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Biomedical subjects

E M Meslin

Publications and source records attributed to E M Meslin.

29 records · Page 2Linked to original sources
PubMed1994

Hospital policies on life-sustaining treatments and advance directives in Canada.

OBJECTIVE: To determine the prevalence and content of hospital policies on life-sustaining treatments (cardiopulmonary resuscitation [CPR], mechanical ventilation, dialysis, artificial nutrition and hydration, and antibiotic therapy for life-threatening infections) and advance directives in Canada. DESIGN: Cross-sectional mailed survey. SETTING: Canada. PARTICIPANTS: Chief executive officers or their designates at public general hospitals. MAIN OUTCOME MEASURES: Information regarding the existence of policies on life-sustaining treatments or advance directives and the content of the policies. RESULTS: Questionnaires were completed for 697 (79.2%) of the 880 hospitals surveyed. Of the 697 respondents 362 (51.9%) sent 388 policies; 355 (50.9%) sent do-not-resuscitate (DNR) policies (i.e., policies that addressed CPR alone or in combination with other life-sustaining treatments). Of the 388 policies 327 (84.3%) addressed CPR alone, 28 (7.2%) addressed CPR plus other life-sustaining treatments, 10 (2.6%) addressed advance directives, and the remaining 23 (5.9%) addressed other life-sustaining treatments. Of the 355 DNR policies 1 (0.3%) stated that routine discussion with patients is required, 315 (88.7%) restricted their scope to terminally or hopelessly ill patients, 187 (52.7%) mentioned futility, 29 (8.2%) mentioned conflict resolution, 9 (2.5%) and 13 (3.7%) required explicit communication of the decision to the competent patient or family of the incompetent patient respectively, 110 (31.0%) authorized the family of an incompetent patient to rescind the DNR order, 224 (63.1%) authorized the nursing staff to do so, and 217 (61.1%) authorized physicians to do so. CONCLUSIONS: Although about half of the public general hospitals surveyed had DNR policies few had policies regarding other life-sustaining treatments or advance directives. Existing policies could be improved if hospitals encouraged routine advance discussions, removed the restriction to terminally or hopelessly ill patients, scrutinized the use of the futility standard, stipulated procedures for conflict resolution, explicitly required communication of the decision to competent patients or substitute decision-makers of incompetent patients and scrutinized the provision allowing families and health care professionals to rescind the wishes of now incompetent patients.

Attitude to Health↗
PubMed1994

United States and Canadian approaches to justice in health care: a comparative analysis of health care systems and values.

The purpose of this study is to compare and contrast the basic ethical values underpinning national health care policies in the United States and Canada. We use the framework of ethical theory to name and elaborate ethical values and to facilitate moral reflection about health care reform. Section one describes historical and contemporary social contract theories and clarifies the ethical values associated with them. Sections two and three show that health care debates and health care systems in both countries reflect the values of this tradition; however, each nation interprets the tradition differently. In the U.S., standards of justice for health care are conceived as a voluntary agreement reached by self-interested parties. Canadians, by contrast, interpret the same justice tradition as placing greater emphasis on concern for others and for the community. The final section draws out the implications of these differences for future U.S. and Canadian health care reforms.

Altruism↗
PubMed1993

Judging clinical research questions: what criteria are used?

The research question is a crucial aspect of every study. Criteria for the evaluation of the merit of the study question or hypothesis have received surprisingly little attention. A set of non-methodological criteria derived from interviews with 40 researchers (clinical investigators and laboratory scientists) is presented. For both types of researcher, the terms that best described the nature of the criteria included potential impact, justification, feasibility, track record, innovation, intuitive response, aesthetics and politics. The latter three criteria are notably subjective; however all the criteria have an element of non-objectivity. There may well be a reluctance to openly acknowledge that crucial choices about what scientific questions should be explored involve criteria which are themselves not 'objective', and indeed, not even 'scientific'.

Adult↗
PubMed1993

Ethical issues faced by clinician/managers in resource-allocation decisions.

This article explores the ethical issues faced by clinicians with management responsibilities (clinician/managers) when making decisions related to resource allocation and utilization at a Canadian teaching hospital. Using a focus group method, 28 individuals participated in four homogeneous groups that included nurse managers, managers from other professional groups, and physician managers. Ethical issues that recurred throughout the discussions included fairness, concern with preventing harm, consumer/patient choice, balancing needs of different groups of patients, conflict between financial incentives and patient needs, and professional autonomy. The particular issue of conflict is analyzed from two perspectives--a theory of professional-bureaucratic roles and of obligation--that illustrate how both management and philosophical issues are related. The findings suggest that decentralizing resource allocation and utilization decisions does raise ethical issues for clinician/managers and that a better understanding of these issues can be obtained using an interdisciplinary perspective.

