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S Afr Med J ; 110(6): 461-462, 2020 04 24.
Artículo en Inglés | MEDLINE | ID: mdl-32880552


Given the increasing numbers of ethical and legal issues arising from the COVID-19 epidemic, particularly in respect of patient-doctor confidentiality, doctors must explain to patients how the measures taken to combat the spread of the virus impact on their confidentiality. Patients must be reassured that doctors are ethically bound to continue to respect such confidentiality, but it should be made clear to them that doctors must also comply with the demands of the law. While the Constitution, statutory law and the common law all recognise a person's right to privacy, during extraordinary times such as the COVID-19 pandemic, confidentiality must be breached to a degree to halt the spread of the virus.

Confidencialidad/legislación & jurisprudencia , Infecciones por Coronavirus/epidemiología , Ética Médica , Relaciones Médico-Paciente/ética , Neumonía Viral/epidemiología , Confidencialidad/ética , Infecciones por Coronavirus/prevención & control , Humanos , Pandemias/legislación & jurisprudencia , Pandemias/prevención & control , Neumonía Viral/prevención & control
BMJ ; 370: m1668, 2020 07 20.
Artículo en Inglés | MEDLINE | ID: mdl-32690477


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.

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
PLoS One ; 15(7): e0236145, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32687536


PURPOSE: Relationship boundaries recognition is an essential element of medical practice. The aim of the study was to assess final year medical students' perceived need for education regarding professional boundaries. MATERIALS AND METHODS: This was a cross-sectional study. An anonymous paper questionnaire was distributed to 128 final year medical students. Standard descriptive statistics, unpaired t-test to evaluate differences between male and female groups and Pearson correlation to determine relationships between variables were used. RESULTS: The survey was completed by 84.4% of students who identified the need for more emphasis in the curriculum for all of topics during training and practice pertaining to boundaries and relationships (mean 6.61±1.32 on a scale of 0 to 9; and 6.66±1.27 respectively). Topics with a high interest ranking requiring additional attention were mistreatment of medical students (mean 7.22±1.96), coping with mistakes in clinical care (mean 7.25±1.63), reporting of medical mistakes (mean 7.58±1.36), and gender bias in clinical care (mean 7.10±1.82). Women perceived a greater need for attention to all topics in the curriculum. Significant differences between the perceptions of female and male students were observed regarding topics such as responding to an impaired colleague (p<0.001), and a physician's social responsibilities (p = 0.001). CONCLUSION: Medical students recognized the need for more education and training in the undergraduate medical ethics curriculum regarding patient-physician relationship boundaries.

Prácticas Clínicas , Aprendizaje , Relaciones Médico-Paciente/ética , Adulto , Estudios Transversales , Ética Médica , Femenino , Humanos , Masculino , Factores Sexuales , Encuestas y Cuestionarios , Adulto Joven
Rev. bioét. derecho ; (49): 7-23, jul. 2020.
Artículo en Español | IBECS | ID: ibc-192091


El objetivo de este artículo es definir y clarificar el criterio del mejor interés (CMI) como un principio ético para la toma de decisiones por representación. En primer lugar, se exponen algunas propuestas conceptuales como la de Kopelman y Buchanan y Brock. En segundo lugar, analizamos algunas críticas que se han hecho al CMI. Por último, este trabajo responde algunas críticas y hace una propuesta integradora

The aim of this paper defines and clarifies the best interest criterion (BIC) as an ethical principle to substitute decision-making. First, this work exposes some conceptual proposals such as Kopelman and Buchanan and Brock. Second, the authors analyze some criticisms that have been made to BIC. Third, we want to respond such critics and we do a conciliatory proposal

L'objectiu d'aquest article és definir I clarificar el criteri del millor interès (CMI) com un principi ètic per a la presa de decisions per representació. En primer lloc, s'exposen algunes propostes conceptuals com la de Kopelman I Buchanan I Brock. En segon lloc, analitzem algunes crítiques que s'han fet al CMI. Finalment, aquest treball dóna resposta a algunes crítiques I fa una proposta integradora

Humanos , Niño , Toma de Decisiones/ética , Pediatría/ética , Bioética , Relaciones Médico-Paciente/ética , Competencia Mental/legislación & jurisprudencia , Privación de Tratamiento/legislación & jurisprudencia , Moral
Rev. bioét. derecho ; (49): 25-40, jul. 2020.
Artículo en Español | IBECS | ID: ibc-192092


