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Medical ethics, moral philosophy and moral tradition.

Medical ethics is commonly assumed to be a form of 'applied moral philosophy' in which practical moral judgments are deduced from moral theories. This account of the relationship between moral theory and moral judgment is inadequate in several reports. The deductivist approach often results in inadequate attention being given to social, historical and developmental contexts. It also fails to explain some common phenomena in practical moral reasoning. In contrast to the emphasis in deductivism, a case-centered or casuistic practical ethics insists on immersion in the particularities of cases and on interpretation of details in light of moral maxims and other mid-level forms of moral reasoning. Two features of casuistics that ought to be distinguished but frequently are not, are: (1) the emphasis on immersion and interpretation, and (2) a claim about the relation between moral judgment and moral theory as sources of moral knowledge. Once we consider case-centered moral judgments as sources of moral knowledge, we must also begin to look critically but open-mindedly to moral traditions which, upon examination, appear to be more dynamic and to have more reformist potential than is commonly assumed.

Cultural Diversity↗

The role of socio-behavioural scientists in health care practice.

This paper attempts to analyse some of the complex problems that face primary health care practice in the developed world today. These are shown to be a degree of depersonalisation, that has come with greater efficiency, and a reduction in the quality of the doctor-patient relationship, which has accompanied increased medical effectiveness. These changes are in turn related to changes in diagnostic methods in primary care, to changes in the organisation of primary care and to change in the stress laid on interventive, preventive and rehabilitative care. All these inter-related problems have to be viewed against a background of shortage of resource which demand a far more stringent system of accountability than has been common until now. A possible solution lies in redefining the traditional medical role and the philosophical basis which underlies that role at a time when primary health care is confronted by the special problems of the AIDS pandemic. This would require major alterations in medical attitudes and in established medical education which may be impossible for the doctors to achieve by themselves. It is suggested that a most important role of socio-behavioural scientists lies in helping the medical profession to remove the attitudinal and educational barriers which prevent the realisation of the concept of a new sort of doctor who may cope with the demands of primary health care as we approach 2000.

Acquired Immunodeficiency Syndrome↗

The viability of the concept of a primary health care team: a view from the medical humanities.

To question the viability of the concept of a primary health care team implies at least the possibility that something about the nature of primary care, and about the nature of giving care in teams, places the two in conflict. In fact, a number of interesting and provocative questions concerning primary health care teams are in the areas of ethics and professional values. Primary care is inherently a 'moral notion', and when the concept of the health care team is yoked to that of primary care, the team takes on the normative coloration of primary care. This occurs at two levels. At a societal and professional level, the concept of a primary health care team depends on extra-professional values (e.g. a society's understanding of the requirements of social justice, funding priorities for health services, or the perceived worth of particular patient populations), and professional values such as autonomy and authority. At the level of face-to-face clinical encounters, questions arise as to a team's ability to maintain interpersonal and moral accountability to patients and society. Future research on the functioning of health care teams should focus more on these normative issues, rather than on the bureaucratic and logistical dimensions of team care that currently predominate in the professional literature.

Behavioral Research↗

What happens in hospices: a review of research evidence.

The growth of the modern hospice movement has been accompanied by some evaluative research, although this has been pursued with greater vigour in the United States than in Britain. Most studies employ the method of outcome measurement (patient or carer satisfaction for example) and only incidentally report on processes occurring within hospices or hospitals. A review of the research evidence suggests that processes of patient care may not always be very different between hospices and hospitals. This may be because hospital staff have learned from the example of hospices, but may also be due to hospice staff associated with traditional care systems compromising their ideals. Evidence from evaluative and from participant observation studies is reviewed to examine differences between hospital and hospice care in five major areas: medical therapies, psychosocial care, disclosure of prognosis, carers' involvement, in-patient care and relations between staff. The quality and scope of the research evidence in many instances needs extending. The relevance of a hospice approach to non-cancer patients is discussed and priorities for future research on the process of hospice care are outlined.

Attitude of Health Personnel↗

Clinical ethics: a role theoretic look.

The new phenomenon of clinical ethics is analyzed from a role theoretic perspective that differentiates consulting, teaching, watching, and witnessing. Teaching and consulting are seen as main role alternatives in clinical ethics practice, with watching and witnessing defining transitional states that reveal the complexity of clinical ethics. The problem of the legitimation of clinical ethics is discussed in terms of legal, professional, and social accountability and authorization. It is argued that the problem of legitimation is tied up with the related issue of expertise that, in turn, reflects the complex role alternatives of consulting, teaching, watching, and witnessing. Finally, the question of methodology and practice of clinical ethics is explored in connection with the four role alternatives delineated.

Bioethical Issues↗

Whose side are we on now? Ethical issues in social research and medical practice.

