Safeguarding Privacy in Georgia: Medical Ethics in the Digital Era – A Cross-Sectional Study

Safeguarding Privacy in Georgia: Medical Ethics in the Digital Era – A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Safeguarding Privacy in Georgia: Medical Ethics in the Digital Era – A Cross-Sectional Study Lela Shengelia, Sulkhan Inaishvili, Nino Grdzelidze This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7325394/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The digitalization of healthcare systems has significantly intensified the importance of medical ethics, especially in the area of data privacy and patient autonomy. In Georgia, historical legacies, evolving legal frameworks, and uneven professional training have shaped a complex ethical environment within the healthcare sector. Objectives This study aimed to evaluate the implementation of ethical practices in the Georgian healthcare system, focusing on patient autonomy, beneficence, non-maleficence, justice, and data protection. It also assessed healthcare professionals’ knowledge, attitudes, and practices concerning medical ethics and digital privacy. Methods A cross-sectional survey was conducted among 412 physicians and nurses across 30 hospitals in Georgia between May and November 2024. A structured questionnaire was developed specifically for this study to assess healthcare professionals’ experiences with ethical dilemmas and data protection. It assessed sociodemographic characteristics, ethical perspectives, sources of ethical knowledge, and data protection practices. The internal consistency of the ethics-related items was verified (Cronbach’s α = 0.82), and data were analyzed using SPSS 20.0 with Chi-square tests and Cramér’s V to assess group differences. Results While 74.3% of participants reported the presence of Standard Operating Procedures (SOPs) for ethical decision-making, 18.2% were unaware of them, indicating a gap in institutional communication. Only 22.8% had consulted an ethics committee, and fewer than 70% had received recent training in data protection. Nurses were significantly less aware of data protection measures compared to physicians (p < 0.05). Key challenges identified included limited cybersecurity infrastructure, underutilization of formal ethical support mechanisms, and disparities in continuous professional development. Conclusions Despite existing ethical frameworks, their inconsistent application and the lack of standardized training compromise ethical decision-making in Georgian healthcare. Institutional reforms are needed to improve ethical awareness, enhance cybersecurity, ensure compliance with data protection regulations such as GDPR, and promote continuous professional education. These measures are essential for safeguarding patient rights and building trust in the digital healthcare era. Medical ethics Georgia patient autonomy GDPR data protection cybersecurity health workforce bioethics digital health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Ethics are essential in healthcare as they serve as a guide for healthcare practitioners. These values are crucial to delivering high-quality healthcare, ensuring that patients receive fair and dignified treatment. Furthermore, by prioritizing the needs of patients, adherence to ethical standards promotes confidence and trust in healthcare. The Hippocratic Oath, created in ancient Greece to hold medical professionals accountable for the well-being and non-maleficence of their patients, is credited with establishing the importance of ethics in healthcare. Since then, these ethics have outlined professional behavior and obligations, and have remained highly relevant in the healthcare industry. To this end, the four pillars of medical ethics were established to ensure that patient safety and care are held to the highest standards. The four pillars of medical ethics - respect for autonomy, beneficence, non-maleficence and justice - ensures patient safety and patient-centered care. Respect for autonomy involves acknowledging and honoring the right of a patient to make their own healthcare decisions. Beneficence obligates healthcare providers to act in the best interest of the patient, promoting their health and well-being. Non-maleficence, the principle of "do no harm", ensures that healthcare professionals avoid causing harm or suffering to patients. Justice sees to it that fairness in healthcare is maintained, ensuring equitable treatment and patient care access (1). Autonomy ensures that patients have the right to decide their treatment plans and that they have the final say in the decision-making process, even when a professional believes a certain action may not be in the best interest of the patient. It must, however, be weighed against conflicting moral values and can, in specific situations, be overridden. For example, if the autonomous actions of a patient should result in harm to others, their autonomy may be restricted. The principle of autonomy, however, does not extend to those who cannot act independently (2). While healthcare providers can educate patients, they cannot make decisions on their behalf. In some countries, resistance to the principle of patient autonomy and its related concepts (such as informed consent and honesty) poses a challenge. In nations, for example, with ancient civilizations and deeply rooted traditions, the practice of paternalism by physicians often stems from the principle of beneficence. The concept of "beneficence" refers to the obligation of medical personnel to act in the best interests of the patient. This entails improving their health and well-being through therapies aimed at health promotion, injury prevention, and pain management. Beneficence is fundamental to healthcare ethics; when deciding on the best treatment for a patient, doctors must weigh the advantages and disadvantages of each option and choose the one that will most benefit the patient (3, 4). The challenging aspect of beneficence is determining what is best for each patient. Before acting, medical personnel should be informed about the particular needs, objectives, and experiences of every patient. They should be aware of the history, religious beliefs, and significant life events of a patient, as these factors can aid patients in making decisions that are best for them. Even seemingly minor elements can have a significant impact on the comfort and effectiveness of treatment (Michael et al, 2019). The third pillar, nonmaleficence, is another core value of medical ethics and emphasizes that medical professionals should "do no harm," thus avoiding causing suffering or harm to the patient through negligence. It serves as a guiding principle, allowing actions to be taken if the potential benefits for the patient outweigh any pain or discomfort they might endure. This simple principle of a doctor having an ethical obligation to avoid causing harm to their patients encompasses several moral tenets, such as not fatally injuring a patient, inflicting pain or suffering, rendering someone helpless, inciting hatred, or denying someone their basic human rights. In practice, doctors apply the principle of non-maleficence by carefully considering the pros and cons of all treatments and interventions, avoiding those that are excessively burdensome, and choosing the best course of action for the patient. This principle is particularly important when making difficult decisions regarding withdrawing or withholding life-sustaining treatment, administering medically supervised nutrition and hydration, and managing pain and other symptoms. The duties and goals of a physician include alleviating suffering such as refractory pain (5, 6). The final pillar, justice, is a multifaceted concept that involves treating every patient fairly. The principle emphasizes equitable care rather than the same type of treatment. It is related to healthcare equity in that no patient should be denied care, have limited access to care, or receive lower quality care due to their financial status, race, gender identity, or any other characteristic. Justice also involves supporting other facilities if they become overwhelmed by accepting their patients or sharing medical resources with a broader community that may lack access to adequate healthcare services. Justice is also relevant in emergencies, as healthcare professionals must evaluate the severity of each patient's condition to determine the order of treatment. Additionally, all patients should receive the same level of care without preferential treatment based on relationships or personal preferences. Justice is typically understood as the fair, equitable, and appropriate treatment of individuals. The most relevant category of justice is distributive justice, which involves the fair, equitable, and appropriate allocation of healthcare resources, guided by justified norms that define the terms of social cooperation. Various valid principles of distributive justice can be used to achieve this goal. These principles are not mutually exclusive and can often be combined in practice (1). All the aforementioned pillars are part of the International Code of Medical Ethics (7, World Medical Association, 2006), adopted in 1949 by the General Assembly of the World Medical Association following World War II. Medical advancements reached exponential heights, leading to the formulation of fundamental ethical principles that now guide medical practitioners in their decision-making processes. These principles continue to influence the resolution of ethical dilemmas in patient care (1). The International Code of Medical Ethics has since undergone numerous amendments, with the last iteration being in 2006. These changes have resulted in benefits for both patients and health professionals. Patients benefit from all ethical standards as these ensure their autonomy is respected, they are treated fairly, and they receive the best possible care as per their preferences and values, leading to patients being able to fully trust their healthcare providers. Without the guarantee of such benefits, many people may delay seeking medical help as healthcare could potentially be intrusive. While patients are the primary beneficiaries of fundamental ethical principles, healthcare personnel also benefit from these rules. Operating within an ethical framework allows healthcare professionals to communicate openly and honestly with patients and their families regarding end-of-life care or to promptly inform patients of their emergency care options. When dealing with ethical dilemmas involving patients, their families, caregivers, or coworkers, practitioners are able to recommend actions that prioritize the needs of the patient (6, 7, 8). Medical Ethics in the USSR After the Soviet Revolution, a system rooted in Socialist humanism called the Semashko health financing model was established in the Russian Soviet Federative Socialist Republic (RSFSR). In 1918, the People’s Commissariat of Public Health was formed to unify the medical and sanitary services of the country (10). The main goals of this system included the eradication of infectious diseases and the development of curative care. The Communist Party (CP) directed the healthcare system to implement extensive sanitary measures (10), including: a) Improving health conditions in populated areas by protecting soil, water, and air from pollution; b) Organising public catering on scientific and hygienic principles; c) Launching initiatives to prevent the outbreak and spread of infectious diseases; d) Creating a comprehensive health legislation code; e) Combating social diseases such as tuberculosis, venereal diseases, and alcoholism; f) Providing qualified medical and pharmaceutical services to all citizens free of charge. The Soviet Government issued a series of policies to further unify the administrative and operational frameworks of medical and sanitary institutions. Key policies included those on health insurance (1917), the nationalization of pharmacies and medical property (1918), maternal and childcare provisions (1918) and compulsory smallpox vaccinations (1919) (11). The Code of Health Legislation served as the primary moral guideline for Soviet doctors, who were committed to enhancing the well-being of the Soviet populace. Subsequently, the Soviet Constitution enshrined the right to health protection, declaring that citizens of the USSR had the right to receive support in old age and in sickness or disability. It guaranteed every citizen access to free medical aid and reinforced the protection of public health (12). Soviet public health initiatives significantly contributed to increased labor productivity and improved hygiene in both industry and agriculture. Concurrently, extensive measures were undertaken to enhance living conditions, with Soviet health services playing a crucial role (9). The USSR allocated resources for social insurance benefits, pensions, free or subsidized accommodation in sanatoria and holiday homes, support for large families and single mothers, free medical aid, and various initiatives aimed at boosting the welfare of the working class. These efforts had a profoundly positive impact on the health of Soviet citizens (12). However, from its inception the Soviet Health System was based on paternalism which restricted the freedom of choice of a patient, as it was believed that this was in their best interest (Pelto-Piri, 2013). Thus, violations of the ethical norms of patients were frequent occurrences in the USSR. Moreover, the Soviet legacy of institutionalizing people with chronic diseases lasted long after the collapse of the Soviet Empire. In the early 50s of the last century, new mental health legislation was adopted, and those with mental health problems and learning disabilities were isolated from society and confined to psychiatric hospitals (9), with psychiatric diagnoses used for political reasons from the 1950s onwards (10). This approach had significant consequences for individuals with mental health issues and those with learning disabilities. Many were institutionalised and completely removed from the communities in which they had once lived. Families were strongly encouraged to forget about their “faulty” relatives, effectively abandoning them to these institutions. Soviet ideology promoted an ideal society in which everyone was expected to conform to socialist standards. Mental health care during the Soviet era was characterised by two main factors: the socialist ideology of the perfect Soviet citizen and the oppression of those who opposed the political system (11). The Russian Association of Psychiatrists espoused the belief that mental illness was a trait of capitalist societies and would eventually vanish under communism. Individuals who were unable to conform to socialist standards due to mental health issues were viewed as underdeveloped (Gordon, 2000; Bonnie, 2002). Citizens faced arrest for distributing pamphlets or writing articles critiquing the regime. During official party celebrations, potential dissenters were often imprisoned, only to be released after the events had concluded. Research conducted after 1989 confirmed that some individuals were confined to psychiatric hospitals solely because their political beliefs diverged from the dominant communist ideology and had not, in fact, actually suffered from any mental disorders nor undergone any official assessment or trial. Within psychiatric hospitals, psychiatrists often administered antipsychotic medications as punishment for those expressing anti-communist views (13; 14). Medical Ethics in Georgia Historically, Georgian medicine has strongly been influenced by a blend of cultural and religious traditions that have shaped its ethical foundations. The first Georgian medical book, Karabadin , which was written in the 10 th century, not only consisted of the medical knowledge of that era, including aspects of Sumerian medicine, but also embedded principles of respect, beneficence, and justice, reflecting a holistic approach to patient care that honors the dignity of every individual ( 15 ). Another key source of medical knowledge is the Karabadin medical book (an updated and edited version of the 10 th century text) authored by the doctor and thinker Zaza Panaskerteli-Tsitsishvili. Considered an ancient Georgian pharmacopoeia, the book, written in the 15th century, contains a wealth of medical knowledge, including herbal remedies, surgical techniques, and ethical guidelines for medical practitioners. The book emphasizes several ethical aspects, such as prioritizing patient well-being and comfort, maintaining patient confidentiality and privacy, and upholding high standards of professional behavior and integrity (15). Another significant medical manuscript is Yadigar Daud, created by King Davit XI. This manuscript offers valuable insights into the medical practices and ethical considerations of its time. It includes guidelines on medical ethics, emphasising the moral responsibilities of physicians towards their patients, cultural sensitivity in understanding and respecting patients' cultural and religious beliefs, and holistic care by addressing the physical, mental, and emotional well-being of patients (16). These texts and the principles they embody have played a crucial role in shaping the ethical landscape of Georgian medicine, ensuring that it upholds the highest standards of patient care and professional conduct (16). After the collapse of the Soviet Union and gaining its independence, Georgia began developing its healthcare sector from the ground up, while the Semashko healthcare system remained in operation. However, the development of this new system and the establishment of ethical standards in medicine were heavily influenced by the imperialistic doctrines dating back to the Soviet period. Thus, the country initiated a prolonged and complex process of reforms, and only by the end of the century was the country capable of implementing new regulations for professional medical activities (17, 18). On 6 May 2003, the Congress of Georgian Physicians adopted the Code of Medical Ethics of Georgia. This code sets out the fundamental ethical principles that govern a physician’s professional behaviour towards patients, colleagues and society. That marked the beginning of the development of medical ethics in modern Georgia (19). At present, the professional activities of physicians are regulated by a range of declarative legal and ethical documents at both the national and international levels. These provisions serve to define the scope of medical responsibility, safeguard patient rights, and establish a foundation for ethical clinical practice (20). The key documents include: the National Legislation of Georgia – including the Law on Medical Practice (2001), the Law on Patients' Rights (2000), and the Law on Health Care (1997) – which provide the legal foundation for healthcare delivery and medical accountability. Additionally, specialised legislation regulates particular domains within the health sector, such as the Law on Public Health (2007), the Law on HIV/AIDS (2009), the Law on Psychiatric Care (2006) and the Law on Human Organ Transplantation (2000) (21). International Legal Policies of the Council of Europe – most notably, the Convention on Human Rights and Biomedicine (1997), commonly known as the Oviedo Convention (22); the Declaration on the Promotion of Patients’ Rights in Europe (1994), which highlights principles of dignity, informed consent, and equitable access to care (23). UNESCO’s Universal Declaration on Bioethics and Human Rights (2005), and the United Nations’ Principles of Medical Ethics (1982) (24). the International Code of Medical Ethics (1949) and a series of influential declarations: the Geneva Declaration , Lisbon Declaration on the Rights of the Patient , Helsinki Declaration on Medical Research Ethics , Tokyo Guidelines on Torture and Physicians’ Roles , etc. (25). Since 2011, the country has implemented a Law on Personal Data Protection, which was amended in 2013. The law strengthened the safety and protection of medical information (26). In 2013, the country implemented the Universal Health Care Programme, though poor quality of healthcare services remained an issue. Consequently, the government of Georgia implemented hospitals’ accreditation procedures in order to improve patient safety, care quality, and operational effectiveness. It acts as a standard for organisations aiming to fulfil global requirements, ensuring that medical facilities follow the strictest guidelines for patient care, safety, and administration (27). According to Article 4, Paragraph 1 of Annex 1 of the State Programme for Universal Health Care , approved by Decree No. 36 of the Government of Georgia on 21 February 2023, a medical facility shall be defined as an institution that has obtained international accreditation (28). A formal certification process ensures that reliable medical facilities follow internationally recognised standards. Hospitals are evaluated by independent external organisations to verify if they meet these strict requirements, which include staff qualifications, clinical procedures, infection control, and patient safety. Accreditation is a continuous commitment to maintaining and improving healthcare quality, not just a badge of honour (28). This study was thus conducted in order to measure patient safety and the implementation of ethical standards, including the current level thereof, for the further improvement of healthcare services. The General Objective of the Study The main objective of the study is to explore the implementation of ethical practices in the Georgian healthcare sector. Specific Objectives of the Study To assess and compare the level of knowledge, attitude and practice of medical ethics among medical staff; To explore the medical staff's experience with ethical dilemmas; To explore the medical staff’s sources from which they derived their ethical understanding; Provide recommendations for policymakers. Methodology A cross-sectional study was conducted involving doctors and ward nurses from approximately 30 hospitals in Georgia. These healthcare institutions employ approximately 20% of the country's medical professionals (21). Study Population The study focused on medical doctors and nurses working in both inpatient wards and outpatient clinics. Doctors included in the study were those who directly consulted with patients and managed their care. Nurses were included in the study if they were involved in patient care and were under the supervision and guidance of doctors. Since both groups are central to ethical decision-making in healthcare, their perspectives offer valuable insights into the level of knowledge, attitudes, and perceptions regarding medical ethics in Georgia. Questionnaire and Variables The participants’ knowledge of medical ethics, data protection, and ethical challenges was assessed using a self-administered questionnaire. This tool was developed following a literature review of similar studies conducted in Barbados, Nepal and India, and was subsequently adapted to fit the Georgian healthcare context. Ethical approval was granted by the Ethics Committee of the University of Georgia. Originally developed in English, the questionnaire was translated into Georgian and then back again to ensure accuracy. It was pre-tested in two healthcare facilities with a sample of doctors and nurses. Feedback from the pre-test was used to refine the wording and eliminate ambiguity. The questionnaire comprised three sections: Sociodemographic Data: Age, gender, professional role, years of experience, and place of work; Ethical Perspectives: This section consisted of 12 statements related to key ethical principles such as respect for patient autonomy, confidentiality, informed consent, and professional duty. Each statement was rated on a 5-point Likert scale, followed by response analysis to assess trends in ethical attitudes among healthcare professionals: 1 – Strongly disagree 2 – Disagree 3 – Neutral 4 – Agree 5 – Strongly agree Sources and Preferences: Participants indicated their primary sources of ethical knowledge (e.g., university courses, hospital policies and personal experience) and preferences when seeking guidance on legal or ethical dilemmas. The internal consistency of the "Ethical Perspectives" section was evaluated using Cronbach’s alpha (α = 0.82), indicating good reliability. Tool Validation The internal consistency of the key attitudinal items in the Ethical Perspectives section was assessed using Cronbach’s alpha, which resulted in a value of 0.82, indicating good reliability. Test-retest reliability was also evaluated by administering the questionnaire to a subgroup of 15 participants two weeks after the initial test. The resulting correlation coefficient (r = 0.87) demonstrated strong temporal stability. Additionally, feedback obtained during the pre-test phase was used to refine ambiguous items, enhancing overall clarity and ensuring semantic equivalence in the final version of the tool. Sampling and Data Collection A total of 430 doctors and nurses were randomly selected and invited to take part in the study. With a refusal rate of just 4%, the final sample comprised 412 participants (236 doctors and 176 nurses), making it a representative subset of Georgia’s healthcare workforce. Data collection occurred between May and November 2024 via Google Forms. Questionnaires were distributed electronically, and participants were required to give informed consent before proceeding. The hospitals included in the study represented a diverse range of institutional types, encompassing urban and rural settings, and included