states in the u.s. have laws governing parental notification in underage abortion. those working in mental health have a duty to warn those who they deem to be at risk from their patients in some countries. traditionally, medical ethics has viewed the duty of confidentiality as a relatively non-negotiable tenet of medical practice. more recently, critics like jacob appel have argued for a more nuanced approach to the duty that acknowledges the need for flexibility in many cases. confidentiality is an important issue in primary care ethics, where physicians care for many patients from the same family and community, and where third parties often request information from the considerable medical database typically gathered in primary health care. privacy and the internet in increasing frequency, medical researchers are researching activities in online environments such as discussion boards and bulletin boards, and there is concern that the requirements of informed consent and privacy are not applied, although some guidelines do exist. one issue that has arisen, however, is the disclosure of information. while researchers wish to quote from the original source in order to argue a point, this can have repercussions when the identity of the patient is not kept confidential. the quotations and other information about the site can be used to identify the patient, and researchers have reported cases where members of the site, bloggers and others have used this information as 'clues' in a game in an attempt to identify the site. some researchers have employed various methods of "heavy disguise." including discussing a different condition from that under study. healthcare institutions' websites have the responsibility to ensure that the private medical records of their online visitors are secure from being marketed and monetized into the hands of drug companies, occupation records, and insurance companies. the delivery of diagnosis online leads patients to believe that doctors in some parts of the country are at the direct service of drug companies, finding diagnosis as convenient as what drug still has patent rights on it. physicians and drug companies are found to be competing for top ten search engine ranks to lower costs of selling these drugs with little to no patient involvement. ] with the expansion of internet healthcare platforms, online practitioner legitimacy and privacy accountability face unique challenges such as e-paparazzi, online information brokers, industrial spies, unlicensed information providers that work outside of traditional medical codes for profit. the american medical association (ama) states that medical websites have the responsibility to ensure the health care privacy of online visitors and protect patient records from being marketed and monetized into the hands of insurance companies, employers, and marketers. with the rapid unification of healthcare, business practices, computer science and e-commerce to create these online diagnostic websites, efforts to maintain health care system's ethical confidentiality standard need to keep up as well. over the next few years, the department of health and human services has stated that they will be working towards lawfully protecting the online privacy and digital transfers of patient electronic medical records (emr) under the health insurance portability and accountability act (hipaa). . looking foward, strong governance and accountability mechanisms will need to be considered with respect to digital health ecosystems, including potential metaverse healthcare platforms, to ensure the highest ethical standards are upheld relating to medical confidentiality and patient data. control, resolution, and enforcement in the uk, medical ethics forms part of the training of physicians and surgeons and disregard for ethical principles can result in doctors barred from medical practice after a decision by the medical practitioners tribunal service.: 32 to ensure that appropriate ethical values are being applied within hospitals, effective hospital accreditation requires that ethical considerations are taken into account, for example with respect to physician integrity, conflict of interest, research ethics and organ transplantation ethics. guidelines there is much documentation of the history and necessity of the declaration of helsinki. the first code of conduct for research including medical ethics was the nuremberg code. this document had large ties to nazi war crimes, as it was introduced in 1997, so it didn't make much of a difference in terms of regulating practice. this issue called for the creation of the declaration. there are some stark differences between the nuremberg code and the declaration of helsinki, including the way it is written. nuremberg was written in a very concise manner, with a simple explanation. the declaration of helsinki is written with a thorough explanation in mind and including many specific commentaries. in the united kingdom, general medical council provides clear overall modern guidance in the form of its 'good medical practice' statement. other organizations, such as the medical protection society and a number of university departments, are often consulted by british doctors regarding issues relating to ethics. ethics committees often, simple communication is not enough to resolve a conflict, and a hospital ethics committee must convene to decide a complex matter. these bodies are composed primarily of healthcare professionals, but may also include philosophers, lay people, and clergy – indeed, in many parts of the world their presence is considered mandatory in order to provide balance. with respect to the expected composition of such bodies in the us, europe and australia, the following applies. u.s. recommendations suggest that research and ethical boards (rebs) should have five or more members, including at least one scientist, one non-scientist, and one person not affiliated with the institution. the reb should include people knowledgeable in the law and standards of practice and professional conduct. special memberships are advocated for handicapped or disabled concerns, if required by the protocol under review. the european forum for good clinical practice (efgcp) suggests that rebs include two practicing physicians who share experience in biomedical research and are independent from the institution where the research is conducted; one lay person; one lawyer; and one paramedical professional, e.g. nurse or pharmacist. they recommend that a quorum include both sexes from a wide age range and reflect the cultural make-up of the local community. the 1996 australian health ethics committee recommendations were entitled, "membership generally of institutional ethics committees". they suggest