within each report, and 32 different terms were identified. This occurred in both those reports that contained a definition and those that did not. See Table ​ Table4 4 for terms and frequencies.

Details of studies that contained an explicit definition of ‘ethical challenges’

StudyStudy titleStudy designStudy field, locationDefinitionConceptsStudy participantsConflict and uncertaintyEmotional or moral distress
Draper and Jenkins [ ]Ethical challenges experienced by UK military medical personnel deployed to Sierra Leone (operation GRITROCK) during the 2014–2015 Ebola outbreak: a qualitative studySemi-structured interviewsSierra Leone/UK‘A shared understanding of what was meant by an ethical challenge was established either during the interview or immediately before it commenced. We took as our working definition that adopted by Schwartz et al.: ‘situations where either the HCPs [health care professionals] knew what they felt was the right thing to do but were somehow prevented from enacting it, or where “doing the right thing” also caused harm’.’
Forbes and Phillips [ ]Ethical Challenges Encountered by Clinical Trials Nurses: A Grounded Theory StudyOnline real-time typing interviews

Oncology clinical trial nurses


Study authors allowed participants to define ethical challenge. 'What does the term 'ethically challenging' mean to you' Results are described using participants’ descriptions
Heggestad et al. [ ]Ethical challenges in home-based care: A systematic literature reviewSystematic Review

Home based care

n/a review

‘Here, we have chosen to define an ethical challenge as “when there is doubt or disagreement about what is right or wrong.”’

This quotation references a definition used in Lillemoen L, Pedersen R. Ethical challenges and how to develop ethics support in primary health care. Nursing Ethics. 2013;20(1):96–108 [ ]

Hem et al. [ ]Ethical challenges when using coercion in mental healthcare: A systematic literature reviewSystematic Review

Mental Healthcare

n/a review

‘An ethical challenge occurs when one does not know how to behave and act in the best way, when one feels doubt or discomfort or when one is uncertain with respect to how one should interact in or react to the situation.’
Jakobsen and Sorlie [ ]Ethical challenges: Trust and leadership in dementia careSemi-structured interviews

Dementia care nursing home


‘The single question invites the informants to express themselves openly through their narratives. Hence, it is up to them to define the situations that are ethically difficult.’
Jia et al. [ ]Nurses' ethical challenges caring for people with COVID-19: A qualitative studySemi-structured interviews

COVID-19 Units


‘The expression “ethical challenges” mainly refers to ethical dilemmas and ethical conflicts as well as other scenarios where difficult choices have to be made. Ethical dilemmas are described as situations that cannot be solved; decisions made between two options may be morally plausible but are equally problematic due to the circumstances. Ethical conflicts, on the contrary, arise when one is aware of the necessity of proper actions but he or she may have trouble exercising these actions because of certain internal or external factors.’
Larkin et al. [ ]Ethical challenges experienced by clinical research nurses: A qualitative studySemi-structured interviews

Clinical research nurse practice


‘For this study, “ethical challenges” were defined broadly to encompass ethical dilemmas, ethical conflicts, and other ethical issues potentially leading to moral distress and moral residue.’
Mlughu et al. [ ]Voluntary HIV Counseling [sic] and Testing Among Commercial Motorcyclist Youths: An Exploration of Ethical Challenges and Coping Mechanisms in Dar es SalaamInterviews & focus groups

Commercial motorcyclist youths


‘In this context, ethical challenge refers to the situation whereby every alternative is morally wrong and still one has to make a choice’
Saghafi et al. [ ]Examining the ethical challenges in managing elder abuse: a systematic reviewSystematic Review

Elder abuse

n/a review

‘ethical conflicts and challenges emerge when two or several ethical values relevant to a particular situation necessitate conflicting measures’
Schofield et al. [ ]Real-world ethics in palliative care: protocol for a systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practiceSystematic review protocol

Palliative care

n/a review

‘The definition of ‘ethical challenges’ will be intentionally kept broad to capture the maximum number of examples. It includes but is not limited to terms such as ethical issues, moral challenges, moral dilemmas, values, good/bad, right/wrong. Ethical challenges can be labelled as such either by authors or participants.’
Schofield et al. [ ]Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practiceSystematic review

Palliative care

n/a review

‘The definition of ‘ethical challenges’ will be intentionally kept broad to capture the maximum number of examples. It includes but is not limited to terms such as ethical issues, moral challenges, moral dilemmas, values, good/bad, right/wrong. Ethical challenges can be labelled as such either by authors or participants.’
Storaker et al. [ ]From painful busyness to emotional immunization: Nurses' experiences of ethical challengesInterview study

Hospital nurses


‘In this article, ethical challenges refer to values that entail emotional and moral stress in healthcare personnel.’

