影响上海市临床医师对基因技术与生命伦理认知的因素

通过上海市临床医师问卷调查,应用Logistic模型分析临床医师对基因技术与生命伦理认知的影响因素。结果显示,临床医师的性别、年龄、学历和职称等人口学因素主要影响对基因技术优势的认知,基因工作经历、伦理委员会任职经历、对伦理与相关法规的知晓度主要影响对基因技术风险的认知。建议加强基因伦理与相关法规教育,重视部属或市属综合性医院基因技术研究与应用的管理。     

ATTITUDES TOWARDS EUTHANASIA AND ASSISTED SUICIDE: A COMPARISON BETWEEN PSYCHIATRISTS AND OTHER PHYSICIANS

Euthanasia and physician assisted‐suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician‐assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables.     

THE NUMBER AND DISTRIBUTION OF PHYSICIANS IN CALIFORNIA

The ratio of physicians to general population in California has been approximately the same for many years, the influx of physicians having kept pace with the population trend.For many years California has licensed more physicians than any other state.The five medical schools in this state have been increasing the number of candidates admitted to the freshman class. Attempts are being made to increase the number of medical schools in this state to seven in anticipation of the future growth and medical needs of the population.The heaviest concentration of physicians is as always in the thickly populated areas as determined by the population physician ratio.A study of the detailed statistics presented in this paper should be of interest to all California physicians.     

The other side of trust in health care: prescribing drugs with the potential for abuse

Defining a nonpaternalistic yet achievable form of trust in medicine in an era of simultaneous patient empowerment and institutional control has been and remains an important task of bioethics. The 'crisis of trust' in medicine has been viewed mainly as the problem of getting patients to trust their health care providers, especially physicians. However, since paradigmatic cases of trust are mutual, bioethicists must pay more attention to physician trust in patients. A physician's view of the reasonableness of trust in a particular patient is affected not just by his or her relationship with that patient, but also by what is going on institutionally, professionally, legally and politically with regard to a given treatment or intervention. Since general moral principles are insufficient in determining the moral value and reasonableness of trust in particular instances, I discuss in detail the role of trust and distrust in the specific case of treating patients with medications implicated in drug abuse. I conclude that it is important to become aware, first, of the clinical significance of physician trust and distrust in patients, and second, of the many factors which inform both of these moral attitudes. These two claims together suggest that a central, but overlooked, virtue of medical practice is reflective, context-responsive trust in patients.     

Was bioethics founded on historical and conceptual mistakes about medical paternalism?

Bioethics has a founding story in which medical paternalism, the interference with the autonomy of patients for their own clinical benefit, was an accepted ethical norm in the history of Western medical ethics and was widespread in clinical practice until bioethics changed the ethical norms and practice of medicine. In this paper I show that the founding story of bioethics misreads major texts in the history of Western medical ethics. I also show that a major source for empirical claims about the widespread practice of medical paternalism has been misread. I then show that that bioethics based on its founding story deprofessionalizes medical ethics. The result leaves the sick exposed to the predatory power of medical practitioners and healthcare organizations with only their autonomy-based rights to non-interference, expressed in contracts, to protect them. The sick are stripped of the protection afforded by a professional, fiduciary relationship of physicians to their patients. Bioethics based on its founding story reverts to the older model of a contractual relationship between the sick and medical practitioners not worthy of intellectual or moral trust (because such trust cannot be generated by what I call 'deprofessionalizing bioethics'). On closer examination, bioethics based on its founding story, ironically, eliminates paternalism as a moral category in bioethics, thus causing bioethics to collapse on itself because it denies one of the necessary conditions for medical paternalism. Bioethics based on its founding story should be abandoned.     

