Bodies and borders: a new cultural history of medicine

Both medicine and the history of medicine have seen many changes in the last four decades. The way we tell the story of medical developments no longer concentrates on the important doctors and their ideas. The influences of social history in the 1960s and 1970s and cultural history in the 1980s and 1990s have broadened and enriched the interpretations of our medical past. The social historians have helped us to include politics, economics, and the leading ideas of any period we wanted to study; the cultural approach has added ethnography as well as an emphasis on language or discourse.Today there is a new history of medicine, one far more willing to cross disciplinary boundaries to ask questions about how we know what we know and why we do what we do.This article highlights some of the work in the adjoining fields of medical anthropology and of literature and medicine to demonstrate new interests, new questions, and new methods of inquiry. However, although we have cast our nets far more widely in the process of professionalizing the history of medicine, there is a question about whether we have lost the appeal to one of our core constituencies: medical students and physicians. We need to welcome some of the new changes in medical history as in medicine itself; the common goal is to achieve a better understanding of what we have done and what we are doing.     

A report from Japan: choices of Japanese patients in the face of disagreement

Background: Patients in different countries have different attitudes toward self-determination and medical information. Little is known how much respect Japanese patients feel should be given for their wishes about medical care and for medical information, and what choices they would make in the face of disagreement.
Methods: Ambulatory patients in six clinics of internal medicine at a university hospital were surveyed using a self-administered questionnaire.
Results: A total of 307 patients participated in our survey. Of the respondents, 47% would accept recommendations made by physicians, even if such recommendations were against their wishes; 25% would try to persuade their physician to change their recommendations; and 14% would leave their physician to find a new one.
Seventy-six percent of the respondents thought that physicians should routinely ask patients if they would want to know about a diagnosis of cancer, while 5% disagreed; 59% responded that physicians should inform them of the actual diagnosis, even against the request of their family not to do so, while 24% would want their physician to abide by their family's request and 14% could not decide. One-third of the respondents who initially said they would want to know the truth would yield to the desires of the family in a case of disagreement.
Interpretations: In the face of disagreement regarding medical care and disclosure, Japanese patients tend to respond in a diverse and unpredictable manner. Medical professionals should thus be prudent and ask their patients explicitly what they want regarding medical care and information.     

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.     

Exact,Distribution Free Confidence Intervals for Late Effects in Censored Matched Pairs

When comparing censored survival times for matched treated and control subjects, a late effect on survival is one that does not begin to appear until some time has passed. In a study of provider specialty in the treatment of ovarian cancer, a late divergence in the Kaplan–Meier survival curves hinted at superior survival among patients of gynecological oncologists, who employ chemotherapy less intensively, when compared to patients of medical oncologists, who employ chemotherapy more intensively; we ask whether this late divergence should be taken seriously. Specifically, we develop exact, permutation tests, and exact confidence intervals formed by inverting the tests, for late effects in matched pairs subject to random but heterogeneous censoring. Unlike other exact confidence intervals with censored data, the proposed intervals do not require knowledge of censoring times for patients who die. Exact distributions are consequences of two results about signs, signed ranks, and their conditional independence properties. One test, the late effects sign test, has the binomial distribution; the other, the late effects signed rank test, uses nonstandard ranks but nonetheless has the same exact distribution as Wilcoxon's signed rank test. A simulation shows that the late effects signed rank test has substantially more power to detect late effects than do conventional tests. The confidence statement provides information about both the timing and magnitude of late effects (© 2009 WILEY‐VCH Verlag GmbH & Co. KGaA, Weinheim)     

Style and Authority in Javanese Muslim Sermons

A preacher claims to address others from a position of implicitly superior insight. To support this claim, he plays upon the style and content of his performance to justify the role he takes. We can therefore ask how people evaluate particular preachers' performances, and what sorts of criteria can be seen to inform those comments. In particular, we can see how such evaluations speak for the interests and concerns of the people who make them. In light of recent efforts to deepen our understanding of how hegemonic discourses may or may not constrain the thoughts of the subordinate, it is worth looking at particular sermons and at responses to them to ask whether they do indeed propagate a vision of things that compromises some people's interests to the advantage of others, and whether, if so, that fact arouses resistance in any form among their listeners. In looking at three sermons delivered in a hamlet in Java in 1987,1 see contrasting styles in the way they are constructed and delivered, and in those contrasts, differences in the self-presentation of the speaker as he justifies his claims to his listeners' attention. At the same time, I note variation in how individuals evaluate the three speakers according to their own self-image.     

