Internal medicine, psychiatry, and emergency medicine residents' views of assisted death practices.

BACKGROUND: Although studies have revealed conflicting attitudes within the medical community regarding assisted death practices in the United States, the views of current resident physicians have not been described. OBJECTIVE: To investigate the perspectives of residents from 3 medical specialty fields regarding the acceptability of assisted suicide and euthanasia practices as performed by 4 possible agents (the resident personally, a referral physician, physicians in general, or nonphysicians in general) in 6 patient scenarios. METHODS: An anonymous survey exploring responses to 6 patient vignettes was conducted with a convenience sample of all residents in the internal medicine, psychiatry, and emergency medicine training programs. RESULTS: A total of 96 residents, 72% of those asked, participated in this study. Overall, residents expressed opposition or uncertainty regarding assisted suicide and euthanasia. The residents were disinclined to directly perform such practices themselves and did not support the conduct of assisted suicide practices by nonphysicians. Respondents were somewhat more accepting of other physicians' involvement in assisted death activities. Conflicting views were expressed by residents, with emergency medicine residents more likely to support assisted suicide practices in 4 of 6 patient vignettes than either internal medicine or psychiatry residents. Residents who reported being influenced by religious beliefs (21 respondents [22%]) did not support assisted death practices, whereas those influenced by personal philosophy (74 respondents [77%]) expressed less opposition. CONCLUSIONS: This study explores the uncertainty and differing views of residents from 3 fields about physician-assisted suicide practices. Study findings are considered within the larger literature on clinician attitudes toward assisted suicide and euthanasia.

Ethical dimensions of psychiatric research: a constructive, criterion-based approach to protocol preparation. The Research Protocol Ethics Assessment Tool (RePEAT).

Preparing experimental protocols that are ethically sound, possess scientific merit, and meet institutional and national standards for human subject protections is a key responsibility of psychiatric investigators. This task has become increasingly complex due to developments in biomedical science, bioethics, and society at large. Practical and constructive approaches to help investigators in their efforts to create protocols that are ethically acceptable have nevertheless received little attention. To better address this gap, the Research Protocol Ethics Assessment Tool (RePEAT) was developed as an educational instrument to help assure that ethically important elements, including scientific design features, are explicitly addressed by investigators in their work with protocols involving human participants. The RePEAT is a brief evaluative checklist that reflects rigorous ethical standards, particularly with respect to criteria for studies that may involve individuals with compromised decisional abilities. For this reason, it may be especially beneficial as a self-assessment tool for investigators and protocol reviewers in psychiatry. To stimulate education and dialogue, this report presents the RePEAT and outlines its content, format, use, and limitations.

Psychiatric research ethics: an overview of evolving guidelines and current ethical dilemmas in the study of mental illness.

The field of psychiatry has an opportunity to construct a more refined, perhaps more enduring understanding of the ethical basis of mental illness research. The aim of this paper is to help advance this understanding by 1) tracing the evolution of the emerging ethic for biomedical experimentation, including recent recommendations of the President's National Bioethics Advisory Commission, and 2) reviewing data and concepts related to compelling ethical questions now faced in the study of mental disorders. Empirical findings on informed consent, the ethical safeguards of institutional review and surrogate decision making, and the relationship between scientific and ethical imperatives are outlined. Psychiatric researchers will increasingly be called upon to justify their scientific approaches and to seek ways of safeguarding the well-being of people with mental illness who participate in experiments. Most importantly, psychiatric investigators will need to demonstrate their appreciation and respect for ethical dimensions of investigation with special populations. Further empirical study and greater sophistication with respect to the distinct ethical issues in psychiatric research are needed. Although such measures present many challenges, they should not interfere with progress in neuropsychiatric science so long as researchers in our field seek to guide the process of reflection and implementation.

Placebos and paradoxes in psychiatric research: an ethics perspective.

The use of placebos in clinical trials, particularly in research with mentally ill people, has emerged as a subject of considerable controversy. We first outline ethical aspects of the primary scientific arguments for and against placebo use in research. Three examples of paradoxical aspects of the ethical use of placebos are discussed: involvement of relatively more vulnerable populations, use of apparently "less than standard" therapy, and the omission of information in placebo comparisons. In the current scientific and regulatory context, placebo use in psychiatric research may be necessary for scientific reasons, and when certain conditions are present, it may be justified on ethical grounds. Four key recommendations to facilitate the ethical use of placebos in research trials are presented. We conclude that placebo trials should be undertaken only after careful evaluation of alternative scientific strategies and, as with all human research, with great respect and genuine consideration for the individuals who choose to participate in these protocols.

