End-of-life decisions in perinatal care: A view from health-care providers in Mexico.

OBJECTIVE: To examine the opinions of a perinatal health team regarding decisions related to late termination of pregnancy and severely ill newborns. MATERIALS AND METHODS: An anonymous questionnaire was administered to physicians, social workers, and nurses in perinatal care. Differences were evaluated using the chi square and Student's t tests. RESULTS: When considering severely ill fetuses and newborns, 82% and 93% of participants, respectively, opted for providing palliative care, whereas 18% considered feticide as an alternative. Those who opted for palliative care aimed to diminish suffering and those who opted for intensive care intended to protect life or sanctity of life. There was poor knowledge about the laws that regulate these decisions. CONCLUSIONS: Although there is no consensus on what decisions should be taken with severely ill fetuses or neonates, most participants considered palliative care as the first option, but feticide or induced neonatal death was not ruled out.

End-of-life decisions in perinatal care: A view from health-care providers in Mexico / Decisiones sobre el final de la vida en la atención perinatal: Una visión del equipo de salud en México

Objective. To examine the opinions of a perinatal health team regarding decisions related to late termination of pregnancy and severely ill newborns. Materials and Methods. An anonymous questionnaire was administered to physicians, social workers, and nurses in perinatal care. Differences were evaluated using the chi square and Student's t tests. Results. When considering severely ill fetuses and newborns, 82% and 93% of participants, respectively, opted for providing palliative care, whereas 18% considered feticide as an alternative. Those who opted for palliative care aimed to diminish suffering and those who opted for intensive care intended to protect life or sanctity of life. There was poor knowledge about the laws that regulate these decisions. Conclusions. Although there is no consensus on what decisions should be taken with severely ill fetuses or neonates, most participants considered palliative care as the first option, but feticide or induced neonatal death was not ruled out.

Objetivo. Explorar la opinión del equipo de salud sobre las decisiones relacionadas con la atención de fetos y neonatos gravemente enfermos. Material y métodos. Se aplicó un cuestionario anónimo a médicos, trabajadoras sociales y enfermeras perinatales. Las diferencias se evaluaron con las pruebas chi cuadrada y t de Student. Resultados. Al tratar fetos y neonatos gravemente enfermos, 82 y 93% de los participantes optaron, respectivamente, por atención paliativa. El 18% consideró el feticidio como alternativa. Quienes optaron por atención paliativa, lo hicieron para disminuir el sufrimiento, mientras que los que eligieron cuidados intensivos lo hicieron para proteger la vida o la sacralidad de la vida. Nuestro estudio mostró un pobre conocimiento de las leyes que regulan estas decisiones. Conclusiones. Aun cuando no existe un consenso sobre las decisiones que deben tomarse con fetos o neonatos gravemente enfermos, la mayoría consideró como primera opción los cuidados paliativos, aunque el feticidio y la muerte neonatal inducida no se descartaron.

Legality and age influence end of life decisions in Mexican physicians.

PURPOSE: To test in two groups of physicians-in-training a simplified questionnaire exploring their acceptance of Physician Assisted Death (PAD), Therapy Withdrawal upon family request (WD), and Personalized PAD (PPAD) on whether the participant would seek PAD for him/herself. MATERIAL AND METHODS: A 4-item questionnaire was answered by 212 residents in different stages of training and grouped as beginners (1st and 3d year internal medicine residents, n = 76) and advanced (5th to 8th year residents of different internal medicine or oncology subspecialties, n = 136). The response options to the PAD and WD questions included a conditioned yes (CYes) dealing with legalization of PAD or the existence of a patient's previous written agreement to WD. RESULTS: Beginners had significantly more Yes plus C-Yes answers than advanced for questions regarding PAD (82 vs. 55%), WD (95 vs. 75%) and PPAD (76 vs. 56%). The importance of legal aspects implied in the conditioned answers can be seen in two findings: a) A sizable 29% of participants conditioned their Yes answers for both questions whereas only 9% gave an unconditioned Yes to both. b) A cross-classification of the PAD and WD answers showed that 13% of participants reversed their No in PAD to C-Yes in WD. CONCLUSIONS: Our simplified questionnaire operated well and was able to confirm the increase in acceptance of PAD and WD by young Mexican physicians, and the need of legislation regarding end of life decisions in our country.

Physician-assisted death. Opinions of Mexican medical students and residents.