Primate origins,human origins,and the end of higher taxa

When people learn that I study human evolution and we start talking about it, they sometimes ask me, “How long ago did the first humans live?” My answer is usually another question: “What do you mean by 'humans'?” That response seems as baffling and wrong‐headed to them as their question seems to me, and it usually takes us a while to straighten things out. © 2012 Wiley Periodicals, Inc.     

The health of European medical research. Attempts are under way to update EU regulations, with the aim of harmonizing clinical research across the continent

The 2001 EU Clinical Trials Directive aimed to harmonize the regulation of medical research, but achieved the opposite. Various attempts are underway to update the directive to make it easier to safely conduct medical research in Europe.Medical research, similarly to finance and business, works best with light regulation; however, protecting patients during clinical trials, and afterwards when treatments have been approved, requires regulation. Attempts to square this circle and the challenge of testing sophisticated drugs and therapies have resulted in increasingly strict regulation of clinical research, particularly in Europe''s leading medical research powers Germany, France, the Netherlands and the UK. There is growing concern among these countries with established pharmaceutical industries that clinical trials are increasingly hard to conduct; in fact, the number of applications has declined significantly during the past decade (Cressy, 2010).There is growing concern among these countries with established pharmaceutical industries that clinical trials are increasingly hard to conduct…Meanwhile, the number of applications for clinical trials has increased in the USA, Canada and some southern European countries, notably Italy and Spain, where the regulatory touch has been lighter and combined, in some cases, with financial incentives, according to Paul Stewart, Dean of Medicine at the University of Birmingham in the UK. There is a danger therefore that Europe''s leading research nations could lose their competitive edge in medical research at a time when radical new treatments are on the horizon. “Europe''s weight in clinical research is diminishing,” commented Markus Hartmann, senior consultant at European Consulting & Contracting in Oncology (Saarbrücken, Germany), which provides advice about medical regulatory affairs. The risk of falling behind extends beyond drug-based therapies to surgery and medical devices, Hartmann added. He explained that the European Commission now considers medical devices and drugs as ‘products'' that can be sold in the internal market, and therefore require a common and harmonized regulatory framework.Hartmann, along with other researchers, traces the recent decline in European clinical trial activity back to the European Union (EU)''s Clinical Trials Directive (CTD) 2001/20, which was supposed to provide a common framework for unifying regulation within the EU by 2020. “The Clinical Trials Directive is contributing to this effect, but is not the only factor,” said Hartmann.The root cause of the problem might be growing aversity to risk—which puts more emphasis on patient protection even when this is not necessary—but the EU directive has certainly fuelled this mood. “That initial EU Directive was actually quite a sensible document, but what was crazy was the legal creep that followed,” said Stewart. “What the lawyers did was legislate for the worst possible scenario, instead of seeing the directive as a facilitating document enabling people to go and do research.”The directive actually had the opposite effect from the original intent: it led to even more regulatory fragmentation within the EU. This was first identified in a 2006 report, co-authored by Hartmann, which cited significant divergence in the national implementations of the EU directive (Hartmann & Hartmann-Vareilles, 2006). France was found to have the strictest regime, in which all trials including those involving cosmetics were rigorously supervised.The directive actually had the opposite effect from the original intent: it led to even more regulatory fragmentation within the EUThis divergence still exists. “Basically, the lack of harmonisation has not been resolved, as the Clinical Trials Directive has been transposed into national legislation in the form of laws, ordinances and rules of implementation that still differ in so many procedural and technical aspects,” said Hartmann.Moreover, although the 2001 directive underlined maintaining current levels of patient protection, Hartmann argued that it has done little if anything to improve safety. “Do not forget the TeGenero disaster with compound TGN1412, tested in spring 2006 in a Northern London hospital,” he said. “This was Europe''s largest clinical research catastrophe so far and happened in the UK, after the UK switched from a very liberal trial notification system, where phase I trials with healthy volunteers were even exempted from notification or authorisation, to the provisions laid down by the Clinical Trials Directive.”These problems have now been acknowledged by both national governments and the EU itself, according to Liselotte Højgaard, chair of the Standing Committee of the European Medical Research Councils, and a medical imaging specialist at the University of Copenhagen in Denmark. “We have had very many meetings in Brussels about the issue […] and in the last year the EU has become convinced it is a problem,” she said. As a result the directive is going to be redrafted well before it runs its full 20-year course. “We have been invited to help them draft a new directive,” said Højgaard. “That is a major achievement.”The aim is to learn from previous mistakes and frame the new document to encourage harmonization and a reduction in bureaucracy and paperwork. “We must make it easier to implement in each member state,” commented Højgaard, who added that the approval process also needs to be streamlined so that clinical trial teams do not have to repeat the same steps at different stages of the approvals process. “One of the things we are thinking about here in Denmark is whether we can make a one-stop-shop approvals process so you don''t have to go in and send an application to the medicinal agency, and also to the ethical committee, and also to clinicaltrials.gov,” said Højgaard. She hopes this new structure will be in place by the time Denmark holds the EU presidency in early 2012, and will encourage the rest of Europe to adopt a similar approach.The aim is to learn from previous mistakes and frame the new document to encourage harmonization and a reduction in bureaucracy and paperworkHartmann also acknowledges progress on the harmonization front. He cited the Voluntary Harmonisation Procedure (VHP), which was introduced in early 2009 by a network of national authorities, the Clinical Trials Facilitation Group (CTFG). It was set up precisely to coordinate implementation of the 2001/20 directive across EU