Perspectives of patients with schizophrenia and psychiatrists regarding ethically important aspects of research participation.

OBJECTIVE: Significant controversy surrounds the ethics of psychiatric research. Nevertheless, few data have been gathered to improve our understanding of how individuals with serious mental illness and psychiatrists view ethically important aspects of biomedical research participation. METHOD: The authors assessed views of clinically diagnosed patients with schizophrenia from three sites by means of structured interviews and views of psychiatrists at two sites with written surveys regarding attitudes affecting motivation to participate in biomedical research, attitudes related to autonomy and influences on participation decisions, and attitudes toward the inclusion of vulnerable populations in research. The schizophrenia patients were asked to indicate their personal views; the psychiatrists were asked to provide their personal views and to predict schizophrenia patients' views. Responses were compared by using repeated measures multivariate analysis of variance. RESULTS: Sixty-three patients with schizophrenia and 73 psychiatry faculty and residents participated. Overall, responses to 23 rated attitudes revealed remarkably similar rank orders and several areas of agreement between patients and psychiatrists. Both groups strongly supported schizophrenia research and autonomous decision making by participants. They saw helping others and helping science as important reasons for protocol participation. Patients endorsed the feeling of hope associated with research involvement, a perspective underestimated by psychiatrists. Psychiatrists also underestimated the patients' acceptance of physician, investigator, and family influences on participation decisions. Psychiatrists agreed more strongly than patients that vulnerable populations should be included in research. CONCLUSIONS: This study helps to characterize previously neglected attitudes of psychiatric patients and clinicians toward ethically important aspects of biomedical research participation. Schizophrenia patients offered highly discerning views, and interesting similarities and differences emerged in comparing responses of patients and psychiatrists.

Pulsed low dose rate brachytherapy for pelvic malignancies.

PURPOSE: The pulsed low dose rate remote afterloading unit was designed to combine the radiation safety and isodose optimization advantages of high dose rate technology with the radiobiologic advantages of continuous low dose rate brachytherapy. This is the first report of a prospective clinical trial evaluating the relative incidence of acute toxicity and local control in patients with pelvic malignancies who underwent interstitial or intracavitary brachytherapy with the pulsed low dose rate remote afterloader. METHODS AND MATERIALS: From 5/11/92-6/21/95, 65 patients underwent 77 brachytherapy procedures as part of their treatment regimen for pelvic malignancies. Using the pulsed low dose rate Selectron, equipped with a single cable-driven 0.3-1.0 Ci Ir192 source, target volume doses of 0.40-0.85 Gy per pulse were prescribed to deliver the clinically determined dose. Forty-five intracavitary and 32 interstitial procedures were performed. Fifty-four patients had primary and 11 recurrent disease. Patients were followed closely to assess incidence of Grade 3-5 acute and delayed toxicity, local control, and survival. RESULTS: With a median follow-up of 16.1 months (range 1-29), 33 patients are NED, 10 alive with disease, 13 dead with disease, 4 dead of intercurrent disease, and 5 lost to follow-up. Local control was maintained until last follow-up or death in 48 cases, local failure occurred in 11, unknown in 5. Grade 3-5 acute toxicities (requiring medical or surgical intervention) occurred in 5 out of 77 procedures (6.5%), delayed complications in 10 patients (15% actuarial incidence at 2 years). In the 52 procedures performed for 42 patients with cervix cancer, the acute toxicity incidence was 5.8%, with a 14% 2-year actuarial incidence of delayed complications. Of 32 interstitial templates performed on 30 patients for pelvic malignancies, there were three incidences of acute toxicity and five delayed toxicities. CONCLUSION: Using the parameters described for this initial clinical study in patients treated for pelvic malignancies, pulsed low dose rate brachytherapy shows no significant increase in acute toxicity above that seen with the standard continuous low dose rate approach. Using the isodose optimization possible with pulsed brachytherapy, local control is excellent in patients treated at initial presentation, although longer follow-up is required for full assessment of local control and late toxicity. Further trials will need to be carried out to determine if larger doses per pulse and shorter total treatment times have comparable therapeutic ratios.

Improved dose distribution with customized I-125 source loading in temporary interstitial implants.

I-125 sources are being used in temporary interstitial implants of various sites. Radiation safety considerations favor its use over other available radioisotopes. Cost containment is achieved by using the same sources for a number of patients. Loading I-125 seeds into implant catheters at our institutions permit customized source arrangement to optimize the implant dose patterns. Clinical examples are given for which the dose distributions achieved with customized source loading are superior to those achievable with standard Ir-192 ribbons.

