Oaths for physicians--necessary protection or elaborate hoax?

The ritual of taking an oath upon graduating from medical school is, with a few exceptions, a routine requirement for graduation. Albeit that many students believe that they have taken the Hippocratic Oath, this is virtually never the case. Very often students themselves write many of these oaths, and taking such an oath impresses the student as well as the public, who are potential patients. It sketches the ethically proper way for physicians to treat their patients. Such an oath is meaningful only when it is not coerced but in reality sketches the physicians' obligations toward patients, society, and each other. The question and problem of a coerced oath are discussed. It is concluded that students when first entering medical school know that such an oath will be a requirement for graduation, and because much of the time the persons taking the oath are writing it, I believe that coercion is not a factor. It is an unfortunate fact that throughout the nation students who are known to behave in ethically inappropriate ways are nevertheless allowed to graduate. Possible ways of addressing this troubling situation are discussed. Equally troublesome is the fact that we who administer the oath as well as the students who swear to it are aware that the system of medical care makes it extremely difficult and at times impossible to truly adhere to the full implications of this oath. According to the oath, physicians (in virtually all formulations) swear that social standing (and by implication economic factors) will not change the way in which patients are treated. This becomes impossible when uninsured patients are sent away at the front desk long before the physician can interact with them. Furthermore, the current fact that physicians often are confronted with not doing what they consider a necessary test (or prescribe what they think would be the best medication) raises the problem of either lying or suggesting to the patient that he/she do so--a fact that in the long run cannot help but damage the physician's veracity and the trust which patients put in their physicians. That virtually all codes of the American Medical Association (AMA) as well as the various specialties insist that physicians work toward universal access is stressed.     

Observations on ethical problems and terminal care.

Progress in medical diagnosis and therapy has raised new problems with far-reaching ethical implications. Medicine must remain a profession and not become a business. Textbooks must address ethical problems in the context of health care decisions and not restrict themselves to pathophysiology and practical therapeutics alone. The relative roles of the principles of autonomy, non-maleficence, beneficence, and justice must be balanced and appropriately applied to individual situations in biomedical ethics. When therapy becomes futile and the suffering of the patient does not justify any anticipated benefit, the patient (and/or patient surrogate) may request withholding or even withdrawing life-prolonging interventions. In the persistent vegetative state, even nutritional support by an unnatural (tube) route may ethically be denied at the patient's (or surrogate's) informed decision. New areas of ethical evaluation have been raised by the desire of some individuals to prolongation of their lives at high expense to the society such that other individuals are denied services because of limitation of available resources. There has been a long-standing conflict of interest between the acceptance by physicians and/or medical institutions of money or gifts from pharmaceutical companies whose drugs they prescribe, stock, or sell. This practice increases the cost of the drugs and is, in effect, a "sick tax," which is morally wrong.     

A direct advance on advance directives

Advance directives (ADs), which are also sometimes referred to as 'living wills', are statements made by a person that indicate what treatment she should not be given in the event that she is not competent to consent or refuse at the future moment in question. As such, ADs provide a way for patients to make decisions in advance about what treatments they do not want to receive, without doctors having to find proxy decision-makers or having recourse to the doctrine of necessity. While patients can request particular treatments in an AD, only refusals are binding. This paper will examine whether ADs safeguard the autonomy and best interests of the incompetent patient, and whether legislating for the use of ADs is justified, using the specific context of the legal situation in the United Kingdom to illustrate the debate. The issue of whether the law should permit ADs is itself dependent on the issue of whether ADs are ethically justified; thus we must answer a normative question in order to answer the legislative one. It emerges that ADs suffer from two major problems, one related to autonomy and one to consent. First, ADs' emphasis on precedent autonomy effectively sentences some people who want to live to death. Second, many ADs might not meet the standard criteria for informed refusal of treatment, because they fail on the crucial criterion of sufficient information. Ultimately, it transpires that ADs are typically only appropriate for patients who temporarily lose physical or mental capacity.     

