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2.
Intern Med J ; 50(9): 1123-1131, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32929818

RESUMEN

Rituals may be understood broadly as stereotyped behaviours carrying symbolic meanings, which play a crucial role in defining relationships, legitimating authority, giving meaning to certain life events and stabilising social structures. Despite intense interest in the subject, and an extensive literature, relatively little attention has been given to the nature, role and function of ritual in contemporary medicine. Medicine is replete with ritualistic behaviours and imperatives, which play a crucial role in all aspects of clinical practice. Rituals play multiple, complex functions in clinical interactions and have an important role in shaping interactions, experiences and outcomes. Longstanding medical rituals have been disrupted in the wake of coronavirus disease 2019 (COVID-19). Medical rituals may be evident or invisible, often overlap with or operate alongside instrumentalised practices, and play crucial roles in establishing, maintaining and guaranteeing the efficacy of clinical practices. Rituals can also inhibit progress and change, by enforcing arbitrary authority. Physicians should consider when they are undertaking a ritual practice and recognise when the exigencies of contemporary practice are affecting that ritual with or without meaning or intention. Physicians should reflect on whether aspects of their ritual interactions are undertaken on the basis of sentiment, custom or evidence-based outcomes, and whether rituals should be defended, continued in a modified fashion or even abandoned in favour of new behaviours suitable for and salient with contemporary practice in the interests of patient care.


Asunto(s)
Conducta Ceremonial , Infecciones por Coronavirus/epidemiología , Neumonía Viral/epidemiología , Pautas de la Práctica en Medicina/ética , Pautas de la Práctica en Medicina/normas , Betacoronavirus , Cultura , Humanos , Pandemias
4.
BMJ ; 370: m1668, 2020 07 20.
Artículo en Inglés | MEDLINE | ID: mdl-32690477

RESUMEN

Despite their ubiquitous presence, placebos and placebo effects retain an ambiguous and unsettling presence in biomedicine. Specifically focused on chronic pain, this review examines the effect of placebo treatment under three distinct frameworks: double blind, deception, and open label honestly prescribed. These specific conditions do not necessarily differentially modify placebo outcomes. Psychological, clinical, and neurological theories of placebo effects are scrutinized. In chronic pain, conscious expectation does not reliably predict placebo effects. A supportive patient-physician relationship may enhance placebo effects. This review highlights "predictive coding" and "bayesian brain" as emerging models derived from computational neurobiology that offer a unified framework to explain the heterogeneous evidence on placebos. These models invert the dogma of the brain as a stimulus driven organ to one in which perception relies heavily on learnt, top down, cortical predictions to infer the source of incoming sensory data. In predictive coding/bayesian brain, both chronic pain (significantly modulated by central sensitization) and its alleviation with placebo treatment are explicated as centrally encoded, mostly non-conscious, bayesian biases. The review then evaluates seven ways in which placebos are used in clinical practice and research and their bioethical implications. In this way, it shows that placebo effects are evidence based, clinically relevant, and potentially ethical tools for relieving chronic pain.


Asunto(s)
Dolor Crónico/tratamiento farmacológico , Relaciones Médico-Paciente/ética , Placebos/efectos adversos , Pautas de la Práctica en Medicina/ética , Teorema de Bayes , Dolor Crónico/psicología , Decepción , Método Doble Ciego , Ética Médica , Humanos , Efecto Placebo , Placebos/administración & dosificación , Pautas de la Práctica en Medicina/estadística & datos numéricos
7.
Med Sci (Paris) ; 36(5): 515-520, 2020 May.
Artículo en Francés | MEDLINE | ID: mdl-32452374

RESUMEN

The genetic tests for "non-rare thrombophilias" (TNR) were introduced into clinical setting immediately after the identification of genetic variants in the mid-90s to predict and prevent venous thromboembolism (VTE). Although being a rare example of a genetic test of susceptibility for complex diseases that has been integrated in medical routine, it is the most widespread post-natal genetics inquiry in France nowadays. Yet, determining whom to test and how to use the results is still controversial. This article outlines the trajectory of its clinical regulation and illustrates the importance of the context of use to understand its diffusion. This analysis is intended to feed a more general reflection on the issues raised by the clinical integration of genetic surveys for common diseases, particularly with regard to the clinical utility of a test (statistical vs. biological), the subjects to be tested (the case index and/or her/his relatives), and the criteria underlying access to these tests (modalities of medico-economic assessment).


