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PubMed2001

Forest fires and environmental haze in Southeast Asia: using the 'stakeholder' approach to assign costs and responsibilities.

The 'seasonal haze' problem is one which afflicts large parts of Southeast Asia in years of drought. The major cause is forest, bush and field fires in the states of Kalimantan and Sumatra in Indonesia, and to a lesser extent in Sabah, Sarawak, and other parts of Malaysia. Almost all of these fires now seem preventable, since they are intentionally set to clear land for cultivation. Theoretically, the government authorities at central, provincial and local levels in these countries should be responsible for controlling activities in their territory. In practice, however, air pollution control through regulatory policies and practices is extraordinarily difficult to implement and maintain in a situation of this kind in developing countries, especially at a time of crippling economic setbacks. Moreover, the establishment of legal liability, through an international tribunal or otherwise, hardly seems a politically feasible course of action for the government of an affluent 'victim state' such as Singapore. Faith in the usual solutions--science, regulation, law and diplomacy--is weakened by one's sense of current realities. The purpose of this paper is to review the issues and suggested responses, the cost implications of each, the responsibilities as well as entitlements that might apply to the various stakeholders, and the special role of Singapore as an affluent 'victim state'. We also discuss the incentive mechanisms that would be needed to manage forest fires.

Air Pollution↗
PubMed2004

[Off-label use in dermatological practice. The conflict between professional duty and legal requirements].

When making therapeutic decisions, doctors often find themselves faced with a dilemma regarding ethical, professional, legal liability, social and service aspects of their duties. These conflicts may be enhanced when medications have to be prescribed for non-approved usages, known as off-label prescribing, because existing therapy options have been exhausted. This option become considerably more difficult since the German Federal Social Court decision of March 2002 which limited off-label use to a number of very strictly defined circumstances. In order to clarify the basis for taking decisions in a given situation, an oncology expert commission has been formed under the coordination of the Department of Health and Social Security. However, this is no solution for the great variety of uncommon dermatological diseases which often require off-label medication usage.

Clinical Trials as Topic↗
PubMed1997

Attitude survey of adverse drug-reaction reporting by health care professionals across the European Union. The European Pharmacovigilance Research Group.

OBJECTIVES: This survey was conducted to assess the attitudes of medical practitioners in the European Union regarding their national spontaneous reporting scheme, to identify reasons for under-reporting and to determine what steps might be effective in increasing reporting rates. National spontaneous reporting schemes rely on health care professionals reporting individual cases of suspected ADRs to a central or regional agency. National schemes, however, vary considerably and reporting rates and patterns differ between member states. Accumulating evidence suggests that doctors' attitudes to national ADR reporting schemes are significant determinants of reporting rates. METHODS: A self-administered questionnaire and letter of invitation was sent to a random sample of approximately 1% of medical practitioners in each of nine EU member states (Denmark, France, Ireland, Italy, the Netherlands, Portugal, Spain, Sweden and the UK). One month later, a reminder letter and a second copy of the questionnaire was sent to the non-responders (except Denmark and Italy). RESULTS: Response rates, and the percentage of responders who stated that they had reported previously an ADR, varied substantially between countries. Issues that appeared to discourage reporting included lack of availability of report forms; the address or telephone number of the reporting agency; lack of information on how to report; and not having enough time to report. Issues which did not apparently discourage reporting included concern about patient confidentiality; fear of legal liability or appearing foolish; reluctance to admit that harm had been caused to a patient; and ambition to collect and publish a personal series of cases. CONCLUSIONS: The results of this survey demonstrate some of the advantages and disadvantages of transnational, multilingual studies of this type, but indicate that there is scope for the further development of such techniques and their use on a wider basis in the EU and elsewhere.

Adverse Drug Reaction Reporting Systems↗
PubMed2004

Anesthetic management of labor pain: what does an obstetrician need to know?

BACKGROUND: Obstetrical anesthesia is considered by many to be a high-risk subspecialty of anesthesia practice that is laden with clinical challenges and medico-legal liability. Anesthesia-related complications are the sixth leading cause of pregnancy-related maternal mortality in the United States. COMPLICATIONS: Difficult or failed intubation following induction of general anesthesia for cesarean delivery remains the major contributory factor to anesthesia-related maternal complications. REQUIREMENTS: Communication skills and exchange of information (between anesthesiologists, obstetricians, and nurses) in an ever changing environment of labor and delivery are essential for a perfect outcome, which is always expected when providing safe passage for both the mother and her fetus from antepartum to postpartum period. The safe provision of labor anesthesia and/or analgesia requires appropriate staff, facilities, and equipment for proper patient safety. DISCUSSION: This article is intended for obstetricians and reviews the current guidelines for the administration of obstetrical anesthesia and analgesia.

