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PubMed1995

Who decides? Patients, parents, or gatekeepers: pediatric decisions in the craniofacial setting.

Special ethical issues arise for the craniofacial team dealing with pediatric patients, which include competency, surrogacy, and the "best interests" standard. Medical decisions for children are made by surrogates, usually parents, who must use the "best interests" standard. The team's primary responsibility is to the child, not the parents. Children should participate as abilities allow, especially for elective procedures. Increasingly, cost considerations also influence medical decisions. The craniofacial team is often a de factor gatekeeper. Ethically responsible team behavior includes: weighing risks and benefits of proposed interventions; promoting discussion with families and patients to identify "best interests;" monitoring outcomes; and advocacy for craniofacial patients individually and at a policy level. Care guidelines and definitions of basic levels of care should be developed to assist teams with decision-making and advocacy efforts. Ethical analysis is part of both good patient care and good policy formation, and should be a part of regular team deliberations.

Abnormalities, Multiple↗

PubMed2003

Simulation-based medical education: an ethical imperative.

Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Health care has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change. Recently, the international patient safety movement and the U.S. federal policy agenda have created a receptive atmosphere for expanding the use of simulators in medical training, stressing the ethical imperative to "first do no harm" in the face of validated, large epidemiological studies describing unacceptable preventable injuries to patients as a result of medical management. Four themes provide a framework for an ethical analysis of simulation-based medical education: best standards of care and training, error management and patient safety, patient autonomy, and social justice and resource allocation. These themes are examined from the perspectives of patients, learners, educators, and society. The use of simulation wherever feasible conveys a critical educational and ethical message to all: patients are to be protected whenever possible and they are not commodities to be used as conveniences of training.

Computer Simulation↗

PubMedDate not supplied

The lottery of life: should organ transplants be used to even the odds?

Life is not always fair and the advantages of health and well-being are not equally distributed. Unfortunately, children can be the innocent victim of their families' misfortune. In the realm of health care, should a child be denied a specific medical treatment because his or her parents are not capable of providing the care necessary to promote a successful outcome of that treatment? How should we as health care professionals make those difficult choices? The following case and the ethical analysis describes a scenario where there was disagreement if a child's family situation should be considered in the decision to list the child for a liver transplant.

Beneficence↗

PubMed1995

Ethical considerations in the use of neuromuscular blockades.

The long-term use of neuromuscular blocking agents in the adult intensive care unit is clinically and ethically challenging. These drugs can be dramatically lifesaving; they also have the potential of causing the patient great emotional, spiritual, and physical harm. Traditional ethical analysis is important but may not be adequate. Rigorous attention should be given to risk-benefit ratios, informed consent, and quality of life. It is suggested that institutions develop written consent forms and information sheets, use adapted values history forms in assessing treatment decisions and quality of life, and fully utilize ethics committees and patient care conferences in caring for these catastrophically ill patients.

Critical Care↗

PubMed2000

Distributive justice in Medicaid capitation: the evidence from Colorado.

In 1995, the state of Colorado began a new funding program for the provision of mental health services to Medicaid recipients. Medicaid funding was restructured from a fee-for-service system into a capitated managed care system. The restructuring altered the way in which mental health resources were allocated within Colorado's mental health system. This article explores the ethical principles inherent in the allocation of mental health resources within Colorado. The allocation system before and after the capitation pilot is analyzed according to three models of distributive justice. Under capitation, access to care corresponds to egalitarian ideals, while service delivery and outcomes follow a more utilitarian philosophy. Results from several empirical studies of the Colorado Medicaid system are used to support this ethical analysis. The analysis leads to the suggestion that the fair-opportunity rule may be a useful principle for developing just distribution systems in other states in the future.

Capitation Fee↗

PubMed2004

A case report: ethics of a proposed qualitative study of hospital closure in an Australian rural community.

BACKGROUND: The GP and qualitative researcher use similar patient-centred approaches, but their roles are different. Guidelines for conducting GP research in small communities are limited. I planned a qualitative study about hospital closure in a small rural Australian town where I worked. Few studies have researched community reaction to hospital closure and this process of change. METHODS: I used historical analysis to improve external reliability, and purposeful sampling to develop and pre-test a qualitative semi-structured research instrument. Newspaper articles, minutes and tape recordings of public meetings, annual reports from 1991 to 1997, quality assurance data and interviews with two health professionals were analysed in this process. These sources were coded using content and thematic analysis. Ethical issues arose during early stages of planning. Ethical guidelines and bioethics principles were discussed with colleagues and a member of an ethics committee. I validated my findings with three other community members involved in the hospital closure. RESULTS: Themes of a transition, from resistance to change and divisions between key stake holders, to a need to appreciate the benefits of change emerged in coding material from 1991 to 1997. The principle of non-maleficence outweighed the principle of beneficence in this study. Existing health services could be harmed by examining the process of change after spending time and resources to reconcile community differences. Individuals could be harmed as confidentiality in a small community was difficult to maintain, and discussions about sensitive issues could produce adverse public criticism. The autonomy of participants to give informed consent was complicated by the author providing clinical services in the community, raising concerns about patients feeling an obligation to participate. CONCLUSIONS: A justified case for discontinuing this study was made by the researcher on ethical grounds. Use of bioethical principles and community representatives to validate findings was a useful technique to guide decisions in a small rural community. This discussion has application in planning other small community studies.

