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The importance of meta-ethics in engineering education.

Our shared moral framework is negotiated as part of the social contract. Some elements of that framework are established (tell the truth under oath), but other elements lack an overlapping consensus (just when can an individual lie to protect his or her privacy?). The tidy bits of our accepted moral framework have been codified, becoming the subject of legal rather than ethical consideration. Those elements remaining in the realm of ethics seem fragmented and inconsistent. Yet, our engineering students will need to navigate the broken ground of this complex moral landscape. A minimalist approach would leave our students with formulated dogma--principles of right and wrong such as the National Society for Professional Engineers (NSPE) Code of Ethics for Engineers--but without any insight into the genesis of these principles. A slightly deeper, micro-ethics approach would teach our students to solve ethical problems by applying heuristics--giving our students a rational process to manipulate ethical dilemmas using the same principles simply referenced a priori by dogma. A macro-ethics approach--helping students to inductively construct a posteriori principles from case studies--goes beyond the simple statement or manipulation of principles, but falls short of linking personal moral principles to the larger, social context. Ultimately, it is this social context that requires both the application of ethical principles, and the negotiation of moral values--from an understanding of meta-ethics. The approaches to engineering ethics instruction (dogma, heuristics, case studies, and meta-ethics) can be associated with stages of moral development. If we leave our students with only a dogmatic reaction to ethical dilemmas, they will be dependent on the ethical decisions of others (a denial of their fundamental potential for moral autonomy). Heuristics offers a tool to deal independently with moral questions, but a tool that too frequently reduces to casuistry when rigidly applied to "simplified" dilemmas. Case studies, while providing a context for engineering ethics, can encourage the premature analysis of specific moral conduct rather than the development of broad moral principles--stifling our students' facility with meta-ethics. Clearly, if a moral sense is developmental, ethics instruction should lead our students from lower to higher stages of moral development.

Engineering↗

The forms and limits of medical ethics.

As medical ethics has evolved over the past several decades, it has come to be regarded as a domain of applied ethics, that is, the application of a rationally based, philosophical theory to moral problems in health care. But an array of difficulties arise in the attempt to apply general moral theories or norms to concrete problems, difficulties that expose the incompleteness and indeterminacy of philosophical moral theory. The doubtful ability of applied ethics to be practically helpful has led to the development of two main competitors. One is the attempt to reprise and rehabilitate the tradition of moral casuistry, which focuses on the analysis of specific cases rather than on the defense and application of theories and norms. The second is the search for moral insight and guidance in narratives or stories. These alternatives suffer from some of the same difficulties that plague applied ethics, however. Another trend in medical ethics rejects the theoretical preoccupation of applied ethics in favour of contextualism--an insistence on situating moral problems in institutional and organizational structures and in social and cultural backgrounds. Social science investigations of medical ethics pay attention to the former, while feminist critiques of medical ethics are concerned with exposing and eradicating cultural biases against women. Contemporary work in medical ethics is diverse, but these manifold approaches hold out the promise of improving our understanding of morality as a truly practical enterprise.

Ethics, Medical↗

Ethical considerations and responsibilities when communicating health risk information.

A large literature treats the ethical issues surrounding communication of health risks. This literature supports the claim that workers have the right to such information and employers the responsibility to provide it. However, the problems arising in particular cases remain difficult to resolve. A "casuistry" of rights and responsibility is suggested, resting on the premise that health information is a common property of all, rather than the particular possession of those who develop it or those who need it.

Communication↗

Is resectoscopic treatment of atypical endometrial polyps a safe option?

OBJECTIVE: This study was undertaken to evaluate the long-term efficacy and prognosis of hysteroscopic resection and coagulation of the polyp base of endometrial polyps with focal atypia in postmenopausal women. STUDY DESIGN: In this observational noncomparative study, conservative treatment was offered to 16 patients, with high anesthesiologic risk, who had endometrial polyps with focal atypia and a surrounding atrophic endometrium. To confirm the focality of the lesion, the polyps were analyzed separately from their bases. Patients with atypia in the polyp base were excluded. RESULTS: After 5 years of follow-up, 13 patients are disease free, 2 underwent vaginal hysterectomy and annessiectomy due to other causes, and 1 died for cardiac disorders. CONCLUSION: Adenomatous polyps with atypia can be treated resectoscopically if the treatment is associated with an accurate histologic examination of the polyp base and its eventual involvement and the features of the remaining uterine mucosa. A thorough follow-up is recommended. Studies on wider casuistries of patients are needed.

