Teleconsulta médica. Análisis y recomendaciones del Departamento de Ética del Colegio Médico de Chile / Medical teleconsultation. Analysis and recommendations from the ethics department of the Chilean medical association

The possibility of allowing patients access to health professionals, has been greatly facilitated by advances in technology. Indeed, nowadays it is possible not only direct contact between one health professional with another, but also the possibility of sending images and other tests to consult distant colleagues. This has undoubtedly enabled better health care for many patients. It is also possible for a patient to consult a doctor directly in a remote and synchronous way with oral and visual contact, thus establishing a new form of medical consultation. It is this last way of relationship, which has already spread as a practice in normal times, which arouses apprehensions about the ethical requirements that a consultation must meet. This work by the Ethics Department of the Chilean Medical Association seeks to reflect on the ethical demands of a medical consultation and on the shortcomings that teleconsultation has. It also aims to propose several recommendations, so that this new form of doctor-patient relationship serves as a complement to traditional care, without jeopardizing the objectives of a medical action.

[Medical teleconsultation. Analysis and recommendations from the ethics department of the Chilean medical association]. / Teleconsulta médica. Análisis y recomendaciones del Departamento de Ética del Colegio Médico de Chile.

The possibility of allowing patients access to health professionals, has been greatly facilitated by advances in technology. Indeed, nowadays it is possible not only direct contact between one health professional with another, but also the possibility of sending images and other tests to consult distant colleagues. This has undoubtedly enabled better health care for many patients. It is also possible for a patient to consult a doctor directly in a remote and synchronous way with oral and visual contact, thus establishing a new form of medical consultation. It is this last way of relationship, which has already spread as a practice in normal times, which arouses apprehensions about the ethical requirements that a consultation must meet. This work by the Ethics Department of the Chilean Medical Association seeks to reflect on the ethical demands of a medical consultation and on the shortcomings that teleconsultation has. It also aims to propose several recommendations, so that this new form of doctor-patient relationship serves as a complement to traditional care, without jeopardizing the objectives of a medical action.

Argumentos éticos a favor y en contra de la participación del profesional médico en la muerte asistida. Análisis del Departamento de Ética del Colegio Médico de Chile / Ethical arguments for and against the participation of the medical profession in assisted death: analysis of the Ethics Department of the Chilean Medical Association

The discussion of a bill that allows medically assisted death (MAD) in Chile, revived the debate about the ethics of this practice. The Department of Ethics of the Chilean Medical Association herein analyzes arguments in favor or against the participation of the medical profession in MAD. Among the main arguments against the participation of physicians in this practice are that MAD conflicts with the basic ethical principles of medical practice, that it is contrary to the purposes of medicine and that it could erode the patients' and society's confidence in physicians. The arguments in favor are related to physician´s compassion and non-abandonment of patients during their illness, choosing palliative care and ushering them to the final instance. Additionally, there is social expectation that this practice will be carried out by trained physicians who can verify that the strict criteria established by the legislation are met, guarantee that it obeys to a repeated request of a fully capable patient, and who is able to deal with the complications of the procedure. In this document we aimed to represent the different perspectives about physicians' participation in MAD, offering arguments to colleagues and stimulating their participation in this important debate.

Aspectos éticos de la conducta del médico ante personas en huelga de hambre: opinión del Departamento de Ética del Colegio Médico de Chile / Ethical aspects of the doctors' behavior towards people on hunger strike: position paper from the Ethics Department of the Chilean Medical Association

Every so often, in Chile there is a discussion about the role of physicians in the care of people on hunger strike (HS). In this document, we review the ethical aspects of health care for persons in HS, aiming to provide guidelines to medical doctors who are required to attend them. First, we make an important distinction between HS and suicide, since the former is used as a protest and denunciation tool, while suicide seeks deliberately to end a life. Then we describe the three roles that the health professional can fulfill: as a treating doctor, as an expert or as an official of a prison. The respect for the autonomy and dignity of the person in HS must prevail whatever the role of the physician. Therefore, we maintain that under no circumstances, people who have autonomously decided to be in HS should be fed by force. Due to the complexity of the issue, we make special considerations about the management of minors and the non-competent persons in HS. In conclusion, we adhere to the principles that inspire the Declaration of Malta, which indicate that it would be preferable to "allow a person on hunger strike to die in dignity, rather than subjecting them to repeated interventions against their will".