a chairperson be preferably someone not employed or otherwise connected with the institution. members should include a person with knowledge and experience in professional care, counseling or treatment of humans; a minister of religion or equivalent, e.g. aboriginal elder; a layman; a laywoman; a lawyer and, in the case of a hospital-based ethics committee, a nurse. the assignment of philosophers or religious clerics will reflect the importance attached by the society to the basic values involved. an example from sweden with torbjörn tännsjö on a couple of such committees indicates secular trends gaining influence. cultural concerns cultural differences can create difficult medical ethics problems. some cultures have spiritual or magical theories about the origins and cause of disease, for example, and reconciling these beliefs with the tenets of western medicine can be very difficult. as different cultures continue to intermingle and more cultures live alongside each other, the healthcare system, which tends to deal with important life events such as birth, death and suffering, increasingly experiences difficult dilemmas that can sometimes lead to cultural clashes and conflict. efforts to respond in a culturally sensitive manner go hand in hand with a need to distinguish limits to cultural tolerance. culture and language as more people from different cultural and religious backgrounds move to other countries, among these, the united states, it is becoming increasingly important to be culturally sensitive to all communities in order to provide the best health care for all people. lack of cultural knowledge can lead to misunderstandings and even inadequate care, which can lead to ethical problems. a common complaint patients have is feeling like they are not being heard, or perhaps, understood. preventing escalating conflict can be accomplished by seeking interpreters, noticing body language and tone of both yourself and the patient as well as attempting to understand the patient's perspective in order to reach an acceptable option. some believe most medical practitioners in the future will have to be or greatly benefit from being bilingual. in addition to knowing the language, truly understanding culture is best for optimal care. recently, a practice called 'narrative medicine' has gained some interest as it has a potential for improving patient-physician communication and understanding of patient's perspective. interpreting a patient's stories or day-to-day activities as opposed to standardizing and collecting patient data may help in acquiring a better sense of what each patient needs, individually, with respect to their illness. without this background information, many physicians are unable to properly understand the cultural differences that may set two different patients apart, and thus, may diagnose or recommend treatments that are culturally insensitive or inappropriate. in short, patient narrative has the potential for uncovering patient information and preferences that may otherwise be overlooked. medical humanitarianism in order to address the underserved, uneducated communities in need of nutrition, housing, and healthcare disparities seen in much of the world today, some argue that we must fall back on ethical values in order to create a foundation to move towards a reasonable understanding, which encourages commitment and motivation to improve factors causing premature death as a goal in a global community. such factors – such as poverty, environment and education – are said to be out of national or individual control and so this commitment is by default a social and communal responsibility placed on global communities that are able to aid others in need. this is based on the framework of 'provincial globalism,' which seeks a world in which all people have the capability to be healthy. one concern regarding the intersection of medical ethics and humanitarian medical aid is how medical assistance can be as harmful as it is helpful to the community being served. one such example being how political forces may control how foreign humanitarian aid can be utilized in the region it is meant to be provided in. this would be congruous in situations where political strife could lead such aid being used in favor of one group over another. another example of how foreign humanitarian aid can be misused in its intended community includes the possibility of dissonance forming between a foreign humanitarian aid group and the community being served. examples of this could include the relationships being viewed between aid workers, style of dress, or the lack of education regarding local culture and customs. humanitarian practices in areas lacking optimum care can also pause other interesting and difficult ethical dilemmas in terms of beneficence and non-maleficence. humanitarian practices are based upon providing better medical equipment and care for communities whose country does not provide adequate healthcare. the issues with providing healthcare to communities in need may sometimes be religious or cultural backgrounds keeping people from performing certain procedures or taking certain drugs. on the other hand, wanting certain procedures done in a specific manner due to religious or cultural belief systems may also occur. the ethical dilemma stems from differences in culture between communities helping those with medical disparities and the societies receiving aid. women's rights, informed consent and education about health become controversial, as some treatments needed are against societal law, while some cultural traditions involve procedures against humanitarian efforts. examples of this are female genital mutilation (fgm), aiding in reinfibulation, providing sterile equipment in order to perform procedures such as fgm, as well as informing patients of their hiv positive testing. the latter is controversial because certain communities have in the past outcast or killed hiv positive individuals. healthcare reform and lifestyle leading causes of death in the united states and around the world are highly related to behavioral consequences over genetic or environmental factors. this leads some to believe true healthcare reform begins with cultural reform, habit and overall lifestyle. lifestyle, then, becomes the cause of many illnesses and the illnesses themselves are the result or side-effect of a larger problem. some people believe this to be true and think that cultural change is needed in order for developing societies to cope and dodge the negative effects of drugs, food and conventional modes of transportation available to them. in 1990, tobacco use, diet, and exercise alone accounted for close to 80 percent of all premature deaths and continue to lead in this way through the