member states, with little success at first. Now, the VHP allows applicants to submit protocols for trials to be conducted in many EU countries to the respective authorities, which agree on an assessment. “Then in a subsequent step, the applicant can submit the protocol to the national authorities for authorisation,” said Hartmann. “The VHP pilot aims to prevent divergent outcomes in the trial authorisation process, for example when a protocol approved in one country is blocked in another country.”These developments could eventually lead to a Europe-wide agency dedicated to clinical research regulation, along the same lines as the European Research Council for fundamental research, which Højgaard described as a great success. Such an agency would organize trials across the whole continent through a single streamlined approvals process, thereby covering a population of 500 million people.Attempts to amend the EU 2001 directive have also been welcomed by big funding bodies such as the Wellcome Trust in the UK, a charitable foundation that funds medical and clinical research globally. “We recently issued a response to a public consultation paper from the European Commission, Assessment Of The Functioning Of The “Clinical Trials Directive” 2001/20/EC, in which we highlighted areas where the Directive could be streamlined to reduce bureaucracy, while maintaining an appropriate regulatory framework,” said David Lynn, Head of Strategic Planning and Policy at the Wellcome Trust. “We would like to see a more risk-based approach to regulation of clinical trials, a rationalisation of the multiple layers of bureaucracy and the approvals process.”Bureaucracy notwithstanding, a fundamental problem is finding the right balance between risks associated with different drugs or therapies. The 2001 directive has instead led to a one-size-fits-all approach, according to Stewart. “Part of the work we''ve been doing at the level of the UK Clinical Research Consortium is to look at risk–benefit analysis, so that you have a lower level of regulation on some things and higher on others that are unproven.” If, for example, an existing drug turns out to be effective against a disease for which it was not originally developed, it would not be necessary to conduct thorough safety trials. This was the case with aspirin, initially developed as a pain killer over a century ago, which also protects against both vascular disease and bowel cancer (ATT Collaboration, 2009; Din et al, 2010). During these trials, safety was still an issue as the drug was being used in a different context, but, even so, it was clear that acute side effects were highly unlikely.Bureaucracy notwithstanding, a fundamental problem is finding the right balance between risks associated with different drugs or therapiesWhile medical regulations in Europe err on the side of safety, they do little to regulate and harmonise the reporting of results after trials have occurred. The results from many clinical trials are never published as they fall victim to reporting bias for various reasons, notably because the pharmaceutical companies providing funding have an interest in promoting results favourable to their products and suppressing negative findings. A recent study by the Institute for Quality and Efficiency in Health Care (IQWiG) in Cologne, Germany, confirmed widespread publication bias in the past, which harmed patients through under-reporting of side effects (McGauran et al, 2010).“The most prominent example of harm caused by publication bias is probably the case of Class I anti-arrhythmic drugs,” said Beate Wieseler, deputy head of IQWiG''s Drug Assessment Department. In this 1980 trial, 9 of 49 patients with suspected acute myocardial infarction who were treated with a class I anti-arrhythmic drug (lorcainide) died, compared with only one patient in the placebo group, and yet the investigators ludicrously dismissed this as chance (Cowley et al, 1993). The results of the trial were not published until 1993 and, although the development of lorcainide was discontinued for commercial reasons, the investigators concluded that as a result of this delay in publication, the continuing use of class I drugs had led to several unnecessary deaths.By the same token, ineffective drugs have sometimes gained market approval after over-reporting of their benefits, in some cases ignoring other, more negative, studies. Wieseler and colleagues found that studies reporting positive results for a particular drug were published in higher impact journals and were more likely to be picked up by other publications and the mass media.Many cases of reporting bias, especially involving suppression of negative results, occurred 10 or more years ago. According to Stewart the situation has improved, although he concedes that, almost inevitably, journals will be drawn towards positive results given the increasing competition for readers and advertisers. “Whether publication bias goes on to the same extent now is debatable,” said Stewart, pointing out that clinical trials now have to be registered in Europe and the USA so that the data is public, even if it is not published in a journal.There will inevitably be some risk of bias in research funded by pharmaceutical companies, which, after all, are in the business to make money. It is therefore important to support ‘investigator-driven'' trials that are independent of any company, and it is here that the Wellcome Trust has an important role. “The Wellcome Trust supports the proposal for Investigator Driven Clinical Trials as joint collaborations across Europe,” said Lynn. “We fund academic clinical trials, which are usually independent of drug company interests.”Independent money for academic clinical trials has indeed been more crucial during the past few years, since the EU 2001/20 directive tends to favour research funded by drug companies with the money and resources to overcome the increasingly high bureaucratic hurdles. Lynn commented that universities had not been well served by recent legislation. “Academic institutions are less-well resourced and equipped than commercial sponsors to deal with the bureaucratic burden imposed by the Directive,” he said.In some cases these burdens have caused even young scientists to give up on promising research because they cannot stomach the paperwork involved…In some cases these burdens have caused even young scientists to give up on promising research because they cannot stomach the paperwork involved, according to Højgaard. “For the first time in my life as a boss, I had the experience when I came in to a morning conference and asked one of the young consultants ‘shouldn''t we do a clinical study on this'' and he said ‘no I simply haven''t got the energy for all this paper workload''.” This experience spurred her to lobby for change. Critics such as Højgaard and others therefore hope that the redrafting of the amendment and the ensuing changes in national legislation will liberate European medical research from the regulatory shackles that have held it back.     