THE FUTURE OF BIOETHICS: THREE DOGMAS AND A CUP OF HEMLOCK

In this paper I argue that bioethics is in crisis and that it will not have a future unless it begins to embrace a more Socratic approach to its leading assumptions. The absence of a critical and sceptical spirit has resulted in little more than a dominant ideology. I focus on three key issues. First, that too often bioethics collapses into medical ethics. Second, that medical ethics itself is beset by a lack of self‐reflection that I characterize here as a commitment to three dogmas. Third, I offer a more positive perspective by suggesting how bioethics may benefit from looking towards public health ethics as a new source of inspiration and direction.     

The impact of provider flexibility and capacity allocation on the performance of primary care practices

The two important but often conflicting metrics for any primary care practice are: (1) Timely Access and (2) Patient-physician Continuity. Timely access focuses on the ability of a patient to get access to a physician (or provider, in general) as soon as possible. Patient–physician continuity refers to building a strong or permanent relationship between a patient and a specific physician by maximizing patient visits to that physician. In the past decade, a new paradigm called advanced access or open access has been adopted by practices nationwide to encourage physicians to “do today’s work today.” However, most clinics still reserve pre-scheduled slots for long lead-time appointments due to patient preference and clinical necessities. Therefore, an important problem for clinics is how to optimally manage and allocate limited physician capacities as much as possible to meet the two types of demand—pre-scheduled (non-urgent) and open access (urgent, as perceived by the patient)—while simultaneously maximizing timely access and patient–physician continuity. In this study we adapt ideas of manufacturing process flexibility to capacity management in a primary care practice. Flexibility refers to the ability of a primary care physician to see patients of other physicians. We develop generalizable analytical algorithms for capacity allocation for an individual physician and a two physician practice. For multi-physician practices, we use a two-stage stochastic integer programming approach to investigate the value of flexibility. We find that flexibility has the greatest benefit when system workload is balanced, when the physicians have unequal workloads, and when the number of physicians in the practice increases. We also find that partial flexibility, which restricts the number of physicians a patient sees and thereby promotes continuity, simultaneously succeeds in providing high levels of timely access.     

FACTS AND FALLACIES ABOUT GONORRHEA AND SYPHILIS

The limitations and special usefulness of clinical and laboratory diagnostic techniques in the diagnosis of gonorrhea are poorly understood and utilized by the average practitioner today. Most physicians and clinics, lulled by complacency or lack of ancillary aid in the area of diagnosis, proceed by measures based in many instances upon past fallacy rather than upon the facts recently developed by research in this disease. The same circumstances apply concerning treatment and management of this disease, particularly in females.All physicians are potentially capable of giving excellent treatment for syphilis today. The problem is to properly diagnose the disease, manage the patient and deal with the source. Looming large in the area of diagnosis is the interpretation of serologic tests for syphilis. No serologic test diagnoses syphilis, but rather gives information as to the immunologic status of the the patient in relation to reagin and treponemal antibodies. None of the antibodies measured in these tests are absolutely specific for syphilis alone.There is no substitute for a well-informed physician, who knows his patient, to relate and interpret even the best of treponemal serologic tests.     

Monitoring Sub-Saharan African Physician Migration and Recruitment Post-Adoption of the WHO Code of Practice: Temporal and Geographic Patterns in the United States

Data monitoring is a key recommendation of the WHO Global Code of Practice on the International Recruitment of Health Personnel, a global framework adopted in May 2010 to address health workforce retention in resource-limited countries and the ethics of international migration. Using data on African-born and African-educated physicians in the 2013 American Medical Association Physician Masterfile (AMA Masterfile), we monitored Sub-Saharan African (SSA) physician recruitment into the physician workforce of the United States (US) post-adoption of the WHO Code of Practice. From the observed data, we projected to 2015 with linear regression, and we mapped migrant physicians’ locations using GPS Visualizer and ArcGIS. The 2013 AMA Masterfile identified 11,787 active SSA-origin physicians, representing barely 1.3% (11,787/940,456) of the 2013 US physician workforce, but exceeding the total number of physicians reported by WHO in 34 SSA countries (N = 11,519). We estimated that 15.7% (1,849/11,787) entered the US physician workforce after the Code of Practice was adopted. Compared to pre-Code estimates from 2002 (N = 7,830) and 2010 (N = 9,938), the annual admission rate of SSA émigrés into the US physician workforce is increasing. This increase is due in large part to the growing number of SSA-born physicians attending medical schools outside SSA, representing a trend towards younger migrants. Projection estimates suggest that there will be 12,846 SSA migrant physicians in the US physician workforce in 2015, and over 2,900 of them will be post-Code recruits. Most SSA migrant physicians are locating to large urban US areas where physician densities are already the highest. The Code of Practice has not slowed the SSA-to-US physician migration. To stem the physician “brain drain”, it is essential to incentivize professional practice in SSA and diminish the appeal of US migration with bolder interventions targeting primarily early-career (age ≤ 35) SSA physicians.     