Canada↗
PubMed1992

Is there a role for preference assessments in research on quality of life in oncology?

The development of ways to evaluate interventions that may have an impact on quality of life is a rapidly-developing area of research in clinical oncology, especially within the context of randomized controlled trials. We propose a role for assessments of preferences in such evaluations, including preference studies designed to assess attitudes toward the clinical acceptability of interventions, and preference trials designed to assess choice behaviour in relation to interventions. We suggest that such preference assessments represent a specific case of a more general issue: the need to develop an 'ethics of evidence', that is, standards for the creation, assessment and communication of evidence. We then outline a framework within which an 'ethics of evidence' might be developed, and suggest that the framework also may provide a useful model for the processes involved in the transfer of research results into clinical practice. As an illustration, we consider the problem of decision making in circumstances where the choice of therapy depends primarily on the patient's own preferences, as, for example, in the choice of mastectomy or breast-conserving treatment in early-stage breast cancer. The long-term goal is to develop criteria which might be used to foster shared rational decision making in such circumstances.

Beneficence↗
PubMed1992

Measuring the ethical sensitivity of medical students: a study at the University of Toronto.

An instrument to assess 'ethical sensitivity' has been developed. The instrument presents four clinical vignettes and the respondent is asked to list the ethical issues related to each vignette. The responses are classified, post hoc, into the domains of autonomy, beneficence and justice. This instrument was used in 1990 to assess the ethical sensitivity of students in all four medical classes at the University of Toronto. Ethical sensitivity, as measured by this instrument, is not related to age or grade-point average. Sensitivity increases between the 1st and 2nd year and then decreases throughout the rest of undergraduate medical training, such that the 4th-year students identify fewer issues than those entering medical school. Students expressing a career choice of family medicine identify more issues than their peers. Several problems with the use of the instrument and the interpretation of the data were found. Nonetheless, these findings, if reproducible, are important and their meaning needs further discussion.

Beneficence↗
PubMed1990

Should living wills be legalized?

Living wills allow patients to state their wish to die and not be kept alive through the use of medications, artificial means or "heroic" measures. They have been made legal documents in 38 states in the United States. Living wills permit advance expression of a patient's wishes, promote effective communication and demonstrate respect for the patient as a person. Problems with legal recognition of such wills include the need for agreement on fundamental terms, possible restriction of patients' rights, limitation of options in decision-making and possible negative effects on the physician-patient relationship. Before legislation is enacted, public and professional attitudes toward the care of terminally ill patients should be assessed. All health care professionals should receive better education in this area, and palliative care services should be made more widely available. Only if these measures fail should living wills be made legal documents in Canada.

Attitude of Health Personnel↗
PubMed1990

Evaluating ethical sensitivity in medical students: using vignettes as an instrument.

As a preliminary step to beginning to assess the usefulness of clinical vignettes to measure ethical sensitivity in undergraduate medical students, five clinical vignettes with seven to nine ethical issues each were created. The ethical issues in the vignettes were discussed and outlined by an expert panel. One randomly selected vignette was presented to first, second and third year students at the University of Toronto as part of another examination. The students were asked to list the issues presented by the patient problem. Responses from 281 students were obtained. These students identified an average of 2.72 ethical issues per vignette. Each response was classified under the domains of autonomy, beneficence and justice. Comparisons were made between classes and between vignettes. There was considerable variation between classes and the responses to different vignettes seem to indicate that different vignettes measure the various domains in different ways. It does appear that the use of vignettes is one way to measure aspects of ethical sensitivity in medical students but more study is required to clarify exactly what is being measured.

Beneficence↗
PubMedDate not supplied

The moral costs of the Ontario physicians' strike.

In a strike to permit extra billing, physicians in Ontario, Canada, sought to balance their concerns for professional autonomy with their primary call to beneficence. But the right to reasonable compensation within a nationalized health care system is not on the same moral plane as the public's right to health care. Having failed to convince either the provincial government or the public of the soundness of their position, Ontario's doctors must now repair the damage done to the relationship with their patients.

Economics, Medical↗