Objeção de consciência na dinâmica do atendimento ao aborto legal em Minas Gerais / Conscientious objection to legal abortion in Minas Gerais state

Objetivo: O objetivo do estudo foi verificar a existência da objeção de consciência na atenção integral à saúde das vítimas de violência sexual, bem como conhecer a estrutura de atendimento das instituições credenciadas na rede de atenção à vítima de violência sexual no Estado de Minas Gerais. Métodos: Trata-se de um estudo de campo de caráter quantitativo, transversal, descritivo e analítico, com proposta de coleta de dados das instituições credenciadas ao atendimento às vítimas de violência sexual no estado. O instrumento foi entregue aos(às) coordenadores(a) desses serviços. Resultados: Verificou-se que 11% dos serviços não possuem médicos e 31% não fornecem treinamento para esse tipo de atendimento. Foi revelado que 85% dessas instituições já encontraram pacientes que desejam fazer o aborto legal, mas 83% delas não tiveram seu pedido atendido. Houve 60% da presença de objeção de consciência por parte de toda a equipe médica, sendo o principal motivo religioso (57%). Conclusão: O sistema de assistência no Estado não está preparado para o atendimento integral às vítimas de violência sexual, principalmente no quesito resolução do aborto legal, sendo a objeção de consciência o maior obstáculo. Faz-se necessária uma rede de referência e contrarreferência funcionante para amenizar esse problema tão sério e evidente. Espera-se que o resultado da pesquisa crie espaços de diálogo dentro do Estado que favoreçam ações adequadas sobre o aborto legal e respeitem o profissional médico se houver objeção de consciência.(AU)

Objective: The aim of this study was to verify the existence of conscientious objection to comprehensive health care for the victim of sexual violence, as well as to understand the service structure of institutions authorized in the health care system for victims of sexual violence in the state of Minas Gerais. Methods: This is a quantitative, cross-sectional, descriptive, and analytical field study aiming to collect data from institutions authorized to assist victims of sexual violence in the state. The instrument was handed in to the coordinators of these services. Results: It was found that 11% have no physician in service and that 31% had no training for this type of care. It was revealed that 85% of these institutions have already encountered patients wishing to have a legal abortion, but 83% of them have not had their request granted. There was a 60% presence of conscientious objection by the entire medical team, the main reason being religious (57%). Conclusion: The assistance system is not prepared for comprehensive care for victims of sexual violence, especially in terms of legal abortions, with conscientious objection being the main obstacle. A functional referral and counter-referral system is needed to alleviate such a serious and evident problem. It is hoped that the research results will promote dialogues in the state that favor appropriate actions on legal abortion, and respect the medical professional, in case of conscientious objection.(AU)

Health literacy in pregnant women facing prenatal screening may explain their intention to use a patient decision aid: a short report.

BACKGROUND: It has been suggested that health literacy may impact the use of decision aids (DAs) among patients facing difficult decisions. Embedded in the pilot test of a questionnaire, this study aimed to measure the association between health literacy and pregnant women's intention to use a DA to decide about prenatal screening. We recruited a convenience sample of 45 pregnant women in three clinical sites (family practice teaching unit, birthing center and obstetrical ambulatory care clinic). We asked participating women to complete a self-administered questionnaire assessing their intention to use a DA to decide about prenatal screening and assessed their health literacy levels using one subjective and two objective scales. RESULTS: Two of the three scales discriminated between levels of health literacy (three numeracy questions and three health literacy questions). We found a positive correlation between pregnant women's intention to use a DA and subjective health literacy (Spearman coefficient, Rho 0.32, P = 0.04) but not objective health literacy (Spearman coefficient, Rho 0.07, P = 0.65). Hence subjective health literacy may affect the intention to use a DA among pregnant women facing a decision about prenatal screening. CONCLUSION: Special attention should be given to pregnant women with lower health literacy levels to increase their intention to use a DA and ensure that every pregnant women can give informed and value-based consent to prenatal screening.

(Bio)Ethics and Primary Health Care: preliminary study on Family Clinics in the city of Rio de Janeiro, Brazil. / (Bio)ética e Atenção Primária à Saúde: estudo preliminar nas Clínicas da Família no município do Rio de Janeiro, Brasil.

