Principios bioéticos y actitudes en la atención de pacientes con VIH, del Hopital Clínico Viedma, 2021 / Bioethical principles and attitudes in the care of patients with HIV, Hospital Clínico Viedma, 2021

La infección por el Virus de la inmunodeficiencia humana, el estigma y la discriminación, así como su interrelación con los derechos humanos, se han transformado en los ejes centrales de las campañas contra el SIDA y a favor de los derechos de las personas viviendo con el VIH/SIDA, constituyéndose en uno de los problemas más frecuentes en el área hospitalaria. El presente estudio se realizó para identificar los principios bioéticos y actitudes del personal de enfermería, elementos de valoración y cuidados que implementan el personal para la prevención de las mismas; con el enfoque cualitativo - cuantitativo de tipo descriptivo y transversal, en el servicio de Infectología del HCV, gestión II/2021. Los resultados más significativos del personal de enfermería son: discriminación con el 20%; rechazo, 20%; actitudes negativas, 20% un 27% percibe una mala atención y 13% trato inadecuado, por tanto 100% de la población ha recibido algún tipo de maltrato del personal de enfermería. Pese a que estos conocen los principios bioéticos de autonomía, beneficencia, no maleficencia y equidad con los pacientes, solo en la parte teórica, ya que en la práctica no las aplican. (AU)

Objeção de consciência e aborto: opiniões e conhecimentos dos estudantes de enfermagem / Objeción de conciencia y aborto: opiniones y conocimientos de los estudiantes de enfermería / Conscientious objection and abortion: opinions and knowledge of nursing students

RESUMO Objetivo: analisar as concepções dos acadêmicos de enfermagem de uma universidade do Centro Oeste do Brasil acerca do conceito e utilização da ferramenta objeção de consciência em situações de abortamento. Métodos: estudo qualitativo do tipo exploratório-descritivo, realizado entre os meses de março a abril de 2016. Participaram do estudo 46 acadêmicos do 7º ao 10º semestre do curso de graduação em Enfermagem. A coleta de dados ocorreu por meio da aplicação de questionário eletrônico enviado por e-mail individualmente aos estudantes. Utilizou-se a análise categorial; os relatos dos participantes foram fragmentados em unidades de significados. Resultados: emergiram duas categorias para cada questão do questionário eletrônico: (1) Meus preceitos morais e crenças vão contra o aborto e não sei se teria condições emocionais e psicológicas; (2) Não me lembro e Ferramenta Legal; (3) Discriminação e comprometimento do serviço e Liberdade de pensamento; (4) Mais consciência sobre nosso papel como profissionais de saúde e ampliar a visão dos estudantes sobre os aspectos éticos e humanitários. Considerações finais: a partir das concepções dos estudantes, percebeu-se que a objeção de consciência é de suma importância quando se trabalha com a temática do aborto e poderia ser mais amplamente abordada no processo de formação acadêmica.

RESUMEN Objetivo: analizar las concepciones de los académicos de enfermería de una universidad del Centro Oeste de Brasil acerca del concepto y la utilización de la herramienta objeción de conciencia en situaciones de aborto. Métodos: estudio cualitativo del tipo exploratorio-descriptivo, realizado entre los meses de marzo a abril de 2016. Participaron del estudio 46 académicos del 7º al 10º semestre del curso de graduación en Enfermería. La recolección de datos ocurrió mediante la aplicación de un cuestionario electrónico enviado por correo electrónico individualmente a los estudiantes. Se utilizó el análisis categorial; los relatos de los participantes fueron fragmentados en unidades de significados. Resultados: surgieron dos categorías para cada pregunta del cuestionario electrónico: (1) Mis preceptos morales y creencias van contra el aborto y No sé si tendría condiciones emocionales y psicológicas; (2) No me acuerdo y Herramienta Legal; (3) Discriminación y compromiso del servicio y Libertad de pensamiento; (4) Más conciencia sobre nuestro papel como profesionales de salud y Ampliar la visión de los estudiantes sobre los aspectos éticos y humanitarios. Consideraciones finales: a partir de las concepciones de los estudiantes, se percibió que la objeción de conciencia es de suma importancia cuando se trabaja con la temática del aborto y podría ser más ampliamente tratada en el proceso de formación académica.

ABSTRACT Objective: to analyze the conceptions of nursing students of a university in the Midwest of Brazil about the concept and use of the conscientious objection tool in abortion situations. Methods: a qualitative exploratory-descriptive study, conducted between March and April 2016. The study included 46 students from the 7th to the 10th semester of the Nursing graduate course. Data collection occurred through the application of an electronic questionnaire sent by email individually to the students. Categorical analysis was used; participants' reports were fragmented into units of meaning. Results: two categories emerged for each question of the electronic questionnaire: (1) My moral precepts and beliefs go against abortion and I don't know if I would have emotional and psychological conditions; (2) I don't remember and Legal Tool; (3) Discrimination and Commitment to Service and Freedom of Thought; (4) More awareness about our role as health professionals and Broaden students' view of ethical and humanitarian aspects. Final thoughts: from the conceptions of students, it was realized that conscientious objection is of paramount importance when working with the theme of abortion and could be more widely addressed in the process of academic training.

