Ethical use of covert videoing techniques in detecting Munchausen syndrome by proxy.

Munchausen syndrome by proxy is an especially malignant form of child abuse in which the carer (usually the mother) fabricates or exacerbates illness in the child to obtain medical attention. It can result in serious illness and even death of the child and it is difficult to detect. Some investigators have used video to monitor the carer''s interaction with the child without obtaining consent--covert videoing. The technique presents several ethical problems, including exposure of the child to further abuse and a breach of trust between carer, child, and the professionals. Although covert videoing can be justified in restricted circumstances, new abuse procedures under the Children Act now seem to make its use unethical in most cases. Sufficient evidence should mostly be obtained from separation of the child and carer or videoing with consent to enable action to be taken to protect the child under an assessment order. If the new statutory instruments prove ineffective in Munchausen syndrome by proxy covert videoing may need to be re-evaluated.     

Malnutrition in infants receiving cult diets: a form of child abuse.

Severe nutritional disorders, including kwashiorkor, marasmus, and rickets, were seen in four children and were due to parental food faddism, which should perhaps be regarded as a form of child abuse. All disorders were corrected with more normal diets and vitamin supplements. In view of the potentially serious consequences of restricted diets being fed to children, families at risk should be identified and acceptable nutritional advice given. When children are found to be suffering from undernutrition due to parental food faddism a court order will normally be a necessary step in providing adequate treatment and supervision.     

Use or abuse of bioinformatic tools: a response to Samach

In a recent paper, we described for the first time the effects of fruit on the expression of putative homologues of genes involved in flowering pathways. It was our aim to provide insight into the molecular mechanisms underlying alternate bearing in citrus. However, a bioinformatics-based critique of our and other related papers has been given by Samach in the preceding Viewpoint article in this issue of Annals of Botany. The use of certain bioinformatic tools in a context of structural rather than functional genomics can cast doubts about the veracity of a large amount of data published in recent years. In this response, the contentions raised by Samach are analysed, and rebuttals of his criticisms are presented.     

Ethical considerations in African traditional medicine: a response to Nyika

Like other so-called 'parallel' practices in medicine, traditional medicine (TM) does not avoid criticism or even rejection. Nyika's article 'Ethical and Regulatory Issues Surrounding African Traditional Medicine in the Context of HIV/AIDS' looks at some of the issues from a traditional Western ethical perspective and suggests that it should be rejected. I respond to this article agreeing with Nyika's three major criticisms: lack of informed consent, confidentiality and paternalism. However, as traditional healers are consulted by over 70% of South Africans before any other type of healthcare professional, a blanket negation of TM is not possible, nor is it politically feasible. A pragmatic approach would be to work within the current structures for positive change. I point out that, as all cultural practices do, TM will change over time. Yet, until some regulations and change occur, the problem of harm to patients remains a major concern.     

Use of a long acting somatostatin analogue in controlling life threatening ileostomy diarrhoea.

A woman presented with persistent ileostomy diarrhoea unresponsive to conventional drug treatment and necessitating parenteral nutrition. Output was four to six litres of watery fluid per 24 hours while she was receiving oral nutrition and two to three litres when she was starved. Treatment with a long acting analogue of somatostatin (50 micrograms subcutaneously every 12 hours) reduced the ileostomy output to 2.0-2.5 litres/24 hours with an oral diet and the effluent became semiformed. Parenteral fluids could be stopped. Somatostatin may have a role in the treatment of secretory diarrhoea, but prospective controlled trials are necessary.     

Adults with a history of child sexual abuse: evaluation of a pilot therapy service.

OBJECTIVE--To evaluate a pilot service offering therapy specifically to adults with a history of child sexual abuse. DESIGN--Questionnaire survey. SETTING--Specialised therapy unit, Breakfree, which offers care, therapy, and support. SUBJECTS--116 clients presenting to the service who were offered therapy. MAIN OUTCOME MEASURES--Scores from three psychological questionnaires--the social activities and distress scale, the general health questionnaire, and the delusions, symptoms, and states inventory--and from questionnaires about the clients'' abuse, previous use of health services, and opinion of the Breakfree service. RESULTS--Clients had received previous help from health services and other agencies without apparent effect; they were highly distressed according to their psychological scores; and they were very frequent users of the health services. The clients showed significant improvement in their psychological scores (Wilcoxon''s matched pairs signed ranks test): social activities and distress scale, z = -3.3, P = 0.001; general health questionnaire, z = -5.8, P < 0.00001; delusions, symptoms, and states inventory, z = -4.8, P < 0.00001). This was most pronounced for those who had completed therapy by the end of the study. Whereas 82/88 clients had a score for the general health questionnaire that indicated clinical distress at the start, only 28/58 did so at the end of the study (only 17/35 among those who had finished therapy). CONCLUSIONS--This group of adults with a history of child sexual abuse were highly disturbed and previous high users of the health service. The specialist service Breakfree was effective in the short term and, if the benefits are sustained, would yield a net cost saving to the health service.     

Essential properties and the right to life: a response to Lee

In 'The Pro-Life Argument from Substantial Identity: A Defence', Patrick Lee argues that the right to life is an essential property of those that possess it. On his view, the right arises from one's 'basic' or 'natural' capacity for higher mental functions: since human organisms have this capacity essentially, they have a right to life essentially. Lee criticises an alternative view, on which the right to life arises from one's 'developed' capacity for higher mental functions (or development of some other accidental property). I argue that his criticisms of this alternative view are misguided or self-defeating, and that there are good reasons to hold we have a right to life accidentally rather than essentially.     

Clinical evaluation and use of urine screening for drug abuse.

Urine drug screening is indicated to evaluate patients who show mental status or behavioral changes and to monitor the abstinence of drug abusers. The appropriate timing for collecting urine specimens may vary depending on the suspected drug of abuse and on laboratory factors. Laboratories use a variety of techniques to do urine screens, and these must be understood by clinicians ordering the screens to interpret results correctly. In treating drug-abusing patients, clinicians must apply structured reinforcement in conjunction with urine screen results to aid patients in achieving abstinence.