Microbial rights?

Our ability to disrupt habitats and manipulate living organisms requires a discussion of the ethics of microbiology, even if we argue that microbes themselves have no rights.Synthetic biology and the increasing complexity of molecular biology have brought us to the stage at which we can synthesize new microorganisms. This has generated pressing questions about whether these new organisms have any place in our system of ethics and how we should treat them.The idea that microbes might have some moral claims on us beyond their practical uses or instrumental value is not a new question. Microbiologist Bernard Dixon (1976) presciently asked whether it was ethical to take the smallpox virus to extinction at the height of the attempts of the World Health Organization in the 1970s to eradicate it. There is no unambiguous answer. Today, we might still ask this question, but we might extend it to ask whether the destruction or extinction of a synthetic microbe that was made by humans is also ethically questionable or is such an entity—in that it is designed—more like a machine, which we have no compunction in terminating? Would two lethal pathogens, one of them synthetic and one of them natural, but otherwise identical, command the same moral claims?In a colloquial way, we might ask whether microbes have rights. In previous papers (Cockell, 2004) I have discussed the ‘rights'' of microbes and further explored some issues about the ethics we apply to them (Cockell, 2008). Julian Davies, in a recent opinion article in EMBO reports (Davies, 2010) described my assertion that they should have constitutional rights as ‘ridiculous''. Although I did suggest that environmental law could be changed to recognize the protection of microbial ecosystems—which would imply statutory rights or protection—nowhere have I claimed that microbes should have ‘constitutional'' rights. Nevertheless, this misattribution provides a useful demonstration of the confusion that exists about exactly how we should treat microbes.Few people are in any doubt that microbes should be conserved for their direct uses to humans, for example, in food and drug production, and their indirect uses such as the crucial role they have in the health of ecosystems. Indeed, these motivations can be used to prioritize microbial conservation and protection efforts (Cockell & Jones, 2009). The crucial question is whether microbes have ‘intrinsic value'' beyond their practical uses. If the answer is ‘no'', then we should have no guilt about deliberately driving microbes to extinction for our benefit. However, there are people who feel uneasy with this conclusion, a feeling that calls forth more complex ethical questions.The question is whether microbes have some sort of ‘interests'' that make demands on our treatment of them that go beyond a mere utilitarian calculation. These arguments themselves question what we define as ‘interests'' and whether interests make demands on us. A microbe has no future plans or thought processes; the sorts of interests that are accepted as being of sufficient scope to place demands on our treatment of other human beings, for instance. However, microbes do have biological interests. A halophilic microbe might eventually die if it is dropped into freshwater. Does our knowledge of what is in the biological interests of a microbe mean that we must show it any consideration beyond practical uses? The answer is not obviously negative (Taylor, 1981), but even if we decide that it is, this does not let us off the hook quite yet.There are other intrinsic value arguments that are more obscure, particularly those around the notion of ‘respect''; the idea that we should show empathy towards the trajectory, however deterministic, of other life forms. These unquantifiable and controversial arguments might, nevertheless, partly explain any unease that we have in watching a group of people smash up and destroy some exquisite microbial mats, just because they were bored.Clearly, human instrumental needs do trump microbes at some level. If they did not, we could not use bleach in our houses, an absurd end-point raised in a 1970s science fiction story that explored the futuristic ramifications of full microbial rights, in which household bleaches and deodorants are banned (Patrouch, 1977).However, we should not be so quick to ridicule ideas about microbial ethics and rights. Although it might be true that phages kill a large percentage of the bacterial population of the world every few days, as Julian Davies points out, human society has achieved an unprecedented capacity for destruction and creation. Our ability to poison and disrupt habitats has been unquantified, with respect to the loss of microbial species. Both synthetic biology and bioterrorism raise the spectre of creating new organisms, including pathogens, which we might need to control or deliberately pursue to extinction. Dixon''s dilemma about the smallpox virus, raised more than 30 years ago, has become an urgent point of discussion in the ethics of molecular biology and microbiology.     