Use of terms closely related to ‘ethical challenge’

Number of studies containing the term (total = 75)Term
 > 30Ethical issues

Ethical concerns

Ethical dilemmas


Ethical aspects

Ethical conflicts

Ethical considerations

Ethical problems


Ethically challenging/demanding/difficult situations

Ethical difficulties

Moral challenges


Ethical dimensions

Ethical questions

Ethical tensions

Moral dilemmas


Ethical complications

Ethical components

Ethical difficulties

Ethical discussions

Ethical disquiet

Ethical elements

Ethical factors

Ethical obstacles

Ethical struggles

Ethical uncertainties

Moral conflict

Moral courage

Moral considerations

Moral issues

Moral problems

Moral question

Morally relevant topics

Moral situations

Those records that offered explicit definitions used four approaches: (1) definition through concepts [ 12 , 57 , 66 ]; (2) reference to moral conflict, moral uncertainty or difficult choices [ 13 , 14 , 48 , 57 , 69 , 98 ]; (3) definition by study participants [ 12 , 48 , 50 , 56 ]; or (4) challenges as linked to their ability to generate emotional or moral distress within healthcare practitioners [ 14 , 14 , 66 , 81 ]. Each definition was associated with one or more of the identified elements, although none covered all four approaches. We describe these approaches below.

Approach 1: definition through concepts

This approach involves primarily defining ‘ethical challenge(s)’ in terms of related concepts. All three definitions using this approach defined ‘ethical challenge(s)’ as a summative collection of related concepts, including ‘ethical dilemmas’, ‘moral dilemmas’, ‘moral challenges’, ‘ethical issues’, and ‘ethical conflicts’ [ 12 , 57 , 66 ], for example:

‘The expression “ethical challenges” mainly refers to ethical dilemmas and ethical conflicts as well as other scenarios where difficult choices have to be made’ [ 57 ] p34

Only one went on to define the other concepts they utilised, ‘ethical dilemmas’ and ‘ethical conflicts’:

‘Ethical dilemmas are described as situations that cannot be solved; decisions made between two options may be morally plausible but are equally problematic due to the circumstances. Ethical conflicts, on the contrary, arise when one is aware of the necessity of proper actions but he or she may have trouble exercising these actions because of certain internal or external factors.’ [ 57 ] p34

Approach 2: moral conflict, moral uncertainty or difficult choices

This approach anchors an ethical challenge to the requirement for an agent to make a (difficult) choice in a situation where moral principles conflict, or there is moral uncertainty as to the ‘right’ way forward.

‘In this context, ethical challenge refers to the situation whereby every alternative is morally wrong and still one has to make a choice’ [ 69 ] p676 ‘An ethical challenge occurs when one does not know how to behave and act in the best way…’ [ 14 ] p93

Approach 3: definition by study participants

Four of the definitions involved research participants themselves defining something as an ‘ethical challenge’ [ 12 , 48 , 50 , 56 ], with three studies explicitly stating that participants would lead this definitional work [ 48 , 50 , 56 ]. Draper & Jenkins offer a starting definition, adopted from Schwartz et al. [ 103 ] with which to prime participants, while Forbes and Phillips [ 50 ] and Jakobsen and Sørlie [ 56 ] left the definition fully with their participants (Table ​ (Table3). 3 ). Finally, Schofield et al. proposed a very broad definition (Table ​ (Table3), 3 ), alongside the specific statement that either participants or researchers could nominate something as an ‘ethical challenge’ [ 12 ].