The Family Health Strategy (FHS) started out as the Family Health Program (FHP) in 1994, and has since has been re-thought and re-worked in Brazil as the primary rationale for reorganizing Primary Healthcare (PHC). Transforming the hegemonic PHC into FHS has resulted in many changes in how healthcare is provided, which have impacted different areas. For example, matters of (bio)ethics must still be elucidated. Within this context, this investigation is characterized as an exploratory study focused on mapping the main (bio)ethical problems identified by PHC workers in the city of Rio de Janeiro. For this reason, we used a questionnaire and asked Family Clinic (FC) healthcare professionals to answer it. The answers were submitted to content analysis as proposed by Bardin. PHC in the context of Family Clinics has unique elements in terms of the (bio)ethical relationships established in this level of healthcare. It is extremely necessary that new theoretical references be proposed, and that education/training measures to address such issues be developed.

(Bio)ética e Atenção Primária à Saúde: estudo preliminar nas Clínicas da Família no município do Rio de Janeiro, Brasil / (Bio)Ethics and Primary Health Care: preliminary study on Family Clinics in the city of Rio de Janeiro, Brazil

Resumo A Estratégia Saúde da Família (ESF) – iniciada como Programa de Saúde da Família (PSF), em 1994 – vem sendo pensada e trabalhada, no Brasil, como lógica prioritária para reorganização da Atenção Primária à Saúde (APS). A transformação do modelo hegemônico de APS em ESF tem promovido várias mudanças no modo de trabalho em saúde, cujos impactos em diferentes esferas – por exemplo, (bio)éticas – ainda precisam ser elucidados. Nesse contexto, realizou-se a presente investigação, caracterizada como estudo exploratório e dirigida ao mapeamento dos principais problemas (bio)éticos identificados pelos trabalhadores da APS do município do RJ. Para isso, utilizou-se um questionário – aplicado aos profissionais das Clínicas da Família (CF) – para coleta de informações, procedendo-se a análise de conteúdo, de acordo com o proposto por Bardin. O trabalho na APS no contexto da CF, possui particularidades em termos das relações (bio)éticas estabelecidas nesse nível de atenção à saúde. Assim, a proposição de novos referenciais teóricos e o desenvolvimento de ações educativas usualmente utilizadas para a abordagem das questões tornam-se extremamente necessários.

Abstract The Family Health Strategy (FHS) started out as the Family Health Program (FHP) in 1994, and has since has been re-thought and re-worked in Brazil as the primary rationale for reorganizing Primary Healthcare (PHC). Transforming the hegemonic PHC into FHS has resulted in many changes in how healthcare is provided, which have impacted different areas. For example, matters of (bio)ethics must still be elucidated. Within this context, this investigation is characterized as an exploratory study focused on mapping the main (bio)ethical problems identified by PHC workers in the city of Rio de Janeiro. For this reason, we used a questionnaire and asked Family Clinic (FC) healthcare professionals to answer it. The answers were submitted to content analysis as proposed by Bardin. PHC in the context of Family Clinics has unique elements in terms of the (bio)ethical relationships established in this level of healthcare. It is extremely necessary that new theoretical references be proposed, and that education/training measures to address such issues be developed.

Programa de Planificación Familiar y Riesgo Reproductivo sensible al género / Program for family planning and reproductive risk gender sensitive

Introducción: la escasa asistencia masculina a la consulta de planificación familiar es reconocida en las publicaciones científicas como una problemática que imposibilita, entre otros factores, el acceso equitativo a ese servicio, dificulta la distribución y manejo de recursos en función de necesidades de atención femeninas y masculinas. Los hombres se encuentran en desventaja con respecto a las mujeres en cuanto a: prestación de servicios de planificación familiar enfocados a ellos como población diana, beneficios de las acciones o estrategias de salud sexual y salud reproductiva plasmadas en planes, programas o políticas de salud y esto constituye, en términos de derechos reproductivos, una limitación al momento de garantizarlos a cada persona sin distinción alguna. Objetivo: identificar en el Programa de Planificación Familiar y Riesgo Reproductivo la contemplación de las necesidades de atención relativas a salud sexual y reproductiva de los hombres. Método: se realizó un análisis de contenido cualitativo de tipo temático al Programa de Planificación Familiar y Riesgo Reproductivo por el que se guían los servicios de planificación familiar en Cuba. Resultados: el Programa de Planificación familiar y Riesgo reproductivo carece de propuestas concretas para lograr la identificación y satisfacción de las necesidades de los hombres; situación que repercute en la escasa participación masculina en el servicio de Planificación Familiar. Conclusiones: el Programa de Planificación familiar y Riesgo reproductivo solo responde de manera explícita a una única necesidad de atención masculina: la falta de orientación y educación sexual de los hombres(AU)