Forecasting Japan's Physician Shortage in 2035 as the First Full-Fledged Aged Society

Introduction

Japan is rapidly becoming a full-fledged aged society, and physician shortage is a significant concern. The Japanese government has increased the number of medical school enrollments since 2008, but some researchers warn that this increase could lead to physician surplus in the future. It is unknown how many physicians will be required to accommodate future healthcare needs.

Materials and Methods

We simulated changes in age/sex composition of the population, fatalities (the number of fatalities for the consecutive five years), and number of physicians from 2010 to 2035. Two indicators were defined: fatalities per physician and fatalities by physician working hour, based on the data of the working hours of physicians for each tuple of sex and age groups. We estimated the necessary number of physicians in 2035 and the number of new physicians to maintain the indicator levels in 2010.

Results

The number of physicians per 1,000 population is predicted to rise from 2·00 in 2010 to 3·14 in 2035. The number of physicians aged 60 years or older is expected to increase from 55,375 (20% of physicians) to 141,711 (36%). In 2010 and 2035, fatalities per physician were 23·1 and 24·0 for the total population, and 13·9 and 19·2 for 75 years or older, respectively. Fatalities per physician working hour are predicted to rise from 0·128 to 0·138. If working hours are limited to 48 hours per week in 2035, the number of fatalities per physician working hour is expected to be 0·196, and the number of new physicians must be increased by 53% over the current pace.

Discussion

The number of physicians per population continues to rise, but the estimated supply will not fulfill the demand for healthcare in the aging society. Strategies to increase the number of physicians and improve working conditions are urgently needed.     

An Ontario solution to medically underserviced areas: evaluation of an ongoing program.

In 1969 a program was established to place physicians in area of Ontario deemed to be medically underserviced. The main features of the program are area designation, physician subsidies, student bursaries, community participation and physician recruitment. From 1969 to March 1973, 162 communities were designated as underserviced and 196 physicians placed. As the program became active the rate of increase of numbers of physicians practising in northern rural areas (population, less than 15 000) increased sharply, exceeding that for the entire province. Fifty-three percent of bursaried students have honoured their commitment. Seventy-five communities have built modern medical centres that have been an important factor in attracting physicians. Still unanswered are whether the physicians will stay and whether the health of the population will be improved.     

Beyond the Sterility of a Distinct African Bioethics: Addressing the Conceptual Bioethics Lag in Africa

In the current debate on the future of bioethics in Africa, several authors have argued for a distinct communitarian African bioethics that can counter the dominancy of Western atomistic principlism in contemporary bioethics. In this article I examine this rather contentious argument and evaluate its validity and viability. Firstly, I trace the contextual origins of contemporary bioethics and highlight the rise and dominance of principlism. I particularly note that principlism was premised on a content‐thin notion of the common morality that is in need of enrichment. I also contend that bioethics is essentially two‐dimensional, being both conceptual and empirical, and indicate the lag in Africa with regard to conceptual bioethics. I then appeal for authentic engagement by 1) African health care professionals, 2) African health care training institutions, 3) Africa's bioethics development partners, and 4) African bioethicists and philosophers, towards addressing this critical lag. I underline the need to maintain the essential universality of bioethics as a discipline. I particularly argue against the pursuit of a distinct African bioethics, as it appears to be rooted in sterile African ethno‐philosophy. Rather, African bioethicists and philosophers would do well to elucidate the universalisability of insights from traditional African thought, for the benefit of bioethics as a whole. Thus we must engage beyond the sterility of a distinct African bioethics ‐ authentically reflecting on the essentially universal contemporary bioethical concerns ‐ to effectively articulate a viable trajectory for bioethics in Africa.     