Anesthesia, Obstetrical↗
PubMed1978

That deaf child and you: a forensic approach to the problems of hearing and speech.

Gesture, particularly manual gesture, is an important element in early childhood language formation. Its attempted elimination from the early communicative experience of hearing impaired children raises serious ethical, and possibly legal, questions. Though deaf children are deprived of information by the suppression of Sign Language so that their pretended education becomes a nullity, their cognitive power remains intact and undiminished. Official and academic refusals to recognize gesture and abhorrence, explicit or implied, of non-vocal language systems are culture-specific in their operation. They have no effect on normal children but are highly destructive of hearing-impaired children in direct proportion to the degree of impairment. Thus, sign-deprivation in profound hearing loss is completely destructive. The responsibility, including legal liability, of professionals stands in the same proportion. The most important developmental period for Sign Language is infancy. It is doubly important therefore that, in addition to educators and indeed prior to them, all health professionals who work with hearing impairment of any type be proficient in the principles and practice of nonvocal communication. Sign Language is the hearing aid of the deaf.

Affective Symptoms↗
PubMed1987

Abnormal findings in "normal" research volunteers.

We report three cases in which medical students who participated in clinical studies as normal volunteers were discovered, during the course of the research, to have potentially serious abnormalities. Their previously unsuspected conditions included chronic persistent hepatitis, a lesion in the cerebral cortex, and seropositivity for hepatitis B and HIV antibodies. These findings were surprising and distressing to both subject and investigator, and raised questions of the need for institutional guidelines, and the potential legal liability of the investigator. We discuss how improvements in Informed Consent Forms might aid in reducing these problems, by alerting the researcher and the subject to the possibility that unsuspected disease might be discovered during the course of a clinical research study.

Adult↗
PubMed1984

What every chemical engineer should know about environmental health hazards.

This paper is the text of a lecture given to an audience composed, for the most part, of students of chemical engineering at a major university. The objective of the paper is to inform such a young, intelligent, and highly technical audience of the basic facts and perceptions--scientific, technical, societal, regulatory, and legal--concerning environmental health hazards. Topics such as toxicity, hazard, and risk--and ways in which risk has been approached and perceived--are discussed as are various public and private efforts to reduce the risks of environmental health hazards. The great uncertainties encountered in this field and seriousness with which it must be taken--including a brief description of possible personal legal liabilities an engineer can face--are stressed. Despite all difficulties, progress has been made in bringing order to a chaotic field and more progress is both needed and possible.

Animals↗
PubMed1993

Patient control over dying: responses of health care professionals.

Decisions concerning how, when and where patients should die have traditionally been the exclusive domain of health care professionals. More recently, patients and their families are demanding increasing control over these decisions. This paper reports on the responses of 20 physicians and 20 nurses in a major teaching hospital regarding the desire of patients to exert more control over the circumstances of their dying. The findings, based on in-depth, semi-structured interviews, suggest that while health care professionals are generally in favour of the principle of patient control over dying, they have reservations about accommodating patients' wishes in actual clinical situations. Key factors that underly their ambivalence on this point are: (1) specific patient circumstances, such as age, severity of illness and mental competence; (2) moral and legal concerns; and (3) the type of intervention requested by patient. The results indicate that patient control over dying represents a challenge to the clinical judgement of health care professionals; that it runs counter to their perception of their role as healers and supporters; that it raises crucial concerns about their personal ethics and legal liability and that it poses a challenge to their professional autonomy and power. It is likely that health care practitioners will increasingly be pressured to concede their autonomy and enter into a partnership with patients in the decision-making process.

Adult↗
PubMed2006

"You've got mail!": the role of e-mail in clinical breast surgical practice.

