A Proposed Set of Ethical Practice Guidelines in the Assessment and Treatment of Pelvic Floor Disorders

The treatment of pelvic floor disorders using biofeedback, behavioral therapies, and other applied psychophysiological treatments has been well documented as effective. Practitioners must take due care to ensure that they practice within the boundaries of what is common practice for their discipline and within the scope of practice allowed by their professional license as outlined by the appropriate state licensing law(s), the ethical principles and practice guidelines and standards for their discipline, and those of the Association of Applied Psychophysiology and Biofeedback if using a biofeedback assessment or treatment. Being competent to provide a particular treatment does not necessarily make it legal and/or ethical. This paper provides a set of recommended practice guidelines for use in the assessment and treatment of pelvic floor disorders. Please note that they have not at this time been endorsed as an official position of the Association of Applied Psychophysiology and Biofeedback or any other professional organization.     

Managing ethical challenges around misattributed parentage within the clinical context: Insights from an African moral theory

This study argues the thesis that a set of guidelines ‐ firmly rooted in a particular interpretation of African moral theory, specifically, Ubuntu – will do a better job than current medical ethics frameworks, in addressing ethical challenges around misattributed parentage within the clinical context. Incidental information such as information with significant personal/health implications raises unique challenges for medical professionals. For example, withholding information of misattributed paternity accidentally discovered in clinical interactions may be seen by a patient as a violation of his/her right‐to‐know. Contrarily, disclosure where a patient has not requested information – or where establishing paternity is not the purpose of clinical visit/interaction – may be taken by the patient as a violation of his/her right ‘not‐to‐know’. Resolving these challenges remain a herculean task. African moral theory contains an under‐emphasized value for addressing such ethical challenges around misattributed parentage in the field of transplant. I seek to contribute this knowledge; and enhance clinician‐patient relationship. This study builds off three completed systematic reviews, which aimed to answer the following questions: “what are the ethical challenges regarding information health professionals face within the clinical contest?” and “what core aspects (or common themes) of Ubuntu can be identified in existing literature describing the same?” In this present study, I applied the definition of Ubuntu which captures the core aspects of the theory in ethical literature on the same, to address ethical issues around unsought information of misattributed parentage in the field of transplant.     

The Ethical and Legal Framework for the Decision Not to Resuscitate

Practicing physicians are frequently faced with the question of whether or not to institute cardiopulmonary resuscitation in case of cardiac or respiratory arrest in a patient in hospital. Medical training has usually not included any systematic analysis of this issue from either an ethical or a legal standpoint. Many physicians may be unaware that ethical and legal principles, as well as professional guidelines, exist to guide such decision making. In practice, physicians make this decision without the benefit of training in ethical analysis. The problem is especially acute in teaching hospitals when young physicians unacquainted with formal ethics or the law must often make decisions emergently. Studies show some discrepancy between ethical and legal principles and the actual decision making by physicians. For this reason, we recommend an approach that will enable physicians to make and implement decisions not to resuscitate that are consistent with current ethical and legal standards.     

Ethical beliefs and practices of AAPB members

Ethical codes and principles and laws govern the behavior of health-care professionals. Yet, the impact that ethical codes and laws have on the actual moral behaviors of health-care professionals is relatively unknown. A survey on the ethical beliefs and practices of health-care professionals was sent to the United States membership of the Association for Applied Psychophysiology and Biofeedback. AAPB's heterogeneous membership offers a unique opportunity to compare the ethical beliefs and behaviors of professionals across various health-care professions, educational levels, licensure and certification statuses, age, years in practice, and gender. The survey examined the respondents' ethical beliefs and practices in the domains of confidentiality, dual relationships, and professional practice. Five hundred thirty-six surveys were returned completed. The results of the survey indicate that all respondents have substantially the same reported ethical beliefs and practices across the three domains. There were no statistically significant differences between the reported ethical beliefs or practices when compared across disciplines, educational levels, licensure or certification statuses, age, or years in practice. Statistically significant gender differences were found.     

