Bioethics for clinicians: 10. Research ethics

Medical research involving human subjects raises complex ethical, legal and social issues. Investigators sometimes find that their obligations with respect to a research project come into conflict with their obligations to individual patients. The ethical conduct of research rests on 3 guiding principles: respect for persons, beneficience, and justice. Respect for persons underlies the duty to obtain informed consent from study participants. Beneficence demands a favourable balance between the potential benefits and harms of participation. Justice requires that vulnerable people not be exploited and that eligible candidates who may benefit from participation not be excluded without good cause. Studies must be designed in a way that ensures the validity of findings and must address questions of sufficient importance to justify the risks of participation. In any clinical trial there must be genuine uncertainty as to which treatment arm offers the most benefit, and placebo controls should not be used if effective standard therapies exist. Researchers have a responsibility to inform themselves about the ethical, legal and policy standards that govern their activities. When difficulties arise, they should consult the existing literature and seek the advice of experts in research ethics.     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

Bioethics for clinicians: 16. Dealing with demands for inappropriate treatment

Demands by Patients or their Families for treatment thought to be inappropriate by health care providers constitute an important set of moral problems in clinical practice. A variety of approaches to such cases have been described in the literature, including medical futility, standard of care and negotiation. Medical futility fails because it confounds morally distinct cases: demand for an ineffective treatment and demand for an effective treatment that supports a controversial end (e.g., permanent unconsciousness). Medical futility is not necessary in the first case and is harmful in the second. Ineffective treatment falls outside the standard of care, and thus health care workers have no obligation to provide it. Demands for treatment that supports controversial ends are difficult cases best addressed through open communication, negotiation and the use of conflict-resolution techniques. Institutions should ensure that fair and unambiguous procedures for dealing with such cases are laid out in policy statements.     

Bioethics for clinicians: 17. Conflict of interest in research, education and patient care

A conflict of interest occurs in a situation in which professional judgement regarding a primary interest, such as research, education or patient care, may be unduly influenced by a secondary interest, such as financial gain or personal prestige. Conflicts of interest exist in every walk of life, including medicine and science. There is nothing inherently unethical in finding oneself in a conflict of interest. Rather, the key questions are whether one recognizes the conflict and how one deals with it. Strategies include disclosing the conflict, establishing a system of review and authorization, and prohibiting the activities that lead to the conflict.     

Bioethics and medicine

The difficult ethical choice to be made between 'extraordinary' treatment or no treatment is discussed with reference to hypoplastic left heart syndrome, which affects a number of neonates each year. The treatment involves heart transplantation and xenotransplantation, which on their own bring about a host of problems.     

Bioethics in contemporary medicine

Bioethics arose in a delicate social and political moment in the United States of America. With time, it has become a social and perhaps political movement. Its scope is wider and different than that of medical ethics. Bioethics appeared in the second half of the twentieth century, in the middle of a spectacular advance in biological knowledge and technology. Meanwhile, medical ethics was formulated in the fifth century B.C. in relation to medical care. This defines the main focus of their respective interests. Anglo-Saxon philosophers, deriving from moral philosophy, applied the principles of beneficence, no maleficence, justice and autonomy to medicine. The Hippocratic oath refers specifically to the first three and to a number of other ethical principles. Nothing in its contents, contradicts the principle of autonomy. The emphasis in the principle of autonomy that some specialists in bioethics pose, even over the principle of beneficence, is determined, according to our judgment, by inherent factors of the North American culture. We believe that medical ethics should be distinguished even though not separated from bioethics. Physicians should go back to the Hippocratic oath as the fundamental guide for their professional activity.     

Professionalism in emergency medicine. SAEM Ethics Committee. Society for Academic Emergency Medicine

INTRODUCTION: F-16 pilots have a high incidence of minor neck injuries. It was hypothesized that pilots who did neck strengthening exercises and pilots who used other preventive strategies would have fewer injuries. METHOD: We surveyed 268 U.S. Air Force F-16 pilots. Subjects were divided into two groups. Group I, the Early Intervention Group, performed an intervention, or not, from the start of their F-16 careers. Outcomes were measured as a percent of pilots reporting an injury during their F-16 careers. Group II, the Midstream Intervention Group, initiated an intervention after sustaining an injury. Injuries before and after the intervention were compared as a median injury rate per 100 h F-16 time. RESULTS: The 1 -yr prevalence of neck injury was 56.6% and for an F-16 career was 85.4%. For every 100 h in the F-16, the risk of injury increased by 6.9%. Only 26.9% of the pilots routinely did neck strengthening exercises. For the Early Intervention Group, fewer injuries were associated with neck strengthening exercises and placing the head against the seat prior to loading +Gz. For the Midstream Intervention Group, a lower median injury rate was associated with neck strengthening exercises, placing the head against the seat prior to loading, warming up with stretching or isometrics, prepositioning the head prior to loading, and unloading prior to moving the head. Interventions not associated with fewer injuries included body exercises and placing the head against the canopy. CONCLUSION: Certain strategies may prevent neck injuries. Prospective research is needed to confirm these results.     

