ABSTRACT
Obstinacy or therapeutic cruelty is a medical practice based on the application of extraordinary and disproportionate methods of life support in terminally ill or irrecoverable patients. It is not without risks and can cause physical, psychological and social damage, which is why this practice is not ethically acceptable. It violates the four principles of bioethics: non-maleficence, beneficence, justice and autonomy. The reasons that lead to therapeutic obstinacy are: 1) lack of a definitive diagnosis; 2) false expectation of improvement of the patient; 3) disagreement (between doctors and family or between doctors themselves) with respect the patient's situation; 4) difficulty in communicating with the patient and his/her family; 5) compliance with unrealistic or futile treatments; 6) cultural or spiritual barriers and 7) medical-legal aspects. Limitation of therapeutic effort (LTE) is a deliberate or thoughtful decision about the non-implementation or withdrawal of therapeutic measures that will not provide significant benefit to the patient. But, refusing a treatment, must not imply the artificial acceleration of the death process. Chile does not contemplate euthanasia or assisted suicide in its legislation. Criteria used to justify the limitation of the therapeutic effort are: 1) futility of the treatment (futility); 2) declared wishes of the patient; 3) quality of life and 4) economic cost. The Healthcare Ethics Committee of the Hospital de Urgencia Asistencia Pública has prepared a LET Clinical Guide, proposing a decision-making flow chart that takes in account the autonomy of the patient, the opinion of the medical team, patient and family. In case of disagreement, the Healthcare Ethics Committee's may be requested to issue a pronouncement.
La obstinación o ensañamiento terapéutico es una práctica médica basada en la aplicación de métodos extraordinarios y desproporcionados de soporte vital en enfermos terminales o irrecuperables. No está exenta de riesgos y puede producir daño físico, psicológico y social, motivo por el cual no es aceptable desde el punto de vista ético. Viola los cuatro principios de la bioética: no maleficencia, beneficencia, justicia y autonomía. Las razones que conducen a la obstinación terapéutica son: 1) la falta de un diagnóstico definitivo; 2) la falsa expectativa en el mejoramiento del paciente; 3) el desacuerdo (entre médicos y familia o entre los médicos mismos) con la situación del paciente; 4) la dificultad para comunicarse con el paciente y con la familia; 5) la conformidad con tratamientos poco realistas o fútiles; 6) barreras culturales o espirituales y 7) aspectos médico legales. La limitación del esfuerzo terapéutico (LET) es una decisión deliberada o meditada sobre la no implementación o la retirada de medidas terapéuticas que no aportarán un beneficio significativo al paciente. Pero, rechazar un tratamiento no puede implicar la aceleración artificial del proceso de la muerte. Chile no contempla en su legislación la eutanasia ni el suicidio asistido. Criterios utilizados para justificar o no, la limitación del esfuerzo terapéutico: 1) la inutilidad del tratamiento (futilidad); 2) los deseos expresos del paciente; 3) la calidad de vida y 4) el costo económico. El Comité de Ética Asistencial del Hospital de Urgencia Asistencia Pública, ha elaborado una Guía Clínica de LET. Propone un flujograma de toma de decisiones que considera la autonomía del paciente, la postura tanto del equipo médico, del paciente y su familia y en caso de no acuerdo, del comité de Ética Asistencial.