道德规范与动物学

道德规范教育如今已经提升到了专业的水平。因此在专业领域里 (例如工程学和医学 ) ,道德规范教育应作为必修课程。但至今很多理科课程仍没有把它列为必修课。这就给我们提出了一个疑问 :理科是专业课程吗 ?如果是的话 ,那么科学家例如动物学家需不需要熟悉他们职责范围内的道德准则和尺度呢 ?动物学家对医学上暴露的一些问题很敏感———包括我们怎样对待动物以及我们怎样或者是否开展基因工程。但是从道德观念上来看 ,道德规范教育的实行是比这两件事更实际的。这篇论文就以上观点进行了进一步的论述 ,并且对把道德规范教育加入理科课程的需求和可能性做了评估。在现实社会里 ,动物科学家是被敬重的专业人士。他们每天面对着许多极可能影响我们生活环境的决策。有鉴于此 ,动物科学家必需掌握道德规范的标准 ,并且有能力做出与此相符合的决策。这才能使我们在动物学的教学过程中确保动物学家持续稳定的专业发展方向     

A discussion of the pediatric clinical guidelines

It is evident from both the AAO and AOA guideline position statements that a visual and eye examination is essential within the first few months of life. Thus, both groups recognize the importance of examining infants within the critical period of visual development. The adequacy of testing performed by lay screeners or primary care physicians to rule out all visual disorders is highly questionable. Photorefraction is a promising screening technique, but as yet needs to be validated by further study. The only adequate means of detecting early vision and eye disorders is through examination by an eye care professional. However, this conclusion immediately underscores the need for eye care professionals prepared to examine very young children. The primary eye care of children should not be considered the responsibility of a minority of ‘pediatric specialists’. Clinical techniques are currently available which would enable all practitioners to evaluate children in the first few months of life, a critical time for an initial evaluation. We believe it is essential for all eye care professionals to be trained in these basics of eye and vision care. The need for widespread pediatric training should be addressed when reviewing the clinical education of interns.Both guidelines yield valuable guidance and background information for the pediatric examination. The AOA guideline is more complete, and includes a useful bibliography. It is well researched, and should be particularly helpful to the newer practitioner. The AAO guideline provides less detailed guidance, and omits some newer and important examination techniques, such as preferential looking for visual acuity and spray application for administering drugs.The AOA and AAO pediatric clinical practice guidelines can serve as helpful examination tutorials for the practitioner. The guidelines do not address the decision making process of diagnosis and treatment options. The references included in the documents can help fill in the gaps, but would require a substantial commitment of time for research and study. We see the need for additional guidelines to help guide the process of difficult decision-making when the patient is ‘in the chair’. The publication of such second generation documents would serve eye care professionals in the total case management of the pediatric patient.     

Current trends in teaching ethics of healthcare practices

The unprecedented progress in bio-medical sciences and technology during the last few decades has resulted in great transformations in the concepts of health and disease, health systems and healthcare organisation and practices. Those changes have been accompanied by the emergence of a broad range of ethical dilemmas that confront health professionals more frequently. The classical Hippocratic ethical principles, though still retaining their relevance and validity, have become insufficiently adequate in an increasing range of problems and situations. Healthcare that has been practised for centuries on the basis of a direct doctor-patient relationship has been increasingly transformed into a more complex process integrating the health-team, the patient (healthcare seeker) and the community. Systematic review of the specialised literatures revealed that Healthcare Ethics education has become a basic requirement for any training programme for health professionals, and should cover the different stages of undergraduate, postgraduate and continuing education. Both theoretical foundations and practical skills are required for the appropriate ethical reasoning, ethical attitude and decision-making abilities. There is growing evidence that physicians' professional and moral development is not only determined by the formal curriculum of ethics; rather more, it is determined by the moral environment of the professional practice, the 'hidden curriculum' which deserves serious consideration by medical education.     