The stance of the sociologist as champion of the underdog or as purveyor of the values and attitudes of the 'superordinate' was posed as a problem by Howard Becker and debated by Alvin Gouldner some two decades age. Since then, those who have addressed the question as to whose side the sociologist should be on, have opted for an 'ironic stance'. This paper, taking the case of a research unit wholly funded by a patient self-help group and located within a University in Britain, notes the difficulties currently faced by the 'lay' researcher working in the field of medicine in times of scarcity and want as compared with those faced some two or three decades ago in times of expansion. It is argued that the self-help group is identifiable both as suffering victim and as overload, since they raise the funds which, sometimes directly and always indirectly, are used to employ researchers. In practice there has always been a constant negotiation between funder and researcher, between expressing the values of one group as against those of another, and in the pursuit of fundamental and underpinning values. With the proviso that the interests of the most vulnerable and stigmatised groups in society are attended to, the self-interest both of sociology as a discipline and of individual sociologists working in these settings, it is argued, is by no means an ethically weak goal to pursue.

Attitude of Health Personnel↗

Can ethnography save the life of medical ethics?

Since its inception contemporary medical ethics has been regarded by many of its practitioners as 'applied ethics', that is, the application of philosophical theories to the moral problems that arise in health care. This 'applied ethics' model of medical ethics is, however, beset with internal and external difficulties. The internal difficulties point out that the model is intrinsically flawed. The external difficulties arise because the model does not fit work in the field. Indeed, the strengths of that work are its highly nuanced, particularized analyses of cases and issues and its appreciation of the circumstances and contexts that generate and structure these cases and issues. A shift away from a theory-driven 'applied ethics' to a more situational, contextual approach to medical ethics opens the way for ethnographic studies of moral problems in health care as well as a conception of moral theory that is more responsive to the empirical dimensions of those problems.

Anthropology, Cultural↗

Creating a dignified option: ethical considerations in the formulation of prehospital DNR protocol.

Increasing numbers of states are recognizing the importance of developing policies to allow Do Not Resuscitate (DNR) orders to be recognized in the prehospital setting, especially by emergency medical personnel. The ethical issues involved in creating such policies have not been widely addressed. Using the experience of developing such a policy for the District of Columbia as a model, we discuss six major ethical issues involved in prehospital DNR order policy development. 1) Can the justification for the policy be grounded in the doctor's duty of beneficence? 2) Should the concept of futility be applied to prehospital DNR orders? 3) How specific should prehospital DNR orders be? 4) How can one maximize patient participation in the prehospital DNR decision? 5) How much consideration ought to be given to the scarcity of health care resources in the development and justification of such policies? 6) Should paramedics be empowered to pronounce DNR patients dead in the field? This discussion ought to be of benefit to all those involved in developing or revising prehospital DNR policies.

Advisory Committees↗

What good are we doing? The role of clinical research in enhancing critical care medicine.

The amount of financial and other resources used by physicians in the treatment of critically ill patients makes it incumbent upon physicians to ensure that sufficient benefit is obtained from these resources and that physicians are in fact doing good for their patients. Knowing that one is in fact doing good requires an understanding of what counts as benefit. Current medical practice suggests that patient benefit is typically understood in terms of physiological changes and responses, highlighting the role of medical subspecialties in patient care. An alternative view is suggested, which requires a broader understanding by physicians of patient needs and welfare. This broader understanding calls for an ambitious research agenda so that physicians will be able to learn how they can genuinely help critically ill patients and their families during times of illness. Carrying out such an agenda requires overcoming the ethical challenges of performing research on patients as vulnerable as critically ill patients. It also requires physicians to establish collaborative ties with other professionals so that truly interdisciplinary research can be performed on a routine basis.

Attitude of Health Personnel↗

The ethical quandaries of acute care nursing practice.

This study explored the perceptions of nurses employed in acute care nursing regarding the ethical quandaries in which they find themselves involved on a recurrent basis. Sixty-five female nurses volunteered to participate in the study. Data were collected over a 2-year period at four institutions. Qualitative methods were used to collect and analyze the data. Three categories were derived from the situational conditions described. These were exploitation, ie, nurses' concern with the inhumane treatment of seriously ill patients; exclusion, ie, the lack of attention paid to patient wishes in treatment decisions; and anguish, ie, the powerlessness and frustration felt by nurses involved in ethical situations. It was concluded that in an era of escalating, complex dilemmas, nurses are willing and motivated to engage in ethical decision-making situations, particularly when the comfort or rights of their patients are involved. The environmental barriers to this practice, however, are staggering. The barriers identified included lack of support or poorly defined mechanisms of support, time pressures, personal concerns over security, and hierarchic forces within the institution. Nurses' inability to act on behalf of patients or with regard to their individual conscience may be contributing to high turnover rates and the nursing shortage, particularly in those areas with high use of technology.