Easy Internet access is changing the practice of medicine in the US. At least 137 million Americans have access to the World Wide Web, and up to one-half would like to communicate with their physicians by e-mail. The membership of the American Society of Breast Surgeons was surveyed to evaluate the current role of e-mail in patient-doctor relationships. Due to the extensive discussions often involved in the evaluation of breast disease, and the elective nature of most surgical procedures, this specialty may be particularly well-suited to using e-mail communication as an extension of discussions during traditional office visits. A questionnaire was e-mailed to all members of the ASBS who had provided an e-mail address. About 1236 questionnaires were sent, and 285 surgeons responded, a 23% response rate. About 130 (46%) responders were female; 209 responders (73%) did not use e-mail to communicate with patients (76% of responding females, 70% of males). The oldest and youngest surgeons were least likely to use e-mail to communicate with patients. There was no gender-related difference in e-mail use. There was no difference in e-mail use between surgeons who limit their practice to breast disease and those who do not. Urban and university-based surgeons were more likely to use e-mail. Medical-legal liability concerns and confidentiality issues were the most common reasons for not using e-mail. Among those surgeons who did use e-mail, ability to answer at one's own discretion, and the ability to provide an organized response were the major reasons for using e-mail. Overall, the membership expressed a preference for personal interaction over electronic communication.

Adult↗
PubMed2005

How and why for the camera-shy: using digital video in psychiatry.

Videotaping and digital editing (desktop video) provide a therapist with compelling material that can be used for therapy with patients, for teaching and professional presentation, and for therapist development. Despite these advantages, many clinicians are reluctant to record their work for reasons that include self-consciousness on the part of the therapist or patient, concerns about negative effects of videotaping on the session, concerns about confidentiality and legal liability, and lack of familiarity with the process of videotaping and the equipment involved. Understanding the benefits, concerns, and basic process involved in video recording and editing should reduce clinician apprehension and encourage more widespread use of this powerful clinical medium.

Confidentiality↗
PubMed2006

Environmental and human exposure assessment monitoring of communities near an abandoned mercury mine in the Philippines: a toxic legacy.

Abandoned mines are an important global concern and continue to pose real or potential threats to human safety and health including environmental damage/s. Very few countries had government mine regulation and reclamation policies until the latter part of the century where legal, financial and technical procedures were required for existing mining operations. Major reasons for mine closure may be mainly due to poor economies of the commodity making mining unprofitable, technical difficulties and national security. If the mine is abandoned, more often than not it is the government that shoulders the burden of clean-up, monitoring and remediation. The topic of abandoned mines is complex because of the associated financial and legal liability implications. Abandoned mercury mines have been identified as one of the major concerns because of their significant long-term environmental problems. Primary mercury production is still ongoing in Spain, Kyrgzystan, China, Algeria, Russia and Slovakia while world production declined substantially in the late 1980s. In the Philippines, the mercury mine located southeast of Manila was in operation from 1955 to 1976, before ceasing operation because of the decline in world market price for the commodity. During this time, annual production of mercury was estimated to be about 140,000 kg of mercury yearly. Approximately 2,000,000 t of mine-waste calcines (retorted ore) were produced during mining and roughly 1,000,000 t of these calcines were dumped into nearby Honda Bay to construct a jetty to facilitate mine operations where about 2000 people reside in the nearby three barangays. In October, 1994 the Department of Health received a request from the Provincial Health Office for technical assistance relative to the investigation of increasing complaints of unusual symptoms (e.g. miscarriages, tooth loss, muscle weakness, paralysis, anemia, tremors, etc.) among residents of three barangays. Initial health reports revealed significant elevation of blood mercury levels exceeding the then recommended exposure level of 20ppb in 12 out of the 43 (27.9%) residents examined. The majority of the volunteers were former mine workers. In this study the abnormal findings included gingivitis, mercury lines, gum bleeding and pterydium. The most common neurologic complaints were numbness, weakness, tremors and incoordination. Anemia and elevated liver function tests were also seen in a majority of those examined. The assessment also revealed a probable association between blood mercury level and eosinophilia. The same association was also seen between high mercury levels and the presence of tremors and working in the mercury mine. To date, there are very limited environmental and health studies on the impact of both total and methylmercury that have been undertaken in the Philippines. Thus, this area of study was selected primarily because of its importance as an emerging issue in the country, especially regarding the combined effects of total and methylmercury low-dose and continuous uptake from environmental sources. At present the effects of total mercury exposure combined with MeHg consumption remain an important issue, especially those of low-dose and continuous uptake. Results of the study showed that four (4) species of fish, namely ibis, tabas, lapu-lapu and torsillo, had exceeded the recommended total mercury and methylmercury levels in fish (NV>0.5 microg/gf.w., NV>0.3 microg/gf.w., respectively). Saging and kanuping also exceeded the permissible levels for methylmercury. Total and methylmercury in canned fish, and total mercury in rice, ambient air and drinking water were within the recommended levels, however, additional mercury load from these sources may contribute to the over-all body burden of mercury among residents in the area. Surface water quality at the mining area, Honda Bay and during some monitoring periods at Palawan Bay exceeded total mercury standards (NV>0.002 ng/mL). Soil samples in two sites, namely Tagburos and Honda Bay, exceeded the EPA Region 9 Primary Remediation Goal recommended values for total mercury for residential purposes (NV>23 mg/kg). The hand to mouth activity among infants and children is another significant route for mercury exposure. Statistically significant results were obtained for infants when comparing the results after one year of monitoring for methylmercury levels in hair for both exposed and control sub-groups. Likewise, comparing the initial and final hair methylmercury levels among pregnant women/mothers in the exposed group showed statistically significant (p<0.05) results. Comparing the exposed and control sub-groups' mercury hair levels per sub-group showed statistically significant results among the following: (a) initial and final total mercury hair levels among children, (b) initial and final methylmercury hair levels among children, (c) final total mercury hair levels among pregnant women, (d) initial and final total mercury hair levels among mothers, and (e) initial and final methyl hair levels among mothers.