Biofeedback Via Telehealth: A New Frontier for Applied Psychophysiology

Psychophysiological diagnostic and therapeutic methods, to include biofeedback, have been found to be empirically effective in the treatment of a variety of physical disorders. In many areas of the country, however, certified biofeedback practitioners are not well distributed, limiting patient access to this treatment modality. Psychologists at Tripler Army Medical Center have pioneered efforts to develop and provide these needed services via a telehealth venue. Such capability significantly improves access to care, particularly for patient's located at considerable distance from the provider. As the telecommunications infrastructure in rural and remote areas is often quite basic, such a system must be capable of operating within these limited parameters. The system developed by the authors provides real-time video and audio interactivity and allows the therapist to monitor and control biofeedback equipment located at the remote site. The authors discuss the clinical applications, the technology, and relevant practical and ethical issues.     

Single-case designs and clinical biofeedback experimentation

Rigorous evaluation of the effects of biofeedback with clinical populations is necessary, but practical problems often preclude utilization of between-groups experimental designs involving large numbers of clients with clinically relevant problems. Single-case experimental designs provide a viable alternative for answering most research questions. In addition, single-case designs possess several distinct advantages for biofeedback research, including a focus on clinical significance, the use of variability as data not error, unique procedures for establishing generality of findings, and an ability to deal with ethical concerns in clinical research. Basic procedures in the use of single-case experimental designs are described and illustrations in clinical biofeedback research are provided.     

Genetic predictive testing for bowel cancer predisposition: the impact on the individual.

When considering the impact of a genetic diagnosis of hereditary predisposition to colon cancer, there are many similarities to other predictive genetic tests, but also many differences. The development and availability of such genetic diagnoses, and the concept of testing being linked to effective prevention, have advanced rapidly, opening up not only unique opportunities but also unique psychosocial situations for the affected families-and unusual ethical issues for the professional. Compared to a diagnosis of sporadic colorectal cancer for a patient, hereditary colorectal cancer requires an understanding of genetics, heredity, and the attendant mathematics of risk calculation, but, most importantly, there must be a belief that it is possible to remain healthy whilst having an increased risk. This paper outlines the possible impact of a genetic diagnosis of hereditary non-polyposis colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP) on both the individual and the family and concludes that genetic testing should be accompanied by genetic counseling. Relevant ethical issues are also introduced, with the opinion presented suggesting that if primary considerations are always for the individual rather than the family or society, then unethical or eugenic decisions are likely to be avoided.     

An interdisciplinary approach to the treatment of a hyperfunctional voice disorder

The purpose of this article is to describe the treatment of a 45-year-old male with a hyperfunctional voice disorder by a biofeedback therapist and a speech-language pathologist. The interdisciplinary approach to the treatment of this voice disorder involved the combined use of traditional voice therapy techniques and EMG biofeedback procedures together with cognitive behavioral therapy. Voice therapy was facilitated through the use of a computer-based, speech-monitoring system. The remediation of this voice disorder was attributed to the collaborative efforts of two professionals representing diverse professional training and treatment protocols. The results showed reductions in muscle activity in the infrahyoid and laryngeal areas as well as improved use of proper breathing and voicing onset behaviors. Follow-up at 10 and 15 months posttreatment intervals indicated that the client had retained all target voice skills and the tension reduction/biofeedback skills. Results suggest that interdisciplinary, collaborative efforts using biofeedback and voice therapy can prove beneficial in the treatment of hyperfunctional voice disorders.Note: Neither author has been compensated in any way for the use of the CAFET System nor does either have any financial interest in the company.     

A Costly Separation Between Withdrawing and Withholding Treatment in Intensive Care

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life‐sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non‐equivalence, and find only relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non‐equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time‐limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions.     

DOES PROFESSIONAL AUTONOMY PROTECT MEDICAL FUTILITY JUDGMENTS?