Structural distress: experiences of moral distress related to structural stigma during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has taken a significant toll on the health of structurally vulnerable patient populations as well as healthcare workers. The concepts of structural stigma and moral distress are important and interrelated, yet rarely explored or researched in medical education. Structural stigma refers to how discrimination towards certain groups is enacted through policy and practice. Moral distress describes the tension and conflict that health workers experience when they are unable to fulfil their duties due to circumstances outside of their control. In this study, the authors explored how resident physicians perceive moral distress in relation to structural stigma. An improved understanding of such experiences may provide insights into how to prepare future physicians to improve health equity. METHODS: Utilizing constructivist grounded theory methodology, 22 participants from across Canada including 17 resident physicians from diverse specialties and 5 faculty members were recruited for semi-structured interviews from April-June 2020. Data were analyzed using constant comparative analysis. RESULTS: Results describe a distinctive form of moral distress called structural distress, which centers upon the experience of powerlessness leading resident physicians to go above and beyond the call of duty, potentially worsening their psychological well-being. Faculty play a buffering role in mitigating the impact of structural distress by role modeling vulnerability and involving residents in policy decisions. CONCLUSION: These findings provide unique insights into teaching and learning about the care of structurally vulnerable populations and faculty's role related to resident advocacy and decision-making. The concept of structural distress may provide the foundation for future research into the intersection between resident well-being and training related to health equity.

Physician autonomy or discrimination: the risks and limits of saying "no".

Respect for patient autonomy is a critical concept in the training of all physicians. Most physicians will make clinical recommendations on a daily basis that reflect a marriage of evidence-based medical fact and the deeply felt aspirations and boundaries that patients share with them. While most physicians are well versed and comfortable managing issues of patient autonomy, many are less confident about ethical and legal guidelines for expressing their own autonomy in clinical decision-making. This paper will review the legal landscape surrounding the patient-physician relationship with a focus on when and how physicians can exercise their personal and professional autonomy in their clinical practice.

Those who tan and those who don't: A natural experiment on colorism.

Are darker-skinned workers discriminated against in the labor market? Studies using survey data have shown that darker skin tone is associated with increased labor market disadvantages. However, it is hard to refute the possibility that other factors correlated with skin tones might affect employment outcomes. To overcome this inherent limitation, we use a natural experiment: we utilize changes in one's own skin tone, generated by exposure to the sun, to explore the effect of skin tone on the tendency to be employed. We find that those people whose skin tone becomes darker by exposure to the sun (but not others) are less likely to be employed when the UV radiation in the previous three weeks in the area in which they reside is greater. These within-person findings hold even when controlling for the week, the year, the region, demographic characteristics and the occupation and industry one is employed in.

National Medical Commission Bill: Opportunity to end educational apartheid?

The Government has superseded the Medical Council of India (MCI) with an interim board of governors that has assumed the powers and functions of the Council, pending passage of the National Medical Commission Bill. While a systemic revamp of medical education is intended, uncertainty prevails on whether medical academia will now be more inclusive.

The "Elderly" in Medicine: Ethical Issues Surrounding This Outdated and Discriminatory Term.

The objective of this study was to investigate and describe how the use of the term "elderly" contributes to bias and problems within the medical system. A systematic review of the relevant literature and history was conducted. The term "elderly" does not define age accurately and carries bias and prejudice that lead to harm through discriminatory practices, institutional prejudices, and "ageist" policies in society and medicine. Doctors and healthcare providers seldom intentionally try to harm any patient, but might do so through unconscious anti-elderly bias. Studies indicate that medical students already demonstrate anti-elderly bias; researchers may lump patients aged 65 and over together, confounding specific information needed for individualized treatments; and out of unwarranted concern, medical and surgical treatments may be denied, despite minimal increased risk of mortality. When the cost of healthcare rises, it is the elderly against whom rationing is suggested. The term "elderly" has no place in medicine. Anti-elderly health care rationing is as unethical as rationing targeted against any group. It is reverse paternalism to make rules that limit others' medical care, happiness, and life span without their consent. Medicine is the science and art of individual communication, evaluation and treatment. Once we deny care to any one group, we open the door to denial to others.

Clinical Ethicists Awakened: Addressing Two Generations of Clinical Ethics Issues Involving Undocumented Patients.