Computer interview support for clinicians.

In a mental health program, a comprehensive computer interview screened 55 adult clients on 28 life problem areas. The computer information was used to compile a standard Problem Oriented Record problem list. The majority of clients indicated that the computer interview was a positive experience, and many found it preferable to a human interview. Raters audited the case records of the Ss and compared the problems found in the records with those indicated by the computer. The computer was found to identify more problem areas and specific problems than human interviewers. On 20 critical problem categories, the interviewers failed to report approximately 3 out of every 4 client problems reported by the computer. (12 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

An effect size primer: A guide for clinicians and researchers.

Increasing emphasis has been placed on the use of effect size reporting in the analysis of social science data. Nonetheless, the use of effect size reporting remains inconsistent, and interpretation of effect size estimates continues to be confused. Researchers are presented with numerous effect sizes estimate options, not all of which are appropriate for every research question. Clinicians also may have little guidance in the interpretation of effect sizes relevant for clinical practice. The current article provides a primer of effect size estimates for the social sciences. Common effect sizes estimates, their use, and interpretations are presented as a guide for researchers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological practice in primary care settings: Practical tips for clinicians.

Many psychologists are finding new opportunities for practice in primary care settings. These settings challenge many aspects of traditional practice and require adaptation and innovation. Psychologists must consider changes in their site of practice, treatment duration, type of intervention, and role as part of a health care team. This article describes the culture of primary care medicine and offers 10 practical tips for the adaptation in psychological practice to primary care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

"Miguel F. Jiménez lecture. The paradigm of modern medicine: molecular genetics

The sequence for bovine link protein cDNA, including 108 bases of the 5' untranslated region (UTR) and 768 nucleotides of the 3' UTR, was determined from polymerase chain reaction products and bovine articular chondrocyte cDNA clones. The deduced primary structure for bovine link protein predicts a protein 354 amino acid residues in length. Comparative analysis with link protein sequence from several other species revealed overall high conservation of protein coding sequence. High nucleotide sequence conservation was observed within the extensive 5' and 3' UTRs of bovine, human, pig, chick and rat link protein mRNA. As evidence that the UTRs might play a role in regulation of link protein mRNA turnover, multiple occurrences of the adenosine-uridine binding factor motif A(Ua)A were found to be conserved between species within 3' UTRs. A polyadenylation signal was conserved between the bovine and chicken sequence, use of which would result in the smallest of multiple bovine link protein mRNA species observed by Northern blot analysis.     

Effectiveness of psychotherapy with children and adolescents: A meta-analysis for clinicians.

How effective is psychotherapy with children and adolescents? The question was addressed by meta-analysis of 108 well-designed outcome studies with 4–18-year-old participants. Across various outcome measures, the average treated youngster was better adjusted after treatment than 79% of those not treated. Therapy proved more effective for children than for adolescents, particularly when the therapists were paraprofessionals (e.g., parents, teachers) or graduate students. Professionals (with doctor"s or master"s degrees) were especially effective in treating overcontrolled problems (e.g., phobias, shyness) but were not more effective than other therapists in treating undercontrolled problems (e.g., aggression, impulsivity). Behavioral treatments proved more effective than nonbehavioral treatments regardless of client age, therapist experience, or treated problem. Overall, the findings revealed significant, durable effects of treatment that differed somewhat with client age and treatment method but were reliably greater than zero for most groups, most problems, and most methods. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comprehensive asthma management: guidelines for clinicians

Asthma is a chronic inflammatory disease characterized by reversible airway obstruction and nonspecific airway hyperreactivity. Asthma is managed in steps according to disease symptoms and severity. Treatment goals are to decrease symptoms, improve pulmonary function, and reduce overall morbidity and the associated cost of medical care. Antiasthma drugs are a key component of asthma management that are classified as either long-term-control medications that control symptoms and prevent disease exacerbations, or quick-relief medications that rapidly relieve airway obstruction and acute asthma symptoms. Several new leukotriene (LT) modulators have been developed that promise to improve asthma control, including LT receptor antagonists montelukast and zafirlukast and the 5-lipoxygenase inhibitor zileuton. Each decreases symptoms and the use of rescue medication, and improves pulmonary function in patients with mild intermittent to moderate persistent asthma.