public, private, and university-affiliated hospitals from various regions of Georgia. This diversity strengthens the generalizability of the findings within the context of the national healthcare system. Sample Size Determination The sample size was calculated based on an assumed 50% prevalence of adequate knowledge of medical ethics and data protection - a conservative estimate used to ensure the maximum required sample size. A 95% confidence level and a ±5% margin of error were applied. Using the standard formula for sample size calculation for proportions in a finite population (approximately 20,000 healthcare professionals in Georgia), the minimum required sample size was determined to be 377 participants. To account for potential non-response, the target sample was increased to 430. Ultimately, 412 participants completed the survey, resulting in a response rate of 96%, which exceeds the threshold for statistical reliability. Ethical Considerations The study was exempted from a full review by the Institutional Review Board of the University of Georgia. Informed consent was obtained electronically, with all participants required to acknowledge their willingness to participate before accessing the survey. Participation was entirely voluntary, and no incentives were provided. Data Analysis Data were analyzed using SPSS version 20.0. Descriptive statistics were calculated using proportions and percentages. Differences in ethical attitudes between doctors and nurses were examined using Chi-Square tests, with Cramér’s V used to measure the strength of associations. Effect sizes were categorized as small (0.5). A p-value of <0.05 was considered statistically significant. Results Sociodemographic Details Out of 412 participants, 57% were doctors and 43% were nurses. The average age of doctors was 43 years (SD = 1.57), while for nurses it was 57 years (SD = 4.77). Among the doctors, 60% were female and 40% male. All participating nurses were female. Only 39.6% of participants were based in the capital, with the remaining respondents employed in various regions of Georgia. In terms of work experience, 44% (n = 182) had over 15 years of experience, 41% (n = 170) had between 5 and 14 years, and 15% (n = 60) had less than 5 years of professional experience. Sources of Medical Ethics and Dilemmas The study highlighted that continuous professional development (CPD) remains a challenge in the Georgian healthcare sector. CPD is not compulsory, and participation often depends on private provider preferences. However, the new regulation related to accreditation made it obligatory for staff to undergo training on different topics. Study results showed that 88.6% of respondents (CI: 85.0–91.5) reported taking part in CPD activities, although these training sessions only partially addressed the four core principles of medical ethics. Specifically, 75.2% (CI: 70.9–79.1) attended training workshops on medical ethics, and 68.2% (CI: 63.2–72.8) received training on personal data protection. Notably, medical ethics training attendance over the last 24 months was split between doctors and nurses, based on the original ratio of 57.3% doctor and 42.7% nurse. It clearly illustrates that the majority from both groups attended the training, with doctors slightly more represented due to their higher overall proportion. Ethical Dilemmas in Practice Most respondents reported infrequent encounters in terms of ethical challenges that related to new diagnostic or treatment methods, with 32.8% selecting "rarely" and 41.0% selecting "very rarely." Similarly, social inequality or restrictions of patient rights were experienced "rarely" (32.8%) or "very rarely" (41.0%). Both doctors and nurses reported rarely or very rarely using new methods of treatment and diagnosis (doctors at 57.3% while nurses were 42.7%). Doctors reported slightly higher use across all categories, and very few nurses reported frequent usage of new methods . Regarding patient education, responses were more varied: 27.2% reported doing so "frequently," while 26.5% indicated they did so "rarely." This reflects differing approaches among healthcare providers. Involuntary hospitalization was reported as occurring "very rarely" by 47.6% and "rarely" by 29.9%, suggesting that it is not a common practice. The breakdown of responses on Involuntary Hospitalization by doctors compared to nurses was 31% and 69% respectively. Descriptive statistics from Likert-scale responses showed that disagreements among professionals were not prevalent, with 39.3% responding "rarely" and 34.0% "very rarely." Regarding unfavorable working conditions, 39.6% selected "rarely" as their response. Similarly, 43.0% reported that patient refusal of treatment "rarely" created challenges, and the same pattern was seen with vaccine refusal. Waiting time for therapeutic treatment was described as a "rare" challenge by 41.5% of respondents. Technical issues related to the universal health insurance system were also marked "rare" at 34.2%. Finally, 43.7% reported that the discontinuation of life-sustaining treatment occurred "very rarely." The distribution of responses regarding Unfavorable Working Conditions in the department was split between doctors (30%) and nurses (70%) for each response category. Ethical Decision-Making in Hospitals Descriptive statistics from the Likert-scale responses were used to assess the ethical decision-making processes within hospitals. The majority of respondents (74.3%) confirmed the existence of a Standard Operating Procedure (SOP) for handling ethical issues. However, 18.2% were unsure of its existence, and 7.5% reported that no such protocol was in place. This suggests a generally strong adherence to ethical guidelines, while also highlighting the need to improve awareness and training regarding existing protocols. The ratio of doctors to nurses that believed improvements needed to be made to the aforementioned protocols was 1:2.5. When asked about encountering situations requiring ethical decisions, nearly half (45.4%) of the participants reported having experienced such cases, while 40.3% stated they had not. These findings point to the frequent occurrence of ethical dilemmas in clinical settings and emphasize the importance of equipping healthcare professionals with appropriate decision-making tools and institutional support. Doctors more frequently recalled encountering issues regarding ethical cases (112) compared to nurses (75). Nurses were far more unsure as to if they had encountered ethical issues (43 compared to 16 for doctors), with a notable portion of nurses responding “no” (100) - far higher than doctors (66). Despite the frequency of ethical challenges, only 22.8% of respondents reported consulting an ethics committee, while a significant 72.1% had not. This may suggest that many ethical concerns are addressed informally or that access to ethics committees is limited. Encouraging greater use of formal ethical resources could enhance the consistency and transparency of decision-making in hospitals. A significantly larger proportion of both doctors and nurses have not approached an ethics committee, with only a minority having done so and very few being unsure. Data Protection in the Healthcare Sector Most participants (79.6%) were aware of data protection regulations applicable to their workplace. However, 10.9% were uncertain, and 9.5% reported not being aware. A significant majority (84.7%) stated that patient data protection measures were in place, although 14.1% were unsure and 1.2% indicated that such measures were not implemented. With regard to data protection protocols during surgical procedures, 65.5% confirmed their existence, 26% were unsure, and 8.5% stated that no such protocols were in place. Most doctors and nurses responded “yes” regarding the implementation of necessary data protection measures for patient information. However, a significantly higher proportion of nurses (44) than doctors (14) responded that they were unsure of protection measures, indicating a potential gap in awareness among nursing staff that may require further training. Data Protection Measures Data protection was a key focus of the study. A large majority of doctors (159) and nurses (190) answered "yes" , indicating high confidence in data protection implementation. More nurses (44) than doctors (14) were again unsure, suggesting a potential communication or training gap. Very few respondents (2 doctors, 3 nurses) answered "no" . Approximately 70% of doctors and 63% of nurses mentioned that they have specific protocols for data protection in surgical procedures. However, 30% doctors and 37% nurses indicated uncertainty, highlighting a potential need for better training or documentation transparency. Regarding consent for blood transfusions, most participants (81.6%) indicated that written consent was obtained. A smaller proportion reported the use of verbal (2.4%) or electronic consent (3.4%), while 8% were unsure. In terms of how patient consent was generally obtained by doctors compared to nurses, 85% of doctors and 78% of nurses reported written consent as the primary method. For pediatric hospitalizations, restricted access (28.2%) and encrypted records (15.5%) were the most commonly mentioned protective measures, though a notable portion (33.7%) were uncertain about the specific practices used. R estricted access was the most frequently selected measure by both doctors and nurses. Doctors reported higher awareness or involvement in measures such as encrypting records and performing regular audits . Nurses showed a much higher rate of being unsure, suggesting a possible gap in awareness or training on data protection policies. Regarding the handling of sensitive information in pediatric care, parental consent procedures (34.7%) and secure databases (23.3%) were most frequently cited, with 23.8% of respondents unsure of the protective protocols in place. Only half of the participants reported the existence of a formal system for reporting data breaches. In contrast, 17.7% stated there was no such system, and 32.3% were uncertain. Strong data protection measures, including encryption, restricted access, and regular security audits, are vital for preventing unauthorised access to personal data. However, 43.4% of respondents were uncertain about how often data audits occur. Quarterly (19.4%) and monthly (17.5%) audits were the most frequently reported frequencies, while 6.8% indicated they were unaware if audits were being carried out. In the event of a data breach, the most common response protocol reported was immediate notification (43%), followed by notification within 24 hours (21.4%). However, 26.5% of participants were unsure about the procedures in place. Cybersecurity Cybersecurity in the healthcare sector concentrates on safeguarding electronic health records and digital infrastructure from unauthorised access, misuse, and disclosure. The findings indicate that 55.8% of respondents confirmed their hospital had a cybersecurity system, while 38.6% were unsure, and 5.6% stated that no system was in place. General Data Protection Regulation (GDPR) Regarding GDPR compliance, 51.5% of participants believed that their hospital’s data processing systems comply with GDPR. Meanwhile, 37.9% were unsure, and 9% indicated only partial compliance. About 53.4% of respondents confirmed regular GDPR training , while 30.8% were unsure , and 15.8% reported no training . Only 59.2% of respondents mentioned that they followed standard procedures when handling patient data requests under GDPR , while 21.8% handled it case by case , and 18.9% reported no structured approach . Around 65% of healthcare providers reported having a system in place for collecting patient feedback on data protection. About 38.3% of respondents reported reviewing their data protection policies "as needed" , while 26.7% were unsure , and only 13.6% reviewed their policies monthly . The attitudes of doctors differed from those of nurses in several areas. In some cases, the differences were supported by both statistical significance and a strong effect size (Cramér’s V > 0.25). Notably, doctors and nurses showed significant differences in their knowledge of medical ethics (p = 0.003), awareness of cybersecurity (p = 0.001), understanding of the General Data Protection Regulation (GDPR) (p = 0.004), and data protection measures (p = 0.004). Although differences in attitudes toward confidentiality (p = 0.341) and paternalism -acting irrespective of the patient’s opinion - (p = 0.341) were not statistically significant, the effect size (Cramér’s V > 0.25) suggests a meaningful practical difference between the two groups in these areas. Data Protection: A Critical Weakness The study identified two interrelated gaps that expose patient data to significant risk, namely inadequate cybersecurity