Atrophy↗

Long-term results of tension-free vaginal tape (TVT) for the treatment of female urinary stress incontinence.

OBJECTIVES: Prospective evaluation of outcome and complications over a 5-year period post-treatment of urinary stress incontinence by TVT, and comparison of our results with the reference studies. MATERIALS AND METHODS: About 94 patients were treated for urinary stress incontinence only by one TVT procedure (single surgical procedure), between April 1997 and December 1998; 68% of patients presented pure urinary stress incontinence and 32% mixed incontinence. We found also a 25.5% rate of sphincter deficiency (UCP < 20 cm H(2)O) in this cohort. Patients were evaluated after 5 years: 52 complete evaluations (clinical, flow measurement with measurement of post-mictional residue, 24h PAD-test, quality of life questionnaire), 30 complete telephone interviews, 12 lost to follow-up (2 patients deceased). RESULTS: About 87% of the patients had a 5-year follow-up. The success rate was 79.2% overall (84.5% for the pure urinary stress incontinence and 67% for the mixed incontinence cases), and 72.2% for the cases of associated sphincter deficiency. We had only a 13% rate of patients lost to follow-up. More than half of the urinary urgency cases were treated successfully, however with a less satisfactory outcome in cases of bladder instability. The urodynamic exploration appeared to reveal that TVT caused dysuria: 52% of patients had a maximum flowrate below 15 ml/s, but the quality of life was improved, with a 95% rate of satisfaction without functional problems. We observed no late complications such as vaginal erosion or rejection of the prolene; the de novo syndrome was rare, with 8.5% of urinary frequency, 6% of urinary urgency and only 5.7% of invalidating dysuria. We saw no cases of pelvic floor disease after TVT treatment. DISCUSSION: Our casuistry results are comparable with the reference studies by Scandinavian authors, Rezapour and Ulmsten, confirming the long-term success of the TVT procedure. Concerning the apparently elevated rates of post-TVT dysuria found by urodynamic exploration, a distinction has to be drawn between post-TVT urinary problems (frequent but oligosymptomatic), and true, severe dysuria (rare). However, "dysuria" in the broad sense did not affect the patients' quality of life, and is a reminder of the absolute necessity of meticulous compliance with the correct surgical techniques. CONCLUSION: Treatment of urinary incontinence by TVT is a reliable, mini-invasive, reproducible technique, almost suitable for outpatients, with no serious complications; it is inexpensive and very successful, including in complicated cases such as sphincter deficiency. All the recent data confirms, with this 5-year follow-up, that the TVT procedure is comparable to the previously gold standard, the Burch colposuspension.

Adolescent↗

Recurrent complicated colon diverticulitis in renal transplanted patient.

Colon perforation due to diverticulitis is a life-threatening complication in the postoperative course of kidney transplantation. In the immunocompromised patient a diagnosis of diverticulitis is difficult to make. We report a 53-year-old woman being kidney transplanted 14 years ago with known diverticulosis. She was admitted with acute severe pain in the lower left abdomen. Abdominal computed tomography (CT) scan indicated a diagnosis of intestinal abscess in the small pelvis. Laparotomy showed a covered sigma perforation with abscess located in the small pelvis (Hinchey-I). Because of the immunocompromised situation of the patient we performed a Hartmann procedure. Her postoperative course was uneventful. In a 6-month interval the intestinal continuity restoration was performed. Twelve days after discharge the patient was readmitted with reduced renal function and increased infection parameters. During physical examination the abdomen was tender. The patient complained of abdominal pain in the left upper abdomen and additional pain in the left shoulder. An antibiotic therapy using ciprofloxacin was already initiated owing to a urinary tract infection. An abdominal CT scan was performed and indicated an intestinal abscess in the left upper abdomen. Laparotomy showed an abscess involving transverse colon, distal jejunum, and proximal ileum (Hinchey-II). Segmental resection of the left colonic flexure, proximal jejunum, and ileum was performed. The postoperative course was uneventful and the patient was discharged on the 8th postoperative day. The present casuistry emphasizes that the immunocompromised patient can undergo diverticulitis twice, and that primary anastomosis is a feasible option for patients with localized peritonitis due to complicated diverticulitis.