Asunto(s)
Pruebas Genéticas , Trombofilia/diagnóstico , Trombofilia/genética , Acceso a la Información/legislación & jurisprudencia , Revelación/ética , Revelación/legislación & jurisprudencia , Francia/epidemiología , Predisposición Genética a la Enfermedad , Pruebas Genéticas/ética , Pruebas Genéticas/legislación & jurisprudencia , Pruebas Genéticas/métodos , Accesibilidad a los Servicios de Salud/ética , Accesibilidad a los Servicios de Salud/legislación & jurisprudencia , Historia del Siglo XXI , Humanos , Recién Nacido , Legislación Médica , Inutilidad Médica/ética , Inutilidad Médica/legislación & jurisprudencia , Tamizaje Neonatal/ética , Tamizaje Neonatal/legislación & jurisprudencia , Tamizaje Neonatal/métodos , Pautas de la Práctica en Medicina/ética , Pautas de la Práctica en Medicina/legislación & jurisprudencia , Pautas de la Práctica en Medicina/tendencias , Valor Predictivo de las Pruebas , Trombofilia/epidemiología
9.
Otolaryngol Head Neck Surg ; 162(6): 811-812, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32284004

RESUMEN

The COVID-19 pandemic has dramatically altered how otolaryngologists contemplate and assume their roles in health care delivery. The ethical implications of this pandemic upon our practice are formidable and distinct from other surgical fields. The salient ethical issues of public health stewardship and safety, distributive justice, and nonabandonment are distilled for the practicing otolaryngologist.


Asunto(s)
Control de Enfermedades Transmisibles/organización & administración , Infecciones por Coronavirus/prevención & control , Prestación de Atención de Salud/ética , Transmisión de Enfermedad Infecciosa/ética , Otorrinolaringólogos/ética , Pandemias/prevención & control , Neumonía Viral/prevención & control , Infecciones por Coronavirus/epidemiología , Transmisión de Enfermedad Infecciosa/prevención & control , Femenino , Humanos , Masculino , Otolaringología/ética , Pandemias/estadística & datos numéricos , Neumonía Viral/epidemiología , Pautas de la Práctica en Medicina/ética , Estados Unidos
10.
Isr Med Assoc J ; 22(4): 249-254, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32286030

RESUMEN

BACKGROUND: The innovation that has taken place in medicine, combined with state-of-the-art technological developments, provides therapeutic options for patients in conditions that were previously considered incurable. This promotion at the same time presents us with new ethical challenges. In this article, we review the journey through life of an advanced heart failure patient, covering a variety of potential clinical and ethics subjects in the field of heart failure treatment. We review the ethical principles of the Hippocratic Oath against the background of the realities of practicing medicine and of the enormous advances in therapeutics.


Asunto(s)
Cardiología/tendencias , Insuficiencia Cardíaca/diagnóstico por imagen , Insuficiencia Cardíaca/terapia , Juramento Hipocrático , Pautas de la Práctica en Medicina/ética , Resultado del Tratamiento , Cardiología/normas , Terapia Combinada , Ecocardiografía Transesofágica/métodos , Femenino , Predicción , Humanos , Masculino , Pautas de la Práctica en Medicina/tendencias
11.
Cuad. bioét ; 31(101): 19-42, ene.-abr. 2020. tab, ilus
Artículo en Español | IBECS | ID: ibc-197135

RESUMEN

The standard of the patient's best interests is the main bioethical standard used in the decision-making process that involves incompetent patients (i.e. neonatology, pediatric patients and incompetent adults). This standard has been widely criticized as being self-destructive, individualistic, vague, unknown, dangerous and open to abuse. With the purpose of defending it, several reforms of this standard have been proposed, especially in the pediatric field. We propose a redefinition of the standard based on two concepts: 1) medical futility as a negative criterion, and 2) the principle of proportionality as a positive criterion. Our work includes a new relationship between concepts in classical moral theology (i.e. ordinary / extraordinary; proportionate / disproportionate) applied to the bioethics of life-sustaining treatments for incompetent patients


El estándar del mejor interés del paciente es el único estándar bioético utilizado en los procesos de decisión de tratamientos en enfermos no competentes (neonatología, pediatría y adultos no competentes). Este estándar ha sido ampliamente criticado por autodestructivo, individualista, vago, desconocido, peligroso y abierto a abusos. Para defender el estándar se han propuesto varias reformulaciones especialmente en el ámbito pediátrico. Nosotros proponemos una redefinición del estándar basada en dos conceptos: 1) el de futilidad médica como criterio negativo, y 2) el principio de proporcionalidad como criterio positivo. Nuestro trabajo incluye una nueva relación entre los conceptos de la teología moral clásica (ordinario / extraordinario; proporcionado / desproporcionado) aplicados a la bioética de los tratamientos de soporte vital en pacientes no competentes