Approach 4: emotional or moral distress

This final approach was to tie ethical challenges to situations where participants feel ‘discomfort’, emotional distress or more specifically moral distress or moral residue [ 14 , 66 , 81 ]. Larkin et al. are clear that this distress must be tied to moral causes, but Hem et al. and Storaker et al. also refer more broadly to ‘discomfort’ [ 14 ] and ‘emotional stress’ [ 81 ] respectively. For example:

‘In this article, ethical challenges refer to values that entail emotional and moral stress in healthcare personnel.’ [ 81 ] p557

To the authors’ knowledge, this is the first rapid review to examine the use of the term ‘ethical challenge(s)’ in empirical healthcare research literature. Notably, only 12/72 (17%) of included studies published in the last 5 years contained a definition for ‘ethical challenge(s)’, despite this being the focus of the research being reported. The definitions identified were found in qualitative studies and systematic reviews and were evenly distributed geographically across high-, middle- and low-income settings. Definitions contained one or more of the identified approaches, although none contained elements from all four. Taken together, these findings suggest that a clear definition of ‘ethical challenge(s)’, and consistent use thereof, is currently lacking.

The four approaches indicate the diverse approaches to understanding ‘ethical challenge(s)’. Approaches 1 and 2 explore the concept from opposite viewpoints, with approach 1 looking from the conceptual perspective, through terms such as ‘dilemmas’ and ‘conflict’, and approach 2 from a participant perspective, specifically in those situations in which someone is trying to make a decision in circumstances where the preferred option is not possible or when they perceive there to be clash in values they feel are important. Within the concept-led definitions (approach 1), the use of a plurality of terms highlights a potential risk of bias, as different readers may interpret these differently. For example, some terms, such as ‘moral dilemma’, have relatively well understood specific meanings for some readers, particularly those with philosophical training [ 104 – 106 ]. The presence in the literature of specific and multiple meanings for some related terms highlights the importance of empirical studies providing a definition of these additional terms alongside their primary definition for ‘ethical challenge(s)’. This is more likely to be relevant where an a priori definition is used, but may be relevant to any prompting text for studies using a participant-led process, as in the study by Draper and Jenkins [ 48 ]. This clarity is important for both readers and future researchers who may undertake a secondary analysis of the data.

Approach 3 involves facilitating participants to nominate something as an ethical challenge [ 12 , 48 , 50 , 56 ]. This speaks to an important question about who, in a research context, is permitted to define or describe the object of interest, in this case ‘ethical challenge(s)’. Restricting the identification of ‘ethical challenge(s)’ to researchers alone may introduce bias by excluding input from those without bioethical ‘expertise’, but with important lived experience of the context under investigation. There is evidence that although clinicians can be sensitive to major ethical dilemmas, they can be less sensitive to small everyday ethical elements in clinical practice, and that ethical awareness varies between individuals [ 107 , 108 ]. Additionally, there is evidence in healthcare ethics research that patients and carers identify ethical challenges in situations that healthcare workers do not [ 109 ]. Therefore, relying entirely on a particular stakeholders’ perspectives (such as clinicians’) may risk missing important ethical challenges present in a scenario (assuming, of course, that we can settle what counts as an ‘ethical challenge(s)’).

In Approach 4, ethical challenges were linked to situations in which participants felt discomfort [ 14 ], emotional stress [ 81 ], moral distress or moral residue [ 66 ]. These concepts are themselves defined in quite varied ways (see, for example, definitions of ‘moral distress’ in a systematic review by Morley et al. [ 110 ]), potentially leading to additional conceptual confusion. Identifying triggers for moral distress is important, as high levels of moral distress are known to have negative impacts on work environments and lead to increased levels of compassion fatigue, increased staff turnover rates and poorer patient outcomes [ 110 – 112 ]. However, it is also possible that the requirement that, to be identified as an ethical challenge, the situation must invoke stress or distress might result in the under-identification of ethical challenges. We anticipate that many practitioners will daily manage multiple low-level ethical challenges, many of which will not generate moral distress or leave a moral residue. As such, the presence of moral distress may not be sufficient or even necessary in order to label a moral event an ‘ethical challenge’. However, the relationship between ‘ethical challenge(s)’ and moral distress is complex, and some might argue that the latter has an important relationship to the former. For example, moral distress, as conceived by Jameton and others [ 110 , 113 , 114 ], is linked to the after-effects of having to handle ethical challenge(s), so some researchers might view the generation of moral distress as relevant to identifying ethical challenges.