Introduction: the low male attendance to family planning consultation is recognized in the scientific literature as a problem which precludes, inter alia, equal access to that service, it makes the distribution and management of resources according to needs of female and maleassistance. Men are at a disadvantage with respect to women regarding: provision of family planning services aimed at them as a target population benefits of actions or strategies of sexual and reproductive health reflected in plans, programs and policies on health and this is, in terms of reproductive rights, a limitation on the time of guaranteeing to every person without distinction. Objective: Identify care needs on sexual and reproductive health of men in the Program for Family Planning and Reproductive Risk. Method: A qualitative analysis was made on thematic content of theProgram for Family Planning and Reproductive Risk by which family planning services are guided in Cuba. Results: Program for Family Planning and Reproductive Risk lacks concrete proposals for identifying and meeting the needs of men, which affects the low male participation in family planning service. Conclusions: Family Planning Program and reproductive risk only responds to a sole need for male assistance: the lack of guidance and sex education for men(AU)

Programa de Planificación Familiar y Riesgo Reproductivo sensible al género / Program for family planning and reproductive risk gender sensitive

Introducción: la escasa asistencia masculina a la consulta de planificación familiar es reconocida en las publicaciones científicas como una problemática que imposibilita, entre otros factores, el acceso equitativo a ese servicio, dificulta la distribución y manejo de recursos en función de necesidades de atención femeninas y masculinas. Los hombres se encuentran en desventaja con respecto a las mujeres en cuanto a: prestación de servicios de planificación familiar enfocados a ellos como población diana, beneficios de las acciones o estrategias de salud sexual y salud reproductiva plasmadas en planes, programas o políticas de salud y esto constituye, en términos de derechos reproductivos, una limitación al momento de garantizarlos a cada persona sin distinción alguna.Objetivo: identificar en el Programa de Planificación Familiar y Riesgo Reproductivo la contemplación de las necesidades de atención relativas a salud sexual y reproductiva de los hombres.Método: se realizó un análisis de contenido cualitativo de tipo temático al Programa de Planificación Familiar y Riesgo Reproductivo por el que se guían los servicios de planificación familiar en Cuba.Resultados: el Programa de Planificación familiar y Riesgo reproductivo carece de propuestas concretas para lograr la identificación y satisfacción de las necesidades de los hombres; situación que repercute en la escasa participación masculina en el servicio de Planificación Familiar.Conclusiones: el Programa de Planificación familiar y Riesgo reproductivo solo responde de manera explícita a una única necesidad de atención masculina: la falta de orientación y educación sexual de los hombres(AU)

Calculus formation: nurses' decision-making in abortion-related care.

Nurses routinely provide care to patients in ethically challenging situations. To explore the continuum between conscientious objectors and designated staff in the provision of care to women seeking abortions, the aim of this study was to thickly describe decision-making, using abortion as the clinical context to elucidate how nurses approach ethically challenging work. A purposive sample of 25 nurses who worked in abortion clinics, emergency departments, intensive care units, labor, and delivery, operating rooms, and post anesthesia care units were interviewed. Qualitative description and thematic analysis were used to identify the cognitive, emotional, and behavioral processes in nurses' decisions to care for women needing abortions. Nurses developed and used multifaceted, real-time calculi when making decisions about their participation in emergent or routine abortion care. Nurses tacked back and forth between the personal and professional and/or held multiple contradictory positions simultaneously. Nurses weighed the role and opinion of others to determine if they know how to or know why they would provide abortion care to women, particularly in the elective abortion context. The parameters of the nurse-patient relationship were complex and specific to the experiences of both the nurse and patient. Findings from this study further develop the science of ethically challenging decision-making and expand our understanding of factors that influence how nurses develop relationships to ethically challenging work.

