Biomedical subjects
I Kleinman
Publications and source records attributed to I Kleinman.
Ethical considerations in living organ donation and a new approach. An Advance-Directive Organ Registry.
Living organ donation should be recognized as an ethical compromise to the principle of nonmaleficence (doing no harm), given the risks healthy donors are allowed to assume. Living organ donation should be reserved for situations in which there is no acceptable alternative. Increasing the availability of cadaveric organs is most desirable, since it would decrease (although probably not eliminate) the need for living organ transplantation and would provide organs (ie, hearts) that could not otherwise be obtained. We propose the development of an incentive-based Advance-Directive Organ Registry, in which all adults are encouraged to register their advance directive regarding organ donations. Those individuals agreeing to permit usable organs to be taken at the time of death would receive priority for organs generated by the program, should a transplant become necessary when there is a shortage of organs. The proposed Advance-Directive Organ Registry is firmly founded on the principles of autonomy, beneficence, and justice.
The right to refuse treatment: ethical considerations for the competent patient.
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HIV transmission: ethical and legal considerations in psychotherapy.
Psychiatrists, particularly psychotherapists, have access to the most intimate details of patients' lives. As a result, psychiatrists may face a number of ethical dilemmas, particularly when the issue of potential human immunovirus (HIV) transmission is involved. This paper examines the principle and the limits of confidentiality, and outlines various ways to resolve situations in which there is a conflict between the risk of HIV being transmitted to the unsuspecting public and the principle of confidentiality. Psychiatrists should not assume that patients engaged in high risk behaviour that may be self-destructive fully understand the risks involved. An educational approach may be warranted with these patients, even though such an approach would not be consistent with non directive therapy.
Death of the analyst.
This paper assesses the impact that the death of two training analysts had on their analysands. The dependent variable, which is length of analytic training, was chosen because it is objective, easily measured and should reflect the disruption due to an analyst's death. Patients of the deceased analysts had a significantly increased length of training (Fisher's exact probability, p less than .02). This work reviews a number of relevant methodological issues and attempts to show how one can examine observable phenomena empirically. It is hoped that clinicians will begin to address how their psychotherapeutic work could be assessed using scientific methodology.
The lifetime prevalence of psychopathology in men with multigenerational family histories of alcoholism.
This paper reports the results of a pilot study of the lifetime prevalence of psychiatric disorders in a group of nonalcoholic men with multigenerational family histories of alcoholism (high-risk) in comparison with that of a control group (nonalcoholic men without multigenerational family histories of alcoholism). Diagnoses were given following the structured interview format of the Schedule for Affective Disorders and Schizophrenia, using the Research Diagnostic Criteria. The prevalence of psychopathology in the probands' first- and second-degree relatives was also determined using the Family History Research Diagnostic Criteria. The results showed a higher lifetime prevalence of psychopathology for the high-risk men compared with control subjects, with the diagnoses of major affective disorder and anxiety disorder predominating. In addition, the data obtained from first- and second-degree relatives indicated a significantly higher prevalence of nonalcoholic diagnoses in the high-risk families (depression in particular), suggesting that alcoholism and depression may be cosegregating in these families. The lifetime prevalence of these disorders is similar to that reported in chronic alcoholics.
Substitute decision making.
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Cadaveric organ donation: ethical considerations for a new approach.
We review various organ procurement strategies from ethical and practical perspectives to understand why these strategies have been relatively unsuccessful. We propose that the CMA recommend the implementation of a required-request policy in hospitals. We also propose a possible new approach in which people from the age of 18 years would voluntarily enrol in an organ donation program, agreeing to permit all usable organs to be taken for transplantation at the time of death. In return they would have priority for receiving organs made available by the program. We believe that this program would save lives, respect the donor's autonomy and satisfy the principles of justice and beneficence.
Informed consent and tardive dyskinesia.
To determine whether a formalized informing process transmitted knowledge concerning the risks and benefits of neuroleptic medication, particularly the risk of tardive dyskinesia, to stable schizophrenic outpatients, the authors administered a multiple-choice questionnaire to 21 patients who were read a standardized information form and 27 patients who were not. The mean scores for the informed patients were significantly higher, and the differences between the two groups remained significant at 6-month follow-up. The information process had no adverse effects on frequency of psychiatric admission, noncompliance with medication, or the need for increased antipsychotic medication.
An examination of HIV antibody testing.
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Tricyclic maintenance therapy in unipolar depression.
The risk of recurrence of depression must be balanced against the problems and risks of maintenance therapy. The goal of maintenance therapy is to prevent new episodes of depression. A review of the literature reveals that the existing data does not provide sufficient evidence to demonstrate the usefulness of tricyclic maintenance therapy. Nonetheless, it would be premature to conclude that this type of treatment is not useful. Further studies of maintenance therapy are indicated and should include a continuation period of at least 16 weeks during which patients are symptom free (that is, Global Assessment Scale 71 or more). In the interim, each patient should be evaluated individually to determine the optimum duration of treatment.
Transmission of human immunodeficiency virus: ethical considerations and practical recommendations.
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Force-feeding: the physician's dilemma.
The right to treatment and the right to refuse treatment are parallel legal rights which, when in opposition, pose a dilemma. In this paper the issues surrounding the possible force-feeding of a hunger striker are examined together with the pertinent legal precedents and possible courses of action. Although the discussion is particularly relevant to hunger strikers, the principles may be applicable to other circumstances.
Contraceptive knowledge and practice among undergraduates at a Canadian university.
A total of 509 undergraduate students aged 17 to 23 years, were tested to assess the adequacy of their knowledge of methods of birth control. A level of adequate knowledge was arbitrarily defined a priori as one standard deviation below the mean score of a random sample of second-year medical students, who were assumed to have more than adequate knowledge on the basis of prior courses in reproductive physiology and human sexuality. Of the undergraduate population sampled, 34 per cent were found to have inadequate knowledge. This population is in need of birth control information. Of nonvirgins in the sample, 20.2 per cent risk unwanted pregnancy, the majority (78.3 per cent) in spite of adequate knowledge. This suggests that lack of motivation, rather than purely lack of information, is an important factor contributing to the unwanted pregnancy rate of the college student population.