Although our review revealed these four approaches, the wider literature indicates there may be alternative approaches available. For example, other potential approaches would define ethical challenges as events that interact with moral principles, such as autonomy, beneficence, non-maleficence or justice, as proposed by Beauchamp and Childress [ 115 ], or as events in which those principles clash, for example as used by Klingler et al. in their research focusing on ethical issues in health surveillance [ 116 ]. However, these approaches were not seen amongst our included papers.

Returning to our included papers, the high rates of use of closely related terms within included manuscript texts may add to difficulties in understanding the exact object of interest if these terms are being used as synonyms for ‘ethical challenge(s)’. This may be particularly the case if terms used include those such as ‘moral dilemma’, which (as shown above) will have specific meanings for some readers. Interchangeable, undefined usage of these terms by study authors within study texts risks further exacerbating the problems caused by a lack of definitional clarity.

Strengths and limitations

This rapid review is the first systematic attempt to describe the definitions of ‘ethical challenge(s)’ available within the recent published literature.

There are, however, five limitations to note. First, the review only includes results from the past 5 years, which inevitably means that older publications, which may have contained further definitions of ‘ethical challenge(s)’, were excluded. The focus on the previous 5 years does, however, allow for an assessment of the term’s use(s) within a reasonable period of time and was felt to be appropriate given the aims and resources available to this project.

Second, our three assumptions listed in the methodology section may have excluded some records that contained a relevant definition. However, these assumptions, and the resulting focus on two search terms, allowed for a balance between retrieved record numbers and team resources.

Third, the four databases searched were chosen for their focus on the healthcare ethics literature; we may therefore may have missed relevant usage in other fields or disciplines. Similarly, we did not search the grey literature, which might have excluded relevant research.

Fourth, for resource reasons, the assessment as to whether a related term was being used interchangeably in the text was undertaken by a single researcher (GS). This subjective assessment risks miscalculating both the number of interchangeable terms identified and the frequency counts.

Finally, we did not review the theoretical literature for conceptual definitions of ‘ethical challenge(s)’, hence the definitions we identified might not match completely conceptual understandings of the term. However, our review shows how the term is currently being used in the research literature. Indeed, if there are strong conceptual definitions within the theoretical literature, then it is clear that they are currently not reaching the researchers whose work was identified by our review.

This review is the first, to our knowledge, to identify and describe definitions (and uses) of the widely-utilised concept of ‘ethical challenge(s)’ within healthcare research. Only 17% (12/72) of retrieved papers presented an explicit definition of ‘ethical challenge(s)’ before beginning to investigate this concept in context. The definitions found contained one or more of four identified approaches, with significant cross-reference to related terms and concepts which themselves have variation in their accepted meanings. We recommend that researchers define the phenomenon of interest—in this case, ‘ethical challenge(s)’—to help ensure clarity. This should either be a priori, or, if using an approach that includes participant participation in the generation of the definition, reporting their final working definition a posteriori. The choice of definition should be justified, including the decision as to whether to include participants in this process. Additionally, if a definition references other conceptual terms, then consideration should be given to defining these as well.

The results of this rapid review suggest that a common conceptual understanding of the term ‘ethical challenge(s)’ is lacking within empirical bioethical research and that there is a need for researchers in this area to consider what conceptual formulations might be most useful. Again, failure to use definitions of crucial research concepts within empirical bioethics research potentially generates confusion and avoidable bias within research outputs, risking misleading ethical analyses, evaluations, and resulting recommendations. We therefore hope this review will help stimulate debate amongst empirical bioethics researchers on possible definitional content for such a commonly used term and prompt further discussion and research. Additionally, given the central role of patient and public partnership and involvement in research, further thought should be given to who should be involved in nominating something as a challenge worthy of study.

Following on from this work, there would be value in conducting an empirical bioethical project combining a full systematic review of definitions of ‘ethical challenge(s)’ (and related terms) integrated with an exploration of the conceptual literature to generate recommendations for approaches towards the content of potential definitions, perhaps related to the identified approaches above. Such a project could also ask authors who currently use the term ‘ethical challenge(s)’ in their research how they conceptualise this. Furthermore, work to better understand the benefits of including study participants in the definition process is also important. Finally, whilst researchers should justify whatever approach they choose to take, there may be merit in examining whether anything is lost if studies lack a robust or agreed definition, or whether doing so affords a flexibility and openness that allows for a broader range of ethical challenges to be identified.


Not applicable.