[Ethical aspects of the doctors' behavior towards people on hunger strike: position paper from the Ethics Department of the Chilean Medical Association]. / Aspectos éticos de la conducta del médico ante personas en huelga de hambre: opinión del Departamento de Ética del Colegio Médico de Chile.

Every so often, in Chile there is a discussion about the role of physicians in the care of people on hunger strike (HS). In this document, we review the ethical aspects of health care for persons in HS, aiming to provide guidelines to medical doctors who are required to attend them. First, we make an important distinction between HS and suicide, since the former is used as a protest and denunciation tool, while suicide seeks deliberately to end a life. Then we describe the three roles that the health professional can fulfill: as a treating doctor, as an expert or as an official of a prison. The respect for the autonomy and dignity of the person in HS must prevail whatever the role of the physician. Therefore, we maintain that under no circumstances, people who have autonomously decided to be in HS should be fed by force. Due to the complexity of the issue, we make special considerations about the management of minors and the non-competent persons in HS. In conclusion, we adhere to the principles that inspire the Declaration of Malta, which indicate that it would be preferable to "allow a person on hunger strike to die in dignity, rather than subjecting them to repeated interventions against their will".

[Position paper from the Department of Ethics of the Chilean College of Physicians about conscientious objection]. / El médico y la objeción de conciencia: Opinión del Departamento de Ética del Colegio Médico de Chile A. G.

The Chilean bill that regulates abortion for three cases (Bulletin Nº 9895-11) includes the possibility that health professionals may manifest their conscientious objection (CO) to perform this procedure. Due to the broad impact that the issue of C O had, the Ethics Department of the Chilean College of Physicians considered important to review this concept and its ethical and legal basis, especially in the field of sexual and reproductive health. In the present document, we define the practical limit s of CO, both for the proper fulfillment of the medical profession obligations, and for the due respect and non-discrimination that the professional objector deserves. We analyze the denial of some health institutions to perform abortions if it is legalize d, and we end with recommendations adjusted to the Chilean reality. Specifically, we recognize the right to conscientious objection that all physicians who directly participate in a professional act have. But we a lso recognize that physicians have ineludib le obligations towards their patients, including the obligation to inform about the existence of this service, how to access to it and -as set out in our code of ethics- to ensure that another colleague will continue attending the patient.

El médico y la objeción de conciencia: opinión del Departamento de Ética del Colegio Médico de Chile A. G. / Position paper from the Department of Ethics of the Chilean College of Physicians about conscientious objection

The Chilean bill that regulates abortion for three cases (Bulletin Nº 9895-11) includes the possibility that health professionals may manifest their conscientious objection (CO) to perform this procedure. Due to the broad impact that the issue of C O had, the Ethics Department of the Chilean College of Physicians considered important to review this concept and its ethical and legal basis, especially in the field of sexual and reproductive health. In the present document, we define the practical limit s of CO, both for the proper fulfillment of the medical profession obligations, and for the due respect and non-discrimination that the professional objector deserves. We analyze the denial of some health institutions to perform abortions if it is legalize d, and we end with recommendations adjusted to the Chilean reality. Specifically, we recognize the right to conscientious objection that all physicians who directly participate in a professional act have. But we a lso recognize that physicians have ineludib le obligations towards their patients, including the obligation to inform about the existence of this service, how to access to it and -as set out in our code of ethics- to ensure that another colleague will continue attending the patient.

[Bioethical responsibilities of the health authority in health care and biomedical research]. / Responsabilidades bioéticas de la autoridad sanitaria en atención en salud y en investigación biomédica.

The reflection on bioethical contents of health policies and their effects on the demands for social justice has been a preferred concern of those who have driven the health reforms that were behind the creation of the National Health Service and, more recently, the regime of health guarantees. In the course of the years, the concern for the vindication of individual rights in the context of health care and research has joined to citizen demands for equitable access to health actions. For this purpose, in 2006 and 2012, specific laws addressing these matters were enacted and in the last year, regulations that make them operative emerged and are being implemented. The wording of the articles of both laws, in the effort to rescue individual rights, raises an imbalance in some respects, with regard to the social impact of their implementation. In certain subjects, its provisions run counter to existing codes of professional ethics in the country and in others; its implementation allows the privatization of the process of ethical review of pharmacological research, which was restricted to public health services. The absence of starting up of the National Bioethics Commission, pending since 2006, has prevented the creation of a pluralistic spaTce for deliberation on these issues and others as provided by law.

