Ethical awareness and issues in gastrointestinal endoscopy practice: A survey study

Abstract

BACKGROUND

Gastrointestinal endoscopy technology has significantly improved the diagnostic accuracy and the successful treatment of gastrointestinal diseases. However, a series of ethical issues have emerged, such as expanding treatment indications, which affect the fair distribution of medical resources. There is limited research on ethical issues in the field of digestive endoscopy.

AIM

To investigate the level of ethical awareness among gastrointestinal endoscopy practitioners and analyze the ethical issues involved in gastrointestinal endoscopy technology.

METHODS

A questionnaire survey was performed to collect relevant data (gender, age, degree of education, professional title, personnel category, the level of understanding medical ethical principles, ethics training and its learning pathways) from gastrointestinal endoscopy practitioners at the Second Hospital of Dalian Medical University and Dalian Friendship Hospital, including licensed physicians and nurses (including trainees and graduate students).

RESULTS

The majority of gastrointestinal endoscopy practitioners have received training on ethics, but there is still considerable room for improvement in their ethical awareness. Different learning pathways may affect the mastery of ethical principles, and understanding of ethical principles is more easily achieved through hospital ethics institutions.

CONCLUSION

To address the ethical issues in gastrointestinal endoscopy technology, it is necessary to enhance the humanistic education of gastrointestinal endoscopy practitioners, incorporate ethical standards into the technology assessment process, and establish a patient-centered diagnostic and treatment model to improve the ethical awareness of practitioners and achieve a balance between technology and ethics.

Key Words: Gastrointestinal endoscopy; Ethical awareness; Ethical issues; Medical ethics; Survey study

Core Tip: This study conducted a survey and analysis of the ethical awareness status of gastrointestinal endoscopy practitioners using a questionnaire. The results have shown that although most practitioners have received ethics training, there is still a significant room for improvement in their ethical awareness, learning through hospital ethics institutions is found to be a most effective way to improve the understanding of medical ethics principles. This study emphasizes the importance of strengthening the humanistic education of practitioners, incorporating ethical standards into the technical evaluation process, and constructing a patient-centered diagnosis and treatment model to achieve a balance between technology and ethics.

INTRODUCTION

Since its inception, gastrointestinal endoscopy technology has significantly improved the diagnostic accuracy and the successful treatment of gastrointestinal diseases. The initial rigid gastroscope was limited in clinical application due to its inconvenient operation and poor patient tolerance. In the 1950s, the advent of fiberoptic endoscopy, with its flexible body and better illumination, improved the comfort and diagnostic rate of the examination. In the 1980s, the introduction of electronic endoscopy brought about higher image resolution and clearer visual effects, making the examination safer and more accurate. In recent years, the development of gastrointestinal endoscopy technology has resulted in not only improvement in the endoscope itself, but also the emergence of various endoscopic treatment techniques. Endoscopic mucosal resection and endoscopic submucosal dissection have provided minimally invasive treatment options for early gastrointestinal tumors[1]. Endoscopic ultrasound helps doctors to more accurately stage gastrointestinal tumors[2]. Endoscopic interventional treatment techniques, such as endoscopic stent placement, have provided effective means to alleviate symptoms in patients with advanced gastrointestinal tumors and improve their quality of life[3]. However, with the rapid development of gastrointestinal endoscopy technology, a series of ethical issues have emerged, such as expanding treatment indications, which affect the fair distribution of medical resources. Gastrointestinal endoscopy practitioners are not only technical executors, but also the primary bearers of ethical responsibilities: Indication grasp, risk communication, and complication management directly affects patient autonomy, maximization of interests, and fair allocation of resources. In addition, gastrointestinal endoscopy often uses conscious sedation or anesthesia, and patients are temporarily limited in their decision-making ability, highlighting the importance of the physician’s fiduciary duty. Therefore, after tracing the evolution of technology, it is necessary to shift the focus to the “gastrointestinal endoscopy practitioners role” - they are both drivers of technological progress and gatekeepers of ethical risks; the strength of its ethical consciousness directly determines whether new technologies can truly translate into patient well-being rather than potential harm. How to avoid and reduce ethical events while advancing technology has become an urgent issue faced in gastrointestinal endoscopy diagnosis and treatment. Addressing these ethical issues is crucial for ensuring high-quality patient care and maintaining public trust in medical practice. Currently, there are few studies on ethical issues in gastrointestinal endoscopy technology. This study investigates the current status of ethical awareness among gastrointestinal endoscopy practitioners using a questionnaire survey, analyzes the ethical issues, and provides references for the development of gastrointestinal endoscopy technology.