Authors' contributions

GS, MD and RH conceived of the idea for the review; LES, GS, MD and RH designed the review protocol; GS and MD conducted the literature searching, screening, data extraction and led on data interpretation but all authors were involved; GS led on drafting the manuscript; all authors critically revised the manuscript for content and approved the version to be published. All authors read and approved the final manuscript.

GS is supported by a Wellcome Trust Research Award for Health Professionals (208129/Z/17/Z). LES is funded by a Career Development Fellowship from the National Institute for Health Research. RH is part-funded by the Wellcome Trust (209841/Z/17/Z) and the NIHR Biomedical Research Centre at University Hospitals Bristol NHS Foundation Trust and the University of Bristol. He serves on various local, regional, and national ethics committees and related groups. The views expressed in this publication are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, the Department of Health, or any of the other organisations with and for whom the authors work.

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The authors declare that there are no conflicts of interests.

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Ethical Issues in Healthcare Essay: Ethical Dilemma

In the complex world of healthcare, many ethical dilemmas arise. They challenge healthcare professionals with difficult choices that can have profoundly affect patients, providers, and the broader healthcare system. The Ethical Issues in Healthcare Essay explores the intricate ethical dilemmas encountered in this field, examining the various factors that contribute to these problems and the potential consequences they may have. It delves into the ethical principles of and frameworks of nursing that guide decision-making in healthcare settings. Pay attention to the importance of balancing values and ensuring the well-being of patients. Through real-life case studies and thought-provoking analysis, this essay provides valuable insights into the ethical dilemmas relevant in healthcare and stimulates critical thinking about the best approaches to navigate these dilemmas.

  • Ethical Issues in Healthcare Essay Introduction
  • Ethical Dilemma of the Present Case
  • Details of the Risen Dilemma

Violated Ethical Principles

Present barriers to ethical practice.

  • Ethical Decision-Making Practices for Similar Situations

Ethical Dilemma in Nursing Essay Conclusion

Ethical dilemma: ethical issues in healthcare essay introduction.

Today, being a nurse is associated with a number of complexities due to the need to comply with diverse obligations in social, political, and healthcare segments (Hamric, Hanson, Tracy, & O’Grady, 2013). It remains apparent that concepts such as fidelity are the core definers of nurses’ actions and behavior, as a nurse plays a role of a mediator between the management of the hospital, healthcare system, patients, and their relatives (Hamric et al., 2013).

Nonetheless, apart from living in a democratic society, ethical dilemmas tend to take place due to differences in the interpretation of ethical standards and guidelines. Today, nursing education is highly focused on this sphere, as only advanced nursing practitioners can contribute to fair decision-making by employing the principles of diverse ethical theories. Along with theoretical frameworks, role models such as Florence Nightingale assist nurses in becoming ethical leaders, who view ethics and justice as their priorities (Dossey, 2010).

Consequently, the primary goal of the paper is to describe ethical dilemmas that incurred in the healthcare setting while referring to its specific characteristics, violated ethical principles, and existent barriers to ethical practice. Based on the analysis of the situation, the most appropriate ethical decision-making theories and initiatives will be suggested to resolve similar cases in the future. In the end, conclusions are drawn to summarize the main findings of the paper and express my emotions about the occurred situation and my potential future attitude towards similar incidents.

Ethical Dilemma and Described Situation

As it was mentioned earlier, ethical dilemmas in nursing are rather common. Thus, one of the cases incurred at my workplace in the recent past. The situation took place at the hospital, where one of the patients was transferred due to some health problems. Thus, after organizing a series of tests, it was revealed that a patient had a type of cancer with a low chance of being cured. The thirty-year-old woman (the patient) was informed about her condition by her family doctor after being released home from the hospital. Thus, it could be said that she lost hope, as her condition continued to worsen, as she stopped taking prescribed medication and accepting the required treatment. The procedures such as insertion of urinary catheters were essential for the maintenance of her organs and survival, but she continued to refuse them.

Apart from the patient’s confrontation, her relatives were able to convince her to stay at the hospital since there was a chance of being cured. Meanwhile, the doctors discovered her as terminally ill and informed her family about this condition. Relatives in collaboration with the medical personnel of the hospital agreed not to inform the patient about her state, as they believed that it would help her regain hope. To support this scenario, family members started planning vacations after her release from the hospital. Unfortunately, the outcome of this situation was rather negative, as the patient died without knowing about her actual medical condition.