Disposal of fetal tissue following elective abortion: what women think.

BACKGROUND AND METHODOLOGY: UK regulations on managing fetal tissue after pregnancy loss, including abortion, are underscored by the concept of 'sensitive disposal'. This involves offering women burial or cremation and, when disposal is by the health care provider, separating fetal tissue from other clinical waste before incineration. We interviewed 23 women who had undergone one or more abortions about their understanding, attitudes and experiences of fetal tissue disposal and 'sensitive disposal'. Transcripts were analysed for representative themes. RESULTS: Prior to the abortion, most participants did not give consideration to disposal methods because their focus was on ending the pregnancy. Appropriate disposal by health professionals was assumed but some women undergoing early medical abortion reported anxiety about how to manage disposal at home. The term 'sensitive disposal' was unfamiliar to most respondents. Participants generally favoured separation of fetal tissue from other clinical waste and approved of incineration as a means of destruction. Ceremonial disposal was approved of following the loss of a wanted pregnancy but not following elective abortion. Most wanted the opportunity to access information about disposal but did not favour being asked or required to make decisions about disposal. DISCUSSION AND CONCLUSIONS: Knowledge about the management of fetal tissue after abortion or the concept of 'sensitive disposal' was limited among the women we interviewed. Current guidelines appear discordant with the views of women terminating an unwanted pregnancy. Further research is needed to better inform policy on this issue.

Access to services: advocacy for abortion.

Twenty-five years ago, in 1989, family planning services in Britain faced a serious crisis with contentious cuts for community clinics being contemplated by health authorities. There was extensive discussion on ethical issues relating to the provision of abortion services. Social acceptance of abortion occurred in association with departure from traditional values due to the exigencies of modern life. Twenty-five years later, in 2014, abortion unfortunately continues to cause controversy in international health, despite guidance for its incorporation in comprehensive reproductive health care services.

Management of ethical issues related to care of seriously ill dialysis patients in free-standing facilities.

CONTEXT: There are few data on the frequency and current management of clinical ethical issues related to care of seriously ill dialysis patients in free-standing dialysis facilities. OBJECTIVES: To examine the extent of clinical ethical challenges experienced by care providers in free-standing facilities and their perceptions about how those issues are managed. METHODS: A total of 183 care providers recruited from 15 facilities in North Carolina completed a survey regarding the occurrence and management of ethical issues in the past year. Care plan meetings were observed at four of the facilities for three consecutive months. Also, current policies and procedures at each of the facilities were reviewed. RESULTS: The two most frequently experienced challenges involved dialyzing frail patients with multiple comorbidities and caring for disruptive/difficult patients. The most common ways of managing ethical issues were discussions in care plan meetings (n = 47) or discussions with the clinic manager (n = 47). Although policies were in place to guide management of some of the challenges, respondents were often not aware of those policies. Also, although participants reported that ethical issues related to dialyzing undocumented immigrants were fairly common, no facility had a policy for managing this challenge. Participants suggested that all staff obtain training in clinical ethics and communication skills, facilities develop ethics teams, and there be clear policies to guide management of ethical challenges. CONCLUSION: The scope of ethical challenges was extensive, how these challenges were managed varied widely, and there were limited resources for assistance. Multifaceted efforts, encompassing endeavors at the individual, facility, organization, and national levels, are needed to support staff in improving the management of ethical challenges in dialysis facilities.

[Ethics in aesthetic surgery]. / Ethique de la chirurgie esthétique.

The use of aesthetic medicine and surgery is increasingly popular, and becomes a true phenomenon of society. Many women and men are asking for such treatments. A large proportion of the population carry the idea that this branch of medicine is a true consumer product. The acts of aesthetic medicine and surgery are not without consequences. They produce important changes in the human body, and carry risks of complications that must be taken into account. The overrated media interest of this subject produce commercial drifts that act against the general health of the patients. The invasive acts of medical aesthetics must be placed in a precise legal and ethical framework to protect the patients. A project of a new Belgian law is on the way, awaiting for publication in "Le Moniteur": this law (proposed by Senator Dominique Tilmans) clarifies the competences required for performing non-surgical aesthetic treatments and specific aesthetic invasive treatments. Other projects of law are being studied, and will concern publicity, information of the public, and rules of private clinics where aesthetic invasive acts are performed. Recent international news have shown, with the PIP breast prosthesis scandal, that surveillance of the medical aesthetic field is mandatory. To provide a better protection of patients, the legislator has decided legislate over the subject.