Probing by Glossina morsitans morsitans and transmission of Trypanosoma (Nannomonas) congolense.

Successive probings on nine mice each by 32 Glossina morsitans morsitans infected with Trypanosoma (Nannomonas) congolense resulted in 54% of the mice (156/288) becoming parasitemic. A second trial with 25 surviving infected flies resulted in transmission by probing to 37.3% (84/225) of the host mice. The patterns of transmission were similar in the two trials, with transmission rates in the first and second probings higher than those for feedings to repletion after nine consecutive probings. Infected flies probed significantly more times and required more time to engorge than noninfected flies. Probing transmissions by cyclically infected flies may be important in the spread of trypanosomes in endemic areas, since feeding interruptions can result in transmission to more than one host at each feeding interval.

Urologic sequelae of childhood genitourinary trauma and abuse in men: principles of recognition with fifteen case illustrations.

Providing urologic care to men who have been traumatized during childhood may be especially challenging because of the extent, severity, and unusual character of their urogenital problems. Recognition of past trauma entails attentiveness to patients' background and behaviors. As illustrated through these 15 cases, patients who present with too many past surgeries, too many unremitting urologic complaints, too little sexual function and too few genital parts, sexual impulses that are too strong, sexualized conduct in clinical settings, and self-destructive behaviors surrounding sexuality may have experienced trauma in the past. While empirical studies are necessary to demonstrate the ultimate utility of these categories, appreciation of these clinical indications improves the urologic care provided to traumatized men in four ways: by elucidating unusual and unusually recalcitrant urologic complaints, thereby clarifying clinical decisions; by allowing for appropriate use of psychiatric consultation; by promoting a better understanding of the sequelae of trauma in men; and by alleviating the discomfort naturally felt by urologists and their staff when caring for these difficult, multiproblem patients.

Cutaneous myiasis caused by the African tumbu fly (Cordylobia anthropophaga).

We describe a patient with cutaneous myiasis caused by the African tumbu fly (Cordylobia anthropophaga). This case demonstrates the need for a detailed travel history and an understanding of the fly life cycle to prevent erroneous diagnosis and to expedite prompt treatment. The nature of the lesions, larval morphological features, histological characteristics, and immune response directed toward fly maggots are described.

Source localization for template implants with particular reference to stepping-source afterloaders.

Source localization from radiographs can be very difficult for template-guided implants if the needle images overlap. At UCSF several techniques to make this task easier have been developed. The techniques include selection of an optimum simulator gantry angle, use of different types of dummies, and differential dummy loading. In addition, several modifications have been made in our brachytherapy planning computer program to facilitate source entry. As a result of these improvements, source localization is now accomplished in much less time with improved accuracy.

Uncertainty and opposition of medical students toward assisted death practices.

To explore medical students' views of assisted death practices in patient cases that describe different degrees and types of physical and mental suffering, an anonymous survey was administered to all students at one medical school. Respondents were asked about the acceptability of assisted death activities in five patient vignettes and withdrawal of life support in a sixth vignette. In the vignettes, actions were performed by four possible agents: the medical student personally; a referral physician; physicians in general; or non-physicians. Of 306 medical students, 166 (54%) participated. Respondents expressed opposition or uncertainty about assisted death practices in the five patient cases that illustrated severe forms of suffering which were secondary to amyotrophic lateral sclerosis, treatment-resistant depressive and somatoform disorders, antisocial and sexually violent behavior, or AIDS. Students supported the withdrawal of life support in the sixth vignette depicting exceptional futility secondary to AIDS. Students were especially opposed to their own involvement and to the participation of non-physicians in assisted death activities. Differences in views related to sex, religious beliefs, and personal philosophy were found. Medical students do not embrace assisted death practices, although they exhibit tolerance regarding the choices of medical colleagues. How these attributes of medical students will translate into future behaviors toward patients and peers remains uncertain. Medical educators must strive to understand the perspectives of physicians-in-training. Expanded, empirically informed education that is attuned to the attitudes of medical students may be helpful in fulfilling the responsibility of imparting optimal clinical care skills.

Caring for medical students as patients: access to services and care-seeking practices of 1,027 students at nine medical schools. Collaborative Research Group on Medical Student Healthcare.