Ethics and evidence-based medicine: is there a conflict?

This article addresses the advantages, disadvantages, and traps to which evidence-based medicine (EBM) may lead and suggests that, to be ethically valid, EBM must be aimed at the patient's best interests and not at the financial interests of others. While financial considerations are by no means trivial, it is hypocritical - if not dangerous - to hide them behind words like "evidence" or "quality."     

Annonce des résultats en médecine nucléaire : enjeux et réflexions. «: Informer le patient,ce n’est pas l’obliger à entendre,mais le préparer à comprendre » - Article 7 de la charte du GT Ethique de la SFMN

Announcing ant delivering results to patients from nuclear medicine tests, and particularly with PET imaging, can vary profoundly from a department to another, even from a physician to another. French regulation regarding patients’ information and access to their health data as well as the National Cancer Institute's (Institut national du cancer–INCa) most recent recommendations concerning cancer announcement ask all medical imaging specialists (nuclear medicine physicians and radiologists) to be more implicated in the announcement process. Moreover, and above all legal considerations, it is ethically difficult to refuse any kind of medical communication to a demanding patient and let that patient, sometimes alone, discover the results without any kind of medical comments from the specialist who wrote the report. Such heterogeneity is real and must therefore be understood and explored. The arguments given by physicians who do not give results or who are not implicated in cancer announcement are analyzed in a non-dogmatic fashion to find concrete answers to patients’ legitimate expectancies.     

Ethical and economic aspects of noncompliance and overtreatment.

Physicians have an ethical responsibility for cost-saving within the current medical care delivery system. Noncompliance and overtreatment are among the causes of excessive health care expenses. An effective means of improving compliance and avoiding unwanted or fruitless treatment is improved physician-patient communication. Improved communication is also the most ethical means of avoiding these expenses. The educated participation of patients in treatment decisions and of the public in health policy formation is ethically and economically preferable to bureaucratic responses and user fees. The public must be made aware of the costs and limited benefits of medical treatments and of the effects of lifestyle on health. The medical encounter must become more supportive and educational. Medical school curricula must emphasize patient involvement, which must be reinforced to medical students and residents by staff physicians'' genuine concern and effort. Quality assessments and assurance should include evaluation of communication, patient satisfaction, use of follow-up and duplication of services.     

Cultural considerations in forgoing enteral feeding: A comparison between the Hong Kong Chinese,North American,and Malaysian Islamic patients with advanced dementia at the end‐of‐life

Cultural competence, a clinical skill to recognise patients' cultural and religious beliefs, is an integral element in patient‐centred medical practice. In the area of death and dying, physicians' understanding of patients' and families' values is essential for the delivery of culturally appropriate care. Dementia is a neurodegenerative condition marked by the decline of cognitive functions. When the condition progresses and deteriorates, patients with advanced dementia often have eating and swallowing problems and are at high risk of developing malnutrition. Enteral tube feeding is a conventional means of providing artificial nutrition and hydration to meet nutritional needs, but its benefits to the frail population are limitedly shown in the clinical evidence. Forgoing tube feeding is ethically challenging when patients are mentally incompetent and in the absence of an advance directive. Unlike some developed countries, like the United States of America, death and dying is a sensitive issue or even a taboo in some cultures in developing countries that forgoing enteral tube feeding is clinically and ethically challenging, such as China and Malaysia. This article in three parts 1) discusses the clinical and ethical issues related to forgoing tube feeding among patients with advanced dementia, 2) describes how Hong Kong Chinese, North American, and Malaysian Islamic cultures respond differently in the decision‐making patterns of forgoing tube feeding for patients with advanced dementia, and 3) reiterates the clinical implications of cultural competence in end‐of‐life care.     