Subject(s)
Humans , Medical Futility/ethics , Critical Care/ethics , Physician-Patient Relations/ethics , Professional-Family Relations/ethics , Surgical Procedures, Operative/ethics , Euthanasia , Cardiopulmonary Resuscitation/ethics , Withholding Treatment , Personal Autonomy , Decision Making , Patient PreferenceABSTRACT
Introducción: Una serie de breves períodos de isquemias a distancia, previo al evento isquémico mayor, pueden limitar el daño miocárdico producido por la isquemia/reperfusión. Objetivo: Evaluar la utilidad del condicionamiento isquémico a distancia, en pacientes programados para procedimientos quirúrgicos de revascularización coronaria. Métodos: Se realizó un estudio cuasiexperimental, explicativo, comparativo con control histórico, en dos grupos de 247 pacientes, propuestos para revascularización coronaria. Se colocó un torniquete en el brazo derecho, en el grupo estudio, alternando 3 insuflaciones con 3 desinsuflaciones con una presión de 200 mmHg, manteniéndola 5 min cada una. Este proceder se realizó previo, durante y después del evento isquémico mayor, provocado por el pinzamiento de la arteria coronaria. Resultados: Se logró una disminución significativa de los parámetros enzimáticos. No se encontraron diferencias significativas (p>0,05) según un conjunto de variables que representan el estado inicial de los pacientes(AU)
Introduction: A series of short periods of distant ischemia, prior to the major ischemic event, can limit the myocardial damage produced by ischemia or reperfusion. Objective: To evaluate the usefulness of remote ischemic conditioning in patients scheduled for surgical procedures of coronary revascularization. Methods: A quasi-experimental, explanatory, comparative study with historical control was conducted in two groups of 247 patients proposed for coronary revascularization. A tourniquet was placed in the right arm in the study group, alternating 3 insufflations with 3 dessufflations with a pressure of 200 mmHg, keeping each for 5 minutes. This procedure was performed before, during and after the major ischemic event, caused by the impingement of the coronary artery. Results: A significant decrease in enzymatic parameters was achieved. No significant differences were found (p>0.05) according to a set of variables that represent the initial state of the patients(AU)
Subject(s)
Humans , Male , Female , Surgical Procedures, Operative/ethics , Ischemic Preconditioning/methods , Myocardial Revascularization/methods , Non-Randomized Controlled Trials as Topic , Anesthesia, Inhalation/methodsABSTRACT
Introdução: O procedimento denominado de bichectomia consiste na remoção parcial de uma estrutura adiposa na região das bochechas e ganhou recente popularidade entre a classe odontológica, que passou a executá-lo amplamente, com demandas predominantemente estéticas e, com isso, dúvidas e incertezas surgiram a respeito dos seus aspectos éticos e legais. Objetivo: O objetivo deste trabalho foi buscar legislações nacionais, bem como normativas e resoluções emitidas por conselhos profissionais, visando abordar tais controvérsias, alumiando os profissionais quanto à legitimidade do procedimento. Resultados: Verificou-se que desde 1978, os Conselhos Federais de Medicina e de Odontologia vêm emitindo resoluções para determinar limiares de atuação profissional, em especial, com enfoque na especialidade Cirurgia e Traumatologia Bucomaxilofacial, visto que é a especialidade odontológica clínica que mais se aproxima de campos de atuação médica. Com o tempo, estes Conselhos foram atualizando estas Resoluções, tendo em vista os avanços técnicos e científicos da área, porém todas as resoluções analisadas são unânimes em afirmar que a realização de bichectomia com finalidade estritamente estética é atribuição médica. Conclusão: Desta forma, com base nos documentos atualmente vigentes, verifica-se que o cirurgião-dentista que estiver disposto a realizar a cirurgia de bichectomia com finalidade exclusivamente estética estará incorrendo em transgressões administrativas e, consequentemente, tais interpretações podem ser vislumbradas em outras esferas (cíveis e criminais).
Introduction: Bichectomy consists of removing part of a fat structure in the region of the cheeks, and it recently gained popularity in the field of odontology, which began to widely perform the procedure, with predominantly aesthetic demands and, with that, doubts and uncertainties arose with respect to its ethical and legal aspects. Objective: The objective of this work was to seek national laws, as well as normative and resolutions issued by professional councils, aiming to address such controversies, enlightening professionals to the legitimacy of the procedure. Results: Since 1978, the Federal Councils of Medicine and Dentistry have issued resolutions to determine thresholds for professional performance, which particularly focused on Oral and Maxillofacial Surgery and Traumatology because it is the closest clinical dental specialty of medical practice. Over time, these Councils have been updating these resolutions, considering the technical and scientific advances of the area, but all the resolutions analyzed were unanimous in affirming that the accomplishment of bichectomy with a strictly aesthetic purpose is a medical attribution. Conclusion: Subsequently, based on the documents currently in force, it is verified that the dental surgeon who is willing to perform bichectomy surgery for aesthetic purposes will be incur administrative infractions and, consequently, such interpretations can be seen in other legal areas (civil and criminal).