BACKGROUND AND AIMS: To explore opinions of young residents and medical students on physician-assisted death (PAD). METHODS: A questionnaire was answered by 140 residents at the beginning of their residency and 99 third- or fourth-year medical students (46 attended religiously administered medical schools [RAMS] and 53 lay-administered medical schools [LAMS]). Main questions were agreement with PAD, therapy withdrawal (TW) and personalized PAD (PPAD) on whether participants themselves would seek help to die. RESULTS: There were no differences of acceptance between residents and students but LAMS students had significantly higher agreement than RAMS students for PAD (68 vs. 33%), TW (79 vs. 39%) and PPAD (57 vs. 48%). LAMS students were also more willing to agree to a physician prescribe/inject a lethal drug, even if PAD were not legalized. However, legality was also an important issue, i.e., 25-58% of those unsure or opposed to PAD would reverse the decision if PAD were legalized, and 42-54% of those unwilling to TW would also reverse if written consent of the patient existed. Overall acceptance of residents and students was significantly higher than our previous study in nearly 1,000 older physicians (50 vs. 39% for PAD and 58 vs. 48% for TW). CONCLUSIONS: PAD and TW acceptability seems to be increasing in Mexico, probably as a result of evolving social attitudes that appeared to be counteracted by a more conservative upbringing at home in our young RAMS students.

A functional ABCA1 gene variant is associated with low HDL-cholesterol levels and shows evidence of positive selection in Native Americans.

It has been suggested that the higher susceptibility of Hispanics to metabolic disease is related to their Native American heritage. A frequent cholesterol transporter ABCA1 (ATP-binding cassette transporter A1) gene variant (R230C, rs9282541) apparently exclusive to Native American individuals was associated with low high-density lipoprotein cholesterol (HDL-C) levels, obesity and type 2 diabetes in Mexican Mestizos. We performed a more extensive analysis of this variant in 4405 Native Americans and 863 individuals from other ethnic groups to investigate genetic evidence of positive selection, to assess its functional effect in vitro and to explore associations with HDL-C levels and other metabolic traits. The C230 allele was found in 29 of 36 Native American groups, but not in European, Asian or African individuals. C230 was observed on a single haplotype, and C230-bearing chromosomes showed longer relative haplotype extension compared with other haplotypes in the Americas. Additionally, single-nucleotide polymorphism data from the Human Genome Diversity Panel Native American populations were enriched in significant integrated haplotype score values in the region upstream of the ABCA1 gene. Cells expressing the C230 allele showed a 27% cholesterol efflux reduction (P< 0.001), confirming this variant has a functional effect in vitro. Moreover, the C230 allele was associated with lower HDL-C levels (P = 1.77 x 10(-11)) and with higher body mass index (P = 0.0001) in the combined analysis of Native American populations. This is the first report of a common functional variant exclusive to Native American and descent populations, which is a major determinant of HDL-C levels and may have contributed to the adaptive evolution of Native American populations.

Attitudes and anticipated reactions to genetic testing for cancer among patients in Mexico City.

The aim of this study was to investigate the attitudes toward cancer predictive genetic testing in a group of non-high-risk women and men and to analyze the factors that may influence their intention to use these tests. We studied a sample of 859 outpatient women and men attending the four tertiary care hospitals of the ISSSTE (Institute of Social Security and Services for Government Employees) in Mexico City. Subjects between the ages of 30 and 74 years with no present or past history of cancer were asked to answer a questionnaire through face-to-face interview. Two different questionnaires were designed, one for women and the other for men, regarding genetic testing of a high-risk gene for breast and prostate cancer, respectively. Descriptive statistics and univariate comparisons were carried out using chi-square test, Wilcoxon's signed rank test, and Friedman test. Multivariate analysis was performed using logistic regression technique. Results showed that the majority of women attended clinics for regular check-ups and for performing screening tests to detect breast cancer, and men did not follow this pattern regarding prostate cancer. Women were more motivated to get genetic testing, more aware about its benefits, and more concerned about having cancer than men.

Physician-assisted death. Opinions of a sample of Mexican physicians.

BACKGROUND: There is insufficient information on what Mexicans think of physician-assisted death, a problem that is currently being discussed in our legislative bodies. This paper discusses the findings among a sample of physicians. METHODS: The sample was formed by 2097 physicians from several specialties employed by a Mexican government health system, distributed throughout the country. Each physician received a structured questionnaire exploring what they thought of two different scenarios related to physician-assisted death: 1) intolerable suffering of patients; and 2) persistent vegetative state (PVS). Questions included data on several personal characteristics of the respondents and two open-ended questions asking the reasons why they answered the main questions as they did. RESULTS: There was an overall response rate of 47.3%. Approximately 40% agreed with physicians helping terminally ill patients request to die because of intolerable suffering caused by incurable diseases, whereas 44% said no and the rest were undecided. This was statistically different from the answers to the scenario where the relatives of a patient in a PVS ask their physician to help him or her die, where 48% of respondents said yes, and 35% said no. The main reasons to say yes in both scenarios were respect for patients or family autonomy and to avoid suffering, whereas those opposed cited other ethical and mainly religious considerations. CONCLUSIONS: The variable with the highest probability to approve both scenarios was of a legal nature, whereas strong religious beliefs were against accepting physician-assisted death. The group was evenly divided with approximately 40% each between those for and against the idea of helping die a patient and approximately 20% were undecided.