Asunto(s)
Humanos , Bioética , Toma de Decisiones Clínicas/ética , Derechos del Paciente/ética , Prioridad del Paciente , Derechos del Paciente/normas , Inutilidad Médica/ética , Pautas de la Práctica en Medicina/ética , Pautas de la Práctica en Medicina/normas , Competencia Mental
14.
BMC Med Ethics ; 21(1): 5, 2020 01 10.
Artículo en Inglés | MEDLINE | ID: mdl-31924198

RESUMEN

BACKGROUND: Ritual circumcision of infant boys is controversial in Norway, as in many other countries. The procedure became a part of Norwegian public health services in 2015. A new law opened for conscientious objection to the procedure. We have studied physicians' refusals to perform ritual circumcision as an issue of professional ethics. METHOD: Qualitative interview study with 10 urologists who refused to perform ritual circumcision from six Norwegian public hospitals. Interviews were recorded and transcribed, then analysed with systematic text condensation, a qualitative analysis framework. RESULTS: The physicians are unanimous in grounding their opposition to the procedure in professional standards and norms, based on fundamental tenets of professional ethics. While there is homogeneity in the group when it comes to this reasoning, there are significant variations as to how deeply the matter touches the urologists on a personal level. About half of them connect their stance to their personal integrity, and state that performing the procedure would go against their conscience and lead to pangs of conscience. CONCLUSIONS: It is argued that professional moral norms sometimes might become more or less 'integrated' in the professional's core moral values and moral identity. If this is the case, then the distinction between conscience-based and professional refusals to certain healthcare services cannot be drawn as sharply as it has been.


Asunto(s)
Conducta Ceremonial , Circuncisión Masculina/ética , Médicos/ética , Pautas de la Práctica en Medicina/ética , Negativa al Tratamiento/ética , Ética Profesional , Hospitales Públicos , Humanos , Recién Nacido , Masculino , Noruega , Investigación Cualitativa
16.
Acad Med ; 95(1): 157-165, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31348062

RESUMEN

PURPOSE: The practice of medicine is rarely straightforward. Data used to facilitate medical decision making may be conflicting, ambiguous, or scarce, and providing optimal care requires balancing clinicians' expertise and available evidence with patients' preferences. To explore uncertainty in decision making across disciplines, the authors performed a scoping review and thematic analysis of the literature to formulate a model describing the decision-making process in medicine under uncertain conditions. METHOD: In 2016, the authors performed a comprehensive search of key databases using a combination of keywords and controlled vocabulary. They identified and reviewed 3,398 records. After applying their inclusion and exclusion criteria to the titles and abstracts and then full texts, 19 articles were selected. The authors applied a qualitative thematic analysis to these articles, using codes to extract themes related to uncertainty in decision making. RESULTS: The 19 articles spanned 6 fields of study and 5 disciplines within the health sciences. The thematic analysis revealed 6 main themes: recognition of uncertainty, classification of uncertainty, stakeholder perspectives, knowledge acquisition, decision-making approach, and evaluation of the decision-making process. CONCLUSIONS: Based on the themes that emerged from their thematic analysis of the literature characterizing the effects of uncertainty and ambiguity on the decision-making process, the authors developed a framework depicting the interplay between these themes with a visual representation of the decision-making process under uncertain conditions. Future research includes further development and validation of this framework to inform medical school curricula.


Asunto(s)
Toma de Decisiones Clínicas/ética , Medicina/estadística & datos numéricos , Médicos/psicología , Pautas de la Práctica en Medicina/economía , Incertidumbre , Adaptación Psicológica/fisiología , Curriculum/normas , Humanos , Conocimiento , Medicina/tendencias , Pautas de la Práctica en Medicina/ética , Investigación Cualitativa , Estrés Psicológico/epidemiología
18.
J Bone Joint Surg Am ; 101(23): e128, 2019 Dec 04.
Artículo en Inglés | MEDLINE | ID: mdl-31800432