Anastomosis, Surgical↗

[Ethics conflicts in the application of mechanical ventilation: analysis of the attitude of critical care and emergency professionals and students].

OBJECTIVE: To analyze the influence of prognosis, life quality or previous instructions in the decision making of applying an invasive (intubation/mechanical ventilation), conservative or palliative procedure. MATERIAL AND METHODS: "Casuistry" methodology: opinion on the appropriate decision regarding five clinical histories representative of ethic conflicts with 542 health professionals (220 intensive care specialist, 150 emergency department professionals, 76 nurses, and 96 students). As control group, 26 students enrolled in a International Master on Bioethics. RESULTS: A great inter-group variability was observed (p = 0.005) with a higher agreement with control group between students and lower with intensivists. The agreement observed was highest in cases with "total support" as the appropriate option (kappa 0.85, 0.69, and 0.66) than in cases with "palliative measures" as appropriate option (kappa 0.22 and 0.46). CONCLUSIONS: 1) A high variability was observed regarding decisions on instituting respiratory support. 2) Decisions regarding the restriction of therapeutic efforts are not accepted in the main, even in scenarios merging into futility, as permanent vegetative status. 3) Among severely deteriorated and handicapped patients, perceived life quality is more appreciated by the patient than that estimated objectively. 4) There is no a consensus opinion for the respect of previous guidelines of vital support refusal. 5) Age and deep psychic deficiency are not considered as cause of discrimination. These features may be considered typical of the mediterranean ethics, in which paternalism and charity are more appreciated values than autonomy.

Attitude of Health Personnel↗

Bioethics and rural health: theorizing place, space, and subjects.

The field of bioethics has been criticized for its universalizing tendencies, attributed in a large part to its foundations in moral philosophy and the level of abstraction of much bioethical discourse. Efforts to particularize bioethics have included the "turn toward casuistry", the emergence of feminist and disability rights critiques of mainstream bioethics, and ethnographic contributions that examine the situatedness of ethical acts, practices, and meanings in local contexts. Such work introduces into bioethics dimensions of space, place, and time; nonetheless, these remain relatively unexplored as constitutive elements and/or influences of the phenomena of ethics discourse and ethics-related practices. Drawing from an ethnographic study of genetics in rural health, this paper presents a sociological discussion of space/time and bioethics through examination of rural health settings. Issues raised include intersections of spatial and power relations, socio-spatial gradients of expertise, and socio-spatial dimensions of ethics knowledge and practices within medical settings.

Bioethics↗

[Localized fibrous tumor of the pleura: analysis of 11 new cases].

We present a retrospective revision of a pathology, rare in his incidence (5% of the pleural tumours) and singular in his characteristics, analyzing the presentation forms, surgical treatment and results. The solitary tumours of the pleura are a rare entity, whose biological behaviour is not related with immunohistochemical characteristics; although considered benign, they present sensitive recidivation index and metastization, independently of the volume that they present. he surgery is the only available treatment, and complete surgical excision is decisive. From August 1995 to January 2003, in the casuistry of the Department of Cardiothoracic Surgery in Santa Marta's Hospital, were analyzed all the patients with the diagnosis of localized fibrous tumour of the pleura (TFLP). In this context, were identified 11 patients with a medium age of 57,54 years old, 6 of them females, in which the diagnosis of located fibrous tumour of the pleura was established; 6 of the tumours were classified as malignant. All the patients were submitted to surgical excision, with different techniques, without significant intra-operative mortality or intra-hospital morbidity, despite the difficulty of surgery in the most voluminous tumours (one of the tumours weight was 2,5 kg). The follow up elapsed between 4 and 84 months (average - 39,4 months). One patient died 13 months after the surgery, after several crises of lung embolism (that began without determinable relationship with the surgery or the initial pathology), despite the controlled ambulatory anti-coagulation.

Female↗

The ground of dialogical bioethics.