infrastructure and infrequent audits, along with poorly defined incident response protocols. Inadequate cybersecurity infrastructure is a challenge for the Georgian healthcare sector since many institutions lack basic safeguards such as encryption, firewalls, and intrusion detection systems, compounded by infrequent audits and poorly defined incident response protocols. Despite the prevalence of the EU’s General Data Protection Regulation (GDPR), most Georgian healthcare institutions have not implemented corresponding frameworks. This regulatory void undermines legal certainty, weakens patient trust, and hinders alignment with international standards. This has a negative effect on patient trust and raises operational and legal risk. Patient trust is negatively impacted in the sense of concerns over data misuse, which may deter patients from fully disclosing critical health information. In regard to operational and legal risk, data breaches can lead to care disruption, legal penalties, and reputational damage. Discussion The findings reveal a healthcare environment in which formal mechanisms to protect patient autonomy are present in theory yet inconsistently recognised and applied in practice. While 74% of respondents confirmed the existence of ethical Standard Operating Procedures (SOPs), 18% were unsure, suggesting that these protocols are either insufficiently disseminated or poorly internalised. If healthcare providers are unaware of existing guidelines, they cannot be expected to adhere to them. Thus, although autonomy-protecting procedures may be technically in place, they are not fully embedded in routine clinical practice. Ethical dilemmas related to autonomy appear to be underreported or go unrecognized. Nearly half of the respondents indicated that they "rarely" encounter such dilemmas, while 40% stated "never." This may reflect either an actual low incidence or, more likely, a lack of awareness or preparedness in identifying situations where patient preference should take precedence over clinical judgment. The limited use of formal ethics committees reinforces this concern: only 23% of respondents had consulted an ethics committee, while 72% had not. This implies that complex ethical issues were often overlooked, resolved informally, or defaulted to hierarchical decision-making, potentially undermining patient-centered care. Despite recent regulations being implemented regarding accreditation and approaches to staff training, disparities and inconsistent access to continuous professional development (CPD) still present a challenge. Although 75% of respondents have received some form of ethics training, only 68% reported having undergone training in data protection. Moreover, nurses in particular have limited access to CPD opportunities. This fragmented approach leaves essential areas such as informed consent and confidentiality insufficiently addressed, particularly among professionals on the frontline of patient interaction. Notably, there are significant differences in confidence and knowledge between doctors and nurses regarding ethics, GDPR, and cybersecurity (Cramér’s V > 0.25). These gaps point to a lack of standardized training across professional roles, resulting in inconsistent application of ethical standards and potentially unequal experiences for patients depending on the provider. Even where protocols and training exist, limited familiarity with real-world ethical dilemmas and underutilization of support structures (such as ethics committees) reduce the system’s ability to consistently uphold patient autonomy. For meaningful change, it is essential to institutionalize ethics training, ensure regular engagement with ethics support structures, and integrate case-based learning into everyday clinical settings. Healthcare professionals are bound by the principle of beneficence - to act in the best interests of their patients. However, this duty is compromised when clinicians lack up-to-date knowledge of available treatments. A knowledge gap may result in suboptimal or overly cautious care, depriving patients of innovative or more effective therapies. This creates significant ethical tension: the intention to provide optimal care conflicts with limited clinical expertise. Without access to up-to-date information, even well-meaning practitioners may unintentionally offer outdated or less effective treatments, with direct consequences for patient outcomes. Recommendations: Implement Mandatory CPD: Regular, structured training on updated clinical guidelines and emerging therapies is essential. Enhance Decision Support: Provide access to evidence-based tools, such as clinical protocols and multidisciplinary case discussions (e.g., tumor boards). Foster Specialist Collaboration: Encourage links with centers of excellence and specialist networks. Strengthen Organizational Culture: Promote a learning environment through journal clubs, protected learning time, and access to academic databases. Adopt GDPR Frameworks: Align internal policies with GDPR principles, including data minimization, transparency, and breach notification. Enhance Technical Safeguards: Implement robust cybersecurity measures such as end-to-end encryption and multifactor authentication. Empower Staff: Provide mandatory training on data privacy and ensure all staff understand reporting procedures. Establish Oversight Mechanisms: Appoint dedicated data protection officers and conduct regular external audits. Recognising that even highly committed clinicians may fall short without systemic support highlights the need for strong institutional mechanisms to ensure up-to-date, high-quality care. By addressing both technological and regulatory shortcomings, Georgian hospitals can significantly strengthen data protection, reduce institutional risk, and build a more trustworthy digital health environment. Declarations Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Clinical trial number: Not applicable. Human Ethics and Consent to Participate: This study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the University of Georgia (Approval No:11-32284). Participation in the survey was entirely voluntary, and informed consent was obtained from all respondents prior to data collection. No personally identifiable information was collected, ensuring anonymity and confidentiality throughout the study. Consent for Publication: Not applicable. Competing interests: The authors declare that they have no competing interests. Authors’ contributions: L.S. and S.I. conceived the study and developed the research design and methodology. L.S. provided oversight of data collection processes and supervised the ethical approval procedures. S.I. conducted the statistical analyses and led the interpretation of the findings. N.G. facilitated institutional engagement by coordinating communication with hospitals and clinical staff, contributed substantially to the administration of the survey, and participated in both data collection and preliminary data analysis. All authors contributed to the literature review and contextual framing of the study. S.I. drafted the initial manuscript, and L.S. undertook critical revisions for important intellectual content. All authors read and approved the final version of the manuscript and accept responsibility for the integrity and accuracy of the work. Acknowledgements: Not applicable. Data Availability : The anonymized datasets that support the findings of this study have been securely deposited at the University of Georgia, which ensures strict compliance with data protection and confidentiality standards. 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Georgia. World Health Organization. 2017; Volume10. პერსონალურ მონაცემთა დაცვის შესახებ [cited 2025 Jul 27]. Available from: http://file:///C:/Users/shengelia_unfpa/Downloads/პერსონალურ%20მონაცემთა%230დაცვის%20შესახებ%20მოქმედი%20კანონი_1711019935.pdf Gov.ge. სამართლებრივი აქტები [cited 2025 Jul 28]. Available from: https://www.moh.gov.ge/general-info.php?id1=6&lang=1 Additional Declarations No competing interests reported. Supplementary Files QuestionnaireontheManagementofEthicalDilemmasandDataProtectioninHospitalsENG.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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These values are crucial to delivering high-quality healthcare, ensuring that patients receive fair and dignified treatment. Furthermore, by prioritizing the needs of patients, adherence to ethical standards promotes confidence and trust in healthcare. The Hippocratic Oath, created in ancient Greece to hold medical professionals accountable for the well-being and non-maleficence of their patients, is credited with establishing the importance of ethics in healthcare. Since then, these ethics have outlined professional behavior and obligations, and have remained highly relevant in the healthcare industry. To this end, the four pillars of medical ethics were established to ensure that patient safety and care are held to the highest standards.\u003c/p\u003e\n\u003cp\u003eThe four pillars of medical ethics - respect for autonomy, beneficence, non-maleficence and justice - ensures patient safety and patient-centered care. Respect for autonomy involves acknowledging and honoring the right of a patient to make their own healthcare decisions. Beneficence obligates healthcare providers to act in the best interest of the patient, promoting their health and well-being. Non-maleficence, the principle of \u0026quot;do no harm\u0026quot;, ensures that healthcare professionals avoid causing harm or suffering to patients. Justice sees to it that fairness in healthcare is maintained, ensuring equitable treatment and patient care access (1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAutonomy ensures that patients have the right to decide their treatment plans and that they have the final say in the decision-making process, even when a professional believes a certain action may not be in the best interest of the patient. It must, however, be weighed against conflicting moral values and can, in specific situations, be overridden. For example, if the autonomous actions of a patient should result in harm to others, their autonomy may be restricted. The principle of autonomy, however, does not extend to those who cannot act independently (2). While healthcare providers can educate patients, they cannot make decisions on their behalf. In some countries, resistance to the principle of patient autonomy and its related concepts (such as informed consent and honesty) poses a challenge. In nations, for example, with ancient civilizations and deeply rooted traditions, the practice of paternalism by physicians often stems from the principle of beneficence.\u003c/p\u003e\n\u003cp\u003eThe concept of \u0026quot;beneficence\u0026quot; refers to the obligation of medical personnel to act in the best interests of the patient. This entails improving their health and well-being through therapies aimed at health promotion, injury prevention, and pain management. Beneficence is fundamental to healthcare ethics; when deciding on the best treatment for a patient, doctors must weigh the advantages and disadvantages of each option and choose the one that will most benefit the patient (3, 4). The challenging aspect of beneficence is determining what is best for each patient. Before acting, medical personnel should be informed about the particular needs, objectives, and experiences of every patient. They should be aware of the history, religious beliefs, and significant life events of a patient, as these factors can aid patients in making decisions that are best for them. Even seemingly minor elements can have a significant impact on the comfort and effectiveness of treatment (Michael et al, 2019).\u003c/p\u003e\n\u003cp\u003eThe third pillar, nonmaleficence, is another core value of medical ethics and emphasizes that medical professionals should \u0026quot;do no harm,\u0026quot; thus avoiding causing suffering or harm to the patient through negligence. It serves as a guiding principle, allowing actions to be taken if the potential benefits for the patient outweigh any pain or discomfort they might endure. This simple principle of a doctor having an ethical obligation to avoid causing harm to their patients encompasses several moral tenets, such as not fatally injuring a patient, inflicting pain or suffering, rendering someone helpless, inciting hatred, or denying someone their basic human rights. In practice, doctors apply the principle of non-maleficence by carefully considering the pros and cons of all treatments and interventions, avoiding those that are excessively burdensome, and choosing the best course of action for the patient. This principle is particularly important when making difficult decisions regarding withdrawing or withholding life-sustaining treatment, administering medically supervised nutrition and hydration, and managing pain and other symptoms. The duties and goals of a physician include alleviating suffering such as refractory pain (5, 6).