Because the United States has failed to provide a pathway to citizenship for its long-term undocumented population, clinical ethicists have more than 20 years of addressing issues that arise in caring for this population. I illustrate that these challenges fall into two sets of issues. First-generation issues involve finding ethical ways to treat and discharge patients who are uninsured and ineligible for safety-net resources. More recently, ethicists have been invited to help address second-generation issues that involve facilitating the presentation for care of undocumented patients. In the current environment of widespread fear of deportation in the immigrant community, ethicists are working with health care providers to address patient concerns that prevent them from seeking care. I illustrate that in both generations of issues, values implicit within health care, namely, caring, efficiency, and promotion of public health, guide the strategies that are acceptable and recommended.

Medidas de salud pública y estigma / Public Health Measures and Stigma / Mesures de salut pública i estigma

Muchas medidas de salud pública pueden tener un impacto mayor en determinadas clases o grupos sociales desfavorecidos. Esto puede atenuar, al menos temporalmente, las desigualdades sociales en salud, en la medida en que estos grupos tienen una prevalencia mayor de las condiciones que las medidas de salud pública quieren afrontar, pero también puede estigmatizarlos, lo que a la larga conduciría a exacerbar de nuevo las inequidades en salud. Se describen los conceptos de clase social, clasismo y estigma. Se analizan distintas corrientes de pensamiento que han concebido el papel del estigma dentro de la salud pública. Se acepta que en condiciones excepcionales se pueden defender algunas medidas de salud pública con ciertos efectos estigmatizantes como consecuencia indeseada, pero nunca de forma deliberada, como componente nuclear o exclusivo de la intervención. Por último, se comentan varias condiciones que deben cumplirse para evitar o minimizar el estigma en las actuaciones de la salud pública: la participación de las clases y grupos sociales involucrados en la toma de decisión; la supervisión ética independiente; rehuir la individualización de los problemas de salud pública y poner el énfasis en que son problemas predominantemente colectivos; la compensación suficiente a las personas y grupos perjudicados; y el esfuerzo por afrontar y corregir las causas profundas y estructurales de las desigualdades en salud

Many public health measures can have a greater impact on certain disadvantage classes or social groups. This may attenuate, at least temporarily, the social inequalities in health as these groups have a higher prevalence of the conditions that public health measures want to address, but it can also stigmatize them, which in turn will exacerbate again health inequities. We describe the concepts of social class, classism and stigma, and analyse different currents of thought that have conceived the role of stigma within public health. It is accepted that in exceptional conditions some public health measures with certain stigmatising effects as an unintended consequence, but never deliberately, as a nuclear or exclusive component of the intervention, can be supported. Finally, we propose several conditions that must be met to avoid or minimize the stigma in public health actions: the participation of the classes and social groups involved in the decision making; independent ethical surveillance; to avoid the individualization of public health problems, which blames the victim, and emphasise that they are predominantly collective problems; sufficient compensation for the individuals and groups harmed; and the effort to confront and correct the deep and structural causes of health inequalities

Moltes mesures de salut pública poden tenir un impacte important en determinades classes o grups socials desfavorits. Això pot atenuar, almenys temporalment, les desigualtats socials en salut, en la mesura en què aquests grups tenen una prevalença major de les condicions que les mesures de salut pública volen afrontar, però també pot estigmatitzar-los, la qual cosa a la llarga conduiria a exacerbar de nou les inequitats en salut. Es descriuen els conceptes de classe social, classisme i estigma. S'analitzen diferents corrents de pensament que han concebut el paper de l'estigma dins de la salut pública. S'accepta que en condicions excepcionals es poden defensar algunes mesures de salut pública amb certs efectes estigmatitzadors com una conseqüència indesitjada, però mai de forma deliberada, com a component nuclear o exclusiu de la intervenció. Finalment, es comenten diverses condicions que han de complir-se per evitar o minimitzar l'estigma en les actuacions de la salut pública: la participació de les classes i grups socials involucrats en la presa de decisions; la supervisió ètica independent; defugir la individualització dels problemes de salut pública i posar l'èmfasi en què són problemes predominantment col·lectius; la compensació suficient a les persones i grups perjudicats; i l'esforç per afrontar i corregir les causes profundes i estructurals de les desigualtats en salut

Ethical, legal and social implications of forensic molecular phenotyping in South Africa.

Conventional forensic DNA analysis involves a matching principle, which compares DNA profiles from evidential samples to those from reference samples of known origin. In casework, however, the accessibility to a reference sample is not guaranteed which limits the use of DNA as an investigative tool. This has led to the development of phenotype prediction, which uses SNP analysis to estimate the physical appearance of the sample donor. Physical traits, such as eye, hair and skin colour, have been associated with certain alleles within specific genes involved in the melanogenesis pathways. These genetic markers are also associated with ancestry and their trait prediction ability has mainly been assessed in European and North American populations. This has prompted research investigating the discriminatory power of these markers in other populations, especially those exhibiting admixture. South Africa is well known for its diversity, and the viability of these particular SNPs still needs to be assessed within this population. South African law currently restricts the use of DNA for molecular phenotyping, and there are also numerous ethical and social considerations, all of which are discussed.