MATERIALS AND METHODS

Subjects

We employed a cross-sectional questionnaire survey to collect relevant data from gastrointestinal endoscopy practitioners at the Second Hospital of Dalian Medical University and Dalian Friendship Hospital, including licensed physicians and nurses (including trainees and graduate students). The survey questionnaires were collected in January 2025. The questionnaire was designed based on a comprehensive review of the literature on gastrointestinal endoscopy and medical ethics. It was pilot-tested among a small group of practitioners to ensure clarity and comprehensiveness, we selected 10 practitioners from Dalian Friendship Hospital as the predictive subjects. Adopting the “one-on-one” cognitive interview method, the questionnaire is required to be filled out within 15 minutes, followed by a 5-minute semi-structured interview to record the following four dimensions: Item comprehension; option discrimination; filling time; suggested modifications. The Cronbach’s α coefficient after the pre-test increased from 0.68 to 0.71, indicating good internal consistency.

Methods

Using “gastrointestinal endoscopy”, “ethical cognition”, “medical ethics”, “Gastrointestinal Endoscopy”, “ethical cognition”, and “medical ethic” as search terms, relevant studies were retrieved from databases PubMed, Web of Science, CNKI, etc. The preliminary questionnaire was designed, and a brainstorming session was organized with experts. After discussion by the research group and assessment of the pilot survey, the questionnaire was finalized. The reliability and validity of the questionnaire were tested, and the Cronbach’s α coefficient was 0.71. “Cognition” refers to the process of recognizing objective factors and acquiring knowledge. In this study, “cognition” refers to the awareness of “ethical principles in gastrointestinal endoscopy”. Respondents who chose “very familiar” or “somewhat familiar” were considered “aware”, while those who chose “average”, “not very familiar”, or “unfamiliar” were considered “unaware”.

Statistical analysis

The EpiData 3.1 software was used to establish the database, and SPSS 21.0 software was used for statistical analysis. Count data were expressed as n (%), and comparisons between groups were made using the χ² test. The effect of learning in different learning pathways was compared using a dichotomy logistic regression analysis. A P value of less than 0.05 was considered statistically significant.

RESULTS

Basic information on survey subjects

A total of 109 questionnaires were collected, with 102 valid questionnaires, resulting in an effective response rate of 93.58%. The age range was 22-59 years, with a mean age of 41.76 years. There were 45 males (44.12%) and 57 females (55.88%).

Current status of ethical awareness

According to the relevant literature[5-8], medical ethical principles that gastrointestinal endoscopy practitioners should follow were summarized. Among the 102 surveyed practitioners, 72 were aware of all four medical ethical principles, with a cognition rate of 70.59%. The principle of respect had the highest awareness, while the principle of justice had the lowest awareness. The specific details are shown in Table 1.

Table 1 Current status of ethical awareness among gastrointestinal endoscopy practitioners.

Ethical principles	Number of subjects	Awareness rate (%)
Principle of respect for autonomy	91	89.22
Principle of beneficence	83	81.37
Principle of justice	79	77.45
Principle of non-maleficence	85	83.33

Distribution and effectiveness of ethical training channels

Among the 102 gastrointestinal endoscopy practitioners, 82 had received training on ethics, accounting for 80.39%. Specifically, 71.95% obtained this training by the hospital ethics institutions, 68.29% through special lectures, 56.10% through academic conferences, 53.66% through medical school education, 48.78% through media channels such as the internet and television.