La relación médico-paciente se encuentra en un proceso de cambio y evolución hacia un tratamiento más humano, sustentado sobre el principio de autonomía, con el objetivo de respetar los derechos del paciente y no sólo imponer la voluntad del médico. Un instrumento que salvaguarda esta situación es el Documento de Voluntades Anticipadas, como extensión del consentimiento informado. A pesar de su regulación internacional y nacional, en ciertos contextos, como el de la salud mental, el modelo hegemónico-paternalista sigue imperando y nos preguntamos por qué

The doctor-patient relations are undergoing a process of change and evolution towards a more humane approach, based on the principle of autonomy , with the aim of respecting the rights of patients and not just imposing the will of the phyisician. Advance Directives, as an extension of Informed Consent documents, can further safeguard such rights. Despite its international and national regulation, in certain contexts, such as mental health, the hegemonic-paternalistic model persists, and the authors question the underlying motive

La relació metge-pacient es troba en un procés de canvi I evolució cap a un tractament més humà basat en el principi d'autonomia, amb l'objectiu de respectar els drets del pacient I no només imposar la voluntat de metge. Un instrument que salvaguarda aquesta situació és el Document de Voluntats Anticipades, com a extensió del consentiment informat. Malgrat la seva regulació internacional I nacional, en certs contextos, com el de la salut mental, el model hegemònic-paternalista segueix imperant I ens preguntem per què

Humanos , Directivas Anticipadas/ética , Directivas Anticipadas/legislación & jurisprudencia , Legislación Médica , Salud Mental/ética , Enfermos Mentales/legislación & jurisprudencia , Planificación/ética , Salud Mental/legislación & jurisprudencia , Planificación/legislación & jurisprudencia , Relaciones Médico-Paciente/ética , Autonomía Personal , Atención Dirigida al Paciente/ética
Rev. salud pública ; 22(3): e184536, May-June 2020.
Artículo en Inglés | LILACS | ID: biblio-1115880


ABSTRACT This article attempts to reflect on the importance of thinking in general about illness and about cancer, from an ethical perspective. This approach reveals the central role of personal dignity and the moral relevance that supports the reasons for respecting people. The ethical values that sustain the practice of medicine must aim at uplifting this dignity and seeking situations of justice, since living in a community expresses intersubjectivity that cannot be truncated by illnesses like cancer. Therefore, situations involving poverty cannot justify the lack of health care, and if such lacks occur, they run counter to ethical awareness in the deepest sense and destroy intersubjectivity. As a result, cancer is suffered as a vital experience, in a framework of lives that are lived and are not simply objects of study; those stricken with cancer are individuals who are denied the human right to health, and undergo the elimination of their dignity, the cancelation of justice, and a death sentence. Society is part of these actions and at the same time, suffers from the disappearance of hope. In this sense, the process of informed consent is used as a tool that encourages dialog and understanding between doctors and patients during proper treatment, on a shared path.(AU)

RESUMEN El artículo pretende hacer una reflexión sobre la importancia de pensar, en general, la enfermedad y, en particular, el cáncer, desde una perspectiva ética. Este acercamiento permite vislumbrar el papel central que tiene la dignidad de las personas y la relevancia moral que apuntalan las razones por las cuales ellas han de ser respetadas. Los valores éticos que sustentan la práctica médica han de apelar a enaltecer dicha dignidad y buscar situaciones de justicia, dado que vivir en comunidad da cuenta de una intersubjetividad que no puede ser truncada por enfermedades como el cáncer. Esto evidencia que las situaciones de pobreza no pueden justificar la carencia de cuidados de salud y que, cuando esto sucede, se contraviene, desde lo más hondo, una conciencia de carácter ético y se rompe la intersubjetividad. El cáncer se sufre en tanto experiencia vital, en un marco de vidas vividas y no simplemente de objetos de estudio; los enfermos son personas a quienes se les niega el derecho humano de la salud, se les borra su dignidad, se cancela la justicia y se les condena a la muerte. La sociedad es parte de estas acciones y a la vez sufre la cancelación de esperanzas. En este sentido, se retoma el proceso del consentimiento informado (CI) como una herramienta que permite el diálogo y la comprensión entre médicos y pacientes en la atención digna, en un camino compartido.(AU)