Subject(s)
Humans , History, 21st Century , Surgical Procedures, Operative , Surgery, Plastic , Cheek , Dentistry , Esthetics , Forensic Dentistry , Legislation, Dental , Mouth Abnormalities , Surgical Procedures, Operative/legislation & jurisprudence , Surgical Procedures, Operative/ethics , Surgery, Plastic/legislation & jurisprudence , Cheek/surgery , Dentistry/organization & administration , Forensic Dentistry/legislation & jurisprudence , Legislation, Dental/organization & administration , Legislation, Dental/ethics , Mouth Abnormalities/surgeryABSTRACT
Las cualidades necesarias en el cirujano han constituido históricamente un tema excepcional en la bibliografía médica. El presente artículo busca caracterizarlas tanto en el cirujano que practica la cirugía convencional como en el que utiliza las nuevas tecnologías, y enfatizar en sus principios éticos. Las tecnologías no significan la deshumanización del cirujano; implican el desarrollo de nuevas habilidades para tratar mejor a los pacientes, pero la aplicación de la cirugía tradicional se impone cuando estas nuevas modalidades fallan. Los principios éticos que han definido siempre los valores del cirujano son laboriosidad, dedicación a los pacientes, deseo permanente de progreso científico, serenidad, estabilidad emocional y desinterés(AU)
The necessary qualities in surgeon are historically an exceptional subject in the medical bibliography. Present paper looks for its characterization for surgeon practices the conventional surgery and for surgeon using the new technologies and to emphasizes on its ethical principles. The technologies no means the surgeon dehumanization; they implicate the development of new abilities to achieve a better treatment to patients, but the application of the traditional surgery is imposed when these new modalities fails. The ethical principles that always have defined the surgeon values are the laboriousness, the dedication to patients, the permanent desire of scientific progress, calm, emotional stability and disinterest(AU)
Subject(s)
Humans , Technological Development/methods , General Surgery , Physician's Role , Surgical Procedures, Operative/ethicsABSTRACT
As normas brasileiras condicionam o acesso às modificações corporais para alteração da identidade sexual à confirmação do diagnóstico psiquiátrico de transexualismo - transtorno de identidade de gênero ou sexual -, e o acompanhamento psiquiátrico por dois anos para sua realização. O desconforto com o sexo anatômico e o desejo de a pessoa modificar a genitália para a do sexo oposto é o principal critério definidor do diagnóstico de transexualismo. A cirurgia de transgenitalização é considerada etapa final do tratamento, e vem sendo admitida pela instância judicial como condição necessária para a alteração da identidade sexual legal. O artigo discute o conflito moral entre o sujeito transexual e as normas vigentes em relação ao exercício da autonomia individual nas práticas terapêuticas, aplicando as ferramentas da bioética, a partir da análise dos argumentos utilizados pelas instâncias de saúde e judicial sobre o tema, nos artigos, documentos e decisões judiciais nacionais. Observa-se que houve avanços no acesso aos recursos terapêuticos e legais, mas as limitações e restrições ainda impostas ao exercício da autonomia do/a transexual podem ter efeitos negativos para a saúde e os direitos daqueles não considerados pela norma vigente como "verdadeiros transexuais". Os direitos da pessoa transexual à assistência integral à saúde, inclusive sexual, e ao livre desenvolvimento de sua personalidade são infringidos no momento em que a autonomia do paciente não é adequadamente preservada pelas normas vigentes, convertendo-se os direitos humanos num tipo de dever de a pessoa adequar-se à moralidade sexual dominante.