Acute Disease↗

How to find future ecstasy-users: targeted and snowball sampling in an ethically sensitive context.

This article documents the design and the sampling procedures of a prospective longitudinal multidisciplinary study on the neurotoxicity of ecstasy (MDMA): the Netherlands XTC Toxicity Study (NeXT). Targeted and snowball sampling was used to recruit 188 respondents who were ecstasy-naive at baseline. All respondents completed baseline questionnaires and underwent medical and neuropsychological examinations. At the end of a 11- to 26- month follow-up period in which they completed four additional questionnaires, 160 respondents remained (85.1%). A total of 65 participants (40.6%) took ecstasy for the first time during the follow-up period. This paper discusses the ethical dilemmas inherent in a study of this type and the specific problems and solutions that emerged in the sampling. The sampling was tightly constrained by our need to locate respondents who were potential future ecstasy users while also meeting strict medical and technical criteria. The 'intention to use' criterion proved to be a clear-cut inclusion rule that was practical to apply in the fieldwork.

Adolescent↗

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program.

PURPOSE: To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations. METHODS: A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement. RESULTS: Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication. CONCLUSIONS: Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.

Antibiotic Prophylaxis↗

Coronary artery imaging with multidetector computed tomography: a call for an evidence-based, multidisciplinary approach.

Modern multidetector computed tomography systems are capable of a comprehensive assessment of the cardiovascular system, including noninvasive assessment of coronary anatomy. Multidetector computed tomography is expected to advance the role of noninvasive imaging for coronary artery disease, but clinical experience is still limited. Clinical guidelines are necessary to standardize scanner technology and appropriate clinical applications for coronary computed tomographic angiography. Further evaluation of this evolving technology will benefit from cooperation between different medical specialties, imaging scientists, and manufacturers of multidetector computed tomography systems, supporting multidisciplinary teams focused on the diagnosis and treatment of early and advanced stages of coronary artery disease. This cooperation will provide the necessary education, training, and guidelines for physicians and technologists assuring standard of care for their patients.

Coronary Angiography↗

Langerhans cell histiocytosis of the orbit: a need for interdisciplinary dialogue.

PURPOSE: To explore specialty-related perceptions and treatment strategies in Langerhans cell histiocytosis (LCH) of the orbit. DESIGN: A perspective. METHODS: We reviewed the reported ophthalmic experience with unifocal LCH of the orbit, analyzed current oncologic clinical trial protocols, and provided a brief summary of contemporary knowledge and theory of LCH pathogenesis. RESULTS: Ophthalmic literature indicates that unifocal LCH of the orbit is usually responsive to local intervention. Current international oncologic protocols identify orbital LCH as a "central nervous system-risk" lesion (at risk for delayed-onset diabetes insipidus) and mandate a 6-month course of chemotherapy. Analysis suggests that the latter strategy is based on cases of orbital involvement in multifocal and multisystem disease. The pathologic Langerhans cell continues to define and unite the LCH variants, but cytokine activation of that cell may be an earlier pathogenetic determinant. Despite a common cellular mediator, LCH may be a heterogeneous process, with severity related to varied "upstream" trigger events. CONCLUSION: Treatment perspectives in LCH are influenced by dissimilar patient encounters and varied interpretations of the basic disease process. Pending documentation of linkage between unifocal orbital LCH and diabetes insipidus, we recommend local intervention, with systemic treatment reserved for incomplete response or local reactivation or the appearance of lesions elsewhere. LCH underscores the need for close interaction between specialists with intersecting clinical interests.

Histiocytosis, Langerhans-Cell↗

In vivo studies of transdisciplinary scientific collaboration Lessons learned and implications for active living research.

The past 2 decades have witnessed a surge of interest and investment in transdisciplinary research teams and centers. Only recently, however, have efforts been made to evaluate the collaborative processes and scientific and public policy outcomes of these endeavors. This paper offers a conceptual framework for understanding and evaluating transdisciplinary research, and describes a large-scale national initiative, the National Institutes of Health Transdisciplinary Tobacco Use Research Centers (TTURCs) program, undertaken to promote cross-disciplinary scientific collaboration in the field of tobacco use science and prevention. A 5-year evaluation of collaborative processes and outcomes observed across multiple TTURC centers conducted during 1999 to 2004 is described. The findings highlight key contextual circumstances faced by participating centers (i.e., the breadth of disciplines and departments represented by each center, the extent to which members had worked together on prior projects, spatial proximity among researchers' offices, and frequency of their face-to-face interaction) that influenced their readiness for collaboration and prompted them to follow different pathways toward transdisciplinary integration. Implications of these findings for developing and evaluating future transdisciplinary research initiatives in the field of active living research are discussed.

Cooperative Behavior↗