Técnicas de manejo de conducta en odontopediatría: aspectos éticos y legales / Behavioral management techniques in pediatric dentistry: ethical and legal aspects

Introducción: la profesión odontológica es una actividad orientada al cuidado de personas, entre ellos los niños, que necesitan un cuidado más específico estando en pleno desarrollo físico y emocional. Al trabajar con los niños se tiene que lidiar con la ansiedad con la que el pequeño entra por primera vez a la consulta. Para solucionar este problema, se han descrito diferentes técnicas cuya elección depende de la edad, de las necesidades del paciente y de la habilidad profesional. Estas técnicas se pueden agrupar en tres grupos: técnicas farmacológicas, técnicas comunicativas y técnicas no comunicativas. Objetivo: revisar la evidencia científica sobre los aspectos éticos y legales de las técnicas de manejo de conducta en odontopediatría. Material y método: se realizó una búsqueda en las bases de datos de PubMed/ Medline, Google Scholar y Scopus de acuerdo a unos criterios de inclusión y exclusión. Resultados: los resultados determinan que el empleo de las técnicas de manejo de conducta disminuye los niveles de ansiedad durante el tratamiento dental. El bajo nivel socioeconómico y educativo, y la utilización frecuente de videojuegos aumentan la ansiedad dental mientras la realización de deporte y una vida saludable la disminuyen. Conclusiones: entre las técnicas de manejo de conducta del paciente pediátrico, las de gestión comunicativa son las más aceptadas por los padres. Aunque no hay ninguna prohibición legal en el uso de técnicas farmacológicas o no comunicativas, estas la mayoría de las veces son rechazadas por los padres. (AU)

Introduction: The dental profession is an activity oriented to the people care, including children, who need more specific care being in full physical and emotional development. When working with children you have to deal with the anxiety with which the child first enters the consultation. To solve this problem, different techniques have been described whose choice depends on the age, patient needs and professional skills. These techniques can be grouped into three groups: pharmacological techniques, communicative techniques and noncommunicative techniques. Objective: To review scientific evidence on the ethical and legal aspects of behavioral management techniques in pediatric dentistry. Material and method: A search was performed in the databases of PubMed/ Medline, Google Scholar y Scopus, according to inclusion and exclusion criteria. Results: The results determine that the use of behavioral management techniques decreases anxiety levels during dental treatment. The low socioeconomic and educational level and the frequent use of video games increase dental anxiety while the performance of sports and a healthy life decrease it. Conclusions: Among the pediatric patient behavior management techniques, those with communicative management were the most accepted by parents. Although there is no legal prohibition on the use of pharmacological or non-communicative techniques, these are most often rejected by parents. (AU)

Técnicas de manejo de conducta en odontopediatría: aspectos éticos y legales / Behavioral management techniques in pediatric dentistry: ethical and legal aspects

Introducción: la profesión odontológica es una actividad orientada al cuidado de personas, entre ellos los niños, que necesitan un cuidado más específico estando en pleno desarrollo físico y emocional. Al trabajar con los niños se tiene que lidiar con la ansiedad con la que el pequeño entra por primera vez a la consulta. Para solucionar este problema, se han descrito diferentes técnicas cuya elección depende de la edad, de las necesidades del paciente y de la habilidad profesional. Estas técnicas se pueden agrupar en tres grupos: técnicas farmacológicas, técnicas comunicativas y técnicas no comunicativas. Objetivo: revisar la evidencia científica sobre los aspectos éticos y legales de las técnicas de manejo de conducta en odontopediatría. Material y método: se realizó una búsqueda en las bases de datos de PubMed/ Medline, Google Scholar y Scopus de acuerdo a unos criterios de inclusión y exclusión. Resultados: los resultados determinan que el empleo de las técnicas de manejo de conducta disminuye los niveles de ansiedad durante el tratamiento dental. El bajo nivel socioeconómico y educativo, y la utilización frecuente de videojuegos aumentan la ansiedad dental mientras la realización de deporte y una vida saludable la disminuyen. Conclusiones: entre las técnicas de manejo de conducta del paciente pediátrico, las de gestión comunicativa son las más aceptadas por los padres. Aunque no hay ninguna prohibición legal en el uso de técnicas farmacológicas o no comunicativas, estas la mayoría de las veces son rechazadas por los padres. (AU)