Justicia Social/ética , Personeidad , Consentimiento Informado/ética , Neoplasias/psicología , Relaciones Médico-Paciente/ética , Pobreza
Pediatrics ; 145(6)2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32398328


A 15-year-old girl is scheduled to undergo an upper lobectomy to debulk metastatic Ewing sarcoma. The anesthesiologist recommended placement of a thoracic epidural catheter to provide postoperative analgesia. The patient did not want a needle to be placed near her spine. She was terrified that the procedure would be painful and that it might paralyze her. Although the anesthesiologist reassured her that sedation and local anesthesia would make the procedure comfortable, she remained vehemently opposed to the epidural procedure. The parents spoke privately to the anesthesiologist and asked for placement of the epidural after she was asleep. They firmly believed that this would provide optimal postoperative analgesia and thus would be in her best interest. Experts discuss the pros and cons of siding with the patient or parents.

Conducta del Adolescente/ética , Anestesia Epidural/ética , Dolor Postoperatorio/prevención & control , Relaciones Padres-Hijo , Relaciones Médico-Paciente/ética , Negativa del Paciente al Tratamiento/ética , Adolescente , Conducta del Adolescente/psicología , Anestesia Epidural/métodos , Anestesia Epidural/psicología , Neoplasias Óseas/psicología , Neoplasias Óseas/cirugía , Femenino , Humanos , Dolor Postoperatorio/psicología , Padres/psicología , Sarcoma de Ewing/psicología , Sarcoma de Ewing/cirugía , Negativa del Paciente al Tratamiento/psicología
Proc Natl Acad Sci U S A ; 117(21): 11368-11378, 2020 05 26.
Artículo en Inglés | MEDLINE | ID: mdl-32381738


Over the past several decades, the United States medical system has increasingly prioritized patient autonomy. Physicians routinely encourage patients to come to their own decisions about their medical care rather than providing patients with clearer yet more paternalistic advice. Although political theorists, bioethicists, and philosophers generally see this as a positive trend, the present research examines the important question of how patients and advisees in general react to full decisional autonomy when making difficult decisions under uncertainty. Across six experiments (N = 3,867), we find that advisers who give advisees decisional autonomy rather than offering paternalistic advice are judged to be less competent and less helpful. As a result, advisees are less likely to return to and recommend these advisers and pay them lower wages. Importantly, we also demonstrate that advisers do not anticipate these effects. We document these results both inside and outside the medical domain, suggesting that the preference for paternalism is not unique to medicine but rather is a feature of situations in which there are adviser-advisee asymmetries in expertise. We find that the preference for paternalism holds when advice is solicited or unsolicited, when both paternalism and autonomy are accompanied by expert guidance, and it persists both before and after the outcomes of paternalistic advice are realized. Lastly, we see that the preference for paternalism only occurs when decision makers perceive their decision to be difficult. These results challenge the benefits of recently adopted practices in medical decision making that prioritize full decisional autonomy.

Toma de Decisiones , Autonomía Personal , Relaciones Médico-Paciente , Adulto , Chicago , Femenino , Administración Financiera/ética , Humanos , Internet , Masculino , Medicina , Paternalismo , Relaciones Médico-Paciente/ética , Lugar de Trabajo
Otolaryngol Head Neck Surg ; 163(1): 63-64, 2020 07.
Artículo en Inglés | MEDLINE | ID: mdl-32340553


The COVID-19 pandemic has forced otolaryngologists and their patients to confront issues that they have rarely if ever previously faced. Prominent among these is the need to put the collective good ahead of the interests of individual patients with otolaryngologic disorders. We argue that the individual doctor-patient relationship remains paramount even at a time when public health principles mandate systems-level thinking.

Betacoronavirus , Infecciones por Coronavirus/epidemiología , Otorrinolaringólogos/psicología , Pandemias , Relaciones Médico-Paciente/ética , Neumonía Viral/epidemiología , Humanos
J Clin Ethics ; 31(1): 89-91, 2020.
Artículo en Inglés | MEDLINE | ID: mdl-32213699


In this comment on Kenneth Iserson's article, "Do You Believe in Magic? Shove, Don't Nudge: Advising Patients at the Bedside," I discuss the definition of and the moral evaluation of nudging. I propose that using persuasive descriptions and intentionally building trust in patients by one's demeanor is a form of nudging. I argue that nudging is not necessarily morally problematic, but that it can be controlling and can limit liberty, despite proponents' claims to the contrary. I agree with Iserson that clinicians should give their patients explicit advice, but add that they should ideally also be aware of the more subtle psychological effects of advice giving.