According to current Brazilian health authority policies, one's access to physical modifications to have his/her sexual identity altered is dependent upon an established psychiatric diagnosis of transsexualism - gender or sexual identity disorder - in addition to two years of psychiatric evaluations, in order to have it come to fruition. The discomfort with his/her sexual anatomy and the desire to have his/her genitalia modified is the defining criteria to the diagnosis of transsexualism. Sex reassignment surgery is considered to be the last step of such a treatment, and it is viewed by the Judiciary as a necessary condition to effect change in the legal sexual identity status of the transsexual person. This paper argues the moral conflict between transsexual issues and current health policies related to one's exercise on autonomy with regard to therapeutic practices. Hence, Bioethics tools are applied to the discussion, due to the result obtained from an analysis of the arguments made by the health authorities and judicial systems, on the subject, through articles, documents, and Brazilian court decisions. Regarding therapeutic and legal access, some advances have been made. However, notwithstanding, limitations and restrictions still being imposed regarding the exercise of the autonomy of the transsexual individual, might have a negative impact on the health and legal rights of those not acknowledged by the current norms as "true transsexuals". The rights of the transsexual individual to a comprehensive healthcare assistance system, including sexually related health issues, as well as the right to the free development of his/her personality are infringed, at the very moment when the patient's autonomy is not duly safeguarded by current health policies, thus making human rights look more like a duty, to which the person must adapt to as the dominant sexual morality.
Subject(s)
Humans , Male , Female , Gender Identity , Humanization of Assistance , Hysterectomy/ethics , Hysterectomy/methods , Mammaplasty/ethics , Mammaplasty/methods , Surgical Procedures, Operative/ethics , Surgical Procedures, Operative/methods , Surgical Procedures, Operative/rehabilitation , Homeopathic Therapeutic Approaches , Delivery of Health Care/ethics , Social Justice/ethics , Social Justice/legislation & jurisprudence , Personal Autonomy , Psychotherapy/trends , Unified Health System/organization & administrationABSTRACT
Surgical procedures have often been introduced into practice without rigorous clinical research to check on safety and proof of cost-effectiveness as is done when researching on a new drug. This is because clinical research involves an inherent tension between the ethical values of pursuing rigorous science and protecting participants from harm. The latter may be particularly challenging when surgery is involved. However; clinical trials are unethical if they are not designed to answer valuable scientific questions with the use of valid research methods. In addition to having scientific merit; clinical trials must present a favorable risk-benefit ratio: the risks to participants must be minimized and justifiable by the benefits to them; if any; and the potential value of the scientific knowledge to be gained from the study. It is also essential that investigators obtain informed consent from participants and have an ethical responsibility to act in their best interest.A randomized; controlled clinical trial carried out in the surgical field; is not a form of individualized surgical therapy; it is a scientific tool for evaluating innovative procedures in groups of surgical research participants; with the aim of improving the care of similar patients in the future. Such clinical trials are not designed to promote the best interests of enrolled patients and may expose them to risks that are not outweighed by known potential benefits. Furthermore; the use of placebo (sham) surgery in controlled clinical trials has been controversial resulting in a lot of debate because the fundamental ethical principles of beneficence and non-maleficence appear to be violated. Patients could be exposed to complications of surgery with no prospects of possible benefits. It is therefore imperative that the use of placebo surgery must be evaluated in terms of the ethical principles appropriate to clinical research. As technology is expanding and health care resources becoming more limited; surgeons are compelled to evaluate surgical procedures and technology to ensure they are safe and effective.In conclusion; trials of surgical procedures including those involving the use of placebo surgery whenever required; should be conducted before new surgical procedures become standard treatments; provided that these trials meet the ethical requirements that are appropriate for clinical research. These ethical issues and requirements in surgical research and their relevance to a developing country like Tanzania is discussed in this paper