Gender identity development in adolescence

This article is part of a Special Issue "Puberty and Adolescence".This article aims to provide an outline of what is currently known on trajectories, and contributing factors to gender identity development in adolescence. We give a historical overview of the concept of gender identity, and describe general identity development in adolescence, gender identity development in the general population and in gender variant youth. Possible psychosocial (such as child and parental characteristics) and biological factors (such as the effects of prenatal exposure to gonadal hormones and the role of genetics) contributing to a gender variant identity are discussed.     

A New Model for Predicting Non-Sentinel Lymph Node Status in Chinese Sentinel Lymph Node Positive Breast Cancer Patients

Background

Our goal is to validate the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram and Stanford Online Calculator (SOC) for predicting non-sentinel lymph node (NSLN) metastasis in Chinese patients, and develop a new model for better prediction of NSLN metastasis.

Methods

The MSKCC nomogram and SOC were used to calculate the probability of NSLN metastasis in 120 breast cancer patients. Univariate and multivariate analyses were performed to evaluate the relationship between NSLN metastasis and clinicopathologic factors, using the medical records of the first 80 breast cancer patients. A new model predicting NSLN metastasis was developed from the 80 patients.

Results

The MSKCC and SOC predicted NSLN metastasis in a series of 120 patients with an area under the receiver operating characteristic curve (AUC) of 0.688 and 0.734, respectively. For predicted probability cut-off points of 10%, the false-negative (FN) rates of MSKCC and SOC were both 4.4%, and the negative predictive value (NPV) 75.0% and 90.0%, respectively. Tumor size, Kiss-1 expression in positive SLN and size of SLN metastasis were independently associated with NSLN metastasis (p<0.05). A new model (Peking University People''s Hospital, PKUPH) was developed using these three variables. The MSKCC, SOC and PKUPH predicted NSLN metastasis in the second 40 patients from the 120 patients with an AUC of 0.624, 0.679 and 0.795, respectively.

Conclusion

MSKCC nomogram and SOC did not perform as well as their original researches in Chinese patients. As a new predictor, Kiss-1 expression in positive SLN correlated independently with NSLN metastasis strongly. PKUPH model achieved higher accuracy than MSKCC and SOC in predicting NSLN metastasis in Chinese patients.     

Comparing Non-Medical Sex Selection and Saviour Sibling Selection in the Case of <Emphasis Type="Italic">JS and LS v Patient Review Panel: Beyond the Welfare of the Child?</Emphasis>

The national ethical guidelines relevant to assisted reproductive technology (ART) have recently been reviewed by the National Health and Medical Research Council (NHMRC). The review process paid particular attention to the issue of non-medical sex selection, although ultimately, the updated ethical guidelines maintain the pre-consultation position of a prohibition on non-medical sex selection. Whilst this recent review process provided a public forum for debate and discussion of this ethically contentious issue, the Victorian case of JS and LS v Patient Review Panel (Health and Privacy) [2011] VCAT 856 provides a rare instance where the prohibition on non-medical sex selection has been explored by a court or tribunal in Australia. This paper analyses the reasoning in that decision, focusing specifically on how the Victorian Civil and Administrative Tribunal applied the statutory framework relevant to ART and its comparison to other uses of embryo selection technologies. The Tribunal relied heavily upon the welfare-of-the-child principle under the Assisted Reproductive Treatment Act 2008 (Vic). The Tribunal also compared non-medical sex selection with saviour sibling selection (that is, where a child is purposely conceived as a matched tissue donor for an existing child of the family). Our analysis leads us to conclude that the Tribunal’s reasoning fails to adequately justify the denial of the applicants’ request to utilize ART services to select the sex of their prospective child.     

A GOOD DEATH: WHO BEST TO BRING IT?*

The author supports the right of persons to terminate their lives when it would be in their "best interests" to do so. He considers cases in which persons are unable to kill themselves and request euthanasia or have requested it beforehand in a living will. Crisp rejects relatives, friends, and most physicians as the agents to carry out the request because of the emotional trauma to the agents and the damage to the image of physicians as savers of lives. He proposes that the practice of euthanasia be part of "telostrics," an area of medical specialization in the care of the terminally ill, and that these "telostricians" should perform voluntary euthanasia.     