La reflexión respecto a los contenidos bioéticos de las políticas de salud y sus efectos sobre la reivindicación de las demandas de justicia social, ha sido preocupación preferente de quienes han impulsado las reformas sanitarias que estuvieron detrás de la creación del servicio nacional de salud y del régimen de garantías en salud, más recientemente. En el curso de los años, a la demanda ciudadana por acceso equitativo a las acciones sanitarias, se ha sumado la preocupación por la reivindicación de los derechos individuales en el contexto de la atención de salud y de quienes participan en investigación científica. Con este propósito se promulgaron, en los años 2006 y 2012, leyes específicas que abordaban estas materias y -en el último año- reglamentos que las hacen operativas y que se encuentran en vías de implementación. La redacción del articulado de ambas leyes, en el esfuerzo por rescatar derechos individuales, plantea una situación de desequilibrio, en algunos aspectos, con respecto a la consideración del impacto social de su aplicación. En ciertas materias sus disposiciones se contraponen a los códigos de ética profesionales vigentes en el país y, en otros, su implementación permite la privatización del proceso de evaluación ética de la investigación farmacológica, que estaba restringido a los servicios públicos de salud. La ausencia de puesta en marcha de la Comisión Nacional de Bioética, pendiente desde 2006, no ha permitido la creación de un espacio pluralista de deliberación sobre estos temas y otros, como preveía la ley.

Assessing ethical and social issues of transtelephonic electrocardiography (TTEGG) in Chile / Evaluación de los aspectos éticos y sociales de la electrocardiografía transtelefónica (TTEGG) en Chile / Avaliação das questões éticas e sociais da eletrocardiografia transtelefônica (TTEGG) no Chile

The aim of this study was to focus on the ethical and social issues derived from the implementation of transtelephonic electrocardiography (TTECG) in the public healthcare sector in Chile, studying patients and healthcare providers' acceptance and expectations concerning: (a) TTECG effectiveness and safety; and (b) data protection issues, such as confidentiality, privacy and security. For this purpose, we developed two psychosocial surveys; the first was addressed to patients receiving transtelephonic electrocardiogram (either in the emergency services of hospitals or in distant primary care services) and the second one aimed at healthcare providers involved in either administering and/or interpreting it. Results included: (a) major acceptability of TTECG in terms of safety and security; (b) privacy and confidentiality of the patients were considered to be well protected; and (c) the patient-doctor relationship was not affected by this device.

El objetivo de este estudio fue centrarse en los asuntos éticos y sociales, derivados de la aplicación de la tele-electrocardiografía (TTECG), en el sector público de salud en Chile, estudiando la aceptación y expectativas de pacientes y proveedores de servicios de salud en relación con: (a) eficacia y seguridad de la TTECG; y (b) cuestiones relacionadas con la protección de datos, tales como la confidencialidad, privacidad y seguridad. Para este fin, aplicamos dos encuestas psicosociales; la primera fue dirigida a los pacientes que reciben TTECG (ya sea en los servicios de urgencias de los hospitales, o en servicios de atención primaria alejados) y la segunda dirigida a los profesionales de la salud dedicados a la aplicación y/o interpretación. Los resultados fueron los siguientes: (a) gran aceptabilidad de TTECG en términos de seguridad y protección; (b) se considera que la privacidad y confidencialidad de los pacientes están protegidos; y (c) la relación entre los pacientes y el médico no se considera afectada por este dispositivo.

O objetivo do presente estudo foi concentrar-se sobre as questões éticas e sociais decorrentes da implementação da eletrocardiografia transtelefônica (TTECG) no sector público da saúde no Chile, estudando a aceitação de pacientes e prestadores de cuidados de saúde e suas expectativas relativas a: (a) eficácia e segurança da TTECG; e (b) questões relacionadas com a proteção de dados, tais como a confidencialidade, privacidade e segurança. Para esse efeito, desenvolvemos dois questionários psicossociais; o primeiro foi dirigido a pacientes recebendo TTECG (quer em serviços de emergência de hospitais ou no distante atendimento primário), e o segundo foi destinado a prestadores de cuidados de saúde envolvidos em qualquer administração ou interpretando-a. Os resultados foram: (a) grande aceitabilidade das TTECG em termos de segurança; (b) a privacidade e a confidencialidade dos pacientes foram consideradas como bem protegidas; e (c) a relação médico-paciente não foi afetada por esse dispositivo.

Assessing ethical and social issues of transtelephonic electrocardiography (TTEGG) in Chile.