According to statistical description, in the analysis of different learning paths and awareness levels, the highest awareness level was achieved through learning from hospital ethics institutions, with a percentage of 71.95%. According to univariate analysis, hospital ethics institutions and specialized lectures have significant statistical significance (P < 0.0001) on awareness, as shown in Table 2. According to expert interviews and academic conferences on work practice, medical schools and online and television media have an impact on ethical awareness, which is included in the binary regression, as shown in Table 3. Using different learning pathways as independent variables, binary logistic regression analysis was conducted. The results showed that learning through hospital ethics institutions made it easier to understand medical ethics principles, and the difference was statistically significant (P = 0.019), as shown in Table 3.

Table 2 Awareness of ethical principles through different learning pathways, n (%).

Learning pathways	Aware	Unaware	χ2	P value
	Number of subjects	Number of subjects
Hospital ethics institutions	59 (71.95)	23 (28.05)	29.747	< 0.0001
Special lectures	56 (68.29)	26 (31.71)	29.889	< 0.0001
Academic conferences	46 (56.10)	36 (43.90)	2.191	0.139
Medical school	44 (53.66)	38 (46.34)	1.167	0.28
Internet/television media	40 (48.78)	42 (51.22)	0.165	0.684

Table 3 Results of binary logistic regression analysis of learning effectiveness of different learning pathways.

Variable	B	SE	Wald χ2	P value	Exp (B)	95%CI
Hospital ethics institution	3.289	1.400	5.520	0.019	26.815	1.725-416.852
Special lectures	2.189	1.373	2.541	0.111	8.931	0.605-131.814
Academic conferences	2.595	1.482	3.065	0.080	13.395	0.733-244.688
Medical school	-2.725	1.691	2.597	0.107	0.066	0.002-1.802
Internet/television media	-2.781	1.770	2.470	0.116	0.062	0.002-1.989
Constant	-1.149	1.902	0.365	0.546	0.317

CI: Confidence interval.

DISCUSSION

The survey questionnaire in this study involved gastrointestinal endoscopy specialists, nurses, and graduate students from two tertiary hospitals, which is representative to some extent. The results show that the ethical awareness of gastrointestinal endoscopy practitioners is still insufficient and needs to be improved[4]. The overall awareness rate of the four ethical principles is only 70.59%, with the “principle of fairness” having the lowest awareness rate (77.45%), significantly lower than the “principle of respect” (89.22%). It can be seen that gastrointestinal endoscopy practitioners are more concerned with operational risks and patient consent, and lack sensitivity to fair issues such as resource allocation and cost accessibility, indicating that “fairness” is a weak link in ethical education for digestive endoscopy. Further analysis of training methods reveals that compared to media such as the internet and television, hospital ethics institution training significantly enhances comprehensive awareness. This indicates that gastrointestinal endoscopy cannot be replaced by structured and case-based training relying on hospital ethics institutions. Designing fair themed seminars and case reviews closely related to endoscopic scenarios is essential to effectively narrow the cognitive gap and achieve a balance between technology and ethics. The ethical issues and related principles of ethics in gastrointestinal endoscopy technology may include the following four aspects.

Informed consent and the principle of respect for autonomy

Before performing gastrointestinal endoscopy, detailed information should be provided to patients or their close relatives regarding the purpose of the diagnosis and treatment, the risks involved, postoperative precautions, possible complications, and preventive measures, and an informed consent form should be signed. However, in real clinical practice, doctors are often regarded as authorities, while patients are in a passive position to accept treatment, leading to insufficient patient participation in medical decision-making[5]. Doctors are usually the main decision-makers in medical treatment, and patients rely on their professional judgment. Under this relationship, doctors may not fully communicate detailed information about the treatment plan with patients and may even intentionally omit or simplify some important medical information based on the patient’s education level, including potential risks and complications, as well as the pros and cons of different treatment options. As a result, patients may accept treatment without fully understanding the consequences, infringing on their right to informed consent and autonomous choice. This phenomenon leads to a distorted attitude of doctors towards patients, where patients are only subject to commands and obedience, without discussion and choice. The doctor-patient relationship evolves into one between a repairman and a faulty machine, sowing the seeds of conflict.