Despite substantial controversy, the use of futility judgments in medicine is quite common, and has been backed by the implementation of hospital policies and professional guidelines on medical futility. The controversy arises when health care professionals (HCPs) consider a treatment futile which patients or families believe to be worthwhile: should HCPs be free to refuse treatments in such a case, or be required to provide them? Most physicians seem convinced that professional autonomy protects them from being forced to provide treatments they judge medically futile, given the lack of patient benefit as well as the waste of medical resources involved. The argument from professional autonomy has been presented in a number of articles, but it has not been subjected to much critical scrutiny. In this paper I distinguish three versions of the argument: 1) that each physician should be free to exercise his or her own medical judgment; 2) that the medical profession as a whole may provide futility standards to govern the practice of its members; and 3) that the moral integrity of each physician serves as a limit to treatment demands. I maintain that none of these versions succeeds in overcoming the standard objection that futility determinations involve value judgments best left to the patients, their designated surrogates, or their families. Nor do resource considerations change this fact, since they should not influence the properly patient‐centered judgment about futility.     

Most Important Factors for the Implementation of Shared Decision Making in Sciatica Care: Ranking among Professionals and Patients

Introduction

Due to the increasing specialization of medical professionals, patients are treated by multiple disciplines. To ensure that delivered care is patient-centered, it is crucial that professionals and the patient together decide on treatment (shared decision making (SDM)). However, it is not known how SDM should be integrated in multidisciplinary practice. This study determines the most important factors for SDM implementation in sciatica care, as it is known that a prior inventory of factors is crucial to develop a successful implementation strategy.

Methods

246 professionals (general practitioners, physical therapists, neurologists, neurosurgeons, orthopedic surgeons) (30% response) and 155 patients (96% response) responded to an internet-based survey. Respondents ranked barriers and facilitators identified in previous interviews, on their importance using Maximum Difference Scaling. Feeding back the personal top 5 most important factors, each respondent indicated whether these factors were barriers or facilitators. Hierarchical Bayes estimation was used to estimate the relative importance (RI) of each factor.

Results

Professionals assigned the highest importance to: quality of professional-patient relationship (RI 4.87; CI 4.75–4.99); importance of quick recovery of patient (RI 4.83; CI 4.69–4.97); and knowledge about treatment options (RI 6.64; CI 4.53–4.74), which were reported as barrier and facilitator. Professionals working in primary care had a different ranking than those working in hospital care. Patients assigned the highest importance to: correct diagnosis by professionals (barrier, RI 8.19; CI 7.99–8.38); information provision about treatment options and potential harm and benefits (RI 7.87; CI 7.65–8.08); and explanation of the professional about the care trajectory (RI 7.16; CI 6.94–7.38), which were reported as barrier and facilitator.

Conclusions

Knowledge, information provision and a good relationship are the most important conditions for SDM perceived by both patients and professionals. These conditions are not restricted to one specific disease or health care system, because they are mostly professional or patient dependent and require healthcare professional training.     

The Excavation of American Indian Burial Sites: A Problem in Law and Professional Responsibility

The excavation of Indian burial sites poses serious ethical problems. Many American Indians regard the excavation of such sites as an affront to their actual and spiritual ancestors, while many archaeologists believe that scientific investigation should take absolute priority. This paper explores the judicial and legislative aspects of this practice in the United States and discusses attempts by professional associations to resolve the conflict. The paper suggests specific guidelines that could be followed by courts and legislators depending on whether the burial site is on reservation or nonreservation property, or whether the physical remains are recent or ancient. [archaeology, applied anthropology, ethics, anthropology and law, anthropology and public policy]     

Addressing the conflict between partner notification and patient confidentiality in serodiscordant relationships: How can Ubuntu help?