Acceptance of induced abortion amongst medical students and physicians in Mexico.

BACKGROUND: Abortion is illegal in most of Mexico, except in the case of rape or physical risk to the mother, but there are several indicators that suggest that at least in Mexico City, society would like to have a more liberal law. The present study was performed to learn what several groups of physicians and medical students residing outside of Mexico City think in this regard. METHODS: Seven colleagues working in different cities agreed to apply a questionnaire to physicians and or medical students available to them, to learn their opinions regarding the acceptability of induced abortion in several scenarios. Questions one to tree inquires if abortion is acceptable up to week 20 of pregnancy at the simple request of the parents, if the fetus has a severe malformation or anencephaly. Questions four to six personalize the situations by supposing that the physician or spouse have a high risk of having a malformed child. Question seven asks if they would offer prenatal diagnosis to a mother who would abort a malformed fetus. Statistical procedure includes multivariate analysis. RESULTS: The inter-city physicians-students composition was very heterogeneous. The majority of respondents disagreed with abortion on demand of the parents, but clearly agrees to it in the presence of severe malformations. In general males, above 30 years old physicians and less religious individuals, are more in favor to abortion than their respective counterparts. The proportion of acceptance is over 70% in most cases. CONCLUSION: We believe that this work shows a preliminary indication of a national trend amongst physicians and medical students favoring induced early abortion if the fetus has a severe malformation.

Acceptance of induced abortion amongst medical students and physicians in Mexico / Aceptación en México del aborto inducido entre estudiantes de medicina y médicos

Background. Abortion is illegal in most of Mexico, except in the case of rape or physical risk to the mother, but there are several indicators that suggest that at least in Mexico City, society would like to have a more liberal law. The present study was performed to learn what several groups of physicians and medical students residing outside of Mexico City think in this regard. Methods. Seven colleagues working in different cities agreed to apply a questionnaire to physicians and or medical students available to them, to learn their opinions regarding the acceptability of induced abortion in several scenarios. Questions one to tree inquires if abortion is acceptable up to week 20 of pregnancy at the simple request of the parents, if the fetus has a severe malformation or anencephaly. Questions four to six personalize the situations by supposing that the physician or spouse have a high risk of having a malformed child. Question seven asks if they would offer prenatal diagnosis to a mother who would abort a malformed fetus. Statistical procedure includes multivariate analysis. Results. The inter-city physicians-students composition was very heterogeneous. The majority of respondents disagreed with abortion on demand of the parents, but clearly agrees to it in the presence of severe malformations. In general males, above 30 years old physicians and less religious individuals, are more in favor to abortion than their respective counterparts. The proportion of acceptance is over 70% in most cases. Conclusion. We believe that this work shows a preliminary indication of a national trend amongst physicians and medical students favoring induced early abortion if the fetus has a severe malformation.

Antecedentes. El aborto es ilegal en la mayor parte de México, excepto cuando el embarazo es resultado de una violación o existe riesgo para la salud de la madre. Hay, sin embargo, indicadores que sugieren que en el D.F. la sociedad quisiera una ley más liberal y en el presente trabajo se explora la situación entre estudiantes de medicina y médicos fuera de la ciudad de México. Métodos. Siete colegas en diferentes ciudades aplicaron un cuestionario para conocer la opinión de los encuestados en relación con el aborto inducido. Las preguntas 1 a 3 averiguan la aceptabilidad del aborto antes de la semana 20 del embarazo por simple solicitud de los padres, por una malformación congénita severa o por la presencia de anencefalia. Las preguntas 4 a 6 personalizan la situación bajo el supuesto que el entrevistado o su cónyuge tengan alto riesgo de tener un bebé malformado y la pregunta siete averigua si ofrecerían el diagnóstico prenatal a una persona que abortaría un producto afectado. Resultados. Fue muy heterogénea la proporción estudiantes-médicos en las siete ciudades. La mayoría de los entrevistados estuvieron en desacuerdo con el aborto por la simple solicitud de los padres, pero más de 70% estuvo de acuerdo cuando había un producto malformado. En general, los varones mayores de 30 años y poco religiosos estaban más a favor del aborto que sus contrapartes. Conclusión. El trabajo muestra de manera preliminar, que existe una tendencia nacional entre estudiantes y médicos que favorece al aborto temprano en el caso de fetos malformados.