Adult↗
PubMed2005

Cesarean delivery for nonreassuring fetal heart rate tracing.

An understanding of cesarean delivery for nonreassuring fetal heart rate tracing is important for several reasons. This article describes the prevalence of cesarean for nonreassuring fetal heart rate tracing and risk factors, indicates what type of fetal heart rate tracing abnormalities prompts cesarean delivery, reiterates the intrauterine resuscitation that the American College of Obstetricians and Gynecologists guidelines, and suggests steps clinicians should undertake to minimize legal liability.

Cesarean Section↗
PubMed1985

Informed consent and the gastrointestinal endoscopist.

The gastrointestinal endoscopist should be familiar with the Doctrine of Informed Consent. Although the concept is difficult to apply clinically, a reasonable approach is presented to the endoscopist. The ultimate goals of informed consent are shared decision making and self-determination, but it is important that the endoscopist also consider the potential legal liability when obtaining informed consent.

Endoscopy↗
PubMed2002

Intrapartum care in the twenty-first century.

Women will continue seeking obstetrical care from nurses, midwives, and physicians throughout the twenty-first century. In many areas of the country, they will be able to find a midwife who will assist them in having a very personal birth experience. The ACNM remains committed to producing more midwives. More midwives may mean that practitioners educated in normal pregnancy will attend the vast majority of normal births, freeing physician colleagues to best use their skills and expertise in caring for women with medical and obstetrical problems. As most midwives are likely to continue working in hospital settings, those settings will continue to change, offering women more of the comforts and amenities of home. Home birth and water birth may continue to be available with midwives in attendance, though the forces of economics and insurers may restrict the availability of these options for women. Women desiring care in a birth center may find it difficult to locate one within a reasonable distance. The in-hospital "birthing suite", with a midwife in attendance, will be the most likely setting for the vast majority of midwifery attended births. A collection of more evidence through research will stir debate amongst health care providers. Increased access to that information will bring consumers into the debate as well. In the twenty-first century, information will be a very powerful force of change in obstetrical health care. In recent years, legal liability and economics have strongly influenced obstetrical practice. Though this may continue to be true, the impact of more evidence on which to base practice, and the new access that women have to that information, will undoubtedly affect the way care is delivered. A central slogan of the ACNM is "Listen to Women". That will happen more than ever in the twenty-first century. There will be more midwives, more evidence to support midwifery care, and more women learning that birth can and should be a personal, healthy, and empowering experience. These women will seek midwives who practice wisely, blending science with art and intuition. They will learn that the childbirth wisdom that has been passed down through the ages, from woman to midwife to healer to nurse and to midwife, again, delivers the birth experience back to the mother and the healthy baby to the world [3,7].

Delivery, Obstetric↗
PubMed1996

Automated screening of cervical cytology specimens.

After more than four decades of research into automation of the process of screening Papanicolaou (Pap) smears, attempts to develop commercially viable automated screening machines have increased in recent years. These developments have been made possible in part because of the improving price-to-performance ratios in computers and other electronics. Although the Pap smear has been responsible for a very significant decrease in mortality of cervical cancer over the past 40 years, concern has arisen over false-negative cases, with their effects on patients, and the associated legal liability, particularly in the United States. In addition, shortages of cytotechnologists, which have been exacerbated by new regulations limiting the number of slides that may be examined per day, have caused concern about handling the workload, which will probably increase as more individuals gain access to preventive health care. Automated screening machines can potentially allow detection of abnormal cases that are missed with conventional screening, although they may substantially increase the cost of Pap smears. The use of automated screening machines represents a change in the way cervical cytology specimens are processed, and with some machines, a significant change in the operation of the cytology laboratory. Current methods for processing and evaluating Pap smears have not changed significantly for the past four decades. This review discusses some of the principles of operation and practical aspects of automated screening machines.