Data Collection↗

PubMed1998

Ethical dilemmas in the care of patients with incurable cancer.

This article aims to identify and describe the ethical dilemmas that are involved in the care of patients with incurable cancer. The data were collected in semistructured focused interviews with 32 patients, 13 nurses and 13 doctors from two central hospitals and four community health centres. The interviews were tape-recorded and transcribed verbatim. Interpretation was based on the method of content analysis. Ethical dilemmas occurred at the time of diagnosis, in connection with telling the truth, in providing information, in the treatment of pain, and in decision-making situations concerning active treatment. Dilemmas of active treatment concerned chemotherapy, intravenous infusions, blood transfusions and antibiotics. There were also problems in relationships between nursing staff and next of kin, as well as a lack of co-operation between nurses and doctors.

Adult↗

PubMed2005

Face transplantation: Part II-an ethical perspective.

In May 2004, researchers at the University of Louisville Medical Center in Kentucky submitted a 30-page detailed document to the University's Institutional Review Board (IRB) that outlines their plan for the first face transplant. Despite the fact that both the Royal College of Surgeons in England in 2003 and France's Comite Consultatif National d'Ethique in 2004 issued reports saying that the risks of this surgery far outweigh the benefits tojustify it at the present time, the IRB at the University of Louisville is presently studying the proposal. Even though the microsurgical skills and anatomical knowledge is well established, face transplantation is more than a matter of technical achievement. The psychological impact on recipients and donor families as well as the long-term risks of a lifetime of immunosuppressant drugs must also be considered. More time is needed to perfect this surgery so that the rejection rate can be lowered and the patient's immune system can be taught to permanently tolerate the transplanted face. An ethical analysis will show that more time is needed to perfect this surgery so that the rejection rate can be lowered and the patient's immune system can be taught to permanently tolerate the transplanted face. To permit this surgery now, when there are so many unknown, life-threatening dangers would be medically irresponsible and ethically objectionable.

Face↗

PubMed1998

Ethics, Malingering, and a lie-detector at the bedside.

A psychiatric consultation is presented in which the physician uses a cardiac monitor in the manner of a lie-detector. Ethical analysis of a clinician's duties in cases of suspected malingering addresses both the standard of informed consent necessary for such assessments and the potential forensic consequences of unanticipated clinical findings.

Duty to Warn↗

PubMed1992

Development of moral judgment and its relationship to the education and training of dietitians.

The purpose of this study was to compare the development of moral judgment in 171 dietetics students before and after training from internships (n = 96), coordinated undergraduate programs (n = 61), and preprofessional practice programs (n = 14). The results of the study supported the research hypothesis that greater moral development growth would occur in supervised practices that allow students more experiences promoting moral growth, such as clinical rotations with patients, peer discussions on ethical issues, and access to instructors trained in ethics. Analysis of covariance indicated differences in the posttest scores of the three groups. Student scores for the internship and the coordinated undergraduate program were significantly different. Scores of preprofessional practice program students did not differ from those of the other groups. Internship programs offered more time in clinical rotations, used trained ethicists more, and used more methods to introduce ethics into the curriculum than did the other programs.

Adult↗

PubMed2003

Ethics seminars: health care proxies and suicidal patients.

Advance directives, health care proxies, and living wills are forms of advance planning that permit patients to make decisions regarding their health care and are used when the patient becomes incapacitated. The ethics of allowing these forms of advance planning are questioned when the patient has attempted suicide. The authors present an ethical analysis of a case of an elder patient who overdosed on sustained-release diltiazem and had a health care proxy who wanted all treatments stopped.

Advance Directives↗

PubMed2001

Ethical decision-making on communication in palliative cancer care: a personalist approach.

Perhaps one of the main ethical dilemmas physicians face in cancer medicine is the question of truthfulness with terminally ill cancer patients. Reluctance to share the truth with the patient about his or her diagnosis and/or prognosis is frequently associated with cultural pressures. Based on two cases, the authors illustrate how ethical analysis can help in solving dilemmas related to truth disclosure to terminally ill cancer patients and their families. A personalist approach reveals that the often-adduced conflict between nonmaleficence/beneficence and autonomy with regard to truth telling originates from a narrow understanding of the concept of autonomy. This confrontation is, therefore, more apparent than real. A brief review of the main ethical systems and the results of their application to clinical decision-making follow the discussion of the cases.

Aged↗

PubMedDate not supplied

Ethical dimensions in genetic screening: a look into the future.