Bioaltruism reconsidered

Altruistic behavior is often regarded as sociobiology's most central theoretical problem, but is it? Altruism in biology, bioaltruism, has many meanings, which can be grouped into two categories. The first I will callcommon bioaltruism. It is primarily of ethological relevance. The second,evolutionary bioaltruism, is a special category in evolutionary respects in that it may indeed pose a problem for evolutionary theory. These categories are logically independent. Moreover, both of them are logically different from altruism in its everyday psychological or moral sense. Sociobiological examples of bioaltruistic behavior concern bioaltruism in the first sense only, so the theoretical problem ‘altruism’ is supposed to pose, is indeed nothing but a theoretical problem and the bioaltruism that actually occurs has no evolutionary relevance. Nevertheless, evolutionary theory is relevant to our understanding of the possibility of common bioaltruism, and that possibility — even though bioaltruism is conceptually different from ethical altruism — is relevant for ethicists: it sheds light on what we can ask people to do or not to do.     

Dr. Balfour Mount and the cruel irony of our care for the dying.

Dr. Balfour Mount of Montreal thinks that the health care system, because of its fixation on disease processes, may have forgotten that it also has a mandate to alleviate suffering. "We need to recapture that vision," says Mount, who describes palliative medicine as a "rich combination" of clinical pharmacology, rehabilitation medicine and internal medicine. Mount says there is a cruel irony in our care of the dying. "Although these are the sickest people in our health care system, when medical technology doesn''t know what to do, the quality and quantity of care falls away. How can we justify that?"     

Conductive education at the Pet? Institute,Budapest.

Conductive education, which was developed at the Petö Institute in Budapest, has been publicised incorrectly as a method of treatment for children with cerebral palsy. From the results of information given and our own observations during a week''s visit to the institute we conclude that a minority of carefully selected children with cerebral palsy and spina bifida, who have a relatively good prognosis, are educated at the institute; the education is carried out with appropriate medical, surgical, and orthotic intervention; and the children probably function better as a result of the intensive programme than do similar children in Britain in areas where therapy is scarce. They seem to achieve, however, what we would expect similar children in Britain to do when facilities are adequate. Though our findings do not therefore justify using public funds to refer children to the institute, some (self selected) families benefit from a visit, particularly from the positive attitudes of the staff. The role of the conductor and the integration of programmes into a classroom setting have much to recommend them, and conductive education, if successfully transferred to Britain, might be beneficial to a wider range of children than in Hungary.     