Overall, the described situation involved relatives, medical professionals, and the patient as the main actors. It could be said that catering to the needs of the family created ethical dilemmas for nurses, as they had to lie and be dishonest to the patient. This type of problem often takes place, but it is still unclear whether physicians should disclose the diagnosis to terminally ill patients or not since it has both advantages and disadvantages.

Specific Ethical Characteristics of Dilemma

It remains apparent that the situation described above can be viewed as one of the examples of communication problems. It could be discovered as the most common issues, as for example, in oncology, along with other matters, nurses have to pay substantial attention to the clarity of communication (Luz et al., 2015). Not being able to consider this aspect of paramount importance will trigger the development of insecurity and destroy the well-developed bond between patients and medical professionals (Luz et al., 2015). Apart from that, ineffective communication and inappropriate people skills also may have an adverse effect on the psychological wellbeing of a patient.

For example, some studies claim that depression is one of the potential consequences of the inability to choose the most appropriate methods to inform terminally ill patients about their medical condition (Marcus & Mott, 2014). Consequently, inappropriate communication with the patient in the first place might have triggered patients’ negative attitudes and lack of desire to continue medical treatment.

Nonetheless, miscommunication is not always the case. For example, sometimes nurses and physicians chose to conceal the truth from terminally ill patients (Safaris, Tsounis, Malliarou, & Lahana, 2014). In the context of the presented case study, the medical personnel did it since they wanted not only to help the patient to regain hope for being cured but also to cater to the needs and desires of her family. Consequently, on the one hand, it is believed to have a positive impact on the psychological wellbeing of a patient while convincing him/her to continue having the required medical assistance (Safaris et al., 2014). However, on the other side, these actions tend to violate the concepts of patient’s autonomy, as every individual has a right to know his/her actual diagnosis and determine the subsequent plan of action (Safaris et al., 2014).

At the same time, it is possible to identify that the situation has some characteristics of multiple commitments dilemma. The assessment of the case shows that communication issue highly interferes with the need to satisfy the needs of several parties including other nurses, physicians, relatives, and patients (Hamric et al., 2013). The main complexity of the chosen case is the fact that different parties had controversial viewpoints. For example, relatives did not want to inform the patient about her terminal illness while other stakeholders had the opposite opinion. In this case, medical professionals had to choose the most suitable plan of action based on their interpretation of ethical guidelines and characteristics of the scenario. To summarize, it could be said that the identified situation has key features of communication problems while highly interfering with other general nursing principles and multiple commitments dilemmas.

Due to the common occurrence of ethical dilemmas, it is easy to depict the core matters that were violated. In the first place, one of them is ignoring the patient’s autonomy, as any nurse is obliged to respect everyone’s freedoms and liberties (Hamric et al., 2013). In this case, the patient had a right to decide whether to continue receiving treatment or not, as only in this instance, her rights and freedoms would be respected. Nevertheless, due to the patient’s attitude towards diagnosis and its potential negative effect on her wellbeing and health, it could be claimed that disregarding the right to autonomy was logical, as it could improve the patient’s medical condition. However, there is not enough evidence to prove that choosing this option was the only right decision.

At the same time, it is evident that apart from a distinct violation of the patient’s autonomy, the rule of veracity was also disrespected. This concept implies that a nurse should tell the truth to a patient and provide only relevant information about his/her medical condition (Hamric et al., 2013). It could be said that deceiving patients can be discovered as one of the most common issues today since some professionals consider it a necessity in some cases. For example, Butkus (2014) views being dishonest to patients as appropriate if they have a mental impairment and cannot make logical decisions due to their psychological problems.

Nevertheless, in the context of the presented situation, the patient did not have any mental issues, but she reacted to the initial diagnosis negatively by expressing the lack of desire to continue treatment. This matter could be discovered as a potential trigger for making a particular decision. However, it is still questionable whether selecting a particular option was appropriate or not.

In turn, the presented situation is more complicated than it seems, as the actions of the medical personnel also did not comply with the rules of confidentiality and privacy. These aspects are the defining principles of the nursing profession, as nurses have to keep all confidential information in order, avoid its leakage, and do not transfer information to third parties (Hamric et al., 2013). In the presented case, the doctors decided that it would be rational to inform patients’ relatives and make a collective decision about subsequent actions. Pursuing this path did not comply with the ethical principles of the medical specialist. Nonetheless, in the context of the case, the violation of these principles is questionable due to the fact that the patient will not possibly want to continue the treatment after being diagnosed as terminally ill.