Renunciation of health care by people living with HIV in France is still associated with discrimination in health-care services and social insecurity - results from the ANRS-VESPA2 survey.

BACKGROUND: This study aimed to estimate the frequency of renunciation of health care among people living with HIV (PLHIV) in France, including health care unrelated to HIV, and to characterize associated socioeconomic and psychosocial risk factors. METHODS: The cross-sectional ANRS-VESPA2 survey was conducted on adult PLHIV attending French hospitals in 2011. Correlates of health-care renunciation in the 12 months before the survey were assessed through logistic modelling. RESULTS: Among the 3,020 PLHIV included in the sample, 17% declared health-care renunciation during the preceding year and 42% had a high level of social insecurity. During the previous 2 years, 8% and 11%, respectively, were discriminated against by medical staff and family. In multivariate analysis, positive associations were found between health-care renunciation and a high level of social insecurity (adjusted odds ratio [95% CI] 3.44 [2.54, 4.65]; P<0.001), having children (1.52 [1.10, 2.10]; P=0.01), smoking tobacco (1.50 [1.13, 1.98]; P=0.01), discrimination by medical staff (1.53 [1.22, 2.29]; P=0.04) or family (2.48 [1.75, 3.52]; P<0.001), major depressive episodes (1.46 [1.02, 2.09]; P=0.04), past or current drug injection (1.54 [1.03, 2.30]; P=0.04), and younger age (0.98 [0.97, 1.00]; P=0.03). Health-care renunciation was also negatively associated with HIV diagnosis after 1996 (1996-2002: 0.64 [0.46, 0.90]; P=0.01; ≥2003: 0.56 [0.40, 0.77]; P=0.001). CONCLUSIONS: In spite of universal health insurance in France, barrier- and refusal-renunciation of health care by PLHIV remain frequent. Poor psychosocial outcomes and discrimination by families and health-care providers compound the negative effect of social insecurity on health-care seeking in this population. To ensure optimal medical care, strategies are needed to prevent discrimination against PLHIV in health-care services. Special attention must be provided to patients experiencing social insecurity.

Addressing patient biases toward physicians.

[Full article available at http://rimed.org/rimedicaljournal-2017-12.asp].

Genetic non-discrimination policy in Canada: Assessing windows of opportunity for policy change.

As the ease of obtaining genetic information for both the diagnosis and treatment of diseases has become increasingly common, so have concerns about the misuse of such information. The obstacles Canada faces in adopting genetic non-discrimination legislation have left health leaders with a lack of clear direction. Using the Kingdon agenda-setting framework, this article will identify lost opportunities for policy change and will analyze the potential for the adoption of a genetic non-discrimination policy in Canada. Windows of opportunity for policy change have existed in the past, but these windows have closed prior to a policy being adopted. More recently, the alignment of problem, policy, and politics streams in the agenda-setting process has resulted in a new window of opportunity. The adoption of a clear and coherent policy will provide the public with protection and health leaders with greater direction around genetic information.

Pacientes ilegítimos: Acceso a la salud de los inmigrantes indocumentados en Chile / Illegitimate patients: Undocumented immigrants' access to health care in Chile

RESUMEN Chile se ha ido convirtiendo en un país de destino para las migraciones sudamericanas, las cuales generan un impacto en los servicios públicos, en particular en salud, a nivel económico, social y cultural. El objetivo de este artículo es aportar información documentada sobre los problemas de acceso a la salud de los inmigrantes indocumentados. Trabajamos desde una metodología cualitativa, basada principalmente en una etnografía del espacio clínico. Para el análisis de los resultados nos hemos basado en las teorías de las relaciones asimétricas de poder, así como en las de las relaciones interétnicas. En los resultados de la investigación, se destaca el incumplimiento de la normativa y el ejercicio del criterio personal discrecional como barreras en el acceso. Concluimos que, en Chile, los inmigrantes en general e indocumentados, en particular, son considerados pacientes ilegítimos.

ABSTRACT In recent decades, Chile has become a destination for immigrants from other South American countries, which has significantly impacted public services - particularly the public health system - at the economic, social, and cultural levels. The aim of this paper is to provide substantiated information on issues concerning undocumented immigrants' access to health care in Chile. A qualitative methodology, fundamentally an ethnography of the clinical setting, was used. Results were then analyzed in relation to theories of power asymmetries and interethnic relations. The research results highlight the lack of compliance with existing regulations and the exercise of discretionary personal judgment as barriers to access. It is concluded that in Chile immigrants in general, and undocumented immigrants in particular, are considered to be illegitimate patients.