Introduction: The dental profession is an activity oriented to the people care, including children, who need more specific care being in full physical and emotional development. When working with children you have to deal with the anxiety with which the child first enters the consultation. To solve this problem, different techniques have been described whose choice depends on the age, patient needs and professional skills. These techniques can be grouped into three groups: pharmacological techniques, communicative techniques and noncommunicative techniques. Objective: To review scientific evidence on the ethical and legal aspects of behavioral management techniques in pediatric dentistry. Material and method: A search was performed in the databases of PubMed/ Medline, Google Scholar y Scopus, according to inclusion and exclusion criteria. Results: The results determine that the use of behavioral management techniques decreases anxiety levels during dental treatment. The low socioeconomic and educational level and the frequent use of video games increase dental anxiety while the performance of sports and a healthy life decrease it. Conclusions: Among the pediatric patient behavior management techniques, those with communicative management were the most accepted by parents. Although there is no legal prohibition on the use of pharmacological or non-communicative techniques, these are most often rejected by parents. (AU)

The impact of hyperlinks, skim reading and perceived importance when reading on the Web.

It has previously been shown that readers spend a great deal of time skim reading on the Web and that this type of reading can affect comprehension of text. Across two experiments, we examine how hyperlinks influence perceived importance of sentences and how perceived importance in turn affects reading behaviour. In Experiment 1, participants rated the importance of sentences across passages of Wikipedia text. In Experiment 2, a different set of participants read these passages while their eye movements were tracked, with the task being either reading for comprehension or skim reading. Reading times of sentences were analysed in relation to the type of task and the importance ratings from Experiment 1. Results from Experiment 1 show readers rated sentences without hyperlinks as being of less importance than sentences that did feature hyperlinks, and this effect is larger when sentences are lower on the page. It was also found that short sentences with more links were rated as more important, but only when they were presented at the top of the page. Long sentences with more links were rated as more important regardless of their position on the page. In Experiment 2, higher importance scores resulted in longer sentence reading times, measured as fixation durations. When skim reading, however, importance ratings had a lesser impact on online reading behaviour than when reading for comprehension. We suggest readers are less able to establish the importance of a sentence when skim reading, even though importance could have been assessed by information that would be fairly easy to extract (i.e. presence of hyperlinks, length of sentences, and position on the screen).

Traducir el pensamiento en acción: Interfaces cerebro-máquina y el problema ético de la agencia / Translating thought into action: brain-computer interfaces and the ethical problem of agency / Traduir el pensament en acció: Interfícies cervell-màquina i el problema ètic de l'agència

En este artículo, nos proponemos dos objetivos: el primero, describir la teoría clásica de la agencia intencional y cómo la neurotecnología de las interfaces cerebro-máquina desafía los requisitos de la teoría clásica de la agencia y de la consciencia corporal. La neurotecnología de las interfaces cerebro-máquina funciona implantando electrodos directamente en el área de la corteza motora del cerebro que controla el movimiento, y está diseñada para detectar las señales neuronales asociadas con la intención de moverse, que son después decodificadas por un algoritmo en un computador en tiempo real. Así, una persona podría pensar en mover su pierna o su brazo y la máquina recibiría la información de su pensamiento para traducir el pensamiento en acción, mediante prótesis internas o exoesqueletos. Esto es posible y sus aplicaciones se proyectan tanto sobre la rehabilitación de la funcionalidad motora, como sobre la posibilidad de mejoramiento (enhancement) de las capacidades humanas. Ambas aplicaciones dan lugar a numerosas implicaciones éticas, pero destacamos principalmente una, que denominamos: el problema ético de la agencia. El segundo objetivo del artículo es explorar brevemente la ética algorítmica en el contexto de las interfaces cerebro-máquina y cómo se entienden en este ámbito la autonomía, la responsabilidad y la privacidad informacional. Finalmente, abogamos por la necesidad de un marco ético de principios que regule la neurotecnología, y en tal sentido apelamos a los nuevos neuroderechos