Nonetheless, it is evident that there are several matters that can be viewed as drivers of the development of ethical issues. For example, Hamric et al. (2013) state that there are a plethora of external and internal factors that may have a substantial impact on the selection and implementation of ethical theories and the decision-making process. In the first place, it is crucial to consider patient-provider barriers, as these stakeholders may have entirely different perceptions concerning appropriate medical treatment and other beliefs (Hamric et al., 2013). It remains evident that these problems take place rather often due to the paramount importance of diversity and multiculturalism in the modern world. These global phenomena imply that dissimilar religious beliefs and cultural dogmas and traditions have to be treated equally and respectfully disregarding differences.

One of the clearest examples of patient-provider barriers is the need to cater to patient’s and relatives’ wishes and desires (Hamric et al., 2013). It is evident that they may be different from the commonly accepted ethical principles for nurses. The selected case study reflected its main concepts of this barrier since the family did not want to inform the patient about her condition. Nonetheless, it incurred due to the controversial attitude of the patient, and this fact provided a rationale for consulting family and concealing the truth. Nevertheless, apart from the positive intentions of these actions, this barrier required medical professionals to violate some of their ethical standards and hide the right diagnosis.

It could be stated that another barrier that is highly linked to the obstacles of the patient-provider relationship is non-adherence (Hamric et al., 2013). This concept implies that a patient may not have the desire to improve his/her wellbeing and psychological and physical condition. In this instance, following and satisfying a patient’s needs want, and desires may result in hurting one’s health. This idea does not comply with the well-defined priority of patient’s safety, as proving the appropriate, high-quality treatment is the core of the patient-centered care model (Rahman, Jarrar, & Don, 2015). The characteristics of this barrier were clearly reflected in the selected case study, as the patient did not want to continue treatment, and it was the main reason for concealing the right diagnosis from the patient. It could be said that this obstacle triggered the selection of this option, as making truly “ethical” decisions (informing about the real diagnosis) might be associated with adverse consequences.

Lastly, many theorists highlight various interprofessional barriers that tend to have a strong effect on ethical decision-making. It could be said that that the main idea of this concept pertains to the fact that different professionals such as nurses and physicians have dissimilar understandings of the same situation and interpret acceptable ethical behavior differently (Hamric et al., 2013). In the context of this case, the physician, who had a conversation with the family, considered that it would be reasonable not to tell the patient about the actual diagnosis. At the same time, it was evident that nurses, who were in direct contact with the patient, experienced discomfort, as they had to conceal the truth.

In this instance, this barrier could not be discovered of paramount importance since the factors such as non-adherence were more influential in the presented context. Nonetheless, the existence of high power distance between physicians and nurses affected the whole process and created obstacles for the decision-making mechanism since the opinions of individuals with higher positions were viewed as dominant.

Ethical Decision-Making Practices to Resolve Similar Situations in Future

The analysis of barriers and characteristics of the situation helps gain a profound understanding of ethical decision-making, and a combination of these factors assists in choosing the most appropriate and relevant theory and framework to address similar problems in the future. The case clearly shows that telling the truth to the patient may not always be good due to its potential ability to cause harm, and disregarding related controversies, deceiving a terminally ill patient may be viewed as an ethical action. To support the rationale behind this decision-making, it is reasonable to refer to casuistry, as its followers have different perceptions towards lying (Butts, 2015). This theory implies that deceiving patients may be discovered as professional duty and obligation while being viewed as a potential benefit for both sides of the patient-provider relationship (Butts, 2015).

Nonetheless, to determine whether lying is appropriate, it is vital to use a well-established decision-making framework. In the first place, all information about the case has to be collected. For example, testing a patient’s ability to make rational decisions and evaluating his/her psychological wellbeing may be essential, as any deviations will ensure that the patient cannot make appropriate autonomous decisions. After that, it is essential to analyze a situation individually, as different matters such as beliefs non-adherence may influence the expected plan of actions (Hamric et al., 2013). Being able to take into account all matters highlighted above will ease the decision-making process and provide a rationale for making a particular decision.