This study evaluates the conflict between patient confidentiality and partner notification in sero‐discordant relationships, and argues the thesis that based on a theoretical formulation of Ubuntu, a health provider is obliged to facilitate friendly relationships in which individuals are true subjects and/or objects of communal friendship. In serodiscordant relationships, the health professional can fulfil this obligation by notifying “others” (particularly a partner with whom an HIV positive patient has a “present” and “actual relationship”) of their spouse's HIV seroconversion, since without such relevant information a partner (subject) of an HIV positive patient cannot “appropriately” care for the patient's condition (object). There is a need to move away from the medical traditional emphasis that has for so long put primacy on doctor‐patient confidentiality as is the case with the Health Professions Council of South Africa Guidelines (Booklet 12) which favours patient confidentiality over partner notification. Given empirical evidence to support effectiveness of partner notification amongst sero‐discordant couples, there is thus, a need to focus emphasis on latter. This shift is necessary for achieving the United Nations’ Sustainable Development of Goal of ending HIV/AIDS epidemic by 2030. I proposed in this study that African ethics, specifically Ubuntu, will do a better job than current ethical frameworks at ensuring that partner notification receives more emphasis in the care of serodiscordant couples. If this framework is integrated into ethical guidelines and codes, it would significantly enhance the care of serodiscordant couples, as well as further boost global effort at ending HIV/AIDS epidemic by 2030.     

Animal psychology and ethology in Britain and the emergence of professional concern for the concept of ethical cost

It has been argued that if an animal is psychologically like us, there may be more scientific reason to experiment upon it, but less moral justification to do so. Some scientists deny the existence of this dilemma, claiming that although there are scientifically valuable similarities between humans and animals that make experimentation worthwhile, humans are at the same time unique and fundamentally different. This latter response is, ironically, typical of pre-Darwinian beliefs in the relationship between human and non-human animals. Another irony is that debate about such issues has facilitated the participation once more of philosophers in questions concerning experimental psychology: ironic because laboratory-oriented psychologists, especially since the turn of the last century, had been eager to establish the independence of their subject from any influence of philosophy and its investigative methods, as well as from any kind of anthropomorphism.In Britain, certainly more so than in the United States, ethical constraints have prevented the development of psychological research with animals along certain routes. By the 1980s British professional and academic societies had published codes of conduct and guidelines for their members, in part responding to public concern about the welfare of animals in the psychological laboratory. What led to the establishment of these codes and guidelines? This paper analyses the historical background against which professional concern for ethical cost in experimental animal psychology began to take shape, leading to the societies’ open pronouncements of the 1980s.     

A practical framework for ethics assessment in wildlife management decision-making

Wildlife professionals lack a framework and process for incorporating ethical considerations in a systematic and transparent way, along with ecological and social science, to support wildlife management decision-making. We provide such a framework and process based on 3 of the major theoretical branches ethicists have developed in Western culture: consequentialist moral theory, which focuses on consequences and outcomes; principle- and rule-based approaches that deal with what is considered right or wrong; and virtue ethical theory, which considers factors such as character, virtue, and aesthetics. The framework can be used to anticipate the ethical consequences of alternative courses of action or taking no action. If wildlife professionals use this framework as an assessment tool to provide input into decision-making, resulting decisions will be more transparent, better understood by stakeholders, and more consistent with public trust responsibilities.     

Dazed and Confused: Sports Medicine,Conflicts of Interest,and Concussion Management

Professional sports with high rates of concussion have become increasingly concerned about the long-term effects of multiple head injuries. In this context, return-to-play decisions about concussion generate considerable ethical tensions for sports physicians. Team doctors clearly have an obligation to the welfare of their patient (the injured athlete) but they also have an obligation to their employer (the team), whose primary interest is typically success through winning. At times, a team’s interest in winning may not accord with the welfare of an injured player, particularly when it comes to decisions about returning to play after injury. Australia’s two most popular professional football codes—rugby league and Australian Rules football—have adopted guidelines that prohibit concussed players from continuing to play on the same day. I suggest that conflicts of interest between doctors, patients, and teams may present a substantial obstacle to the proper adherence of concussion guidelines. Concussion management guidelines implemented by a sport’s governing body do not necessarily remove or resolve conflicts of interest in the doctor–patient–team triad. The instigation of a concussion exclusion rule appears to add a fourth party to this triad (the National Rugby League or the Australian Football League). In some instances, when conflicts of interest among stakeholders are ignored or insufficiently managed, they may facilitate attempts at circumventing concussion management guidelines to the detriment of player welfare.