\u003c/p\u003e\n\u003cp\u003eThe final pillar, justice, is a multifaceted concept that involves treating every patient fairly. The principle emphasizes equitable care rather than the same type of treatment. It is related to healthcare equity in that no patient should be denied care, have limited access to care, or receive lower quality care due to their financial status, race, gender identity, or any other characteristic. Justice also involves supporting other facilities if they become overwhelmed by accepting their patients or sharing medical resources with a broader community that may lack access to adequate healthcare services. Justice is also relevant in emergencies, as healthcare professionals must evaluate the severity of each patient\u0026apos;s condition to determine the order of treatment. Additionally, all patients should receive the same level of care without preferential treatment based on relationships or personal preferences. Justice is typically understood as the fair, equitable, and appropriate treatment of individuals. The most relevant category of justice is distributive justice, which involves the fair, equitable, and appropriate allocation of healthcare resources, guided by justified norms that define the terms of social cooperation. Various valid principles of distributive justice can be used to achieve this goal. These principles are not mutually exclusive and can often be combined in practice (1).\u003c/p\u003e\n\u003cp\u003eAll the aforementioned pillars are part of the International Code of Medical Ethics (7, World Medical Association, 2006), adopted in 1949 by the General Assembly of the World Medical Association following World War II. Medical advancements reached exponential heights, leading to the formulation of fundamental ethical principles that now guide medical practitioners in their decision-making processes. These principles continue to influence the resolution of ethical dilemmas in patient care (1).\u003c/p\u003e\n\u003cp\u003eThe International Code of Medical Ethics has since undergone numerous amendments, with the last iteration being in 2006. These changes have resulted in benefits for both patients and health professionals. Patients benefit from all ethical standards as these ensure their autonomy is respected, they are treated fairly, and they receive the best possible care as per their preferences and values, leading to patients being able to fully trust their healthcare providers. Without the guarantee of such benefits, many people may delay seeking medical help as healthcare could potentially be intrusive. While patients are the primary beneficiaries of fundamental ethical principles, healthcare personnel also benefit from these rules. Operating within an ethical framework allows healthcare professionals to communicate openly and honestly with patients and their families regarding end-of-life care or to promptly inform patients of their emergency care options. When dealing with ethical dilemmas involving patients, their families, caregivers, or coworkers, practitioners are able to recommend actions that prioritize the needs of the patient (6, 7, 8).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical Ethics in the USSR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter the Soviet Revolution, a system rooted in Socialist humanism called the Semashko health financing model was established in the Russian Soviet Federative Socialist Republic (RSFSR). In 1918, the People\u0026rsquo;s Commissariat of Public Health was formed to unify the \u0026nbsp;medical and sanitary services of the country (10). The main goals of this system included the eradication of infectious diseases and the development of curative care. The Communist Party (CP) directed the healthcare system to implement extensive sanitary measures (10), including:\u003c/p\u003e\n\u003cp\u003ea) Improving health conditions in populated areas by protecting soil, water, and air from pollution;\u003c/p\u003e\n\u003cp\u003eb) Organising public catering on scientific and hygienic principles;\u003c/p\u003e\n\u003cp\u003ec) Launching initiatives to prevent the outbreak and spread of infectious diseases;\u003c/p\u003e\n\u003cp\u003ed) Creating a comprehensive health legislation code;\u003c/p\u003e\n\u003cp\u003ee) Combating social diseases such as tuberculosis, venereal diseases, and alcoholism;\u003c/p\u003e\n\u003cp\u003ef) Providing qualified medical and pharmaceutical services to all citizens free of charge.\u003c/p\u003e\n\u003cp\u003eThe Soviet Government issued a series of policies to further unify the administrative and operational frameworks of medical and sanitary institutions. Key policies included those on health insurance (1917), the nationalization of pharmacies and medical property (1918), maternal and childcare provisions (1918) and compulsory smallpox vaccinations (1919) (11).\u003c/p\u003e\n\u003cp\u003eThe Code of Health Legislation served as the primary moral guideline for Soviet doctors, who were committed to enhancing the well-being of the Soviet populace. Subsequently, the Soviet Constitution enshrined the right to health protection, declaring that citizens of the USSR had the right to receive support in old age and in sickness or disability. It guaranteed every citizen access to free medical aid and reinforced the protection of public health (12).\u003c/p\u003e\n\u003cp\u003eSoviet public health initiatives significantly contributed to increased labor productivity and improved hygiene in both industry and agriculture. Concurrently, extensive measures were undertaken to enhance living conditions, with Soviet health services playing a crucial role (9). The USSR allocated resources for social insurance benefits, pensions, free or subsidized accommodation in sanatoria and holiday homes, support for large families and single mothers, free medical aid, and various initiatives aimed at boosting the welfare of the working class. These efforts had a profoundly positive impact on the health of Soviet citizens (12).\u003c/p\u003e\n\u003cp\u003eHowever, from its inception the Soviet Health System was based on paternalism which restricted the freedom of choice of a patient, as it was believed that this was in their best interest (Pelto-Piri, 2013). Thus, violations of the ethical norms of patients were frequent occurrences in the USSR. Moreover, the Soviet legacy of institutionalizing people with chronic diseases lasted long after the collapse of the Soviet Empire. In the early 50s of the last century, new mental health legislation was adopted, and those with mental health problems and learning disabilities were isolated from society and confined to psychiatric hospitals (9), with psychiatric diagnoses used for political reasons from the 1950s onwards (10). This approach had significant consequences for individuals with mental health issues and those with learning disabilities. Many were institutionalised and completely removed from the communities in which they had once lived. Families were strongly encouraged to forget about their \u0026ldquo;faulty\u0026rdquo; relatives, effectively abandoning them to these institutions. Soviet ideology promoted an ideal society in which everyone was expected to conform to socialist standards. Mental health care during the Soviet era was characterised by two main factors: the socialist ideology of the perfect Soviet citizen and the oppression of those who opposed the political system (11).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Russian Association of Psychiatrists espoused the belief that mental illness was a trait of capitalist societies and would eventually vanish under communism. Individuals who were unable to conform to socialist standards due to mental health issues were viewed as underdeveloped (Gordon, 2000; Bonnie, 2002). Citizens faced arrest for distributing pamphlets or writing articles critiquing the regime. During official party celebrations, potential dissenters were often imprisoned, only to be released after the events had concluded. Research conducted after 1989 confirmed that some individuals were confined to psychiatric hospitals solely because their political beliefs diverged from the dominant communist ideology and had not, in fact, actually suffered from any mental disorders nor undergone any official assessment or trial. Within psychiatric hospitals, psychiatrists often administered antipsychotic medications as punishment for those expressing anti-communist views (13; 14).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedical Ethics in Georgia\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHistorically, Georgian medicine has strongly been influenced by a blend of cultural and religious traditions that have shaped its ethical foundations. The first Georgian medical book, \u003cem\u003eKarabadin\u003c/em\u003e, which was written in the 10\u003csup\u003eth\u003c/sup\u003e century, not only consisted of the medical knowledge of that era, including aspects of Sumerian medicine, but also embedded principles of respect, beneficence, and justice, reflecting a holistic approach to patient care that honors the dignity of every individual (\u003cstrong\u003e15\u003c/strong\u003e).\u003c/p\u003e\n\u003cp\u003eAnother key source of medical knowledge is the\u003cem\u003e\u0026nbsp;Karabadin\u0026nbsp;\u003c/em\u003emedical book (an updated and edited version of the 10\u003csup\u003eth\u003c/sup\u003e century text) authored by the doctor and thinker Zaza Panaskerteli-Tsitsishvili. Considered an ancient Georgian pharmacopoeia, the book, written in the 15th century, contains a wealth of medical knowledge, including herbal remedies, surgical techniques, and ethical guidelines for medical practitioners. The book emphasizes several ethical aspects, such as prioritizing patient well-being and comfort, maintaining patient confidentiality and privacy, and upholding high standards of professional behavior and integrity (15).\u003c/p\u003e\n\u003cp\u003eAnother significant medical manuscript is Yadigar Daud, created by King Davit XI. This manuscript offers valuable insights into the medical practices and ethical considerations of its time. It includes guidelines on medical ethics, emphasising the moral responsibilities of physicians towards their patients, cultural sensitivity in understanding and respecting patients\u0026apos; cultural and religious beliefs, and holistic care by addressing the physical, mental, and emotional well-being of patients (16). These texts and the principles they embody have played a crucial role in shaping the ethical landscape of Georgian medicine, ensuring that it upholds the highest standards of patient care and professional conduct (16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAfter the collapse of the Soviet Union and gaining its independence, Georgia began developing its healthcare sector from the ground up, while the Semashko healthcare system remained in operation. However, the development of this new system and the establishment of ethical standards in medicine were heavily influenced by the imperialistic doctrines dating back to the Soviet period. Thus, the country initiated a prolonged and complex process of reforms, and only by the end of the century was the country capable of implementing new regulations for professional medical activities (17, 18).\u003c/p\u003e\n\u003cp\u003eOn 6 May 2003, the Congress of Georgian Physicians adopted the Code of Medical Ethics of Georgia. This code sets out the fundamental ethical principles that govern a physician\u0026rsquo;s professional behaviour towards patients, colleagues and society. That marked the beginning of the development of medical ethics in modern Georgia (19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt present, the professional activities of physicians are regulated by a range of declarative legal and ethical documents at both the national and international levels. These provisions serve to define the scope of medical responsibility, safeguard patient rights, and establish a foundation for ethical clinical practice (20). The key documents include: the National Legislation of Georgia \u0026ndash; including \u003cem\u003ethe Law on Medical Practice\u003c/em\u003e (2001), \u003cem\u003ethe Law on Patients\u0026apos; Rights\u003c/em\u003e (2000), and \u003cem\u003ethe Law on Health Care\u003c/em\u003e (1997) \u0026ndash; which provide the legal foundation for healthcare delivery and medical accountability. Additionally, specialised legislation regulates particular domains within the health sector, such as \u003cem\u003ethe Law on Public Health\u003c/em\u003e (2007), \u003cem\u003ethe Law on HIV/AIDS\u003c/em\u003e (2009), \u003cem\u003ethe Law on Psychiatric Care\u003c/em\u003e (2006) and \u003cem\u003ethe\u003c/em\u003e \u003cem\u003eLaw on Human Organ Transplantation\u003c/em\u003e (2000) (21). International Legal Policies of the Council of Europe \u0026ndash; most notably, \u003cem\u003ethe\u003c/em\u003e \u003cem\u003eConvention on Human Rights and Biomedicine\u003c/em\u003e (1997), commonly known as the Oviedo Convention (22); \u003cem\u003ethe\u003c/em\u003e \u003cem\u003eDeclaration on the Promotion of Patients\u0026rsquo; Rights in Europe\u003c/em\u003e (1994), which highlights principles of dignity, informed consent, and equitable access to care (23). UNESCO\u0026rsquo;s \u003cem\u003eUniversal Declaration on Bioethics and Human Rights\u003c/em\u003e (2005), and the United Nations\u0026rsquo; \u003cem\u003ePrinciples of Medical Ethics\u003c/em\u003e (1982) (24). \u0026nbsp;\u003cem\u003ethe International Code of Medical Ethics\u003c/em\u003e (1949) and a series of influential declarations: \u003cem\u003ethe Geneva Declaration\u003c/em\u003e, \u003cem\u003eLisbon Declaration on the Rights of the Patient\u003c/em\u003e, \u003cem\u003eHelsinki Declaration on Medical Research Ethics\u003c/em\u003e, \u003cem\u003eTokyo Guidelines on Torture and Physicians\u0026rsquo; Roles\u003c/em\u003e, etc. (25).