The ethical dimensions of four areas of genetic screening, prenatal screening and diagnosis, newborn screening, carrier detection, and presymptomatic genetic testing, are discussed. Ethical analysis of genetic technologies focuses on the goals, values, and professional obligations that underlie the development and use of these technologies. We live in a complex, diverse society, in which there are multiple, often contradictory, values and belief systems that influence public and personal views about the morality of genetic technologies. Some of these prevailing views are presented to highlight the ethical issues nurses may encounter in reproductive health care, an area in which genetic information and services are increasingly important aspects of care.

Civil Rights↗

PubMed2000

[Cloning: applications in humans. II. Ethical considerations].

Reproductive cloning in adults/children evokes unfavourable reactions. Direct objections are that cloning is unnatural, that it affects human dignity and violates the individual's right to genetic uniqueness. Consequential objections concern unjustified health risks for the progeny, unjustified psychosocial risks for the clone child and the risk of cloning for eugenetic purposes. There is consensus that reproductive cloning of existing persons is unjustifiable as yet because of the health risks for the offspring. Reproductive cloning of embryos is possible by means of nucleus transplantation and of embryo splitting. The ethical analysis of reproductive cloning of embryos depends on the purposes and applications. At least some of the moral objections against cloning of adults/children are not or not completely applicable to reproductive cloning of embryos. Conditions to be put to reproductive cloning of embryos are efficacy, safety and, at least for the time being, avoidance of asynchrony in transferring identical embryos. The ethical aspects of its application in the context of genetical reproductive techniques must be evaluated separately. Therapeutic cloning may be acceptable if alternatives are lacking.

Cloning, Organism↗

PubMed2001

[Cloning: applications in humans 2. Ethical considerations].

Reproductive cloning in adults/children evokes unfavourable reactions. Direct objections are that cloning is unnatural, that it affects human dignity and violates the individual's right to genetic uniqueness. Consequential objections concern unjustified health risks for the progeny, unjustified psychosocial risks for the clone child and the risk of cloning for eugenetic purposes. There is consensus that reproductive cloning of existing persons is unjustify as yet because of the health risks for the offspring. Reproductive cloning of embryos is possible by means of nucleus transplantation and of embryo splitting. The ethical analysis of reproductive cloning of embryos depends on the purposes and applications. At least some of the moral objections against cloning of adults/children are not or not completely applicable to reproductive cloning of embryos. Conditions to be put to reproductive cloning of embryos are efficacy, safety and, at least for the time being, avoidance of asynchrony in transferring identical embryos. The ethical aspects of its application in the context of genetical reproductive techniques must be evaluated separately. Therapeutic cloning may be acceptable if alternatives are lacking.

Cloning, Organism↗

PubMedDate not supplied

Resource allocation. The cost of care: two troublesome cases in health care ethics.

With the cost of health care rising rapidly, both physicians and administrators regularly face resource allocation decisions. Under these conditions of relative scarcity, the equitable and appropriate distribution of limited resources becomes an ethical as well as a financial issue. Through ethical analysis, physician executives can assist their physician colleagues and fellow administrators to find rationally defensible answers to questions regarding the distribution of limited resources. Six criteria are frequently "weighted in the balance" by ethicists when analyzing whether justice is served in the distribution of a limited resource: need, equality, contribution, ability to pay, effort, and merit. The authors argue that, from an ethical standpoint, the best single criterion upon which one can base an allocation decision is that of merit, defined as the potential to benefit from the investment of additional resources.

Decision Making↗

PubMed2006

Ethical issues in heart failure: overview of an emerging need.

Modern therapies in cardiovascular medicine aim at preventing death and improving patients' quality of life. However, cardiologists often focus on what can be done rather than what should be done, and the latter consideration may be neglected in the midst of therapeutic optimism. The life-saving success of cardiovascular treatments, combined with an aging population, has created an epidemic of heart failure, a disease that portends considerable morbidity and mortality and raises important questions about what should be done. This and the following essays in this section address the emerging need for ethical analysis of issues raised by patients with heart failure. In this overview, we discuss end-of-life care in end-stage heart failure, new therapies for heart failure, and heart failure research.

Cardiology↗

PubMed2002

Genetics and education: the ethics of shaping human identity.

This paper suggests an analogy between education and genetic interventions as means of shaping the identity of children and future adults. It proposes to look at issues discussed in the philosophy of education as a possible source of insight for ethical guidelines regarding future genetic interventions. The paper focuses on situations of conflict between parents and state regarding the authority to determine the child s best interests. It describes the current formulation of the conflict in the literature as lacking the crucial element of the child s right to a cultural identity. It argues that this element is a necessary component in an ethical analysis of the child s best interests in a multicultural, liberal society which respects diversity. The paper therefore proposes a better model for the moral evaluation of identity-shaping decisions and offers some implications of this model for genetics.

Child↗