A study was carried out in Australia and the UK of the legislation and procedures relating to the welfare and use of animals in scientific research. In Australia, a National Code of Practice for the Care and Treatment of Laboratory Animals has been adopted and it is a legal obligation for all Institutions to adhere to the Code. Each institution has an Animal Ethics Committee (AEC) responsible for ethical review and animal welfare which must include, within certain stipulated parameters, a veterinarian, a research scientist, a member of a rights/welfare organisation and an additional lay member. In the UK the situation is different, as the Home Office directly administers the law regarding the use of animals in research. In April 1999 the Ethical Review Process (ERP) was introduced; every Institution must establish an ERP which must include a named veterinarian and representatives from the Animal Care and Welfare Officers and others. In both countries great emphasis is placed on the principles of replacement, reduction and refinement in experimental research. Substantial differences in culture and ethical review structure between the two countries are identified. However, various recommendations are outlined, based on the Australian experience, to build on existing structures and further develop the UK ERP. These recommendations should be seen as long-term aims and seek to further improve animal welfare through facilitating communication, increasing accountability and creating an environment conducive to open discussion.

Introduction: Research on prehospital emergency work traditionally has focused on medical issues, but paramedics often have to make ethical choices. The goal of this exploratory study was to understand how paramedics experience difficult ethical dilemmas regarding resuscitation of cancer patients.

Methods: Paramedics from ambulance services in Norway were interviewed about resuscitation of cancer patients with cardiac arrest. The qualitative study included naturalistic, semi-structured interviews and a cognitive-emotional, interpretive approach.

Results: All study participants believed that it ethically can be correct not to resuscitate if the patient is expected to survive for only a short time with a very low quality of life and severe negative illness experiences. However, this belief sometimes failed to match formal or informal guidelines and contextual factors such as expectations of relatives. When confronting these challenges, the majority of the paramedics relied heavily on the advice of medical experts, but some had to make more autonomous decisions.

Discussion: The concept of a double pressure situation can be used to analyze the ethical dilemmas regarding resuscitation of cancer patients. The pressure from “below” is grounded in individual caring frameworks, and in the belief that it can be wrong to resuscitate. The pressure from “above” is objective and system-related, related to uncertainty, and grounded in the fundamental and irreducible value of human life.

Conclusions: The findings of this qualitative, exploratory study suggest that ethical concepts and analyses of double pressure situations should have an important role in education and training designed to prepare emergency personnel for difficult life and death choices. More research is needed to shed light on how ethical dilemmas arise in prehospital work.

The bioethics movement has long promulgated a model of ‘principled decision-making’ in which ethical dilemmas and conflicts between various rights, interests, and ethical principles are central. In many respects this movement has had a laudatory impact on health care and on health professionals, but we will also argue that the bioethical model of ethical analysis has important limitations. The model's theoretical orientation is discontinuous with the training and skills of health professionals, the manner in which health professionals conceptualise and solve problems that arise in a clinical setting, and the time constraints inherent in most clinical situations. As such, the model is not readily applicable to much of the day-to-day work of clinicians and, in particular, to the routine ethical questions and situations that arise in caring for patients. What we suggest is that the bioethical model does not take into account that health care professionals, as part of their daily work, encounter and manage difficult, often conflictual situations and that they do so by bringing to bear conceptual frameworks and therapeutic techniques that have, embedded within them, the ethical values and goals of their own fields, as well as established ways of dealing with problems and addressing competing priorities. We further argue that from a systems perspective, the bioethical model and the pragmatic, problem-focused ethical decision-making of clinicians operate on different levels of complexity; whereas the former is especially appropriate for situations that resist consensus or that raise significant issues of public policy, the latter serves as an effective framework in less difficult or complex situations that can be moved effectively toward consensus and closure.

Objectives and Methods: Many authors have argued that ethical, legal, and social issues (“ELSIs”) should be explicitly integrated into health technology assessment (HTA), yet doing so poses challenges. This discussion may be particularly salient for technologies viewed as ethically complex, such as genetic screening. Here we provide a brief overview of contemporary discussions of the issues from the HTA literature. We then describe key existing policy evaluation frameworks in the fields of disease screening and public health genomics. Finally, we map the insights from the HTA literature to the policy evaluation frameworks, with discussion of the implications for HTA in genetic screening.

Results and Conclusions: A critical discussion in the HTA literature considers the definition of ELSIs in HTA, highlighting the importance of thinking beyond ELSIs as impacts of technology. Existing HTA guidance on integrating ELSIs relates to three broad approaches: literature synthesis, involvement of experts, and consideration of stakeholder values. The thirteen key policy evaluation frameworks relating to disease screening and public health genomics identified a range of ELSIs relevant to genetic screening. Beyond straightforward impacts of screening, these ELSIs require consideration of factors such as the social and political context surrounding policy decisions. The three broad approaches to addressing ELSIs described above are apparent in the screening/genomics literatures. In integrating these findings we suggest that the method chosen for addressing ELSIs in HTA for genetic screening may determine which ELSIs are prioritized; and that an important challenge is the lack of guidance for evaluating such methods.