Changing opinions of Mexican geneticists on ethical issues.

BACKGROUND: The discussion of ethical issues in the practice of medical genetics is quite recent in Mexico. However, in the present report we were able to compare the results obtained with the same instrument in two surveys performed with a 12-year interval. METHODS: A semistructured questionnaire including 52 questions that explore many different situations in the form of case vignettes related to ethical dilemmas was sent on two occasions to geneticists certified by the Mexican Board of Human Genetics. The first survey was performed in 1993, obtaining a response rate of 72% (64 individuals) and the second in 2005 with a 61% response rate (86 individuals). The areas explored were fairness of access to genetic services, full disclosure of all relevant information, respect for parental choices, protection of patients' privacy, use of prenatal diagnosis only for information about the health of the fetus, voluntary vs. mandatory screening and patients' confidentiality vs. the defense of third party interests. RESULTS: All questions analyzed in the paper were answered by at least 80% of the geneticists surveyed, although in many instances their experience with the situation explored was limited. The complete results of the 2005 survey are given in the text and tables, whereas the 1993 results are used mainly for comparison and given in full only when practical. There was a tendency to answer general questions one way and later change opinions when confronted with specific cases. There was a clear paternalistic attitude and a generalized opinion that one of the goals of medical genetics is to diminish the proportion of individuals with genetic diseases, not for eugenics reasons, but to avoid suffering of the patients and their families. CONCLUSIONS: Comparison of both surveys clearly shows a tendency towards increasing respect for privacy and autonomy of the patients.

[Conscientious objectors among physicians]. / Objeción de conciencia en la profesión médica.

Conscientious objection refers to the possibility that an individual decides not to comply with a legal mandate because of his or hers convictions, which is accepted by some political constitutions. The classical example is to refuse participation in obligatory military service for personal reasons of conscience, but in the present paper we refer to its use in medical practice utilizing three examples: euthanasia, abortion and the refusal to prescribe emergency contraception. We conclude that in all situations patients rights supersedes conscientious objection.

[Genomic medicine. Myths and reality]. / Medicina genómica. Mitos y realidades.

Genomic medicine is simply the routine use of genomic analysis, preferably by direct DNA studies, to improve the quality of medical care. A likely consequence will be to increase the predictive and prevention capacities of medicine, including common diseases, such as cancer, diabetes and others. The most common variability of the genome are the SNPs (single nucleotide polymorphisms), every person having between 3 and 10 million of them. SNPs may or not be harmless, and studies are in progress in cases and controls studies to answer the question of whether they determine why some persons have a given disease and others do not, and if they have something to do with that the individual variation in the response to drugs. We discuss in the same context the haplotype map project (HapMap) as a tool to facilitate the study of possible associations of genome changes and common diseases. We discuss the most successful effort in gene therapy, that of severe combined immunodeficiency, in which 17 out of 18 patients responded well to the procedure, although 2 of them developed late side effects in the form of acute leukemia, very likely related to the therapy. The ethical social and legal problems of genomic medicine are discussed very lightly and several references are given to readers interested in this matter.

Association of vitamin D receptor polymorphisms with osteoporosis in mexican postmenopausal women.

It has been reported that Vitamin D receptor polymorphisms are associated with osteoporosis, particularly those demonstrated by the BsmI and FokI restriction enzymes. Herein we report the results of a case-control study performed in postmenopausal Mexican women. We studied 65 osteoporotic women (< or = -2.5 SD bone mineral density [BMD] of young normal females) and 57 controls (over 90% > or = -1.5 SD BMD of young normal females. Restriction enzymes BsmI and FokI were used to identify polymorphisms. Odds ratios and their 95% confidence intervals were calculated, and analysis was performed controlling for age as a covariate. The BsmI genotypes revealed a higher frequency of the bb genotype in cases than in controls, contradicting much of the literature that suggests this genotype protects females against osteoporosis. Regarding the FokI genotypes, we were unable to confirm that the FF genotype has a protective effect against osteoporosis. The inconsistencies found in the literature and the results obtained in the present work suggest to us that other genetic and nongenetic factors are involved in the occurrence of osteoporosis, confounding the results of the possible association of osteoporosis and VDR polymorphisms.