Toma de Decisiones , Principios Morales , Comunicación Persuasiva , Relaciones Médico-Paciente , Humanos , Relaciones Médico-Paciente/ética , Confianza
J Med Internet Res ; 22(1): e16713, 2020 01 29.
Artículo en Inglés | MEDLINE | ID: mdl-32012083


BACKGROUND: Patients' withholding information from doctors can undermine medical treatment, create barriers for appropriate diagnoses, and increase systemic cost in health care systems. To date, there is limited literature detailing the association between trends of patients withholding information behavior (WIB) and the patient-physician relationship (PPR). OBJECTIVE: The aim of this study was to explore the prevalence trend of WIB after 2011 and examine the effects of PPR on WIB and its time trend. METHODS: A total of 5 iterations of data from the Health Information National Trends Survey (years: 2011-2018; n=11,954) were used to explore curvilinear trends of WIB among the US population. Multiple logistic regression models were used to examine curvilinear time trends of WIB, effects of PPR on WIB, and moderation effects of PPR on the WIB time trend. RESULTS: The WIB prevalence has an increasing trend before 2014, which has the highest rate of 13.57%, and then it decreases after 2014 to 8.65%. The trend of WIB is curvilinear as the quadratic term in logistic regression model was statistically significant (P=.04; beta=-.022; SE=0.011; odds ratio [OR] 0.978, 95% CI 0.957-0.999). PPR is reversely associated with WIB (P<.001; beta=-.462; SE=0.097; OR 0.630, 95% CI 0.518-0.766) and has a significant moderation effect on time trends (P=.02; beta=-.06; SE=0.025; OR 0.941, 95% CI 0.896-0.989). In general, poor quality of PPR not only significantly increased the WIB probability but also postponed the change of point for WIB curvilinear trend. CONCLUSIONS: Findings suggest that the time trend of WIB between 2011 and 2018 is curvilinear and moderated by the quality of the PPR. Given these results, providers may reduce WIB by improving PPR. More research is needed to confirm these findings.

Informática Médica/métodos , Relaciones Médico-Paciente/ética , Adolescente , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto Joven
Acad Med ; 95(6): 911-918, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-31977341


PURPOSE: To examine differences in students' empathy in different years of medical school in a nationwide study of students of U.S. DO-granting medical schools. METHOD: Participants in this cross-sectional study included 10,751 students enrolled in 41 of 48 campuses of DO-granting medical schools in the United States (3,616 first-year, 2,764 second-year, 2,413 third-year, and 1,958 fourth-year students). They completed a web-based survey at the end of the 2017-2018 academic year that included the Jefferson Scale of Empathy and the Infrequency Scale of the Zuckerman-Kuhlman Personality Questionnaire for measuring "good impression" response bias. Comparisons were made on empathy scores among students in different years of medical school using analysis of covariance, controlling for the effect of "good impression" response bias. Also, comparisons were made with preexisting data from students of U.S. MD-granting medical schools. RESULTS: A statistically significant decline in empathy scores was observed when comparing students in the preclinical (years 1 and 2) and the clinical (years 3 and 4) phases of medical school (P < .001); however, the magnitude of the decline was negligible (effect size =0.13). Comparison of findings with MD students showed that while the pattern of empathy decline was similar, the magnitude of the decline was less pronounced in DO students. CONCLUSIONS: Differences in DO-granting and MD-granting medical education systems, such as emphasis on provision of holistic care, hands-on approaches to diagnosis and treatment, and patient-centered care, provide plausible explanations for disparity in the magnitude of empathy decline in DO compared with MD students. More research is needed to examine changes in empathy in longitudinal study and explore reasons for changes to avert erosion of empathy in medical school.

Actitud del Personal de Salud , Educación Médica/métodos , Empatía , Medicina Osteopática/educación , Relaciones Médico-Paciente/ética , Facultades de Medicina/organización & administración , Estudiantes de Medicina/psicología , Estudios Transversales , Femenino , Humanos , Masculino , Estudios Retrospectivos