Abortion misinformation from crisis pregnancy centers in North Carolina.

BACKGROUND: This study assessed the accuracy of medical information provided by crisis pregnancy centers in North Carolina. STUDY DESIGN: We performed a secondary data analysis of a "secret shopper survey" performed by a nonprofit organization. Reports from phone calls and visits to crisis pregnancy centers were analyzed for quality and content of medical information provided. Web sites of crisis pregnancy centers in the state were also reviewed. RESULTS: Thirty-two crisis pregnancy centers were contacted. Nineteen of these were visited. Fourteen centers (44%) offered that they "provide counseling on abortion and its risks." Inaccurate information provided included a link between abortion and breast cancer (16%), infertility (26%) and mental health problems (26%). Of the 36 Web sites identified, 31 (86%) provided false or misleading information, including 26 sites (72%) linking abortion to "post-abortion stress." CONCLUSIONS: Many crisis pregnancy centers give inaccurate medical information regarding the risks of abortion. Overstating risks stigmatizes abortion, seeks to intimidate women and is unethical.

Informing egg donors of the potential for embryonic research: a survey of consent forms from U.S. in vitro fertilization clinics.

OBJECTIVE: To understand whether and to what extent U.S. IVF clinics inform egg donors that resultant embryos initially intended to be implanted for reproductive purposes may in fact be used for research instead. DESIGN: Four hundred seventy U.S. IVF clinics were asked to respond to a questionnaire and provide a copy of the egg donor consent form(s) used at the clinic. SETTING: Four hundred seventy U.S. IVF clinics listed in a Centers for Disease Control and Prevention database; only forms from clinics that both accepted donor eggs and provided excess embryos for research were analyzed for content. PATIENT(S): Not applicable. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Responses to the questionnaire, demographic data from a Centers for Disease Control and Prevention database, and the content of egg donor consent forms. RESULT(S): Of 222 U.S. IVF clinics that responded to our query, 100 clinics both accepted donor eggs and provided some excess embryos for research. We received 66 consent forms from these 100 clinics, which showed that although most egg donor consent forms inform donors that they will not have control over embryos resulting from their eggs, 30% inform them that some embryos may be used for research, and even fewer mention stem cell research. CONCLUSION(S): Egg donors in the United States, including some who may have a moral objection to research and stem cell research, are not being informed that embryos created with their donated eggs may in fact be used for these purposes. This can be corrected with the inclusion of succinct, nontechnical language in egg donor consent forms.

What do patients want? Expectations and perceptions of IVF clinic information and support regarding frozen embryo disposition.

OBJECTIVE: To describe frozen embryo holders' expectations and perceptions of IVF clinic information, support, and storage fees and their relevance to embryo disposition decision making. DESIGN: Qualitative interview study. SETTING: Three northern California IVF practices. PATIENT(S): One hundred six families (110 women and 74 men) with an average of six frozen embryos in storage for 5 years. INTERVENTION(S): Three in-depth interviews over 1 year. MAIN OUTCOME MEASURE(S): Thematic analysis of interview transcripts. RESULT(S): Although embryo holders expected that IVF clinics were under obligation to assist in the disposition decision and would be their main source of information, these expectations did not become manifest until years after embryo cryopreservation. Patients expressed a variety of preferences for the timing, format, and content of information and support, ranging from detailed written information to counselor/advocates that could provide logistical guidance and/or psychologic support. Embryo holders perceived an insufficiently defined infrastructure to facilitate donation to other couples, whereas donating to medical research was seen as less complicated and more likely to be encouraged and supported by physicians and clinics. Although increasing storage fees motivated disposition decision making, they could be interpreted as coercive and/or not reflective of actual clinic costs. CONCLUSION(S): Frozen embryo-holding patients' expectations of information and support to assist them with disposition decision making and embryo donation suggests that IVF clinics may benefit from a review of their frozen embryo counseling, storage, and disposition policies and procedures.