Dialogical ethics are a procedural alternative to substantive ethics such as consequentialism, deontology, principlism, casuistry, virtue ethics and care ethics. Dialogical ethics are procedural in that they do not establish goods in advance, unlike substantive ethics, but rather determine goods through a procedure enacted by the actual parties involved (although some substantive notion of justice may still be required); and they are dialogical in that the procedure is that of dialogue, involving both empathic critical discussion and negotiation. A fundamental tenet of dialogical ethics may be the use of appropriate rules of order regulating dialogue among the parties involved. Some of the central characteristics of such rules of order are that they are reciprocally regulated by dialogue, that they override other ethical considerations, and that they institute empathic critical discussion and negotiation within the ethical dialogue. Dialogical bioethics are the application of dialogical ethics to ethical problems in medicine. The approach of dialogical bioethics has proven fruitful for resolving bioethical problems such as that of medical futility, where approaches of substantive ethics have reached an impasse. There is room for further study of special challengeswithin dialogical bioethics, such as the incompetence of some involved parties, conflicts of interests of third parties, and the cost-effectiveness of this ethical approach.

Bioethics↗

Ethical case deliberation and decision making.

During the last thirty years different methods have been proposed in order to manage and resolve ethical quandaries, specially in the clinical setting. Some of these methodologies are based on the principles of Decision-making theory. Others looked to other philosophical traditions, like Principlism, Hermeneutics, Narrativism, Casuistry, Pragmatism, etc. This paper defends the view that deliberation is the cornerstone of any adequate methodology. This is due to the fact that moral decisions must take into account not only principles and ideas, but also emotions, values and beliefs. Deliberation is the process in which everyone concerned by the decision is considered a valid moral agent, obliged to give reasons for their own points of view, and to listen to the reasons of others. The goal of this process is not the reaching of a consensus but the enrichment of one's own point of view with that of the others, increasing in this way the maturity of one's own decision, in order to make it more wise or prudent. In many cases the members of a group of deliberation will differ in the final solution of the case, but the confrontation of their reasons will modify the perception of the problem of everyone. This is the profit of the process. Our moral decisions cannot be completely rational, due to the fact that they are influenced by feelings, values, beliefs, etc., but they must be reasonable, that is, wise and prudent. Deliberation is the main procedure to reach this goal. It obliges us to take others into account, respecting their different beliefs and values and prompting them to give reasons for their own points of view. This method has been traditional in Western clinical medicine all over its history, and it should be also the main procedure for clinical ethics.

Beneficence↗

[Neuroendocrine tumors of the larynx (NETL)].

UNLABELLED: CASUISTRY: The case of a patient with atypical carcinoid of the larynx is reported and literature about neuroendocrine tumors of the larynx (NETL) is reviewed. BACKGROUND: Especially terminology, histological differentiation, diagnostics and therapy are discussed. CONCLUSIONS: Neuroendocrine tumors are rare and untypically located in the larynx. In spite of this they should to be known as an important differential diagnosis of a laryngeal neoplasia, because of possible malign or highly malign course. The typical localisation of neuroendocrine tumors (NET) are the gastrointestinal tract and the lung, but the clinical course differs from the one of laryngeal manifestation. This means diagnostics and therapy have to be adapted to this special disease. That's why it is important to explore the identity of these tumors scientifically. This is difficult because of the low rate of patients with this disease. The message of this report is the conclusion of the established and appeal for publications of new cases of NETL.

Adult↗

[Pancarditis as cause of death after abscess tonsillectomy].

Paratonsillar abscesses are preferably treated by abscess tonsillectomy as operative therapy. The casuistry of a patient aged 17 who was tonsillectomized for a paratonsillar abscess and died after 12 days prompted a discussion on the scope of preoperative diagnostics. The clinical examination and anamnesis of the young man prior to the operation did not give evidence of any concomitant diseases. It was only through extensive microscopic investigations of the myocardium after autopsy that inflammatory infiltrates of the epicardium, endocardium and myocardium in the vicinity of portions of the conduction system were detected. The relevance of autopsy to the quality assurance in clinical activities is emphasized. Legal questions of possible negligent homicide as a result of the failure to take diagnostic and therapeutic measures are raised.

Adolescent↗

[Accidents with the "paraglider"].

With a collective of 46 patients we show the details and kinds of accidents caused by paragliding. The base for the casuistry of the accidents was a questionnaire which was answered by most of the injured persons. These were questions about the theoretical and practical training, the course of the flight during the different phases, and the subjective point of view of the course of the accident. The patterns of the injuries showed a high incidence of injuries of the spinal column and high risks for the ankles. At the end, we give some advice how to prevent these accidents.