PURPOSE: The personal health care of medical students is an important but neglected issue in medical education. Preliminary work suggests that medical student-patients experience special barriers to health care services and report problematic care-seeking practices that merit further inquiry. METHOD: A self-report questionnaire was piloted, revised, and distributed to students at nine medical schools in 1996-97. The survey included questions regarding access to health services, care-seeking practices, and demographic information. RESULTS: A total of 1,027 students participated (52% response rate). Ninety percent reported needing care for various health concerns. Fifty-seven percent did not seek care at times, in part due to training demands, and 48% had encountered difficulties in obtaining care. A majority had received treatment at their training institutions, and students commonly pursued informal or "curbside" care from medical colleagues. Almost all participants (96%) were insured. Differences in responses were associated with level of training, gender, and medical school. CONCLUSION: Medical schools shoulder the responsibility not only of educating but also of providing health services for their students. Students encounter barriers to care and engage in problematic care-seeking practices. Greater attention to issues surrounding medical student health may benefit students and their future patients.

An invitation for medical educators to focus on ethical and policy issues in research and scholarly practice.

Medical education research and medical education practice both involve being methodical, innovative, self-observing, forward-looking, and open to peer review, and both are scholarly activities. For these reasons, distinguishing between these two activities is often difficult. There are three important reasons to clarify the distinctions: the moral difference between education research and education practice; federal regulations governing education research that require more safeguards than often exist in education practice; and the fact that student participants in research have characteristics in common with members of special populations. The authors explain why attention to issues of safeguards in education research and practice is likely to grow at academic health centers, yet maintain that these issues are neglected in the medical education literature. They demonstrate this with findings from their review of 424 education research reports published in 1988 and 1989 and in 1998 and 1999 in two major medical education journals. Each article was evaluated for documentation of six ethically important safeguards and features (e.g., informed consent). The rates of reporting the six features and safeguards were relatively low (3-27%). Nearly half (47%) of the empirical reports offered no indication of ethically important safeguards or features, and no article mentioned all six. Furthermore, those rates did not increase substantially after ten years. The authors discuss a number of implications of their findings for faculty, training institutions, students, and editors and peer reviewers, and conclude with the hope that their findings will raise awareness of these neglected issues in medical education and will stimulate all those involved to reflect upon the issues and set standards on the ethical aspects of research and scholarly practice.

Medical students as patients: a pilot study of their health care needs, practices, and concerns.

BACKGROUND: The personal health experiences of medical students may contribute in important but previously unacknowledged ways to their well-being and education. This pilot study surveyed medical students about their health care needs, practices, insurance status, and concerns about seeking care. METHOD: A questionnaire was developed and distributed to 151 students at the University of New Mexico School of Medicine in 1993-94. Participant privacy was protected. Responses were compiled and analyzed using logistic regression models and odds ratios. RESULTS: A total of 112 students responded. Most reported health care needs and half routinely received care at their training institution. One-third had informally requested prescriptions or diagnostic tests from medical school faculty and housestaff; one-fourth used such informal consultation as their "usual" method of obtaining care. Eighteen students were uninsured. The students reported that they had not sought care for several reasons, and many had experienced difficulty in obtaining care. The students indicated concern about confidentiality and about the dual role as both student and patient at the training institution. They believed that their academic standing would be jeopardized if they developed certain health problems. When asked about hypothetical scenarios, a majority preferred to avoid the dual role of medical-student-patient. When asked about scenarios in which medical student peers exhibited suicidal depression or severe drug abuse, the students overwhelmingly preferred not to notify the medical school administration. Significant differences in responses were found with respect to gender and training level. CONCLUSION: This pilot study examined the health care needs, practices (including the use of informal consultation), insurance status, and concerns of students at one medical school. The findings highlight the students' perceptions of illness and vulnerability during medical school training. Constructive implications for academic medicine are discussed regarding initiatives in the areas of policy, research, and the resources and structure of student health care services.

Assessing medical students' competence in obtaining informed consent.

BACKGROUND: Medical schools increasingly place emphasis on preparing students to perform routine, ethically important clinical activities with sensitivity and acumen. A method for evaluating students' skills in obtaining informed consent that was created at our institution is described. METHODS: Formal assessment of medical students' professional attitudes, values, and ethics skills occurs in the context of three required and developmentally attuned comprehensive examinations. A videotaped station tested senior medical students' ability to obtain informed consent from a standardized patient who expresses concern about undergoing cardiac catheterization. Two checklists were completed by the patient. Videotapes were reviewed by a faculty member, and students' reactions to the assessment experience were documented. RESULTS: Seventy-one senior students participated, and all performed well. Mean scores of 6.3 out of 7 (range 5 to 7, SD = 0.5) on the informed consent checklist and 8.7 out of 9 (range 6 to 9, SD = 0.5) on the communication skills checklist were obtained. Students endorsed the importance of the skills tested. CONCLUSIONS: This method of examining medical students' abilities to obtain informed consent has several positive features and holds promise as an ethics competence assessment tool.