The aim of this study was to focus on the ethical and social issues derived from the implementation of transtelephonic electrocardiography (TTECG) in the public healthcare sector in Chile, studying patients and healthcare providers' acceptance and expectations concerning: (a) TTECG effectiveness and safety; and (b) data protection issues, such as confidentiality, privacy and security. For this purpose, we developed two psychosocial surveys; the first was addressed to patients receiving transtelephonic electrocardiogram (either in the emergency services of hospitals or in distant primary care services) and the second one aimed at healthcare providers involved in either administering and/or interpreting it. Results included: (a) major acceptability of TTECG in terms of safety and security; (b) privacy and confidentiality of the patients were considered to be well protected; and (c) the patient-doctor relationship was not affected by this device.

Thymectomy for non-thymomatous myasthenia gravis.

BACKGROUND: Treatments currently used for patients with myasthenia gravis (MG) include steroids, non-steroid immune suppressive agents, plasma exchange, intravenous immunoglobulin and thymectomy. Data from randomized controlled trials (RCTs) support the use of some of these therapeutic modalities and the evidence for non-surgical therapies are the subject of other Cochrane reviews. Significant uncertainty and variation persist in clinical practice regarding the potential role of thymectomy in the treatment of people with MG. OBJECTIVES: To assess the efficacy and safety of thymectomy in the management of people with non-thymomatous MG. SEARCH METHODS: On 31 March 2013, we searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL (2013, Issue 3), MEDLINE (January 1966 to March 2013), EMBASE (January 1980 to March 2013) and LILACS (January 1992 to March 2013) for RCTs. Two authors (RS and GC) read all retrieved abstracts and reviewed the full texts of potentially relevant articles. These two authors checked references of all manuscripts identified in the review to identify additional articles that were of relevance and contacted experts in the field to identify additional published and unpublished data. Where necessary, authors were contacted for further information. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials of thymectomy against no treatment or any medical treatment, and thymectomy plus medical treatment against medical treatment alone, in people with non-thymomatous MG.We did not use measured outcomes as criteria for study selection. DATA COLLECTION AND ANALYSIS: We planned that two authors would independently extract data onto a specially designed data extraction form and assess risk of bias; however, there were no included studies in the review. We would have identified any adverse effects of thymectomy from the included trials. MAIN RESULTS: We did not identify any RCTs testing the efficacy of thymectomy in the treatment of MG. In the absence of data from RCTs, we were unable to do any further analysis. AUTHORS' CONCLUSIONS: There is no randomized controlled trial literature that allows meaningful conclusions about the efficacy of thymectomy on MG. Data from several class III observational studies suggest that thymectomy could be beneficial in MG. An RCT is needed to elucidate if thymectomy is useful, and to what extent, in MG.

Corticosteroids for Bell's palsy (idiopathic facial paralysis).

BACKGROUND: Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti-inflammatory action which should minimise nerve damage. OBJECTIVES: The objective of this review was to assess the effect of corticosteroid therapy in Bell's palsy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (9 December 2008) for randomised trials, as well as MEDLINE (January 1966 to December 2008), EMBASE (January 1980 to December 2008) and LILACS (9 December 2008). We contacted known experts in the field to identify additional published or unpublished trials. SELECTION CRITERIA: Randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group where no therapy considered effective for this condition was administered, unless it was also given in a similar way to the experimental group. DATA COLLECTION AND ANALYSIS: Two authors independently assessed eligibility, trial quality, and extracted the data. MAIN RESULTS: Eight trials with a total of 1569 participants were included. Allocation concealment was appropriate in six trials, and the data reported allowed an intention-to-treat analysis in four, while unpublished data from the fifth and sixth trials were provided by the authors. The data included in the main outcome of this meta-analysis were collected from seven trials with a total of 1507 participants. Overall 175/754 (23%) of the participants allocated to corticosteroids had incomplete recovery of facial motor function six months or more after randomisation, significantly less than 245/753 (33%) in the control group (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.61 to 0.83). There was, also, a significant reduction in motor synkinesis during follow-up in those receiving corticosteroids (RR 0.6, 95% CI 0.44 to 0.81). The reduction in the proportion of patients with cosmetically disabling sequelae six months after randomisation, however, was not significant (RR 0.97, 95% CI 0.44 to 2.15). The trial not included in the primary outcome of this meta-analysis showed a non-significant difference in outcomes between the arms. AUTHORS' CONCLUSIONS: The available evidence from randomised controlled trials shows significant benefit from treating Bell's palsy with corticosteroids.

WITHDRAWN: Corticosteroids for Bell's palsy (idiopathic facial paralysis).