Computational modelling of lung injury: is there potential for benefit?

State-of-the-art medical care of the victims of current conflicts is generating large quantities of quality clinical data as a by-product. Observational research based on these data is beginning to have a profound influence on the clinical management of both military and civilian trauma patients. Computational modelling based on these datasets may offer the ability to investigate clinical treatment strategies that are practically, ethically or scientifically impossible to investigate on the front line. This article reviews the potential of this novel technology to aid development of treatment for blast lung and other unresolved medical scenarios.     

"Sweeping up after the parade": professional, ethical, and patient care implications of "turfing"

"Turfing" denotes a patient transfer or triage from one physician to another when the care of that patient feels more troublesome than it is worth. A widespread phenomenon in medical training programs, turfing appears to allocate patient care to meet physicians' rather than patients' needs. Although turfing reportedly causes inter-physician discord and inter-specialty stereotyping, its deeper consequences are poorly understood. Turfing is an interpersonal conflict masquerading as a medical issue. After examining turfing alongside other patient-related slang, I analyze the distinction between "the turf," a person, and "to turf," a practice. Several explanatory models from medical practice are explored in order to illuminate turfing's implications for medical professionalism, ethics, and patient care. I suggest that a physician's medical specialty or practice type--that is, professional culture--may link to that physician's degree of altruism. If so, then what it means fundamentally to be a physician might vary across medical specialties. Such a link calls for a new notion of cultural competence, one that physicians may apply not to patients but to each other.     

Empirical Study of Data Sharing by Authors Publishing in PLoS Journals

Background

Many journals now require authors share their data with other investigators, either by depositing the data in a public repository or making it freely available upon request. These policies are explicit, but remain largely untested. We sought to determine how well authors comply with such policies by requesting data from authors who had published in one of two journals with clear data sharing policies.

Methods and Findings

We requested data from ten investigators who had published in either PLoS Medicine or PLoS Clinical Trials. All responses were carefully documented. In the event that we were refused data, we reminded authors of the journal''s data sharing guidelines. If we did not receive a response to our initial request, a second request was made. Following the ten requests for raw data, three investigators did not respond, four authors responded and refused to share their data, two email addresses were no longer valid, and one author requested further details. A reminder of PLoS''s explicit requirement that authors share data did not change the reply from the four authors who initially refused. Only one author sent an original data set.

Conclusions

We received only one of ten raw data sets requested. This suggests that journal policies requiring data sharing do not lead to authors making their data sets available to independent investigators.     

八年制学生医学免疫学实验教学改革的探索

为了适应我国医学教育培养高素质创新人才的要求、提高本科生创新意识和综合能力,本研究对我校八年制医学生医学免疫学实验教学进行了系列探索与实践。经过5年的实践表明,我校医学免疫学实验教学改革已取得初步成效：优化了医学免疫学实验教学内容、初步探索出一套行之有效的实验室开放模式、建立了适合本科学生进行创新思维和综合训练的技术平台、建立并完善了实验教学质量保障体系。为国内高等医学院校建立医学免疫学实验教学模式提供了有价值的参考。     

'Hitting you over the head': oncologists' disclosure of prognosis to advanced cancer patients