Automation↗
PubMed1999

Emerging infectious diseases and professional integrity: thoughts for the new millennium.

The challenges of infection control can put the professional in conflict with political, legal, or administrative authorities. What is likely to be effective infection control policy may not be popular institutional policy. Economic implications of an outbreak investigation or infection control strategy may dominate a debate that should be informed by the greatest good for the public. Privacy concerns, legal liability fears, economic disincentives, and failures to confront issues that are embarrassing for the institution inhibit public health professionals whose helpful insights can protect the public health only when accompanied by policy change. We discuss key issues that can inhibit effective infection control responses, highlighting that personal and professional integrity is as vital a feature of disease control in the new millennium as it has been throughout the history of infection prevention and control.

Communicable Disease Control↗
PubMed2000

Measuring risks in humans: the promise and practice of epidemiology.

Epidemiology has been considered the fundamental science of public health policy. The use of epidemiologic data in environmental health policy has been limited particularly in the environmental regulatory arena. Epidemiologic risk assessment (ERA) is different from risk assessment and the interplay between the two has led to some misconceptions over the promise and practice of epidemiologic data. The current risk assessment process was designed in a time when the need for regulation was great and the epidemiologic information was sparse. There was little time for the consideration of conducting specific studies to improve the information base for environmental health policy. Animal bioassays could be conducted under standardized protocols within defined time periods. The limitations and uncertainties of animal studies also became standardized and risk assessors became comfortable with their models of extrapolation. As the cost of regulations have grown, the economic realities of regulating with little or no data to support actual public health benefit have become a political and legal liability. Major among epidemiology's advantages is that the information is of direct relevance. The majority of epidemiology data are observation and whether the number of studies is broad enough, the data can be generalized to major segments of the population. The uncertainties in animal-based risk assessments are likely to be greater than the uncertainties associated with epidemiologic studies. Another advantage is the range of extrapolation is often smaller. Another advantage is that epidemiologic data include the genetic diversity and variability in other endogenous factors inherent in human populations. The homogeneity of animal studies has often been cited as an advantage but is unrepresentative of the heterogeneity of the human race. Epidemiology does have its limitations. A major limitation is the time needed to obtain a database sufficient for policy-making purposes and the resources needed to conduct the research to develop the database. This has often prompted the conduct of poorly designed studies, forced the use of data collected for other purposes or improper use of existing data. Four situations where epidemiology should be pursued are discussed. Once an environmental health decision has been made, epidemiologic studies should be considered for documenting the reduction of exposure and therefore disease in the population. This traditional use of epidemiology has rarely been applied in the environmental health arena. A final consideration on the use of epidemiologic data is the need to provide a sense of perspective to set priorities in the larger context of public health priorities. The role of environmental pollutants in causing disease may in some cases be minor in comparison to other risk factors and needs to be considered in setting environmental regulations.

Epidemiologic Methods↗
PubMed1997

Forensic child and adolescent psychiatry: a review of the past 10 years.

OBJECTIVE: To review important developments in child and adolescent forensic psychiatry from 1987 through 1996. METHOD: Major changes in the law and developments in research and practice were surveyed in the areas of the legal regulation of psychiatry, family law (divorce and child abuse), consultation to juvenile and criminal courts, civil litigation, and the development of the subspecialty. RESULTS: There has been a large increase in research based on quantifiable descriptive data of forensic populations, although studies using comparison or control groups remain relatively rare. While managed care has heavily influenced treatment practice, legal liability remains largely with the clinician. Issues regarding techniques of evaluation for sexual abuse have been scrutinized by the courts and by researchers. Legislative responses to rising rates of juvenile violence have been in the direction of treating violent adolescent offenders as criminally responsible adults. There has been a major move toward setting standards for forensic evaluations, training, and credentials. CONCLUSIONS: Child and adolescent forensic psychiatry remains an area encompassing diverse clinical issues. It remains unclear the extent to which it will develop into a formal subspecialty.

Adolescent↗