The aim of this article is twofold: Firstly, we intend to describe the classical theory of intentional agency and to analyze how the neuro-technology of brain-machine interfaces (BCI) challenges the demands of that classical theory of agency and body consciousness. BCI neuro-technology works by implanting electrodes directly into the motor brain cortex that controls movement and detect neuronal signals associated with the intention to move, what is decoded by an algorithm on a computer in real time. Thus, someone could simply think about moving a leg or an arm and the tool (a prosthesis or exoskeleton) would receive the information to translate thought into action. This is yet feasible and its applications could involve rehabilitation of motor function and the possibility of enhancing human abilities. Both applications give rise to various several ethical implications but mainly to one that we call "the ethical problem of agency". Secondly, we briefly explore the ethics of algorithms in the context of BCI neuro-technology and the way autonomy, responsibility, and informational privacy are understood. Finally, we advocate the need for an ethical framework of principles governing neuro-technology, such as the new neuro-rights

En aquest article, ens proposem dos objectius: el primer, descriure la teoria clàssica de l'agència intencional i com la neurotecnologia de les interfícies cervell-màquina desafia els requisits de la teoria clàssica de l'agència i de la consciència corporal. La neurotecnologia de les interfícies cervell-màquina funciona implantant elèctrodes directament en l'àrea de l'escorça motora del cervell que controla el moviment, i està dissenyada per a detectar els senyals neuronals associades amb la intenció de moure's, que són després decodificades per un algoritme en un computador en temps real. Així, una persona podria pensar a moure la seva cama o el seu braç i la màquina rebria la informació del seu pensament per a traduir el pensament en acció, mitjançant pròtesis internes o exoesquelets. Això és possible i les seves aplicacions es projecten tant sobre la rehabilitació de la funcionalitat motora, com sobre la possibilitat de millorament (enhancement) de les capacitats humanes. Totes dues aplicacions donen lloc a nombroses implicacions ètiques, però destaquem principalment una, que denominem: el problema ètic de l'agència. El segon objectiu de l'article és explorar breument l'ètica algorítmica en el context de les interfícies cervell-màquina i com s'entenen en aquest àmbit l'autonomia, la responsabilitat i la privacitat informacional. Finalment, advoquem per la necessitat d'un marc ètic de principis que reguli la neurotecnologia, i en tal sentit apel·lem als nous neuro-drets

Influencing relatives to respect donor autonomy: Should we nudge families to consent to organ donation?

Refusing consent to organ donation remains unacceptably high, and improving consent rates from family or next-of-kin is an important step to procuring more organs for solid organ transplantation in countries where this approval is sought. We have thus far failed to translate fully our limited understanding of why families refuse permission into successful strategies targeting consent in the setting of deceased organ donation, primarily because our interventions fail to target underlying cognitive obstacles. Novel interventions to overcome these hurdles, incorporating an understanding of cognitive psychology and behavioral change therapy, may be beneficial. One potential intervention is to use the concept of nudge theory, where decision-making is influenced by encouraging positive reinforcement and indirect suggestion. Purposefully nudging families to given consent for organ donation by understanding, and then overcoming, their inherent cognitive biases is novel but also controversial. This article explores the roles of relatives in decisions about organ donation, how nudge theory translates to organ donation and discusses the arguments for and against its application.

Different games of moral bioenhancement.

Rakic has serious misgivings about Wiseman's inability to frame ethical issues in the context of transcending existing realities (the 'is') with the aim of achieving what we believe is morally right (the 'ought'). This inability to think beyond the present is misguided in ethics. He also criticizes Wiseman for making the unimaginative and unsubstantiated assumption that moral bioenhancement (MBE) technologies have reached their zenith already. Rakic argues that MBE will become more effective in the time to come, that it ought to be optional for every free individual, and that it should be directed at enhancing our motivation to act in line with how we believe we ought to act. He concedes however that the enhancement of our motivation to act morally can only be effective in a limited number of morally unambiguous cases. In response, Wiseman argues that Rakic's reflections epitomize a way of articulating MBE that is unhelpful, misguidedly optimistic, and missing the most important things needing discussion. Such reflections are based on inappropriate metaphors, a too future-oriented view detached from basic realities, and a false sense of what is possible on the global level should MBE be applied. Such ways of thinking about MBE are misguided from the outset, and indicative of the enthusiasm for a discourse in need of realignment. This should take the form of a more modest, synergistic outlook acutely aware of the inexorable limitations imposed on MBE by the internal complexity of moral goods, human agents, and the contexts in which moral action occurs.