Accidental Falls↗

[Pseudocondylomata of the vulva (author's transl)].

The present casuistry study deals with condylomata acuminata-like lesions of the vulva of two sexually mature 20 and 22 years old Turkish sisters, and a 34 year old Yugoslavian women. Based on clinical and histological particularities the verruciform structures are interpreted as - atavistic? - malformation without functional significance. Their relation to the papillas of corona glans are proved in detail.

Adult↗

[Indications and complications of surgical treatment of orthopedic diseases in patients over 80].

Due to increasing life expectation the number of elder patients, who need medical care, increases, too. Orthopedic surgery of elder patients especially deals with degenerative changes of locomotor and supporting apparatus, as well as with traumatic lesions. Because of the polymorbidity the rate of complications and risks of operative treatment raises. Representation of a casuistry of 173 operative intervention in patients undergoing operative treatment between 1965 and 1984 (20 years), who where 80 years and older. Most of the cases were operations of choice without any vital indication. Concerning emergency operations traumatological cases were well to the fore. All operative interventions are classified in localisation and intra- and postoperative complications. There was rather a high mortality in these patients compared to the average mortality in our clinic. The indication for operative treatment in high aged patients needs a careful and critical examination of risks and the attainable results. Aesthetic aspects are lesser important. The interdisciplinary collaboration of internal specialists, surgeons, haemostasiologists a.o. is very important to prepare the patients for surgical treatment and to reduce the postoperative complication rate.

Aged↗

[Gliding polyethylene-PMMA combination as "wear model"].

The situation, described in this casuistry, shows the fatal consequences of the huge amount of wear particles from the PE-PMMA-components of a total hip prosthesis. The prosthesis had been implanted in Russia. It was made of a PE-ball fixed to a titanium stem and a socket, which had been molded intraoperatively in situ. The combination of PMMA and PE in the bearing surface caused an extreme osteolysis in the proximal femur and the acetabulum and the loosening of the cup and the stem within only a few months.

Aged↗

By-person factor analysis in clinical ethical decision making: Q methodology in end-of-life care decisions.

OBJECTIVE: To determine the usefulness of Q methodology to locate and describe shared subjective influences on clinical decision making among participant physicians using hypothetical cases containing common ethical issues. DESIGN: Qualitative study using by-person factor analysis of subjective Q sort data matrix. SETTING: University medical center. PARTICIPANTS: Convenience sample of internal medicine attending physicians and house staff (n = 35) at one midwestern academic health sciences center. INTERVENTIONS: Presented with four hypothetical cases involving urgent decision making near the end of life, participants selected one of three specific clinical actions offered for each case. Immediately afterward and while considering their decision, each respondent sorted twenty-five subjective self-referent items in terms of the influence of each statement on their decision-making process. By-person factor analysis, where participants are defined as variates, yielded information about the attitudinal background the physicians brought to their consideration of each hypothetical case. We performed a second-order factor analysis on all of the subjective viewpoints to determine if a smaller core of shared attitudes existed across some or all of the four case vignettes. Factor scores for each item and post-sort comments from interviews conducted individually with each respondent guided the interpretation of ethical perspective used by these respondents in making clinical decisions about the cases. MEASUREMENTS AND MAIN RESULTS: Second-order factor analysis on seventeen viewpoints used by physicians in the four hypothetical urgent decision cases revealed three moderately correlated (r2 < 40%) subjective core attitudinal guides used broadly among all the cases and among sixteen of the seventeen original factors. Across all the cases, our participants were guided in general by: (1) patient-focused beneficence, (2) a patient- and surrogate-focused perspective that includes risk avoidance, and (3) best interest of the patient guided by ethical values. Economic impact on the physician, expediency in resolution of the situation, and the expense of medical treatment were not found to be influential determinants in this study. CONCLUSIONS: Q sorting and by-person factor analysis are useful qualitative methodological tools to study the complex structure of subjective attitudes that influence physicians in making medical decisions. This study revealed the subjective viewpoints used by our physician participants as they made ethically challenging treatment decisions. The three second-order factors identified here are grounded in current bioethical values as well as the personal traits of physicians. The participants' decision methods appear to resemble casuistry more than principle-based decision making. Generalizability of results will require further studies.

Adult↗