The disclosure of prognosis to terminally ill patients has emerged as a recent concern given greater demands for patient involvement in medical decision-making in the United States. As part of the informed consent process, American physicians are legally and ethically obligated to provide information to such patients about the risks, benefits, and alternatives of all available treatment options including the use of experimental therapies. Although not legally required, the disclosure of a terminal prognosis is ethically justified because it upholds the principle of self-determination and enables patients to make treatment decisions consistent with their life goals. To understand oncologists' attitudes about disclosing prognostic information to cancer patients with advanced disease, we interviewed fourteen oncologists and conducted one focus group of medical fellows. Although oncologists reported to disclose prognosis in terms of cancer not being curable, they tend to avoid using percentages to convey prognosis. Oncologists' reported reluctance to disclosing prognosis was conveyed through the use of metaphors depicting the perceived violent impact of such information on patients. Oncologists' reluctance to disclose prognosis and preserve patient hope are held in check by their need to ensure that patients have 'realistic expectations' about therapy. We discuss these data in light of the cultural, ethical, and legal dimensions of prognosis disclosure, patient hope and the doctor–patient relationship, and recommend ways to enhance the communication process.     

Questionable Gate-keeping: Scientific Evidence for Complementary and Alternative Medicines (CAM): Response to Malcolm Parker

The more popular complementary and alternative medicine (CAM) has become, the more often it is demanded that the integration of CAM should be limited to those approaches that are scientifically proven to be effective. This paper argues that this demand is ethically and philosophically questionable. The clinical legitimacy being gained by CAM and its increasing informal integration should instead caution against upholding the biomedical framework and evidence-based medicine as conditions of acceptance. Patients’ positive experiences with CAM deserve a truly scientific exploration of non-biomedical conceptualizations of health and illness. It is also problematic to request scientific evidence when there is proven resistance against CAM in research institutions, under-funding and a lack of suitable research methodologies. This is even more so, when much conventional medicine is not practiced with the same level of evidence as demanded from CAM.     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

Educational pelvic exams on anesthetized women: Why consent matters

It is argued here that the practice of medical students performing pelvic exams on women who are under anesthetic and have not consented is immoral and indefensible. This argument begins by laying out the ethical justification for the practice of informed consent, which can be found in autonomy and basic rights. Foregoing the process of consent within medicine can result in violations of both autonomy and basic rights, as well as trust, forming the basis of the wrong of unauthorized pelvic examinations. Several objections to this argument are considered, all of which stem from the idea that this practice constitutes an exception to the general requirement of informed consent. These objections suggest that nonconsensual pelvic examinations on women under anesthetic are ethically acceptable on utilitarian grounds, in that they offer benefits either to the patient or to society, or on the grounds of triviality, in that consent is already presumed, or the practice is insignificant. Each of these objections is rejected and the practice is deemed indefensible.     

易分解有机碳对不同恢复年限森林土壤激发效应的影响

土壤有机碳库作为陆地生态系统最大的碳库,其微小的改变都将引起大气CO_2浓度的急剧改变。易分解有机碳的输入可以通过正/负激发效应加快/减缓土壤有机碳(SOC)的矿化,并最终影响土壤碳平衡。以长汀县不同恢复年限森林(裸地、5年、15年、30年马尾松林以及天然林)土壤为研究对象,通过室内培养向土壤中添加~(13)C标记葡萄糖研究易分解有机碳输入对不同恢复阶段森林土壤激发效应的影响。研究结果表明,易分解有机碳输入引起的土壤激发效应的方向和强度因不同恢复阶段而异。易分解有机碳输入的初期对各恢复阶段森林土壤均产生正的激发效应,然而随着时间的推移,15年、30年马尾松林以及天然林相继出现负的激发效应。从整个培养期(59 d)来看,易分解有机碳的输入促进了裸地与5年生马尾松林土壤有机碳的矿化,有机碳的矿化量分别提高了131%±27%与25%±5%;但是减缓了15年生马尾松林土壤有机碳的矿化,使其矿化量减少了10%±1%;然而,易分解有机碳输入对30年生马尾松林及天然林土壤有机碳的矿化则无明显影响。土壤累积激发碳量与葡萄糖添加前后土壤氮素的改变百分比呈显著正相关关系(R~2=0.44,P0.05),表明易分解有机碳输入诱导的土壤激发效应受土壤氮素可利用性的调控,土壤微生物需要通过分解原有土壤有机碳释放的氮素来满足自身的需求。