Indications for diagnosis and treatment and the principle of beneficence

Doctors should strictly adhere to the industry standards, operating procedures, and guidelines for gastrointestinal endoscopy diagnosis and treatment, and strictly control the indications and contraindications for these procedures. However, some doctors overly rely on gastrointestinal endoscopy technology in clinical decision-making, recommending treatment plans based on the advantages of the technology rather than the best interests of the patient, thereby expanding the indications for treatment[6]. For example, although endoscopic treatment techniques are minimally invasive surgeries, they are not suitable for all patients. Some doctors fail to fully consider the individual differences and actual needs of patients, and include them in the treatment indications with seemingly reasonable motives. This leads to patients bearing unnecessary risks, economic burdens, and psychological stress. Due to the asymmetry of information between doctors and patients, the patients lacking necessary medical knowledge are unable to fully understand the pros and cons of different treatment options and are in a passive position in the decision-making process. When doctors recommend treatment plans, they may emphasize the advantages of gastrointestinal endoscopy technology while downplaying its potential risks and complications. As a result, patients are unable to make choices that truly align with their best interests.

Medical costs and the principle of justice

Gastrointestinal endoscopy technology typically relies on expensive equipment and consumables, leading to increased medical costs and becoming a barrier for some patients to access medical services. Some hospitals, in order to recover costs and pursue economic benefits, tend to adopt more expensive new gastrointestinal endoscopy technologies rather than more traditional and cost-effective methods, exceeding the actual needs of patients. This situation results in unnecessary economic burdens for patients. The patients with better economic conditions are more likely to afford these costs, while those with poorer economic conditions may be unable to receive the best treatment strategies due to cost issues, limiting the fair distribution of medical resources and seriously violating the principle of justice[7]. Moreover, advanced endoscopy technologies and equipment are available in developed areas or large medical institutions, while these resources are lacking in less developed areas or smaller medical institutions. Originally, patients could choose their treatment methods based on their conditions, but now the situation has evolved into medical technology selecting patients.

Diagnostic and treatment safety and the principle of non-maleficence

Gastrointestinal endoscopy practitioners should receive systematic training and pass assessments to provide the best possible diagnosis and nursing care, prevent unintentional but foreseeable harm, and minimize unavoidable but controllable harm. However, in remote areas or smaller hospitals, due to insufficient funding, slow equipment updates, and a lack of professional technical personnel, doctors with insufficient skills and violations of operating procedures still exist[8]. Some hospitals do not pay enough attention to the quality management of gastrointestinal endoscopy diagnosis and treatment, fail to establish a sound postoperative follow-up system, lack emergency drugs and equipment in the endoscopy center, and do not have dedicated anesthesiologists involved in sedation anesthesia. Some doctors, having just mastered gastrointestinal endoscopy technology, may rush into practice with limited guidance from other hospital doctors or by watching a few live demonstrations at academic conferences. They may even violate regulations by reusing single-use medical devices during operations, severely affecting patient safety, treatment outcomes and causing harm to patients. Based on our findings from the survey, we propose the following countermeasures.

Strengthening the cultivation and education of humanistic spirit among practitioners

The cultivation and education of humanistic spirit can enable gastrointestinal endoscopy practitioners to better understand and respect the needs and rights of patients, and provide more humanized medical services[9]. Medical education should emphasize the importance of humanistic spirit from the basic stage, through curriculum design and clinical practice, to cultivate medical students’ compassion and sense of responsibility towards patients, making them realize that they need to care for patients, not just treat diseases. Medical schools should offer courses such as medical ethics, doctor-patient communication skills, and medical psychology to enhance future practitioners’ ability to deal with ethical issues in actual work. Medical institutions should provide continuous humanistic education and training for practitioners. Our survey found that practitioners are more likely to understand ethical principles through hospital ethics institutions. Therefore, these institutions can adopt forms such as seminars and case discussions, covering content related to ethical practice and decision-making simulations, to help practitioners better understand patients’ feelings and improve their ethical awareness, balancing the application of technology and patient interests in clinical decision-making. In addition, medical institutions should link the results of practitioners’ professional ethics assessment with career promotion, further training, salary and bonus benefits, and establish a working atmosphere that values humanistic spirit.