The genesis and correction of unprofessional behavior in surgeons: The role of society, education and genetics.

BACKGROUND: Most surgeons are ethical. Increasingly, however, a variety of unprofessional behaviors are surfacing. Awareness of these behaviors and their causation is required to plan their eradication. OBJECTIVES: To (i) identify the prevalent causes of unprofessional behaviors amongst surgeons; and (ii) suggest corrective interventions. METHODS: Literature was searched and models constructed to interpret interrelationships between causes. FINDINGS: Unprofessional behaviors extend beyond those frequently discussed, necessitating the term 'dysprofessionalism'. Causal influences arise from (i) an overpowering society; (ii) limited education and (iii) the underdeveloped state of human nature at birth. Societies corrupt by role-modeling avarice and encouraging industry-despite consequent pollution. Society brooks no interference. Surgeons are loath to oppose, resulting in an unprofessional silence. Surgical education based on best evidence is an indoctrination, with little opportunity to deploy alternatives. Evidence based guidelines increasingly risk errors, as publication fraud increases. Effective interaction with government/legislation is not taught. Human nature and our brain remain arrested in a stage of strongly stabilized evolutionary selection. Humans are born with larval brains requiring intense educational interventions. Genetic modification holds promise as it can circumvent birth in undeveloped states, and facilitate trans-generational transfer of knowledge. CRISPR/Cas-9 techniques make this possible, necessitating ethical discussion-an urgent issue. Reforming society would otherwise be an impossible task as behaviors cannot be taught in classrooms. CONCLUSION: Instances of dysprofessionalism are unlikely to diminish using current approaches. Discussion of the ethics of genetically modifying embryos is urgently needed, as this could provide a possible shortcut to positive changes in human behavior, but risks unwanted changes and misuse.

Why physicians ought not to perform virginity tests.

In this article I argue that it is not morally justified for physicians to perform virginity tests. First, I contend that, on the basis of the principle of non-maleficence, physicians should not perform virginity tests, because of the potential harms to those who are tested that can result from such tests. Second, I highlight some of the social harms that the practice causes, and argue that physicians ought not to be complicit in causing these harms. Third, I argue that physicians ought not to perform virginity tests on the grounds that testing for virginity is scientifically impossible, and physicians are morally obliged to practise according to scientific principles. Finally, I contend that an ethically sound response to virginity testing requires that the medical profession as a whole should follow the example of the Quebec College of Physicians in declaring this practice by physicians as unethical.

The ethics of distress: toward a framework for determining the ethical acceptability of distressing health promotion advertising.

Distressing health promotion advertising involves the elicitation of negative emotion to increase the likelihood that health messages will stimulate audience members to adopt healthier behaviors. Irrespective of its effectiveness, distressing advertising risks harming audience members who do not consent to the intervention and are unable to withdraw from it. Further, the use of these approaches may increase the potential for unfairness or stigmatization toward those targeted, or be considered unacceptable by some sections of the public. We acknowledge and discuss these concerns, but, using the public health ethics literature as a guide, argue that distressing advertising can be ethically defensible if conditions of effectiveness, proportionality necessity, least infringement, and public accountability are satisfied. We do not take a broad view as to whether distressing advertising is ethical or unethical, because we see the evidence for both the effectiveness of distressing approaches and their potential to generate iatrogenic effects to be inconclusive. However, we believe it possible to use the current evidence base to make informed estimates of the likely consequences of specific message presentations. Messages can be pre-tested and monitored to identify and deal with potential problems. We discuss how advertisers can approach the problems of deciding on the appropriate intensity of ethical review, and evaluating prospective distressing advertising campaigns against the conditions outlined.

Stigmatization and public health ethics.

Encouraged by the success of smoking denormalization strategies as a tobacco-control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on consequentialist grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health-related stigmatization.

Ethics on the dental treatment of patients with mental disability: results of a Netherlands - Belgium survey.