FROM INTEGRATIVE BIOETHICS TO PSEUDOSCIENCE

Integrative bioethics is a brand of bioethics conceived and propagated by a group of Croatian philosophers and other scholars. This article discusses and shows that the approach encounters several serious difficulties. In criticizing certain standard views on bioethics and in presenting their own, the advocates of integrative bioethics fall into various conceptual confusions and inconsistencies. Although presented as a project that promises to deal with moral dilemmas created by modern science and technology, integrative bioethics does not contain the slightest normativity or action‐guiding capacity. Portrayed as a scientific and interdisciplinary enterprise, integrative bioethics displays a large number of pseudoscientific features that throw into doubt its overall credibility.     

Genetic Counseling—A Health Department Service to Physicians

Questions about inheritance in all kinds of diseases and defects are commonly asked of nearly all physicians. In attempting to answer these questions, however, the physician is often hampered by lack of formal instruction in clinical genetics.Since the health department, if it is to carry out its epidemiologic function, must be as concerned over the increasing identification of genetic agents in disease as it is and has been over environmental disease agents, it should come to represent a source of assistance not now generally available to the physician. In short, as it carries out those activities by which its store of general genetic information is increased, and until other sources of genetic consultation become reasonably available, the health department can be of real service to physicians as a resource to which they may turn for help when dealing with families wanting genetic information.Such a service has been provided experimentally for the last two years by the Contra Costa County Health Department.This program calls for the taking of family pedigrees by public health nurses on families with questions of a genetic nature who are health department clients and on families who are referred by their private physicians for this service. An interpretation of each pedigree is made by the department''s physician in charge of the program and submitted to the family''s physician for his use in counseling the family. Evidence to date suggests the process can be a highly useful service to the practitioner and his patient.     

Is deleting the digital rectal examination a good idea?

Although the supply of physicians in the United States has doubled during the past 20 years, there is still disagreement as to whether we currently have or should expect a significant surplus of physicians. The evidence suggests that despite the rapid expansion in the pool of available physicians, serious physician shortages persist for certain rural populations, ethnic and occupational groups, and other medically disadvantaged segments of the population. Medical students'' declining interest in rural practice and primary care specialties suggests that problems of geographic and specialty maldistribution may worsen despite a rising population of physicians. It is unlikely that a significant physician surplus will develop unless there is a conscious attempt to limit the proportion of national wealth expended on medical care. Pockets of shortage can be reduced by broadening the availability of health insurance, lessening large income disparities between different specialties, changing the way teaching institutions are reimbursed for their training costs, and supporting direct governmental service programs such as the National Health Service Corps.     

Een cultuurvergelijkend onderzoek naar behandelbesluiten van artsen met betrekking tot demente verpleeghuispatiënten met pneumonie

A cross-cultural study of physician treatment decisions for demented nursing home patients who develop pneumoniaThis qualitative interview study in the Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and the Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families’ wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

A cross-cultural study of physician treatment decisions in relation to demented nursing home patients who develop pneumonia

This qualitative interview study in The Netherlands and North Carolina (US) found that physician treatment decisions are influenced by contextual differences in physician training and healthcare delivery in the US and The Netherlands. Dutch physicians treating nursing home residents with dementia and pneumonia assumed active, primary responsibility for treatment decisions while US physicians were more passive and deferential to family preferences, even in cases where they considered the families' wishes inappropriate. Dutch physicians knew their patients well and made treatment decisions based on what they perceived was in the best interest of the patient while US physicians reported limited knowledge of their nursing home patients due to a lack of contact time. Efforts to improve care for patients with poor quality of life who lack decision-making capacity must consider the context of societal values, physician training, and the processes by which physicians negotiate patient and family preferences.     