“What Do Animals Mean to You?”: Naming and Relating to Nonhuman Animals

ABSTRACT

This article presents an analysis of data from over 200 accounts of, and responses to questions about, how animals feature in people's lives. The accounts were generated by a Mass Observation Project (MOP) directive on “Animals and Humans.” The MOP, based at a UK university, sends out two or three directives a year, asking correspondents to write in response to a series of questions and prompts. The “Animals and humans” directive began with the question, “What do animals mean to you?” followed by a range of prompts about respondents' experiences of animals. The paper is specifically concerned with issues of how language both reflects and contributes to typologies of living creatures. It presents a qualitative analysis of some of the themes that emerged from responses to the directive, as well as a more quantitative analysis of the words chosen by respondents to denote different kinds of animals. Using these different methodological approaches, it focuses on how moral ambiguity is expressed and the ways in which categories and meanings shift depending on linguistic context. These methods complement each other, with the computer-assisted linguistic analysis providing a different and more quantitative method of revealing aspects of people's values, attitudes, and assumptions as they report on the role of animals in their lives. Overall, the paper shows how a corpus linguistic analysis can demonstrate the permeability of categories and boundaries, and the moral ambiguity toward animals that is revealed in the way language is used.     

Advance directives, dementia, and 'the someone else problem'

Advance directives permit competent adult patients to provide guidance regarding their care in the event that they lose the capacity to make medical decisions. One concern about the use of advance directives is the possibility that, in certain cases in which a patient undergoes massive psychological change, the individual who exists after such change is literally a (numerically) distinct individual from the person who completed the directive. If this is true, there is good reason to question the authority of the directive ‐ which is supposed to apply to the individual who completed it, not to someone else. This is 'the someone else problem'.
After briefly introducing advance directives as a basis for medical decision-making, this paper elaborates 'the someone else problem' in the context of severe dementia. The paper then reconstructs the reasoning that leads to this putative problem and exposes the important underlying assumption that we are essentially persons. An alternative view of what we are, one that regards personhood as inessential, is then considered, before several arguments are advanced in favor of that alternative view. The paper next explores implications for advance directives: 'The someone else problem' is effectively dissolved, while it is noted that a related problem (one beyond the paper's scope) may persist. A few implications beyond advance directives are also identified.     

构建融合医学人文教育的新型医学遗传学教学模式

医学遗传学是广泛涉及基础与临床学科的综合性课程,对于医学生是至关重要的必修课程。现代医学已由传统的生物-医学模式向生物-心理-社会医学模式转化,医学诊疗模式从最初的以"疾病为中心"到"以病人为中心"的方式转变,医生不仅精通医术,更要理解患者的心理,与其进行良好的沟通,因此现代医学成为了一门具有自然科学、人文社会科学双重属性的综合性科学体系。长期以来,我国医学院校的教学仍然是生物医学知识和技能占据主导地位,人文课程不受重视。因此,必须加强医学人文知识的学习和技能培训,只有这样才能在未来的医疗工作中掌握良好的医患沟通技巧,建立和谐的医患关系,对处理好日渐增多的医疗纠纷、维护医患双方的共同利益具有重要意义。     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Prenatal Diagnosis: A Directive Approach to Genetic Counseling Using Decision Analysis

The decision which prospective parents face concerning mid-trimester amniocentesis for prenatal diagnosis was examined by decision analysis. The prospective parents'' decision depends on the likelihood of the birth of a child affected by a genetic disorder, the risk of amniocentesis, and the probability that the diagnoses provided by the amniocentesis will be correct. The couple''s decision must also depend on their attitudes toward each possible outcome. The likelihoods of the outcomes can be obtained from appropriate medical consultation, while the relative costs or burdens of the outcomes should be obtained from the prospective parents. A truly informed decision for this couple can then be formulated from these probabilities and values, thus allowing genetic counseling to be more directive. The technique is illustrated for the prenatal diagnosis of Down''s syndrome, meningomyelocele, and Duchenne muscular dystrophy.     

When (if ever) may doctors discuss religion with their patients?

There is ongoing debate within the bioethics literature regarding to what extent (if any) it is ethically justifiable for doctors to engage in religious discussion with their patients, in cases where patients cite religious considerations as influencing their medical decision-making. In this paper, we concede that certain forms of religious discussion between doctors and patients are morally permissible (though not necessarily morally obligatory), insofar as patients’ religious beliefs may comprise an important part of their overall wellbeing and can influence their medical decisions. However, we argue that it is not morally permissible for doctors to engage in substantive religious discussion with their patients, beyond simply inquiring about the patient's values (which may include their religious values) or referring patients to a chaplain or religious figure for further discussion. In support of this claim, we put forward two key arguments which have remained relatively unaddressed in the current debate. First, we argue that it is not practical for doctors to engage in substantive religious discussion with patients, and hence it cannot be morally obligatory for them to do so. Second, we argue that, while doctors might have a professional duty to ensure that their patient's religious interests (if any) are addressed, this does not entail that doctors themselves are the ones who should directly address these interests. Along the way, we anticipate and respond to some possible objections to these two key arguments.     

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.