\u003c/p\u003e\n\u003cp\u003eSince 2011, the country has implemented a Law on Personal Data Protection, which was amended in 2013. The law strengthened the safety and protection of medical information (26). In 2013, the country implemented the Universal Health Care Programme, though poor quality of healthcare services remained an issue. Consequently, the government of Georgia implemented hospitals\u0026rsquo; accreditation procedures in order to improve patient safety, care quality, and operational effectiveness. It acts as a standard for organisations aiming to fulfil global requirements, ensuring that medical facilities follow the strictest guidelines for patient care, safety, and administration (27).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to Article 4, Paragraph 1 of Annex 1 of the \u003cem\u003eState Programme for Universal Health Care\u003c/em\u003e, approved by Decree No. 36 of the Government of Georgia on 21 February 2023, a medical facility shall be defined as an institution that has obtained international accreditation (28). A formal certification process ensures that reliable medical facilities follow internationally recognised standards. Hospitals are evaluated by independent external organisations to verify if they meet these strict requirements, which include staff qualifications, clinical procedures, infection control, and patient safety. Accreditation is a continuous commitment to maintaining and improving healthcare quality, not just a badge of honour (28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was thus conducted in order to measure patient safety and the implementation of ethical standards, including the current level thereof, for the further improvement of healthcare services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe General Objective of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main objective of the study is to explore the implementation of ethical practices in the Georgian healthcare sector.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSpecific Objectives of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eTo assess and compare the level of knowledge, attitude and practice of medical ethics among medical staff;\u003c/li\u003e\n \u003cli\u003eTo explore the medical staff\u0026apos;s experience with ethical dilemmas;\u003c/li\u003e\n \u003cli\u003eTo explore the medical staff\u0026rsquo;s sources from which they derived their ethical understanding;\u003c/li\u003e\n \u003cli\u003eProvide recommendations for policymakers.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Methodology","content":"\u003cp\u003eA cross-sectional study was conducted involving doctors and ward nurses from approximately 30 hospitals in Georgia. These healthcare institutions employ approximately 20% of the country\u0026apos;s medical professionals (21).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study focused on medical doctors and nurses working in both inpatient wards and outpatient clinics. Doctors included in the study were those who directly consulted with patients and managed their care. Nurses were included in the study if they were involved in patient care and were under the supervision and guidance of doctors. Since both groups are central to ethical decision-making in healthcare, their perspectives offer valuable insights into the level of knowledge, attitudes, and perceptions regarding medical ethics in Georgia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire and Variables\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants\u0026rsquo; knowledge of medical ethics, data protection, and ethical challenges was assessed using a self-administered questionnaire. This tool was developed following a literature review of similar studies conducted in Barbados, Nepal and India, and was subsequently adapted to fit the Georgian healthcare context. Ethical approval was granted by the Ethics Committee of the University of Georgia.\u003c/p\u003e\n\u003cp\u003eOriginally developed in English, the questionnaire was translated into Georgian and then back again to ensure accuracy. It was pre-tested in two healthcare facilities with a sample of doctors and nurses. Feedback from the pre-test was used to refine the wording and eliminate ambiguity.\u003c/p\u003e\n\u003cp\u003eThe questionnaire comprised three sections:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSociodemographic Data: Age, gender, professional role, years of experience, and place of work;\u003c/li\u003e\n \u003cli\u003eEthical Perspectives: This section consisted of 12 statements related to key ethical principles such as respect for patient autonomy, confidentiality, informed consent, and professional duty. Each statement was rated on a 5-point Likert scale, followed by response analysis to assess trends in ethical attitudes among healthcare professionals:\u003c/li\u003e\n\u003c/ul\u003e\n\u003col start=\"1\" type=\"1\"\u003e\n \u003cul type=\"circle\"\u003e\n \u003cli\u003e1 \u0026ndash; Strongly disagree\u003c/li\u003e\n \u003cli\u003e2 \u0026ndash; Disagree\u003c/li\u003e\n \u003cli\u003e3 \u0026ndash; Neutral\u003c/li\u003e\n \u003cli\u003e4 \u0026ndash; Agree\u003c/li\u003e\n \u003cli\u003e5 \u0026ndash; Strongly agree\u003c/li\u003e\n \u003c/ul\u003e\n\u003c/ol\u003e\n\u003cul\u003e\n \u003cli\u003eSources and Preferences: Participants indicated their primary sources of ethical knowledge (e.g., university courses, hospital policies and personal experience) and preferences when seeking guidance on legal or ethical dilemmas.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe internal consistency of the \u0026quot;Ethical Perspectives\u0026quot; section was evaluated using Cronbach\u0026rsquo;s alpha (\u0026alpha; = 0.82), indicating good reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTool Validation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe internal consistency of the key attitudinal items in the Ethical Perspectives section was assessed using Cronbach\u0026rsquo;s alpha, which resulted in a value of 0.82, indicating good reliability. Test-retest reliability was also evaluated by administering the questionnaire to a subgroup of 15 participants two weeks after the initial test. The resulting correlation coefficient (r = 0.87) demonstrated strong temporal stability.\u003c/p\u003e\n\u003cp\u003eAdditionally, feedback obtained during the pre-test phase was used to refine ambiguous items, enhancing overall clarity and ensuring semantic equivalence in the final version of the tool.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and Data Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 430 doctors and nurses were randomly selected and invited to take part in the study. With a refusal rate of just 4%, the final sample comprised 412 participants (236 doctors and 176 nurses), making it a representative subset of Georgia\u0026rsquo;s healthcare workforce. Data collection occurred between May and November 2024 via Google Forms. Questionnaires were distributed electronically, and participants were required to give informed consent before proceeding.\u003c/p\u003e\n\u003cp\u003eThe hospitals included in the study represented a diverse range of institutional types, encompassing urban and rural settings, and included public, private, and university-affiliated hospitals from various regions of Georgia. This diversity strengthens the generalizability of the findings within the context of the national healthcare system.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Determination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sample size was calculated based on an assumed 50% prevalence of adequate knowledge of medical ethics and data protection - a conservative estimate used to ensure the maximum required sample size. A 95% confidence level and a \u0026plusmn;5% margin of error were applied. Using the standard formula for sample size calculation for proportions in a finite population (approximately 20,000 healthcare professionals in Georgia), the minimum required sample size was determined to be 377 participants. To account for potential non-response, the target sample was increased to 430. Ultimately, 412 participants completed the survey, resulting in a response rate of 96%, which exceeds the threshold for statistical reliability.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was exempted from a full review by the Institutional Review Board of the University of Georgia. Informed consent was obtained electronically, with all participants required to acknowledge their willingness to participate before accessing the survey. Participation was entirely voluntary, and no incentives were provided.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed using SPSS version 20.0. Descriptive statistics were calculated using proportions and percentages. Differences in ethical attitudes between doctors and nurses were examined using Chi-Square tests, with Cram\u0026eacute;r\u0026rsquo;s V used to measure the strength of associations. Effect sizes were categorized as small (\u0026lt;0.1), medium (0.1\u0026ndash;0.5), or large (\u0026gt;0.5). A p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eSociodemographic Details\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOut of 412 participants, 57% were doctors and 43% were nurses. The average age of doctors was 43 years (SD = 1.57), while for nurses it was 57 years (SD = 4.77). Among the doctors, 60% were female and 40% male. All participating nurses were female. Only 39.6% of participants were based in the capital, with the remaining respondents employed in various regions of Georgia. In terms of work experience, 44% (n = 182) had over 15 years of experience, 41% (n = 170) had between 5 and 14 years, and 15% (n = 60) had less than 5 years of professional experience.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of Medical Ethics and Dilemmas\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study highlighted that continuous professional development (CPD) remains a challenge in the Georgian healthcare sector. CPD is not compulsory, and participation often depends on private provider preferences. However, the new regulation related to accreditation made it obligatory for staff to undergo training on different topics. Study results showed that 88.6% of respondents (CI: 85.0\u0026ndash;91.5) reported taking part in CPD activities, although these training sessions only partially addressed the four core principles of medical ethics. Specifically, 75.2% (CI: 70.9\u0026ndash;79.1) attended training workshops on medical ethics, and 68.2% (CI: 63.2\u0026ndash;72.8) received training on personal data protection. Notably, medical ethics training attendance over the last 24 months was split between doctors and nurses, based on the original ratio of 57.3% doctor and 42.7% nurse. It clearly illustrates that the majority from both groups attended the training, with doctors slightly more represented due to their higher overall proportion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Dilemmas in Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost respondents reported infrequent encounters in terms of ethical challenges that related to new diagnostic or treatment methods, with 32.8% selecting \u0026quot;rarely\u0026quot; and 41.0% selecting \u0026quot;very rarely.