Discrimination against gay,lesbian and bisexual family physicians by patients

BACKGROUND: Discrimination against gay, lesbian and bisexual (GLB) patients by physicians is well known. Discrimination against GLB physicians by their colleagues and superiors is also well known and includes harassment, denial of positions and refusal to refer patients to them. The purpose of this study was to identify and quantify the attitudes of patients toward GLB physicians. METHODS: Telephone interviews were conducted with 500 randomly selected people living in a large urban Canadian city. Subjects were asked if they would refuse to see a GLB family physician and, if so, to describe the reason why. They were then given a choice of 6 reasons obtained from consultation with 10 GLB people and 10 heterosexual people. RESULTS: Of the 500 subjects 346 (69.2%) were reached and agreed to participate. Of the 346 respondents 41 (11.8%) stated that they would refuse to see a GLB family physician. The 2 most common reasons for the discrimination (prevalence rate more than 50%) were that GLB physicians would be incompetent and the respondent would feel "uncomfortable" having a GLB physician. Although more male than female respondents discriminated against GLB physicians, the difference was not statistically significant. The proportion of male and female respondents who discriminated increased with age (p < 0.01). CONCLUSIONS: The observed prevalence of patient discrimination against GLB family physicians is significant. The results suggest that the discrimination is based on emotional reasons and is not related to such factors as misinformation about STDs and fear of being thought of sexually. Therefore, educational efforts should be directed against general perceptions of homosexuality rather than targeting specific medical concerns.     

PRIVACY, THE INDIVIDUAL AND GENETIC INFORMATION: A BUDDHIST PERSPECTIVE

Bioinformatics is a new field of study whose ethical implications involve a combination of bioethics, computer ethics and information ethics. This paper is an attempt to view some of these implications from the perspective of Buddhism. Privacy is a central concern in both computer/information ethics and bioethics, and with information technology being increasingly utilized to process biological and genetic data, the issue has become even more pronounced. Traditionally, privacy presupposes the individual self but as Buddhism does away with the ultimate conception of an individual self, it has to find a way to analyse and justify privacy that does not presuppose such a self. It does this through a pragmatic conception that does not depend on a positing of the substantial self, which is then found to be unnecessary for an effective protection of privacy. As it may be possible one day to link genetic data to individuals, the Buddhist conception perhaps offers a more flexible approach, as what is considered to be integral to an individual person is not fixed in objectivity but depends on convention.     

Lessons from Queer Bioethics: A Response to Timothy F. Murphy

‘Bioethics still has important work to do in helping to secure status equality for LGBT people’ writes Timothy F. Murphy in a recent Bioethics editorial. The focus of his piece, however, is much narrower than human rights, medical care for LGBT people, or ending the HIV/AIDS pandemic. Rather, he is primarily concerned with sexuality and gender identity, and the medical intersections thereof (i.e. DSM diagnosis; access to SrS or ARTs). It is the objective of this response to provide an alternate account of bioethics from a Queer perspective. I will situate Queer bioethics within Queer studies, and offer three ‘lessons’ that bioethics can derive from this perspective. These are not definitive rules for Queer bioethics, since it is a field which fundamentally opposes categorizations, favoring pastiche over principles. These lessons are exploratory examples, which both complement and contradict LGBT bioethics. My latter two lessons – on environmental bioethics and disability – overlap with some of Murphy's concerns, as well as other conceptions of LGBT bioethics. However, the first lesson takes an antithetical stance to Murphy's primary focus by resisting all forms of heteroconformity and disavowing reproduction as consonant with Queer objectives and theory. The first lesson, which doubles as a primer in Queer theory, does heavy philosophical lifting for the remainder of the essay. This response to Timothy F. Murphy, whose work is certainly a legacy in bioethics, reveals the multiplicity of discourses in LGBT/Queer studies, many of which are advantageous – even essential – to other disciplines like bioethics.