BACKGROUND: Inflammation and oedema of the facial nerve are implicated in causing Bell's palsy. Corticosteroids have a potent anti-inflammatory action which should minimise nerve damage and thereby improve the outcome of patients suffering from this condition. OBJECTIVES: The objective of this review was to assess the effect of steroid therapy in the recovery of patients with Bell's palsy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (searched November 2005) for randomised trials, as well as MEDLINE (January 1966 to November 2005), EMBASE (January 1980 to November 2005) and LILACS (January 1982 to November 2005). We contacted known experts in the field to identify additional published or unpublished trials. SELECTION CRITERIA: Randomised trials comparing different routes of administration and dosage schemes of corticosteroid or adrenocorticotrophic hormone therapy versus a control group where no therapy considered effective for this condition was administered, unless it was also given in a similar way to the experimental group. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed eligibility, trial quality, and extracted the data. MAIN RESULTS: Four trials with a total of 179 patients were included. One trial compared cortisone acetate with placebo; one compared prednisone plus vitamins, with vitamins alone; one compared high-dose prednisone administered intravenously against saline solution, and one, not-placebo controlled, tested the efficacy of methylprednisolone. Allocation concealment was appropriate in two trials, and the data reported allowed an intention-to-treat analysis. The data included in the meta-analyses were collected from three trials with a total of 117 patients. Overall 13/59 (22%) of the patients allocated to steroid therapy had incomplete recovery of facial motor function six months after randomisation, compared with 15/58 (26%) in the control group. This reduction was not significant (relative risk 0.86, 95% confidence interval 0.47 to 1.59). The reduction in the proportion of patients with cosmetically disabling sequelae six months after randomisation was also not significant (relative risk 0.86, 95% confidence interval 0.38 to 1.98). The trial not included in the meta-analysis showed a non-significant difference in outcomes between the arms. AUTHORS' CONCLUSIONS: The available evidence from randomised controlled trials does not show significant benefit from treating Bell's palsy with corticosteroids. More randomised controlled trials with a greater number of patients are needed to determine reliably whether there is real benefit (or harm) from the use of corticosteroid therapy in patients with Bell's palsy. One trial, with 551 participants, comparing prednisolone with acyclovir with both and with neither has just been published and will be included in an update of this review.

Surgical versus non-surgical treatment for carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome results from entrapment of the median nerve in the wrist. Common symptoms are tingling, numbness, and pain in the hand that may radiate to the forearm or shoulder. Most symptomatic cases are treated non-surgically. OBJECTIVES: The objective is to compare the efficacy of surgical treatment of carpal tunnel syndrome with non-surgical treatment. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (January 2008), MEDLINE (January 1966 to January 2008), EMBASE (January 1980 to January 2008) and LILACS (January 1982 to January 2008). We checked bibliographies in papers and contacted authors for information about other published or unpublished studies. SELECTION CRITERIA: We included all randomised and quasi-randomised controlled trials comparing any surgical and any non-surgical therapies. DATA COLLECTION AND ANALYSIS: Two authors independently assessed the eligibility of the trials. MAIN RESULTS: In this update we found four randomised controlled trials involving 317 participants in total. Three of them including 295 participants, 148 allocated to surgery and 147 to non-surgical treatment reported information on our primary outcome (improvement at three months of follow-up). The pooled estimate favoured surgery (RR 1.23, 95% CI 1.04 to 1.46). Two trials including 245 participants described outcome at six month follow-up, also favouring surgery (RR 1.19, 95% CI 1.02 to 1.39).Two trials reported clinical improvement at one year follow-up. They included 198 patients favouring surgery (RR 1.27, 95% CI 1.05 to 1.53). The only trial describing changes in neurophysiological parameters in both groups also favoured surgery (RR 1.44, 95% CI 1.05 to 1.97). Two trials described need for surgery during follow-up, including 198 patients. The pooled estimate for this outcome indicates that a significant proportion of people treated medically will require surgery while the risk of re-operation in surgically treated people is low (RR 0.04 favouring surgery, 95% CI 0.01 to 0.17). Complications of surgery and medical treatment were described by two trials with 226 participants. Although the incidence of complications was high in both groups, they were significantly more common in the surgical arm (RR 1.38, 95% CI 1.08 to 1.76). AUTHORS' CONCLUSIONS: Surgical treatment of carpal tunnel syndrome relieves symptoms significantly better than splinting. Further research is needed to discover whether this conclusion applies to people with mild symptoms and whether surgical treatment is better than steroid injection.