This study evaluates several ethical dilemmas of by dental practitioners treating persons with mental disabilities (PMD) by dentists in the Netherlands and Belgium. Ethical dental care for PMD is a hot topic. Worldwide different treatment strategies are used in the dental treatment of this patient group. In addition, cultural aspect seems to play an important role in the choices made. The latter can explain the difficulty in creating European and worldwide guidelines on this issue. A questionnaire was sent to dental practitioners interested in treating PMD persons both in the Netherlands and in Belgium including questions on the use of behaviour management techniques, use and attitude towards sedation and physical fixation and the cooperation with other health care personal. Behaviour management techniques and sedation are frequently used. Dentist of the Netherlands and Belgium in general reject the restraint of PMD persons. However, limited use of manual restraint in accordance with the carers and the close surrounding of the patient seems to be accepted. Dental practitioners are sometimes confronted with an emotional dilemma in treating PMD and the majority feels that it is a continuous challenge to obtain optimal result of the dental treatment.

The promises and perils of non-invasive brain stimulation.

Non-invasive brain stimulation promises innovative experimental possibilities for psychology and neuroscience as well as new therapeutic and palliative measures in medicine. Because of its good risk-benefit ratio, non-invasiveness and reversibility as well as its low effort and cost it has good chances of becoming a widespread tool in science, medicine and even in lay use. While most issues in medical and research ethics such as informed consent, safety, and potential for misuse can be handled with manageable effort, the real promise of brain stimulation does raise one prominent moral worry: it may lay the foundation of reliable, precise and stable manipulations of the mind. This article addresses this worry and concludes that it is not the possibility of manipulation, but the shift in our understanding of our mind which stands in need of careful consideration.

The essence of psychiatric nursing: redefining nurses' identity through moral dialogue about reducing the use of coercion and restraint.

In this article, we focus on core values of psychiatric nurses in relation to coercion and constraint. We analyze changes that took place in a project aiming at reducing coercion at a closed inpatient ward of a psychiatric hospital. Using the philosophy of Hans-Georg Gadamer and Margaret Urban Walker, we analyze both the process of moral changes through dialogue and the outcome in terms of new identities and moral responsibilities. We conclude that the project stimulated nurses to redefine their roles and develop a deeper intersubjective understanding of core values of their profession.

Do nonphysical punishments reduce antisocial behavior more than spanking? a comparison using the strongest previous causal evidence against spanking.

BACKGROUND: The strongest causal evidence that customary spanking increases antisocial behavior is based on prospective studies that control statistically for initial antisocial differences. None of those studies have investigated alternative disciplinary tactics that parents could use instead of spanking, however. Further, the small effects in those studies could be artifactual due to residual confounding, reflecting child effects on the frequency of all disciplinary tactics. This study re-analyzes the strongest causal evidence against customary spanking and uses these same methods to determine whether alternative disciplinary tactics are more effective in reducing antisocial behavior. METHODS: This study re-analyzed a study by Straus et al.1 on spanking and antisocial behavior using a sample of 785 children who were 6 to 9 years old in the 1988 cohort of the American National Longitudinal Survey of Youth. The comprehensiveness and reliability of the covariate measure of initial antisocial behavior were varied to test for residual confounding. All analyses were repeated for grounding, privilege removal, and sending children to their room, and for psychotherapy. To account for covarying use of disciplinary tactics, the analyses were redone first for the 73% who had reported using at least one discipline tactic and second by controlling for usage of other disciplinary tactics and psychotherapy. RESULTS: The apparently adverse effect of spanking on antisocial behavior was replicated using the original trichotomous covariate for initial antisocial behavior. A similar pattern of adverse effects was shown for grounding and psychotherapy and partially for the other two disciplinary tactics. All of these effects became non-significant after controlling for latent comprehensive measures of externalizing behavior problems. CONCLUSIONS: These results are consistent with residual confounding, a statistical artifact that makes all corrective actions by parents and psychologists appear to increase children's antisocial behavior due to child effects on parents. Improved research methods are needed to discriminate between effective vs. counterproductive implementations of disciplinary tactics. How and when disciplinary tactics are used may be more important than which type of tactic is used.