"America responds to AIDS," but did college students? Differences between March, 1987, and September, 1988.

To assess thoughts, perceptions, attitudes, and behavior related to AIDS, data were collected from 2 similar samples of college students. The sets of data were collected 18 months apart. Results indicate increased awareness and knowledge and changed attitudes and behaviors in some cases, but the absolute magnitudes of the differences are small for most between-group comparisons. Also, the evidence suggests that many students lack detailed knowledge and fail to see the implications of their knowledge for change in their own behavior. These findings imply educational efforts must go beyond merely providing knowledge and explicitly link facts to personal belief systems and decision making.

Comparative sensitivity of four Anopheles (Diptera: Culicidae) to five repellents.

Five repellents were evaluated against Anopheles albimanus Wiedemann An. freeborni Aitken, An. gambiae Giles, and An. stephensi Liston, using a "free choice," dose-response testing procedure on rabbits. Overall, deet was the most effective repellent based on effective dosages (ED50's and ED95's), except against An. albimanus. An. albimanus was significantly more tolerant to deet compared with dimethyl phthalate or ethyl hexanediol. Permethrin was effective against all four anopheline species at the ED50 levels; however, the ED95 values were higher compared with the other repellents. There were significant differences in sensitivity of some of the four species to all the repellents tested, except dimethyl phthalate and indalone. The variability in the response of these anopheline species to repellents confirm that the extrapolation of repellent data from one anopheline species to another is unreliable and that comprehensive tests are needed for each species.

Laboratory evaluation of repellents against four anopheline mosquitoes (Diptera: Culicidae) and two phlebotomine sand flies (Diptera: Psychodidae).

Deet, the lactone CIC-4, and the piperidine compounds A13-37220 and A13-35765 were evaluated for initial repellency against laboratory-reared Anopheles albimanus Wiedemann, An. freeborni Aitken, An. gambiae Giles, An. stephensi Liston, and Phlebotomus papatasi (Scopoli) using a dose-response testing procedure on human volunteers. In addition, deet and CIC-4 were tested against Lutzomyia longipalpis (Lutz & Neiva). In general, the repellency of A13-37220, A13-35765, and CIC-4 was not markedly different from that of deet against each species tested; however, the different species varied greatly in response to the repellents. Overall, An. stephensi, L. longipalpis, and P. papatasi were the most sensitive, and An. albimanus the most tolerant species. The four repellents subsequently were tested against An. stephensi and An. albimanus to determine the duration of repellency. AI3-37220 provided effective (> 90%) protection against An. stephensi bites for 7 h, whereas deet, AI3-35765, and CIC-4 provided 6, 5, and 3 h of protection, respectively. Each of the four compounds provided < 1 h of protection against An. albimanus bites.

Perceptions of the ethical acceptability of using medical examiner autopsies for research and education: a survey of forensic pathologists.

BACKGROUND: Forensic pathologists face difficult moral questions in their practices each day. Consistent ethical and legal guidelines for autopsy tissue use extending beyond usual clinical and legal imperatives have not been developed in this country. OBJECTIVE: To obtain the perceptions of medical examiners regarding the ethical acceptability of autopsy tissue use for research and education. METHOD: A written, self-report questionnaire was developed and piloted by a multidisciplinary team at the University of New Mexico, Albuquerque. All individuals who attended a platform presentation at the National Association of Medical Examiners Annual Meeting in September 1997 were invited to participate. RESULTS: Ninety-one individuals completed the survey (40% of all conference registrants and approximately 75% of presentation attendees). Sixty-three percent of respondents had encountered an ethical dilemma surrounding autopsy tissue use, and one third reported some professional ethics experience. Perspectives varied greatly concerning the ethical acceptability of using autopsy tissues to demonstrate or practice techniques (eg, intubation, brachial plexus dissection) and of fulfilling requests to supply varying kinds and quantities of tissues for research and education. Most respondents indicated that consent by family members was important in tissue use decisions. Respondents agreed on the importance of basic values in education and research, such as integrity, scientific or educational merit, and formal institutional approval of a project. Characteristics of the decedent did not influence decisions to release tissues, except when the individual had died from a mysterious or very rare illness. Attributes of medical examiners, with the exception of sex, also did not consistently predict responses. CONCLUSION: Significant diversity exists in beliefs among medical examiners regarding perceptions of the appropriate use of autopsy tissues for education and research. There is need for further inquiry and dialogue so that enduring policy solutions regarding human tissue use for education and research may be developed.