\u0026quot; Similarly, social inequality or restrictions of patient rights were experienced \u0026quot;rarely\u0026quot; (32.8%) or \u0026quot;very rarely\u0026quot; (41.0%). Both doctors and nurses reported \u003cstrong\u003erarely\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eor \u003cstrong\u003every rarely\u0026nbsp;\u003c/strong\u003eusing new methods of treatment and diagnosis (doctors at 57.3% while nurses were 42.7%). Doctors reported slightly higher use across all categories, and very few nurses reported \u003cstrong\u003efrequent\u003c/strong\u003e usage of new methods\u003cstrong\u003e.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding patient education, responses were more varied: 27.2% reported doing so \u0026quot;frequently,\u0026quot; while 26.5% indicated they did so \u0026quot;rarely.\u0026quot; This reflects differing approaches among healthcare providers. Involuntary hospitalization was reported as occurring \u0026quot;very rarely\u0026quot; by 47.6% and \u0026quot;rarely\u0026quot; by 29.9%, suggesting that it is not a common practice. The breakdown of responses on Involuntary Hospitalization by doctors compared to nurses was 31% and 69% respectively. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDescriptive statistics from Likert-scale responses showed that disagreements among professionals were not prevalent, with 39.3% responding \u0026quot;rarely\u0026quot; and 34.0% \u0026quot;very rarely.\u0026quot; Regarding unfavorable working conditions, 39.6% selected \u0026quot;rarely\u0026quot; as their response. Similarly, 43.0% reported that patient refusal of treatment \u0026quot;rarely\u0026quot; created challenges, and the same pattern was seen with vaccine refusal.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWaiting time for therapeutic treatment was described as a \u0026quot;rare\u0026quot; challenge by 41.5% of respondents. Technical issues related to the universal health insurance system were also marked \u0026quot;rare\u0026quot; at 34.2%. Finally, 43.7% reported that the discontinuation of life-sustaining treatment occurred \u0026quot;very rarely.\u0026quot;\u0026nbsp;The distribution of responses regarding Unfavorable Working Conditions in the department was split between doctors (30%) and nurses (70%) for each response category.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Decision-Making in Hospitals\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics from the Likert-scale responses were used to assess the ethical decision-making processes within hospitals. The majority of respondents (74.3%) confirmed the existence of a Standard Operating Procedure (SOP) for handling ethical issues. However, 18.2% were unsure of its existence, and 7.5% reported that no such protocol was in place. This suggests a generally strong adherence to ethical guidelines, while also highlighting the need to improve awareness and training regarding existing protocols. The ratio of doctors to nurses that believed improvements needed to be made to the aforementioned protocols was 1:2.5.\u003c/p\u003e\n\u003cp\u003eWhen asked about encountering situations requiring ethical decisions, nearly half (45.4%) of the participants reported having experienced such cases, while 40.3% stated they had not. These findings point to the frequent occurrence of ethical dilemmas in clinical settings and emphasize the importance of equipping healthcare professionals with appropriate decision-making tools and institutional support.\u0026nbsp;\u003cstrong\u003eDoctors\u003c/strong\u003e more frequently recalled encountering issues regarding ethical cases (112) compared to \u003cstrong\u003enurses\u003c/strong\u003e (75). \u003cstrong\u003eNurses\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ewere far more unsure as to if they had encountered ethical issues (43 compared to 16 for doctors), with a notable portion of \u003cstrong\u003enurses\u003c/strong\u003e responding \u003cstrong\u003e\u0026ldquo;no\u0026rdquo;\u003c/strong\u003e (100) - far higher than \u003cstrong\u003edoctors\u003c/strong\u003e (66).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDespite the frequency of ethical challenges, only 22.8% of respondents reported consulting an ethics committee, while a significant 72.1% had not. This may suggest that many ethical concerns are addressed informally or that access to ethics committees is limited. Encouraging greater use of formal ethical resources could enhance the consistency and transparency of decision-making in hospitals.\u003c/p\u003e\n\u003cp\u003eA significantly larger proportion of both doctors and nurses have \u003cstrong\u003enot\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eapproached an ethics committee, with only a minority having done so and very few being unsure.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Protection in the Healthcare Sector\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost participants (79.6%) were aware of data protection regulations applicable to their workplace. However, 10.9% were uncertain, and 9.5% reported not being aware. A significant majority (84.7%) stated that patient data protection measures were in place, although 14.1% were unsure and 1.2% indicated that such measures were not implemented. With regard to data protection protocols during surgical procedures, 65.5% confirmed their existence, 26% were unsure, and 8.5% stated that no such protocols were in place.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMost doctors and nurses responded \u0026ldquo;yes\u0026rdquo; regarding the implementation of necessary data protection measures for patient information. However, a significantly higher proportion of nurses (44) than doctors (14) responded that they were unsure of protection measures, indicating a potential gap in awareness among nursing staff that may require further training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Protection Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData protection was a key focus of the study.\u0026nbsp;\u003cstrong\u003eA\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003elarge majority\u003c/strong\u003e of doctors (159) and nurses (190) answered \u003cstrong\u003e\u0026quot;yes\u0026quot;\u003c/strong\u003e, indicating high confidence in data protection implementation. More nurses (44) than doctors (14) were again unsure, suggesting a potential communication or training gap. Very few respondents (2 doctors, 3 nurses) answered\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026quot;no\u0026quot;\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproximately 70% of doctors and 63% of nurses mentioned that they have specific protocols for data protection in surgical procedures. However, 30% doctors and 37% nurses\u0026nbsp;indicated uncertainty, highlighting a potential need for better training or documentation transparency.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding consent for blood transfusions, most participants (81.6%) indicated that written consent was obtained. A smaller proportion reported the use of verbal (2.4%) or electronic consent (3.4%), while 8% were unsure. In terms of how patient consent was generally obtained by doctors compared to nurses,\u0026nbsp;85% of doctors and 78% of nurses reported \u003cstrong\u003ewritten consent\u003c/strong\u003e as the primary method.\u003c/p\u003e\n\u003cp\u003eFor pediatric hospitalizations, restricted access (28.2%) and encrypted records (15.5%) were the most commonly mentioned protective measures, though a notable portion (33.7%) were uncertain about the specific practices used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eR\u003cstrong\u003eestricted access\u003c/strong\u003e was the most frequently selected measure by both doctors and nurses.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eDoctors\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003ereported higher awareness or involvement in measures such as\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eencrypting records\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eand performing \u003cstrong\u003eregular audits\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eNurses\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eshowed a much higher rate of being unsure, suggesting a possible gap in awareness or training on data protection policies.\u003c/p\u003e\n\u003cp\u003eRegarding the handling of sensitive information in pediatric care, parental consent procedures (34.7%) and secure databases (23.3%) were most frequently cited, with 23.8% of respondents unsure of the protective protocols in place.\u003c/p\u003e\n\u003cp\u003eOnly half of the participants reported the existence of a formal system for reporting data breaches. In contrast, 17.7% stated there was no such system, and 32.3% were uncertain.\u003c/p\u003e\n\u003cp\u003eStrong data protection measures, including encryption, restricted access, and regular security audits, are vital for preventing unauthorised access to personal data. However, 43.4% of respondents were uncertain about how often data audits occur. Quarterly (19.4%) and monthly (17.5%) audits were the most frequently reported frequencies, while 6.8% indicated they were unaware if audits were being carried out.\u003c/p\u003e\n\u003cp\u003eIn the event of a data breach, the most common response protocol reported was immediate notification (43%), followed by notification within 24 hours (21.4%). However, 26.5% of participants were unsure about the procedures in place.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCybersecurity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCybersecurity in the healthcare sector concentrates on safeguarding electronic health records and digital infrastructure from unauthorised access, misuse, and disclosure. The findings indicate that 55.8% of respondents confirmed their hospital had a cybersecurity system, while 38.6% were unsure, and 5.6% stated that no system was in place.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeneral Data Protection Regulation (GDPR)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRegarding GDPR compliance, 51.5% of participants believed that their hospital\u0026rsquo;s data processing systems comply with GDPR. Meanwhile, 37.9% were unsure, and 9% indicated only partial compliance. About \u003cstrong\u003e53.4% of respondents confirmed regular GDPR training\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003ewhile\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e30.8% were unsure\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003e15.8% reported no training\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eOnly\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e59.2% of respondents mentioned that they followed standard procedures when handling patient data requests under GDPR\u003c/strong\u003e\u003cstrong\u003e,\u003c/strong\u003e while\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e21.8% handled it case by case\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eand \u003cstrong\u003e18.9% reported no structured approach\u003c/strong\u003e\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eAround \u003cstrong\u003e65% of healthcare providers reported having a system\u0026nbsp;\u003c/strong\u003ein place\u003cstrong\u003e\u0026nbsp;for collecting patient feedback on data protection.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eAbout \u003cstrong\u003e38.3% of respondents reported reviewing their data protection policies \u0026quot;as needed\u0026quot;\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003ewhile \u003cstrong\u003e26.7% were unsure\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003eand only \u003cstrong\u003e13.6% reviewed their policies monthly\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe attitudes of doctors differed from those of nurses in several areas. In some cases, the differences were supported by both statistical significance and a strong effect size (Cram\u0026eacute;r\u0026rsquo;s V \u0026gt; 0.25). Notably, doctors and nurses showed significant differences in their knowledge of medical ethics (p = 0.003), awareness of cybersecurity (p = 0.001), understanding of the General Data Protection Regulation (GDPR) (p = 0.004), and data protection measures (p = 0.004). Although differences in attitudes toward confidentiality (p = 0.341) and paternalism -acting irrespective of the patient\u0026rsquo;s opinion - (p = 0.341) were not statistically significant, the effect size (Cram\u0026eacute;r\u0026rsquo;s V \u0026gt; 0.25) suggests a meaningful practical difference between the two groups in these areas.