Introducing ethical review into the assessment of new gastrointestinal endoscopy technologies

In the development and application of gastrointestinal endoscopy technology, the assessment of new technologies should not be limited to their advanced nature and effectiveness but should also include considerations of patients’ quality of life, psychological needs, and social impact. The assessment should fully consider patients’ needs and expectations, focusing on the accuracy of disease diagnosis and treatment, the impact on patients’ daily lives, and patient acceptance to ensure that the technology better meets patients’ actual needs. In addition, the assessment should also pay attention to the fairness of application, whether it can equally benefit patients with different economic conditions, social status, or geographical locations. Therefore, medical institutions should establish and improve ethical review mechanisms and set up new medical technology ethics committees. Experts in medical ethics, legal experts, community members, and patient representatives should all be included in the committee and participate in the technology assessment process, focusing on reviewing the patient informed consent process and the rationality of diagnostic and treatment indications to ensure that new technologies undergo strict ethical review[10].

Establishing a patient-centered diagnostic and treatment model

Gastrointestinal endoscopy practitioners should always prioritize patients’ interests, placing their needs, preferences, and values at the center of medical decision-making to improve the quality of medical services and patient satisfaction[11]. Practitioners should adopt a more personalized approach to meet patients’ needs, communicate fully with patients to understand their symptoms, concerns, and expectations, and jointly develop treatment plans. Patients are not only recipients of medical services but also partners in the decision-making process. Practitioners need to pay attention not only to patients’ physical health but also to their psychological, social, and spiritual well-being. Medical institutions can collect valuable feedback through regular patient satisfaction surveys, focus group discussions, and individual interviews, establish effective feedback mechanisms, and continuously improve service processes to enhance service quality.

Medicine is not a pure scientific research but a combination of natural sciences and humanities. With the rapid development of gastrointestinal endoscopy technology, while we enjoy the medical convenience and improved therapeutic effects it brings, we must also face the accompanying ethical issues. Our findings suggest that improving the ethical awareness of gastrointestinal endoscopy practitioners can contribute to more equitable access to medical resources and better patient outcomes. This study highlights the need for enhanced ethical training and education to improve practitioners’ ethical awareness. By incorporating ethical standards into technology assessment processes and constructing a patient-centered diagnostic and treatment model, we can achieve a balance between technological advancement and ethical considerations. Gastrointestinal endoscopy practitioners need to truly start from the needs of patients and maintain a “responsible” attitude in diagnosis and treatment. Looking to the future, the development of gastrointestinal endoscopy should focus on both technology and ethics. Practitioners should provide precise, efficient, and safe medical services on the basis of safeguarding patients’ rights and respecting their wishes, making gastrointestinal endoscopy technology a powerful tool for promoting human health.

This study has several limitations. First, the sample size was small and limited to two hospitals, which may affect the generalizability of the findings. Future studies should include larger and more diverse samples to validate our results. Second, the questionnaire relied on self-reported data, which may introduce bias. Future research could benefit from incorporating objective measures of ethical awareness.

CONCLUSION

This study conducted a survey and analysis of the ethical awareness status of gastrointestinal endoscopy practitioners using a questionnaire. The results have shown that although most practitioners have received ethics training, there is still a significant room for improvement in their ethical awareness. Different learning paths have a significant impact on the degree of mastery of ethical principles, and learning through hospital ethics institutions is found to be a most effective way to improve the understanding of medical ethics principles. This study emphasizes the importance of strengthening the humanistic education of gastrointestinal endoscopy practitioners, incorporating ethical standards into the technical evaluation process, and constructing a patient-centered diagnosis and treatment model to achieve a balance between technology and ethics. In addition, this study suggests that ethical review should be introduced in the evaluation of new gastrointestinal endoscopy technologies to ensure that the development and application of new technologies fully consider patients’ quality of life, psychological needs, social impact, and fair distribution of medical resources. In summary, this study provides valuable ethical guidance for the development of gastrointestinal endoscopy technology. While technology advances, it is necessary to pay attention to ethical education and protection of patient rights, ensuring the quality and fairness of medical services.