RESUMEN

BACKGROUND: Opioid addiction affects patients of every race, sex, and socioeconomic status. Overprescribing is a known cause of the opioid crisis. Various agencies have implemented requirements and programs to combat practitioner overprescribing; however, there can be adverse ethical consequences when regulations are used to influence physician behavior. We aimed to explore the ethical aspects of some of these interventions. METHODS: We reviewed various interventions for opioid prescribing through the lens of ethical inquiry. Specifically, we evaluated (1) requirements for educational programs for prescribers and patients, (2) prescription monitoring programs, (3) prescription limits, (4) development of condition-specific pain management guidelines, (5) increased utilization of naloxone, and (6) opioid disposal programs. We also evaluated patient satisfaction survey questions relating to pain. RESULTS: The present analysis demonstrated that the following regulatory interventions are ethically sound: requirements for educational programs for prescribers and patients, robust prescription monitoring programs that cross state lines, increased prescribing of naloxone for at-risk patients, development of condition-specific pain management guidelines, improvement of opioid disposal programs, and elimination of pain-control questions from patient satisfaction surveys. However, implementation of strict prescribing limits without accommodation for procedure and patient characteristics may have negative ethical consequences. CONCLUSIONS: Although the importance of addressing the current opioid crisis cannot be understated, as surgeons, we must examine ethical implications of any new regulations that affect musculoskeletal patient care.


Asunto(s)
Analgésicos Opioides/efectos adversos , Dolor Crónico/tratamiento farmacológico , Utilización de Medicamentos/ética , Pautas de la Práctica en Medicina/ética , Mal Uso de Medicamentos de Venta con Receta/ética , Analgésicos Opioides/administración & dosificación , Dolor Crónico/diagnóstico , Femenino , Humanos , Masculino , Epidemia de Opioides/prevención & control , Dimensión del Dolor , Relaciones Médico-Paciente , Reproducibilidad de los Resultados , Factores de Riesgo , Índice de Severidad de la Enfermedad , Estados Unidos
19.
Aust J Gen Pract ; 48(12): 876-882, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31774994

RESUMEN

BACKGROUND AND OBJECTIVES: International surveys indicate that placebo use by general practitioners (GPs) is remarkably high, but usage in Australia is currently unknown. To address this, the aim of this study was to examine rates of use and beliefs about placebos in Australian general practice. METHOD: This study was conducted using a cross-sectional internet-based survey of a random sample of Australian GPs from a national database between February and April 2018. In total, 641 GPs opened the email invitation and 136 (18%) took part. RESULTS: Thirty-nine percent of GPs had used an inert placebo, and 77% had used an active placebo. GPs primarily used placebos because they believed placebos could provide genuine benefit and viewed themselves as having a strong role in shaping patients' expectations. Of concern, antibiotics were the most common type of active placebo prescribed. DISCUSSION: Placebo use by Australian GPs is fairly common, particularly the use of active placebos. Ethical issues surrounding the prescription of placebos in general practice are discussed.


Asunto(s)
Actitud del Personal de Salud , Decepción , Médicos Generales , Placebos/uso terapéutico , Pautas de la Práctica en Medicina/estadística & datos numéricos , Adulto , Anciano , Antibacterianos/uso terapéutico , Australia , Estudios Transversales , Femenino , Medicina General , Humanos , Masculino , Persona de Mediana Edad , Rociadores Nasales , Efecto Placebo , Pautas de la Práctica en Medicina/ética , Solución Salina , Crema para la Piel , Encuestas y Cuestionarios
20.
CJEM ; 21(6): 717-720, 2019 11.
Artículo en Inglés | MEDLINE | ID: mdl-31771692

RESUMEN

Choosing Wisely Canada (CWC) is a national initiative designed to encourage patient-clinician discussions about the appropriate, evidence-based use of medical tests, procedures and treatments. The Canadian Association of Emergency Physicians' (CAEP) Choosing Wisely Canada (CWC) working group developed and released ten recommendations relevant to Emergency Medicine in June 2015 (items 1-5) and October 2016 (items 6-10). In November 2016, the CAEP CWC working group developed a process for updating the recommendations. This process involves: 1) Using GRADE to evaluate the quality of evidence, 2) reviewing relevant recommendations on an ad hoc basis as new evidence emerges, and 3) reviewing all recommendations every five years. While the full review of the CWC recommendations will be performed in 2020, a number of high-impact studies were published after our initial launch that prompted an ad hoc review of the relevant three of our ten recommendations prior to the full review in 2020. This paper describes the results of the CAEP CWC working group's ad hoc review of three of our ten recommendations in light of recent publications.


Asunto(s)
Toma de Decisiones Clínicas/métodos , Medicina de Emergencia/normas , Evaluación de Resultado en la Atención de Salud , Guías de Práctica Clínica como Asunto , Pautas de la Práctica en Medicina/ética , Canadá , Femenino , Humanos , Masculino , Medición de Riesgo , Sociedades Médicas/normas
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