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Protection: A Critical Weakness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study identified two interrelated gaps that expose patient data to significant risk, namely inadequate cybersecurity infrastructure and infrequent audits, along with poorly defined incident response protocols. Inadequate cybersecurity infrastructure is a challenge for the Georgian healthcare sector since many institutions lack basic safeguards such as encryption, firewalls, and intrusion detection systems, compounded by infrequent audits and poorly defined incident response protocols. Despite the prevalence of the EU\u0026rsquo;s General Data Protection Regulation (GDPR), most Georgian healthcare institutions have not implemented corresponding frameworks. This regulatory void undermines legal certainty, weakens patient trust, and hinders alignment with international standards.\u003c/p\u003e\n\u003cp\u003eThis has a negative effect on patient trust and raises operational and legal risk. Patient trust is negatively impacted in the sense of concerns over data misuse, which may deter patients from fully disclosing critical health information. In regard to operational and legal risk, data breaches can lead to care disruption, legal penalties, and reputational damage.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings reveal a healthcare environment in which formal mechanisms to protect patient autonomy are present in theory yet inconsistently recognised and applied in practice. While 74% of respondents confirmed the existence of ethical Standard Operating Procedures (SOPs), 18% were unsure, suggesting that these protocols are either insufficiently disseminated or poorly internalised. If healthcare providers are unaware of existing guidelines, they cannot be expected to adhere to them. Thus, although autonomy-protecting procedures may be technically in place, they are not fully embedded in routine clinical practice.\u003c/p\u003e\n\u003cp\u003eEthical dilemmas related to autonomy appear to be underreported or go unrecognized. Nearly half of the respondents indicated that they \u0026quot;rarely\u0026quot; encounter such dilemmas, while 40% stated \u0026quot;never.\u0026quot; This may reflect either an actual low incidence or, more likely, a lack of awareness or preparedness in identifying situations where patient preference should take precedence over clinical judgment. The limited use of formal ethics committees reinforces this concern: only 23% of respondents had consulted an ethics committee, while 72% had not. This implies that complex ethical issues were often overlooked, resolved informally, or defaulted to hierarchical decision-making, potentially undermining patient-centered care.\u003c/p\u003e\n\u003cp\u003eDespite recent regulations being implemented regarding accreditation and approaches to staff training, disparities and inconsistent access to continuous professional development (CPD) still present a challenge. Although 75% of respondents have received some form of ethics training, only 68% reported having undergone training in data protection. Moreover, nurses in particular have limited access to CPD opportunities. This fragmented approach leaves essential areas such as informed consent and confidentiality insufficiently addressed, particularly among professionals on the frontline of patient interaction.\u003c/p\u003e\n\u003cp\u003eNotably, there are significant differences in confidence and knowledge between doctors and nurses regarding ethics, GDPR, and cybersecurity (Cram\u0026eacute;r\u0026rsquo;s V \u0026gt; 0.25). These gaps point to a lack of standardized training across professional roles, resulting in inconsistent application of ethical standards and potentially unequal experiences for patients depending on the provider.\u003c/p\u003e\n\u003cp\u003eEven where protocols and training exist, limited familiarity with real-world ethical dilemmas and underutilization of support structures (such as ethics committees) reduce the system\u0026rsquo;s ability to consistently uphold patient autonomy. For meaningful change, it is essential to institutionalize ethics training, ensure regular engagement with ethics support structures, and integrate case-based learning into everyday clinical settings.\u003c/p\u003e\n\u003cp\u003eHealthcare professionals are bound by the principle of beneficence - to act in the best interests of their patients. However, this duty is compromised when clinicians lack up-to-date knowledge of available treatments. A knowledge gap may result in suboptimal or overly cautious care, depriving patients of innovative or more effective therapies.\u003c/p\u003e\n\u003cp\u003eThis creates significant ethical tension: the intention to provide optimal care conflicts with limited clinical expertise. Without access to up-to-date information, even well-meaning practitioners may unintentionally offer outdated or less effective treatments, with direct consequences for patient outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecommendations:\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eImplement Mandatory CPD:\u003c/strong\u003e Regular, structured training on updated clinical guidelines and emerging therapies is essential.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEnhance Decision Support:\u003c/strong\u003e Provide access to evidence-based tools, such as clinical protocols and multidisciplinary case discussions (e.g., tumor boards).\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eFoster Specialist Collaboration:\u003c/strong\u003e Encourage links with centers of excellence and specialist networks.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStrengthen Organizational Culture:\u003c/strong\u003e Promote a learning environment through journal clubs, protected learning time, and access to academic databases.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAdopt GDPR Frameworks:\u003c/strong\u003e Align internal policies with GDPR principles, including data minimization, transparency, and breach notification.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEnhance Technical Safeguards:\u003c/strong\u003e Implement robust cybersecurity measures such as end-to-end encryption and multifactor authentication.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEmpower Staff:\u003c/strong\u003e Provide mandatory training on data privacy and ensure all staff understand reporting procedures.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEstablish Oversight Mechanisms:\u003c/strong\u003e Appoint dedicated data protection officers and conduct regular external audits.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eRecognising that even highly committed clinicians may fall short without systemic support highlights the need for strong institutional mechanisms to ensure up-to-date, high-quality care. By addressing both technological and regulatory shortcomings, Georgian hospitals can significantly strengthen data protection, reduce institutional risk, and build a more trustworthy digital health environment.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles of the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of the University of Georgia (Approval No:11-32284). Participation in the survey was entirely voluntary, and informed consent was obtained from all respondents prior to data collection. No personally identifiable information was collected, ensuring anonymity and confidentiality throughout the study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e L.S. and S.I. conceived the study and developed the research design and methodology. L.S. provided oversight of data collection processes and supervised the ethical approval procedures. S.I. conducted the statistical analyses and led the interpretation of the findings. N.G. facilitated institutional engagement by coordinating communication with hospitals and clinical staff, contributed substantially to the administration of the survey, and participated in both data collection and preliminary data analysis. All authors contributed to the literature review and contextual framing of the study. S.I. drafted the initial manuscript, and L.S. undertook critical revisions for important intellectual content. All authors read and approved the final version of the manuscript and accept responsibility for the integrity and accuracy of the work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability :\u003c/strong\u003eThe anonymized datasets that support the findings of this study have been securely deposited at the University of Georgia, which ensures strict compliance with data protection and confidentiality standards. Due to the sensitive nature of the data and privacy agreements with participants, the datasets are not publicly available but can be accessed from the corresponding author upon reasonable request and with appropriate institutional approvals.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVarkey B. Principles of clinical ethics and their application to practice. Med Princ Pract [Internet]. 2021;30(1):17\u0026ndash;28. Available from: http://dx.doi.org/10.1159/000509119\u003c/li\u003e\n\u003cli\u003eGrisso T, Appelbaum PS. Assessing competence to consent to treatment: A guide for physicians and other health professionals. vii [Internet]. 1998;211. Available from: https://psycnet.apa.org/fulltext/1998-07232-000.pdf\u003c/li\u003e\n\u003cli\u003eBeauchamp T. The principle of beneficence in applied ethics. In: Zalta EN, editor. The Stanford Encyclopedia of Philosophy. Spring 2019. 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Available from: https://www.moh.gov.ge/general-info.php?id1=6\u0026amp;lang=1\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Medical ethics, Georgia, patient autonomy, GDPR, data protection, cybersecurity, health workforce, bioethics, digital health","lastPublishedDoi":"10.21203/rs.3.rs-7325394/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7325394/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe digitalization of healthcare systems has significantly intensified the importance of medical ethics, especially in the area of data privacy and patient autonomy. In Georgia, historical legacies, evolving legal frameworks, and uneven professional training have shaped a complex ethical environment within the healthcare sector.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003e This study aimed to evaluate the implementation of ethical practices in the Georgian healthcare system, focusing on patient autonomy, beneficence, non-maleficence, justice, and data protection. It also assessed healthcare professionals\u0026rsquo; knowledge, attitudes, and practices concerning medical ethics and digital privacy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA cross-sectional survey was conducted among 412 physicians and nurses across 30 hospitals in Georgia between May and November 2024. A structured questionnaire was developed specifically for this study to assess healthcare professionals\u0026rsquo; experiences with ethical dilemmas and data protection. It assessed sociodemographic characteristics, ethical perspectives, sources of ethical knowledge, and data protection practices. The internal consistency of the ethics-related items was verified (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;0.82), and data were analyzed using SPSS 20.0 with Chi-square tests and Cram\u0026eacute;r\u0026rsquo;s V to assess group differences.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWhile 74.3% of participants reported the presence of Standard Operating Procedures (SOPs) for ethical decision-making, 18.2% were unaware of them, indicating a gap in institutional communication. Only 22.8% had consulted an ethics committee, and fewer than 70% had received recent training in data protection. Nurses were significantly less aware of data protection measures compared to physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Key challenges identified included limited cybersecurity infrastructure, underutilization of formal ethical support mechanisms, and disparities in continuous professional development.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eDespite existing ethical frameworks, their inconsistent application and the lack of standardized training compromise ethical decision-making in Georgian healthcare. Institutional reforms are needed to improve ethical awareness, enhance cybersecurity, ensure compliance with data protection regulations such as GDPR, and promote continuous professional education. These measures are essential for safeguarding patient rights and building trust in the digital healthcare era.\u003c/p\u003e","manuscriptTitle":"Safeguarding Privacy in Georgia: Medical Ethics in the Digital Era – A Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 02:06:59","doi":"10.21203/rs.3.rs-7325394/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"285ce237-6a9f-493c-852a-eb988adf8fbf","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-22T05:24:47+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 02:06:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7325394","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7325394","identity":"rs-7325394","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}