At the same time, referring to similar cases in the past and practical experience can also be viewed as important since these aspects are the main features of casuistry (Hamric et al., 2013). Conducting this analysis will help determine the differences between the situations when deceiving patients is discovered as appropriate and when it is not. This evaluation will have an advantageous influence on the decision-making process, as it will help provide support for choosing a particular option with real-life examples. After that, the decision has to be thoroughly discussed with the representatives of different professions since it will help explain the reasons for this solution, identify gaps in it, and minimize stress levels. Based on the steps provided above, the casuistry theory is the most appropriate method, as it will help avoid bias by considering the practical side of ethics and the existence of potential exceptions.

Overall, it could be said that the selected case is only one of the examples of ethical dilemmas faced by nurses in the modern world. Medical professionals have to constantly be under pressure and decide whether they should disclose the truth to the patients or conceal the important details of their diagnoses and medical conditions. In this scenario, nurses chose to take the side of the family and did not inform the patient about her terminally ill condition while the patient died in ignorance. The main reasons for this decision can be related to the absence of a patient’s desire to continue medical treatment in the first place.

Thus, other barriers pertain to different attitudes of medical specialists, patients, and relatives towards the problem and other interdisciplinary and interprofessional obstacles and challenges. Based on these factors, it could be said that the problem is mostly communicational but with the elements of multiple commitments dilemma due to the need to satisfy the controversial interests of different parties. Nonetheless, it seems that the selected action violated a patient’s freedoms and rights and the nurse’s code of ethics.

As for my emotions, I can freely state that it would be hard for me to make a similar decision and conceal the right diagnosis from a patient. At first glance, I viewed the actions of medical personnel and family as wrongful. This situation evoked emotions like doubt, frustration, skepticism, and frustration. Nonetheless, after sufficient evaluation, I discovered that the actions were ethical and logical. For example, I think that deceiving patients was necessary, as otherwise, her condition might have worsened due to the absence of desire to continue medical treatment and the potential development of depression.

Consequently, I can freely claim that this case assisted me in understanding that strictly following ethical guidelines might not always be appropriate. When facing a similar situation in the future, I will employ the concepts of casuistry theory, as it states that every decision is highly dependent on the characteristics of the situation. Meanwhile, every case has to be discovered individually while referring to practical examples from the past. Collecting and evaluating the most important details of the case will help unveil whether deceiving patients is appropriate. Apart from the complexity of the decision-making process and the necessity to consider a plethora of factors, I will rely on this theory, as it will help design a logical solution while taking into account the preferences of different participants.

Butkus, M. (2014). Compassionate deception: Lying to dementia patients. Philosophical Practice: Journal of the American Philosophical Practitioners Association, 9 (2), 1388-1396. Web.

Butts, J. (2015). Nursing ethics: Across the curriculum and into practice. Burlington, MA: Jones & Bartlett Learning. Web.

Dossey, B. (2010). What would Florence Nightingale say about ethical dilemmas facing nurses? .

Hamric, A., Hanson, C., Tracy, M., & O’Grady, E. (2013). Advanced nursing practice: An integrative approach. St. Louis, MI: Elsevier Saunders. Web.

Luz, K., Vargas, M., Schmidtt, P., Barlem, E., Tomaschewski-Barlem, J., & Rosa, L. (2015). Ethical problems experienced by oncology nurses. Revista Latino-Americana de Enfermagem, 23 (6), 1187-1194. Web.

Marcus, J., & Mott, F. (2014). Difficult conversations from diagnosis to death. The Ochsner Journal, 14 (4), 712-717. Web.

Rahman, H., Jarrar, M., & Don, M. (2015). Nurse level of education, quality of care and patient safety in the medical and surgical wards in Malaysian private hospitals: A cross-sectional study. Global Journal of Health Science, 7 (6), 331-337. Web.

Safaris, P., Tsounis, A., Malliarou, M., & Lahana, E. (2014). Disclosing the truth: A dilemma between instilling hope and respecting patients’ autonomy in everyday clinical practice. Global Journal of Health Science, 6 (2), 128-137. Web.

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Home / Essay Samples / Health / Medical Ethics / Analysis of Ethical Issues in Healthcare

Analysis of Ethical Issues in Healthcare

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  • Topic: Medical Ethics

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